By Julie Cardoso, RDCS, RVT, RPhS, Eduard Marmut

In the last decade, the diagnosis and treatment of venous disease has become one of the most rapidly surging practices in the field of medicine. A principal factor is the notably high prevalence for venous disease, particularly chronic venous obstruction and reflux—chronic venous insufficiency can be diagnosed in more than 27% of adults. Including asymptomatic reticular veins and telangectasias (spider veins)—which present as miniscule blue veins below the skin, a view you are likely to see firsthand if you look away from this page and down at your legs—this percentage rises markedly.

Compounding with the high prevalence, a progression in medical technology and, consequently, an increase in the convenience of venous procedures, have been additional factors. In the span of a decade, the practice has progressed from vein stripping to thermal ablation (e.g. endovenous laser, radiofrequency) and non-thermal ablation (e.g. occlusion catheter, sclerotherapy). These are minimally invasive procedures that feature less pain and complications, require less postoperative effort, and allow the patient to resume normal activity faster than vein stripping.

Venous ultrasound is an essential utility for both diagnosis and treatment of venous disease. Regarding diagnosis, it is used to identify the location, extent, and severity of venous pathology. Using this information, a plan for venous treatment can be constructed. During treatment, venous ultrasound allows the physician to obtain vein access as well as guide therapy via real-time visualization. As the pilot of a submarine would be unable to blindly navigate the waters without sonar technology, the physician would be unable to blindly navigate the complex venous system without ultrasound at their disposal. A prosperous venous practice in not possible without competent ultrasound technologists and physicians able to utilize their input, making venous ultrasound and the venous practice an inseparable package.

The rapid evolution of vein care

Unfortunately, while the venous practice experienced a rapid surge, corresponding venous ultrasound has fallen behind. Currently, a void exists in comprehensive education of venous ultrasound. The American Registry for Diagnostic Medical Sonography (ARDMS) has awarded credentials to over 90,000 medical professionals worldwide^[3]. Cardiovascular Credentialing International (CCI) recommends that “any professional working in the area of phlebology ultrasound” holds a Registered Phlebology Specialist (RPhS) credential.

For an active registered vascular specialist (RVS) or technologist (RVT), the qualification prerequisite for this credential is diagnostic ultrasound experience in venous disease. Although it would be impossible to determine the degree to which this qualification prerequisite serves as the exclusive obstacle to obtaining the recommend credential, it warrants consideration. According to the CCI database, out of the vast number of active RVS and RVT credential holders, only 257 individuals (less than 0.5%) are currently identified as active RPhS credential holders.

Comprehensive deficiencies in diagnostic sonography

Furthermore, being registered does not certify that a technologist has the knowledge to perform a comprehensive ultrasound for diagnosis of venous disease. Frequently, newly-registered technologists will know how to perform an ultrasound for diagnosis of deep vein thrombosis but not a complete protocol for reflux and venous obstruction. This is due to a significant deficiency in comprehensive education: the lack of emphasis on pathology in venous ultrasound training. In all facets, ultrasound institutions place a far greater emphasis on basic venous anatomy.

During the semester, trainees scan their fellow colleagues who ordinarily present as normal, having no trace of venous disease. During clinicals, students may be exposed to venous disease but are frequently supervised by technologists too preoccupied with patients to elaborate on the pathology, and are therefore statistically unlikely to hold the recommended ultrasound credential.

Even if one were to search outside of the institutions, classes that teach a complete protocol for reflux and venous obstruction are scarce due to a lack of organized ultrasound training nationwide. Basic venous anatomy is essential, but it is insufficient to make a successful venous ultrasound technologist. An effective technologist should be experienced in scanning the entire range of venous disease states.

Another significant deficiency in comprehensive education is the lack of advanced hands-on training. Indeed, one of the most frequent complaints expressed by technologists green to the venous practice is their lack of technical preparation for venous examinations and procedures. Newly-registered technologists have a solid grasp on basic maneuvering of the probe but, similar to their solid grasp on basic venous anatomy, this is insufficient.

Venous examinations have a high degree of complexity given the wide range of pathology and anatomic variability—venous procedures even more so. Both the technologist and the physician should be experienced with advanced techniques in patient positioning, image optimization, as well as ergonomics that improve efficiency and safety. Coordination is also crucial. A common language should be established between the professionals performing diagnoses and the professionals performing treatments in order to optimize clinical outcomes.

These deficiencies, among numerous others, have formed a void in comprehensive education of venous ultrasound. Ironically, it comes at a time when more technologists and physicians than ever are seeking training in this area. Thus, it was inevitable that someone would step in to fill this void. Dr. Nicos Labropoulos, a pioneer in the vascular world who has published over 200 papers, was the visionary behind the Ultrasound Hands-On Training (HOT) course. This course was constructed around five focal points tailored specifically to alleviate these deficiencies.

Introducing Ultrasound Hands-On Training (HOT)

The primary focal point, from which the course derives its name, is hands-on training. Obtaining an education via didactic lectures certainly has its merit, but the Ultrasound HOT course attempts to address the complaints of professionals regarding their lack of technical preparation. To achieve comprehensive education, Ultrasound HOT supplements didactic lectures with four hours of hands-on training per course day.

This portion of the course consists of varying ultrasound stations, each featuring a specific area of venous anatomy that attendees devote attention to scanning. One station allows the attendees to obtain ultrasound-guided venous access by utilizing the “Blue Phantom” peripheral venous ultrasound training model, which simulates human tissue and blood fluids and features superficial and deep vessels of different diameters.

The remainder of the stations do not feature an ultrasound training model, instead featuring patients with authentic venous disease. This encapsulates another focal point: live patient pathology. Patients with various patterns of reflux in the superficial and perforator veins as well as deep vein pathology in the lower extremities, abdomen, and pelvis are examined with appropriate positioning.

Ultrasound HOT selects patients ranging from healthy volunteers to those with varicose veins and skin damage, ensuring that almost the entire spectrum of venous disease is covered. The didactic lectures also heavily emphasize venous pathology, allowing attendees to reflect on the material as they cultivate their venous ultrasound technique on live patients.

Another focal point is monitoring and achieving tangible progress in ultrasound scanning. Ultrasound HOT makes it a priority to ensure the attendees witness step-by-step, benchmark progress in their ultrasound education. This is achieved by frequent assessment of the attendees’ venous knowledge. At each station, the attendees are not simply left to their own devices.

Each attendee is required to fulfill complex technical tasks, such as demonstrating a proper view of the ovarian vein or measuring an accurate reflux waveform, prior to moving to the next station. Prior to the didactic lecture portion of the course day, the attendees’ knowledge is also assessed through a written examination. After the examination is complete, every question receives elaboration—a reason is given for each correct answer and each incorrect choice.

The need for vein expert guidance

Ultrasound HOT believes that each of the previously mentioned focal points would achieve comprehensive education to a lesser quality if they were not guided by an expert in the venous ultrasound field. Throughout the course, the attendees are guided by Dr. Labropoulos, two vascular surgeons, and at least six technologists—each have extensive experience in regards to venous disease. At least one expert is present at each ultrasound station to take the attendees through every step of their ultrasound imaging. Any questions regarding anatomy, pathophysiology, diagnosis, treatment, and follow-up are promptly answered.

Simultaneously, issues with the clinic organization, marketing, billing, and expansion are discussed when applicable. In order to optimize comprehensive education, Dr. Labropoulos supervises the stations to ensure that all participants have learned the key concepts. Dr. Gasparis, another expert well-known in the vascular world, is present to share examples from numerous clinical cases, in regards to both their diagnosis and management.

The final focal point of Ultrasound HOT is intensive interaction. Ultrasound HOT sets aside the one-sided lecture method utilized all too often in the institutions, and makes each portion of the course a two-sided exchange. Interaction between the instructors and attendees during didactic lectures is encouraged, as the instructors will often pause to exchange questions and comments.

Similarly, hands-on training is implemented in order to encourage interaction between the patients and attendees. This is achieved in a relaxed environment where the participants have an opportunity to consolidate their knowledge. An enduring knowledge bolstered by interaction, instead of an upload of information, is what Ultrasound HOT strives to provide its attendees.

Ultrasound HOT found its humble beginnings in 2014 as a single venous ultrasound training course. Since then it has grown into a biannual, three-day event (one day devoted to arterial testing) hosted by world-class experts in the venous field. Ultrasound HOT continues to closely follow all areas of venous imaging and procedures worldwide, ensuring that no new developments are overlooked and that current techniques, criteria, and protocols are taught together with the most recent advances.

During each meeting, controversial matters are discussed and solutions to topical issues are offered. In the near future, Ultrasound HOT plans to increase its attendees, frequency, and accessibility. However, the ultimate goal of Ultrasound HOT will never change: to enhance training through a rigorous and interactive program, and ensure the void we currently have in comprehensive education of venous ultrasound is permanently filled.

References:

1. Bradbury, A. W., A. D. Lambert, R. B. McLafferty, and C. V. Ruckley. "Chapter 12: Chronic Venous Insufficiency Presentation." Handbook of Venous Disorders; Guidelines of the American Venous Forum. 3rd Ed. (2009). American Venous Forum. Web. <www.veinforum.org/patients/vein-handbook.html>
2. Coleridge-Smith, P., N. Labropoulos, H. Partsch, K. Myers, A. Nicolaides, and A. Cavezzi. "Duplex Ultrasound Investigation of the Veins in Chronic Venous Disease of the Lower Limbs- UIP Consensus Document. Part I. Basic Principles." Eur J Vasc Endovasc Surg 31(1) (2006): 83-92.
3. "Discover ARDMS: Earn Your Ultrasound Technician Certification." American Registry for Diagnostic Medical Sonography. Web. <www.ardms.org>.
4. Intersocietal Accreditation Commission. “IAC Standards for Vein Center Accreditation: Superficial Venous Evaluation and Management.” (2015): 21-3.
5. Lurie, F., A. Comerota, B. Eklof, R. Kistner, N. Labropoulos, J. Lohr, W. Marston, M. Meissner, G. Moneta, Peter Neglen, D. Neuhardt, F. Padberg, and H. Welsh. "Multicenter Assessment of Venous Reflux by Duplex Ultrasound." J Vasc Surg 55 (2012): 437-45. Print.
6. Ombrellino, Michael, and Lowell S. Kabnick. "Varicose Vein Surgery." Semin Intervent Radiol 22(3) (2005): 185-94.
7. "Registered Phlebology Sonographer (RPhS)." Cardiovascular Credentialing International. Web. <www.cci-online.org/content/register-phlebology-sonographer-rphs>.