The 2023 AVF – Boston Scientific Translational Research Grant will award $85k over a period of 2 years for an original, translational research project in venous disease addressing one or more of the following:

Nonthrombotic venous obstruction
Venous thromboembolism
Superficial venous insufficiency

THE SUBMITTED RESEARCH PROJECT MUST ALSO ADDRESS THE FOLLOWING:

Human subject requirement: Patient-oriented research involving human subjects or with tissue of human origin
Delivery of appropriate care to appropriate patients and/or translate new clinical data into clinical decision making

The grant is open to residents and fellows in a training program and physicians who have completed their training within the past ten (10) years and have not previously received this award.

IMPORTANT: The 2023 AVF-BSCI Translational Research Grant will accept submissions from International as well as US-based researchers

Jobst Clinical Research Grant

Submission Deadline: Monday, October 15, 2022

The American Venous Forum is now accepting submissions for the 2023 AVF-JOBST Clinical Research Grant which will provide a $85,000 grant over two years for original, clinical research in venous diseases, lymphatic diseases, or lipedema with an emphasis on:

Prevention of disease and its progression
Diagnosis of disease
The science of management of the above conditions, especially with compression therapy.

THIS OPPORTUNITY IS OPEN TO:

Residents and fellows in a training program located in the United States
Physicians who have completed their training within the past ten (10) years and are currently based in the United States
Applicants who have not previously received this award
Nonthrombotic venous obstruction
Venous thromboembolism
Superficial venous insufficiency

Message from the Editor: What Room?

Steve Elias, MD
Editor-in-Chief, AVF Newsletter
Communications Councilor, AVF Board of Directors

When you feel the urge and you need to go, you have choices. But what to choose? Maybe the semantics or euphemisms confuse you. We have done a bad job. The myriad of names for the proper place to relieve oneself are confusing. Let’s go through a few and rate the monikers 1-10:

1. Bathroom

Clearly one can bathe in the bathroom in a bath. But many bathrooms in public places or restaurants don’t have a bath. There is usually a toilet and a sink. So why when it is that time of urgency do we go to the bathroom? You don’t want a bath. Rating: 5

2. Comfort Station

This may actually make sense. We’ve all experienced comfort after using the Comfort Station. So, I kind of get it. But the word comfort is somewhat misleading. Someone may think the comfort station is used for other types of comfort such as emotional and enter thinking that’s what they’re going to get. But as a name for what it’s supposed to be used for, not bad. Rating: 8

3. Washroom

Similar to the bathroom. A lot of euphemistic washing. One can usually wash in the washroom. There is almost always a sink in addition to the necessary accoutrement, the toilet. But the name implies that the main intent is to wash. To be clear, it is not. Rating: 6

4. WC (Water Closet)

This is the European connection. The WC implies that water is stored in this closet. Upon opening the door, one would expect to see cases of bottled water and may enter if thirsty. There are no water bottles in most water closets. But there is water in the toilets and sinks…not to drink. Rating: 4

5. Restroom

While this is best understood as the euphemism for needing to relieve yourself, it is still imprecise. Does anyone go to the restroom to rest? Of course not, we go to the restroom to do some important work, not rest. But in any case, this is the most used term. Rating: 9There are many other terms that have been used to inaccurately describe what the room is being used for: men’s room, women’s room, latrine, head, loo etc. For these you can fill in your own narrative. But in this issue of Vein Specialist we give you the narrative. We strive to tell you what the narrative should be. And this issue is mostly about venous imaging. Imaging for venous and lymphatic disease. Our contributors help you understand what is out there to evaluate venous and lymphatic disease. Ultrasound, venography, IVUS, CTV, MRV are discussed from different perspectives rather than the usual. Other new or novel imaging modalities are highlighted as well: lymphoscintigraphy and MR lymphangiography are examples of this. Thermal imaging is another example of a completely non-invasive technique. These all follow the title of this issue, The Better To See You With. But there are other really important articles in this issue of Vein Specialist including our all important annual meeting with the theme: One World, Many Voices: Our Future Is Together.

So while imaging options for venous and lymphatic disease are established and evolving and our future is together when researching the past the name Thomas Crapper inevitably comes up when speaking about bathrooms. He was an English plumber and businessman born in 1836 who founded the plumbing equipment company, Thomas Crapper and Company. He was an inventor who held 9 patents related to waste management. Urban folklore has promulgated the myth that the term for bowel relief comes from his name. Untrue. Most likely it came from Middle English origin and the Dutch word “krappen”, to pluck off and the Old French ”crappe”: siftings, waste or rejected matter. Thomas Crapper had the misfortune or fortune of becoming a plumber with the surname Crapper. Famous or infamous? You decide. And in this issue of Vein Specialist you can decide when you need what type of imaging to help patients. The better to see you with. Because if you can’t see it, you can’t treat it and you can’t help patients. Please read this issue of Vein Specialist whether at home, in the restroom, bathroom, WC, washroom or comfort station. No matter where, you’ll be able to better use the right imaging for the right patient. And when you flush and it all disappears, thank Thomas Crapper, the inventor of the toilet. Not the inventor of the euphemism.

One World, Many Voices: Our Future is Together

Free Upcoming Webinar

September 13, 2022 — 8:00 – 9:15 PM ET

Venous Stenting with Venovo: One and Done?

Iliofemoral Stenting & You: Tips and Tricks for Success in the Deep Venous Space – Sheila Blumberg, MD

Now or Later? Should We Place a Venovo Stent Following Acute DVT Thrombectomy with Aspirex? – Patrick Muck, MD

The Great Divide: To Cross or Not Cross the Inguinal Ligament with Dedicated Venous Stents? – Erin Murphy, MD

Back by Popular Demand! Venovo and its role in Complex Iliofemoral Reconstructions – Kush Desai, MD

Supported by an education grant from:

VENOUS2023: One World, Many Voices Our Future is Together

Mikel Sadek, MD
Chair, AVF Annual Program Committee

The Program Committee for VENOUS2023 has the vision to bring you the most comprehensive, compelling, and cutting-edge venous program to date. We had the humbling objective of manifesting this concept for the world of venous and lymphatic disease to best serve the American Venous Forum and its membership.

Our group deliberated how best to capture the vision for the upcoming annual AVF meeting. We carefully reviewed the feedback from last year’s attendees and shared our collective experience as members of the Program Committee. An animated discussion ensued.

Today, we are facing countless challenges and each one of us has been touched by events in our one world. Each one of us has a unique perspective based on our cumulative life experience. Each one of us has something to say, and we speak with many unique voices. Little is guaranteed in life except for death and taxes, as per Benjamin Franklin. Certainly, time is a constant, and with the known passage of time, we take stock of the present and look to the future. Sometimes we like what we see, and sometimes we don’t. Regardless, we push together even to Arthur C. Clarke’s Childhood’s End, or for us, to San Antonio, Texas, for VENOUS2023.

To that end, the theme for VENOUS2023 is:

One World, Many Voices: Our Future is Together

Clinical and Scientific Voices

First and foremost, the goal is to bring the highest quality clinical and basic science from all corners of the earth—and a sphere has many corners. The venous world has many voices including lymphatic, aesthetic, deep, superficial, thrombus…to name a few. Moreover, there will be an increased effort to incorporate expert clinician experience to augment the discussions on basic science, retrospective reviews, and randomized controlled trials.

International Voices

We are expanding on prior initiatives to incorporate an additional and more robust International Session. With the assistance of our industry partners, a novel International Industry Session will be presented, which has the potential for tremendous future expansion.

All Voices

We will be augmenting the Diversity, Equity, and Inclusion aspects to the program. We understand that this will always be a work in progress, but we aim to have a program that is closer to being representative of the population that we treat. This includes, but is not limited to, the program content, presenters, keynote presenters, moderators, and the audience.

We hope to bring these exciting aspects – and many others – to VENOUS2023 in San Antonio, TX, to build on the prior meeting successes, and to continue to lay the path for future growth. The vision is to become the central repository for the many voices of those involved in venous and lymphatic disease, because the way to move forward, for our patients and ourselves, is together.

Reflections and Advice from the 2022 AVF Grant Winners

Andrea Obi, MD
Chair, AVF Research Committee
Past Chair, AVF Digital Media Committee
Member, AVF Newsletter Committee

2022 Boston Scientific Research Grant Recipient

Where did you get your inspiration for this project?

I think a lot of research ideas come from clinical observations. For me, evaluation of chronic venous disease was a frequent consult during my clinical rotations. Venous disease restricts daily activities, is costly to the healthcare system, and requires extensive outpatient resources.

How far in advance did you start writing / working on the project?

My mentor Dr. Sachdev has been fantastic in bringing me up to speed with the data and results that were already established when I first began my dedicated research time. This gave me the opportunity to work on tying everything together and solidifying our specific research aims for the project a few months before the grant deadline.

What was the most challenging part of putting together the proposal?

The most challenging part of the proposal for me was to appropriately convey our ideas in a way that was easy to understand and follow, all while highlighting the translational aspects of it. The process of taking an idea from either ends of the spectrum and build upon it enough to form a clear and concise proposal was the most difficult to grasp.

What advice would you give to someone writing a Jobst or Boston Scientific grant this year?

It’s very important and valuable to be able to jot down all the ideas that come into mind and refer to them later on because you never know where and how they might fit into your proposal. I find the speech-to-text dictation functions on phones to be useful if I’m on a long drive; other times, I’ll simply type up what comes across my mind on the notepad app of my phone.

What was something unexpected that you encountered in the writing or submission process?

Budgeting was something that I did not have a lot of experience with; the process of appropriately allocating funds to each aspect of a project was a learning process. It really put in perspective the detailed planning that goes into setting up a project.

2022 Jobst Grant Recipient

Where did you get your inspiration for this project?

I was fortunate to receive a Marie Sklodowska Curie Research Fellowship in Galway, Ireland, during my residency. I shared an office with a postdoctoral researcher, Andrew Cameron, who recognized that there were numerous unmet needs in management of venous leg ulcers and was awarded a commercialization grant to develop technologies that improve the delivery of compression therapy. We experimented with a few different approaches to monitor pressure after a dressing was applied, but the most promising strategy involved the use of a remote pressure sensor that sits underneath a wrap or bandage.

How far in advance did you start writing / working on the project?

Technically, I started writing the grant about a month before it was due, but I had been working out a structure for the study for years prior.

What was the most challenging part of putting together the proposal?

The real challenge for me was the timing of the due date, which was approximately 1 month after I started my first faculty position. I had just moved, started my first job, was learning how to be an attending for the first time, had to learn a new hospital and prepare for the boards, and then had to write and submit a grant at a brand-new institution!

What advice would you give to someone writing a Jobst or Boston Scientific grant this year?

It’s all about the mentors. I started a new job where there really was no active venous research program or clinical practice. However, I have two amazing clinical partners/mentors who were able to help me put together a research plan that fits within our infrastructure and will hopefully allow us to answer some interesting questions. I also reached out to some of my mentors from training.

What was something unexpected that you encountered in the writing or submission process?

I had never written a grant that involved a clinical trial, so developing the study protocols has been a completely new experience. As I put together the grant various questions arose that I needed to address: how long it takes for a patient to complete a survey? Where do you put the patient if they come for an office visit, and you need to run tests? Fortunately, my mentors and our clinical coordinator team have run a number of clinical trials before and were able to steer me in the right direction.

Now Accepting Research Grant Submissions

BSCI Translational Research Grant

Deadline Approaching — August 15, 2022

$85k over a period of 2 years for an original, translational research project in venous disease addressing one or more of the following:

Nonthrombotic venous obstruction
Venous thromboembolism
Superficial venous insufficiency

International submissions accepted!

Submission Deadline: Monday, August 15, 2022

Jobst Research Grant

$85k over a period of 2 years for clinical research in venous diseases, lymphatic diseases, or lipedema with an emphasis on:

Prevention of disease and its progression
Diagnosis of disease
The science of management of the above conditions, especially with compression therapy

Submission Deadline: Monday, October 15, 2022

Ascending and Descending Venography: Adjunct Tool for Evaluation of Pelvic Venous Disorders and Deep Venous Disease

Amber Liles, MD, MPH
Interventional Radiology, University of Michigan

Noninvasive imaging studies such as venous duplex and CT venogram (CTV) are a mainstay in the assessment of pelvic venous disorders but may suggest multiple contributing etiologies for the patient’s symptoms, making treatment decisions challenging. For example, consider a 32-year-old female with multiple prior pregnancies presenting to clinic with asymmetric left lower extremity swelling, pelvic pain that is worse during menstruation, and painful vulvar varicosities with dyspareunia. CTV shows an enlarged left gonadal vein, bilateral para-uterine varicosities, compression of the left common iliac vein (LCIV) by the right common iliac artery, and vulvar varicosities without a clear source. This is not an uncommon scenario, and it is not always clear what potential pathology should be targeted for treatment. Should the patient undergo gonadal vein embolization, LCIV stenting, both, or neither? In these challenging cases, descending venography can be a helpful adjunct to noninvasive studies, allowing for more complete flow assessment of the deep veins of the pelvis.

For a comprehensive evaluation of pelvic venous disorders, we often start with left renal venography. A catheter is advanced in the left renal vein near the hilum, and venography is performed with Valsalva maneuver, assessing for both gonadal vein reflux and signs of renal vein compression (Figure 1). If there is concern for Nutcracker syndrome, evaluation of the left renal vein with intravascular ultrasound (IVUS) and manometry is performed. If the patient has gonadal vein reflux and renal vein compression without Nutcracker syndrome, repeat left renal venography and manometry with an occlusion balloon in the left gonadal vein can better estimate the effect of potential left gonadal vein embolization on renal vein flow.

The catheter is then advanced into the left gonadal vein and reflux into deep pelvic veins is assessed. If a tilt-table is available, reverse Trendelenburg positioning can simulate a more physiologic state and is preferred. The same is repeated for the right gonadal vein, usually originating directly from the inferior vena cava (Figure 2).

If gonadal vein reflux does not fully explain pelvic symptoms, further evaluation of the iliac veins is performed during the same procedure. The LCIV is assessed for external compression first with venography and then with IVUS if venographic signs of compression exist (Figure 3). Both internal iliac veins (IIV) are evaluated, assessing for reflux and cross-pelvic collateralization. In patients with perineal or gluteal varicosities, potential pelvic escape points may not be immediately apparent on IIV injection but may be more readily seen with a balloon occlusion catheter in the IIV. Additionally, direct injection of the greater saphenous veins to evaluate for an external pudendal contribution to varicosities can be helpful in select patients.

After either targeted or comprehensive assessment with descending venography, appropriate endovascular treatment can be rendered, often during the same procedure. In some patients, multiple underlying etiologies for a pelvic venous disorder may still be evident. In these cases, a multidisciplinary approach with potential staging of treatment is recommended

Similar to descending venography, ascending venography can be a helpful adjunct in the assessment of iliofemoral or femoropopliteal deep venous disease. Venous duplex studies, as currently performed in most practices, generally show vessel patency and presence of chronic thrombus well but provide limited assessment of global flow and usually no evaluation of the deep femoral vein. Consider this scenario: You’re performing iliocaval recanalization in a patient with IVC filter-associated iliocaval thrombosis. A duplex study shows chronic thrombus in the recanalized femoral veins. Three hours into the procedure, you’ve successfully recanalized the iliocaval segments but you realize that there is severe bilateral femoral and deep femoral disease, limiting inflow to the pelvis. In a patient with femoral disease on a preprocedural duplex study, ascending venogram provides additional information about severity of disease and flow dynamics between the superficial and deep system, allowing for better procedural planning and patient counseling.

At our institution, ascending venography is performed with injection of contrast into a small vein of the foot on a tilt-table with the patient in near standing position. Compression is often applied to the superficial venous system below the knee to allow for better filling of the deep veins. The evaluation includes assessment of not only the femoropopliteal segment but also assessment of the tibial veins, the deep femoral vein, and the greater saphenous vein. In practice, there can be a fair amount of discrepancy between venous duplex studies and ascending venograms regarding vessel patency; therefore, it’s important to know the strengths and weakness of both and use them as complimentary tools in appropriate patients.

Click images below to enlarge.

Figure 1. Left renal venography in two different patients. A, left renal venography shows reflux into a dilated left gonadal vein (arrow) and filling of the lumbar venous plexus (arrowhead). B, left renal venography shows flattening of the vein centrally with collateral flow through the lumbar plexus (arrowheads) but no reflux into the left gonadal vein.

Figure 2. Descending gonadal venography. A, right gonadal venography shows reflux of contrast into right para-uterine veins. B, left gonadal venography shows reflux of contrast into large pelvic varicosities with cross-pelvic collateralization to the right internal iliac vein. This patient went on to have bilateral gonadal vein sclerosis and embolization.

Figure 3. Left iliac venography shows extrinsic compression of the central left common iliac vein with left internal iliac vein reflux, cross-pelvic collateralization, and filling of an ascending lumbar vein.

Figure 4. Ascending venogram of the right lower extremity. A, normal filling of deep and superficial veins of the calf with eventual drainage into the normal popliteal vein. B, normal appearance of the popliteal and peripheral femoral veins (arrow). C, postthrombotic change of the femoral vein (black arrow) with preferential flow to the deep femoral (white arrow) and greater saphenous veins (block arrow). D, the right iliac veins are occluded.

Imaging for Lymphatic Disease

Brett Carroll, MD
Director, Vascular Medicine
Co-Director, Raynaud’s Center, Beth Israel Deaconess Medical Center

Options for the evaluation of the lymphatic system are increasing. Objective assessment of lymphatic function can be clinically useful, particularly for patients with unexplained limb edema. Classic physical exam findings (eg, Stemmer’s sign, distribution of edema, and certain skin changes) are very consistent with lymphedema. In cases with a clear prior lymphatic insult, such as regional lymphadenectomy or radiation, there is generally little need to perform lymphatic imaging to confirm the diagnosis. However, in patients with limb swelling without clear etiology on history or exam, additional lymphatic imaging can be helpful to objectively evaluate for the presence of lymphatic dysfunction.

Invasive lymphangiography, with direct cannulation of a lymphatic vessel or lymph node, had been the traditional modality for lymphatic assessment. Though features of slow transit or obstructive lymphatic anatomy can be visualized with invasive lymphangiography, it is now more commonly utilized in the cases of central lymphatic disease such as a chylothorax or chylous ascites. Nuclear lymphoscintigraphy has surpassed invasive lymphangiography as the current preferred modality for evaluation of lymphatic function at most centers (1). Protocols vary by institution. Injections of sulfur colloid bound to a nuclear tracer (most often technetium-99) are performed in the distal feet or hands, and the tracer is taken up by the lymphatic system. Transit of the radiotracer is serially imaged over 2 to 4 hours. Delayed or decreased uptake of the tracer in the inguinal or axillary lymph nodes is consistent with lymphatic dysfunction. The presence of channels can also be evaluated. Additional findings like dermal backflow are also consistent with lymphatic congestion and dysfunction. Nuclear lymphoscintigraphy offers high specificity and sensitivity. It has few adverse effects – there are rare allergic reactions and the injections can be transiently uncomfortable. Nuclear lymphoscintigraphy is an excellent modality to evaluate for overall lymphatic function, but lacks detailed anatomic evaluation limited by the granularity of nuclear imaging. Interestingly, there is overlap between venous and lymphatic disease with older nuclear lymphoscintigraphy studies demonstrating worsened lymphatic function in concordance with more severe chronic venous disease. Understanding this interplay is important when placing the findings of lymphoscintigraphy in the clinical context of patients with concomitant venous disease (2).

For a more specific evaluation of localized lymphatic dysfunction and anatomy, utilization of indocyanine green (ICG) lymphangiography is growing. ICG is a fluorescent dye that is injected intradermally in the hand or foot. It has rapid transit time within the lymphatics and allows for real time imaging of superficial lymphatic flow and anatomy. ICG maybe more sensitive than nuclear lymphoscintigraphy to detect early-stage disease (3). Additionally, there is clearer anatomic visualization of the superficial lymphatics and localized areas of dysfunction in a variety of patterns and severity. Such findings can be useful to guide both manual lymphatic drainage and target specific disease locations for lympho-venous bypass surgeries. ICG lymphangiography is generally only available at high-volume lymphatic centers.

Finally, there is growing utilization of magnetic resonance imaging (MRI) to evaluate lymphatic anatomy and the sequalae of the disease. MR lymphangiography involves injection of gadolinium intradermally and can demonstrate detailed lymphatic anatomy – how best to utilize such findings is still evolving (4). MRI is also valuable in evaluating the composition of the affected limb. Lymphedema leads to adipose tissue deposition and MRI offers the ability to differentiate fat from edema in the limb. Such an evaluation is instrumental in assessing appropriate candidates for liposuction and localizing the areas of adipose deposition to guide the surgical approach (5).

Depending on the clinical presentation, the evaluation of lymphedema may not require any imaging at all. However, in patients with unclear etiology to limb swelling or patients undergoing consideration for lymphatic surgery, a multimodality imaging assessment can be incredibly helpful in the diagnosis and management of lymphatic disease.

Figure 1. Nuclear lymphoscintogram in a patient with left lower extremity lymphedema. Left panel is image captured at 30 minutes demonstrating a lymphatic channel in the right lower extremity (red arrow) and dermal backflow (green arrow). The right panel is image captured at 2 hours with good uptake in the right inguinal lymph nodes (yellow arrow) with continued slow transit time and persistent

Vein Specialist Newsletter: Venous Imaging Update, July 2022

Vein Specialist

AVF Newsletter

Table of Contents

Membership Matters

Venous Imaging

International

Now Accepting Research Grant Submissions

Message from the Editor: What Room?

1. Bathroom

2. Comfort Station

3. Washroom

4. WC (Water Closet)

5. Restroom

One World, Many Voices: Our Future is Together

Free Upcoming Webinar

September 13, 2022 — 8:00 – 9:15 PM ET

Venous Stenting with Venovo: One and Done?

VENOUS2023: One World, Many Voices Our Future is Together

Clinical and Scientific Voices

International Voices

We are expanding on prior initiatives to incorporate an additional and more robust International Session. With the assistance of our industry partners, a novel International Industry Session will be presented, which has the potential for tremendous future expansion.

All Voices

Reflections and Advice from the 2022 AVF Grant Winners

2022 Boston Scientific Research Grant Recipient

2022 Jobst Grant Recipient

Now Accepting Research Grant Submissions

Ascending and Descending Venography: Adjunct Tool for Evaluation of Pelvic Venous Disorders and Deep Venous Disease

Imaging for Lymphatic Disease

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