Solving the Venous Leg Ulcer Together

Moderated by Dr. Ariel Soffer

Panelists: Dr. Vickie Driver, Dr. Robert Kirsner, Dr. Mark Melin, Dr. David Wright

Vein Magazine prides itself in bringing together key opinion leaders from various disciplines who share the common goal of improving vein disease. We welcome today some of the world’s top thought leaders in the various disciplines of the growing venous clinical space, with the hope that we can learn from each one of them how to best reduce the burden venous leg ulcers (VLUs) place on individual patients and our healthcare system in general.

Annually, about 600,000 people suffer from venous leg ulcers in the U.S. alone, costing about $9,600 each to treat, or about six billion dollars annually. The U.K. and Australia have recently published their cost data and reported similar proportional costs. The overall prevalence of the VLU rises to about three percent in the over 65 age group.

The pathogenesis of most venous ulcers seems to be from venous hypertension resulting mostly from venous incompetence. These factors combined with lipodermatosclerosis, leukocyte plugging of the capillary, tissue hypoxia, and microvascular dysfunction might often initiate the skin opening of the venous ulcers. Mechanical triggers seem to vary from trauma of the lower extremity due to scratching itchy skin over the aggravated ankle region, to otherwise harmless abrasions from minor contact that worsen and simply don’t have the normal venous conditions to properly heal.

VLUs represent about 80 percent of all leg ulcerations in most populations and are almost always associated with chronic venous insufficiency. The healing rates are protracted with only about 60 percent on average healed by 12 weeks. Once healed, 75 percent develop a recurrence within three weeks. At least 60 percent of VLUs result in a chronic wound that is unrelenting.

VLUs impact more females than males, more obese people than those that are not obese, and more people who are immobile compared to those who are active. A history of deep vein thrombosis (DVT) or phlebitis also seems to be a contributing factor. VLUs also result in reduced mobility, poor quality of life, and a notable financial burden on patients and the healthcare systems.

With that, join Vein Magazine’s medical director, Dr. Ariel Soffer, as he leads a distinguished panel of experts in an exploration of the benefits of taking a multidisciplinary approach to the treatment of venous leg ulcers.

Dr. Ari Soffer: Let me start with my esteemed colleague and good friend, Dr. Craig Walker. Tell me about your specialty and your particular purview of the VLU and how we might all work better together to optimize its diagnosis and treatment.

Dr. Craig Walker: Thank you Ariel for including me in this great panel and for such an important subject. So, I got into venous work in a circuitous route. I’m an interventional cardiologist, and for 39 years I have been one of the busiest peripheral arterial vascular revascularization doctors, particularly in the field of limb salvage for ischemic ulceration. Early on, I developed very close relationships with podiatrists, family doctors, primary care physicians, and wound care centers. At the time, one thing that became obvious was that in most cases our arterial ulcers were healing quickly when we were able to achieve blood flow. Yet, patients who had the so- called venous ulcers (ulcers that were very different, typically above the ankle, typically associated with edema and leg discoloration), they were not doing so well. Witnessing this, I developed an interest in superficial and deep venous circulation.

It became obvious that diagnosing vein disease involved a lot more than whether there was ‘clot or no clot,’ as we were taught in medical school. Iliac veins and the vena cava are incredibly important and when there is a stricture or a compression there, it can be a huge problem. Superficial venous insufficiency is important. Yet, when ulcer patients have venous studies in hospitals, most of those studies simply report ‘clot or no clot.’ They often have no mention of any form of insufficiency. There’s usually no interrogation of the iliacs or the common femoral veins. That’s a big problem. It’s why so many of these patients are treated for years and at great expense in wound healing centers rather than first receiving the appropriate care that deals with the mechanical problems they have at the venous level.

When wound healing centers started asking me for help diagnosing and treating wounds, I started to look at where the problems were, and I started to identify many patients who had May-Thurner syndrome, who had obstructive webs and had a severe superficial venous insufficiency with perforators leading directly into these areas of the venous ulcers. We were able to quickly cure most of these venous ulcers. Of all of my patients, the most grateful are the ones who’ve had these venous ulcers for years and then are properly treated. In particular, one wife of a patient was having to change bedsheets three times a night for over 15 years. She had to supplement her husband with protein drinks at night because he was losing so much protein from his massive venous ulceration.

The correct diagnosis is often not made. This is a problem all over the world. Often it’s because vein studies only report ’clot or no clot’ and nothing else, and many of these patients are left believing that they have no chance for further diagnosis or treatment options.

Many of these unrealized issues of venous insufficiency are also often deemed purely lymphatic. Yet, we have found that when we can fix the venous issue, and in particular when we can improve flow in the iliac system, it often also improves flow with lymphatic pumps.

This is an imminently treatable area. It’s something that causes tremendous problems for patients and we really have to do a better job. We have to stress the importance of better diagnosis, in general, because a vein study does not report issues such as venous insufficiency or, in my opinion, do a complete venous mapping study.

Dr. Soffer: Let me go to Mark. Right now you’re spending lots of time in a busy wound clinic and are widely considered a lymphatic expert. What is your take on Dr. Walker’s point regarding the lymphedema part of this equation?

Dr. Mark Melin: I’m going to dive straight down to dermal arterial perfusion. One of the things that we’ve stressed in our wound clinic is recognizing the existence of interstitial edema in almost every one of our patients. (Today, the word that is most published in peer-reviewed literature is phlebolymphedema.) In our clinic, we talk about treating our patients and leading with LOVE. L-O-V-E stands for Lymphedema Of Venous Etiology. We try to pick up on that lymphatic dysfunction in everybody immediately in order to decrease interstitial edema. We try to optimise five- micron arterial perfusion for delivery of oxygen and nutrients. We do a lot of that with dermal micro deformation. Just as a negative pressure wound therapy vac works by the open cells within the sponge, the struts that cause micro deformation in the wound probably have some impact on lymphatic function.

We are trying to improve interstitial fluid drainage by improving dermal lymphatic collector function in a manual lymphatic drainage-like effect using fuzzywale circumferential contact at ~8mmHg (EdemaWare®). We use an inelastic Velcro compression over EdemaWare. We also consistently use adjunctive micronutrients and micronized purified flavonoid fraction (MPFF).

The Guyton theory says that if you stimulate lymphangions in the proximal thigh, you’ll literally “draw up” all that interstitial lymphatic fluid. So we focus on the thighs, around the knees, around the ventromedial lymphatic bundle to maximize lymphangion contractility, resulting in a “straw like sucking” of the fluid out of the tissues, like draining a flooded farm field. We can find this to be true not only in venous leg ulcers but also in the lymphatic dysfunction associated with diabetic foot ulcers. One of the commonly-identified factors is the shedding of the endothelial glycocalyx.

When the glycocalyx is shed, you have more lymphatic dysfunction because more interstitial fluid accumulates due to the loss of the barrier permeability and functional endothelium. A quick mnemonic for the glycocalyx is E-P-I-C. The E is for endothelial cell functionality, producing endothelial nitric oxide among other cytokines. The P is for the permeability layer. It’s like a GORE-TEX™ layer when it’s intact; when venous hypertension exists, the glycocalyx is shed, resulting in increased interstitial edema and an associated decrease of microvascular perfusion. The I stands for inflammation quenching, and the C is for coagulation prevention.

Lymphangions can accommodate up to 20 times normal flow, at which point diastolic distension occurs, resulting in lymphangion failure. This also results in lymphatic valvular incoptience and dermal backflow. This is why all edema is lymphedema. We know that when you lose the endothelial glycocalyx, you also lose the ability to produce endothelial nitric oxide. This can impact lymphangion contractility, immune disfuction, and arterial vasodilation.

We treat everybody with micronutrients, and we commonly use B12, B6, folate, vitamin C, vitamin D, and micronized purified flavonoid fraction (MPFF).

Single nucleotide polymorphisms (SNP) such as MTHFR abnormalities may impare endotheliel nitric oxide production in patients with wounds.

So really, in our wound clinic, right away we’re thinking from the cellular level outword as we’re working with all of our lower extremities (both from the venous ulceration of lymphatic dysfunction to the lymphatic dysfunction of diabetic foot ulcers) within the context of a functional versus shed endothelial glycocalyx.

As we develop more countermeasures for glycocalyx restoration, we’re going to see better treatment of lymphatic dysfunction, which allows for more of a holistic treatment of regenerative and restorative components for dermal regeneration that actually lead to more cost-efficient options for management, better outcomes, and ideally decreased recidivism rates.

Dr. Soffer: Let’s go now to Dr. Kirsner and his perspective from the dermatologic point of view.

Dr. Robert Kirsner: If we go back in time, let’s say 35 years ago when dermatology was beginning to do more surgery, dermatologists were interested in acute wounds and how acute wounds heal. At the University of Miami, which is a little bit of a reflection of a greater universe, they said, “well, you’re interested in wound healing, can you help with the chronic wounds?” And interestingly, while vascular surgeons were interested, at the time, in arterial disease, and plastic surgeons were interested in pressure ulcers, and orthopedic pysicians and podiatrists were interested in diabetic foot ulcers, nobody wanted to deal with the venous leg ulcer. At the time, vascular surgeons experienced a combination of some reimbursement issues, and also a lack of good techniques to consistently fix the venous system. So, it was dropped in the hands of dermatologists to manage venous disease with compression.

At that time, there wasn’t a reliable way to fix the venous circulation, so we focused on other aspects of the condition. Dermatologists became interested in the skin manifestations of venous disease (atrophie blanche, lipodermatosclerosis, etc.). We got interested in the local treatment of wounds, and by chance being in the right place at the right time, I was the first person to ever apply Apligraf to any patient in the world. (Apligraf went on to FDA approval seven years later.) We were interested in drugs and medical therapies to improve healing. Fast forward with some advanced therapies and improved ways to treat the venous system, we’ve kind of come full circle where now we have the ability to treat early and effectively the venous system, but all the things we’ve learned about these other aspects of care, both dermatologists use and other specialties come in to help with–whether it’s debridement, whether it’s closing the wound with things like cell and tissue-based products or grafts or flaps or things like that.

Being in an academic medical center and having this interest in wound healing, we’ve been able to create a group of scientists that have augmented our clinical care to really understand the basic pathophysiology of venous disease.

Early on, for example, one of the hypotheses called the growth factor trap hypothesis of venous ulcers was developed at the University of Miami. Later on, certain biomarkers, such as cMYC and ß-catenin were shown to be predictors of healing of venous leg ulcers if they were present in the wound edge. Another idea developed at UM was that biofilms might impair healing. So, I think dermatologists have helped nurse the care of venous leg ulcers until the technical aspects of fixing venous disease came along. But during that time, science and other adjunctive therapies often pioneered by dermatologists have helped other specialties really take a more holistic approach to the disease.

Dr. Soffer: Next we’ll go to Dr. Vickie Driver, and I appreciate her perspective as a podiatric surgeon.

Dr. Vickie Driver: Everyone who has come before me today has had an important message, really very different, which I find intriguing because it’s all these pieces that when put together make the sum of the discussion. From my perspective as a foot and ankle specialist for 25 years, we’ve been treating venous leg ulcers inappropriately for most of that time because we weren’t working in a multidisciplinary team that included wound healing, vascular specialists, dermatologists, lymphedema specialists, and infection disease specialists. We were and still are treating these patients in silos. The reality of siloed care is that these patients close one wound to get another because many times the proper diagnosis was not made or the etiology treated. As was suggested before, this can occur in just a few months.

Often, we don’t understand the care we could give our patients if we were working together, or we don’t understand the proper diagnosis because we haven’t done the study (to Craig’s point), or we wait until the wound has been open for months before suggesting that the patient needs to go get a diagnostic study. Many times, if a patient has a leg ulcer we’re calling it a venous leg ulcer because of the anatomy, when in fact it might be mixed disease or something else entirely, such as squamous cell carcinoma. Additionally, we haven’t focused our wound healing educational programs on the complexity and clinical functional requirement of the deep veins, superficial veins, and the communicators and how they can be evaluated.

We often don’t understand how they might feed into the ulcer or directly contribute to the problem. We often just forget to talk about the importance of this anatomical mapping.

Wound centers that are most helpful for patients have anatomical pictures on the wall or plastic models that show the anatomy to patients. This allows us to help patients understand the culture of our practice and why interdisciplinary care is key.

Additionally, our EMR protocols don’t have triggers to say, “If it hasn’t healed in this time, who do we need to involve?” We also don’t think about the dermatologic condition of the skin. It’s not just the wound—it’s all the periwound tissue that we many times don’t properly manage.

Many patients with venous disease also have lymphedema, and in many situations we cannot utilize lymphedema specialists unless the wound is closed. It’s the chicken and egg problem. I prefer to have a lymphedema specialist as part of the wound care center to avoid this problem.

Being prepared to get patients situated with compression pumps sooner rather than later is key.

We need a more complete teaching mechanism to help us understand how to evaluate mixed diseases. Most venous leg ulcers are not pure and need additional work up, especially to evaluate for concomitant arterial disease or pathergy.

Also, we’ve run many RCTs and venous leg ulcers—most of them failed. Is this because the therapy doesn’t work? It could be a design problem of the study, but it also could be that the protocol indication is for venous leg ulcers, but we don’t have a proper diagnosis schematic to follow when running the study.

Gary Gibbons and I conducted a study looking at ultrasound way back and we found roughly only 38 percent of the 100 percent of the patients that were enrolled actually had a venous leg ulcer purely. The rest had mixed arterial disease, infection, and failed skin grafts.

I believe that this is a disease that’s treatable. I think we can win far more than we do. Unfortunately, many people who lecture on venous disease with ulcerations believe that you just need more compression or an unna boot and they will all heal. That isn’t the only answer. We now know that there are several venous procedures that will help our patients and we need to screen patients early on to see if they are a candidate for intervention.

Lastly, we have non-cellular and cellular skin substitutes that can be utilized in conjunction with a proper diagnostic, proper compression, elevation and or a venous procedure that will help prevent an infection by closing these advanced wound therapies sooner.

Dr. Soffer: Let me get to Dr. David Wright and his perspective from a vascular surgeon’s point of view.

Dr. David Wright: I started full-time work on veins and venous disease and in particular leg ulcers back in 1985, and I’ve been doing that ever since. I contributed to developing the four-layer bandage system for leg ulcers. I undertook the physical measurement of each component. I investigated all the patients attending a busy leg ulcer clinic in the hospital. 80 percent of them had simple vein disease and of those, more than 60 percent had simple superficial vein disease. Today, with Varithena, radiofrequency and laser ablation, those are really treatable patients with few contraindications; yet, they’re obviously not identified nor given best care. Disappointingly, there remains a constant one percent or two percent of the elderly population with persistent leg ulcers that remain open for years and years.

I remember having a patient that had her leg ulcer open for 20 years and simple treatment with compression in that instance healed the ulcer within a fairly short space of time. We are missing a simple solution for an enormous number of patients, which in turn results in an enormous cost. Why don’t we investigate absolutely everyone? Dr Soffer and I believe that through thermal imaging, which doesn’t seem to be affected by body mass index, we can pick out patients with clear vein disease very simply, very early on, and at very low expense. These patients can then be investigated more formally and offered appropriate care.

We now have multiple choices for the diagnosis and treatment of venous ulcers. By getting all of our colleagues to be aware of the huge role that chronic venous insufficiency (CVI) plays in the VLUs, we can have a tremendous impact on patient care. You can fix superficial vein disease relatively easily these days, so we could cut more than 50 percent of all the leg ulcers that are present in a community just by measures that we already know, but it’s about education and we’ve already heard it from other contributors.

Persistent leg ulcer is also a multifactorial problem. You need to combine physical therapy and nutrition into the management. Many leg ulcer patients are elderly with poor joint movement. If their ankles don’t move, they don’t exercise the calf pump properly, which contributes to persistent venous hypertension. Nutrition has a part to play as well as allot of these patients are obese, eat a high-calorie, low protein, low vitamin diet which will also contribute to poor healing. All of these aspects and more contribute to persistence of leg ulcers. To optimize care all aspects need to be considered and corrected where possible.

And the final thing that I’ll end on is that an individual’s lifestyle is rarely considered. If a patient sits in a chair with their feet dependent all day, whether they’ve got vein disease or not, they’ve got venous hypertension sufficient to cause leg ulcer. When taking their history, you actually must see what they’re actually doing during the day and take all aspects into account. Consider their physical movement, their lifestyle, their nutrition. All these things contribute to leg ulcers—not only the venous status.

One thing we know we can do is to diagnose superficial vein disease. We can now easily and inexpensively screen for CVI using thermal imaging (as our group recently published). We can then progress it to ultrasound and see whether it’s appropriately treatable. These patients heal incredibly rapidly if you identify the location and then reverse venous hypertension. It’s a wonderful thing. That woman, 20 years on, sobbed on my lab coat uncontrollably. She had 20 years of continuous leg ulcer; you quickly fix the root problem and you’ve got the most grateful patient you’ve ever had in your life.

Dr. Soffer: Craig, let me ask you a specific question because you really changed my perspective on things in the past. When I went to your first New Cardiovascular Horizon (NCVH) meeting as an attendee many years ago, I saw the number of podiatrists in particular that were attending and I was fascinated by

how you were engaging them as an important part of the vascular conversation. How do

we continue to add that inclusive enthusiasm to our dermatologic colleagues, wound care colleagues, etc.? Also, how do we get all this done from the ultrasound point of view, because that still stands as the gold standard?

Dr. Walker: Let’s address the ultrasound being the gold standard. It’s a pretty darn good standard assuming you have a really good tech. Unfortunately, the overwhelming majority of venous studies done in the United States do not have a tech who is well-versed in looking for venous insufficiency—be it evidence of iliac vein compression, or superficial venous insufficiency. The physicians at the centers get back a report, ’clot or no clot.’ If it says no clot, they assume it can’t be a venous etiology. That is very wrong. So, we really have to push to make sure that if we order a vein study, we must also include in that to evaluate for any evidence of venous insufficiency or evidence suggestive of iliac vein obstructive disease of any sort.

Even doing that, we still may not have a technician who understands how to do those studies well. I thought that was a local phenomenon until we started with our meeting. I heard the same report from doctors all over the United States.

Even within my own organization (we now have 91 cardiologists and 1,150 employees), I would state that of the 50 or so echo techs that we have, only about seven of them are really proficient in performing good venous studies. This is a problem that we face throughout the United States. I’m very optimistic that thermal imaging may help in this regard as a screening tool to see who might be appropriate for ultrasound. The difference in time between doing a good thermal mapping imaging study and doing a good venous ultrasound is about an hour, and thermal can be done anywhere by almost anybody. Additionally, a negative thermal screening study also reduces wasted time in the ultrasound lab. If a thermal screening result is negative, it is very unlikely that venous insufficiency actually exists, so thermal screening is very helpful.

I also have another interest in the venous system because I have found combined venous and arterial disease to be a relatively common problem—something that historically has not been discussed frequently. From a physiological perspective, capillary perfusion is a result of mean pressure coming into that capillary bed minus the mean backpressure. Venous disease with higher back pressure clearly can lessen capillary perfusion, which is a big problem in terms of wound healing. We can apply Apligrafs and other things to a venous ulcer, but if it’s still oozing tons of fluid at the same time, it’s not apt to take as well. So, I do think that we have to ultimately create an algorithm of the steps in the diagnosis of the CVI and the VLU, just like we have with so many critical cardiovascular situations we deal with regularly.

I don’t think any venous ulcer should be treated for a year without someone assessing the vascular status with a quality ultrasound of some sort that’s riskless. It’s low-cost and it can absolutely save costs and save limbs over time. That is simply not happening. We have a breakdown in how that’s occurring and I don’t believe anyone should be treated with all these advanced therapies for years in today’s world without an appropriate vascular assessment. I think we have to elevate the diagnosis and treatment of veins to the level of arteries because more ulcers are coming from veins than ever appreciated. They’re a huge part of the circulation.

And now that we’re able to appreciate the lymphatics better, they are now on our awareness horizon. I love the concept of having multidisciplinary teams of people looking at this because this is not going to be a one-answer deal. We have to have stepwise progression as we have in medicine. Step one is you have to get a great vascular assessment for every VLU. That’s simply not happening.

My perspective is much newer than many others. I was so focused on arterial cases (doing well over 1,000 limb salvage cases a year and training doctors all over the world), that I underestimated the importance of veins. And I must say, as Dr. Wright has pointed out, these are the most thankful patients in the world because they feel like they’ve been ignored forever. To some degree we have ignored them. Many of us have put this on the back-burner. This is a very important disease. Every day in my practice, I’m seeing more and more venous disease and I’m trying to get more young people from many disciplines to help me with this.

Dr. Soffer: Well, it’s very interesting how you talk about this problem that we have with triage, right? So, for triage, you need screening. And when you and I trained back in the day from a cardiovascular perspective, the triage tool for arterial disease was really the Arterial Brachial Index (ABI). So the ABI was and is a very important triage mechanism. I’d like to ask both Dr. Driver and Dr. Kirsner, two questions: A) Have you seen any of these triaging or screening capacities, whether it’s an ABI for arterial studies or other screening mechanisms for vascular disease in VLU patients? And B) How do we get more people to get appropriate ultrasounds done by qualified, experienced technicians?

Dr. Kirsner: There’s no question that we have to move out of the realm of just clinical examination. Because of the prevalence of the disease, a lot of people touch hands on a patient with a venous leg ulcer. And everybody doesn’t have the same level of training and expertise. When that occurs, we really need to have reliable testing, whether it’s as triage or truly diagnostic to help homogenize care so that we can really raise a level of care. Raising veins to the level of arteries is quite appropriate because virtually all physicians appreciate the idea (at least we hope they appreciate the idea) that if you have a wound on a lower extremity, you should definitely have an arterial study. In fact, I teach all my trainees that’s the first study. If you had to prioritize, that’s going to be the first study you want.

We want to really raise the level and have venous ultrasound be part of the initial evaluation for a variety of reasons. Now, as was pointed out, there’s always going to be some cases of venous ulcers that may not have reflux or outflow problems or calf muscle pump dysfunction based on ankle range of motion and things of that nature. But as a screening test, the ultrasound is in a very good position to pick up the vast majority of diagnoses. And then at least we know venous desease exists. If venous disease doesn’t exist, then of course, you want to question the diagnosis and get an even more advanced evaluation or other ancillary tests, such as a skin biopsy, to make sure you’re not missing some other etiology of the wound.

Dr. Driver: We know that normal venous blood flow depends on healthy cardiac function, an effective venous pressure gradient, a calf muscle pump, and veins with functional and intact valves. We have solid evidence that VLUs occur when valves become incompetent and venous reflexes lead to ambulatory conditions with hypertension and inflammatory responses, hyperpigmentation and clotting. It is likely that as a wound care community, we have focused all too much on the tissue injury, the hyperpigmentation, the wound in front of us, and not enough on developing matrices for clinicians to be responsible for. If you have a leg wound, you need a diagnosis. If it’s in the anatomical location of venous ulcerations, don’t assume it is a VLU. You need an appropriate diagnostic test.

I love the idea of raising the level of importance of veins to arteries. I think we must continue to make sure that people understand that the ends of the body matter, and that we’re not just talking about the head or the hands—we’re talking about the end that people walk on. That sounds very trite, but for some reason, we think of venous leg ulcers with lots of wrapping and these wounds drain and they’re smelly. There’s this perception that they never go away. Therein, we must continue to tell stories of cases as we add in these teachings like you’re doing today. But again, I think it’s a lot about critical clinical metrics for centers to develop that will trigger a diagnostic ultrasound and arterial studies early and not wait for infection or a deeper more complex ulceration to develop. appropriate ultrasound. We need to know more about that. What should our expectations be?

What are we really looking for? I can tell you that is something that most of us do not know.

Dr. Kirsner: If somebody came to a doctor with cancer, that doctor would work with a surgical oncologist, a plastic surgeon for reconstruction, a medical oncologist for chemotherapy, and a radiation oncologist for radiation. The idea is to loop in a team of physicians if you don’t possess the expertise in one area, for the betterment of the patient. Venous ulcers also require bringing in many people who have different expertise to care for those patients.

Dr. Melin: I keep thinking of the IAC accreditation standard. The Intersocietal Commission for the Accreditation of Vascular Laboratories has a very high bar. The other thing I believe in is a checklist mentality. When a pilot gets into a cockpit, what do they do?

They run the same checklist, whether they’re going to fly 50 miles or 5,000 miles. We have to start adopting that kind of mentality, not just for the initial consult, but every time we see the patient to make sure we haven’t missed something. We have to then circle back and make sure that the standards on the checklist we created are sufficient to make the diagnosis.

Making the correct diagnosis is what places us on the correct algorithmic pathway for treatment that results in accelerated outcomes.

If we could routinely use a screening tool like thermography that could give a clear picture that allows us to better focus on the anatomical areas of concern, that would be ideal and a paradigm shift. Not only would that allow us to better focus on areas of CVI, but it would also allow us to be more complete in that imaging so that we don’t miss anything. When ultrasound techs are mapping the venous anatomy looking for CVI, there’s a lot of surface area to cover.

A single thermographic image that can be acquired quickly, can drive venous mapping and allow one to focus on the area of the ultrasound image that shows the insufficiency and where treatment may be needed. Studies have already shown that thermography is going to make it easier to accomplish good venous mapping in our busy labs. It’s going to improve the identification of venous disease as well as save techs lots of time along the way and with improved ergonomic benefit. It’s going to improve diagnostics and diagnostics will drive accelerated outcomes—because then we’ll know where to go on our “checklist” moving forward.

This new paradigm shift to stop thinking of ultrasound as a screening tool and instead think of point-of-care thermography (POCT) as a screening tool, can reshape how we treat venous leg ulcers and potentially lymphedema. Especially now, there have been some reports in Africa that thermography has been used in non-filarial versus filarial lymphedema to look at lymphatic dermal patterns. There was a study in Poland that looked at upper extremity lymphedema in post-mastectomy patients using thermography. Once we start to see adequate pixelation rates and we start to get some artificial intelligence and machine learning involved, we’re going to start to see lymphatic dermal patterns, and this will benefit the treatment of patients.

Dr. Wright: I wonder whether the U.S. is ready for a leg ulcer diagnostic service. There is perhaps a need for a facility in every metropolitan area that will take all leg ulcer patients through a standardized and comprehensive diagnostic workup.

The technology—whether it starts with thermography or ABPI—then ultrasound examination can follow.

A comprehensive series of tests, following a flow chart, when complete, could give most patients a firm diagnosis and a referral back to their original physician. The technology is proven and available. It is just not used. There is so much benefit that could be provided to the population of leg ulcer patients that, overall, would be cost beneficial.

Moderator: Dr. Ariel Soffer, MD is a board-certified cardiovascular specialist, Co-Founder/CEO of USA Therm, medical Director ofVein Magazine, and chairman of the Vein Forum at the NCVH in New Orleans.

His academic background includes University of Miami Medical School, Cedars Sinai/UCLA residency, Chief of Cardiology at Jackson North Health System, and currently a clinical professor at Nova Southeastern University School of Allopathic Medicine. He holds multiple patents, and his publications include two books and multiple peer-reviewed journal articles.

Dr. Vickie Driver, DPM is board- certified by the American Board of Podiatric Surgeons and is an American College of Foot and Ankle Surgeons Fellow. She is System Chief of the Inova Wound Healing, Hyperbaric and Limb Preservation Centers and a professor at the University of Virginia’s School of Medicine. She has co-authored more than 150 publications and abstracts. Dr. Driver is also the chair of the Wound Care Collaborative Community, an important collaboration between the FDA and the Centers for Medicare & Medicaid Services (CMS).

Dr. Robert Kirsner, MD, PhD was a chairman and Harvey Blank professor in the department of dermatology and cutaneous surgery at the University of Miami Miller School of Medicine. He is the Chief of Dermatology and Director of the Wound Care Center at the University of Miami Hospital, and has published over 550 research articles.

Dr. David Wright, MD is a vascular surgeon from the U.K. and a Royal College of Surgeons Fellow. He served as Vice President of Medical Affairs for BTG (now known as Boston Scientific) for over a decade. He co-created a widely used novel treatment now known as Varithena, which has impacted all of our professional lives and the vascular health of so many of our patients. He is also co-creator of ThermPix, a novel point-of-care thermography medical device developed by USA Therm.

Dr. Mark Melin, MD is board- certified in general surgery, Medical Director of the M Health Fairview Wound Healing Institute, and an adjunct associate professor in the Department of Surgery at the University of Minnesota.

He is also quite passionate in the educational contributions of the lymphatic system, glycocalyx, and their inclusive capacity in their effect in aerospace medicine.

Dr. Craig Walker is a board- certified interventional cardiologist. He’s founder of the Cardiovascular Institute of the South, founder and chairman of the New Cardiovascular Horizons (NCVH) Symposia, and clinical editor of Vascular Disease Management. Dr. Walker completed postgraduate training at Harvard Medical School and is now a professor at LSU and Tulane Medical Schools. He’s formally trained thousands of cardiovascular specialists throughout the years on the importance of peripheral circulation and now has one of the busiest and most advanced venous programs in the country.