Incorporating Phlebology into a Cardiology Practice

by Doreen Saltiel, MD

“Doc, we’re ready.” I get up, in scrubs, wearing a scrub cap I received as a gift; I get a mask and enter the procedure room. The sterile table is set: micropuncture kit, sterile bowl with sterile saline, catheters, syringes, 4x4s, towels, etc. The patient is prepped and draped using standard sterile technique. I approach the patient, say hello and ask, “Do you have any last minute questions?”, “Who is here with you today?”, and finally, “Are you ready?” He answers the questions and says, “Doc, let’s do it!” Everybody is gowned and gloved; I gown and glove and we are ready to start! No, it’s not a cardiac procedure. It is a great saphenous vein EVLT. Yes, it is strikingly similar to a diagnostic/interventional cardiology procedure. This is why cardiologists are the perfect physician group to perform endovenous procedures.

Why Cardiologists?

From a training perspective, a cardiologist’s training includes anatomy and physiology of the vascular system, both arterial and venous systems; expertise in noninvasive diagnostic testing; cardiac and peripheral arterial, as well as venous testing modalities; expertise in invasive and interventional treatment modalities; safely cannulating arteries and veins, as well as expert catheter and wire manipulation skills in both simple and complicated vascular beds. Additionally, cardiologists already take care of a significant percentage of patients with venous disease.

Phlebology is a cardiologist’s best kept secret! The cardiologist who chooses to become a phlebologist will have more control over his/her life. No early morning rounding, no waiting until it’s your time in the lab, no on-calls, no long nights into the wee hours of the morning, and no longer being exhausted. You have little hospital time, a fun officebased practice and procedures, as well as more time off!

For those cardiologists still wanting the adrenaline rush from acute interventions, there is acute deep system work that has been neglected and is in need of our expertise. There is so much more to acute venous thrombosis than anticoagulation. There are acute deep venous thrombosis (DVT) and pulmonary embolism (PE) interventions as well as chronic DVT thrombolysis and stenting. For patients, these procedures dramatically change the course of events, including improved short and long-term morbidity and mortality.

Issues to Consider

However, before you say “sign me up,” you need to consider and plan for the following issues:

  • Dedicated staff with a very specific knowledge base
    • Ultrasound. This includes at least one dedicated venous sonographer who is either already certified in venous disease or has enough general vascular experience so he/she can be trained to be a venous sonographer (an RVT credential does not guarantee an expertise in venous scanning). Venous scanning is more than a “DVT sweep.” The DVT exam is the tip of the iceberg.
    • Nursing. A dedicated venous RN who understands the disease and all the nursing issues associated with caring for venous patients to include pre- and post-procedure patient needs. You may also want a medical assistant who understands venous disease and can assist with procedures.
    • Scheduling Coordinator. In addition to scheduling patient procedures, this individual precertifies all procedures and checks the medical necessity coverage criteria for each patient’s insurance plan. This is a moving target!
  • Equipment
  • Ultrasound machine: Dedicated good quality ultrasound machine that is available for venous scans and procedures.
  • Bed/Stretcher: This needs the capability for reverse Trendelenberg and Trendelenberg as well as height adjustment.
  • Endovenous equipment: This will depend on the minimally invasive modality chosen.
  • Miscellaneous equipment: Phlebectomy hooks, suture, 4x4s, surgical light, etc.
  • Autoclave: This will be practice specific, whether or not you are hospital based.
  • Dedicated space: A procedure room large enough to accommodate the necessary equipment and personnel. We use the procedure rooms for venous duplex scans on clinic days.
  • Marketing: Other than your own patients, most patients are self-referred with the majority having real disease that you can treat. In addition to a website, I recommend direct marketing to patients such as TV, radio, health fairs. and other local events.
  • Segmenting Cardiology from Phlebology: This will be important as you market to other providers, some of whom will be cardiologists. You need to separate the two practices such that you get the venous referrals without being threatening to other cardiology practices.
  • Insurance Coverage: This is also a moving target in venous disease. Medical necessity guidelines are constantly changing as are reimbursement. However, knowing the medical necessity guidelines and taking the time to articulate the patient’s specific need for the procedures usually assures payment.

Phlebology is the natural next evolution for cardiologists. Our knowledge base and technical expertise make us the right physician group to join our surgical colleagues in decreasing the current high morbidity and mortality associated with acute and chronic venous disease. We have all the tools in our toolbox. Yes, it will be a little painful in the beginning as you sort through the issues. The key is consistency.

In my office, the same ultrasound technicians do all the scans and assist with the procedures—they know the patients and their anatomy as well as I do. My nurse knows all the patients and they know her. They feel comfortable calling her with questions and issues before there is a problem. My scheduling coordinator is also my medical assistant and the patients know her too. These small details will set you apart from all others. However, as the saying goes: “No pain, no gain,” so for a few growing pains, the gains will be enormous! Phlebology is very satisfying in today’s frustrating and difficult health care arena. I can honestly say that I have fun every day.