If you know Mel Rosenblatt, then you know he’s outstanding in the field of phlebology. One of his colleagues expresses it best:
“Mel's passion for clinical medicine knows no bounds. His energy is limitless and his diligence when it comes to patient care keeps him working long hours toward the goal of treating disease and relieving suffering. Mel is always ready to lend a helping hand - whether it's agreeing to present a talk or sharing his expertise regarding a particular patient's issue. He is a creative problem solver and inventor, but never wants to claim the credit, brushing off his contributions as not as important as others'. His incredible intellect makes him sought after as a speaker, advisor, and thought leader. His honesty, even when the truth is difficult to speak, truly distinguishes him and makes him an invaluable part of any team and a truly special doctor.”
We sat down to ask a few pointed questions that we think are best answered by a man with his extraordinary expertise. Here’s what he had to say.
VM : What role should interventional radiology take in the education of practitioners that treat vein disease?
MR : Phlebology is a specialty that overlaps with many other specialties. It attracts physicians that have strong interests in particular aspects of venous disease. Yet, no one specialty embraces all knowledge that a phlebologist needs to know. Interventional radiologists have always been on the forefront of endovascular treatment. This is particularly true in the treatment of complex venous disease which requires fluoroscopic image guidance. These include DVT thrombolysis, venous stenting, endovascular treatment of pelvic venous reflux and treatment of venous and lymphatic malformations. In these areas, the interventional radiologist often has the most experience. These pathologies are an integral part of the venous curriculum.
A well rounded phlebologist needs some level of training these area and the interventional radiologists with venous expertise is best suited to provide it.
VM : Who needs "Phlebology Boards"?
MR : Since no one specialty gives trainees exposure to all aspects of phlebology, there is clearly a need to create a phlebology curriculum and a test that confirms a candidate’s knowledge of the material. As an example, a vascular medicine fellowship provides extensive training in clotting disorders and their medical management, while this may be completely absent in an interventional radiology or vascular surgery fellowship. Thus, it is essential that a process be put in place that ensures that any educational gaps be filled.
Participating in the board exam process demonstrates a physician’s dedication to the specialty and his or her willingness to fill these gaps and be armed with all the knowledge necessary to treat the patient in the best possible way. In some specialties, the phlebology board will be critical to the future of their practice. Cardiothoracic surgeons who have elected to dedicate their practice solely to phlebology are in a precarious position when it comes to board recertification. Recertification will require them to have performed a certain number of cardiothoracic surgical procedures which they may not have accomplished. Thus, they may be in a position where they will have no board certification at all. This could have an impact on hospital privileging and third party reimbursement. A board certification in phlebology would allow them to be board certified in the field with which they practice. In the future, phlebologists from other subspecialties may also find themselves in this precarious position. This is one of the many reasons why this board is so important to the physicians who want to practice in this specialty. Currently, the phlebology board is not recognized by the American Board of Medical Specialties, but this recognition is the goal – a goal that will benefit everyone in the field of phlebology.
VM : Should there be “Centers of Excellence” that treat pelvic venous disease issues, or can the average phlebologist do this?
MR : The treatment of pelvic venous disease can sometimes be very complex, but it does not always have to be treated in a complex manor. Many patients with pelvic venous disease present with just moderate sized upper thigh varicosities and minimal symptoms. These varicosities can be effectively treated with injection sclerotherapy alone. This is certainly within the expertise of the average phlebologist. When this treatment fails to alleviate symptoms or does not eliminate the varicosities, then a more aggressive approach is likely needed. This aggressive approach requires unique physician expertise and the use of fluoroscopic imaging. These imaging tools and expertise are not typically found in every phlebology practice. Thus, centers of excellence in treating pelvic venous disease can be very important. When it becomes clear to the treating phlebologist that a patient is not responding to basic therapy, it is important that they know where the patient can be referred. Without this knowledge, the patient may be told that they are untreatable and have no choice but to continue to suffer from this issue.
VM : What venous pathology do we need better techniques to treat?
MR : Of all the different venous pathology, the most difficult to treat is the venous malformation. Patients with this pathology often have severe pain associated with the malformation or have severe chronic venous insufficiency. The pain is only improved when the malformation is eradicated. Unfortunately, eradicating a venous malformation is very difficult.
The typical detergent sclerosant agents are often not fully effective and recurrence is common. ETO H is a very
powerful and more effective sclerosant, but it can cause severe tissue injury and nerve damage. There is a great
need for a sclerosant that can reliably occlude the abnormal vessels while sparing the surrounding soft tissue. The need for a safe effective sclerosant is not just for the treatment of venous malformations. Good sclerosants are needed for the treatment of superficial varicosities. The currently available sclerosants are effective, but their use is associated with local venous thrombosis, occasional skin discoloration and the formation of new smaller veins; these all tend to resolve over time, but therein lies the problem. The time that it takes for patients to realize the full cosmetic and clinical benefits of sclerotherapy are too long. The ideal sclerosant would not cause any of these inflammatory or thrombotic events. Ideally, after the material is injected, the vein would spasm, disappear and remain permanently occluded with little, if any, inflammatory process. Developing a drug that can accomplish this would have a profound effect on the treatment of superficial venous disease.
by Jane Acciacca