Phlebology Forum January - February 2014

JANUARY - FEBRUARY 2014

Randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy, and surgical stripping for great saphenous varicose veins with 3-year follow-up PAGE 8

The role of duplex ultrasound in the workup of pelvic congestion syndrome PAGE 12

From the Editor-in-Chief Nick Morrison, MD, FACS, FACPh, RPhS

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Contributing Editor/Reviewer: Claudine Hamel-Desnos, MD Associate Editor: Jean-Jerome Geux, MD, FACPh

jan - feb ‘14

contents

Randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy, and surgical stripping for great saphenous varicose veins with 3-year follow-up

9

The role of duplex ultrasound in the workup of pelvic congestion syndrome

Factors that influence perforator thrombosis and predict healing: Perforator sclerotherapy for venous ulceration without axial reflux

Contributing Editor/Reviewer: Fedor Lurie, MD, PhD

Contributing Editor/Reviewer: Marcondes Figueiredo, MD

Associate Editor: Mark Forrestal, MD, FACPh

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Associate Editor: Sherry Scovell, MD

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Name

ACP Role

Date Submitted

Disclosure

Stephanie Dentoni, MD

Recruitment & Retention(Chair), Leadership Development

9/8/13

Nothing to Disclose

Mark Forrestal, MD, FACPh

ACP BOD(President-Elect) Advocacy(Chair), Nominating, Finance, Exhibitor Advisory, Phlebology Forum,

9/8/13

Cooltouch Lasers: Speaker, Trainer

Mitchel Goldman, MD, FACPh

Phlebology Forum

9/8/13

Merz Aesthetics/Kreussler: Consultant/Research; New Star Lasers: Consultant

Jean-Jerome Guex, MD, FACPh

ACP BOD, Advocacy Standing, AMA HOD Task Force, International Affairs, VeinLine, Leadership Development, Annual Congress Planning

9/8/13

Servier International: Speaker/Consultant; Thusane: Scientific Committee Member; Vascular Insights: Scientific Committee Member

Lowell Kabnick, MD, FACS, FACPh

Phlebology Forum

9/8/13

Angiodynamics: Consultant, Shareholder, Patent; Veniti, Scientific Advisory Board; BTG: Consultant

Neil Khilnani, MD, FACPh

ACP BOD(Secretary), Member Engagement(Chair), CME Standing, CME, CME Workgorup 1,

9/8/13

Sapheon: Data Safety Board Member

Ted King, MD, FAAFP, FACPh

ACP BOD, Leadership Development, Annual Congress Planning, Public Education

9/8/13

BTG International: Consultant/Advisory Board Member/Principal Investigator; Veniti: Advisory Board/ Consultant; Sapheon: Investigator

Mark Meissner, MD

ACP BOD, Eductation, CME, Fellowship Training(Chair)

9/8/13

Nothing to Disclose

Nick Morrison, MD, FACS, FACPh

ACP Foundation (Chair), ACP Ethics and Industrial Advisory Committees, Phlebology Forum (Editor-in-Chief)

2/24/14

medi: Educational Grant; Merz: Consultant/Speakers Bureau; Sapheon: Principle Investigator; VeinX: Scientific Advisory Board

Eric Mowatt-Larssen, MD

ACP Leadership Development CME Workgroup 2 & 3

6/25/12

BTG International, Inc.: Consultant

Diana Neuhardt, RVT, RPhS

ACP BOD, Member Engagement, Education, VeinLine, Phlebology Forum, Leadership Development, Public Education(Chair), CME-Workgroup 2

6/15/12

Nothing to Disclose

9/8/13

Nothing to Disclose

Pauline RaymondMartimbeau, MD, FACPh

ACP Foundation BOD

5

The Scientific Committee of the 2014 ACP Annual Congress invites you to submit an abstract for consideration at the Annual Congress, November 6-9, 2014 in Phoenix, AZ. Please submit an abstact on any one of the following topics:

7. PELVIC VENOUS DISEASE – REFLUX & OBSTRUCTION 8. SCIENTIFIC REPORTING + Vein Registry Reports + Quality of Life Assessments + Outcomes Reporting + Technological Advances

1. BASIC SCIENCE 2. CCSVI 3. CHRONIC VENOUS INSUFFICIENCY AND VENOUS ULCERATION 4. COMPRESSION THERAPY 5. DEEP VENOUS THROMBOSIS 6. LYMPHEDEMA

9. SUPERFICIAL VENOUS DISEASE + Venous Ablation + Sclerotherapy + Miscellaneous 10. TECHNOLOGICAL ADVANCES 11. VENOTONIC DRUGS 12. VENOUS DIAGNOSTICS 13. VENOUS MALFORMATIONS

Deadline for Submission is June 2, 2014 Abstracts must be submitted online and are limited to 250 words.

For additional details and to submit online, please visit:

acpcongress.org

advancing vein care

ACP 2014

28TH ANNUAL CONGRESS

www.phlebology.org | 510.346.6800

6

From the

Editor-in-Chief Dear Readers In this issue of Phlebology Forum, the three-year results of one of the most important ongoing clinical trials comparing the four most commonly-used methods of saphenous ablation is discussed and expertly analyzed by Dr. Claudine Hamel-Desnos, a very important investigator in her own right. Her comments are insightful and very apropos for the practicing phlebologist.

Two other topics of great interest to phlebologists which are often overlooked are presented: pelvic venous insufficiency and minimally-invasive treatment for venous ulcers.

A paradigm for the workup of pelvic venous insufficiency is detailed from one of the most important academic vascular labs in the U.S., Stonybrook, followed by a critical review from Fedor Lurie now of the Jobst Clinic.

And finally further investigation of a simple and popular method of treating incompetent perforators associated with venous ulcers is reviewed and a commentary provided

by Marcondes Figueiredo of Brazil who has published his own work on this subject.

If our readers have any suggestions regarding articles they would like to see reviewed in Phlebology Forum, please let me or ACP staff know via email.

Nick Morrison, MD Editor-in-Chief Phlebology Forum nickmorrison2002@yahoo.com Mike Armitage ACP Staff Liason Phlebology Forum marmitage@acpmail.org

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endovenous laser ablation, radiofrequency ablation, foam sclerotherapy, and surgical stripping

Randomized clinical trial comparing

for great saphenous varicose veins with 3-year follow-up Author: Rasmussen L., Lawaetz M., Serup J., MS, Bjoern L., Vennits B., Blemings A., Eklof B. J Vasc Surg: Venous and Lym Dis 2013;-:1-8 Contributing Editor/Reviewer: Claudine Hamel-Desnos, MD Associate Editor: Jean-Jerome Geux, MD, FACPh

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SUMMARY Rasmussen et al. report the 3 year-follow-up results of a randomized clinical trial (RCT) of which, protocol and outcomes at 1 year-follow-up were previously published, in 2011.12

Between 2007 and 2009, in two private surgical centers in Denmark, 500 patients (580 legs) with great saphenous vein (GSV) reflux were randomized to endovenous laser ablation (EVLA), radiofrequency ablation (RFA), ultrasound guided foam sclerotherapy (UGFS) or surgery consisting of high ligation and stripping. All procedures were performed in a treatment room using sedation and tumescent anesthesia. In addition, varicose veins were removed by phlebectomies during the same procedure in all the treatment groups. At 3 years, the rate of closure/absence of GSV was lower in UGFS group compared with those of the 3 other groups, whereas all other criteria were equivalent for the 4 groups (VCSS, quality of life, recurrent varices).

Commentary We must underline the authors’ merit of having realized the first RCT, comparing 4 GSV treatment methods (EVLA, RFA, UGFS and surgery) directly between them. It is a study well developed from a methodological aspect. The authors conclude efficiency equivalence for the 4 arms on the clinical scores and the varicose recurrences at 3 years, and an inferiority of the foam on the criterion occlusion/absence of GSV in comparison to the 3 other groups.

Concerning the surgery arm, if the conditions of realization of the action (treatment room, light sedation and tumescent anesthesia) and the return to a professional activity (4 Days of time off work only), are in compliance with some of the experts’ practices, they are not the reflection of the “real life”, or at least, are not transposable to all countries. Thus in France, according to a report from the National Health Insurance Funds made over the year of 2010, varicose veins’ surgery is realized, for a very wide majority, in an operating theater, under general anesthesia, and time off work by patient reach an average of 26 days, strongly impacting the comparative cost evaluation.

Besides, the results from the Rasmussen’s study about the arm stripping are better in terms of absence of GSV and varicose recurrences, than those described in literature. 3,4 1

Rasmussen LH, Lawaetz M, Bjoern L, Vennits B, Blemings A, Eklof B. Randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy and surgical stripping for great saphenous varicose veins. Brit J Surg 2011; 98(8): 1079-87

2 Caisse Nationale d’Assurance Maladie. Rapport de l’assurance maladie sur les charges et produits pour l’année 2013. Constats. Juillet 2012 3 Luebke T, Brunkwall J. Systematic review and meta-analysis of endovenous radiofrequency obliteration, endovenous laser therapy and foam sclerotherapy for primary varicosis. J Cardiovasc Surg 2008; 49: 213-33 4 Van den Bos R, Arends L, Kockaert M et al. Endovenous therapies of lower extremity varicosities: a meta-analysis. J Vasc Surg 2009; 49: 230-9

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Surgery is operator-dependent and is here, undoubtedly, in the excellence of the conventional varicose veins surgery.

We can understand and honor the authors for trying to meet the identical conditions of execution for all the techniques, especially with the practice of phlebectomies associated in every group. Therefore, as it is usually the case, the difficulty and the limits of the evaluation of varicose recurrences are raised. Indeed, the results with regard to these recurrences, evaluate at least as much the phlebectomies as the trunks treatment methods themselves. In addition, if the systematic and simultaneous combination of phlebectomies is often the rule with stripping, it is called into question for thermal ablation5,6,7,8, and it seems inappropriate for the foam arm. Indeed, the UGFS, method purely medical requiring no anesthesia, is here transformed into a technique performed in surgical conditions. Thus, this arm is given the inconvenience and side effects of surgery (sedation, tumescent anesthesia, costs, scars, ecchymosis,...). The average time off work is almost equivalent to the surgery arm (3 and 4 days respectively), whereas the treatment of varicose veins by UGFS does not require any time off the current activity and even less off the professional activity.

For the injection foam technique, the use of the “5-Fr cannula” injected into the knee area, method often preferred by the surgeons, is probably not the best option to ensure proper occlusion of the GVS in its proximal portion of the thigh. Indeed, before reaching this segment, the quality of the foam is reduced on its journey. The proximal part of the GSV must yet be well “locked” to reduce the risks of recanalization. The staged injections technique with “fresh” foam and at least one proximal site of injection is often preferred.9,10

We must note that the sclerotherapy is also an operator-dependent technique. 11,12

The results of the foam arm in the Rasmussen study et al. are however overall consistent with those of literature, with a truncal occlusion rate of 75 % at 3 years 3,4,13. It is usually admitted that the sclerotherapy requires, in a certain proportion, “retreatments”, retreatments that are however, simple and well accepted by the patients14.

5 Onida S., Lane T.R.A., Davies A.H. Phlebectomies: to delay or not to delay? Phlebology 2012; 27:103–104 6 Welch HJ. Endovenous ablation of the great saphenous vein may avert phlebectomy for branch varicose veins. J Vasc Surg. 2006; 44: 601-5 7 Bush R L., Constanza Ramone-Maxwell C. Endovenous and Surgical Extirpation of Lower-Extremity Varicose Veins. Semin Vasc Surg 2008 ; 21:50-53 8 Hamel-Desnos C. Thermal ablation and additional treatments. Phlébologie 2013, 66, 2 : 70-78 9 Watkins M.R. Deactivation of sodium tetradecyl sulphate injection by blood proteins. Eur J Vasc Endovasc Surg. 2011 ; 41, 521-525 10 Rabe E., Breu FX, Cavezzi A., Coleridge Smith P., Frullini A., Gillet JL., Guex JJ., Hamel-Desnos C., Kern P., Partsch B., Ramelet AA., Tessari L., Pannier F., for the Guideline Group. European guidelines for sclerotherapy in chronic venous disorders. Phlebology 2013; 11 Wright D. et al. on behalf of the European phase III investigators group. Varisolve® polidocanol microfoam compared with surgery or sclerotherapy in the management of varicose veins in the presence of trunk vein incompetence: European randomized controlled trial. Phlebology 2006; 21:180-90 12 13

Rabe E., Otto J., Schliephake D., Pannier F. Efficacy and Safety of Great Saphenous Vein Sclerotherapy Using Standardised Polidocanol Foam (ESAF): A Randomised Controlled Multicentre Clinical Trial. Eur J Vasc Endovasc Surg. 2008; 35, 238-245 Jia X., Mowatt G., Burr J. M., Cassar K., Cook J., C. Fraser C. Systematic review of foam sclerotherapy for varicose veins. British Journal of Surgery 2007; 94: 925–936

14 Chapman-Smith P., Browne A. Prospective five-year study of ultrasound-guided foam sclerotherapy in the treatment of great saphenous vein reflux.

Phlebology 2009; 24: 183-188

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We shall also take into account that the diameters of the GSV were rather large, with a truncal average at 9 mm and an extreme max. at 20 mm for the UGFS arm (respectively EVLA and stripping: average 8 mm, maximum 12 and 14; RFA 7 mm, maximum 12). Some authors have indeed demonstrated that the rates of efficiency of the UGFS were better for diameters lower than 6 mm.15,16

Concerning the 2 thermal units, the RFA may seem a little favored over the EVLA group, by the use of the Fast catheter, while the “new generation” fiber (radial fiber) was not used for EVLA.

Finally, this 4-arm RCT was expected by health authorities and by the practitioners in many countries and we can thank the authors for having made a success of this difficult challenge. This work also has the merit of raising all the complexity of analysis and the difficulty of implementing this type of RCTs comparing several techniques that involve very different trainings. The biases are then almost inevitable because the investigators, whatever they may be, cannot have, in an equivalent manner, the same expertise of practice for each technique.

15 Coleridge Smith P. Chronic Venous Disease Treated by Ultrasound Guided Foam Sclerotherapy. Eur J Vasc Endovasc Surg 2006; 32 : 577-583 16 Myers KA, Jolley D, Clough A, Kirwan J. Outcome of ultrasound-guided sclerotherapy for varicose veins: medium-term results assessed by ultrasound surveillance. Eur J Vasc Endovasc Surg. 2007 Jan; 33(1):116-21

March 27-29-2014 Club Med Trancoso-BA - Brazil Before

We are pleased to welcome you to participate in the International Meeting on Aesthetic Phlebology.

Plan your trip to interact with IMAP and enjoy the gorgeous Club Med Trancoso, Brazil.

The core of IMAP is Clinica Miyake’s 51 years' experience on leg vein treatment with an important concern on the aesthetic point of view. We will also share the results we have gotten since we tested the first VeinViewer prototype in 2005. As IMAP is a problem based learning event, share your experience with the audience. One big room and plenty time for discussion.

After

Photography, tennis, golf and archery contest for those who plan to spend the whole week (pre-congress, hands-on activities from 24th to 27th and IMAP from 27th to 29th March 2014) Warm regards Kasuo Miyake, MD, PhD President of IMAP www.congressovenoso.com facebook.com/phlebologymeeting

Augmented Reality: a milestone in Phlebology

The role of duplex ultrasound in the workup of pelvic congestion syndrome Authors: Rafael D. Malgor, MD, Demetri Adrahtas, MD, Georgios Spentzouris, MD, Antonios P. Gasparis, MD, Apostolos K. Tassiopoulos, MD, Nicos Labropoulos, RVT, DIC, PhD JAMA. 2013 Oct 9;310(14):1482-9.

Contributing Editor/Reviewer: Fedor Lurie, MD, PhD Associate Editor: Mark Forrestal, MD, FACPh

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Commentary The Malgor et al. article reports their experience in the use of duplex ultrasound (DU) in the work up of pelvic congestion syndrome (PCS). 48 patients presenting with PCS were investigated in their vein center and their data analyzed retrospectively.

Their conclusion is that DU has a high sensitivity for the identification of left ovarian vein diameter but greatly reduced sensitivity for the right ovarian vein.

Furthermore they recommend computed tomography venography when DU results are equivocal or negative, but they agree that all venography including conventional venography are equally accurate to show the presence of pelvic varices.

...duplex ultrasound has a high sensitivity for the identification of left ovarian vein diameter but greatly reduced sensitivity for the right ovarian vein.

Our comments on this informative article may be influenced by our investigation protocol, which is different.1

In our practice after the usual gynecologic exam to rule out gynecologic causes for signs and symptoms of PCS, the first investigation is tranvaginal ultrasound that allows us to confirm the presence of pelvic varices as well as the presence or absence of compression syndromes identified by non continuous or continuous flow. If the latter is identified compression syndrome is highly probable and consequently either left renal vein compression (LRVC) or more frequently iliac vein compressions (IVC) are investigated by transabdominal DU.

We do not routinely use computed tomography venography or magnetic resonance venography to identifying gonadal vein size or reflux.

If PCS treatment is planned, a super selective venography by brachial access is performed that allows us to identify LRVC or IVC, gonadal vein size and competence, pelvic varices as well as reflux feeding lower limb varices. Treatment is performed in the same session for all of these anomalies.

1 Leal Monedero J. Zubicoa Ezpeleta S, Perrin M. Pelvic congestion syndrome can be treated operatively with good long term results. Phlebology 2012;27 Suppl 1:65–73

Factors that influence perforator thrombosis and predict healing: Perforator sclerotherapy for venous ulceration without axial reflux Authors: Kiguchi MM, Hager ES, Winger DG, Hirsch SA, Chaer RA, Dillavou ED J Vasc Surg. 2014 Jan 6. pii: S0741-5214(13)02091-0. doi: 10.1016/j.jvs.2013.11.007.

Contributing Editor/Reviewer: Marcondes Figueiredo, MD Associate Editor: Sherry Scovell, MD

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OBJECTIVE Refluxing perforators contribute to venous ulceration. We sought to describe patient characteristics and procedural factors that (1) impact rates of incompetent perforator vein (IPV) thrombosis with ultrasound-guided sclerotherapy (UGS) and (2) impact the healing of venous ulcers (CEAP 6) without axial reflux.

METHODS A retrospective review of UGS of IPV injections from January 2010 to November 2012 identified 73 treated venous ulcers in 62 patients. Patients had no other superficial or axial reflux and were treated with standard wound care and compression. Ultrasound imaging was used to screen for refluxing perforators near ulcer(s). These were injected with sodium tetradecyl sulfate or polidocanol foam and assessed for thrombosis at 2 weeks. Demographic data, comorbidities, treatment details, and outcomes were analyzed. Univariate and multivariable modeling was performed to determine covariates predicting IPV thrombosis and ulcer healing.

RESULTS There were 62 patients (55% male; average age, 57.1 years) with active ulcers for an average of 28 months with compression therapy before perforator treatment, and 36% had a history of deep venous thrombosis and 30% had deep venous reflux. At a mean follow-up of 30.2 months, ulcers healed in 32 patients (52%) and did not heal in 30 patients (48%). Ulcers were treated with 189 injections, with an average thrombosis rate of 54%. Of 73 ulcers, 43 ulcers (59%) healed, and 30 (41%) did not heal. The IPV thrombosis rate was 69% in patients whose ulcers healed vs 38% in patients whose ulcers did not heal (P < .001). Multivariate models demonstrated male gender (P[.03) and warfarin use (P[.01) negatively predicted thrombosis of IPVs. A multivariate model for ulcer healing found complete IPV thrombosis was a positive predictor (P [ .02), whereas a large initial ulcer area was a negative predictor (P [ .08). Increased age was associated with fewer ulcer recurrences (P [ .05). Predictors of increased ulcer recurrences were hypertension (P [ .04) and increased follow-up time (P [ .02). Calf vein thrombosis occurred after 3% (six of 189) of injections.

CONCLUSIONS Conclusions: Thrombosis of IPVs with UGS increases venous ulcer healing in a difficult patient population. Complete closure of all IPVs in an ulcerated limb was the only predictor of ulcer healing. Men and patients taking warfarin have decreased rates of IPV thrombosis with UGS.

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COMMENTARY A venous leg ulcer represents the severe end of the spectrum of chronic venous disease. Venous ulcers are the most common form of leg ulcer. Observational studies have reported the prevalence of venous leg ulcers to be 1-1.5%.

Chronic venous leg ulcers affect between 500,000 and 2 million persons annually in the USA and account for over 50% of leg ulcers1.

Venous ulcer has always posed considerable challenge to doctors. Diagnosing it is relatively simple; treatment is the key issue1.

Studies based on scientific evidence relating to the treatment of venous ulcer are scarce, as substantiated by a systematic review of the therapeutic effectiveness of chronic venous ulcer: Â of 10,066 citations identified in the literature search, only 66(0.06%) met our liberal inclusion criteria for providing evidence on the effectiveness of interventions for chronic venous ulcers. On tackling different therapeutic procedures for patients with ulcers, the reviews concluded that the data is insufficient to determine what is the best treatment. Although the

Studies like these have shown that the ultrasoundguided sclerotherapy is a therapeutic method which is well established worldwide and that it will be more and more used in those patients with advanced chronic venous insufficiency, as it is of low cost, technically accessible and can be repeated without hospitalization.

rate of strictness in the reviews of the scant evidence collected is high, we know that in practice there is successful treatment for this kind of pathology2.

The design of the study is retrospective and has a small sample. The method is consistent, with uniformity in the preparation of foam under the Tessari technique, and always uses some kind of compression and follow-up of about thirty months.

The ultrasound-guided sclerotherapy technique with foam is effectively applied to  patients having in their peri-ulcer region skin and subcutaneous alterations, surgical scars deriving from the removal of varicose veins or ligature of perforator veins, which are difficult to perform. However, the foam injected through a needle succeeds reaching where

1

van Gent WB, Wilschut ED, Wittens C. Management of venous ulcer disease. BMJ 2010; 341: c6045.

2 Lazarus, G., Valle, M. F., Malas, M., Qazi, U., Maruthur, N. M., Doggett, D., Fawole, O. A., Bass, E. B. and Zenilman, J. (2014), Chronic venous leg ulcer treatment: Future research needs. Wound Repair and Regeneration, 22: 34â&#x20AC;&#x201C;42. doi: 10.1111/wrr.12102.

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the scalpel cannot3.

For patients with venous ulcers, there are two important issues: the healing and the recurrence of the ulcers. In this article the authors have successfully addressed these two issues.

Healing had as its premise or basic requisite the insufficient perforator thrombosis, which occurred in 52% of the cases treated. The non-healing of almost half of the ulcers in the patients can be justified by the fact that 66% had had the deep venous system affected, despite having the perforator veins treated under the ultrasound-guided sclerotherapy.

The deep reflux kept feeding or provoking the chronic venous hypertension, thus keeping the ulcer open.

Recurrence, which is another challenge to be met, is inherent to this chronic and degenerative pathology. This study has shown that recurrence was associated with follow-up. Each additional year of the follow-up was associated with a 56% increase in the chance of recurrence.

We have also noticed, based on a 4 to 5-year follow-up observation study using foam treatment in patients with the same profile, that recurrence begins at a point after the 24th month and that it will occur along the time in most of the cases treated3.

Studies like these have shown that the ultrasound-guided sclerotherapy is a therapeutic method which is well established worldwide and that it will be more and more used in those patients with advanced chronic venous insufficiency, as it is of low cost, technically accessible and can be repeated without hospitalization.

Treatment of the venous ulcer still needs clinical studies of a more in-depth nature, with a higher degree of evidence, so that solid guidelines can be established. At present it is the consequences of the chronic venous disease that are treated; nevertheless the mechanisms leading to it have to be better clarified, so that what causes it can also be treated. With the present therapeutic options, some recurrence is expected to take place. Resolution techniques, based on the etiology of the disease, would improve the way whereby to tackle it and the quality of life of the patients with chronic venous disease.

3 Figueiredo M, Araujo SP, Figueiredo MF. Late Follow-Up of Saphenofemoral Junction Ligation combined With Ultrasound-Guided Foam Sclerotherapy in Patients With venous ulcers.Annals Vasc Surg. Vol. 26, No. 7, October 2012.

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fellowship in vein care at NYU train in the treatment of deep and superficial venous disease at one of the nationâ&#x20AC;&#x2122;s leading institutions for vascular medicine.

In partnership with the New York Univeristy Langone Medical Center, the American College of Phlebology (ACP) is offering a fellowship to qualified candidates, which provides 12-months of postgraduate training in the AMA self-designated practice specialty of phlebology.

The program is designed to train fellows in the diagnosis and treatment of both deep and superficial venous disease through a comprehensive curriculum of fundamental principles, diagnostic evaluation, treatment and adjunctive education.

Fellows will train with NYU Vein Center Director and Phlebology Program Director, Lowell Kabnick, MD, FACS, FACPh, RPhS. Dr. Kabnick is an internationally recognized leader in the field of vein care and has pioneered several breakthrough technologies for treating the underlying causes of many vein problems.

In addition, fellows will learn from twelve physicians in the Division of Vascular and Endovascular Surgery under the leadership of Dr. Mark Adelman.

apply today For more information and to apply, please contact: Felicia Brockett Fellowship Coordinator Vascular Surgery NYU Department of Surgery e: Felicia.Brockett@nyumc.org p: 212-263-6378

advancing vein care

www.phlebology.org

510.346.6800