Introducing the 2026 Focused Issue on Venous Disease: What excites us most about the future of this field

Heather L Gornik, MD, MSVM

It is with great excitement that I introduce our 2026 Vascular Medicine focused issue on venous disease. Indeed, this is the second time in my 12-plus year tenure as Editor-in-Chief that we have focused on this important aspect of vascular medicine . . . our first focused issue on venous disease was in 2015.

What excites me most about the present and future of this field is the growing enthusiasm for venous disease as an important aspect of vascular medicine and the proliferation of high-quality research in this arena. Although our 2015 focused issue was rich in articles on venous thromboembolism (VTE) and anticoagulation, it had only a few papers on other topics (e.g., thoracic outlet syndrome and venous leg ulcers). In contrast, our 2026 issue has a broadened scope. The issues include research related to pulmonary embolism (PE) and deep vein thrombosis (DVT) as well as superficial venous disease, ¹ chronic venous insufficiency, ² pathophysiology of venous disease,^3,4 and pelvic venous insufficiency. ⁵ VTE continues to be importantly represented, including a state-of-the-art review on exercise for the prevention and treatment of post-PE syndrome and a single-center study that surprisingly shows no impact of transition from standard to a high-sensitivity troponin assay in the PE management strategy.^6,7

We hope you enjoy the rich content in this issue, and I can only imagine what advancements we will see in our next focused issue on venous disease (in 2036?!). In the spirit of looking forward, several members of our Editorial Board were invited to share what excites them most about the future of venous disease, and their responses are included below.

Yogendra Kanthi, MD, FSVM

Advances in the management of venous disease are entering an exciting new phase, propelled by a growing recognition that inflammation is both a driver and amplifier of venous pathology. Although the etiology of venous diseases is heterogeneous, they converge into phenotypes that engage inflammation, fibrosis, and thrombosis. The venous system, once thought to be a passive conduit, is a critical immune reservoir where leukocytes marginating along the endothelium continuously sample antigenic cues. Venous valves, sinus pockets, and venules function as microanatomic niches that concentrate immune cells, promote cytokine exchange, and shape the kinetics of venous rheology, inflammation, thrombosis, and fibrosis. Harnessing this new understanding opens the door to mechanism-based diagnostics and therapies that target the cellular and molecular choreography of venous immune regulation. With emerging tools in spatial immunology, single-cell profiling, and targeted immunomodulation, the field is at the precipice of major advances that will transform patient care. This is an exciting time in which vascular medicine is uniquely poised to lead this next phase of discovery and translation, combining mechanistic insight with clinical expertise in thrombosis, venous physiology, and immunovascular biology.

Robert D McBane II, MD, MSVM

I am excited by the emerging understanding of how calf muscle pump failure contributes to major adverse cardiac events, including all-cause mortality. Normal calf pump function requires a complex interaction between patent venous channels, competent valves, compliant walls, functioning lower-extremity joints, intact neuromuscular function, and effective calf muscle contraction. This pump enhances right atrial preload for normal cardiovascular physiology through augmented venous return from the lower extremity. Impairment leads to chronic venous disease, which is a major cause of vascular morbidity. Calf muscle pump function can be readily measured as part of a comprehensive assessment of lower-extremity venous physiology using air plethysmography. Emerging data suggest that the health implications of calf pump failure extend beyond mere leg swelling and skin ulceration. Among 2728 patients, impaired calf pump function (assessed by plethysmography) increased all-cause mortality rates among patients with and without heart failure. ⁸ Combined heart and calf pump failure carried poor prognosis compared to isolated heart or calf pump failure alone. Among 5913 patients, mortality outcomes were inversely proportional to the severity of calf pump failure with a graded deterioration of survival for each 10% decrement of calf pump ejection fraction. ⁹

Coined ‘Calf rEF’ to indicate calf pump failure with reduced ejection fraction, the precise mechanism responsible for the pathophysiology and mortality outcomes have yet to be elucidated. Future research will seek to identify variables responsible for this dysfunction and opportunities for improved outcomes.

Ido Weinberg, MD, FSVM

For decades, venous diseases, and even VTE, have played second fiddle to arterial disease. But it seems like the near- and medium-term futures of this field are poised to be very exciting. On the horizon we can already see innovations in medication (e.g., factor XI inhibitors) and medical devices (e.g., mechanical thrombectomy). High-lever data are finally being collected to test these advances for their utility. Furthermore, many unanswered questions are being brought into focus, offering reasonable hope for more tailored care delivery to patients with venous disease.

Office-based and bedside point-of-care ultrasound (POCUS) to the benefit of patients is of particular interest. I believe that with thoughtful implementation there is potential to improve patient care on several levels: education through demonstration, rapid diagnosis (or ruling out a diagnosis), and expanding the reach of ultrasound to communities where it may not be economically feasible to have a full vascular laboratory. Obvious use cases include DVT screening and monitoring, as well as tools to plan and implement invasive treatments for venous insufficiency. A word of caution, though. A few years ago, we reported that the data regarding vascular POCUS were limited and the training that typically precedes the implementation of this technology was often minimal. ¹⁰ Furthermore, data are lacking concerning the accuracy of POCUS compared with the traditional vascular lab-based, full-protocol ultrasound. Possible ways to make vascular POCUS safer for patients include research studies focused on the use of this technology in the vascular space, ¹¹ standardization of provider training, and potential widespread implementation of AI models to enhance image acquisition and interpretation of results.

Geoffrey D Barnes, MD, FSVM

We are seeing the rapid development of new drugs and devices to tackle both the acute and the chronic phases of venous thromboembolic disease. The past 5–10 years have introduced new innovations in the care of these patients, and the next 5 years will bring higher quality evidence, including randomized trials comparing a wide variety of therapies against current standards of care in acute PE and acute DVT. These trials will assess both short-term and long-term outcomes that are highly patient-centered. In addition, new pharmacologic therapies aim to reduce the burden of VTE while reducing the risks of bleeding and/or targeting new inflammatory pathways that likely contribute to thromboembolic risk. As a result of these new trials and innovations being developed and tested, our ability to provide evidence-based care for patients with acute VTE is going to improve dramatically. And with this new evidence will likely come updated guideline references to help clinicians determine how best to integrate these drugs and devices into their practice.

Gregory Piazza, MD, FSVM

I am encouraged by our enhanced ability to more precisely describe the risk of adverse short- and long-term outcomes in patients with acute PE. Traditionally, risk stratification schemata have focused on a small number of prognostic categories, each with wide heterogeneity in both presentation and outcomes. ¹² Accordingly, the precision of management recommendations have been limited, particularly regarding which lower-risk patients may be safely treated without hospitalization (‘home PE therapy’) and which higher-risk patients require reperfusion to avoid clinical deterioration. Of particular note, the explosive advancement of catheter-based intervention for PE has outpaced our ability to identify patients in whom such therapies are likely to be beneficial and cost-effective. Emerging strategies for risk stratification are poised to advance our ability to determine clinical risk phenotypes and more precisely match therapeutic decision-making. The incorporation of more nuanced clinical risk tools—such as the Composite Pulmonary Embolism Shock (CPES) score and the National Early Warning Score (NEWS), that can be performed serially to detect changes in clinical trajectory before hemodynamic collapse, as well as advanced biomarkers of preclinical shock like serum lactate, and enhanced imaging assessment of the right ventricle and pulmonary vasculature—has great potential to add an unparalleled level of prognostic precision. ¹³ These innovations coupled with artificial intelligence’s (AI) ability to rapidly assimilate such large quantities of data will offer the clinical and research communities the capacity to identify risk phenotypes across the spectrum of PE presentations and could usher in a new era of precision medicine and more efficient scientific investigation.

Suresh Vedantham, MD

Biology-targeted endovascular intervention will become the norm in venous disease care. In current practice, endovascular deep venous procedures are aimed at modifying gross macroscopic features of the disease (i.e., restoring flow by eliminating major obstruction). However, clinical trials have demonstrated that this may be helpful for selected patient groups, but it is not nearly sufficient to reduce most of the clinical disease burden. Thankfully, progress is being made in better characterizing the underlying biology of venous thrombus resolution, endothelial recovery, inflammation, fibrotic changes, and the modifying factors. Armed with this understanding, future endovascular tools will integrate elements (e.g., drug coatings and biodegradable elements) that can tackle both the macroscopic and the microscopic factors that influence clinical disease. The result will be a more individualized targeting of specific therapies to patients who are likely to benefit, and better clinical outcomes.

Mobile technology and AI will transform the prevention, treatment, and monitoring of VTE. Better primary and secondary prevention will stem from an ability to more accurately profile an individual’s risk for VTE and its complications (e.g., recurrence, acute deterioration from PE, postthrombotic syndrome, post-PE syndrome) based on combinations of known risk factors, social determinants of health, mobile health data, and varied additional data sources. This capability will apply to people living their daily lives, not just to hospital inpatients; it may even become possible to prevent many of the prehospital fatal PE events that are currently considered beyond reach. VTE treatment will be improved by an enhanced ability to individualize the prediction of risks and benefits of therapy based not only on aggregated data on the efficacy and safety of specific treatments but also on information that reflects a patient’s real-world environment and behaviors. The development and validation of new mobile health tools and sampling strategies (e.g., ecological momentary assessment) will enable real-time monitoring of the venous health of outpatients, enabling well-timed and well-targeted intervention, faster and more patient-centered clinical trials, and stronger engagement of patients in their own health.

Raghu Kolluri, MD, MSVM

What excites me the most about venolymphatic disease is the progress of discovery: how little we understood about venous disease two decades ago, how much we have learned since, and how much more we need to uncover. The awareness of VTE has grown tremendously. Chronic venous disease (CVD), once dismissed as a mere cosmetic condition, now rightfully receives the recognition it deserves, with a better understanding of its morbidity and societal and economic impact. ¹⁴ We have seen the introduction of on-label venous stents, newer venous ablative therapies, rapid advances in thrombectomy technologies, and widespread adoption of direct oral anticoagulants—all of which have led to a meaningful transformation of venous practice. The future of venous disease is even more compelling because the focus is shifting to patient-reported outcomes, both by trialists and by regulatory agencies, in VTE and CVD trials. ¹⁵ This evolution will improve decision-making for our patients. Despite these advances, our understanding of venous pathology and physiology remains significantly behind that of coronary artery and peripheral artery disease. I see this knowledge gap not as a setback but as an opportunity—a huge potential for new insights, discoveries, and innovations. I look forward to better physiologic assessment methods for venous obstruction, similar to fractional flow reserve in coronary circulation. Likewise, I anticipate a shift toward vein-sparing technologies instead of current vein-ablative therapies. All in all, the time for venous disease is here, and we are just beginning to realize what is possible.