The Coming of Age of Phlebology
The historic lack of interest in venous disease might be the greatest inconsistency in medicine. While it is one of the most common ailments in industrialized nations, consuming over a billion United States healthcare dollars per year, it is often neglected in medical education, research and even in practice.
Venous disorders include a spectrum of diseases ranging from trivial telangiectasias to disabling venous malformations, ulcers and fatal pulmonary emboli.
There is a general perception that venous disorders are unimportant because only a few cause death, and it is thought that the visible manifestations of venous disorders are simply a nuisance; however, venous disorders permeate every aspect of medical care. Every specialty and subspecialty must know something about the conditions that are present in their particular patient populations. Not until the recent recognition of Phlebology as an American Medical Association (AMA) recognized specialty, has there been a discipline solely dedicated to the diagnosis and treatment of venous disorders in the United States.
The recognition of Phlebology as a distinct area of medical practice, the creation of an academic fellowship program, a board certification exam, new insights into the causation of venous disease and introduction of endovascular treatments are evidence of a growing interest in venous disease.
Acute and chronic venous disorders affect up to 40% of Americans. The precise prevalence of venous disease is uncertain because, compared to other conditions, relatively little epidemiological research has been conducted in this area. Chronic venous insufficiency (CVI) is the modern term for what was until recently referred to as the post thrombotic or post phlebitic state. The term encompasses the several entities of venous edema, skin and soft tissue changes, and healed or open venous leg ulcers. In the remote past, it was thought that these entities were caused by previous deep venous thrombosis, which in turn had produced destruction of venous valves. As improved diagnostic methods were applied to limbs with CVI, it was found that a majority of these limbs had never had deep venous thrombosis, and a new term had to be invented.
Venous ulcers and venous thromboembolic (VTE) disease are responsible for causing significant morbidity and mortality correspondingly. The venous ulcer is the most serious manifestation of CVI. Venous ulcers are the seventh leading cause of disability in the United States and cause the loss of two million worker days per year. One percent of the population has evidence of an active or healed venous ulcer.
Venous thromboembolism has been a subject of much recent attention. Deep vein thrombosis (DVT) and pulmonary embolism affect an estimated 350,000 to 600,000 Americans each year, and the numbers are expected to increase as the U.S. population ages. In 2008, the American College of Chest Physicians (ACCP) published new guidelines in treating VTE and during the same year, the Surgeon General issued a Call to Action to reduce the number of cases of deep vein thrombosis and pulmonary embolism in the United States. In reference to VTE, the acting Surgeon General Dr. Galson stated, “Over the last several decades we have seen dramatic drops in the mortality rates from cardiovascular disease, the leading cause of death in this country. Yet challenges remain, and certain areas of medicine have not seen improvements. Additionally, as in any area of medicine, gaps still remain in our knowledge about how best to care for certain patient subpopulations, and further research is needed.”
Although much research still needs to be done, there have been great strides in the last decade. Less invasive endovenous treatment procedures such as, radiofrequency, laser and chemical ablation of incompetent veins have replaced open surgery. The increase in publications on comparative outcomes data has allowed physicians to practice by evidence-based treatments. Progress in the development of better diagnostic modalities and scientific research on causation has led to a new understanding of the pathophysiology and hemodynamics of venous disorders.
Due in part to these treatment and research advances, the subject of venous disease has gained a captive audience amongst American physicians, as in the rest of the world. European phleblological societies have been in existence for over 60 years and formal post-graduate training programs in Phlebology have long existed. Treatment of venous disease is no longer principally the domain of vascular surgeons. Practicing phlebologists include physicians from disciplines such as vascular surgery, general surgery, interventional radiology, dermatology and internal and family medicine.
The largest phlebologic society in the United States is The American College of Phlebology (ACP), was founded in 1985 in California. Now, the ACP has become the largest phlebologic society in the world, with over 2,500 members. Forty countries outside of the United States are represented in the membership. Another society dedicated to the study of both venous and lymphatic disorders is The American Venous Forum (AVF), which was founded in 1988. The development and new popularity of phlebological societies has allowed for sharing of knowledge between national and international experts.
In 2005, in response to a request from the ACP, the American Medical Association (AMA) recognized Phlebology as a self-designated sub-specialty of medicine. With the AMA’s formal acknowledgement, Phlebology is now identifiable as a primary or secondary focus of a physician’s work. In 2007, Phlebology was officially added to the list of American Osteopathic Association-recognized (AOA-recognized) self-designated areas of practice focus. The same year, the ACP was granted membership to the Specialty and Services Society of the AMA, giving the largest caucus in the AMA House of Delegates.
The first academic Fellowship in Phlebology was established in San Diego by vascular surgeon Dr. John Bergan, one of the pioneers of American Phlebology and medical director of the Vein Institute of La Jolla. Dr. Bergan was the principal founding member of the AVF, a past president-elect of the ACP as well as past president of the Society for Vascular Surgery (SVS). In 2008, the first American Phlebology fellow supported by the ACP matriculated at The Vein Institute of La Jolla.
In 2007, the American Board of Phlebology founded an independent specialty board to improve the quality of medical practitioners in phlebology as well as the care of patients with venous disorders. This was to be done through rigorous testing, improved education standards and reliable certification. In the spring of 2008, the American Board of Phlebology administered the first Board Certification Exam in Phlebology and a single honorary Fellowship was given to Dr. Bergan. Two hundred seventy six candidates from a variety of medical backgrounds sat for the exam. Candidates were required to meet specific experience based criteria to be eligible for the exam and this is still done.
San Diego is home to many practicing phlebologists, researchers and leaders in the field. The Vein Institute of La Jolla is collaborating with UCSD faculty researcher Dr. Geert Schmid-Schonbein and surgery resident Dr. Elizabeth Pocock on basic science and clinical research studies, with the goal of the advancement of the entire field of phlebology. Local research interests include genetics of varicose veins, biomarkers associated with venous insufficiency and VTE, and the development of medications and other treatments to ameliorate the cascade of events that lead to severe chronic venous insufficiency. The greatest obstacle to research remains the lack of educational grants and academic support as in other areas of medicine. In the near future, we hope to see more dedicated vein centers and the creation of more fellowship training programs. The world of medical science finally has acknowledged that venous disease is a common condition that requires specialized care. The medical specialty of phlebology has come of age in the United States. This has been referred to as ‘Cinderella has come to the ball.’