The 2024 Venous Symposium (May 8–11) in New York City was highlighted by keynote speaker Peter Pappas, MD, regional medical director and program director of the venous and lymphatic medicine fellowship at the Center for Vein Restoration in Morristown and Union, New Jersey. Pappas spoke about new frontiers in venous and lymphatic disease management while looking at the past, present and future of how disruptive technologies have shaped treatment.
“It is my hope that in the next 20 to 30 minutes, what I’m about to tell you will inspire a new generation of venous clinicians, researchers, and physicians to do better,” Pappas told the audience.
He began his address by speaking about his history as a vascular surgeon. Early on, Pappas said, he was told “we have this field in venous disease in which there is really not a lot of basic science research. It’s the forgotten stepchild of vascular disease and we really want to elevate the quality of the work that’s being done there.
“I knew nothing about it. As I read the current literature, I quickly realized my mentors were correct and that this was a career opportunity,” Pappas continued, explaining how he dedicated his first year to benchwork research and his second year to clinical work.
“I was the first vascular surgeon at that time to get a K08 training grant from the National Institutes of Health [NIH],” he said, “and it opened the door for me for the next 20 years.”
Pappas pointed to the different grants now available, including three types from the American Venous Forum (AVF) for trainees or trained surgeons within the first five years of their careers.
On the current state of benchwork research, Pappas referenced a study conducted in a dermatology lab in Europe that was “the last breakthrough in our understanding of the pathophysiology of venous ulceration,” he explained.
“These investigators determined that macrophages demonstrate different physiologic phenotypes. You have macrophages that regulate tissue destruction (M1 type), and macrophages that regulate tissue repair (M2 type),” Pappas told the audience. “In venous disease, there’s a push towards tissue destruction.” That iron overload from red blood cell extravasation stimulates macrophages to produce tumor necrosis factor alpha (TNFalpha), he explained. This cytokine keeps macrophages in the M1 phenotype, resulting in ongoing tissue destruction .
Pappas speculated that, based on these observations, possible future clinical applications could include the utilization of existing TNF-alpha blockers and/or iron chelators to promote wound healing. However, he added that, thus far, the current utilization of these drugs have been limited to testing in animal models.
“So let’s talk a little bit about disruptive technologies,” Pappas continued. “Mark Meissner [University of Washington School of Medicine, Seattle] and I were talking one day 15 years ago, and he introduced me to the term disruptive technology when discussing the impact the iPhone had on our daily activities.
“I would submit to you that the major disruptive technology in venous disease was the development of the VNUS catheter, which was originally called the Restore catheter. The original intent of this catheter was to restore venous valvular function and not to destroy the vein.
“After testing the feasibility of restoring valve function, it was discovered that the technique resulted in vein closure and the rise of thermal ablative technologies.
“I remember sitting in the audience in the early 1990s when the first clinical data on thermal ablative technologies was presented. I couldn’t believe this actually worked, and I was a late adopter because I wanted to see the data before subjecting patients to this brave new world,” he stated.
“As a result, this changed my perspective on the management of venous disease.”
Moving from catheters to stents, Pappas also touched on Raju and Neglen’s groundbreaking paper on the efficacy of Wallstents in patients who have venous outflow obstruction.
This work laid the foundation for venous stent outcomes, with Pappas telling the audience that “Raju and Neglen’s results are the gold standard to which all future venous stent trials are measured against.”
