Despite the prevalence of venous pathology and the demand for effective treatments, there is a significant unmet need in venous disease.1 General lack of venous education and understanding within medical education and training has certainly been one of the main reasons for current practices. This void in education extends to professional practice and careers, making it less likely for physicians to incorporate new knowledge or skills into their practice because it is simply easier to stick with the familiar. Current emphasis on productivity in healthcare, and lack of incentive for physicians to take on the added challenge of learning complex skills that are poorly remunerated further exacerbates the problem. Furthermore, a lack of collaborative culture across specialists keeps physician skills in silos and prevents growth in a shared understanding of venous disease.

Successful collaborative models do exist. Driven by clear intentions to best serve patients and improve outcomes, multidisciplinary inter- and intra-institutional collaborations, serve as examples of the clear benefit of such a model. Stroke teams, pulmonary embolism response, acute coronary syndrome, acute/critical limb ischemia teams are just a few examples that have succeeded to improve the delivery of comprehensive high-quality care in a collaborative manner.2,3,4,5 The undeniable benefit of adopting such an approach in the venous space would serve to foster the growing diversity and collaboration of venous specialists as seen at major society venous meetings. However, more works remains to be done in order to translate these relationships at institutional levels.

In this paper we highlight the benefit, to our patients and trainees, of cross-specialty collaboration. Our collaboration aims to improve the educational and access gaps in venous disease through joint case sharing, despite system and financial pressures that may disincentivize such joint work. In other clinical settings, similar approaches have shown promise in improving patient outcomes, with data showing the impact on health outcomes in systems that function with multidisciplinary teams.6,7 Patients benefit most from collaborative partnerships across medical specialties, and this approach may ultimately lead to better venous care for those in need.

Comprehensive venous care necessitates a distinct understanding of the venous system, which constitutes a separate aspect of the circulatory system. Despite the overall high burden of venous disease, although there are not data to compare, personal experience in medical that education and training in the field of cardiovascular medicine have traditionally concentrated on the pathophysiology and therapies for the heart and arterial system with often less emphasis on venous disease.

The burden of venous disease representing varicose veins, as reported by the Edinburg vein study is estimated to effect 40% men and 32% in women.8 The progressive nature of venous disease is not insignificant with an estimated 32% of patients progressing from CEAP classification C2 disease if they have saphenous reflux and up to 19.8% in its absence.9,10 Venous thromboembolism (VTE) including deep venous thrombosis (DVT) and pulmonary embolism (PE) is the 3rd most common cardiovascular condition and the most common cause of preventable hospital related death with 100,000 deaths annual in the United States, and associated treatment costs totaling more than $10 billion dollars annually.8,9,10 As life expectancy increases and risk factors persist, the burden of advanced venous disease will increase.

The prevalence and progression of chronic venous disease has an increasing adverse impact on Quality of life (QOL) scores such that patients with ulceration have similarly poor QOL scores as patients with congestive heart failure.11 It is important to realize that chronic diseases that affect QOL, ultimately impacts mental health and in many ways CVI patients can be thought of as chronic pain patients, in whom rates of depression are prevalent in up to 24% of patients, which is as much as double of the general population.9,11,12 Importantly, treatment of venous disease positively impacts and improves QOL scores – reflecting the imperative role of a venous specialist and team in the healthcare community for the growing demand in venous disease.

The field of venous care is currently experiencing significant innovation and investment as reflected by growth in device development and research. This presents an exciting opportunity to actively participate in the advancement of a rapidly evolving field. Venous disease is complex, progressive and a high burden disease which can only benefit from multidisciplinary collaborations which enhance patient management and works to improve outcomes.

Venous disease management is multifaceted, involves complex considerations, and access to advanced therapies. Patients seeking treatment for venous conditions often encounter challenges in finding healthcare providers who can offer comprehensive evaluations and effective venous treatments. Lack of access to comprehensive care can result in recurrence in sub optimally treated diseases. Patients with more severe chronic venous insufficiency (CVI), such as those with ulcers, often rely on wound centers for extended periods and experience delays in proper venous evaluation.13 Similarly, individuals with pelvic venous disease frequently spend years visiting multiple providers before someone considers venous issues as the potential cause of their symptoms. Even if a venous source is recognized, locating a local expert in venous care capable of providing the most suitable therapies remains a significant challenge for these patients. Furthermore, patients with thrombo-occlusive venous disease are often diagnosed in an emergency care setting and have poor outpatient follow-up to ensure adequacy of treatment provided and monitor for progression of disease. Therefore, considering the complexity of venous disease, long-lasting chronicity, and significant multifaceted disease burden, educating both the medical community and the general public about venous disease management and therapy options is crucial. By establishing an organized collaborative team within a venous center model, one can enhance patient care outcomes and decrease overall costs to our health care system.14

What does a comprehensive venous care team look like? There is certainly no predefined "model platform" for a venous care team. Venous disease management does not exclusively belong to a specific specialist but rather a diverse group of specialists, each with exceptional skills and shared passions for an area of medicine often overlooked. The significance of adopting a multidisciplinary approach to forming our institutional team became evident through participation and engagement at national meetings and various venous educational forums. There is more to learn from one another than if we remain in silos and these collaborative relationships provide an excellent opportunity to impart a broader range of skills onto our trainees and younger colleagues.

In 2021, following the availability of the COVID-19 vaccination and the allowance of more elective/non-urgent procedures, we started to jointly review patients with pelvic venous disease, both acute thrombotic and chronic occlusive. The start of our collaboration also coincided with the FDA recall of two dedicated venous stents.15 Our early cases really set the stage for how we would approach future cases, not just from a case planning and management standpoint, but also from a logistical and administrative standpoint. The lessons we share continue evolve and grow in our collaboration, which is patient care driven.

We focused our initial concerted efforts towards patients with extensive multi-level chronic venous occlusive disease (prior failed recanalization-reconstruction attempts) which often involved chronically indwelling IVC filters. Our mutual consensus was that this subset of patients would derive the greatest benefit from our combined skill sets in complex endo-venous procedures.

The patients most likely to benefit for intervention were also those with clinical indications such as venous ulceration, lifestyle limiting venous claudication, and chronic pelvic pain of venous origin lasting longer than 6-12 months.

Lengthy discussions with the patients and family regarding expectations are a critical part of the process and these lay out the framework to help the patient understand their disease process and therapeutic options. Such discussions include risks and benefits of the procedure (if they are candidates) based on our current knowledge on outcomes for venous stenting. We emphasize to the patients the importance of medical management, compliance, post procedure follow-up and expectations including, the possibility of a failed attempt and possible staged interventions.

It is imperative to understand the extent of disease as well as the anatomic suitability to successfully carry out complex endo-venous reconstruction. Therefore, each patient is discussed in a multidisciplinary fashion, ahead of the intervention, including pre-procedural imaging and work up. From these discussions, access approach, positioning and tools/devices are decided upon with significant lead time to assure all options are available on the day of intervention.

During the planning stages, imaging plays a crucial role in thoroughly assessing venous inflow and outflow, which are essential to understand in order to achieve successful outcomes. The following diagnostic imaging is generally obtained prior to complex venous intervention:

Computed Tomography (CT) abdomen and pelvis with or without intravenous (IV) contrast: This provides valuable anatomic venous detail and is particularly useful in evaluating for other sources of compression or pathology. From this we can also get information regarding venous outflow

Bilateral lower extremity venous insufficiency studies: This diagnostic test provides detailed information relevant to access vessel options and venous inflow. It also serves as a baseline waveform directionality evaluation and can be used to compare with surveillance post-procedural imaging.

Preoperative diagnostic venography (typically performed through a bilateral popliteal approach): Here we obtain more detailed information on anatomy, collaterals, and feasibility of intervention. Evaluation of profunda vein inflow is limited based on typical access points and direction of flow.

The importance of venous inflow evaluation cannot be underestimated.16 Some more challenging cases can have extensive collateralization at the groin on venography which creates uncertainty regarding stent landing zones and inflow. In these more challenging cases we perform a pre-procedure duplex ultrasound of the femoral-profunda vein confluence and common femoral vein and obtain waveform and diameter measurements (the latter in sagittal and cross-sectional views). This dedicated ultrasound serves as a confirmatory study regarding appropriate venous inflow and instills additional confidence in proceeding with the reconstruction.

Before each procedure, patients undergo laboratory work up, type and screen, and blood bank is notified to place blood on hold. Our procedures are typically performed under general anesthesia, either in the hybrid operating room or in the interventional radiology angiography suite. In selected cases we combined fluoroscopy and CT reconstruction to guide intervention. An arterial line and foley catheter are placed.

Individual operator device preferences, such as wires, catheters, sheaths and dedicated venous stents, are readily available. Following case planning discussions, case specific devices generally get special order, as needed, ahead of time and following case planning discussions. Having this lead time is very important as not all devices are stocked, and many require sometimes to ship and arrive.

Our interventional techniques often require three access points with jugular and bilateral popliteal or mid-femoral vein based on patient anatomy. We consider Intravascular ultrasound (IVUS) the gold standard and is always used on procedure day to assess lesion location, length, landing zones and post stenting endoluminal result.

In cases where removal of chronically indwelling IVC filter is needed, we prefer endobronchial forceps technique. In these cases, we have covered aortic cuff stents readily available in case of hemodynamically unstable rupture. Although in our experience adequate tamponade and hemostasis of a focal perforation site can be achieved with a 20 mm or 22 mm prolonged balloon occlusion. Long shaft balloons are the most versatile when working from the femoral/popliteal location at time of stenting in order to reach the IVC at the renal confluence. Although not routinely required, the FDA approved IVC laser retrieval device CavaClear™ (Philips, Amsterdam, Netherlands) is selectively on standby depending on how long the IVC filter has been in place and when there have been prior failed attempts. Depending on how challenging the IVC filter is to remove, and the amount of time and radiation used, we may decide to stage the removal and reconstruction when feasible. Less commonly and less desirable, we will endotrash and exclude the IVC filter by stenting across it.

In cases of long segment IVC chronic occlusions, we start off with standard fluoroscopy guided wire and catheter techniques for recanalization. When this is not successful, we consider transitioning to cone beam bean Cone beam CT reconstruction and sharp recanalization.

At the completion of all recanalization cases, no protamine is given, ace wraps and sequential compression devices (SCD) are placed on each leg and initiated on the way to recovery. Patients are observed in the post-anesthesia care unit (PACU) and generally observed with an overnight stay. Lovenox® is given upon arrival to the PACU and then continued for 1 month. To avoid delays or gaps in anticoagulation, we have found it useful to order/authorize Lovenox® pre-procedure and have it covered/approved and ready to initiate on the day of surgery. In occasional cases where it is financially prohibitive, DOAC with loading dose would be the alternative. Literature on usage of anti-platelet therapy remains controversial, but our current practice involves placing patients on clopidogrel for 3 months.

At one month, the patients are seen for follow up with bilateral lower extremity and IVC/iliac vein duplex. So long as duplex and clinical exam show improvement, the patient is then transitioned to a twice daily DOAC. Clopidogrel is switched to aspirin 81mg daily at 90 days. Clinical and imaging surveillance continues at 3, 6 and 12 months and annually thereafter. Collaborative case discussion and updates continue during the follow up period.

As physicians, it is important to consider financial infrastructure and reimbursement policies when starting collaborations that manage complex cases that requiring significant time commitment yet are tied to low productivity values. Local organizational infrastructure can play a crucial role in how these collaborative partnerships may or may not be fostered. In our system, radiology, and vascular surgery function as separate departments, with neither specialty sharing joint privileges.

This traditional model affects financial and reimbursement disbursement as procedural services are generally tied to the site of service (i.e operating room versus IR suite). Additionally, the current structure of venous coding, billing and reimbursement does not account for complex interventions, whether collaborative or not. Unlike certain complex open arterial cases, coding for venous procedures, as far as we know, do not allow for 62 (joint) or 82 (assist) modifiers. Our primary objective was to provide a much-needed service to patients therefore coding and billing became secondary and did not deter our efforts. Nonetheless, it was important to understand this in order to assure that our time and efforts were appropriately shared and distributed. Our existing operational framework involves alternating billing for each case to ensure equitable distribution of productivity and reimbursement. By no means do we consider this an ideal model but has provided a mutually agreed upon process to navigate a dated reimbursement paradigm.

Importantly, commitment and support from both the physicians and health care systems are essential for the success of these collaborative relationships to succeed.