All right. Good afternoon, everyone. Thank you for joining us at the William Blair Gross Stock Conference this year. My name is Margaret Kazar Andrews. I am the medical technology analyst that covers Penumbra for Blair. For a complete list of research disclosures or conflicts of interest, please see williamblair.com. Before I'm going to turn it over to Adam, maybe I'll do just a short, brief comment on our end. You know, Penumbra has been one of our top names, you know, not only for this year, but also for the next two to five years. And the pitch, frankly, has been relatively straightforward. You know, one, you have this large VTE market that is actively adopting mechanical thrombectomy products. In the meantime, you also have one of your largest competitors that may be going through some integration issues that maybe you can take advantage of.
Two, you've got an upcoming approval of a new CAVT platform for Neuro. Remember, this is the platform that created this big growth in VTE to start out with a few years back. Three, you've got upcoming clinical data that's coming out that could really change societal guidelines and drive an inflection in adoption of mechanical thrombectomy in general. That's starting in 2026 and going to keep going after that. Throw on some margin expansion on top of it, and you know, you've got a pretty good story to want to own. That said, I'm going to leave it to Adam to provide more context on that. Thanks.
Thank you, Margaret. Great to see everyone. Really happy to be here at William Blair, and thank you for including us. I am going to stand just this way because otherwise I have no idea what this light is here. This is our safe harbor disclosure. Just a quick background for those of you who do not know, we are a company based in California in a town called Alameda, California, in the northern California Bay Area. As of now, all of our products are manufactured in two large facilities in California, one on our campus in Alameda and the other about two hours away near Sacramento in a town called Roseville.
We have plans underway, or not just plans, to build a facility outside the U.S. that will be used either for expansion, but either for products that have a slightly different margin profile or for products that are sold internationally, depending on where we are at that time. It's not planning on coming online until about 2027. Right now, company-wide, we have over 4,500 employees, again, manufacturing, R&D, and all the other functions, sales and marketing, and so on. We have products available throughout the world. The company's been around now. We're in our 21st year, so we have been selling internationally for quite some time. We have folks in most of the countries in the world and have many, many, many years of experience selling in international markets, watching the changes country by country as things change, which it always does.
I think we're well positioned to continue to make our products available as appropriate and able in countries throughout the world. We're based with sort of three buckets of products: embolization, which is basically platinum coils. Technology's been around for a while, started many, many years ago with a company in the neuro space called Target Therapeutics, made a detachable platinum coil. Our access portfolio, which is really catheters that form the sort of highway to go where you're needing to go. It's sort of a larger catheter that you then put a smaller catheter through. Those access tools really have—we have revolutionized them initially in the neuro space. Thrombectomy, which is really what drives our current growth and what we really started the company for. The idea of taking clot out of the brain was what motivated us to start Penumbra.
That has expanded to all other parts of the body: the arterial side, the veins, the lungs, even the coronary. It is driving, I think, the growth primarily going forward. Quick little deeper dive on thrombectomy, just to sort of level set. I'm using numbers from the U.S. as an example. Obviously, if you apply this to all the other countries, the numbers would be much higher, but these are just U.S. If you take the five basic vascular beds, you're looking at an opportunity of well over a million patients. I want to comment a little on these numbers. These are conservative estimates. I say that because other companies have different numbers. No one knows with certainty what exact numbers these are. We have taken the position of being a bit more conservative.
For example, if you look at PE, other companies are well over 200, 250,000. That may be true. Obviously, we do not know for sure, but we have taken a much more conservative approach on what this is. Obviously, if the denominator is bigger, the opportunity to help and possibly impact a lot more patients is even greater than this. I wanted to give you a quick sense. Sometimes these numbers are sort of lost in the headlines. If you just look at the five buckets, DVT, you know, the venous side, is actually the largest number. That is just of a type. If you take all DVT, it is much larger than that. I want to point that out because, you know, that is a huge opportunity for us to help a lot of patients.
It's not one that always gets the attention that stroke and pulmonary embolism get. In terms of sheer numbers of people that can be helped, it's obviously pretty significant. We're starting to make some interesting inroads there that I'll address in a moment. Just to give you guys some sense of what those numbers really are, our current technology, we call it CAVT or computer-assisted vacuum thrombectomy. This is the idea of using a computer chip to orchestrate or control the valve that opens and closes the aspiration that comes from that pump you can see in the picture. What we have learned is that the analog versions that we've had, the idea of a catheter and a pump, or some companies have a catheter and a syringe, that's great, except you can't do—it's one-dimensional. You can't do anything with it.
You either turn it on or off. What we have found as we've gone into larger vessels and moved to this next level is that if you can control that in a way that is, you know, the computer controls it, senses when you're in clot, when you're not in clot flow, you can dramatically change the effectiveness of how fast you can ingest clot without having additional blood be sucked out. That's a huge thing. This technology, which is now several years old, we're on our second version, if you can see there on the slide, Lightning Flash 2.0. Lightning Flash, you know, the original Lightning Flash, we didn't actually call it 1.0, but 2.0 is solely an update to the algorithm, to the computer programming that changed pretty dramatically how this product worked.
One can think going forward how what that opportunity looks like when you can much more quickly change a computer program than physically make a new product or a new size or what have you. I am really excited about the innovation coming, and I'll address that in a second. On the arterial side, you have Lightning Bolt 7, Lightning Bolt 6X, and Lightning Bolt 12. The numbers are just sizes of catheters. That is a technology that is a little more sophisticated. It uses something we call modulated aspiration that really can deal with taking slightly more focal clot out very effectively. Your time of ingestion of the clot is reduced pretty dramatically. That has been the big innovation that we've seen.
Thunderbolt, which is a very similar technology to Lightning Bolt, that is the same fundamental technology, is the product name brand used on the neuro side. We just completed our clinical trial and submitted that to the FDA for review and ultimately clearance. I'm excited about that. There's been a lot of anticipation. I think, you know, we have spent the better part of 21 years here innovating over and over again on the catheters. How do you make these catheters big enough, not too big that you actually mess up aspiration? That's a different story. There is a time when you go too big, and some folks have where aspiration is actually negatively impacted, but big enough, just big enough. The next thing, but that can also track easily up to the brain.
The next thing is how do you impact ingestion times? How do you make the case shorter again and more effective and more predictable? That is where Thunderbolt comes in. I am very, very excited. Everyone who knows knows that we are excited about bringing that to the market. I am going to not go through a ton of cases, but I do want to highlight a couple of things. This is using Lightning Flash 2.0. The image on the far left is the left side blocked. You can see the middle image where the contrast fills that whole space. It is now open. Then, of course, the now obligatory picture of, you know, the blood clot that was taken out of that patient. The thing to note there is the device time. It is two minutes.
When I mean device time, I do not mean skin to skin, you know, tracking things there. That is not what it is for patients. And, you know, can always get a little easier or better, but that is not really the problem here. It is how fast can that clot come out? In this case, it was two minutes that the device was on. That used to be, you know, an hour plus. Obviously, I showed you a really good case, but there are a lot of them in this timeframe. That has become the new standard, you know, very quick on these cases. I think that is really what I want people to take away from here. Again, Lightning Flash 2.0, but this time used in a DVT. Again, you can see the blockage on the left side.
The two next pictures where it's post, you can see it says post up there where the contrast fills that. It's wide open. Again, the clot that is coming out there, it took eight minutes of device time for all of that clot to open up the vein in the leg. Moving to the arteries, this is a Lightning Bolt 6x. Again, you can see the blockage on the darker artery there. It sort of looks like a stub at the end on the bottom of the two darker ones. The next middle picture, it's wide open and all of those clots. The clot's a little different. It's a little smaller, more focal pieces of clot. Again, it was less than two minutes once the device was turned on to get that clot out.
Compare that to an open surgery case where you would do a cut down, you would open up the artery and sort of balloon and drag it through the artery, take it out, then sew it all up versus doing a quick interventional procedure that the device time itself was less than two minutes. It's a different moment in time for this technology. Here's Lightning Bolt 7. Again, you can see this is pretty dramatic where this is a mesenteric artery. You can see the blockage there in the middle of the left-hand picture and then all the branches wide open. Again, less than one minute to take out what is a relatively small focal piece of clot from the tip of that artery. Okay. That's just giving you a little bit of sense. This is a DVT that we use Lightning Bolt 12 for.
Lightning Bolt 12 is primarily used in smaller veins, but can be used occasionally in larger arteries. Again, five minutes of device time and again, opening up that vein pretty easily. The final one, just because I'm excited, Thunderbolt has, you can see the picture on the left, the blockage and see that little bubble in the middle and then the artery that sort of stops on the picture on the right where that's wide open and you've taken all of that clot. We don't yet, not in neuro, they don't always take pictures of all the clots, so we don't have that. This was also in a clinical trial and felt, I think, a little silly to do that. You don't have the clot picture, but you can see how fast that worked in those patients.
I want to touch briefly on the other parts of our business because they matter to us as well, our embolization and access business. Our access business really has been sort of, you know, the thing that's redefined, particularly the neurovascular space. When we started, there was no neuro-specific guide catheter that anyone made. We were the first company to do that. We opened up the capacity many, many years ago to access easily the case times and so on because of our guide catheters. I put down Neuron MAX 088. That's a number that if you follow the field at all, you might have heard companies are out there with catheters that they thought could be used at that size for stroke. We made the first Neuron Max 088 product many, many years ago as a guide catheter. It's a great guide catheter.
The size is the right size for guide catheter. We've sold well over a million units of that product. It's the market leader. Obviously, one can, you know, imagine, you know, if the goal is to use that as a guide catheter, but push it a little higher up, one can do that, you know, make a new version that does that. That's on the access side. On the embolization side, we have some of these coils are used in neuro, but the bulk of them are sold on the vascular side where the fundamental premise of our coils is big, bigger coils or larger, longer, softer coils. The combination of the bigger, longer, softer is really the defining thing of our coil franchise. Just recently, you can see there under Ruby, the second one, there's something called the XL system.
We just are in the early stages of getting ready to launch the Ruby XL coil, which is by far the biggest, longest, softest coil that we've launched. It will be used really to open up another round of types of lesions that we can do. We're pretty excited. The business is, we haven't had a new coil launch in a while. The team's pretty ready to go. I think we can make a big difference with that. I've talked a little bit about this for a bit now, this sort of the four-pronged strategies, like what do we have to do over the next number of years? It really starts with innovation. I'll touch on that in a minute, a little deeper. It also in talk, we need to continue to invest in our commercial team, providing them focus.
We're doing that now because we have a lot to do on the embolization side and the thrombectomy side. How do we properly provide focus? We're doing that as well as the third prong, which is what we call market access, the idea of how do we, what do we do? How do we, what kind of data do we need to have hospitals realize that they can treat more of these patients? It's not only good clinically, that's obviously the first and most important part, but that it's also very importantly good financially. You're not asking a hospital to lose money by doing the right thing and treating more and more patients. I'll touch on that in a second. Of course, doing all of those three things, wow, we're expanding our margins and increasing profitability and cash flow.
We have proven we can do that. I think we are going to continue to do that going forward. Sort of, you know, hold us to these four things. That is what I am holding us to. If we do this, I think we will continue to build a very successful company. I want to briefly touch about innovation. We are 21 years in business. We are, I think, more confident in our innovation, our ability to innovate now than we ever have been. The team is extraordinary. We just keep going. The way we innovate, the way the teams are set up, the way we think about, you know, what we spend, what we do not spend, I think is really a key to our success. This is a public webcasting.
I'm not going to give you every secret, but I would be delighted to, we've hosted a few folks out to our company, not to show them the products we're working on because that wouldn't work, but to like, how do we do it? What is like the secret to sort of how we set this up in the mindset of our team in R&D? It's some of the most fun I've ever had doing that because I think there's an insight into why I think we have been so successful and will continue to be around R&D. I want to briefly talk a little bit more about the idea of market access. Market access is this fundamental idea of how do you talk to hospitals to say, it's in your power to treat more patients with DVT or PE or ALI?
Why would you do that? What we have done is we have used Vizient, which is one of the largest GPOs, covers 40 some odd % of hospitals. They have gone and looked at their data. We have created a propensity match data set with our product in each of those categories, arterial, DVT, and PE separately, looking propensity matched against patients that got what is considered the standard care, anticoagulation, and shown the difference in clinical outcomes. Each one has a slightly different measure to say, are the patients doing better clinically? It confirms that, yes, they are doing better clinically. Then what is that financial impact on the hospital? Does it cost us money? Does it make us money?
You know, when you look at all the costs on both sides of that ledger for both patient sets against the reimbursement for those patients, both public and private, you know, because reimbursement, you know, comes in different forms. It is about 50/50. It is a mix of public and private payers. The reality is it is better clinically and it is more profitable. It is very much more profitable. Those are the numbers that we are sharing with hospitals. We are sitting down and really laying that out. They are obviously deciding, you know, we have the power and the control to, you know, look at this and think about treating more and more of these patients by focusing on the right protocols and doing things. Those that we have already done this with have been very successful.
We've seen a significant uptick in the patients that are getting a better treatment. And everyone seems pretty happy about it, obviously, the patients the most. This is going to be key. It's time-consuming. You know, you're going hospital by hospital, meeting with the leadership of the hospital. I've done some of them. It's incredibly fun because, you know, when do you get to go and say, by the way, you know, your patients can get better and you can make more money? It's not something that normally we're, you know, we're going to charge you some, you know, more and you're fighting about price over product. It's a lot of fun and the work is rewarding. I'm excited to see that continue. Now that we've sort of proven it out conceptually, we're going to accelerate that.
That is the core of how do you grow this market, not just take share. I'm going to sort of end with just a quick review and then we'll maybe have a minute or two for questions or not on our past, you know, financial performance. The slides sort of are there. It shows historically ending with Q1 and what our revenue is, breakdown for the US thrombectomy number as well with some of the growth numbers there. This is some of the profit, the performance, the gross profit and so on. Again, you can see there's sort of a rhythm to that, you know, every year, you know, start first couple of quarters, the margin is a little smaller because of sales meetings and payroll taxes and all that kind of stuff. Then it grows throughout the year.
We're, I think, right on track to be where we had said we were going to be. This is what we've said for our 2025 guidance on the last quarter's call. We're excited to be in a position where we can continue to see the kind of growth we're seeing. Just as a quick aside, this has come up a bunch, I think it's been said, but just as a level setting, you know, we've talked about China in last call and our revenue from China is sort of going down because of tariffs now, but also before it had gone down just because of the economic situation. We're, you know, sort of now going, you know, significantly down.
If you were to just take China out of the revenue from 2024 to 2025 even, you would be in a situation where that guidance that we've given for the company, which is 12%-14%, would be probably closer to 16%-18%. That is the sort of headwind that we're facing just, you know, this year on China. It's not that much, but, you know, it's notable because I understand, you know, if you're looking at guidance, you know, growth ranges, you know, it has a one-time sort of impact there. I think we're in really good shape going forward. We're set up for the ability to help an awful lot of people going forward. With that, thank you. Turning it back to you if you have a question or two. There are questions in the audience. I'd say raise your hand. Happy to do it.
I'm not Mike, so I'm going to have you repeat the question. Oh, okay. But that's not all. You know, I want to start with VTE. I mean, you guys have put up 40% plus growth for a few quarters now. You know, market growth seems like it's relatively stable. I know there's been a little noise maybe around that more recently, but yes, a couple of things. One, what's driving that growth for you all if you could differentiate it? Two, you know, how can you speak to that 20% market growth in VTE, not only in 2025, but 2026 and beyond, especially in the context of data that's coming? Yeah. The question is around our VTE growth. The last couple of quarters, VTE has grown at 40%. The question is what's driving that growth?
The market growth aspect of that is that, you know, somewhat sustainable going forward. Let me, I'll start with the first part of the question. Obviously, over the last couple of quarters, we've seen a pretty significant shift in share toward our product. That, you know, I think folks heard me talk about that maybe a quarter or two before it actually happened, but then it happened. It takes a while for sharedership. People have to change their mind. They have to get comfortable. You know, they have to try a case, you know, and then decide to go. We saw a pretty big group move toward using us frontline in the last couple of quarters. That process, you know, by no means are we, you know, the dominant yet player. We're starting to catch up. There's a lot more to get.
Share shift does not happen linearly. I have said this a bunch of times. You know, there are times when there is a big data set or there is a reimbursement decision, something that drives much faster shift. In this case, it is really personal preference. You know, there is like, what is better? And what have I heard my friends say? It is a word of mouth thing. It takes time. You get a group of people who are the most open and willing. They tend to come first. You get the next group. As you start to convert those, you start to engage with the next group of folks. It takes them some time. It is not a linear process, but I think it is pretty clear that the best product works and ultimately will take most of that share. We are in the middle of that.
It's hard to compete with the sort of impression if people are giving us a fair, you know, trial. There was a physician who really was struggling with the decision to try us, did the first case and not to, you know, embarrass this particular person who's a wonderful guy. You know, they're almost like, I won't say disappointed, thrilled. The case was amazing, but now like, oh God, now I have to actually deal with the fact that I probably should switch. You know, it's a process. I'm pretty excited about that. The next phase is that you don't wait for, but you can't really do what I said around market access and go to the hospitals if the people in those hospitals don't want to use your product.
You first have to convert them and then you have to work with their hospitals to talk about the larger opportunity than what they're currently doing, which, you know, can be 80%-90% of the possible cases we're not treating. You know, we're 10% or 15% penetrated. There's a lot more to get with the market access data that I just talked about that we got from Vizient. The two are really tied together. I think it sets us up for multiple years of growth. That's really even before, you know, we talked about Storm PE, which we ran out of time. Storm PE's randomized clinical trial in PE that I'm excited about, you know, because I think it will help the field move forward in that sense pretty significantly. I'll end it on that.
Brick will be in the Adler room. Thank you so much.
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