Call for Formalized Pathways in Vascular Medicine Training: JACC Review Topic of the Week

Presidential address: The modern vascular specialist--surgeon, clinician, and interventionist.

As we begin the new year, the societies representing vascular medicine and phlebology embrace new opportunities while facing the existing challenges of growth and recognition. This issue of Vascular Medicine is devoted solely to venous disease, a core area of vascular medicine training. As the field of phlebology also relates to venous disease, the question arises, what is the relationship between vascular medicine and phlebology and are vascular medicine specialists also phlebologists? If you search a most trusted source (and yes I say this with sarcasm), Wikipedia, for the definitions of vascular medicine and phlebology you will find that vascular medicine, aka angiology, is the “medical specialty which studies the diseases of the circulatory system and of the lymphatic system, i.e., arteries, veins and lymphatic vessels, and its vessels” while a phlebologist is a “medical specialist in the diagnosis of disorders of venous origin.” 1,2 If you agree with these categorizations, it would seem that vascular medicine specialists indeed are also phlebologists. However, some might argue that the depth and knowledge of the phlebologist surpasses vascular medicine core training in venous disease. With this background, let’s take a closer look at key areas that may help distinguish vascular medicine from phlebology. First, who are practicing vascular medicine specialists? In general, these include physicians (MD or DO) who have completed internal medicine training and have sought additional formal fellowship training or practice-based experience in vascular medicine and are eligible to sit for the American Board of Vascular Medicine certifying examination. 3 This group includes a substantial membership of cardiology trained specialists including interventional cardiologists. In contrast, providers practicing phlebology come from numerous specialties and training pathways including general and vascular surgery, family medicine, internal medicine, dermatology, obstetrics and gynecology, emergency medicine, interventional radiology, cardiology and of course, vascular medicine. Most have practice-based training in venous diseases or training through vascular surgery, and can choose to certify through the American Board of Venous and Lymphatic Medicine (ABVLM), formerly known as the American Board of Phlebology. 4

Supervised exercise therapy (SET) is the cornerstone of medical therapy for symptomatic peripheral artery disease (PAD). Despite the efficacy of SET, initial reports following the 2017 Centers for Medicare and Medicaid Services (CMS) reimbursement decision indicate low SET uptake, referral, and completion. Vascular medicine specialists are key to the success of such programs. We examined rates of SET referral, completion, and outcomes in a health system with a robust SET program during the first 5 years of CMS reimbursement. A retrospective chart review of patients with PAD referred to SET between October 1, 2017 and December 31, 2022 was conducted. Patient demographic and medical characteristics, SET indication, referring provider specialty, SET participation (e.g., exercise modality, number of sessions, treadmill prescription), and outcomes were abstracted. Descriptive statistics, t-tests, and multiple linear regression were used to examine the sample, evaluate outcomes, and explore outcomes by relevant covariates (i.e., age, sex, referring provider specialty). Of 5320 patients with PAD, N = 773 were referred to SET; N = 415 enrolled and were included in the present study. Vascular medicine and vascular surgery specialists were the two primary sources of referrals (30.6% and 51.6%, respectively). A total of 207 patients (49.9%) completed SET. Statistically significant and clinically meaningful improvements were observed in all outcomes. SET referral and completion rates are low in the 5 years following CMS reimbursement, despite the advocacy of vascular medicine specialists. SET is effective in improving patient functional capacity and quality of life. Additional efforts are needed to increase both SET availability and referrals as part of comprehensive treatment of PAD.

Incorporating Vascular Imaging Training into the Cardiology Fellowship Curriculum

To study the interobserver variability between a cardiologist and vascular medicine specialist in the screening of the abdominal aorta during transthoracic echocardiography (TTE). Consecutive patients, > 55 years of age, underwent abdominal aortic imaging following standard TTE. Two cardiologists and one vascular medicine specialist performed a blinded review of the images. Interobserver agreement of abdominal aortic size was determined by the correlation coefficient and paired t test. Interobserver reliability for each cardiologist was assessed using Bland-Altman plots. Ninety patients were studied. The mean age of patients was 72 ± 10 years and 48% were male. The mean aortic diameter was 2.31 ± 0.50 cm and 5 patients (5.5%) had an abdominal aortic aneurysm (AAA). The additional time required for the abdominal aortic images was 4.4 ± 0.9 min per patient. Interobserver agreement between the 2 cardiologist interpreters and the vascular medicine specialist was excellent (P > 0.05 for all comparisons). On Bland-Altman analysis of interobserver reliability, the 95% lower and upper limits for measurement by the cardiologists were 84% and 124% of that of the vascular specialist. The assessment of the abdominal aorta during a routine TTE performed by a cardiologist is accurate in comparison to that of a vascular medicine specialist. In selected patients undergoing TTE, the detection rate of AAA is significant. Additional time and effort required to perform imaging of the abdominal aorta after TTE is less than 5 min.

Section II - Transthoracic Echocardiography

Background and Objectives: The clinical relevance of “corona phlebectatica” and the management of risk factors for recurrence of venous ulcers in patients with chronic venous disease may be variable based on vascular specialists in different geographical areas of Italy. The aim of the present survey is to evaluate the management of patients with chronic venous disease by vascular specialists in different areas of the national territory. In particular, this involves ascertaining the clinical/prognostic relevance attributed to the presence of the “corona phlebectatica” as well as to the management of risk factors related to recurrence of venous ulcers. Materials and Methods: The web-based survey aimed at vascular medicine specialists with particular interest in venous disease. A questionnaire was developed, based on 12 questions, in relation to clinical assessment, risk factor management, and therapy in patients with chronic venous disease. Results: Almost all of the specialists involved actively participated in the survey, declaring that they personally manage chronic venous disease overall. There was a strong agreement in the prognostic consideration attributed to the presence of “corona phlebectatica” and to the management of risk factors for venous ulcer recurrence, regardless of the different geographical areas of interest. Conclusions: Accordingly with the results of this self-assessment survey, the skills and experience of the specialists involved appear to be of a good standard, both in the clinical evaluation and in the management of the progression of chronic venous disease. However, the need to reach more cultural insights into the correlations between chronic venous disease and risk factors correlated with disease progression emerges. Moreover, there was the need for a greater and tighter overall clinical control of a patient with chronic venous disease, also in relation to the presence of comorbidities.

Cardiologists have gained considerable experience and expertise in the diagnosis and management of coronary artery disease. Interventional therapy has now become a standard cornerstone of therapy for coronary artery disease, and endoluminal stents are being used in over 70% of all coronary interventions. Diagnosis and treatment of peripheral arterial disease (PAD) has recently gained momentum. In the past, vascular surgeons and interventional radiologists were the classic caregivers for PAD patients, with an interest in deciding between intervention or no intervention. In addition, the majority of PAD patients had few medical resources since many medical specialists did not view PAD as important for many reasons, such as: (1) few effective options for the management of patients with PAD, (2) PAD did not represent a significant health hazard to patients, (3) few patients actually suffered from PAD, and (4) patients did not view PAD as a significant limitation in their quality of life. Over the past decade, a new medical specialty, vascular medicine, had dedicated itself to the comprehensive management of these complex patients. Vascular medicine specialists are predominantly internists and cardiologists. These physicians not only view PAD as an important medical issue, they understand the increasing prevalence of PAD among the "baby-boomer" generation, the shortened life-expectancy of patients with PAD, and the marked reduction in the quality of life among PAD patients. Most importantly, vascular medicine physicians are now aware of several effective options for patients with PAD.

Assessment of Duplex Ultrasound Carried Out by the Vascular Surgeon After Locoregional Anesthesia for Preferred Arteriovenous Fistula Access

Vascular specialist response to medicare evidence development coverage advisory committee (MEDCAC) panel on peripheral artery disease of the lower extremities.

Two Decades of Progress in Vascular Medicine

Max Nieuwdorp is an internist, endocrinologist and vascular medicine specialist at Amsterdam University Medical Centers. He chairs the Diabetes Center there and is chief of the Department and Laboratory of Vascular Medicine.

In this observation, we report an unusual presentation of a pilomatricoma in an 8-year-old girl who was initially referred to the department of vascular medicine for diagnosis and care of a suspected mixed lymphatic venous malformation. The lesion on her left shoulder presented as a giant bluish-purple red solitary mass, painful and rapidly growing, measuring 7 cm in anteroposterior diameter. This mass did not present the typical characteristics of a lymphatic venous malformation but exhibited warning signs of malignancy on clinical examination and imaging. The diagnosis of pilomatricoma was reached by fine-needle aspiration biopsy of the mass, showing mummified "ghost" squamous cells and a granulomatous inflammatory reaction stroma with scattered multinucleated giant cells and no sign of malignancy. Complete surgical excision associated with plastic surgery was curative. Diagnostic and management approach to skin lesion in childhood is subject of great concern for health care professionals, including dermatologists and vascular medicine specialists who may be confronted with this atypical presentation of one of the most common causes of superficial neck masses in children.

Vascular Medicine Patient Information Page: What is a vascular medicine specialist?

Current Opinion in Lipidology was launched in 1990. It is part of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of lipidology is divided into six sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editors for this issue. SECTION EDITORS Kausik K. RayKausik K. RayProfessor Ray received his medical education (MB ChB, 1991) at the University of Birmingham Medical School, UK. His clinical training in Cardiology was conducted in Birmingham and Sheffield and he obtained his MD (2004) at the University of Sheffield, UK, for work on the interleukin 1 system and its influence on endothelial function, inflammation and coronary disease. He pursued a postdoctoral fellowship at Harvard Medical School, USA, under Professor Braunwald and Professor Cannon and finally an MPhil in epidemiology (2007) from the University of Cambridge, UK. A Fellow of the American College of Cardiology, the European Society of Cardiology, the American Heart Association and the Royal College of Physicians, Kausik Ray is also a member of the British Cardiovascular Society and the European Atherosclerosis Society (EAS) Consensus Panel. Professor Ray has been the national lead investigator, served on the committees or been PI for several major medical trials, including T-EMERGE 8, SOLID TIMI 52, SAVOR TIMI 54, DAL OUTCOMES II, DAL-ACUTE, ODYSSEY OUTCOMES, DECLARE TIMI 58, CAMELIA TIMI 61 and THEMIS. Professor Ray's research interests have focused on large scale population studies and trials for the prevention and reduction of coronary events. He has investigated the early benefits of high intensity statin therapy, the advantages of more/less intensive glycaemic control, and the risks/benefits of aspirin therapy. These have influenced American Heart Association/American College of Cardiology and European Society of Cardiology guidelines. His work on statins and diabetes risk led to a global label change for statins by the FDA and EMEA. He continues to investigate the role of lipids, lipoproteins, diabetes, inflammation and thrombosis, and coronary events. Professor Ray has published his research in numerous journals including the New England Journal of Medicine, Lancet, The Journal of the American Medical Association, Archives of Internal Medicine, Circulation, the Journal of the American College of Cardiology, and the European Heart Journal. Currently, Professor Ray leads the EAS familial hypercholesterolaemia (FH) Studies Collaboration and the first global FH registry as well as being the principal investigator for the TOGETHER study assessing vascular risk in 250 000 individuals in London. G. Kees HovinghG. Kees HovinghDr G. Kees Hovingh (1974) is an internist, vascular medicine specialist and staff member at the Department of Vascular Medicine at the Academic Medical Center (AMC) of the University of Amsterdam, the Netherlands. He received his medical degree at Groningen University, the Netherlands, in 2000. During his study, he spent one year (1999) at the department for organ transplantation at Massachusetts General Hospital, Boston, USA. In 2001, he started his PhD under supervision of Prof. dr J.J.P. Kastelein, head of the Department of Vascular Medicine at the AMC. During his PhD, several studies were performed which ranged from clinical intervention trials to basic-research, including large scale sequencing of candidate genes. During his thesis, Dr Hovingh focused on studies to unravel the molecular defects underlying HDL disorders and studies addressing its consequences for atherosclerosis progression. Dr Hovingh has identified mutations in a large number of pivotal genes in lipid metabolism. In 2005, Dr Hovingh started his residency in internal medicine at the AMC. Between 2007 and 2008, he was trained in molecular medicine as a post-doctoral fellow in the Genetics Department at Harvard Medical School, Boston, USA. Under the supervision of Profs. C.E. Seidman and J. Seidman he worked on a novel subgenome capture method for next generation sequencing. Dr Hovingh's position at the AMC and the department of Vascular Medicine allows him to devote his time to science, and in particular to scientific guidance of PhD students. Moreover, his clinical position does enable him to identify patients with extreme lipid phenotypes. He is head of the clinical trial unit and is (co-author) on 130 peer reviewed manuscripts.