IR’s Role in the Venous Arena: Past, Present, and the Evolving Training Paradigm

Amish Patel, MD and Robert A Lookstein MD FSIR FAHA
Icahn School of Medicine at Mount Sinai
New York, NY

When we asked prominent interventional radiologists around the country about their involvement with venous disease, the responses varied, spanning the spectrum from involvement with central venous access to superficial vein care. This response highlights the breadth of involvement of interventional radiologists in treating venous disease; most offer basic hospital-based services while many are also involved in advanced comprehensive venous care. Some provide common therapies like venous ablation or sclerotherapy while others are at the forefront of venous care, performing complex IVC filter removals, venous reconstructions, and vascular malformation treatments.

In the past, the field of interventional radiology struggled to secure its identity in several arenas and venous disease was no different. The origins of this difficulty can be traced back to how an interventional radiologist was originally trained. “When I did my fellowship, the training was limited to acute venous thrombolysis and some chronic venous stenting.  We didn’t do anything with superficial venous disease,” says Dr. Rusty Hofmann, Chief of Interventional Radiology at Stanford School of Medicine in Palo Alto, CA. However, in the decade or so since then, the practice of interventional radiology has changed greatly. “Caring for the patient begins at the time of the consultation with medical management and, only if needed, procedures; seeing our patients through the entire management of their problems has become the standard of care for most interventional radiologists working in all areas of interest, including veins,” says Dr. Neil Khilnani, Fellowship Director at New York Presbyterian Hospital-Weill Cornell Medical College in New York, NY. This approach is characteristic of the success of interventional radiology’s comprehensive approach in many areas besides veins, including areas such as oncology.

As the practice of interventional radiology changed, so too did its training. “My experience during fellowship was mostly technical and very little clinical,” says Dr. Geogy Vatakencherry, Program Director at Kaiser Permanente Los Angeles Medical Center. Restricted by a relatively short 1-year length, interventional radiology fellowships produced effective proceduralists, but ineffective clinicians. Now an attending, Dr. Vatakencherry says his own fellows actively participate in his hospital’s clinics, including those related to venous diseases.

Fellow participation in a vein clinic is not unique. Dr. William O’Connell, interventional radiology fellow at Northwestern Memorial Hospital in Chicago, IL, says his “hospital’s vein clinic was essential to his exposure to endovenous treatment.” Dr. Khilnani agrees and dedicates a month of his fellow’s education to the vein clinic. He believes that “establishing a full service consultative outpatient vein practice and offering all aspects of high quality care is essential . . . [fellows] need to know how to manage the large volume of patients at the lower end of the disease severity spectrum in addition to the PE, acute DVT, and chronic DVT patients whom are they are caring for in our hospital practices.”

Dr. Deepak Sudheendra, Assistant Professor at the Hospital of the University of Pennsylvania in Philadelphia, PA, anticipates “increased emphasis on the education of venous procedures in fellowship. Currently, [some] training programs do not focus on venous disease, especially venous insufficiency. There is an art and science to venous disease.”

At the higher end of severity, namely PE and DVT, Dr. Khilnani believes that success goes beyond training. “Getting faculty to become leaders on their multidisciplinary committees at the hospital is key,” he says. Likewise, Dr. Nilesh Patel of the Central DuPage Hospital in Winfield, IL, credits his large role in the treatment of venous disease to his section’s “very strong relationship with the emergency department, internists, and primary care [physicians].”

Just as a close relationship with potential referring physicians offers a great benefit, so too does a close relationship with other physicians occupying the endovenous arena. “Our vein clinic is a collaborative joint practice with interventional radiology and vascular surgery,” says Dr. Parag Patel, Fellowship Director at the Medical College of Wisconsin in Milwaukee, WI. “We advocate for collaborative multidisciplinary treatments across our service lines. This has been effective in offering our patients the best treatments for venous disease.”

While these multifaceted approaches have helped our field realize its identity in the treatment of venous disease, the recent recognition by the American Board of Medical Specialties of interventional radiology as a unique medical specialty and the creation of an interventional radiology residency will have an even more profound effect. This training paradigm will expand the interventional radiology trainee’s clinical and technical exposure to many clinical areas, including venous diseases. Unlike training of the past, the expanded residency will have the capacity to accommodate enhanced expectations for both more in-depth understanding of diseases and their natural history as well as allowing IRs to develop enhanced clinical and technical skills. These expectations will surely beget specific, detailed standards that all trainees must meet to be board certified. In essence, say goodbye to the technically adept, but clinically deficient interventional radiologist.  

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