Updated:
by
Peter J. Pappas, MD, FACS
Medically reviewed by Peter J. Pappas, MD, FACS
Modern vein care has changed dramatically in just a couple of decades. Treatments that once required hospitalization, general anesthesia, large incisions, and weeks away from work can now be performed in an outpatient setting with minimally invasive technologies.
But as vein procedures became easier to perform, a new problem emerged: physicians from many different specialties began offering vein treatment without receiving formal education in venous and lymphatic disorders.
Center for Vein Restoration’s Venous and Lymphatic Medicine Fellowship was created to help close that training gap.
We spoke with Peter J. Pappas, MD, director of CVR’s fellowship program, about why the program was established, how fellows are trained, and why structured education matters to patients seeking specialized vein care.
The reason these fellowship programs were developed was to correct the disparities in patient outcomes caused by the emergence of new technologies and lack of formalized graduate medical education.
Dr. Peter J. Pappas
Schedule a consultation with Center for Vein Restoration (CVR) to receive prompt, expert evaluation in a safe outpatient setting.
Historically, venous disease was largely treated by vascular surgeons because the available treatments were open surgical procedures. Patients with large varicose veins would be admitted to the hospital, placed under general anesthesia, and undergo vein stripping through multiple incisions.
These procedures were very painful and required lengthy recovery periods. More complex venous conditions were even harder to treat, and results were not always predictable.
The field changed when catheter-based treatments, injectable medications, and minimally invasive vein-removal techniques became available. These advances made effective outpatient treatment possible and significantly expanded access to care.
However, they also made it possible for physicians without extensive vascular surgery training to begin performing vein procedures.
As Dr. Pappas explains, the challenge was no longer simply teaching physicians how to use a catheter or inject a medication. The larger challenge was ensuring that practitioners understood venous anatomy, ultrasound interpretation, patient selection, lymphatic disease, compression therapy, treatment planning, and long-term care.
A void developed in terms of how we ensure the same quality care is being delivered to patients across the board, regardless of what your initial training was.
Dr. Peter J. Pappas
CVR launched its fellowship to create a structured pathway for physicians seeking to become true specialists in venous and lymphatic medicine. Dr. Pappas joined CVR in 2016, and the program welcomed its first fellow in 2017.
One of the most important distinctions of the program is its emphasis on both technical and cognitive education.
Learning how to perform the technical aspects of vein procedures is only one part of becoming a specialist. Fellows must also understand why a treatment is appropriate, how to interpret diagnostic findings, when not to perform a procedure, and how venous disease interacts with lymphatic dysfunction and other medical conditions.
Dr. Pappas regularly reminds fellows that mastering a procedure is not the program's ultimate goal.
I'm not concerned one iota about you becoming facile or experts at doing the procedures. I'm more concerned with you getting your cognitive skill sets, because that's what defines you as a specialist.
Dr. Peter J. Pappas
That distinction matters to patients. A technically successful procedure may still fall short if the underlying diagnosis is incomplete or the treatment plan doesn't address the patient's full condition.
Formal fellowship training prepares physicians to evaluate the entire clinical picture rather than focusing only on visible veins or a single ultrasound finding.
The fellowship is organized into four three-month rotations, with responsibilities increasing as each fellow develops.
During the first six weeks, fellows spend their time in the ultrasound laboratory alongside vascular technologists. They learn how to perform and interpret venous reflux studies and scans used to rule out deep vein thrombosis. They also study ultrasound physics, machine settings, probe positioning, anatomy, and venous physiology.
Dr. Pappas considers this training foundational.
If you don't understand ultrasound physiology, you're not going to be able to perform procedures.
Dr. Peter J. Pappas
After building that foundation, fellows begin training in the procedure room. Early responsibilities may include ultrasound-guided vein access, administering tumescent anesthesia, assisting with ambulatory phlebectomy, and performing selected foam sclerotherapy injections under supervision.
During later rotations, fellows continue developing these skills while learning cosmetic sclerotherapy, improving procedural efficiency, moving between consultation and treatment rooms, and managing the flow of a busy vein practice.
They also complete a non-invasive vascular laboratory rotation that includes education in arterial ultrasound. The goal is to prepare fellows for independent practice and relevant certification examinations.
By the final rotation, fellows focus on remediating remaining skill gaps, credentialing, and the transition into their own CVR clinics.
The expectation is, by the end of the 12 months, you can now practice independently as a specialist.
Dr. Peter J. Pappas
The fellowship extends well beyond hands-on training.
From September through late spring, fellows attend a weekly lecture series featuring CVR faculty and visiting experts. Fellows also prepare grand rounds presentations, participate in journal clubs, and conduct detailed literature reviews based on clinical questions encountered in practice.
These reviews are shared not only with Dr. Pappas and the other fellows, but also with the broader CVR physician community. Faculty members can add perspectives, identify additional studies, and participate in the educational discussion.
Over time, fellows build a personal library of research, powerpoint presentations, classic journal articles, and clinical reviews they can use throughout their careers.
The program also provides access to textbooks, vascular imaging resources, conference attendance, research opportunities, and clinical equipment. A full-time fellowship coordinator helps manage participants' educational and administrative needs.
A training program cannot succeed through written curricula and clinical volume alone. It also requires dedicated physicians who are skilled practitioners and committed educators.
CVR operates clinics across the country, but not every experienced physician automatically serves as a fellowship mentor. Dr. Pappas looks for faculty members who are passionate about teaching and capable of explaining both the reasoning and technique behind patient care.
You need to have people who not only can do the procedures, but who actually are good teachers.
Dr. Peter J. Pappas
Fellows rotate among different mentors and locations so they can observe more than one approach to care. This exposure helps them understand that there may be several clinically sound ways to evaluate a patient, perform a procedure, or manage a practice.
What remains consistent is the expectation of careful diagnosis, evidence-based decision-making, professionalism, and patient-centered care.
Without the mentors, without the structure, without the format, without the policies, the procedures, the infrastructure—everything that CVR provides—there is no training program.
Dr. Peter J. Pappas
The fellowship also emphasizes communication and professionalism.
Fellows interview patients, present cases to supervising physicians, observe consultations, and eventually conduct visits while faculty evaluate their performance. Communication is reinforced during interactions with vascular technologists, nurses, medical assistants, attending physicians, and patients.
The program evaluates physicians across several competencies, including medical knowledge, systems based practice, clinical judgment, patient care, professionalism, and communication.
This approach helps fellows learn how to explain complex conditions clearly, set realistic expectations, discuss treatment options, and listen to the concerns that brought the patient to the clinic.
For patients, these skills can be just as important as procedural ability. Vein disease is often chronic, misunderstood, or dismissed as cosmetic. Patients need physicians who can connect symptoms, imaging findings, medical history, and personal goals into a clear care plan.
Formalized training gives physicians a concentrated year of reading, clinical evaluation, ultrasound education, supervised procedures, case discussion, and mentorship.
According to Dr. Pappas, that experience separates a venous and lymphatic medicine specialist from a physician who has only encountered portions of vein care through another residency or specialty.
You're going to spend an intensive 12 months reading, learning, and doing, and that's what separates you from someone who hasn't done formalized training.
Dr. Peter J. Pappas
The inclusion of lymphatic medicine is especially important. Lymphatic disease is not consistently taught in traditional medical subspecialty programs, even though venous and lymphatic conditions frequently overlap.
For patients, a physician with formal education in both systems may be better prepared to recognize complex swelling, understand compression needs, distinguish venous symptoms from other conditions, and develop a more complete treatment plan.
CVR's fellowship began with one fellow and has grown into what Dr. Pappas describes as the largest program of its kind in the country. The program has graduated dozens of physicians and has the capacity to continue expanding.
Dr. Pappas believes that formal fellowship training will become increasingly common as venous and lymphatic medicine continues to develop as a specialty.
More and more of the people practicing in the field are going to have been formally trained, and not having that formal training is going to be the exception rather than the rule.
Dr. Peter J. Pappas
That evolution will take time. But each trained specialist helps raise expectations for diagnosis, education, treatment, and continuity of care.
For prospective fellows, the program offers a structured path into a growing field with significant patient need. For patients, it represents CVR's broader investment in developing physicians who understand vein care beyond the performance of individual procedures.
Schedule a consultation with Center for Vein Restoration (CVR) to receive prompt, expert evaluation in a safe outpatient setting.
Who is eligible to apply for CVR's fellowship program?
The fellowship is designed for physicians who have already completed an ACGME accredited residency and want focused education in venous and lymphatic medicine. Applicants may come from different medical backgrounds, but they enter the program as licensed physicians with prior patient-care experience.
How long is the CVR Venous and Lymphatic Medicine Fellowship?
The fellowship is a 12-month program divided into four three-month rotations. Fellows progress from ultrasound and foundational skills to supervised procedures, consultations, practice management, and independent clinical readiness.
Is the fellowship primarily focused on procedures?
No. Although fellows receive extensive procedural training, the program places equal or greater emphasis on diagnostic reasoning, ultrasound interpretation, medical knowledge, patient selection, professionalism, communication, and longitudinal treatment planning.
How does fellowship training benefit CVR patients?
Fellowship-trained physicians complete structured education in the diagnosis and management of venous and lymphatic disease. This can help them evaluate the full spectrum of a patient's symptoms, select appropriate treatments, recognize complex conditions, and provide more comprehensive care.
Do fellows train at only one CVR location?
No. The program uses a national training model, with fellows working at selected CVR sites and participating in remote lectures and conferences. Rotating among mentors gives fellows exposure to different clinical approaches while maintaining a consistent educational structure.
What makes CVR's fellowship different from informal vein-procedure training?
Informal training may teach a physician how to perform a particular procedure. CVR's fellowship is designed to prepare an independent specialist through supervised clinical care, ultrasound education, formal lectures, research reviews, journal clubs, mentorship, certification preparation, and progressive responsibility.
About Vein Disease
Spider Veins
Varicose Veins
Vein Disease Treatments
Treating Spider Veins
Treating Varicose Veins
About Us
Patient Resources
Physician Resources