Chapters Transcript Video Expanding Your Practice to Include Deep Venous Disease Treatment, Featuring Dr. Mikel Sadek and Dr. Lowell Kabnick Expanding Deep Venous Treatment to Your Practice. On behalf of the BD Peripheral Interventions clinical and education team, it is a pleasure to welcome you to this program on expanding venous treatment to your practice with a focus on deep venous disease. It is an honor to introduce the course director and moderator, Doctor Kabnick. Doctor Kabnick, a fellowship trained vascular surgeon at Mount Sinai Hospital in New York City, started the Bain Center of New Jersey in 1986, and in 2007 became the director of the New York University Vein Center. Doctor Kabnick is a world-renowned surgeon teacher who provides a patient-centric Educational approach to vein care, enabling the creation and improvement of many of today's most advanced non-invasive vascular surgery techniques. Doctor Kabnick is a recognized as an international authority on the diagnosis and treatment of venous disease. His interests lie in superficial and deep venous interventions. Thank you very much for that outstanding introduction. It gives me great pleasure to introduce Doctor Michael Sadik now, who is an outstanding vascular surgeon who I've known and worked with many years at New York University. His vascular surgery interests are focused in treating peripheral arterial and venous disease. Doctor Sadik is the director of the NYU Langone Vein Center and co-director of the NYU Limb Salvage and Restoration Center. He is also an associate professor at NYU Grossman School of Medicine, and associate director of vascular surgery residency and fellowship. He received his medical degree from the University of Medicine and Dentistry in New Jersey and completed his residency in general surgery at the NYU Langone Medical Center in 2011 and vascular Surgery Fellowship at the NYU Langone Medical Center in 2013. Doctor Sadik has been an invited presenter at many prestigious vascular and venous conferences and has authored numerous publications and peer-reviewed journals and book chapters. Welcome, Doctor Sadik. Integrating deep venous therapies to existing endovenous practice is a growing discipline that is attractive to multiple specialties. The physician expanding his or her practice should have a working knowledge of venous anatomy and pathophysiology, treatment alternatives, risks, benefits, and indications. Duplex ultrasound. Both diagnostic and intraoperative, interventional procedure skills, and post-procedural patient management. This session will discuss practice considerations for practices exploring and expanding therapeutic treatment options to include deep venous disease management. Michael, this is your first question. As you know, being a vascular surgeon, there are many areas of interest that we can develop our skill sets and develop our practices too. Please share your professional journey as a vascular surgeon and the influencing factors that led you to specialize in venous disease, specifically care management for patients with deep venous disease. Well, thank you so much, Doctor Kavnik, for the, uh, the, the insightful and always challenging to answer questions. Thank you also to BD for the opportunity to be here and to, and to have this, uh, and this discussion and hopefully to be able to uh give something back to some extent. Um, so, in terms of the, the influencing factors that perhaps led me to narrow the focus of, of my, my practice on, on deep venous disease. I think, you know, there are a few, there's, there are a few ways to look at this and perhaps, uh, uh, almost a three-pronged approach. First, there, there was a clear clinical need, you know, I, I had started out early on as a junior faculty at the Bellevue Hospital, which is our local city hospital. And I would keep seeing poorly responding ulcerations, patients that were just told nothing can be done. They all had lymphedema de facto, you know, and, um, And, and it was just a sinking feeling until you realize that perhaps you could look a little bit deeper, no pun intended, and perhaps do a little, a little bit more in terms of an evaluation and potential treatment. So I think that's sort of the first, uh, you know, prong of the, of the sort of the three-pronged approach to this. Uh, second, I thought I had an intellectual interest. I, I realized that early on, I think, uh, at least in my training, that There's a lot that we know, but so much that we still have yet to learn. And it, it, it, it was very synergistic between my research interests and pursuing, um, My clinical interests in, in deep venous disease that, uh, you know, I kind of started tailoring my career, uh, towards that pathway. And then third, I think as with anything else in life, a lot of things are based on internal factors, but a lot are, are, are based on external factors. And eventually, your mentors play a big role in, in, in, in what you end up choosing to do. You like to emulate, um, your mentors to some extent and full disclosure, you're, you're clearly my mentor in Venous disease, uh, you know, low. And so, I think that, you know, when you see a positive influence that, that you wanna emulate, that, that always has a huge impact on, on how you steer your career. Uh thank you, uh, Michael, uh, thank you for the, the plug on that. And it's kind of interesting that you looked at Both arterial and venous disease, and when you mastered superficial venous disease, there was another frontier. And that frontier was deep venous disease, and you're spot on to say that. Our knowledge base really needs to be developed with that. We're still learning about deep venous disease and what we do. As you reflect, what are a few interesting experiences and learnings you would like to share specific to integrating deep venous and superficial. Venous patient management into your practice. That, that's, that's, that's a wonderful question, and, and a very loaded question. And, and I think a lot of what um You know, Any little bit of advice that I can impart or anything that I've noticed so far in my, uh, ear early career or fledgling career, uh, I'll, I'll try to impart what I can. Um, having said that, a lot of it is still anecdotal, and as you said, the, the evidence is still accumulating. Um, I think one of, uh, at least in my mind, one of the things that I do when I'm trying to integrate the two superficial versus uh deep venous disease versus looking at both is to assess the level of severity that the patient presents with. That's a very Nebulous and loaded concept because there are different ways to look at it. There are simple ways, perhaps people are familiar with the CAP classification or just the clinical component where you can look at people with cosmetic varicosities versus patients who have venous ulcerations. And then there are patient reported ways to look at disease pathology and Then there are clinician viewpoints. Um, and they, they can be discordant. But perhaps patients at the milder end of the spectrum, you might start with the focus on superficial venous disease and creep towards looking into deep venous disease if the treatment is inadequate. Patients at the very severe end of the disease spectrum, and again, you have to take all three into consideration, the clinician's perspective, the patients, and just, you know, the objective criteria that are out there, uh, based on the variety of classification systems that we use. Um, but at the, at the more severe end, you might look at deep venous disease first and then Follow that with superficial venous disease, or you might even de facto know you're going to treat all of the above in the more severe patient, or at least interrogate all of, all of the above. And then somewhere in the middle, you have to play it by ear and really. I think that's, that's where the patient experience comes into play. And it's not really a patient-reported outcome, but maybe patient-reported symptoms um are probably the biggest driving factor. Not all edema is the same, for example. And so, a patient who is truly debilitated from their condition. You might choose to pursue deep uh pathology first versus superficial. So, I think that's the first thing that I do. I try to get a clinical picture, then I start looking at the ultrasounds and further studies, uh, and I'll use the severity of the clinical picture to guide the subsequent, um, evaluation and then treatment. There are many ways to obtain the Venus knowledge and skill sets required for a deep Venus practice. What education resources do you suggest for onboarding if your practice is beginning to integrate and offer venous disease management? For example, professional societies, proctors, industry, and all of the above. I, I developed an interest in, in venous disease and deep venous disease, and superficial and perforators and all of the above early on, because I felt that knowledge was lacking in the field, and training was also lacking in the field. Um, You know, I'm, I'm a vascular surgeon by training, as are you, um, as are many of us, but, but there are many others out there who might be interventional radiologists or dermatologists, or, or, or phlebologists with a, with a medical background or, or any number of combinations and permutations. Um, And even in, in our field, and that's the one that I can speak to in, in vascular surgery, training in venous disease is limited. Um, I think some of the best resources are, are the national meetings, the big ones in the international meetings, such as the Union of International Phlebology that, that, that you're, you know, soon to be ahead of and The American Venus Forum and, and various other tremendous societies that are out there because you get current and in addition, There's a recognition that the, um, the training is limited in, in, in our current paradigm. And so many of them offer ongoing training courses. I have learned a lot and, and been able to also Teach a lot, uh, in conjunction with industry. So industry is another tremendous resource, especially since they provide the devices that are integral to, to these treatments. In the end, you're gonna have to start doing the procedures and you're going to need a proctor or somebody close at hand who can assist initially, whether it's in the same department or a parallel department that you're working with. For example, if, if you work closely with the interventional radiologist and they have somebody with experience. And you happen to be a vascular surgeon with limited experience, that might be a reasonable way to start. But, um, I think that having a, a mentor close at hand who can Who can proctor you initially and then, and help you, help troubleshoot when the going gets tough. I think, I think that's sort of the last, last aspect that, that helps with the education. So, let's assume that you're now out practicing. And you've learned superficial venous disease, and you have that down. You know, the indications, etc. and now you're starting to explore deep venous disease. How would you do that? Now, you know out there that there are centers for deep venous disease, you know that there are some scientific papers that, that are out there. How, how would you suggest that somebody that's entering the deep venous field would start to acquire the knowledge? I think the first thing is that if you really wanna treat venous disease, you have to delve into the deep venous world. And if you're not gonna do it yourself, you have to be very closely affiliated with somebody who will do it. Um, because you just cannot treat the patient completely. It's not to say that every patient's gonna get a stent, but you need to know when to evaluate for it. And you need to know when to treat in conjunction with treating the superficial venous disease. It's just the only way to treat the patient completely. And, and, and not leave things hanging and not leave patients underserved. Um. Clearly, you need to have some familiarity or start to gain some familiarity with using fluoroscopy. That's, that's gonna be the next big thing. So, if you had zero experience, you're gonna have to do some kind of proctorship. And, and some kind of radiation-based, um, uh, lecture series to, to, to be able to function with the, with the C arm and, and to do fluoroscopy. Cause that's the one big difference between, um, Uh, uh, you know, deep venous work and, uh, and superficial venous work, which is all ultrasound-based, which is its own incredibly challenging skill set to build up. But we've moved on from that. They're already, this, this, uh, hypothetical that that individual is, is already facile with superficial venous disease. Um, So once you've done that, Then I think You probably need to observe cases and, and, and there probably has to be a requisite number of cases that are observed in, in some sort of training or proctorship program. Um, you, you, you probably ought to. Get some familiarity as part of that proctorship, perhaps an associated lecture series or didactics related to standard wire catheter skills for, for, um, venography or angiography in general. And then, once you've completed those, you need to do a certain number of Proctor cases. Um, and again, this is somebody who has not had any endovascular skill or training in their particular kind of medical, uh, residency or, or fellowship. Um, But I think that's the way you, you would need to get started. So when you started, what were the unexpected challenges? And continued resolution. Well, I think the first big unexpected challenge was that Um, there, there was a lack of a desire to, to understand the emphasis needed to look into deep venous disease. That's still the case. There, there are still many patients with venous ulcers, with You know, pigmentation, lipodermatosclerosis, advanced venous disease that's subjectively and objectively debilitating to the patient from whichever angle you look at it. And It's just not thought to look at the deep venous system initially. It's chalked off to something else, or perhaps they're just getting UU boot uh treatments for their venous ulcers, and they, they just keep coming back or the patient is too old to, to, you know, they're too old to look into the deeper venous system. So I think that, that's the first big um Unexpected challenge, uh, you know, that I encountered and, and that, as you said, I'm still encountering to some extent. Although it's getting better. That, you know, just to recognize the importance of looking deep, especially when, when the disease is more advanced. Um, So that's, that's from that side. The technical side is, you know, treating veins is not the same as treating arteries. And it's a little bit of a rude awakening when you're, when you're doing it. So that, that's sort of the other side of the coin completely. Um, the wire catheter techniques are very different. Somebody who's very slick at Repairing aneurysms or opening arteries in the legs might not have a full sense of what's going on with the venous system. Or the nuances, um, What about the challenges of where you do the procedure? So that's, that's another, another great point, um. You know, early on in my surgical training, everything was done in the hospital. Eventually, and, and We, we had a, a good opportunity to add an outpatient facility to our, uh, to our practice. Um, And, and I think Early on, particularly when you're learning, and, and, and perhaps it was the case very early on in the experience with endothermal ablation where patients had their procedures done under general anesthesia. You kind of need a more controlled setting. So I think it's, it's not a terrible idea for the first few cases until you develop a certain level of comfort and skill set. To perhaps do things in, in a hospital setting if that's available. Now, if it's not an outpatient setting, you can pretty much take care. Of virtually everything. I would say the very challenging complex recantalizations that go from the level of the hepatic vein down to the femoral vein, you probably ought to restrict those, you know, those challenges to the hospital setting. Um, but short of that, Most everything can be done in the outpatient setting. Now, a lot of things come into play. The wires, the catheters, the devices, all of that works out really nicely. Um, and, and those challenges were overcome relatively quickly. The bigger challenge is how to Manage the patient in the peri-procedural period. I think patients learn that, you know, clinicians learn the technical skill very quickly. But then there's still the patient. The patient, you know, and there are things associated with venous stents, in particular, that are idiosyncratic to, um, to deep venous treatment. And that's potentially post-procedural pain or intra-procedural pain, uh, when, when you're treating patients with balloon venoplasty and stenting. Um, Managing anticoagulation on an outpatient setting. Um, And then Managing them so that You can have a relatively short, um, recovery period, and, and they can still go home and then managing their post-procedural pain at home. I, I think those were some of the big challenges that, that have taken a little bit of time to iron out and, and make a little bit more seamless over time. Yeah. So, so I'll, I'll speak, I'll speak to the equipment portion specifically. I allude, and, and, um, at least just to try to give a focused answer to this question. Um, at, at the very least, you need access to fluoroscopy. So whether it's a sea arm or, um, Or a, or a hybrid room. If you happen to be at, at, at, at an institution that offers that. Um, there are also fixed imaging systems in certain outpatient settings. So, regardless one way or the other, you need access to, to fluoroscopy. Um, for these types of procedures, it may be beneficial to also have access to an anesthesiologist. Now, that's not equipment, that's personnel. But, but sometimes early on, Particularly with deep venous interventions, um, working with an anesthesiologist can be helpful. Unless you have your own robust experience administering anesthesia. One way or the other, you're going to need good sedation for certain components of the procedure. Um, Then in terms of equipment, capital equipment, you, you need what I would think on the back table is similar to a standard angiographic procedure, and that's maybe where some similarities, the few similarities that exist lie, um. Between arterial work and venous work. You need your typical back table prep, iodinated contrast. Perhaps the ability to use uh carbon dioxide contrast if you really need to in certain patients. Although again, delve into the complex patients later, not early on. So perhaps just patients, uh, you know, without renal failure, uh, you know, when, when you're starting out. Um, So, you know, iodate, iodinated contrast, the standard syringes that come with that, um, a certain basic set of wires and catheters. Typically, uh, a standard set would be a, a stiff wire to exchange devices over. Um, and then, Uh, a hydrophilic wire, the standard being a glide wire, to get through lesions that might be slightly more challenging. You'll then need sheets, you'll need um. Balloons, and you will need stents. Ultimately, that's what's in the armamentarium, at least for the basic, um, um, treatment of venous disease. And so, just to keep in mind, if you're used to doing arterial work, and now you're gonna switch to venous work, venous work tends to go through larger systems. So you're talking about 9, 10, and 11 French sheath systems. And balloons and stents that go through that rather than the smaller things that we use in arterial work, which typically goes from 4 to 4 to 7 friends. So you have to plan your wires, your catheters, and your tubes accordingly. And, and, uh, in particular, the intravascular ultrasound that we use. Goes through an 8 or 9 French system depending on, on what you're using. So that's, that's, I think the capital equipment that, uh, that you need. So if I were to go into deep venous disease, Are you telling me that I need to know the book knowledge, the procedural knowledge, and how to manage the patient? Intra-op, pre-op, intra-op, and post-op. I would say that absolutely. I mean, that's, that's one way or the other, you need to accumulate that knowledge. Now, how you accumulate it depends a lot on what your prior experience was. I think, I think, you know, people come in to deep venous disease. Often with different backgrounds entirely. Even within vascular surgery. Forget about other specialties. One training program may have Given, placed a huge emphasis on the medical side. Of the treatment of the, uh, of, of, of the treatment of vascular disease in general. Another may have just Been operating, doing open aortic surgery all day. And, and they had limited knowledge. So, so one way or the other, you do need exactly what you said. You need, you need all of those aspects to have the complete picture. I, I think, you know, the toughest thing about treating venous disease isn't necessarily putting in the stent, especially if it's for the non-thrombotic lesion. I think most practitioners who delve into that, find that in the non-thrombotic case, at least, post-thrombotics is another story. That, that is legitimately challenging. You may need all sorts of tools and tool kits that are out there to, to, to manage those patients. And, and, and that is still, uh, uh, you know, a, a very vibrant area of research. But, um, but You can go ahead and do a procedure in 15 minutes and throw the stent. In there, but you, you do need to know to begin with pre-procedurally, whether it was the correct thing to even um assess for in that patient. And once you've, once you've determined that, um, whether at the time of the procedure. Whether it's, whether you're interpreting your images correctly, whether it's the venogram or the intravascular ultrasound or, or the combination of the two, and, um, and how to manage them. And then post-procedure, how to do it. If somebody has a history of DVT for example, You might want to manage them a little bit differently. Uh, again, Doctor Sadik, thank you for sharing your knowledge, expertise, and considerations for physicians exploring and expanding deep venous treatment to existing practice. On behalf of BD and me, Paul Cabnick, thank you for your time in pursuit of further education. For questions or clarification, please do not hesitate to reach out directly to a member of the BD Peripheral Interventions, Education and Training team. Thank you. Published July 16, 2026 Created by Related Presenters Mikel Sadek, MD Vascular Surgery View full profile Lowell S Kabnick Venous Specialist View full profile
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