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Abstract

The core content for a medical specialty outlines the scope of the discipline as well as the categories of knowledge considered essential to practice in the field. It provides a template for the development of curricula for medical school, graduate, and postgraduate education, as well as for creating certification standards. Venous and Lymphatic Medicine (VLM) is a specialty that has benefitted from contributions from specialists from several medical disciplines. Optimally, the societies, boards, and residency review committees representing these disciplines would uniformly recognize the scope of VLM to develop education and assessment standards to allow training and identification of qualified practitioners. In order to inform the standard setting bodies and other stakeholders of the current scope of VLM, a task force of VLM experts from cardiology, dermatology, emergency medicine, general surgery, interventional radiology, vascular medicine, and vascular surgery was formed to revise a 2014 consensus document defining the core content of the specialty of VLM.

Keywords

Curriculum phlebology training venous lymphatic education

Introduction

Professional medical societies, graduate medical education accreditation councils, and certification boards share responsibility to set training and clinical standards for all health care disciplines. The medical societies define best clinical and educational practices through clinical practice guidelines and post graduate education curricula. Their definitions inform board standards for certification of practicing physicians and allied health care providers as well as the training requirements for graduate medical education utilized by residency review committees.¹

The core content for a specialty outlines the areas of knowledge considered essential to practice in the field, serving as a template for the development of curricula for medical school, graduate, and postgraduate education, and informs certification standards. Venous and Lymphatic Medicine (VLM) is a specialty that has benefitted from contributions from specialists from several medical disciplines. VLM is a unique medical specialty with a broad array of clinical conditions, knowledge, and skills that are required to evaluate and treat affected individuals adequately. In order to promote high quality homogenous care delivery to optimize patient outcomes, societies representing these various disciplines, as well as their boards and residency review committees, would optimally utilize a coherent and consistent core content scope, as well as training and professional standards to allow development and identification of qualified practitioners from within their disciplines.

A multi-disciplinary task force was assembled in 2014 which created a VLM core content document to define the scope of the specialty.² This document was endorsed by the American Venous Forum and the American College of Phlebology (now known as the American Vein and Lymphatic Society.) VLM has continued to mature since the publication of that document, with a greater understanding of underlying pathophysiologies and advances in diagnostic and therapeutic modalities. In order to inform the standard setting bodies of the current status of the scope of VLM, a multi-disciplinary task force made up of VLM experts was formed to revise the 2014 consensus document.

Methods

A multi-disciplinary task force was assembled in early 2021 to update and codify the 2014 VLM core content document. The revision was developed with input from recognized experts in cardiology, dermatology, emergency medicine, family medicine, interventional radiology, general surgery, vascular medicine, and vascular surgery. These experts were nominated by societies that represent physicians involved in VLM care and those that include venous curricula in their continuing medical education and graduate medical education training programs. The members of the revision task force reviewed the original 2014 document and recommended edits to the document informed by a detailed review of the medical literature. During a series of regularly scheduled conference calls from mid-2021 through August 2022, the comments of each task force member were discussed, and consensus edits were incorporated into the document. The document was then circulated with multiple venous and lymphatic societies in the United States for their review and comment. The task force considered the suggestions of the societies to produce a final core content document.

Venous and lymphatic medicine

Description of the field

VLM is the discipline encompassing knowledge of anatomy, embryology, physiology, pathophysiology, epidemiology, diagnosis, and evaluation and management of acute and chronic venous and lymphatic disorders. These disorders include, but are not limited to, the following: symptoms and signs of venous and/or lymphatic dysfunction including dermatologic disorders of venous/lymphatic origin, deep and superficial venous insufficiency and thrombosis, pelvic venous disorders, upper extremity venous disorders, venous aneurysms, congenital vascular and lymphatic malformations, venous/lymphatic tumors, lymphedema, and other disorders of venous, lymphatic, and mixed origin.

Evaluation and management of patients with venous and lymphatic disorders require knowledge, skill, and experience with the history and physical examination, laboratory testing, noninvasive imaging including Duplex ultrasonography, CT, and MR Venography (CTV and MRV), venous and arterial physiological testing and lymphoscintigraphy, as well as invasive diagnostic techniques such as venography and intra-vascular ultrasonography (IVUS). A broad array of therapeutic modalities is used to manage and treat a wide range of venous and lymphatic disorders. Currently these include compression therapy, pharmacological treatment, anticoagulation, saphenous ablation, sclerotherapy, and percutaneous endovascular therapies for vascular and lymphatic malformations, obstruction, and reflux in the deep and pelvic venous systems as well as open surgical approaches.³

Venous and lymphatic medicine core content overview

The core content of VLM which defines the specialty as well as the requisite knowledge, skills, and attributes of a VLM physician can be summarized into five categories. They are introduced in the following paragraphs and summarized in Table 1. A detailed core content outline is presented in Table 2.

Table 1.

Core content outline.

Basic science	15
Diagnostic evaluation	20
Knowledge, Procedures, and skills integral to the practice of venous and lymphatic medicine	24
Clinical management	32
Other components and core competencies important in the practice of venous and lymphatic medicine	37

Table 2.

Detailed venous and lymphatic medicine core content.

1. Basic science

1.1. Anatomy (Venous, Arterial, and Lymphatic Systems)

1.1.1. Structure of venous wall and endothelium

1.1.2. Venous valves

1.1.3. Anatomical nomenclature

1.1.4. Lower extremity venous and adjacent nerve anatomy

1.1.4.1. Superficial venous system

1.1.4.2. Perforating veins

1.1.4.3. Deep venous system

1.1.4.4. Nerves of the lower limb

1.1.5. Pelvic venous anatomy

1.1.6. Abdominal venous anatomy

1.1.7. Thoracic venous anatomy

1.1.8. Upper extremity venous anatomy

1.1.8.1. Superficial system

1.1.8.2. Deep system

1.1.9. Cerebral and jugular venous anatomy

1.1.10. Pelvic and lower extremity arterial anatomy

1.1.11. Lymphatic anatomy

1.2. Embryology

1.2.1. Venous embryology of the thorax, ambdomen, pelvis and lower extremities

1.2.2. Variant venous anatomy of the thorax, abdomen, pelvis, and lower extremities

1.2.3. Lymphatic embryology of the thorax, abdomen, pelvis and lower extremities

1.2.4. Congenital arteriovenous, venous and other vascular anomalies based on ISSVA classifications

1.3. Genetics

1.3.1. Venous disease

1.3.2. Lymphatic disease

1.3.3. Congenital arteriovenous, venous, and other vascular malformations

1.4. Venous physiology and hemodynamics

1.4.1. Flow through collapsible tubes and the reservoir function of the venous system

1.4.2. Venous valves and their function

1.4.3. Muscular pump function

1.4.4. Venous pressures—normal and abnormal

1.5. Venous pathophysiology

1.5.1. Primary lower extremity superficial and deep venous insufficiency

1.5.1.1. Genetics

1.5.1.2. Disorders of the vein wall

1.5.1.3. Disorders of the valves

1.5.1.4. Ambulatory venous hypertension

1.5.1.5. Inflammation

1.5.2. Secondary lower extremity superficial and deep venous insufficiency

1.5.2.1. Post-thrombotic venous disease; reflux and obstruction

1.5.2.2. Venous obstruction, extrinsic

1.5.3. Chronic venous insufficiency (C3-C6 disease)

1.5.3.1. Microcirculatory dysfunction

1.5.3.2. Subcutaneous and cutaneous involvement

1.5.4. Superficial and deep venous obstruction etiologies

1.5.4.1. Non thrombotic

1.5.4.1.1. Adjacent artery

1.5.4.1.2. Bony or ligamentous (eg: effort thrombosis)

1.5.4.1.3. Aneurysm or cyst

1.5.4.1.4. Other Mass (e.g., nodal or malignancy)

1.5.4.1.5. Obesity

1.5.4.2. Post thrombotic

1.5.4.3. Congenital

1.5.5. Pathophysiology of venous ulceration

1.5.6. Pathophysiology of swelling

1.5.6.1. Venous

1.5.6.2. Lymphatic

1.5.6.3. Phlebolymphatic

1.5.6.4. Central venous hypertension

1.5.6.5. Medical causes of edema

1.5.6.6. Iatrogenic

1.5.6.7. Lipedema

1.5.7. Pathophysiology of pelvic venous disorders

1.5.7.1. Reflux

1.5.7.1.1. Ovarian veins

1.5.7.1.2. Internal iliac veins

1.5.7.1.3. Pelvic escape point veins

1.5.7.2. Obstruction

1.5.7.2.1. Left renal vein

1.5.7.2.2. Common and external iliac veins

1.5.7.3. Combinations of reflux and obstruction

1.5.8. Lymphatic physiology and pathophysiology

1.5.8.1. Normal lymphatic function

1.5.8.1.1. Revised Starling mechanism

1.5.8.2. Pathophysiology

1.5.8.3. Congenital conditions

1.5.8.4. Acquired conditions

1.6. Venous histology and histopathology

1.7. Wounds and wound healing

1.7.1. Acute wounds

1.7.2. Chronic wounds

1.8. Coagulation and thrombosis

1.8.1. Normal function of the coagulation system

1.8.2. Blood/vessel wall interactions

1.8.3. Hypercoagulable conditions

1.8.3.1. Congenital

1.8.3.2. Acquired

1.8.4. Inflammation and thrombosis

1.8.5. Deep and superficial Venous thromboembolism, natural history, and sequelae

1.9. Compression therapy

1.9.1. Mechanism of action of compression therapy devices

1.9.1.1. Hemodynamic effects

1.9.1.2. Physiologic effect on lymphatic system

1.9.2. Dynamic versus static compression devices

1.9.3. Compression dosage/strength and duration

1.10. Pharmacology

1.10.1. General pharmacological principles

1.10.2. Sclerosants

1.10.3. Sclerosant microfoams

1.10.4. Cyanoacrylates

1.10.5. Anticoagulant and antiplatelet drugs

1.10.6. Thrombolytic and antithrombotic agents

1.10.7. Anesthetic agents

1.10.8. Veno-active (phlebotonic) agents

1.11. Physics

1.11.1. Ultrasound

1.11.2. IVUS

1.11.3. Cutaneous laser and Intense pulsed light

1.11.4. Endovenous laser

1.11.5. Radiofrequency

1.12. Infection control

1.12.1. Clean technique

1.12.2. Sterile technique

1.12.3. Cleaning and disinfection of equipment and surfaces

2. Diagnostic evaluation

2.1. History

2.2. Physical examination

2.3. Non-invasive arterial testing

2.3.1. Ankle Brachial Index

2.3.2. Arterial pulse volume recording

2.4. Venous and Lymphatic imaging

2.4.1. Venous ultrasound- performance and interpretation

2.4.1.1. Reflux evaluation

2.4.1.1.1. Superficial

2.4.1.1.2. Perforator

2.4.1.1.3. Deep

2.4.1.1.3.1. Deep lower extremity veins

2.4.1.1.3.2. Pelvic and abdominal veins

2.4.1.2. Venous obstruction

2.4.1.2.1. Lower extremity veins

2.4.1.2.2. Pelvic and abdominal veins

2.4.1.2.3. Upper extremity, neck, and thoracic veins

2.4.1.3. Ultrasound protocols

2.4.1.4. Lower extremity

2.4.1.4.1. Acute symptoms

2.4.1.4.2. Chronic symptoms

2.4.1.5. Upper extremity

2.4.1.6. Abdomen and pelvis

2.4.1.6.1. Iliac veins and IVC

2.4.1.6.2. Gonadal veins and venous plexuses of the pelvis

2.4.1.6.3. Renal veins

2.4.1.7. Ultrasound guided procedures

2.4.1.8. Duplex ultrasound after venous treatment

2.4.2. Intravascular ultrasound (IVUS)- performance and interpretation

2.4.3. MRI and MR venography- interpretations

2.4.4. CT and CT venography- interpretation

2.4.5. Conventional venography- performance and interpretation

2.4.6. Lymphatic imaging and interpretation

2.4.6.1. Lymphangiography

2.4.6.2. Radionuclide lymphoscintigraphy

2.4.6.3. MR lymphography

2.4.6.4. Indocyanine green lymphography

2.4.6.5. Volumetric measurements and imaging

2.4.6.6. Transillumination, performance and interpretation

2.5. Dynamic Venous function tests- interpretation

2.5.1. Air plethysmography

2.5.2. Photoplethysmography

2.5.3. Ambulatory venous pressure

2.6. Laboratory test indications and interpretations

2.6.1. Basic coagulation assessment

2.6.2. Hypercoagulability evaluation

2.6.2.1. Acquired

2.6.2.2. Inherited

2.6.3. Assessment of activated coagulation using D-dimer

2.6.4. Skin biopsy - indications

2.7. Venous thromboembolic disease

2.7.1. Risk assessment using tools (i.e., Caprini and wells)

2.7.2. Diagnostic algorithms

2.7.2.1. Superficial vein thrombosis

2.7.2.2. DVT

2.7.2.3. PE

2.8. Interpret classification systems and assessment tools

2.8.1. CEAP (chronic venous disorders)

2.8.2. Hamburg (vascular malformations)

2.8.3. International Society for the Study of Vascular Anomalies (ISSVA, for vascular malformations)

2.8.4. Venous Clinical Severity Scale (VCSS, for chronic venous disorders)

2.8.5. Villalta (for post thrombotic venous disease)

2.8.6. SVP (Symptoms, varices, pathophysiology, for pelvic venous disorders)

2.8.7. Rutherford classification for acute and chronic limb ischemia

2.8.8. Quality of life (QOL) assessments

2.8.8.1. Generic

2.8.8.2. Venous specific

3. Knowledge and skills integral to the practice of venous and lymphatic medicine

3.1. Conservative therapy

3.1.1. Principles and practice

3.1.2. Patient education and resources

3.2. Compression therapy

3.2.1. Graduated medical compression stockings

3.2.2. Shortstretch bandages

3.2.3. Bandaging techniques

3.2.4. Multi-layered compression

3.2.5. Adjustable compression wraps

3.2.6. Compression pumps

3.2.7. Other compression devices

3.3. Pharmacological for venous disorders

3.4. Wound care

3.4.1. Compression

3.4.2. Dressings

3.4.3. Topical

3.4.4. Pharmacologic

3.4.5. Surgical

3.4.5.1. Debridement

3.4.5.2. Skin grafting and related procedures

3.4.5.3. Skin substitutes and their role

3.5. Endovenous saphenous vein ablation

3.5.1. Thermal ablation

3.5.2. Non-thermal ablation

3.6. Surgery for venous incompetence

3.6.1. Ligation and division

3.6.2. Ligation and stripping

3.6.3. Surgical treatment of perforating veins

3.6.4. Deep venous surgery

3.6.4.1. Valve reconstruction

3.6.4.2. Venous transposition

3.6.4.3. Venous bypass

3.6.4.4. Prosthetic venous valves

3.6.5. Saphenous vein preservation strategies for venous reflux

3.6.5.1. Conservative and hemodynamic cure of Venous insufficiency in ambulatory patients (CHIVA)

3.6.5.2. Ambulatory selective varices Ablation under local anesthesia (ASVAL)

3.7. Microphlebectomy

3.8. Sclerotherapy

3.8.1. Liquid

3.8.2. Foam

3.8.3. Visual

3.8.4. Ultrasound-guided

3.8.5. Transillumination-guided

3.8.6. Fluoroscopy-guided

3.9. Endovascular embolization

3.9.1. Mechanical

3.9.2. Chemical

3.10. Pelvic venous disorders

3.10.1. Embolization

3.10.2. Iliac venous stenting

3.10.3. Venous bypass or transposition

3.10.4. Venous ligation (open and laparoscopic)

3.10.5. Autotransplantation

3.10.6. Pharmacological

3.10.6.1. Venoactive medications

3.10.6.2. Hormonal treatments

3.11. Venous extrinsic compression syndromes

3.11.1. Iliac vein compression

3.11.2. Left renal vein compression

3.11.3. Popliteal Vein Entrapment

3.11.4. Subclavian vein compression (Paget-Schroetter)

3.12. Venous thromboembolism (VTE) treatments

3.12.1. VTE prophylaxis

3.12.1.1. Pharmacologic

3.12.1.2. Nonpharmacologic

3.12.2. Anticoagulation

3.12.2.1. Initial treatment and duration of therapy

3.12.2.2. Management of recurrent VTE

3.12.2.3. Secondary prevention

3.12.3. Superficial venous thrombosis

3.12.4. DVT and pulmonary embolism

3.12.4.1. Pharmacologic treatment

3.12.4.1.1. Anticoagulation

3.12.4.1.2. Systemic/intravenous thrombolysis

3.12.4.1.3. Image guided catheter thrombolysis

3.12.4.2. Mechanical thrombectomy

3.12.4.3. Pharmacomechanical thrombectomy

3.12.4.4. Surgical thrombectomy

3.12.5. Vena cava filter placement and retrieval

3.12.5.1. Permanent

3.12.5.2. Retrievable

3.12.5.3. Convertible

3.13. Post-thrombotic deep venous obstruction treatments

3.13.1. Endovenous venoplasty and stenting

3.13.2. Surgical bypass(Palma-Dale, May-Husni; prosthetic)

3.13.3. Endophlebectomy for restoration of venous inflow

3.14. Superior vena cava (SVC) syndrome and upper extremity venous obstruction treatments

3.14.1. “Effort” thrombosis (Paget-Schroetter Syndrome)

3.14.1.1. Thrombolysis (pharmacologic, mechanical, pharmacomechanical)

3.14.1.2. First rib resection (transaxillary, infraclavicular)

3.14.1.3. Venous reconstruction

3.14.2. Superior vena cava syndrome

3.14.2.1. Thrombolysis (pharmacologic, mechanical, pharmacomechanical)

3.14.2.2. Venous stenting

3.14.2.3. Surgical reconstruction

3.14.2.4. Radiation for malignant SVC syndrome

3.15. Venous aneurysm management

3.15.1. Popliteal

3.15.2. Iliac

3.15.3. Inferior vena cava

3.15.4. Saphenous

3.16. Energy-based treatments for venous disorders

3.16.1. Cutaneous laser and light-based treatment

3.16.1.1. Telangiectasia and reticular vein treatment

3.16.1.2. Vascular malformation treatment

3.16.1.3. Pigmentation treatment

3.16.1.4. Physics and safety, cutaneous laser and light-based modalities

3.16.2. Thermocoagulation and ohmic thermolysis

3.17. Lymphedema therapies

3.17.1. Conservative

3.17.1.1. Pharmacologic and lifestyle (weight loss, exercise)

3.17.2. Complete decongestive physiotherapy

3.17.2.1. Decongestive phase vs. maintenance phase

3.17.2.1.1. Physiologic basis for manual lymphatic drainage and compression therapy

3.17.3. Dynamic compression therapy (pneumatic and non-pneumatic pumps)

3.17.4. Compression bandaging/adjustable wraps

3.17.4.1. Bandages (including short-stretch and multi-layer)

3.17.4.2. Graduated compression stockings

3.17.4.3. Adjustable wraps

3.17.5. Surgical treatment

3.17.5.1. Lymphovenous bypass

3.17.5.2. Lymph node transfer

3.17.5.3. Liposuction

3.18. Treatment of vascular anomalies

3.18.1. Transcutaneous laser

3.18.2. Percutaneous sclerotherapy

3.18.3. Image guided embolization

3.18.4. Surgery

3.19. Anesthesia

3.19.1. Sedation and analgesia

3.19.2. Topical anesthesia

3.19.3. Local anesthesia

3.19.4. Tumescent anesthesia

3.20. Treatment of medical emergencies

3.20.1. Basic life support/advanced cardiac life support

3.20.2. Management of anaphylaxis

3.20.3. Management of air embolism

3.21. Management of procedural complications

3.21.1. Superficial venous procedures

3.21.1.1. Infection

3.21.1.2. Thrombotic complication (DVT, superficial phlebitis, EHIT, EGIT)

3.21.1.3. Allergic complications (e.g., sclerosant, cyanoacrylate, or other implant)

3.21.1.4. Pigmentation

3.21.1.5. Telangiectatic matting

3.21.1.6. Neurological complications

3.21.1.7. Skin necrosis

3.21.1.8. Intravascular coagulum

3.21.2. Deep venous procedures

3.21.2.1. Hemorrhage

3.21.2.2. AV fistula and pseudoaneurysms

3.21.2.3. Coil migration/embolization

3.21.2.4. Stent migration/embolization

3.21.2.5. Pulmonary embolism

3.21.2.6. Neurologic symptoms, including stroke (i.e., foam embolization)

3.21.2.7. Stent stenosis

3.21.2.8. Stent occlusion/thrombosis (acute and chronic)

3.21.2.9. IVC filter fracture or migration

4. Clinical management

4.1. Superficial venous incompetence

4.1.1. Telangiectasia

4.1.2. Reticular veins

4.1.3. Varicose veins

4.1.4. Recurrent varicose veins

4.2. Perforator incompetence

4.3. Deep venous incompetence

4.4. Chronic venous insufficiency

4.4.1. Edema

4.4.2. Corona phlebectatica

4.4.3. Venous skin injury

4.4.3.1. Hyperpigmentation

4.4.3.2. Eczema

4.4.3.3. Lipodermatosclerosis

4.4.3.4. Atrophie blanche

4.4.3.5. Recognition of other cutaneous conditions

4.4.3.5.1. Inflammatory

4.4.3.5.2. Skin cancer

4.4.3.5.3. Infections

4.4.3.5.4. Vasculitis/vasculopathy

4.4.3.5.5. Drug reactions

4.4.3.5.6. Autoimmune

4.4.4. Venous ulceration

4.4.4.1. Epidemiology

4.4.4.2. Etiology

4.4.4.3. Diagnosis

4.4.4.4. Treatment

4.4.5. Non venous causes of ulceration

4.4.5.1. Neuropathic

4.4.5.2. Arterial

4.4.5.3. Pyoderma gangrenosum

4.4.5.4. Malignancy

4.4.5.5. Other vasculitis/vasculopathy

4.4.5.6. Medication reaction

4.4.5.7. Other rare conditions

4.5. Pelvic Venous disorders

4.5.1. Chronic pelvic pain

4.5.1.1. Venous origin chronic pelvic pain

4.5.1.2. Non-venous origins of chronic pelvic pain

4.5.1.3. Chronic overlapping pain syndromes

4.5.2. Symptomatic left renal vein compression

4.5.3. Vulvar varices

4.5.4. Varicocele

4.5.5. Venous claudication

4.5.6. Pelvic origin extra-pelvic and sciatic varices

4.6. Venous thromboembolism

4.6.1. Superficial thrombophlebitis

4.6.2. Deep vein thrombosis

4.6.2.1. Phlegmasia cerulea dolens

4.6.2.2. Phlegmasia alba dolens

4.6.3. Post-thrombotic syndrome

4.6.4. Pulmonary embolism

4.6.5. Paradoxical embolism

4.6.6. Post-pulmonary embolism syndrome

4.6.7. Chronic thromboembolic pulmonary hypertension

4.6.8. Upper extremity venous thrombosis

4.6.8.1. Primary venous thrombosis

4.6.8.2. Secondary venous thrombosis

4.7. Venous obstruction and compression syndromes

4.7.1. Popliteal vein

4.7.2. Iliac vein

4.7.3. Left renal vein compression

4.7.4. Inferior vena cava

4.7.5. Superior vena cava

4.7.6. Axillo-subclavian

4.8. Vascular malformations

4.8.1. Capillary malformations

4.8.2. Venous malformations

4.8.3. Lymphatic malformations

4.8.4. Arteriovenous malformations

4.8.5. Combined and complex malformations/syndromes

4.8.6. Venous aneurysms

4.9. Venous tumors

4.10. Recognition of life and limb threatening syndromes

4.10.1. Compartment syndromes

4.10.2. Acute limb ischemia

4.10.3. Infection

4.10.3.1. Severe skin/soft tissue infections

4.10.3.2. Necrotizing fasciitis

4.10.3.3. Osteomyelitis

4.10.3.4. Septic arthritis

4.10.3.5. Septic thrombophlebitis

4.10.3.6. Sepsis

4.10.3.7. Gangrene

4.10.4. Phlegmasia

4.10.4.1. Phlegmasia alba dolens

4.10.4.2. Phlegmasia cerrula dolens

4.11. Management of treatment-related complications

4.11.1. Neurological complications

4.11.2. Sclerotherapy complications

4.11.3. Saphenous ablation complications

4.11.4. Phlebectomy complications

4.11.5. Cutaneous laser complications

4.11.6. Compression complications

4.11.7. Pharmacologic treatment complications

4.11.7.1. Complications of anticoagulation

4.11.7.2. Complications of thrombolytic therapy

4.11.8. Stent complications

4.11.9. IVC filter complications

4.11.10. Anesthetic toxicity

5. Other components and core competencies important in the practice of venous and lymphatic medicine

5.1. Epidemiology and evidence-based medicine skills

5.1.1. Fundamentals of study design and hypothesis testing

5.1.2. Clinical classification tools

5.1.3. Patient reported outcomes measures

5.1.4. Statistical sampling and population analysis

5.1.5. Normal distribution, means and standard deviations, medians, interquartile ranges, incidence, prevalence

5.1.6. p-values and confidence intervals

5.1.7. Kaplan-Meier curves

5.1.8. Sensitivity, specificity, negative predictive value, positive predictive value

5.1.9. Sample size and power analysis

5.1.10. Systematic reviews and meta-analyses

5.1.11. Practice guidelines and their interpretation

5.1.12. Healthcare disparities

5.2. Communication skills

5.3. Patient care

5.3.1. Multidisciplinary care

5.3.2. Psychosocial treatments

5.4. Medical informatics

5.5. Medicolegal issues

5.6. Medical ethics and professionalism

5.7. Healthcare systems and government regulatory agencies

5.8. Quality assessment and improvement

5.9. Certification

5.10. Patient safety

5.10.1. Facility accreditation

Basic science

Basic science understanding integrated with clinical knowledge, is essential for accurate diagnosis and informed therapeutic decision-making and facilitates comprehension and incorporation of scientific advances. Basic science in VLM includes the anatomy of the venous, arterial and lymphatic systems, venous and lymphatic embryology, genetics and epidemiology of venous disease, venous histology and histopathology, and venous and lymphatic physiology and pathophysiology. In addition, it is important to understand venous hemodynamics and the processes leading to complications of chronic venous insufficiency. A thorough understanding of coagulation and thrombosis, thrombophilias, fibrinolysis, and thrombolysis is necessary. Knowledge of the diagnosis and management of venous leg ulcers and pharmacology relevant to venous medicine is essential. Fundamental physics principles related to imaging techniques especially ultrasound and fluoroscopy, thermal and non-thermal ablation and compression should be understood. Importantly, the risks of diagnostic modalities including the biological effects of ionizing radiation should be considered and strategies enacted to minimize patient and operator exposure. In addition, VLM physicians should utilize accepted and updated nomenclature in communication with colleagues and the current medical literature.

Diagnostic evaluation

A thorough understanding of the value and interpretation of clinical, imaging and laboratory examinations is essential to providing appropriate, safe, and effective management of VLM conditions. The practitioner must be able to recognize signs and symptoms of acute and chronic venous and lymphatic disorders of the lower and upper extremities, chest, abdomen, and pelvis. Diagnostic algorithms and clinical guidelines for each VLM condition must be well understood. The VLM specialist must also be able to differentiate signs and symptoms of acute and chronic venous and/or lymphatic disease from other causes. This is particularly true for the differential diagnosis of leg symptoms and signs, swelling, dermatological manifestations of venous disease, and leg ulcers.

Clinicians must also know how to appropriately utilize, interpret, and sometimes perform laboratory and non-invasive imaging evaluations of the venous and lymphatic systems. This includes evaluations of coagulation, Duplex ultrasound, and ankle-brachial index (ABI) and plethysmography, venous plethysmography, conventional venography, IVUS, MRV, CTV, ascending and descending venography, and lymphatic imaging such as lymphoscintigraphy, MR lymphangiography, indocyanine green mapping, and limb volume calculations. The clinician must understand the indications, predictive value, contraindications, risks, benefits, and alternatives for each type of diagnostic test.

Other essential areas of knowledge include familiarity with the relevant evidence based guidelines, disease classification instruments and patient-reported outcome measures for acute and chronic venous, lymphatic and arterial diseases. These clinical tools include the CEAP and Symptoms-Varices-Pathophysiology (SVP) classifications, Rutherford classification for acute and chronic limb ischemia, lymphedema staging; risk assessment tools for venous thromboembolism (VTE), widely accepted objective venous and lymphatic disease assessment scores (e.g., VCSS and Villalta Score), and specific patient-reported outcome measures.^4–12

Knowledge and skills integral to the practice of venous and lymphatic medicine

VLM physicians require knowledge, skills, and professional capability in the care of patients with venous and lymphatic disease. They must understand the full spectrum of the various clinical conditions, as well as their natural history. This includes evidence-based approaches to prevent disease progression; indications and contraindications for each type of diagnostic evaluation and treatment; risks and benefits of treatment; conservative care; treatment and follow-up of treatment. As many of the techniques required in the care of patients with venous and lymphatic disorders require image guidance, a thorough “hands on” knowledge of the safe and effective use of ultrasound and fluoroscopy is required.

Clinical sciences

The health issues that comprise venous and lymphatic disease are listed in Table 2. These include diseases of the extremities, chest, abdomen, and pelvis. Although venous disorders of the head and neck are sometimes related, issues in these areas are usually managed by other disciplines of medicine.

Other components and core competencies important in the practice of venous and lymphatic medicine

Evidence based clinical practice is necessary to enhance patient outcomes. The ability of physicians to critically read the medical literature and interpret the requisite statistics to assess the quality of studies and the strength of the conclusions drawn is essential. Physicians in all disciplines of medicine need to be well-versed in integrating scientific evidence along with patient values and preferences in their practices.¹³ In addition, understanding the clinical tools used to assess and categorize patients with VLM health issues is necessary. Awareness of relevant clinical practice guidelines, accreditation, and certification standards is essential and symmetric to core content requirements of other specialties, for example, interventional radiology, family medicine, and general surgery.^14–16 Finally, the core competencies that are common to all medical specialties are an essential part of the practice of VLM.¹⁷

Conclusion

This updated VLM core content document defines the specialty, the areas of knowledge a specialist should possess, skills necessary to provide appropriate care, and attributes of physicians who can be considered proficient in its delivery. Graduate medical education VLM curricula in all disciplines, societies offering post VLM graduate education and boards certifying competence in VLM may be informed by these statements, made by the broad array of multi-disciplinary experts, with the hope of making the training comprehensive for the benefit of patients.

Footnotes

Acknowledgments

Zoe Deol, MD and Jeff Schoonover, MD were the co-chairs of the multi-specialty initiative that culminated in this update to the Core Content for Training in Venous and Lymphatic Medicine. Additional support and input by the following also require acknowledgement: Steven Zimmet, MD, Raghu Kolluri, MD and Fedor Lurie, MD

Author Contributions

All authors contributed to the creation of this revised Corn Content document equally

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

American Vein and Lymphatic Society provided video conference logistical, and staff support to manage the conference calls related to the project.

Guarantor

Neil Khilnani, MD

ORCID iDs

NM Khilnani

PJ Pappas

RR Attaran

KR Desai

Appendix

References

Accreditation Council for Graduate Medical Education (ACGME) . Common program requirements (residency). Chicago, IL: ACGME, 2022, pp. 1–56. www.acgme.org/globalassets/pfassets/programrequirements/cprresidency_2022v3.pdf (Accessed 9 October 2022).

Zimmet

Min

Comerota

, et al. Core content for training in venous and lymphatic medicine. Phlebology. 2014 Oct; 29(9): 587–593. DOI: 10.1177/0268355514545120.

Masuda

Ozsvath

Vossler

, et al. The 2020 appropriate use criteria for chronic lower extremity venous disease of the American Venous Forum, the Society for Vascular Surgery, the American Vein and Lymphatic Society, and the Society of Interventional Radiology. J Vasc Surg Venous Lymphat Disord 2020 Jul; 8(4): 505–525.e4. DOI: 10.1016/j.jvsv.2020.02.001.

Lurie

Passman

Meisner

, et al. The 2020 update of the CEAP classification system and reporting standards. J Vasc Surg Venous Lymphat Disord. 2020 May; 8(3): 342–352. DOI: 10.1016/j.jvsv.2019.12.075.

Hardman

Jazaeri

, et al. Overview of classification systems in peripheral artery disease. Semin Intervent Radiol. 2014 Dec;31(4):378–388. DOI: 10.1055/s-0034-1393976.

Meissner

Khilnani

Labropoulos

, et al. The Symptoms-Varices-Pathophysiology classification of pelvic venous disorders: A report of the American Vein & Lymphatic Society International Working Group on Pelvic Venous Disorders. Phlebology. 2021 Jun;36(5):342–360. DOI: 10.1177/0268355521999559.

Executive Committee of the International Society of Lymphology . The diagnosis and treatment of peripheral lymphedema: 2020 Consensus Document of the International Society of Lymphology. Lymphology 2020; 53(1): 3–19.

Cronin

Dengler

Krauss

, et al. Completion of the Updated Caprini Risk Assessment Model (2013 Version). Clin Appl Thromb Hemost. 2019 Jan-Dec; 25: 1076029619838052. DOI: 10.1177/1076029619838052.

Passman

McLafferty

Lentz

, et al. Validation of Venous Clinical Severity Score (VCSS) with other venous severity assessment tools from the American Venous Forum, National Venous Screening Program. J Vasc Surg 2011 Dec; 54(6 Suppl): 2S–9S. DOI: 10.1016/j.jvs.2011.05.117.

10.

Soosainathan

Moore

Gohel

, et al. Scoring systems for the post-thrombotic syndrome. J Vasc Surg 2013 Jan; 57(1): 254–261. DOI: 10.1016/j.jvs.2012.09.011.

11.

Aber

Poku

Phillips

, et al. Systematic review of patient-reported outcome measures in patients with varicose veins. Br J Surg 2017 Oct; 104(11): 1424–1432. DOI: 10.1002/bjs.10639.

12.

Lurie

Malgor

Carman

, et al. The American Venous Forum, American Vein and Lymphatic Society and the Society for Vascular Medicine expert opinion consensus on lymphedema diagnosis and treatment. Phlebology. 2022 May; 37(4): 252–266. DOI: 10.1177/02683555211053532.

13.

Albarqouni

Hoffmann

Straus

, et al. Core Competencies in Evidence-Based Practice for Health Professionals: Consensus Statement Based on a Systematic Review and Delphi Survey. JAMA Netw Open 2018; 1(2): e180281. DOI: 10.1001/jamanetworkopen.2018.0281.

14.

Society of Interventional Radiology - Residency Essentials Program Curriculum. https://www.sirweb.org/learning-center/learning-center/residency-essentials-and-fundamentals/residency-essentials/program-curriculum/ (Accessed 18 Oct 2022).

15.

Family Medicine Residency Curriculum Guidelines. https://www.aafp.org/students-residents/residency-program-directors/curriculum-guidelines.html (Accessed 23 Oct. 2022).

16.

Curriculum

SCORE.

Outline for General Surgery 2021 - 2022. https://files.surgicalcore.org/curriculumoutline_gs.pdf (Accessed 9 October 2022).

17.

Edgar

McLean

Hogan

, et al. The Milestones Guidebook. Chicago, IL: Accreditation Council for Graduate Medical Education (ACGME), 2020, pp. 1–41. https://www.acgme.org/globalassets/milestonesguidebook.pdf (Accessed 24 August 2022).