Episodes
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About Dr. Anthony Comerota (Host)
Dr. Comerota is a board-certified vascular surgeon. He joined Inova as the Medical Director of the Eastern Region Heart and Vascular Institute, with over 36 years of clinical experience. Dr. Comerota served as a faculty member at Temple University Health Sciences Center where he became Chief of Vascular Surgery, Professor of Surgery, Program Director of General and Vascular Surgery, President of the Medical Staff and President of the Medical Alumni Association. He also served as Director of the Jobst Vascular Institute, ProMedica Toledo Hospital from 2002 - 2015 and Executive Director of Research, ProMedica Health System and Jobst Vascular Institute from 2015 to January 2017.
Dr. Comerota has been a major contributor to the development of some of the newest forms of treatment for vascular disease and has been the principal investigator of seven major national trials and a co-investigator of numerous others.
Dr. Comerota has a special interest in acute and chronic venous thromboembolic disease, complex deep venous reconstruction, and carotid artery disease. He became interested in venous thromboembolic disease because it is a serious and common vascular disorder.
About Dr. Riyaz Bashir (Guest)
While maintaining his full medical and academic responsibilities at the Temple University and Temple University Hospital System, Dr. Bashir serves in an ex-officio Chief Medical Consultant role for Thrombolex.
Dr. Bashir shares the product design creation responsibilities with Mr. Green. Dr. Bashir is a Professor of Medicine at Temple University School of Medicine and is the inventor of the Bashir Endovascular Catheter. His specialties include: carotid artery and peripheral vascular diseases, coronary and endovascular interventions (including carotid stenting and gene and stem cell therapy).
He attended medical school at the University of Kashmir, Government Medical College, Srinagar, India. His training includes a fellowship, interventional cardiology, Mayo Clinic; fellowship, vascular medicine and endovascular intervention, Tufts University School of Medicine, St. Elizabeth’s Medical Center; fellowship, cardiovascular medicine, Tufts University School of Medicine, St. Elizabeth’s Medical Center; residency, internal medicine, University of Kashmir, S.M.H.S. Hospital and Nassau University Medical Center, SUNY at Stony Brook.
His certifications include: interventional cardiology, vascular technology, endovascular interventions, vascular medicine, cardiovascular disease, and internal medicine.
About the Bashir Endovascular Catheter
The BASHIR™ Endovascular Catheter is a device intended for the localized infusion of physician specified fluids, including thrombolytics, into the peripheral vasculature.
The distal infusion segment of the device is 12.50 cm long and consists of an expandable basket with mini-infusion catheters, each with multiple infusion holes.
It is used for the delivery of the physician-specified fluids at multiple cross-sectional points of the target vessel location.
The infusion basket can be expanded using the red actuator located on the handle at the proximal end of the device.
After expansion, the mini-infusion catheters may be returned to their original closed positions by depressing the white button on the actuator and advancing the actuator toward the distal end of the device.
BASHIR™ Endovascular Catheters are for use only by trained physicians in strict accordance with the FDA-cleared IFU. Read more.
Dr. Steve Elias bids adieu -- VEIN Magazine thanks him for 12 wonderful episodes of the VEIN Magazine Podcast. Be sure to listen to his new show -- The Venous Edge Podcast
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Steve Elias: Welcome everybody once again to the Vein Magazine Podcast, or better known as vein specialists sitting around and talking, having drinks. Today we're at the American Venous Forum annual meeting, and with us is Peter Lawrence from UCLA, Peter Gloviczki from the Mayo Clinic and Mark Meissner, from the entire world because he is the world's best-known vein specialist. Is this true Mark Meissner?
Mark Meissner: I have no response to that Steve, because that clearly is not true.
Steve Elias: It takes three vein specialists to do a good job writing new guidelines on the care of varicose veins. And that's why we're here today. We have three people that are on the SVS AVF committee to rewrite the guidelines for the care of patients with varicose veins. Why do we need new guidelines? Don't we already know what we need to do to take care of varicose veins, Peter?
Peter Gloviczki: We have an idea of how to take care of varicose veins, but it's time to write new guidelines. The last guidelines we wrote were published in 2011, so that covered the literature until about the end of 2009. A lot has happened since that time. New evidence emerged, new treatment modalities were introduced and independent of the progress, every clinical practice guideline has to be rewritten every five years.
Steve Elias: What are some of the new things we need to address in the guidelines?
Peter Lawrence: We need to both respond to the MEDCAC report, which was done by CMS and has a big impact on reimbursement. There were several issues there that many of us disagreed with. There were the conclusion, the MEDCAC, one of them being the optimal way of imaging, and the conclusion that duplex ultrasound was not established as the best way to image veins. And you know, all of us, I think, believe that that's the case. So there needs to be, the guidelines need to really address that issue and look at the literature.
The second is since 2011 there's been the introduction of non-thermal as well as thermal techniques to close veins.
The third thing new guidelines need to address is that we see many physicians who are considered vein specialists ablate the perforator vein without any other vein being ablated in the extremity. So the role of certain locations, particularly perforators need to be addressed in the guidelines.Steve Elias: There is actually a process by which people need to evaluate the literature and the data that's available when you're writing guidelines. I had a little bit of trouble getting my arms around what we need to know when we write guidelines. What are the guidelines for writing guidelines?
Mark Meissner: The guidelines to writing guidelines were part of the Medicare Improvement for Patients and Physicians Act in 2008 that authorize the Institute of Medicine to develop guidelines for writing guidelines. That is a document that's out there. It's a very good document. It's very long, but the executive summary is fairly short, and you can read that and come away with what you need. Peter already mentioned one of them, which is those trustworthy guidelines need to be updated every five years because new information, new data, new evidence comes along, practice patterns change, so they need to be updated.
But there's actually eight elements of it that need to be included in trustworthy guidelines, and essentially that establishes the process and the process is, first of all, coming up with the panel that's going to do the guidelines and there are criteria for that. Any guidelines should include all stakeholders in the guideline, whether you're a vascular surgeon, radiologist, phlebologist in the community. It should include all stakeholders. It should include a methodologist, always, to help you evaluate the data. Optimally it would include patients as well, although that's a bigger hurdle.
Mark Meissner: The second is that every guideline should be based on a systematic review of the literature. It may not be strong enough to do a meta-analysis on, but the literature should be systematically reviewed, and my takeaway from that, which may or may not be true, is that if you can't generate a data table from it showing the outcome and the results, it probably shouldn't be in a guideline. You ought to be able to do that.
The third essential component is grading the evidence, the Society of Vascular Surgery as well as most organizations throughout the year, throughout the world, have chosen the grade approach to do it. So you grade the evidence. The fourth component is writing it and then having an external review of it and I missed the second component which is developing the questions, which is probably the most important thing is developing a reasonable question for...
Steve Elias: Did the original guidelines follow the approach that Mark just outlined or this approach came into being after those guidelines are written?
Peter Gloviczki: I think this so-called PICO guideline, or PICO technique to develop a guideline, came after 2010 when we really wrote the guidelines, but the guidelines had a lot of the components of currently anticipated guidelines. Very specifically, we had explicit and transparent questions that we pose and we used the appropriate evaluation when we graded the evidence, the level of evidence and the strength of recommendations.
There are additional components that we will be very careful to include in the new guidelines, and very specifically that transparent representation of the data that we collect and that's what Mark was referring to, the data tables. And that really just makes it transparent to everyone who reads the guidelines, what the literature offers in regard to the evaluation or the treatment that we recommend.
Steve Elias: Is the audience MEDCAC that we're playing to, or are we playing to the practicing physician to give them real guidelines and then MEDCAC can come in secondarily, but there are people out there want to know, "Oh hey, I got this patient, has this problem. What do the guidelines tell me I should consider doing?" What audience are we playing too?
Peter Lawrence: Both, but most importantly to the patient. I think Mark's talked today about being patient-focused. That's always the best approach to use, and what is in the best interest of patients. But guidelines require or are followed or used by well-intentioned physicians who want to do the right thing and the reason that the MEDCAC comes in is because they also have a huge impact on reimbursement because many people follow the CMS guidelines, and they're based on MEDCAC, so if they come to conclusions which are felt to be by most people practicing inappropriate, then I think that you can be misled or they can be misled.
The challenge of MEDCAC is that having sat on that for six years, and particularly on the venous MEDCAC, is that the group that does the research is given some limits and they were told, as I understand it, because I got all the data that they provided to the MEDCAC committee, was that they only would consider prospective studies less than 10 years with more than 500 patients. And as we all know, things like duplex ultrasound was developed and established the standard of care well before that. So there are a lot of changes that could be done, that are needed in the MEDCAC decision in summary, which happened as you probably know, because you are involved in it, over a period of six hours. In six hours made decisions that probably should have been done over a year with several meetings.
Steve Elias: What are some of the questions we should ask so that we can help the practicing physician? As Peter said, do the MEDCAC people understand what it takes to manage patients with varicose vein disease? What are some of those?
Mark Meissner: Part of the thing for trustworthy guidelines, which I'm surprised MEDCAC didn't realize, is having all stakeholders involved in the systematic review. And that was part of the problem with the MEDCAC systematic review, it was done by people with no knowledge of venous disease, with no clinical input whatsoever. And not that as clinicians we can do the methodology of it, but we can guide it and do not have clinical input in a systematic review is just not appropriate.
The SVS and the AVF have used the Mayo Group to do their statistical part of it, but they have always offered, if there was an interested panel member, which I participated in it for the thrombolytic guidelines, to be part of the systematic review and actually review the evidence with them, which I think is very valuable. And I think the Mayo Group recognizes that some clinical input is required. So I think that's part of the problem with the MEDCAC process.
To answer your question directly, I think we need to look at what's been developed since 2011 when the last guidelines came along. Probably the biggest thing in superficial venous disease is the non-thermal technologies. Those need to be addressed. Unfortunately a lot of the data is not real strong to support them, but I think if you follow the guideline process on what raises or lowers the degrees of confidence in the estimate of the effect for those guidelines, we can confidently recommend non-thermal technologies in an evidence-based fashion that will influence, I think, both patients, physicians as well as payers and really that's our role, is to interpret the data in light of... Lend some clinical credibility to what evidence is out there.
So I think that's a big one in 2019, is what is the role of non-tumescent technologies?. I think there are other things; a big question is what is the role of compression after endovenous ablation? And I think there's been some evidence that's come along since 2011. I think the management of complications, particularly thrombus extension at the saphenofemoral junction, not a lot of data, but that can be addressed. And those are some of the, three of the important questions, as well as I, think Peter's question is important too, is duplex ultrasound, the evidence-based standard of care for the evaluation of venous disease?
Steve Elias: I mean this to me, with the duplex ultrasound, it kind of blows my mind. I mean it's kind of like, we already know duplex ultrasound is the gold standard but how are we going to answer this question? Is there not data that duplex ultrasound is the gold standard.
Peter Lawrence: There's a lot of data, but if you're restricted in doing the systematic review to the last 10 years and much of the data was developed 15 to 30 years ago, then you're going to miss it in the 10-year review. So it all has to do with the budget and how much, if they had been able to go back 20 or 30 years, I think they would have come to the conclusion that duplex ultrasound was the best diagnostic technique and was appropriate today. So in all of it has to do with the restrictions of the limitation in doing the systematic review.
Mark Meissner: And not only that, that that question was not asked appropriately because that question should have been asked is in patients with symptomatic venous disease, acute deep venous thrombosis, anything else, is duplex ultrasound more accurate than X comparator in the diagnosis and what's the X comparator? Is it venography? Is it CT venography? And there's virtually no data to suggest that anything is better than duplex ultrasound. So it's not only a problem that they didn't look far enough back, but the questions weren't formatted appropriately.
Peter Lawrence: I’ll add that the people sitting on the MEDCAC committee who voted, there were two clinicians who took care of patients and one was Tony Comarado who was invited as a guest. So his votes were counted separately from the rest. I was the only person who took care of venous disease. These were well-intentioned people, but none of them had taken care of patients with venous disease. And so it's not surprising that their decisions were not particularly appropriate or relevant because they had no background in venous disease management.
Steve Elias: For the physicians who are taking care of patients they look to this, not just for guidance in a particular patient, but they look to it for, to cover themselves when they're treating the patient and they're concerned that people are going to say, "I'm doing the wrong thing." And they look to the guidelines and say, "No, the guidelines tell me this." So how does a practicing physician utilize the guidelines that we're going to be writing? In other words, how would you say to them, "Here are the guidelines, here's what you can do with these guidelines."
Peter Gloviczki: You bring up an excellent point. What is the goal of a guideline? Is the goal of a guideline to decide on reimbursement? Is the goal of the guidelines to protect the physician? No, I think the guideline should have one major goal in mind: deliver the best care to our patients. That is our primary goal, and any guideline should be part of the decision making of what is the type of tests that we order and what is the treatment that we offer to our patients. So a guideline should be used by the physician and by the patient, but a guideline should be a major tool to determine the best care, together with the physician's clinical experience and judgment, together with the patient's values and preferences, together with the most cost effective and affordable treatment and all this is going to ultimately decide the best treatment for the patient.
Steve Elias: Does industry have any role in giving us any information when we're writing the guidelines?
Peter Lawrence: Industry shouldn’t have a direct input but there are industry studies or supported studies which are good studies. So in reviewing the systematic review, not all, but there are industry-sponsored studies that are very well conducted and industry obviously has a lot more money than societies or individuals. So they have the potential to do excellent studies.
I think that the key is so that industry is both not in the room influencing or writing the studies, number one, and that the people who are writing the studies aren't influenced by industry, that they fully disclose their connections to industry. There's no reason to exclude people who have a relationship with industry. It just has to be disclosed and balanced with people who don't have a connection. We shouldn’t be in an antagonistic relationship with industry, because it's critical to us having good devices and developing good care, and as was pointed out in Mark's lecture today, right now they're very involved in training physicians in the use of devices. So until we have another system, they're a very important role in clinical care, just not sitting in the room while the guidelines are being written.
Steve Elias: Logistically what happens? All of you got us all together, the people who are writing this; now what are the steps. Who gets what roles? Who's addressing one issue, another issue. I want readers to understand that guidelines are not a willy-nilly couple of, as Mark says, BOGSAT—a bunch of old guys sitting around and talking. It actually is a real process. It takes a lot of work.
Peter Gloviczki, you bring up a very good point. Putting together an expert committee is the most important to me. A panel of experts, who are experts in the topic of the guidelines. The second step is really, discuss and agree on explicit and transparent questions. Once we have the questions then we actually decide and divide the guidelines to a different group of people who are going to work out the guidelines based on topics and grade them. And then I think we all kind of have regular phone conferences where we debate the grading and answer questions or answer comments, and like this, the entire committee is involved in the final decision making.
Steve Elias: How long do you think it's going to take in general, the process?
Peter Gloviczki: It's going to take about a year to a year and a half to write the varicose vein guidelines, because we have to have, first, the appropriate questions for the systematic reviews. To have a good set of guidelines, we need systematic reviews or data tables for each of the questions that we ask. That takes time and I would say it's about a year, year and a half. What do you think?
Peter Lawrence: We're told that it will take for the systematic review about four months, and then after that, we'll do the work of the committee, and then it has to go out to the public or to review by professionals who get a chance to have input. So I think a year, to a year and a half. One of the things, just to add to what Peter said, is that one of the things, and I, this is not my own personal learning experience, but the doc committee, which Peter chaired and now Tom Ford chairs.
Steve Elias: Now, Mark, are you good with that? Three or four critical questions, or five questions, that the practicing physician, when he sees a patient with varicose veins needs to answer. He said, "Okay, I got someone with varicose veins. How am I going to treat him? Okay. And here are the five questions I need to ask myself and go to the guidelines to say the guidelines tell me this, this and this." In other words, you know, in general, I think of a simplistic, practical approach rather than a bombastic scholastic approach that, as Peter said, you got to read through a hundred pages to find out what the hell to do with the patient. Is our goal, should I go also be to make it as simple as possible for the overall practicing physician?
Mark Meissner: Well, I think the goal should always be to make it as simple as possible, but I think we all realize, as practicing physicians, that we go to multiple sources for our information, and I think it's important to discern, there's a difference between expert opinions, sort of best practices, standard of care, which is important. One of the recommendations which I often cite as an example, in the original varicose based guidelines, is every patient should have a CEAP designation, which is certainly very true, but that belongs in an expert opinion sort of piece. And I think if you're looking for that comprehensive of expert opinion, you go to the Handbook of Venous Disorders, which does a very nice job putting it all in one place.
But then the practice guidelines need to be things that are really based on evidence and data, and not an expert opinion. And I don't think there are a lot of questions that can be answered with data. And so I do think that everything, every question we ask ought to be answered with the data. And then we should look to other important sources, like the Handbook and things to answer those questions about what well-meaning physicians consider the standard of care, but isn't necessarily supported by data.
Steve Elias: All right, so in conclusion, I want to ask the three of you, I mean all three of you have treated veins for a long time. Why do we need to go through all this? Can't the three you just come up with, "Here's what you do."? Don't you guys know enough? Why do we need to go to the literature? Why do we need literature, Peter Gloviczki? You guys, if I asked you, Peter, I have a 42-year-old patient, has varicose veins and the woman is like, she stands all day, she works as a waitress. She has saphenous vein incompetence. Couldn't you tell me what to do? Do you need the literature? Do I need guidelines?
Peter Gloviczki: I think we absolutely need guidelines. We need evidence, we need evidence to support our expert opinion. And I think that is a combination of clinical experience and evidence-based clinical practice guidelines that will deliver the best care to our patients. So I think the best thing we can do is put together our evidence-based guidelines and have that available to our physicians who will then make the final decision based on their experience and the patient's values and preferences.
Peter Lawrence: We need guidelines, not necessarily for the person who's been doing it for 30 or 40 years, but for the well-intentioned clinician who wants some advice and is looking to do the right thing for patients. So those of us who are very experienced might occasionally be surprised by something in the practice guidelines, but unlikely. But the person who's inexperienced is going to be the person who benefits most greatly from the practice guidelines.
Steve Elias: There's a significant amount of work that goes into writing guidelines. They're not taken lightly and that's why they are so important. And that's why MEDCAC looks at these guidelines. Practitioners look at these guidelines, and societies look at these guidelines, and it's not an easy process, and it's a very rigorous process and those are things that people could hang their hats on.
Peter Lawrence: Practice guidelines, although the intent is not to establish standards when people vary so much from what is in practice guidelines, there can be a benchmarking and I think it does a have a threat to those who are doing very inappropriate care. They're out of the practice guidelines. So an institution, a hospital, a society, if someone varies so much repeatedly from practice guidelines, it can become a way to either stop that practice or at least give them feedback about how inappropriate.
Steve Elias: Yes, and we're definitely dealing with that issue of overuse and abuse in the varicose vein world.
Peter Gloviczki: I would finish emphasizing how important the guidelines are, but I would finish with a quote of Mayo, who said that the best interest of the patient is the only interest that should be considered.
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Missing episodes?
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In this episode, Dr. Steve Elias is joined by Dr. Thomas Maldonado from NYU Langone Medical Center, Dr. Peter Pappas from Center for Vein Restoration and Dr. Thom Rooke from the Mayo Clinic to discuss lymphedema and phlebolymphedema.
Thank you to our sponsor Tactile Medical, maker of the Flexitouch. The Flexitouch system is an advanced intermittent pneumatic compression device (lymphedema pump) used by tens of thousands of patients to self-manage lymphedema and nonhealing venous leg ulcers. -
Getting vascular residents excited about vein disease can be hard, especially when the bulk of their training focuses on arterial care.
Yet, as they enter their careers, they are likely to find that up to 80 percent of their patients need treatment for chronic venous insufficiency-related conditions like varicose veins.
“We are doing our trainees a disservice if we don’t offer a dedicated venous rotation,” said Ellen, a vascular surgeon and program director at Duke University Health System.
The calls most program directors receive from trainees 2-6 weeks after graduation aren’t about endovascular aortic repair, she noted, instead, they are about how to effectively treat varicose veins.
Patrick, a vascular surgeon and program director at Good Samaritan Hospital, goes further, saying calls can become more targeted, with former trainees wondering how to manage perforators, venous ulcers, deep vein thrombosis, and zoned reflux.
“Those are everyday problems and everyday scenarios,” he said that they aren’t necessarily prepared for because the bulk of their training may have been in arterial care.
Enriching trainee education on vein disease, they agreed, equips them to handle such cases and, should they choose to make vein care their specialty, there is a "land of opportunity."
Listen on.
This episode is sponsored by Clear Sky Local, a marketing company that has worked intimately with vein clinics to help them effectively market their businesses and generate new patients. Find out about their patient accelerator at https://clearskylocal.com/
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Harkening back to the first VEIN podcast, this episode seeks to gain a wider perspective on the vein world—not from physicians, like before, but from vein specialists who work to improve patient care through product innovation.
In this episode, Scott Centea, Sr. Director of Global Marketing, Peripheral Vascular at AngioDynamics; Brian Dempsey, Peripheral Account Manager at Philips Healthcare; and Eric Heil, Vice President of US Commerical at BTG International, join Steve at the 2019 American Venous Forum's annual meeting to discuss the industry’s role in education, appropriate treatment, and the development of new products.
In their discussion, the group poignantly points out difficulties with getting products covered by government-sponsored health care programs like Medicare and reflect on the roadblocks they and others face just trying to get devices to market.
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Dr. Steve Elias speaks with Dr. Angela A. Kokkosis and Dr. Pamela S. Kim, both of whom work at Stony Brook Medicine, Division of Vascular and Endovascular Surgery, to see what some of the younger members of the vein community have to say about the ever-evolving world of veins.
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Dr. Steve Elias is joined by some of the faculty of the New York Venous Symposium which will be held in New York on April 11, 12 and 13, 2019. Here, Drs. Ellen Dillavou, Kathleen Gibson, Neil Khilnani, and Joseph Raffetto discuss what they love about the meeting, why it's unique and what attendees can expect from the 2019 symposium. Learn why the NYVS has become known as the most interactive meeting in the vein space and what's in store for both experts and vein treatment newcomers. Plus some tips on where to eat in New York City while attending the meeting.
To learn more about the New York Venous Symposium visit: http://venous-symposium.com/
This promotional episode was sponsored by NormaTec. Get back to normal with compression therapy that works. To learn more visit: http://www.normatecusa.com/
This podcast is a product of Vein Magazine. For more information visit: https://www.veindirectory.org/magazine/
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Recorded from the 9th annual European Venous Forum Hands-On Workshop. EVF HOW course directors Dr. Marianne De Maeseneer from Belgium, Dr. Tomasz Urbanek from Poland and Dr. Steven Black from the UK join Dr. Steve Elias at the 2018 EVF HOW meeting in Cyprus to discuss the 2018 meeting and venous education in Europe. To learn more about the European Venous Forum visit https://europeanvenousforum.org/
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Dr. Steve Elias is joined by Dr. Margaret Mann, chair of the Improving Wisely project with the American Vein and Lymphatic Society and AVLS President Dr. Marlin Schull. What is the Improving Wisely project? How is it being applied to the vein specialty? And what were the results of the 2018 pilot program?
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In this episode Drs. Steve Elias, Mark Meissner, and Neil Khilnani discuss the organization formerly known as the American College of Phlebology's (ACP's) recent name change to the American Vein and Lymphatic Society (the AVLS). What was behind this decision and what was the process of choosing a new name.
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Ep 3. Too Many Venous Meetings?Welcome to the VEIN Magazine Podcast with Dr. Steve Elias—Real discussions on venous disease and treatment.
Dr. Steve Elias joins Dr. Bill Marston and Dr. Mark Meissner to talk about the state of venous education meetings.
Are these meetings the best format for CME? Can online education be viable? And where are the West-coast meetings?
To learn more about EVM, visit expertvenousmanagement.com.
We’d love to have your thoughts on this episode and the VEIN Podcast.
Review us on iTunes and read the full episode transcript at Bit.ly/veinmeetings.
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Behind the scenes at Expert Venous Management 2018
Welcome to the VEIN Magazine Podcast —Real discussions on venous disease and treatment.
Our host Dr. Steve Elias shares some whiskey with Dr. Nicos Labropoulos and Dr. Tony Gasparis while discussing EVM and venous education.
How was the Expert Venous Management course started, how is it different, and what’s in store for 2019?
Learn more about Expert Venous Management and Venous Symposium.
We’d love to have your thoughts on this episode and the VEIN Podcast. Leave a comment on our episode page.
Episode TranscriptDr. Steve Elias: Okay, well, welcome everybody to what I'd like to call vein specialists sitting around, having drinks, talking. Today we have Tony Gasparis and Nicos Labropoulos talking with us.
Most of you probably do know Tony and Nicos and they have been in the education business for a very long time, running their Venus Symposium in New York City every year. Also, they do a lot of individual teaching at their institution, Stony Brook, as well as all over the world. People come to them and they go to people to help teach.
But we are speaking to you today from the first day after a course that's called Expert Venous Management. It's the first day of the two day course. This course was really started to fulfill a need that we thought existed in the vein world.
Maybe Nicos, can you give us an idea about what is this need? Why do we need Expert Venous Management or a course like that versus the courses that are out there?
Dr. Nicos Labropoulos: I think this is an important course because it takes the people to a different level. First, everybody has an equal opinion, is extremely interactive, it’s not based out of lectures, but real clinical cases that we prepare and other faculty brings. And we discuss the advantages and disadvantages of every technique, approach, outcome, without any hesitation and it’s actually fascinating because people they actually talk and they talk about reality.
We don't always agree with each other but this exactly what medicine all about and it's a course that I really truly enjoy myself.
Steve: If you enjoy yourself then everybody is going to enjoy themselves. Speaking of enjoying yourself Nicos, what do you happen to be drinking at the moment? People might like to know what your choice of beverage is tonight.
Nicos: I'm drinking Stella Artois. It’s one of the beers I like a lot and it happened to be here at the hospital. A beer we cannot have in our own hospital but it's good to be at Jersey for this reason.
Steve: Right. In Jersey we have beer during our hospital. In New York you guys are not allowed to have it.
Dr. Tony Gasparis: No, we're not.
Nicos: They're going to escort you out.
Steve: Now Tony, when we first starting talking about this idea, do you happen to remember where it was?
Tony: It was at VEITH, we were at the lobby having drinks and we talked about putting this course together. I can't remember though, what was the triggering factor?
Steve: The triggering factor was: I said aren't we all bored about giving the same lectures at various meetings, that we've given for so many times, and it's not becoming fun anymore? So I said can we do something that's fun? Do you remember that?
Tony: Well, this course definitely is fun.
Nicos: Absolutely
Steve: Right. It's fun for us, and it's fun, I think, for the attendees.
Nicos: I think the key issue here was the clinical cases because this meeting was truly based on real clinical cases. For example today, you see how animated was the crowd and the person themself telling their story. It's very captivating.
Steve: Yeah it is. Very much so. Now, to put on this course…so, Tony after you take a sip of, what are you drinking?
Tony: I don't know. I was just going to ask you to tell me a little bit about Tin Cup.
Steve: Okay, so Tony is drinking a whiskey called Tin Cup. It's an American whiskey and it says here it is cut with Rocky Mountain water. It's really a mixture of, I would say, between a bourbon and a rye. It's a little sweet but it's American and that's what I like. It's not scotch whiskey, even though I do like scotch whiskey. Tony seems to be enjoying it.
Tony: I enjoy it. It's actually very good.
Steve: I may have to give him another refill soon.
Let’s talk a little bit about the roles each one of us plays here. We all have our little roles before the meeting and during the meeting. Tony, what would you say your role is before the meeting? I could tell you what your role is during the meeting. Which is not to be around during the meeting, but before the meeting what do you see is your major contribution to EVM?
Tony: Well, I'm not going to concentrate on myself, but I think between the three of us, we all put together the program and the topics. At least the type of clinical cases we want to have presented. Other than that, my specific role is mostly organizing the details of putting together the meeting and fundraising for the meeting, as well as marketing for it.
Nicos: I believe that we actually complement each other and we work well together. This is the best fun about this meeting. My role is actually bringing innovation. I try to look here and there to bring new ideas that all of us three approve, and for the most part have worked well. We don't accomplish everything because of the time we have but I think for the most part we do well.
Steve: I do think and I appreciate that you're always challenging us to come up with some new idea. What are we going to do different next meeting that we haven't done already? And I think that's important to keep us thinking ahead.
Tony: Yes, change it a bit and make it interesting, it can be a challenge. But still, other than providing the alcohol and the entertainment during the meeting, what is your role?
Steve: My role, before the meeting?
Tony: And hosting it, I guess, right?
Steve: Yes, it's held here at Englewood Hospital so I guess I do host the meeting. What is my role? I guess I don't exactly know what my role is before the meeting. Whatever you tell me to do, I do. I do...
Nicos: You do deliver I have to ... You do deliver.
Tony: And I love the patients from today.
Steve: Oh yes getting great patients. So yes, we do have live patients here and I kind of work hard to think of the right patient, not just with the right pathology but also the right personality.
Tony: The other nice thing about it is it's a very intimate meeting. We kind of restrict it to about 50, 75 people. Obviously to run this meeting from a financial perspective, dealing with the financials, we do heavily rely on industry and I think they play a very important role to the success of this meeting.
Steve: But the other nice thing when you mention industry about the meeting, what I think they also like, is that it is a non-CME meeting so they're sitting in listening to all the lectures and today for instance, we had comments by multiple representatives from various industries. If we were speaking about a problem, a clinical problem, that involved their technique, that could help and as a matter of fact ...
Steve: A technique that could help and as a matter of fact, who is it from the mechanical firm Beckme said what about a mechanical firm that can be only in this patient that was pregnant and you were a little bit.
Nicos: [Inaudible].
Steve: Right, should I really consider giving thrombolysis in a patient that's 36 months pregnant.
So I thought some of that allows industry, 'cause they have seen sometimes many more cases than any of us have seen 'cause they go to various different physicians.
To me the other nice thing is that industry is involved, not just monetarily, but also they can make their comments without worrying what they can or can't say.
Because in many other meetings they’re not even allowed to come in to listen to the talk so they can't learn, and here we let them learn. And I think what we're trying also to create here is... you can go into a little different area, is the management of vein disease, especially nowadays is a partnership between industry and physicians, and societies.
And the better way to get better partnership is by sharing information and including industry into our meetings in a non CME way we can do that. But with CME for whatever reason they can't, but when they feel part of the whole thing, the whole meeting, I think they're engaged better and it's just good for going forward.
Nicos: Steve I have a question for you here. You've been teaching people and you've taught the fellowship training for a long time, what do you think is the next way in which medicine and industry have to meet? What's the next step? What can we do to do better?
Steve: That's a good question. And I think aside from the meetings like this where people can be more open, as younger people are coming up through training they are very adept at the whole electronic, use of cell phone and electronic devices for learning and stuff like that. I think we, just like here with this podcast.
Because I think people are, I think we're gonna move in that direction, where people are gonna be getting their information more and more...
Tony: Through e-learning.
Steve: Through e-learning, and meetings will be important because there is nothing like one on one, you know, seeing someone in person, but I think this e-learning, done the right way, done in a way that is personal, and not just listening to somebody talk and you fall asleep halfway through it, is kind of the way to go.
Tony: I mean it's definitely a way of providing education, obviously there are limitations on that form, especially if you're doing a podcast where it's just audio versus a video effect.
But also you know how difficult it is to get interaction between the FNDs and the faculty, even in a regular meeting face to face, imagine having to get that interaction over a web. I think it makes it even harder sometimes—especially if there's multiple people in that educational venue.
But definitely it has its role. It does allow you to provide education without having to travel, but there are limitations I think still.
Steve: I agree with you. People get bored if they're just sitting in their house or something listening and they do get distracted. So there may be a way to do it, I'm not sure what, but I think we need to explore that electronic way, e-learning, in some manner or means because I think it can be a more efficient way of supplementing the live meetings.
But I don't think it's ever going to replace live meetings.
Tony: No.
Steve: No because we need the interactions.
Nicos: I think the biggest thing EVM brings, it does put the patient in the center of attention and I think that' amazing by itself.
Steve: Yeah, no, when you bring the live patients here—I think that's an excellent point. When you bring the live patients here and people see then and see what their concerns are it just, doctors we do this all the time, the people that come here they take care of patients all the time, but you're right, sometimes we lose sight of what we're really doing.
Steve: What did we do different this year at EVM that we haven’t done so far?
Nicos: The industry session I think was a good idea, and both of us were going back and forward for a long time, but I'm glad this went through this year.
Tony: So that's like a town hall meeting where we have industry, that's going to be tomorrow of course, and open discussion between them and the attendees.
We have some preset questions that we're going to be asking them, that Steve put together, and then an open forum between the attendees and the industry.
Steve: Right, this again is a theme in trying to incorporate industry in a way they could really have a positive impact, because attendees don't get to talk to industry like this in a forum, they can talk individually, but let's see if industry, we try and get them to open up here.
This meeting, obviously, is a very casual meeting. We tell industry they cannot wear their usual shirt and ties or dresses that they wear, and they come in jeans. And I think it's going to help, and we see how it goes.
Steve: All right, next year. What are we thinking of for next year?
Tony: We're putting the program together right now? Are you putting us on the spot there, Steve?
Steve: No, I want to put myself on the spot also. Right. I want to give people some idea also about how we come up with these things. We kind of bounce different ideas off of each other.
Nicos: What about if we having actually solving a case and separating the people in different teams, and then come up with a solution, and everybody hears what every team has to say about the solution of how they solved the problem?
Tony: We can actually do that during the when session, put a case up-
Nicos: I think it'll be great.
Tony: ... and have each table come up with a solution.
Steve: That's not a bad idea. In other words, right.
Nicos: And hear different expertise, different backgrounds, and have couple cases.
Steve: Right. Solve this case.
Nicos: Yeah. Solve this case.
Tony: So I got another one.
Steve: Go ahead.
Tony: How about have industry bring a case? Talk about getting them involved.
Steve: Yeah.
Tony: So they present the case.
Nicos: No, no.
Steve: No? Why?
Nicos: Because every time we hear industry bringing something by themselves, it's biased, and everybody here is biased against it. Although I like industry participate, not in this way.
Tony: But it could be a case that they were involved with that there was a complication, or something …
Nicos: Usually it doesn't happen this way. He doesn't bring a case …
Tony: So they're not going to bring a case where something didn't go right.
Nicos: No, no, no. They're going to talk to their supervisors or top people and they’re going to selsct … bad business. No, stay out of this.
Steve: They're gonna get what I call industry speak.
Nicos: Yeah, yeah.
Steve: How about we get industry involved with solving a case? So in other words …
Nicos: Yes. This way, yes.
Steve: ... in other words, we have a case, say we present a case of DVT. And we have four or five industry here that treat DVT, okay? Balloons, catheters, mechanical thrombectomies, mechanical chemical. And we put them up on the panel. So the industry that has technology that treats DVT, we put them on a panel, we present the case, and we ask them to see what they would do.
Tony: But even the first one, if we pre-screen the cases and make sure that they're appropriate-
Steve: You're talking about industry's case?
Tony: Yeah. I mean, either way. I'm not having a problem.
Steve: No, I like this other thing.
Nicos: Yeah, I think that's much better.
Tony: That's right.
Steve: An industry clinical panel for a specific disease state. And then for superficial, we could have all the technologies that treat saphenous incompetence and varicosities.
Nicos: Yes.
Steve: That may be good, to get to see what they think. And then they could send their representative that they feel comfortable with. What do you think of that?
Nicos: No, I think that's the best way, because it is eliminates any bias, the people express their opinions, and all the parties are present.
Steve: All right, so I think we have solved the EVM problems. This year everything went well, and I think we have some good ideas for next year. And Nicos is almost finishing his beer.
Tony: Do we have the dates for next year?
Steve: Oh, yes, the dates for next year.
Nicos: Seven and eight.
Steve: It's June 7th and 8th at Englewood Hospital in 2019.
Tony: What are the Venous Symposium dates, Nico?
Steve: Venous Symposium?
Nicos: Venous is April 11, 13.
Steve: 11, 12, 13, and that, aside from this meeting, is the most interactive meeting in the world, isn't it?
Nicos: I think so, because, Steve, thank you for all your help, because you made the Venous Symposium a different meeting. Thank you.
Steve: No, we all worked together. So, yeah, all right, it's good. I think we got some good ideas. Let's wrap up, and we'll see what ideas come to fruition for next year. But good, guys. I think we solved our problems for next year.
Tony: Excellent.
Nicos: Thank you, Steve.
Tony: Thanks Steve.
Steve: Yes. On to dinner.
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The ATTRACT Trial—what are the practical takeaways?
Real, practical info for the venous specialist.
The episode is hosted by Dr. Steve Elias and we have the principal investigator on the ATTRACT Trial, Dr. Suresh Vedantham, as well as Dr. Bill Marston, Dr. Raghu Kolluri and Dr. Darren Schneider.
For a complete transcript of this discussion, visit the VEIN Magazine website.
One year later, what did the ATTRACT Trial NOT tell us, and where do we go from here?
If you like this discussion then you’ll love VEIN Magazine. Check out VEINMagazine.com for more info.
