The world is changing. Just as the COVID-19 pandemic accelerated change all around us, we find the needs of the healthcare industry have also changed. Healthcare providers around the world are working hard to deliver quality care to their patients. They need partners that can adapt to their changing needs and help them improve the well-being of their patients. This is our purpose at Teleflex, to improve the health and quality of people's lives.
Since becoming exclusively focused on medical products in 2011, we have shown our ability to adapt to change and deliver long-term growth. Over this time, we have delivered a total return of approximately 560%. We delivered approximately 85% growth in revenue. We completed 80 mergers and acquisitions with a value of over $4 billion.
With more than 14,000 employees in 31 countries, we've grown our global team by 22%. As the world evolves, our customers are demanding that their medical device partners have global sector knowledge, local capabilities, and an experienced and diverse team. Teleflex is that partner, and we can provide all of this to our healthcare customers while continuing to deliver for our investors.
Through our diverse portfolio of established industry brands and innovative and differentiated range of high-growth products, and our relentless focus on what our customers need, and by leveraging our world-class global operations capabilities, we can transform how healthcare is provided and create success. Our long-term strategic objectives will form the foundation for predictable growth. By building on our momentum, we will drive long-term durable growth.
To meet this strategic objective, we will drive sustainable revenue growth, achieve margin and earnings expansion, optimize our product portfolio, and advance corporate social responsibility and an inclusive culture. After all, it is our strong company culture that builds trust and loyalty and makes us uniquely positioned to succeed and grow during times of change. With people at the center of everything that we do, and with over 14,000 employees around the world, we are already working towards these strategic goals.
At Teleflex, we know the world is changing, and we embrace the challenge of adapting to this change and driving long-term durable growth, delivering on our purpose to improve the health and quality of people's lives.
Good morning, everyone, and welcome to the Teleflex Incorporated 2022 Analyst and Investor Day. My name is Larry Keusch, and I am Vice President of Investor Relations and Strategy Development. Before we begin the presentations, I would like to remind you that some of the matters discussed today will contain forward-looking statements regarding future events. We wish to caution you that such statements are, in fact, forward-looking in nature and are subject to risk and uncertainties, and that actual events or results may differ materially.
Despite the challenges presented by the COVID pandemic over the past two years, we are proud of the momentum of the business and how the team has executed to maintain continuity with our customers, the patients they serve, and our communities.
Over the course of the next several hours, we will discuss the key pillars of our strategy to drive growth at Teleflex from 2023 through 2025, using 2022 as the base year. As you can see from the agenda, we have a lot of ground to cover today. Kicking off our first session, we'll start with a strategic overview from Liam Kelly, Chairman, President, and CEO of Teleflex. Liam will cover the key pillars that underpin our corporate growth strategy.
You will then hear from several members of Teleflex senior leadership who will highlight our efforts related to corporate social responsibility and our commercial strategy and global supply chain. Our second session will be led by our Chief Medical Officer, Michelle Fox, who will host two clinical panels diving into our interventional urology and interventional business units.
In our third session, Tom Powell, our Executive Vice President and Chief Financial Officer, will present our long-range financial targets. Following each session, we will host a Q&A session with the Teleflex presenters. Please limit your questions to the topics discussed in that particular session of the meeting. After the formal presentations conclude, we will be hosting a breakout session with all of the business unit leaders in the Kennedy Room down the hallway. We would encourage you to speak with our team to get a further appreciation for our business units and leadership.
Lastly, we will be posting a video on the investor relations section of the Teleflex website that showcases our emergency medicine portfolio. We are proud of the foundation that we have built in emergency medicine, and we encourage you to take a look at the video, which provides some additional information and perspective on an exciting part of our business that supports our high-growth portfolio. Now, I am very pleased to turn it over to Liam Kelly to speak about our corporate strategy and supporting pillars. Liam.
Tha nk you, Larry, and good morning, everybody. I hope you are all keeping well and staying safe. I am delighted to welcome you to the 2022 Teleflex Analyst and Investor Day. I am excited that we are hosting this meeting with a live audience, and I'm eager to share our corporate growth strategy with you. This is the first Analyst and Investor Day that we have hosted since 2018. Over the last number of years, we have executed on our strategic objectives and have grown the business in new and exciting ways.
Today's meeting comes at a great time for Teleflex. There has been significant progress at the company since we hosted our last Analyst and Investor Day. As you will see throughout the presentations today, we are making moves to position ourselves for predictable, long-term, durable growth.
Over the course of our meeting today, members of our leadership team will dive into the details on how we will achieve our growth strategy and drive our financial outlook. Let's get started. In order to know where we are going, it is important to know where we are. I will spend some time talking about Teleflex as we stand today and review the positive momentum we have created over the past few years. We will look ahead and review our key strategic drivers that will enable us to achieve long-term, durable growth.
Finally, I will leave you with the main key takeaways that I hope each of you will keep top of mind after this meeting concludes. Since becoming exclusively a medical device company in 2011, we have placed our customer at the center of what we do every day.
Our mission is to be a premier supplier of outstanding products and services that genuinely make a difference to people's lives around the world. This foundation has been carefully built brick by brick. In order to execute on our multi-year strategy, we have expanded our product portfolio with innovative technologies, extended our geographic reach, executed on our acquisition strategy, driven margin expansion, and enhanced our financial flexibility. Today, we are a company with global scale that is built on innovation and brand power.
We have over 23,000 products across seven clinical areas providing scale and depth, and we employ more than 14,000 employees in over 30 countries around the world. Our 2021 revenue was $2.8 billion, and we serve over 100,000 customers worldwide. We also have industry-leading brands with category leadership.
Our industry-leading brands include Arrow, QuikClot, UroLift, and Weck, differentiate us in the market and allows us to stand out as a leader in the space. We have become one of the largest medical device companies in the world by growing and continuously reshaping our company through organic and inorganic initiatives. We have taken a deliberate long-term view and looked at growth beyond the near term. We have consistently invested to grow our scale, augment our portfolio, and strengthen our organization.
From 2011 through the end of 2021, we have generated approximately 560% total return for our shareholders, delivered revenue growth of 85%, drove a 13.3% CAGR in adjusted earnings per share, and completed over 80 strategic acquisitions with a value of $4.4 billion.
Throughout this growth, our people have remained a trusted partner to our healthcare customers across global diverse markets. Every single day, we estimate that our products are used in over 24,000 surgical procedures in the United States. They are being used by clinicians in over 2,000 patients who require vascular access intervention. To care for more than 8,000 patients in the intensive care unit, have been used by emergency responders to treat more than 4,000 patients in the field, and have been instrumental in treating patients in over 3,500 interventional cardiology procedures.
Our products also help treat nearly 200 men a day with benign prostatic hyperplasia or BPH. Today, Teleflex has a diversified product portfolio consisting of innovative products and more mature franchises with category leadership, which we believe will enable us to maintain a cadence of durable growth over time.
We believe our diversified portfolio also provides competitive advantages and helps to insulate the company from the impact of exogenous macro events. Our scale puts us in a strong position to leverage our broad product portfolio across the numerous clinical specialties and care settings that we serve. Typically, our products are necessary in the treatment algorithm for patients, which helps keeps us positioned for consistent use in critical care and surgical procedures.
In addition, more than 70% of our products have an average selling price less than $250 and offers an advantage relative to price pressure typically felt on more expensive medical devices. Our profitability has continued to improve through positive mix shift towards higher margin products, benefits from restructuring programs, operational efficiencies, and operating expense leverage. Our portfolio of products adds value to highly relevant clinical areas.
We have products with category leadership in seven key clinical verticals, including vascular access, interventional cardiology and radiology, minimally invasive surgery, minimally invasive BPH treatments, emergency medicine, and anesthesia. Teleflex is much more than a supplier of quality products. We are a partner to the healthcare community and can help clinicians work across key therapeutic areas and specialties.
When we look holistically at the healthcare industry, from doctor's office to the emergency room to the operating room, we are able to deliver products, services, and education that allows clinicians to deliver quality care and improve patient outcomes. When we talk about creating a strong foundation for growth, it is imperative that we also talk about our global supply chain. We are proud of our global supply chain capabilities, which have been bolstered by investment over the last long-range planning period and transformed with new management and enhanced processes.
Throughout this journey, our global supply chain vision remains anchored on achieving a best-in-class end-to-end supply chain, as recognized by our customers and business partners alike. We absolutely see our supply chain strategy as a critical piece to achieving the durable growth objective for Teleflex. Today, our global supply chain has 21 distribution centers and over 2 million sq ft of manufacturing space. We have roughly 9,000 global supply chain employees and over 1,500 suppliers, and we are managing approximately $1 billion in annual spend.
The resilience of our global supply chain has been demonstrated throughout the COVID-19 pandemic. We have been able to keep our workers safe, manage raw material shortages, and minimize back orders to ensure that our products continue to be available to our customers so that they can treat patients.
Being able to navigate through these unprecedented challenges validates our investment and efforts into our supply chain and gives us confidence as we look forward. Although we expect supply challenges to persist for some time, we will continue to lean in as we focus on effective execution and servicing our customers. At Teleflex, we're committed to delivering a personal and meaningful experience with every single customer interaction.
Serving our customers with unrelenting attention builds loyal advocates and helps us to develop innovative solutions that improve the health and quality of people's lives around the world. Every decision we make is with the customer in mind, and as such, we will continue to optimize our portfolio, increase clinical education, and focus on the overall experience to bring even more value to our customers. We have built a stronger Teleflex over the past several years and have executed against our strategic initiatives.
At the same time, we have also learned a lot about our company, especially as the global coronavirus pandemic tested the organization and our own capabilities. We came away confident in the clinical necessity of our products, our supply chain, our business development capabilities, and most importantly, our own people. I believe that we are better positioned now to drive growth than at any point over the past decade since we became exclusively a medical device company. Let me expand on the strategic priorities that will enable us to deliver long-term, durable growth.
We will drive sustainable constant currency revenue growth, achieve margin and earnings expansion, optimize our product portfolio, and advance corporate social responsibility and an inclusive culture. The first strategic priority is to drive sustainable constant currency revenue growth. As we look into the future, there is much to be excited about.
We are positioned for a 6% to 7% revenue growth CAGR over the three-year period from 2023 through 2025, using year-end 2022 as our jumping-off point. Our combination of growth drivers and a diversified portfolio will help to provide consistency in growth, while our continued focus on margin expansion and our revenue base will drive attractive free cash flow generation. This will be prioritized for internal growth drivers and inorganic opportunities. We view our business in three buckets being our high growth portfolio, durable core, and other.
Our high growth portfolio is expected to be a key contributor to the 6% to 7% constant currency revenue CAGR over the long range plan. This portfolio has many of our most exciting products, and we believe there is a long runway for market penetration.
Our durable core is expected to show steady growth over the plan period due to share gains, underlying market growth, and our category leadership. We intend to grow the percentage mix of our high growth portfolio over time through multiple organic drivers, including new product introductions and market expansion. As you know, we believe that not all growth is created equal, and we will preferentially invest in products that can drive accretive growth and margin improvement.
Accordingly, we will continue to preferentially direct investment to our high growth portfolio. Now, that is not to say that we won't support key products and businesses in our durable core, including interventional, vascular access, surgical, and OEM.
To sustain our momentum, a key building block of Teleflex's long-term growth investment strategy will be to transform our internal development capabilities, resulting in an improved new product launch cadence and associated increase in our new product revenue. Although our new product cadence is not yet where we would like it, we have already made the investments into enhancing our processes for research and development. In turn, we are better positioned to allocate appropriate resources to fuel our new product development over our long-range plan.
There are two key elements embedded in our new product strategy. We are building on our new product development pipeline with a focus on a disciplined approach to advancing our projects. We are also actively engaged in strategies to accelerate time to revenue for our new product development.
We are confident that we can drive increasing momentum in our new product cadence over the coming years. Looking outside the United States, we have an opportunity to expand our commercial presence in overseas markets. Our international sales account for approximately 35% of corporate revenues. We see a lot of potential in our Asia-Pacific business with new product launches, expansion in our sales team, and a strengthening of our leadership.
Many of the launches are for products already used in the United States, such as PICC, EZ-IO, UroLift, and from the interventional access portfolio, which reduces the risk profile. Finally, while not necessarily unique to Teleflex, demographics will continue to be a tailwind for the Teleflex portfolio and will have a positive impact for the utilization of our products in the healthcare industry.
In the United States, the number of people over 65 years of age is expected to increase to 20.6% of the population by 2030 versus 16.9% in 2020. The story is similar for virtually every developed country around the world. With our portfolio purposefully tilted towards procedures that are common as people age, we believe that the trends in demographics will be an important driver for long-term durable growth at Teleflex. As we focus on our high growth portfolio, we are confident in the discrete drivers for organic constant currency revenue growth.
Of note, we believe that we are still early in our penetration of sizable market opportunities for our existing portfolio of products. When taking into account the six product families in our high growth portfolio, we are just 5% penetrated in an addressable market of approximately $14 billion.
With our preferential investment into our growth drivers, we believe that there is a meaningful opportunity to expand our global sales base. Turning now to our second strategic priority. We will continue to achieve margin and earnings expansion. We are confident that there are a number of levers to pull that will enhance our margins. Importantly, we have a slate of margin expansion drivers that are already in place and will contribute throughout the long-range plan and complement our methodical approach to consistent productivity initiatives.
Mix shift towards our portfolio of high growth drivers will be the primary driver of adjusted gross margin expansion during the long-range plan. UroLift 2, MANTA, hemostatic products, EZ-IO, and OnControl Intraosseous Family, and PICC all represent products that have margins in excess of the corporate average.
In addition, our already announced restructuring initiatives will be another incremental driver of margin expansion as well as other operating efficiencies. Turning to our sales infrastructure, we still have an opportunity to drive distributor-to-direct conversions and positively influence gross margins. This has been a successful strategy for Teleflex, and we see an opportunity for additional conversions. Currently, 5% of our global revenue is generated from the distributor channel, and we believe there is an opportunity to convert a quarter of these revenues to direct sales over time.
In addition, as we execute on our acquisition strategy, we will reload on the opportunities to convert to direct sales. Offsetting a portion of our margin expansion will be purposeful and disciplined incremental investments to maintain our current momentum. We will allocate investments to drive global product launches, expand our geographic footprint, and develop new products.
Although these directed investments will increase operating expense as a percentage of sales through the planning period compared to 2020, we will be targeted in our spend. We are confident that our strategy is prudent and will continue to position Teleflex for durable high growth. Our third strategic priority is to optimize our product portfolio through new product introductions, continued M&A, and through divestiture of non-core assets. We have a history of successful acquisitions across our business units.
From 2011 to 2021, we completed 80 M&A transactions while deploying $4.4 billion in capital. Over the same timeframe, our stock has generated approximately a 560% total return to our shareholders. Of note, as our business development competencies have strengthened, nearly 80% of our total capital deployed for M&A has occurred since 2017.
In this timeframe, we have executed on multiple scale transactions, including the acquisition of NeoTract and Vascular Solutions in 2017, and HPC and Z-Medica in 2020. We also continue to show an ability to drive new product introductions and expand the geographic reach for our acquired assets. Using the acquisition of NeoTract as an example, we have launched UroLift 2 and Advanced Tissue Control, and this year we are launching this novel minimally invasive therapy for BPH in Japan and China.
As you are aware, we issued a press release yesterday that announced the marketing clearance of UroLift in China, and we expect to launch the product there in the fourth quarter of this year. As we look into the future, we will continue to pursue a steady cadence of acquisitions which will augment our high-growth portfolio.
We have an experienced business development team with strong institutional knowledge, and we believe that we are best in class at sourcing, conducting in-depth due diligence, and integrating acquisitions with a solid track record over the past decade. Teleflex is a thoughtful acquirer. We are not just making decisions based on incremental revenues and EBITDA. We take a very disciplined approach to identifying and deciding which opportunities will fit our key criteria.
We are looking for assets with category leadership, obvious clinical benefits, the ability to lower the overall cost of care, and strong intellectual property protection. We also pay very close attention to opportunities that allow us to leverage our infrastructure and expand our geographic footprint. From a financial perspective, we look for assets that are accretive to growth and margins with a focus on exceeding our weighted average cost of capital in a reasonable period of time.
Z-Medica, our most recent acquisition, is a perfect example of our disciplined approach to M&A. This market-leading QuikClot and Control+ products solve an obvious need to control bleeding faster in trauma or surgical situations, reducing blood loss up to 39% versus standard gauze and provide improved visibility in procedures. The QuikClot Control+ has intellectual property that provides protection through 2033, has very little international market penetration, and clearly fits into our emergency medicine and military global channels.
From a financial perspective, the acquisition of Z-Medica aligned to our well-established acquisition criteria. In particular, the transaction was accretive to revenue growth and margins with an attractive ROIC profile. Moving forward, you can expect Teleflex to continue to maintain a routine M&A cadence with a very disciplined approach.
With our balance sheet now at 1.7x leverage and our outlook for strong free cash flow generation, we have ample flexibility to execute on our strategy. Our focus will remain on differentiated assets that are accretive to our long-range growth profile and our margins. The strategy will continue to revolve around finding assets with single-use products, possess strong intellectual property protection, are backed by a favorable economic analysis, and have room for geographic expansion.
We will continue to optimize our portfolio through a disciplined review process focused on M&A as well as divestiture opportunities. We will learn from our portfolio moves and will be relentless in our focus to improve our process with each subsequent transaction. Our June 2021 divestiture of the respiratory assets to Medline is an example of our strategy which will improve growth and margins over time.
Our fourth strategic priority is to systematically advance corporate social responsibility and an inclusive culture while remaining true to our core values. These values define our company, shape our corporate culture, guide our business practices, and direct the way we interact with our stakeholders, from healthcare professionals and their patients to our employees and shareholders, to our suppliers and distributors, and to the countless individuals who make up the communities in which we live and work around the world every day.
In 2020, we established a comprehensive structured approach to CSR at Teleflex, which allows us to bring together the great work that was already happening throughout our organization for many years. We plan to expand Teleflex's CSR program through a five-year roadmap, setting meaningful and measurable goals to advance the progress, transparency, and disclosure of the program.
We believe that fortifying our culture, creating a welcoming work environment, and looking out for the safety of our own employees is foundational for Teleflex. We are confident that by leveraging our core values and acting in a responsible way at every level, our actions will turn into growth and contribute to long-term savings. Now, before turning things over to my colleagues, I want to leave you with these key takeaways. Teleflex is well-positioned to drive long-term durable growth, and we will do this by focusing on four strategic priorities. Our first priority is to drive sustainable constant currency revenue growth.
We believe that our high-growth portfolio and durable core provide a strong foundation for a 6% to 7% organic constant currency CAGR from 2023 through 2025. With continued investment into our current growth drivers and new product development, we will turn our positive momentum into future opportunities.
Second, we will achieve adjusted margin and earnings expansion over the long-range plan with excellent line of sight into levers for improvement throughout the LRP, while funding investment in organic growth drivers. Based on 2022 as the base year for our long-range plan, we expect to achieve 250 to 350- basis points of adjusted growth and 200 to 300- basis points of adjusted operating margin expansion by the end of 2025.
T hird, we will continue to optimize our product portfolio with a disciplined approach. The current flexibility in our balance sheet and expected strong cumulative free cash generation of at least $1.7 billion during the long-range plan set us up really nicely to execute on our acquisition strategy.
We will also continue to evaluate the business and identify non-core assets that may no longer fit within the Teleflex strategic direction. Finally, we will advance corporate social responsibility and an inclusive culture. Our core values will remain a focus throughout the organization. This will help us to retain top talent, attract new talent, and leverage internal innovation. We will make strides in furthering our CSR programs and reducing our impact on the environment.
Now that you've had an overview of our strategic priorities, I would like to introduce Karen Boylan, our Corporate Vice President Global Strategic Projects, to dive deeper into our corporate social responsibility initiatives. Karen?
Thank you, Liam. Good morning, everyone. My name is Karen Boylan, and I'm the Corporate Vice President Strategic Projects for Teleflex. Among my other responsibilities, I also chair the Corporate Social Responsibility Steering Committee for the company. Today, I am pleased to highlight our CSR progress and discuss how it will help enable long-term durable growth. I will briefly show how the CSR program fits within the overall strategic direction of the company before going into the main section of my presentation, which will be to define and explain our CSR pillars.
Finally, I will leave you with a few key takeaways from my presentation. How does CSR play into the overall strategic direction? As you heard from Liam earlier, Teleflex is committed to advancing our agenda across specific strategic priorities, and our commitment to corporate social responsibility will play a large part in the process.
By strengthening our sustainability efforts as a company and continuing to focus on our people and delivering to the healthcare community, we can become a better partner to all of our key stakeholders, which in turn can have a direct impact on growth.
In order to drive our CSR program forward, we have established a steering committee which includes a number of our executive team as sponsors as we align ourselves against our core four strategic pillars. This chart shows how our CSR activities align within each pillar. We have hired dedicated resources to help lead our organizational efforts and to drive change in each of the pillars.
As reflected in its charter, the Nominating and Governance Committee of our Board of Directors has oversight of Teleflex's strategy and practices with respect to environmental, social, and governance matters, and in coordination with the Audit Committee, the companies reporting on these matters to internal and external stakeholders. Our first pillar, principles of ethics and governance, provides a foundation for Teleflex. Our governance structures play a key role in ensuring we act with integrity in all our business practices and interactions and remain compliant with all applicable laws and regulations.
We are focused on ensuring that our governance structures, which includes the makeup of our board of directors, are in line with industry standards and our stakeholders' expectations. At present, 33% of our directors are women, which is consistent with industry averages.
As part of its succession planning efforts and consistent with Teleflex's corporate governance principles, our board will continue to seek to identify candidates whose respective experience expands or complements the board's existing expertise in overseeing our company. This includes the candidate's potential to contribute to the diversity of the board with respect to gender, race, ethnicity, national origin, and other differentiating characteristics. Other key areas of focus include a dynamic and comprehensive global compliance program.
Our corporate compliance program charter and integrity code, together with our code of ethics and anti-corruption policy, provide a framework for our global approach to compliance. Lastly, I want to highlight that we undertake an annual enterprise-wide risk assessment program to identify critical risks facing our organization and ensure that we have mitigating strategies in place to address them.
As a manufacturer, our global operations are the source of our largest environmental impact, but also represent a tremendous opportunity to make a difference as a responsible corporate citizen. Our second pillar, planet and environment, is largely focused on our global operations and supply chain function.
Guided by our zero harm vision, the global operations team has been working over the past number of years to baseline and improve our carbon footprint as an organization, investing in software and dedicated roles, including the addition of a sustainability director in our global supply chain organization. The goal is to better assess our current standing, track our progress, and plan next steps, including the targeted reduction in purchased energy and reduction in waste to landfill, each by 10% by 2023.
We now have solar panels installed and operational at strategic manufacturing locations in Mexico, Malaysia, and India, and we are continuing to explore the feasibility of similar projects at several other sites globally as ways to reduce energy consumption and otherwise move to clean energy solutions. We are taking an integrated risk-based approach to evaluating our carbon emissions and carbon footprint. This includes governance, risk management, and strategy while evaluating key metrics to progress towards creating science-based targets.
Our third pillar, people, relates to our most valuable resource, our Teleflex employees. The last 24+ months have tested all of us at Teleflex. The resilience of our employees globally has served as a daily inspiration to serve our customers, the patients they treat, and the local communities.
Our global and local crisis management teams reacted quickly, putting strategies in place to help keep our employees safe and our operations running to ensure our customer needs and those of patients were being met. As a critical supplier, our employees remained at the front line of our manufacturing and distribution operations. Other employees returned to the front lines of their healthcare specialty to help in the fight against COVID-19, and we are extremely proud of the efforts of all of our employees during this crisis period.
We continue to support employees as we experience spikes in COVID-19 variants in various countries. Our dedication to supporting our employees while maintaining a high level of service to our customer is exemplified by our Americas customer Net Promoter Score, which increased 15% between quarter four 2020 and quarter four 2021.
We pivoted quickly to increase employee training and development opportunities available on our internal HR learning platform, Connect Learning. We are also proud of the steps we have taken as an organization to cultivate our commitment to diversity, equity, and inclusion. With global and regional DEI councils created to invest in our employee resource groups and inclusive leadership training. In fact, Teleflex was recently named to Forbes Best Employers for Diversity 2022 list, and this recognition represents an important milestone in our DEI journey.
We take our CSR commitment seriously and view our progress against our key metrics, along with our strong corporate culture, as the means to both attract and retain key talent. This is evidenced by our strong employee engagement scores and employee referral talent recommendations, industry turnover at or below corporate peers, and robust promotion from within outcomes.
For our fourth pillar, which focuses on prosperity and sustainable healthcare, I would like to highlight our clinical and medical affairs team, which is responsible globally for our robust training programs and education programs. In 2020, as a response to COVID-19, we meaningfully expanded our digital learning environments to ensure that clinicians could safely continue receiving education. We continued this effort in 2021, expanding globally.
As we look to other activities that represent this pillar, we have already made progress in several areas of focus. More recently, we also galvanized the organization to provide critical humanitarian aid to Ukraine during a time of extreme turmoil.
We have ramped up our efforts to ensure access to care, regardless of location or socioeconomic status, and we are committed to designing clinical trials that are inclusive and represent the demographic diversity of the populations in the regions where the research is being conducted. We are also committed to ensuring that our medical advisory boards are made up of diverse voices in terms of gender, ethnicity, culture, and location.
Between 2020 and 2021, Teleflex has increased funding in education and clinical research grants, and we plan to continue to expand these areas of support in future years. Finally, our employee-driven JOIN Act with Purpose initiative and the Teleflex Foundation fall under the community engagement focus of this pillar.
Both initiatives provide opportunities for employees to support their local communities and organizations close to their hearts and will continue to be an important part of our CSR program. Lastly, I want to highlight our core values, which we believe are a competitive advantage for Teleflex, as they enable us to cultivate our unique company culture. These core values are entrepreneurial spirit, building trust, making it fun, and putting people at the center of everything we do.
Indeed, a strong company culture is instrumental in the ability to perform at a high level during times of change, and we believe directly correlates to strong financial results. Ultimately, it is our culture that is formed by the embodiment of our core values that is the underlying thread that connects all of our efforts related to corporate social responsibility.
CSR is a big topic, and it encompasses a lot of activities at Teleflex. Before I finish up, I want to leave you with a few key takeaways. Teleflex is committed to advancing our agenda across specific strategic priorities, and our commitment to corporate social responsibility will play a large part in the process. As part of our focus on our four CSR pillars, we have created a roadmap that outlines our efforts around environmental targets, including a commitment to science-based targets and a reduction of greenhouse gas emissions.
The roadmap also provides a continued focus on governance and compliance with connectivity to risk management processes, a theme of community centered around our Teleflex employees, and a patient-first focus to improve global health and expand access for underserved populations and healthcare systems. We have made significant progress in our CSR efforts.
In July 2021, we published our 2020 Global Impact Report, which provides a comprehensive view of our program and demonstrates how we seek to address evolving environmental, social, and governance standards, and identify and quantify measurements of our sustainability and societal impact. We look forward to publishing a substantial update in quarter three of this year, which will show additional progress. We are proud of our work to promote our CSR program, which helps us attract top talent and leading companies with which to partner.
While the direct financial impact is not always easy to quantify, in engaging our key stakeholders, we are keenly aware that our mission and focus is a powerful asset to the organization, and one that we will continue to strengthen. Around the globe, more than 14,000 Teleflex employees are united in the understanding that what we do every day makes a difference to improve the health and quality of people's lives. Thank you, everyone, for your time. I will now hand over to Jay White.
Thanks, Karen, and good morning. It's a pleasure to be here with you today to talk about our global commercial business. Today I'm gonna walk you through how the commercial organization fits within the strategic priorities that Liam mentioned earlier. Then I'm gonna spend a good portion of my time going into more depth on key commercial growth opportunities before finishing up with a few key takeaways. Let's start with the role the commercial organization has in driving long-term, durable growth. These are the priorities that Liam shared moments ago.
While the commercial organization is critical to ensuring the success of all four pillars, today I'm gonna focus on two of them, driving sustainable revenue growth and optimizing our product portfolio. We are driving long-term, durable growth through a disciplined approach, focusing on our high-growth portfolio, as well as maintaining consistent growth in our durable core.
Our strategic blueprint has allowed us to outpace the market in several key product areas over the last several years. This focused approach and disciplined investment strategy will continue to be pivotal factors in our success moving forward. Since our last Investor and Analyst Day in 2018, we have focused on optimizing our product portfolio with the intent of improving our revenue growth, entering large and fast-growing markets with significant unrealized potential, and building a robust, diversified portfolio. I am pleased to say that we've accomplished these goals.
As you can see from the chart, we have built a portfolio capable of delivering durable, sustainable revenue growth. The robustness of our portfolio has been proven over the last couple of years as we have successfully navigated and mitigated the impact from the COVID-19 pandemic.
Our balanced global business allowed Teleflex to execute at a high level and deliver for our customers at a critical time. As elective procedures were postponed, our life-saving critical care products helped to mitigate the impact. With roughly 60% of our product portfolio either benefiting from the treatment of patients with COVID or insulated from the decline in elective surgical procedures, our efforts have paid off in building a durable and sustainable portfolio.
Today, my goal is to outline our key commercial growth opportunities and share why we are confident in our ability to deliver long-term, durable growth. There are three key commercial growth opportunities that we are focused on delivering. One, globalization in key markets. Two, optimizing our product portfolio. And three, expanding market share with high-growth franchises. Let's start with globalization in key markets.
We are increasing our investments into select markets with differentiated products, allowing us to maximize our returns. These markets create a significant opportunity for growth with products that are highly differentiated and proven to enhance clinical outcomes. These products all have category leadership positions in North America, and we are applying these proven tactics to drive growth globally, reducing our risk profile and maximizing margins. As I mentioned earlier, our focus on globalization of key markets creates a significant opportunity for Teleflex.
Today, we generate 59% of our revenues through our Americas reporting segment, implying that we have a significant opportunity in select overseas geographies. Our strategy is to take a disciplined approach to product selection by market to create the best opportunity for profitable growth.
Taking this selective approach allows us to concentrate our resources, tools, and investments to accelerate the growth opportunity at a faster rate while maximizing margins. For example, we believe that the Asia-Pacific region is a significant opportunity for Teleflex, and we are investing to expand our commercial presence in this region. It is projected by 2030 that 65% of the global middle-class population will live in the Asia-Pacific region and account for 3.5 billion people as compared to 2 billion in 2020.
We have already made and will continue to make investments to assure we are well-positioned to maximize the growth opportunity. Our investments are focused on key drivers of growth, including the sales organization, marketing, clinical education, clinical studies, market access, and reimbursement. Digging into our globalization strategy, which is predicated on three key initiatives.
First, we're focused on bringing market-leading, highly differentiated products with a clear roadmap for success to large, fast-growing markets. We have spent time on market intelligence studies and have a clear understanding of the in-country dynamics. It is all about bringing the right products into the right markets. Second, we are actively strengthening our commercial channel. Dealer-to-direct conversions have been a significant driver of value over the past several years.
Going direct has accelerated our revenue growth, strengthened our customer relationships, and delivered incremental gross and operating margin. While not every market is a fit for dealer-to-direct conversions, as Liam stated, we believe there are incremental opportunities to take our business direct in several countries outside of North America. We also continue to invest in people, programs, processes, and tools that are foundational to growth and clinical leadership.
Third, we will continue investing in the customer experience to ensure we are building brand loyalty that will accelerate revenue and boost profitability. Our focus is on delighting the customer with every interaction and creating a smooth experience across the entire customer journey, regardless of product. The investments made to date have focused on our Americas market, where we have seen a twofold improvement in customer loyalty metrics.
We have made meaningful advances in order management and fulfillment, including a new e-commerce site for self-service, while expanding our online clinical education resources through our Teleflex Academy. Ultimately, our customer experience strategy focuses on delivering value beyond products to maximize our share position across categories and markets. Now I want to move to the second commercial key growth opportunity, which is optimizing our product portfolio.
This has been a key factor in continuously improving the growth rate at the company over the past decade. We have methodically repositioned Teleflex within large and expanding markets with significant opportunity for growth. We are optimizing our portfolio through several strategic objectives. First, we will continue to enhance our cadence of new products. Second, we will remain active with our M&A strategy to augment our internal projects. In addition, we routinely conduct portfolio reviews across the business to ensure alignment with our growth objectives.
As Liam already discussed M&A, I will focus on my discussion around new products. When we think about portfolio optimization, new products are a key component of the strategy. We define a new product as any product that was launched during the previous 36 months, after which time they're captured in volume.
Over time, we have delivered a steady cadence of increasing growth driven by innovation. Although we have demonstrated our ability to drive consistent growth from new products, we have also set our sights on improving our innovation process. In order to improve our new product cadence, we have developed a harmonized process that builds on best practices from across Teleflex and beyond to deliver innovative, high quality, and most importantly, highly valued new products to our customers. Today, I want to highlight a few new products that have recently launched or will launch in the short term.
First, we are excited about the recent addition of two new products to the UroLift family. We have launched the UroLift 2, which represents an evolution over the first generation device. The innovative delivery system is designed to reduce medical waste and streamline the procedure while maintaining proven UroLift outcomes.
Specifically, the volume of packaging materials consumed during an average UroLift case is expected to be reduced by nearly 50% compared to the prior generation of the device. Given the improvements, we are enhancing the procedure for urologists, increasing the level of profitability for Teleflex, and also reducing the environmental impact, a triple win scenario. As noted previously, we still expect to convert the vast majority of UroLift physicians in the US to UroLift II by the end of 2022.
The launch of the UroLift ATC system delivers the same proven UroLift implant, but through an enhanced delivery device on the distal tip, making it easier to treat BPH patients with challenging anatomies, including an obstructive medium lobe. The tissue control wings are strategically shaped to hold tissue during manipulation for enhanced control and to minimize view obstruction, making it easier to secure and retract prostate tissue.
Moving on, our interventional business has a robust emerging new product pipeline, and today I am going to highlight three specific products for which we are or soon will be seeking FDA approval. GuideLiner Coast and Ringer are products designed to be utilized in the cardiac cath lab. We expect GuideLiner Coast will strengthen our portfolio in complex procedures by adding a lubricious coating to the current line of industry-leading catheters. Ringer is a unique technology that we expect will be the first of its kind on the market.
Angioplasty requires the inflation of a balloon in the vasculature to restore blood flow and potentially place a stent. The inflation of the balloon effectively blocks blood flow, presenting an inherent challenge in current PCI techniques.
The Ringer is designed to allow an interventionalist to perform angioplasty and treat perforations while at the same time allowing blood to continue to flow through the center of the balloon to keep the tissue perfused. Finally, Wattson is a unique combination device for structural heart physicians who place TAVR valves. In a TAVR procedure, the pumping of the heart is temporarily stopped through electrical stimulation for the valve implant to be accurately placed. Once in place, the heart is electrically stimulated again to restore rhythm.
The current stimulation technique is complicated by the necessity for wires and catheters for the valve delivery, as well as an additional venous access site in order to place a temporary pacing catheter in the right ventricle.
Wattson is designed to eliminate the need for extra wires and catheters and the additional access site by allowing the structural heart physician to place the wire directly in the left ventricle for pacing and delivery, thereby streamlining the TAVR procedure. The vascular business unit's Arrow brand has built a reputation of innovation, and you can expect to see a consistent cadence of new products out of this business unit. Today, I want to highlight three key products.
Our newest maximal barrier kit, the ErgoPack Complete, integrates the tools clinicians need to fight against catheter-related bloodstream infections. The kit is arranged in an ergonomic configuration that is top to bottom, left to right, helping to minimize scattered sharps and blood spills, which in turn is helping hospitals stay compliant with multiple guidelines, including CDC, SHEA, INS, and OSHA's bloodborne pathogen standards.
We are seeing strong reception to the ErgoPack Complete and are now in over 700 hospitals since the launch in October of 2020. The second product that I want to highlight is the pressure-injectable Arrowg+ard Blue Advance Midline. The Arrowg+ard Blue Advance Protection reduces the risk of catheter-related complications, including occlusion, phlebitis, and thrombus accumulation on catheter surfaces for at least 29 days. Other unique features of this product include a glide-through sheath and a blue flex tip feature that helps to minimize vessel damage.
The last product that I want to highlight is the Arrow VPS Rhythm DLX device with tip tracker technology. This new system, which is currently pending FDA approval, integrates state-of-the-art vascular ultrasound with ECG tip location and electromagnetic navigation technology in one device for our bedside PICC placement.
We expect to offer the vascular ultrasound and ECG tip location capabilities to be purchased separately, allowing customization to meet a variety of clinicians' needs. Once approved, the DLX device will add to one of the broadest tip navigation portfolios on the market today. The third and final commercial growth opportunity for Teleflex is to expand market share with high-growth franchises. As previously shared, we have built a diverse portfolio with multiple highly differentiated products that have upside share potential in the markets in which we compete.
Our high-growth portfolio, which is spread across several business units, includes UroLift, MANTA, Hemostats, EZ-IO, OnControl, and PICCs. In 2021, these products represented approximately 25% of Teleflex's total revenues and are expected to grow significantly faster than the corporate average.
Our durable core platforms accounted for well over 60% of revenues in 2021 and are expected to grow at a healthy mid-single digit CAGR over the long-range plan. Going forward, investments will be focused on our high-growth portfolio to drive further share gains in North America and global expansion as a second wave of growth. As we continue to optimize our portfolio, you should expect select product launches and future acquisitions to fold into our high-growth portfolio.
Over the next several slides, I'm gonna speak to our high-growth portfolio and touch on some of the exciting products in our core portfolio. We are extremely pleased with the success we have seen with the UroLift, and are excited about the future growth potential.
To date, I'm proud to report that more than 350,000 patients have been treated globally with more than 3,400 urologists trained in the US. With a global target market of $12 billion, we remain extremely excited about the growth that lies ahead for this best-in-class, minimally invasive technology. As we have stated in the past, we estimate the US target market to be $6 billion. With roughly 5% to 6% penetration to date, the runway for growth remains long. If we look at key countries outside of the US, we see an addressable market of $6 billion plus.
We launched UroLift in Japan in April of this year, which was on time and coincided with reimbursement availability. Initial cases have been conducted, and we are excited about the potential to penetrate this $2 billion market opportunity.
In the second half of 2022, we expect to have the reimbursement addressed in France and initiate launches in China, Spain, and select provinces in Italy. For 2023, we have our sights set on launches in Taiwan and India, representing two large market opportunities. In 2024, we expect to launch in Germany and establish reimbursement in Brazil.
Although we are early in our overseas expansion, we see a nice cadence of new markets coming online, which gives us confidence around a robust growth for UroLift through the long-range planning period. I believe a key differentiator of UroLift from most other BPH treatments is our commitment to clinical data. UroLift remains one of the most widely studied products in the BPH market.
We are pleased with results supporting safety and effectiveness across a multitude of studies, including our early randomized controlled and physician-initiated studies to the most recent publications on real-world data. We are seeing rapid relief with minimal complications and results consistent with the LIFT pivotal study. In January, a comparative analysis of sexual function outcomes from UroLift studies and the medical therapy of prostatic symptoms trial was published in the peer-reviewed journal European Urology Focus.
This indirect comparison revealed that UroLift is superior to BPH medical therapy in preserving erectile and ejaculatory function and sexual satisfaction. Importantly, this study challenges the idea that medical therapy is the most conservative treatment option for BPH. Over time, we believe that more clinical research like this publication will allow clinicians to consider UroLift as the first-line therapy for treating BPH.
We will continue to invest in clinical studies to secure our market leadership position, support the brand, and ensure we meet our high growth expectations. Over the next three years through 2025, we continue to expect interventional urology to be one of our highest growth business units. Moving on, I'd like to now discuss the MANTA Large Bore Closure device and OnControl Bone Biopsy device.
These two devices are part of our interventional business unit, which is an area where we have made significant investments to optimize our portfolio and create a sustainable growth business with margins in excess of corporate average. Our global interventional business is now in excess of $400 million in revenue and is set to drive high single- to double-digit growth for Teleflex. MANTA presents a $200 to 300 million market opportunity for Teleflex.
The Manta device is the first commercially available biomechanical vascular closure device designed specifically for large bore femoral arterial access site closure. The Manta device provides simple deployment, rapid hemostasis, and reliable closure. We have deployed a multi-pronged investment strategy to accelerate the adoption curve with Manta, which is focused on expanding our clinical specialists in the field to broaden our training capabilities with regard to interventional cardiologists.
In addition, we invested in sales roles in the US and Europe, accelerated marketing programs, clinical education programs, and clinical studies. We expect Manta to be one of our highest growth products with solid double-digit contributions annually. The Arrow OnControl Powered Bone Access System represents one of the first major advances in bone and bone marrow sampling procedures in over 40 years.
The Arrow OnControl device reduces procedure time by up to 55%, reduces the need for second attempt procedures, provides greater overall patient satisfaction, and provides consistently larger, high-quality core specimens. We expect double-digit growth from the OnControl device over the next several years. Next, I'd like to highlight the EZ-IO and QuikClot hemostatic products. As a reminder, these products are sold by our emergency medicine sales force, which is part of our global anesthesia business.
Like our interventional business, this is a portfolio that we have strategically assembled over the last several years. With the addition of Z-Medica in late 2020, combined with the market leadership of EZ-IO, we are well-positioned as a leader in this space with highly differentiated products and lots of opportunity for growth and innovation.
The Arrow EZ-IO is designed to provide controlled vascular access via the intraosseous route in situations where intravenous access is difficult to obtain in emergent, urgent, or medically necessary cases. Using IO access, providers can deliver life-saving fluids and medications rapidly and effectively. Over the last decade, this product has significantly impacted the vascular market, and we expect high single-digit growth over the next several years. Our hemostatic product portfolio addresses a $600 million market opportunity.
Our proprietary hemostatic technology consists of a nonwoven material impregnated with kaolin, an inorganic mineral. When kaolin contacts blood, it activates the Factor XII, which accelerates the body's natural clotting cascade. QuikClot targets the $300 million external hemostatic market, which covers pre-hospital, emergency room, and interventional call points.
The QuikClot Control+ is a newer product that targets a $300 million internal hemostatic product market across trauma and general surgery. QuikClot Control+ is the first hemostatic dressing indicated for temporary control of severe internal bleeding. It may also be used for control of severely bleeding wounds, such as surgical wounds and traumatic injuries. We also continue to seek FDA clearance for our unique freeze-dried plasma product for use by first responders to address trauma patients. We continue to see a $100 million market opportunity in military and civilian uses.
We are working towards a BLA resubmission and will provide a further update at a later time. Moving on to PICCs, which are sold by our vascular access business. Our market leadership in vascular access has been a cornerstone for Teleflex for years.
With the business unit accounting for nearly 25% of corporate revenues, vascular access plays a key role in the patient care continuum, as approximately 90% of all patients entering a hospital will receive some sort of vascular access device. Vascular-related complications cost healthcare systems billions of dollars each year, including $2 billion for the US healthcare system alone. More importantly, it takes over 100,000 patients' lives annually. Complications include infection, thrombosis, occlusion, or tip malposition.
The US PICC market alone is a $250 to 300 million market, and we are the fastest-growing company in this space. We are in a unique position with the only antimicrobial, antithrombogenic catheter on the market. In addition, we offer a broad portfolio of tip navigation devices, providing caregivers multiple options to reduce tip malposition.
As I mentioned earlier, once approved, the VPS Rhythm DLX will add to this broad family of tip positioning products. Moving on to our durable core. A large portion of these products within the durable core category should not be ignored. They are highly differentiated and maintain strong market leadership positions. A perfect example is our OEM group, which is a valuable component of our growth story. OEM generates revenue growth slightly above the corporate average that is both reliable and diversified.
This business allows us to engage in product categories that we do not currently participate in, such as stents and orthopedics. It also allows us to generate growth with an accretive operating margin while mitigating risk because our partners fund the investments and is capital efficient, which allows us to deploy capital to fund investment in other high-growth areas.
Other examples of market-leading products are Arrow central venous catheters, arterial catheters, GuideLiner, Turnpike, Arrow intra-aortic balloon pump, Hem-o-lok ligation clips, LMA laryngeal masks, and many others. As mentioned earlier, our durable core is currently just over 60% of our revenue and is expected to grow in the 4% to 5% range compounded over the long-range plan. I know I went through a lot of information, so I want to be sure to leave you with a few key takeaways.
In closing, we are confident we have built a platform that can deliver durable and sustainable growth over our long-range horizon. We have multiple regions, sites of service, and products that will contribute to this durable growth profile.
We will accomplish this by executing against three commercial growth opportunities, globalization of key markets, optimizing of a product portfolio, and expanding market share with high-growth franchises. Thanks for your time, and I will now turn things over to James Winters, our Corporate Vice President, Manufacturing and Supply Chain, to discuss our global operations.
Thank you, Jay, and good morning, everyone. It's my pleasure to be here today to discuss the role of our global manufacturing and supply chain operations as part of Teleflex's strategy to drive long-term durable growth over the coming years. My name is James Winters, and I'm the Corporate Vice President of Manufacturing and Supply Chain, and I'm responsible for the development and execution of Teleflex's global supply chain strategy and the operational performance of our end-to-end supply chain.
Today, I'm going to provide an overview of our global supply chain, so you can see the notable scale of the function and get a sense of the transformational improvements we have made in our core competencies in recent years. I will talk about our future global supply chain strategy and how it supports the company's strategic growth priorities and will enable us to deliver long-term durable growth.
I will then finish up with a few key takeaways. Let's start first and foremost with our global supply chain footprint. In terms of scale, Teleflex's global supply chain is broad and is comprised of approximately 2 million sq ft of manufacturing space around the world with major manufacturing operations in the Czech Republic, Malaysia, Mexico, and the United States, and we also have 21 distribution centers. We have more than 9,000 supply chain employees across the globe and over 1,500 suppliers, and we manage approximately $1 billion in annual spend. This is where we are today as a global supply chain function.
Now let's focus on where we are going and some of the key actions we have already taken to help get us there. As Liam mentioned earlier, our goal is to drive long-term durable growth through specific strategic priorities.
The global supply chain function is key to achieving these priorities, most notably to drive margin and earnings expansion and to advance corporate social responsibility and an inclusive culture. To do this effectively and to ensure we align all 9,000 employees within the global supply chain function with a common sense of purpose, we created our global supply chain vision. The core of this vision is that together, we will build a best-in-class end-to-end supply chain as recognized by our customers and business partners.
To achieve this vision and to support our company's global growth strategy, the global supply chain function is focused on five core pillars, position for durable growth, gross margin expansion, enterprise excellence, a relentless focus on quality, and sustainability. These pillars are all supported by our high-performing leadership and culture.
I'll now take the opportunity to walk you through each of these global supply chain pillars in a little more detail. Firstly, to ensure our global supply chain is appropriately positioned for durable growth, we mapped our top 11 revenue families globally, accounting for 50% of total Teleflex sales, and we have invested in excess of $48 million to increase supply chain resiliency, redundancy, and flexibility. We did this both internally in our own manufacturing sites and distribution centers, as well as externally with our raw material supply base and sterilization partners.
We changed our standard operating conditions to ensure our internal workforce and equipment capacity gave us flexibility to ramp up to meet unexpected demand surges. Given the demands on certain products during the pandemic, we have demonstrated this ability to meet unanticipated demand surges over the past two years.
We also established a global command center with advanced analytics capability to give us visibility across our network with respect to operational performance at a product line and site level and product demand insights. This visibility gives us the ability to preempt potential future supply disruptions by mitigating them before they occur. All of these elements together helped improve our Net Promoter Score in the Americas 15% year-over-year when comparing quarter four 2021 to quarter four 2020. This is a great external validation from our customer base.
We will continue to leverage our global supply chain to drive consistent gross margin and earnings expansion. By 2025, we plan to source greater than 80% of our revenue from geographies that are optimized for Teleflex's cost structure.
To put this in terms of scale, our restructuring programs have generated $125 million in savings from 2014 through 2021. We also delivered approximately 200- basis points in gross margin improvement from 2018 to 2021. More than 1,000 headcount has been transferred to geographies optimized for Teleflex's cost structure with a $100 million capital investment. We are truly proud of our achievements here, and we'll consider project management and execution of complex transfers a core competence in the Teleflex global supply chain.
Between 2023 and 2025, we expect to realize a further $24 to 28 million in incremental cost savings related to announced restructuring programs, are approximately a 70- basis point tailwind to our gross margin profile.
Our operating philosophy within global supply chain includes enterprise excellence and servant leadership at its core, and this represents the third pillar of our global supply chain strategy. We relentlessly seek to eliminate non-value-add activities from our processes and to empower our 9,000-person workforce in global supply chain. We have carefully fostered and developed a very strong competence in enterprise excellence and consider this a distinct competitive advantage for Teleflex and our customers.
Through this, we have demonstrated that we can drive sufficient cost improvement programs annually to cover material and direct labor inflation, as well as any additional strategic investments we need to make in our facilities while delivering savings from our footprint restructuring projects to the business. While material and freight costs remain elevated well above historical levels, we will remain focused on mitigating inflation impacts with this approach.
Our fourth supply chain pillar centers on our relentless focus on achieving the highest standards of product quality and is built on the premise of doing it right first time, every time. We believe that the focus on the patient is important and permeates our culture throughout the entire organization. We have also adopted training within industry, TWI, as our global standard for training, and this foundational focus has delivered consistent annual improvements in our core quality metrics, which is reflected in feedback from our customers.
Here are some of the key metrics that support how our focus on product quality has improved operationally between 2018 to 2021. We have achieved a 38% reduction in the number of field actions, a 55% reduction in ship holes, and we have seen an 18% year-over-year reduction in scrap.
As Karen mentioned earlier, sustainability practices have a positive and active influence on us as a company and how we impact the planet and the environment. We are increasing our commitment to corporate social responsibility and regularly identify and implement ways to reduce energy, waste, and water consumption. For example, we have increased the use of solar panels in our manufacturing facilities, installed low-energy lighting, and increased recycling to reduce landfill waste.
We have already made significant progress on our goal of reducing our purchased energy through the installation of solar panels at five of our manufacturing locations across the globe and remain on target to achieve a targeted reduction in purchased energy and waste to landfill by 10% respectively by 2023.
All the advances that we've made in the past four years in our global manufacturing and supply chain would not have been possible without having the right leadership, workforce, and culture in our organization. This represents the foundation of our global supply chain strategy, and we are proud that our site and regional leaders are representative of the regions in which we operate and that our leaders are predominantly local nationals.
We have placed a strong emphasis on personal development and have a robust succession planning pipelines to ensure continuity of local leadership within each of the regions. At its core, our objective within supply chain is to enable the company to meet its long-term durable growth goals and to ensure we deliver on Teleflex's purpose of improving the health and quality of people's lives.
Before turning things back to Lawrence, I want to leave you with a few key takeaways. We are focused on a very clear and deliberate strategy to ensure global supply chain resilience and flexibility to enable long-term durable growth. We expect to realize between $24 million and $28 million in incremental cost savings related to existing restructuring programs from 2023 to 2025. We will maintain the highest standards for product quality.
We will continue to leverage our enterprise excellence approach to mitigate inflation, and we will fulfill our commitment to corporate social responsibility. Thank you very much, and I'll now hand you back to Lawrence.
Thank you, James. I'd now like to invite all of the speakers from this morning to have a seat on the stage. Once assembled, we will begin our first Q&A session of the day. For the live audience, please raise your hand if you would like to ask a question, and we will have someone bring over a mic. Please state your name and the name of your firm before asking your question, and please limit yourself to one question. If you'd like to ask additional questions, you can raise your hand again. For those of you on the live webcast, there is an option to submit questions, and we will take questions from virtual attendees.
Thank you. Hi, Matt O'Brien, Piper Sandler. Just for starters, I—there was a lot of information given on the guidance side of things. I didn't hear a reaffirmation of the 15% for UroLift here this year. Then how should we think about the growth profile of that business over the long-range plan just with, you know, Japan and China and all the other countries? Is it a 15%+ grower over the LRP? Thanks.
Thanks, Matt. We reaffirmed our guidance this morning, and that includes the 15% growth for UroLift. We will address the UroLift growth in the LRP in the second Q&A, Matt. Tom will go through it in his section. We'll address it at that stage if you don't mind.
Both in the past. How do you see that changing over the new LRP period, and what role do you see Dev... [crosstalk]
I think if you look at a best-in-class med tech company, I think Teleflex is the best-in-class 50 gross margin expansion, 200 to 300 operating margin expansion. That ends up in a company that will at the midpoint looking at our 2022 jump off point, 1.5%, just taking the midpoint on both of those in 2025. You know, when we began our journey us to get there. Well, if you look at Teleflex in 2025, we are a best-in-class med tech company.
As we outlined in the prepared remarks, our leverage is at 1.0x. Yes, we are active out there in the marketplace. I think our disciplined approach remain disciplined, in particular during the LRP. Just to be clear, there is no additional M&A in the LRP. That's over a public exit, and maybe if you could be a little bit more specific on, you know. A quick follow-up on freight and shipping. There were distributor destocking events in the past. Just a question on what percent of overall revenue is distributor-related, and when you consider freight rates going higher, is there a risk that distributors hold their leaner inventory levels? Thanks.
Okay. I'll ask Jay in a moment to comment on the distributor aspect of it. In relation to the other part of your question, I think that for sure public company valuations are tightened. That's obvious to everybody sitting in the audience. In the past, Anthony, when you're talking to a private company, everybody was doing an IPO. You know, patience has disappeared. People are now much more realistic that the IPO market has tightened at the moment.
Everyone in the audience knows that. You don't need Liam Kelly to tell you. I think with that built into them, so therefore the valuations have at least tempered compared to where they were. Distributors in North America. Just to be clear, we're talking about distributors in North America, the Owens & Minor and the Cardinal Health around the world.
Sure.
To answer the question right off the bat, we don't have any material concerns about inventory levels. I think we're well-positioned from a diversified. Just standard operating procedure out of our distributors during this period. About 60 material concerns in that area.
Thanks. From a freight inflation and lead time perspective, we're hedging some of our high volume rates to make sure that we had protected Teleflex. They have proven current. China lockdown may present some new eventualities, but again, from a resiliency perspective, you know, hopefully when I touched on it earlier, our command center. That's the capability we've developed from an analytics perspective to proactively not wait for a risk to happen, to proactively identify it and mitigate it before it occurs.
I'll just make a quick comment on China just to build on what James said. Just for everybody to be clear, we don't manufacture in China, so it isn't an issue for us of getting product out of the country. It's an issue of getting product into the country. We normally hold a couple of months, a few months of inventory in the channel cause we should be able to mitigate that and get product through the channel.
Two quick ones for me. Just on the M&A, Liam, I thought I might have missed it, but just elaborate on where if you are targeting certain specific... [crosstalk]
M&A. We plan to do M&A. It will be accretive to our top line growth. It'll be accretive to our margin. It is just naturally the high growth bucket will grow faster than everything else because it is growing faster than everything else, and it will expand beyond 25% of Teleflex. Regarding the areas that we're looking at, I think that's what makes Teleflex. We have significant. For us, for me in particular, it's all about call point. Where's the margins and higher growth in that segment?
We're already in interventional cardiology, interventional radiology. We can go north or south on the human body. Peripheral vascular medicine is a key call point for us. The intensive care unit with our vascular organization is a key call point for it. HPC was a great token for that business. Z-Medica, our other most recent. That's the spectrum we look at, Rich. That's what I meant by that statement of the high growth. We would expect to add to that over time and make it a bigger part of Teleflex.
Got it. Just to follow up. On restructuring, obviously, you have some benefits still from existing restructuring plans that you've laid into your long-range plan. How do we think about, you know, on a go-forward basis, the opportunity for additional restructuring? Have you gotten the manufacturing footprint over the years kind of where it needs to be, and we shouldn't really look to that as a potential future area of savings, or do you still have some room there? Thank you.
We constantly look at our overall footprint on an ongoing basis and make decisions then based on that. I think we still have some opportunities to bring more margin expansion through that. Even within the LRP, what we've laid out is the ones we've already announced, Rich. Also, as you know, every time we do an M&A, it gives us further opportunity to optimize our manufacturing footprint.
Jayson.
Thanks, Jayson Bedford, Raymond James, and I appreciate all the detail here. You mentioned share gains in both the high growth and durable core. This could be a difficult answer just given the breadth of the portfolio, but where would you peg your share today and how quickly do you think your end markets are growing? Then just as a quickie, and I'll ask it upfront here, Asia Pacific, I imagine there's some opportunity to go from distributor to... [crosstalk] Is it new products coming into market and regulatory issues, or is it just more bandwidth?
It's growing into a $600 million end market. $300 million of that is external bleeding, $300 million is internal bleeding. That's a market development opportunity going in, educating customers on the use of an impregnated gauze as distinct from a non-impregnated gauze, reducing bleeding significantly by using an impregnated gauze and developing that market. The end markets for those types of gauzes is probably growing 2%.
By market development, we're actually accelerating the growth in that market and getting, you know, high single, low double-digit growth. It's the same with UroLift. It's the same with intraosseous. It's the same with MANTA. You're developing that market and growing much faster in an end market.
If you look into our durable core, in that instance, you're again taking share within the market with some of our key products and expanding that market also by expanding overseas. I'll let Jay spend a moment just talking about the expansion into Asia. He might want to add to what I said.
Yeah, I think I'll first touch on just to say it. We're very confident in our ability to deliver the 6% to 7% growth that we've outlined, and that's because the diversification of where that growth is coming from. We've got multiple products, right? The six products we highlighted in high growth, plus multiple market-leading products in our durable core, are gonna continue to contribute to that. And then, of course, international expansion in multiple different countries and regions continues to add to that.
We're operating in multiple different sites of service even within those regions and countries. We've got a multitude of different growth drivers. And again, that's why we have such a high confidence in our ability to drive that 6% to 7% growth. Specific to your question, again, we've outlined six m arket due to our highly differentiated and clinically proven products.
Those are areas that we're focusing our investments, both in our US market, but also in our international markets. We do see continued investment in our global, specifically Asia Pacific being one very attractive region for us. There's certainly two contributors to that growth, right? The underlying markets are markets. That is certainly the foundation that we're excited about.
More importantly, we've got market leading market leadership positions on proven products in the US that we can take that blueprint into those markets and launch those products. We, again, know what it takes to be successful. We've proven that out over time and are able to take those products into those markets, which contributes a big part of the growth as well.
Liam, you've talked about Teleflex being in chapter three in a 10-chapter book. What excites you about the next couple of chapters for Teleflex, including product or pipeline front, or will it come from M&A? I'm hoping you can talk a little bit about R&D spend, perhaps geographic expansion within your LRP of 6% to 7%.
Yes. I'll anticipate that our R&D spend will grow faster than revenue through the LRP period. We've said to the investment community we want to put more dollars to work in R&D in order to augment our portfolio. Jay outlined a number of products within our portfolio. Pretty exciting. I think the ErgoPack, which is already in the market, is getting great penetration into that marketplace. I think the Advanced Tissue Control product and the UroLift 2 are what market leadership should be about. You should actually lead the market and bring new products and bring new technologies.
If you look at what should excite us and excite every investor in the future, 6% to 7% rock-solid growth for a company like Teleflex with expanding gross and operating margins giving a double-digit return on earnings per share. We've said earlier our balance sheet is in great shape. We're a serial acquirer. We're actually good at it. We're a modest company. It's all part of our values. We are actually really good at doing M&A. We're excellent at adding to the company.
Our past record speaks for itself. 80 transactions completed, $4.4 billion of capital put to work. The vast majority of that put to work since 2017 in order to continue to augment our portfolio. We will do scale transactions. We will do tuck-ins. Confident of that.
With $1.7 billion of free cash flow being generated over the three-year LRP, that just gives us even more firepower as we go through the next number of years. That's what excites me, is all aspects, R&D, M&A, and the team. I mean, part of this exercise is to present to you why we're so proud of the management team that we have and tell all these individuals that are gonna stand up in front of you and present what makes Teleflex a great company.
Our core values and our mission are unique to us as a company, and we strive to be a better organization every day. I couldn't be more excited about the next number of years for Teleflex. You're going to answer your question directly.
Thank you.
Okay, we are going to get started. Welcome back from the first break of the morning. We'll now kick off section two of the program, which is a deep dive into select growth drivers. We'll be hosting two panel sessions with clinicians aimed at gathering insights into the clinical rationale and benefits of UroLift therapy to treat BPH and MANTA, our unique large bore closure device. I'd like to introduce Michelle Fox, who is Corporate Vice President and Chief Medical Officer of Teleflex. Michelle will moderate the Q&A sessions for each of our physician panels, and following the conclusion of each panel, we'll take questions from the audience. Michelle.
Hello. It's a pleasure to speak to you today. As Larry stated, my name is Michelle Fox, and I'm the Corporate Vice President and Chief Medical Officer at Teleflex. Clinical and Medical Affairs serves as a bridge between the organization and the external medical community. Our dedicated team of professionals execute on key initiatives that support healthcare providers around the world who deliver essential care. Much like many of my colleagues have stated, 2021 presented many challenges in the wake of COVID-19.
During this time, CMA representatives demonstrated the ability to thrive in dynamic environments. When access was restricted, clinical and medical affairs led the design and implementation of clinical development programs, covering a broad range of products and therapeutic areas in collaboration with our strategic business partners. We expanded our offerings on Teleflex Academy across 88 countries, with healthcare staff accumulating over 56,000 continuing education credits collectively.
By combining virtual platforms for case support and presentations with our ability to conduct safe in-person education, we set a record by reaching 130,000 healthcare professionals. Together, we delivered on our purpose of improving the health and quality of patients' lives through education. In 2022, along with a multitude of other critical initiatives, we will continue to develop our approach to human factors and clinical excellence, which will drive innovation.
We will always support expansion through multimodality education that is customer-centric, and we will continue to develop and manage key opinion leaders and medical advisory boards. In fact, we have a few key opinion leaders here today, which brings me to our expert panel discussion.
We are joined today by key members of our leadership team and members of the healthcare community to dive deeper into two key franchises within our high-growth portfolio: UroLift and our interventional business. We are very fortunate to have these key opinion leaders joining us to share insights from their practices. Before making introductions, I'd like to point you to the disclosure that the three physicians that you'll hear from today, Dr. Matt Ashley, Dr. Greg Eure, and Dr. Matthew Summers, are paid consultants to Teleflex.
Their opinions they express today are their own and do not necessarily reflect the views of Teleflex Incorporated. For our first panel discussion, I am joined by Kevin Hardage, our President of Interventional Urology at Teleflex. I will now turn the floor over to Kevin for brief remarks on interventional urology business.
Thanks, Michelle. Good morning. My name's Kevin Hardage. As Michelle said, I'm the president and general manager of the Interventional Urology business unit. I'm glad to be here this morning to share more on Teleflex Interventional Urology and also the UroLift system, the number one minimally invasive BPH procedure chosen by urologists who want an effective alternative to medical therapy or major surgery for their patients. As we emerge from the pandemic challenges, UroLift procedures continue to rebound as we focus on moving our existing UroLift users back to pre-pandemic levels.
Last year, we pivoted to address the pandemic challenge by leveraging remote training capabilities and ramping up patient education and our direct-to-consumer campaign to help build patient awareness. The 2021 campaign responses more than doubled compared to 2020, with brand awareness growing by 60%.
That said, there remains a significant opportunity to drive greater awareness for UroLift, which has increased 16% of target consumers based on our survey research. UroLift 2 and UroLift Advanced Tissue Control, also referred to as ATC, adoption is growing steadily. As of first quarter, UL2 has started to build momentum, and we remain confident in our plans to convert the vast majority of US accounts by the end of the year.
On ATC, a significant number of accounts are now using purpose-built devices for obstructive median and large lateral lobes, and this is important as we seek to expand the use of UroLift across various patient anatomies. We continue to focus on physician education for treating the full indication, and we're also executing on the large urologist runway opportunity to expand our customer base, having trained more than 3,400 urologists to date.
We continue to take share from competitors in an under-penetrated market. When you look outside the US, procedures are emerging for us as far as emerging opportunities and very high-growth potential opportunities. Teleflex officially launched the UroLift system in Japan in early April as the market activities continue to ramp up across. The feedback from the initial cases has been very positive, and we are working to methodically build traction in this very important market opportunity.
Early market access is steadily progressing in Brazil and other parts of the world. UroLift remains differentiated from other outpatient BPH treatments with its strong clinical results. Studies have shown rapid symptom relief and recovery with durable results and no new sustained sexual dysfunction. With that, I appreciate the time. I'm gonna now turn it back over to Michelle, who's gonna help facilitate and lead the clinical panel as we bring up our esteemed colleagues. Michelle?
Thank you. I'm now pleased to introduce Dr. Matt Ashley and Dr. Greg Eure. Dr. Ashley is based out of Bend, Oregon, and practices all aspects of urology, including treatment of enlarged prostates, kidney stones, voiding dysfunction, and all urologic cancers at Summit Urology Medical Group. He specializes in minimally invasive prostate procedures and has achieved the UroLift Center of Excellence designation based on his additional training and validated successful patient outcomes with the UroLift system. Dr. Ashley sees over 100 BPH patients per month and performs about 10 UroLift cases per month.
Great. Let's switch over.
Dr. Greg Eure offers expertise in all aspects of adult urology. Based in Virginia Beach, he practices general urology with an interest in the treatment of BPH, including minimally invasive and laser techniques, and men's health issues, including prostate cancer and erectile dysfunction. He is a recognized international expert in the use of UroLift, in the UroLift system, and has had the opportunity to teach and lecture across the US and globally.
Dr. Greg Eure serves on an international medical educational advisory board and sees over 100 BPH patients per month, and he typically performs about 15 UroLift cases per month. We'll go ahead and get started. Our first question, which I'd like to direct to both of you, is over the past three years, have you seen any shift in the mix of your treatment modalities for BPH, including watchful waiting, drugs, and surgery?
Good question. I've definitely seen that mix shift over the past few years due to a number of different factors. Basically, guys are showing up to clinic earlier in the disease state. Their symptoms are there, but they're not quite as far progressed as in the past. Typically, these guys are younger, they're healthier, and that population is much more interested in a minimally invasive procedure, something that they can get back to their life quicker.
The preservation of sexual function is a big deal to these guys. It's quite a bit different than years ago when these guys would typically show up at the office much further along in their disease state, and they just, you know, needed something to fix that issue. It's a much more nuanced discussion now, and a new group of guys that we're seeing.
Great. Thank you.
Yeah. Thanks, Michelle, and thanks for the opportunity. I would agree. You know, we've seen the same thing in our practice. I would say three or four years ago, I would be one day operating and four days in the clinic. Now it is almost switched. I'm two to three days operating and just one day doing procedures in the office and really just one clinic day. I think that, again, is because of the options we've had before. You know, medication, and then it was a big jump to an invasive surgery.
A roto-rooter, and guys didn't want that until it was a last resort. But now as more and more word gets out that there's an excellent minimally invasive option that doesn't impact sexual function, yeah, we have more than enough patients. I mean, it's good.
I think from a physician perspective, you're catching these guys more... [crosstalk]
Yeah.
Upstream, basically. That's, you know, important long term for them. You know, we're keeping them out of trouble as opposed to trying to drag them back from, you know, a much further along down the road.
Great. Thank you. The next question I'll again direct to both of you. What has your experience been with the use of UroLift 2 and ATC? Please share your insights on these devices.
Do you want me to go first?
Yeah. I mean, they've been a good addition. The UL2 is really, I mean, you saw the image, but it's more ergonomic. It saves space. You know, I'll be honest, I didn't think it would be that big of a difference, but having used it in some of the prototypes before, it really is, at least anecdotally, even better. Better tensioning, I think are gonna lead to better outcomes, better durability. You know, time will tell. We'll prove that. Again, it's been great. In our surgery center, you know, I made the decision early on, going forward, that's all we want. That's what we want to use. The ATC is a nice addition as well.
I think middle lobes are a fuzzy thing and depending on where that comes from, as to, you know, the impact of that. It's not a huge percentage of patients, but again, having this device gives docs that, you know, for Matt and I mean, we were okay with the device before, but this actually makes our life easier. It really helps with the docs who don't have that experience to get in the game with treating middle lobes, if you will.
I think with UL2 in my practice, I've had a similar experience where I didn't think it would really change that much, and now looking back, it's for me, it's addressing the full range of indications.
Right.
Even though I thought I was doing that before, it's really the prostates on the smaller side and the prostates on the bigger side that I would be hesitant with earlier iterations of... [crosstalk]
Right.
The device. The technical advances with the UL2 really allow, you know, me to feel comfortable on those two ends.
Yeah.
when I teach other physicians that come to my program, a really common way that they come in is, "I feel comfortable with the middle-of-the-road prostates, but the smaller prostates and the bigger prostates, I'm doing other things, and.. .
Right.
I don't feel comfortable doing that. With the way that UL2 has advanced and the kind of things that it can do that UL400 can't do, that's a much more comfortable transition. People can feel more confident going into it.
Right.
That's what I'm able to show, you know, in those live cases. As far as the ATC, that's really probably my favorite advancement because it's, you know, with UL2, I'm treating, you know, a wider range, and I feel like the surgeries are just going better. With the ATC, that's a new group of patients there. Something that I was doing on a very narrow group of median lobes beforehand, now it's, you know, I feel very comfortable with a lot of median lobes.
You know, most of the physicians that come into my program have never done one of these. They're very hesitant to do it. That's really the wow moment of the teaching program is when you see, you know, the appearance of one of these median lobe cases after a nice, you know, ATC implant. It's really impressive.
I'll pa... [crosstalk]
Go ahead.
I'll follow a little bit more to say, both Matt and I are fortunate to get to train other doctors and residents to how to do the UroLift procedure, and this, the UL2 makes that easier. It's a simpler device, simpler step, I think, for those. I'll put a quick plug in too. You know, I applaud Teleflex for. You know, I've worked with a lot of companies over the years, and nobody's put in the effort, the resources, and I'm sure the dollars to make sure that. You know, they don't want all 10,000 to 12,000 urologists doing one or two cases a year. Just like anything, the more of something you do, the better at it you are.
I think they take that philosophy to make sure they've trained doctors, they're in it for the long haul and to get, you know, better outcomes. I think I've surely seen that in my seven years of doing them. They continue with that commitment, which is awesome.
If one of you wouldn't mind following up on just a question around UL2. I just outlined that we're gonna be moving a majority of our business from UL400 to UL2. A lot of times, questions will come in, "Does that seem a little aggressive?" Based on your experiences with the device, your practices, and being able to make that migration, maybe just one or both of you just could speak to that process and whether it's simple or whether it's complex?
Yeah. Well, in my practice, the transition was really simple. As far as the staff is concerned, supplying the device, it just takes up a lot less space. For someone who's either doing the procedures in the office where space is really limited or you know, a small surgery center, which is where most of my cases are done, space is really at a premium. The staff love the new packaging. Less waste, less space requirement.
As far as you know, the support, you know, the scrub techs and the MAs that are actually doing the procedure with us, very easy transition. I've helped with multiple, you know, other offices around the country make that transition there on their first day, and it's really seamless.
Thanks. Appreciate it.
Yeah.
That's actually a nice transition, so thank you, to our next question. We know that over the past two years, the pandemic impacted practices with disruptive stops, starts, and stops again as cases went up and down. Since COVID has waned, have cases increased, and how would you expect your volume to trend going forward?
Okay.
Yeah, I mean, I've seen, you know, I mean, definitely challenging years. We're coming out of that, you know, pretty strong now. Plenty of cases, but the opportunity, we're still short-staffed to some degree. We're digging out of that. I could potentially run a couple rooms at the surgery center, could run longer during the day. It's really staff is a limitation with that. Again, it's, you know, it's a good problem to have and I think we're recovering from that well. Yeah.
Yeah, as far as the bounce back, a couple things, you know, particular to UroLift. Other types of procedures that had really hard stops, you know, things that were typically more hospital-based, those are procedures that people have been waiting, you know.
Yeah.
9, 12, you know, a year and a half for.
Mm-hmm.
I'm seeing a lot of patients now that are, you know, kind of resurfacing and saying, "Okay, I'm on the wait list for my hip. It's gonna happen in two months. Let's talk about UroLift. I want to get this done as soon as I can afterwards." The long backlogs that are being worked through, the people with these long wait lists were often kind of, you know, going to be up next because they've just been waiting for so long. They don't want anything to derail those really long, you know, their spot in line, basically. As far as, you know, staffing, we always hear about, you know, staffing and then the challenges.
Like, one example from my group is, you know, we typically had someone who was just in charge of making sure that the schedules were filled on a day-of basis. So whether it was your clinic, someone canceled late for surgery, they were in there, and they were putting that new patient in, you know, immediately. So everything stayed really full. Those kind of employees, those are the first ones.
That's the first position to not be filled cause we need people just, you know, taking vitals and putting people in rooms. So that there's a little bit lower volume, you know, as far as there's open spots. You know, that one surgery slot might not get filled until you get your staffing all the way back up.
As far as, you know, the staffing levels, we had an email like, gosh, a couple weeks ago saying that for the first time in two years, we were at full staff. That lasted for about 30 minutes until someone quit. We had a really good 30 minutes there, though. The point being is that we're getting close. It's at least in my environment, we're almost there.
Yeah. Another sign I think things are waking up. Recently, I've seen a handful of patients who got worked up pre-pandemic, and now they've come out of the shell and saying, "Hey, can I still get that UroLift? Am I still a candidate?" Again, that's good. You know, staff shortage, but it's also provider shortage. I mean, I'm a 25-man group. We could probably use, you know, 10 more men or women urologists. I think the future, and we're surviving with APPs, so advanced practice providers, PAs and nurse practitioners. We have over 30 of those. Again, I think, like Matt said, treating earlier in the disease spectrum is the future.
I just got to go to our national or international A, American Urological Association in New Orleans meeting, and one of the recurrent themes in talking to the other KOLs from around the world, you know, diagnostics, finding these patients, and really helping with the APPs funnel them in. That's what we're seeing in our practice. Diagnosing them early, getting them off the pills, making sure they know that that's an option, and then fixing them, releasing them, and then make room for a new one. I think that's where we're moving towards.
Great. Thank you. Another question. UroLift is a broad-based BPH procedure and can be performed in a hospital outpatient setting, an ASC, or in an office. As you know, CMS has made some meaningful changes to the reimbursement for office-based urology procedures for 2022. Has the CMS ruling impacted your practice, and can you speak to the impact for other urologists within your professional networks?
Fair enough.
Yeah, I think both Matt and I do the majority of ours in an ambulatory surgery center, which is a great idea, you know, site for that. I know for Teleflex, it's about 30%-ish of cases are done in a clinic office setting. I know they're. I mean, not to get into politics, but it's a ridiculous sort of path that they're, I think they're going. I mean, again, the movement is out of hospitals.
Patients don't want to go to the hospital if they don't have to. If they can be fixed in your clinic or in an ambulatory surgery center, it's much more favorable for everyone involved. Again, hopefully the battles with that reimbursement will continue to be successful. I know Teleflex is gonna do, and I've already started. Michelle may comment about making the economics work for those doctors who want to keep that site of service.
Mm-hmm. I think that in traveling around, you know, seeing doctors that are purely office based, I honestly expected it to be more disruptive. I really... [crosstalk]
Yeah.
Just didn't see nearly as much hesitation. Certainly, I haven't, you know, spoken to or trained anyone that was changing sites of service or changing modalities.
Right.
Part of the nuances as far as the surgeon incentive perspective is that, you know, many surgeons, myself included now, many urologists, we're more RVU based than fee-for-service based. That changes a lot of the surgeon's individual, you know, incentivizing factors. It takes something really big to change a site of service for something that you're comfortable with, your patients are doing well, particularly if you're RVU based. From the medical group that I work for that, you know, that pays me based on RVUs hasn't made a bit of difference to them at all.
They are very much focused on, you know, how UroLift is providing them with the quality reimbursements, the, you know, the decreased total cost of care, all the things that are much more important to them from a big picture standpoint. They've been really very much behind the procedure throughout the whole CMS changes.
Great. Thank you. One final question. In 2020, Teleflex began a national direct-to-consumer advertising campaign across television and social media channels and has since augmented that investment in 2021. Since the campaign began, have you noticed an increase in patient awareness or activity relating to pursuing the UroLift procedure as a potential option to treat BPH?
I think, I mean, certainly, we see a lot of patients coming in. You know, they came in because they saw the commercial. We actually have, you know, there's a special kind of phone number that funnels them, you know, through to our office. So, we get a lot of interest from that, much more than I was anticipating really when it came out. So that's been great for us as a conversation starter, as a way to get guys in the door. You know, the other thing that I've been really noticing lately in addition to the direct to consumer is just we're reaching kind of a watershed moment of enough guys have been treated with this now.
Yeah.
That the word of mouth effect is that's probably where I get most of my, you know, brand new what we would call, you know, a self-referred patient not coming from their primary care doctor, someone who just walks in the door because their brother, their uncle, or their neighbor had one of these. In the past, this was something we had to battle against in the past, in the days when all we had was TURP. This would k eep guys out of the office cause usually.
Right.
Someone they knew had not had a good experience with that. Now it's really we're seeing the opposite, and me personally, I get more of those kind of, you know, just walk in the door patients in that kind of context than the, you know, the commercial, although that's certainly a significant driver as well.
Great.
Yeah, it definitely has driven them in. Like Matt said, you know, in the past, the BPH patient would come in drugged by his cath or by his wife. You know, "You're gonna get this fixed now.
Mm.
Again, you know, treating this earlier, I've even had guys who've seen the commercial come in and say, "I'm really not having any problems yet, but can I start? Can I get that UroLift so I-- for prevention so I don't have issues in the future?
Mm-hmm.
Again, I think you know the DTC is just helping with that awareness and maybe the future is even more disease specific. You know the talk we give constantly to patients to educate them on that this is most likely progressive, the whole bladder health these guys have brought to the forefront, which has been excellent and really you know digitally getting to these patients even more may be a future move.
Thank you. That was a great discussion.
We got our names up and applause. How about that?
Thank you. Thank you, Michelle. We will allow some questions from the audience at this point. Just need a microphone. Go ahead, Matt.
Hey, Jay mentioned previously in the last segment that looking more at UroLift as a first-line therapy and you guys are talking about treating this disease state at an earlier age and finding these patients a little bit younger. Can you j ust talk through like the progression of how, if somebody came in with symptoms, how would you typically treat them? How long would you keep them on, like, medication management before you'd actually think about recommending them for a minimally invasive UroLift procedure?
Would you mind, Michelle, I don't know if the mic was on. Would you just paraphrase the question quickly?
Sure. I'd be happy to. Everyone can hear, the question was really if looking at UroLift as an alternate to a first-line medical therapeutic management, you know, what is their thoughts on when they would likely go to UroLift versus pursuing the medical management, and how does that support bladder health?
Exactly. In addition, also, what insurance would allow that to be... [crosstalk]
Sure.
Covered.
Sure. Yeah, no, it's a good question. I mean, our guidelines, the AUA guidelines, say we can offer it as a first line, so that's support. You know, insurance isn't gonna be a problem as long as the diagnosis is there, the symptom score is there. It varies with carriers, what their criteria are, but not a barrier either.
You know, I think it's both our way of handling it is educating the patients early on, letting them know what their option is. Honestly, I mentioned bladder health before. You know, I think that really patients understand that, and they resonate with that. What I mean by that, we'll say, you know, the prostate is a confusing thing for a lot of guys. It's an acorn, a walnut.
There's a straw in the middle. Where is it? Does it have cancer? What does it have to do with me, you know, voiding? Whereas the bladder, a muscular sac, it has two functions. It stores urine, and it empties, and it's that muscle squeezing urine through the blockage. Like any muscle, you overuse it a lot, it first gets stronger. You overuse it, you burn it out, and you don't want to be one of the guys on the catheter commercials.
You know, they all. That resonates. They all get that. Again, and then I think that's what I mentioned earlier, these diagnostic tools. I think there's gonna be more of a focus on that to really see which guy, hey, this guy is progressing.
You know, here's the other thing, not to get on too much of a soapbox, but you know, all of you guys and gals, I'm sure you check your heart rate, your sleep cycles, you know. With the Peloton, you can track with your watch your heart rate, you know, all the numbers. You look at SportsCenter. A guy comes in, "Okay, I got BPH. You know, how bad is it? Give me some numbers. Give me data." That really engages the patient in that process. I don't, you know, I don't sell the procedure at all.
It's educating the patient, telling them where they are in that spectrum and what I think's gonna happen. You know, I tell 'em, "If I could predict the future, I wouldn't be working, you know, my behind off here." Again, I think that's where the future is to get patients earlier in the process and save the bladder.
Yeah. I think for me, the issue of medication trial is really that I offer that as—or I should say it's really driven by insurance requirements. I have lots of guys, most insurers that I deal with do not require a medication trial. Now, some guys want one, and that's great, and that's one of the options starting off there, but a lot of guys don't. You know, something that we've historically not been great at as physicians, as urologists, is really talking about the downsides of medications.
Right.
When you really lay that out there, unless there's an insurance requirement, I have many guys that go through the whole, you know, workup and ultimately end up with a minimally invasive procedure who've never taken a medicine, you know, before, which years ago would've seemed crazy.
Right.
now, I mean, that's really what people are after. There's just kind of a small sliver of commercial payers where in my market where they have to have a documented medication trial, but it's a pretty small minority of them.
You both proctor across the country. Are you seeing that movement start to take, you know, take shape as far as your peers across urology?
I think it's, you know, as I'm working with other urologists, it's really one of the most important and one of the most, I guess, fruitful ways to talk to patients but also to primary care doctors, is to, you know, have them understand that you don't have to be on this medicine for five years and fail, you know, to come in and see us. It's, you know, getting them to see that, you know, medicines, they are an option. For some guys, they work great, and it's good, but for a lot, they don't. It's not, you know, a necessary part of the workup anymore.
That's something that as far as, you know, the light bulb moment for the primary care doctors, they're used to kind of putting these guys on their meds and then putting them on cruise control for a year and then saying, "Oh, well, it's not working. I guess it's time to see the urologist." You know, changing that discussion and that kind of mentality, that's been really important.
That's how I position UroLift as well. You know, you're on your pills. You're happy. I've got a minimally invasive procedure that can get you off the pills and likely improve your symptoms. You know, the other thing too, the beauty of this, you know, for Matt and I to tell a patient, "You're gonna have a catheter overnight. It's no big deal," it's not to us, but to a lot of patients it really is.
If you can offer them something with, I tell them 80+% chance you'll go home without a catheter, and it will, you know, confidently not impact sexual function, then that all of a sudden, you know, brings that awareness and changes that thought process.
Yeah. I think not to belabor the medicine point too much, but I have lots of guys that are doing symptomatically well on their medicines.
Right.
As soon as they hear that there's the possibility I can take one less pill.
Right. Two, yeah
I mean, that's something that we just have not recognized as.
I know.
physicians. It's basically patients come to the doctor. You never get a pill taken away.
Right.
You just get more every time you come in.
Right.
That's a, you know, really nice discussion point and something that really, you know, opens patients' eyes for them.
I know. Some of them are on a ton of medication... [crosstalk]
Mm-hmm.
Would love the opportunity... [crosstalk]
Mm-hmm.
To come off one or two.
Vic?
Vik Chopra, Wells Fargo. For the doctors maybe, do you use UroLift on all your BPH patients or do you use something else on patients with large prostates and median lobes? And if so, what? And then one for the Teleflex team maybe. Can you talk about maybe what percentage of sales you expect international to be by 2025? Thanks.
You want to go ahead?
Yeah. I mean, my bias is that I wouldn't want to go to the urologist who does 12 different BPH procedures. You know, you're not gonna be great at all of those. I think having an invasive procedure that you get good at, focus on to remove, ablative procedure that you remove tissue, and then a minimally invasive. You know, my go-to for the minimally invasive is UroLift. I do an invasive, my ablative procedure is a green light laser to vaporize the prostate. Those who are massive in size, you know, there's a little more trend to HoLEP to those kind of things. As you know. That's kind of how I-
Mm-hmm.
Approach it.
Yeah. I think you know, for me, throughout the full range of UroLift indications, that's my minimally invasive option. Like Greg said, you know, just because you're in that range though does not necessarily mean that you're a great UroLift candidate. One of the really important skills that you know, I teach these urologists I work with is you know, how to recognize you know, who you know, what patients are not right for a UroLift. That ends up you know, in my practice being a relatively small minority. In those patients, for me, it's TURP. That's just what I'm the most comfortable with.
You know, if there's some factor there that says that this guy is going to do better, whether it's a patient factor or you know something you know from the technical side on my part, in that small sliver of guys, it's typically TURP for me.
Yeah. Again, Vik, the other part of that is, you know, I tell the patient it depends on the size and the shape of your prostate. Again, in the past, you know, there wasn't as much focus on figuring out how, you know, you failed medicine, you get a surgery. Now it's, "Well, what are you gonna be best from? And then what side effects are you willing to risk to get to that?
Yeah. I think the, you know, the way I teach urologists is these procedures, they're complementary. They're not really, you know, competitive. If you select the right guys for the UroLift, that's gonna be the vast majority. The ones that don't fall into that often do really well with a TURP or whatever you do.
That's right.
We'll take one more.
Mm-hmm.
Brief question.
Okay, sorry.
Rich.
Hi. Thanks. Rich Newitter of Truist. On the reimbursement comments, thanks for that perspective there. You know, I'm not surprised it's kind of year one of the reimbursement change. It's a phased in reimbursement cut situation. I'm curious, as you speak to doctors and do you talk to them about what they think their behavior you know may look like as reimbursement cuts do get implemented more aggressively over the next several years? Do you think that side of care you know could potentially begin to migrate?
Yeah. It's sad to say, in a room full of business minds, most of my colleagues don't think business-wise like that, believe it or not. Now more and more owned by hospitals and corporations that, you know, I think some of those decisions may be made by them. You know, as you know, the reimbursement has gone up a little bit in surgery centers and in the hospitals. You know, I think time will tell. Again, hopefully they can have some impact on that. I know there's a lot of lobbying.
There are all these other procedures trying to get into this space that are gonna depend on office reimbursement. I think there's gonna be enough of a, you know, drumbeat to have some. Again, just common sense, it doesn't make sense.
On the volumes, so it sounds like, you know, you see the demand. You know the demand... [crosstalk]
Yeah.
Is robust. There's clearly a backlog. It's a matter of when you can get to it, and it sounds like staffing is the bottleneck. You know, the best that you can predict, do you think that staffing issue will be resolved in the next six months, or do you think this is something that probably takes a longer period of time to work through?
I would say we're slowly seeing it get better, the staffing issue. Yeah, I mean, I think six months is a good thought. Then the other thing too, you know, three to four years ago, it was me doing the most in the group, the Center of Excellence. Now I have two partners who are that same volume and more starting to adopt. Again, that'll help the, you know, expand the bandwidth and as well.
Okay. I think we will move on to our next panel. Thank you, Dr. Eure. Thank you, Dr. Ashley.
Thanks, guys.
Thank you.
Kevin. Appreciate it. We will now start our interventional panel. I'd like to introduce Scott Holstine, who is the President and General Manager of that.
Thanks, Larry. Good afternoon. I'm Scott Holstine. I'm the President and General Manager of the Interventional Business Unit. At present, Teleflex Interventional focuses on four broad market categories: mechanical circulatory support, coronary interventions, structural heart, and peripheral interventions. The first three markets that I mentioned are primarily found in the cardiac catheterization lab for complex and minimally invasive cardiology procedures.
Indeed, mechanical circulatory support, coronary interventions, and structural heart are all foundational components to any comprehensive cardiac cath lab, and Teleflex offers key enabling technologies in each of these segments. The Teleflex foundation in the cardiac cath lab is established with leading technologies that support mechanical circulatory support and complex coronary interventions, including complex PCI and chronic total occlusions.
Medical guidelines call for the presence of an intra-aortic balloon pump in every cardiac cath lab, and Teleflex offers one of two leading pumps in the world with the AC3 Optimus intra-aortic balloon pump, enabling Teleflex to establish a capital foundation in the cath lab to provide critical circulatory support in numerous cardiac procedures.
Teleflex is also recognized as a leader in complex percutaneous coronary interventions, commonly referred to as complex PCI, with leading global market share for guide catheter extensions and micro catheters that allow physicians to access and treat very tortuous and calcified vasculature in complex PCI procedures. A few of these products that are highlighted on this slide are the GuideLiner V3 guide extension catheter and the Turnpike family of micro catheters. A natural extension of these technologies and therapies are peripheral vascular procedures performed primarily by interventional radiologists.
These procedures are similar to the coronary procedures I just referenced. The basic difference is that these interventions happen outside of the heart. Some interventional cardiologists still perform procedures in the peripherals, but the emergence of these and many other technologies that enable minimally invasive options have fueled procedure growth in both the coronaries and peripherals. Interventional cardiologists simply don't have the time or bandwidth to address the peripheral procedure needs.
Further, interventional radiologists have adopted a wide array of interventions treating a wide variety of diseases in the peripheral vasculature. While Teleflex has many enabling products in the peripheral space, the current flagship is the OnControl powered bone access system, which allows for best in class standard of care technology for bone marrow biopsy and bone lesion biopsy.
OnControl continues to represent an important growth driver for Teleflex as one of six key global franchises in our high growth portfolio, and has generated strong double-digit growth exceeding 18% on average over the past five years. Teleflex continues to invest in OnControl not only with the development of new products to enhance the portfolio, but also physician education and patient awareness of the technology and offering. Finally, I'll comment on structural heart as it is the focus of today's clinical panel.
While recent advances in transcatheter valve replacement, commonly referred to as TAVR, as well as endovascular aneurysm repair, commonly referred to as EVAR, offer a wide range of treatment options for interventional cardiologists and vascular surgeons. The procedures themselves result in a wide range of complications when it comes to closing the large incision required to facilitate these new procedures.
The historic standard of care for closing these large bore insertion sites requires the surgeon to use multiple suture mediated closure devices in an effort to provide hemostasis or stop the flow of blood so that the patient can start recovering from the procedure. The first of its kind MANTA device is revolutionizing large bore closure by achieving fast, simple deployment with one reliable device.
We know that the potential impact of bleeding complications can result in a higher cost of care per patient, potentially resulting in a 2x increase in hospital length of stay, a 3x increase in mortality, and a 60% increase in healthcare costs. When a physician chooses the MANTA device, its innovative design achieves low major complication rates and rapid time to hemostasis, helping patients get home faster and potentially reducing healthcare costs.
During today's panel, Dr. Summers will provide a clinical explanation and personal experience with this key advance in structural heart. Finally, MANTA represents the first of several investments in the structural heart lab as Teleflex has products in the R&D pipeline and acquisition landscape that will complement MANTA in the future. I'll now turn it back over to Michelle.
Thank you, Scott. I'd like to introduce Dr. Matthew Summers, interventional cardiologist with the structural heart team at Sentara Heart Hospital. Dr. Summers performs complex coronary and structural interventions including transcatheter aortic valve replacements, coronary stent procedures requiring mechanical support, and chronic total occlusion interventions.
He is a fellow at the American College of Cardiology and has published several clinical research studies in top medical journals. I'd also like to introduce Dr. Chris Buller, our medical director. Dr. Summers is here today to give you an overview of the adoption and implementation of MANTA in his practice. Welcome, Dr. Summers.
Thank you.
Thanks, Michelle. I'm just gonna open with a couple of remarks. Thanks, Matthew, for being here.
Of course.
Dr. Summers really is representative of a typical interventional cardiologist who has adopted MANTA. He comes from the very best training out of Mayo Clinic, Duke University, and Cleveland Clinic, has joined a large practice that includes complex PCI and TAVR in large volumes. I believe you're doing 500 TAVRs a year at Sentara. He's highly self-critical of his practice. He reports his results as his whole group does publicly, and they publish on the results. It's that kind of self-critical practice that we see amongst the MANTA adopters. With that introduction, Matthew. I don't want to take any more time.
Sure.
Tell us about your journey through training and on to use of MANTA?
Absolutely. Well, thanks for having me. As Chris said, I am a structural heart and complex coronary interventional cardiologist at Sentara Heart. It's a large, quaternary care, referral center, where a lot of patients from the region come for highly complex procedures, including transcatheter valve replacements and repairs, as well as, what we call CHIP procedures, which is complex or high-risk, interventional, procedures, which are PCI stent procedures that require mechanical support.
I typically obtain large bore access five or more times a week with my current practice. I came three years out from training at Cleveland Clinic. I came from an established sort of way that we dealt with large bore access, which, as you know, as an interventionalist is meticulous attention to detail of where you puncture the artery. But then, before MANTA, it was deployment of two suture-based devices that requires additional time, that were not purpose-built for large bore access, but they were adopted to solve a problem, as far as how we close these blood vessels after we do our procedure.
Six months into fellowship, our center, which is a large volume center as Chris mentioned, trialed MANTA as our large bore access closure device. After about two weeks, we adopted it as our primary, and actually now it's our sole large bore access closure device.
We've found it incredibly useful, not just in patient outcomes, as was mentioned, facilitating next-day discharge, which is a huge benchmark for us and a measure for us. Time to hemostasis is very important. Procedural efficiency is very important. We have not seen anything but good outcomes after that adoption. It has taken us from not just including it within the structural heart space, but it is the primary way that we close mechanical support devices that require large bore access.
Now we're doing this in 550 TAVR cases a year at our center, split between two to three operators and almost 200 CHIP procedures that require mechanical circulatory support. Coming from training, where outcomes and your denominator, so to speak, where your total case volume coming out of fellowship is very, very low, obviously, but critically reviewed by your colleagues and by your referrers, there's really no tolerance for procedural complications. Vascular outcomes are one that are sort of inherent with large bore access in and of itself.
If there was any concerns from our standpoint about a new device leading to differences in what's established as the standard of care for vascular closure, we would have noticed them, and I certainly would have been very attentive to them.
We've seen just the opposite, that it helps us improve the efficiency of the procedure, the patient outcomes are excellent, and it helps us focus really on the primary reason that we're in the cath lab or the hybrid OR, which is to do a good valve replacement, get the patient through the procedure, and not necessarily have to worry so much as we did with Perclose and other closure devices about large bore complications or setting up for the closure so meticulously at the beginning of the procedure.
Yeah. Tell us about the learning process. How was it supported by Teleflex? How long was the learning curve? When did you feel comfortable with the device?
Well, you know, the comfort level for other devices is a little bit higher, obviously, because they've been used for years. We had a similar device, Angio-Seal, used for smaller bore access sites. It was very similar to that closure device, just adopted for the large bore access sites. We had someone from Teleflex come out for a week and we deployed several of these devices on a benchtop model, and then we used it immediately in patients and had excellent outcomes. As I mentioned, we've now adopted it for all of our patients. Within a matter of two weeks, we had adopted it as our primary closure device.
Right. In the field of large bore closure for mechanical circulatory support, the mechanical circulatory support devices often go in non-electively, in a way that doesn't allow you to know the depth of the artery at the time.
Sure.
the way it's customarily done with TAVI procedures. What's the experience like with the new 14 French dilator that allows for post-procedural measurement of artery depth and the use of MANTA therefore in those urgent and emergent... [crosstalk]
Sure.
MCS cases?
Yeah, that's a good question. It was something that we didn't think about before MANTA. You'd put the device in, patients would be crashing, they'd be very, very sick, and then after the fact, you'd try to figure out how you were going to seal the device or take device out and seal the artery without complication. It often involved a vascular surgeon cutting down and repairing the blood vessel. Now what we have, and our techs have gotten so facile with it.
I had a case last Sunday, a gentleman that was in cardiogenic shock. He comes into the cath lab, pretty typical scenario, and our techs dropped the pre-measurement tool, the depth tool on the table. It takes literally, you know, 15, 20 additional seconds while you're getting an Impella in, to pre-measure in anticipation of the closure in a few days, when the Impella is taken out.
I think it's actually, if you incorporate it into your normal workflow as far as large bore access, even in shock, even in patients that are critically ill, it actually improves things on the back end because you're not trying to figure out a way to get the patient and have their large bore access closed after the fact. You've already got that number from the depth locator, and you can close it with MANTA after the fact.
Great.
I think we just have time for one more question before we open it up.
Well, why don't we open it up? I think we're ready to open it up.
Okay.
Yeah. Matt, please.
Okay. Matt O'Brien, Piper Sandler. Sorry for this question. It's an acute one, but it's getting a lot of attention right now, and Dr. Summers, given your practice. Contrast dye, is that an issue at your center? Are there certain procedures you're kind of pushing to the back burner right now because of that? I'll just add in my question on MANTA, which is more important. Just, you know, you're a very sophisticated center obviously and want what's best for your patients.
As Teleflex is trying to penetrate this $200 to 300 million market opportunity, do you think they can get to, you know, half of that group, or do you just think there's a lot of centers that are gonna say, "Hey, you know, I'm just gonna throw a couple Percloses in there and just be done. It's cheaper," versus MANTA being so expensive? Thanks.
The patients are coming through the door at increasing volumes, and the procedural efficiency component of it, getting more patients on in a day, getting them through quicker, getting them out of the hospital the next day, these are measures that we use to try to tackle the problem of increasing volume. I think as more centers adopt this, they'll realize what we've realized, which is that it doesn't just help our patients, which is our primary focus. It helps us help more patients by improving the efficiency of the procedure in and of itself.
Speaking of the contrast issue, that's something that is, you know, continually looked at. In the procedures that I do, very few of them are elective. Even during COVID when most cardiac elective procedures were put on the back burner or delayed, patients still come into the hospital with heart attacks, and you can't delay those. Patients with severe aortic stenosis have an inherent mortality rate waiting for aortic valve replacement. None of those procedures are technically elective even though TAVR patients do come in on an outpatient basis.
There's a variety of things that we all do in the cath lab if you do a lot of these procedures to minimize your contrast use, and we've basically continued to incorporate them, and we don't have any impending risk of being out of contrast.
I know it's a concern at other centers that maybe are less, you know, their volumes don't dictate that they are very conscientious of dye use. Most of my patients have chronic kidney disease, and we're already upfront focused on how much dye we're using. We're doing TAVRs with 10 or 15 cc's of dye. We're doing multi-vessel PCIs with Impella with, you know, less than 50, 60 cc's of dye. We're doing contrast-free procedures. We've already sort of been prepped for any concerns about contrast volumes across the country. We don't currently have any significant concerns about that.
Terrific. Other questions? Shagun?
Thank you so much. Shagun Singh from RBC. I was just wondering what your take is on the CHOICE-CLOSURE study and how your colleagues are viewing the data. Then just one question for Teleflex. You know, you talked about a focus in structural heart, you know, focused internally as well as externally. Can you just give us any more color there on pipeline products or timeline or areas where you may be looking externally? Thank you.
Yeah. CHOICE-CLOSURE is something that commonly comes up when I talk to other operators at other centers that are still using preclosures, their dedicated technique. When that came out last fall, we looked at our own data, and the number of patients in that trial, for instance, was a little over 500. Our data on MANTA use was well over 1,000 patients, and our complication rate was 1.7%. There's a lot of things that you can focus on in that trial about why there's differences, but it really doesn't fit with what we've seen when you adopt the device as your standard, as far as closure
One of the caveats to that trial, as you probably know since you brought it up, is that in the Perclose arm, almost 60% of patients ended up getting a third device, and that wasn't counted as a device failure. There's a lot of nitpicking you can do about the trial in and of itself, but certainly our experience is that we have unchanged vascular complication rates and that our procedural times have went down.
Mm-hmm.
Thank you. Regarding the pipeline, Jay White presented earlier Wattson. Wattson fits right into the structural heart bag as a facilitator for the placement of the valve. As Liam commented earlier, we're looking across the entire spectrum of Teleflex at acquisition opportunities.
Other questions?
Not now.
Jayson?
Maybe just to follow up and along a similar line of questioning for Dr. Summers. What do you think the biggest sources of resistance are today in terms of it sounds like you've embraced the technology, a lot of your peers haven't. Is it just a function of, is cost a factor? Do we need more clinical data? Or is it just a function of, you know, you're a young guy. Is it just a matter of the younger group kind of moving up and adopting it a little bit more, and the older guys who have used Perclose for years kind of retiring?
That's a good question. I think, and you can probably speak to this as well, but every interventionalist has their favorite wire, every interventionalist has their favorite catheter, and guide, and brand of those. It's certainly true that some of the resistance may be just people are more familiar with Perclose ProGlide. It's been out for several years. There's a certain subset of interventionalists that are constantly trying new devices and new therapies, and that does tend to be younger guys doing the newer things.
In our group, as a counterpoint to that is, there's two of us that do the vast majority of these TAVR procedures and Impella procedures, and after we incorporated it, all of the other operators that do large bore access in our group have adopted it as their primary modality. I think it's probably just familiarity. It's similar to that older interventionalists having their favorite wire.
Once we actually do get it in their hands and they realize how easy it is to use, we've found, at least in our own group, that others that were previously using Perclose as the standard technique are now adopting MANTA as their primary closure for large bore access.
Is cost a factor?
For us, it hasn't been. What we were finding is that, like I mentioned from CHOICE-CLOSURE, you end up using a third device, so you can end up using three Percloses, maybe even an Angio-Seal on top of that, for some of these calcified arteriotomies. The other thing that happens with Perclose is there's needles that drive in the sutures.
All of these patients, almost all of them, have terribly calcified vessels, and so you can end up burning two or three Percloses just getting the needle to deploy in an attempt to preclose the vessel. We use one device, MANTA. Maybe the cost is a little bit different, but as a total, what we've found is that the cost is actually better because we're using one device.
Okay. Yep. Last question.
Hi. Kevin [inaudible] with Morgan Stanley. For your colleagues in the field, prior to, like, introducing MANTA, what are perceived barriers to adoption that you would highlight, you know, outside of just having to shift current practice and what they're comfortable with? Thank you.
Yeah. I think people hear one-liners from trials and then don't dig into them. You mentioned CHOICE-CLOSURE, but the adoption of any new device, at least in our field, is really a matter of a colleague or someone showing someone how to use that device and then actually getting their hands on it and becoming comfortable with it.
What we've found, at least in our group, which is a high volume center, is that once people get their hands on the device and use it in patients, have another colleague that they trust that's using it across the board, that it becomes adopted. There hasn't been any hesitation, at least, at our center with my colleagues. Colleagues at other centers who have used it also kind of have that same perception that once they become familiar with it's become their standard device.
Okay. Terrific. Dr. Summers, thank you. Dr. Buller, thank you. Michelle and Scott, appreciate it. We're going to take a five-minute break, so that's a bit shorter than we had originally planned to get us back on schedule. We'll be back here in five minutes, please. How are you? Okay, we're going to get started if people could please take their seats. Welcome back from the second break, and we'll now move on to the presentation of the 2023 to 2025 long-range plan financial objectives. It's my pleasure to introduce Tom Powell, Executive Vice President and Chief Financial Officer of Teleflex.
Well, thanks, Larry, and good afternoon, everyone. You've heard Liam lay out our strategy for durable revenue growth over the long range plan with investment into the business for portfolio optimization and improving profitability. Our execution through the pandemic on our strategic pillars has been a testament to the strength of our corporate culture and will of our talented global team.
Looking ahead, we remain committed to enhancing shareholder value creation. Today, I will focus my remarks on the financial outlook in our long-range plan, which runs from 2023 through 2025, with our year-end results for 2022 serving as the base year of the plan.
As you'll see, we have a balanced plan that drives an above-average organic constant currency top-line CAGR, provides for attractive margin expansion, enables a double-digit adjusted earnings per share CAGR, and generates strong free cash flow to execute on our capital deployment strategy. Before I discuss where we are headed as an organization, I want to first take a moment and look back at where we started. Thus, my presentation will be a review of Teleflex key financial metrics since becoming exclusively a medical device company in 2011.
Comments on our 2022 financial outlook, and a detailed review of our value creation framework for the next three years, including our long-range plan. We have methodically transformed Teleflex over the past decade, adding growth drivers through organic and inorganic investment, expanding our geographic footprint and building our commercial capabilities.
Clearly, the COVID-19 pandemic has been a challenge over the last two years, with global disruptions to patient care and supply chains. However, the unwavering commitment of our associates has positioned us well as we now anticipate entering a more normal environment with less disruption from COVID-19 and increasing elective surgical procedure volumes. Importantly, the core building blocks for Teleflex remain in place and provide a strong foundation for our financial objectives over the next three years.
To give you some sense of our financial progress, we have improved the revenue growth profile of the business, moving from 8% average annual constant currency growth from 2012 through 2017, to 10% average constant currency growth from 2018 to 2019.
Excluding the impact of M&A over these periods, underlying constant currency growth also accelerated from 3.4% from 2012 through 2017, to 6%+ for 2018 and 2019. Importantly, we continue to exhibit recovery in the business, growing 5.8% constant currency adjusted growth, or I should say, constant currency adjusted for selling days in the respiratory divestiture in the first quarter of 2022.
Regarding profitability, we have driven significant improvements with adjusted gross margin increasing by almost 1,200- basis points and adjusted operating margin expanding 900- basis points for the year ending 2021 as compared to 2011. Product mix, shift restructuring benefits, operating efficiencies and price all have been drivers of the gross margin expansion over the last 10 years.
We have also realized strong operating expense leverage as we streamlined our management and reorganized our sales force structures and leveraged shared services organizations. On the SG&A line, we remain disciplined and focused a disproportionate amount of investment dollars to support our higher growth franchises while also maintaining an appropriate level of spend for our durable core. R&D investment has methodically increased, and we continue to drive greater efficiency with our revamped R&D prioritization process, which Liam discussed earlier.
Turning to capital allocation, M&A has been a key priority for Teleflex. Over time, we have demonstrated that our disciplined approach to M&A can drive consistent improvements in our financial metrics. For example, our adjusted ROIC has improved to 10.3% in 2021 from 6.4% in 2012, despite the impact of the pandemic.
Regarding 2022, we are reaffirming our financial guidance for the year. We are reaffirming our year-over-year GAAP and constant currency revenue guidance of 2.3% to 3.8% and 4% to 5.5%, respectively. When excluding the impact of the respiratory divestiture, our underlying constant currency outlook for 2022 is 5.5% to 7%. We are also reaffirming our adjusted gross margin and adjusted operating margin guidance.
Finally, there is no change to 2022 adjusted EPS guidance of $13.70 to 14.30. Looking ahead to our financial outlook from 2023 through 2025, we have our sights set on three key financial objectives that we believe are capable of driving attractive financial returns and value creation for our shareholders.
These should not be a surprise to anyone who has followed Teleflex, as they are an extension of our financial strategy that we have executed against over the past number of years. The first objective is to drive durable, constant currency top line growth. From our presentations this morning, you should now have a clear picture of how the combination of our high growth portfolio and durable core can generate dependable above average revenue growth. Turning to the second objective, we see a pathway to continued adjusted gross and operating margin expansion.
Our third objective is to generate strong free cash flow to enable our capital allocation strategy. We will continue to prioritize investments in organic and inorganic opportunities that can further accelerate our financial returns.
As shown on this slide, there are a number of key assumptions that support our 6% to 7% revenue CAGR over the long range plan. Growth in the plan is organic constant currency and driven by a combination of volume, new products and pricing. In addition, we assume no change in the operating environment and have not incorporated any additional undisclosed restructuring programs. Moving on to a more detailed discussion of our 2023 to 2025 long range plan.
When referencing growth rates associated with the long range plan, please note that, as mentioned earlier, they are compounded annual growth rates for the period from 2023 to 2025, with year-end 2022 results serving as the base year for the three-year measurement period. A key strength for Teleflex is our diversified portfolio.
We have an attractive mix of medically necessary products and an expanding portfolio of growth drivers. The breadth of our product portfolio has served us well during the COVID-19 pandemic, with natural hedges in place when demand picked up for products used in the treatment of COVID patients and helped offset the exposure to elective surgical procedures. We believe that a diversified approach to our revenue base remains the right strategy, and this will guide our investment in new product development and inform our M&A strategy.
Looking at revenue in our long-range plan, we project a healthy 6% to 7% constant currency CAGR. Underpinning our growth outlook is continued strength in our high-growth portfolio. This product portfolio accounted for approximately 25% of total revenue in 2021, and includes UroLift, the MANTA Large Bore Closure device, hemostatic products, our EZ-IO and OnControl, and PICC.
We expect sales of products in this portfolio to increase at a 14% to 15% CAGR. Within the high-growth portfolio, we assume a 15% constant currency revenue CAGR for UroLift. UroLift growth will be driven by a combination of expansion in the usage in the US and penetration into overseas markets. Our durable core portfolio accounted for a little over 60% of total revenue in 2021, and includes many products with strong category leadership, including central venous catheters, complex PCI catheters and wires, metal and polymer ligation clips, and our OEM business.
These are products that are utilized every day in hospitals in the US to enable a wide range of patient procedures. Given the strong market position and geographic expansion opportunities for this portfolio, we expect sales of products in our durable core to increase at a 4% to 5% CAGR.
Turning to our other category. This segment includes our urology care products, respiratory products that were not divested to Medline, and the manufacturing service and transition agreement revenues. We expect revenues to decline at a 6% to 7% CAGR. Now turning to adjusted gross margin. By the end of 2025, we expect to generate 250 to 350- basis points of adjusted gross margin expansion as compared to our year-end 2022 results. Our adjusted gross margin forecast does not assume future acquisitions or additional footprint consolidation initiatives that are currently unannounced.
Building on our past successes, we are confident in our ability to drive future adjusted gross margin improvement through a number of levers. The largest contributor to adjusted gross margin expansion during the long-range plan is mix, including a greater proportion of total revenues coming from our high-growth portfolio.
The LRP also assumes that continued annual operating efficiencies and a modest increase in price will largely offset the expectation of continued inflationary headwinds. We will continue to focus on the optimization of our global price structure, with a particular focus on our differentiated products and geographic opportunities. In addition, we continue to closely monitor inflation and have assumed ongoing inflationary pressures during the long-range planning period. Finally, our adjusted gross margin is expected to realize continued benefits from announced restructuring programs.
Since inception in 2014, we have captured approximately $125 million in pre-tax savings from our restructuring programs through 2021. Based on the currently announced restructuring programs, we anticipate roughly $24 to 28 million in pre-tax savings during the long-range planning timeframe, with the majority to be realized in 2023.
Moving to adjusted operating margin, we are expecting 200 to 300- basis points of expansion by the end of 2025, as compared to our year-end 2022 results. As you can see, the pace of the adjusted operating margin expansion in the long-range plan is slightly slower than adjusted gross margin. In order to deliver durable growth, we believe that it's important to invest in strategic growth initiatives, including our high-growth portfolio, and to make proactive investments in our people. These incremental investments will offset the typical expense leverage as our base of revenue builds.
For example, we will continue to invest behind our high-growth portfolio and advance our new product innovation. We will invest in our global sales infrastructure, training, and direct-to-consumer activities, as well as systems and capabilities as we expand our global footprint.
We will also reallocate and increase R&D dollars to enhance new product development. Now, turning to some comments on non-operating items to assist with your modeling. We expect our interest expense to reach approximately $24 to 28 million in 2025. We assume an average tax rate of 12% over the long-range plan, and we expect shares outstanding to be approximately 48.5 million by 2025. Considering the combined financial outlook that we have provided today, we expect to drive a double-digit adjusted EPS CAGR over the long-range plan.
Then turning to my final topics of the day, which are our free cash flow objective and capital allocation. We expect to generate at least $1.7 billion in cumulative free cash flow over the three-year period of 2023 through 2025.
The key drivers of free cash flow generation are growth in net income and efficiencies in working capital. We will continue to invest in our operations and expect capital expenditures to be in the range of $90 to 100 million per year during the planning period. Then moving to our capital allocation priorities, which remain unchanged from our previous long-range plan and have served us well. We are focused on four key priorities for cash generation. First, we will continue to invest in the business with the potential for capital investment to execute on footprint consolidation and other productivity initiatives.
Second, portfolio optimization remains a priority with a focus on M&A. Third, we will pay down debt when appropriate. Fourth, we will maintain our dividend. We will continue to prioritize our capital allocation to enhance our returns while retaining flexibility should business conditions change.
Regarding M&A, we remain focused on pursuing inorganic opportunities that are consistent with our global growth strategy and are aligned with our call points. From a financial perspective, we seek acquisitions that can accelerate organic growth, are accretive to margins, and generate a return on invested capital that exceeds our weighted average cost of capital by year four or five. Our balance sheet is in a sound position and allows us the flexibility to continue to execute against our M&A strategy with gross leverage at 1.7x at the end of our first quarter and a debt covenant ceiling of 4.5x .
We are excited about the long-range plans outlined today. We believe that we have established a high-growth portfolio of durable core, and a durable core that can deliver a dependable 6% to 7% constant currency CAGR.
As we benefit from mix, announced restructuring plans, as well as operational efficiencies and price to largely offset our expectations for continued inflationary pressure, we see a meaningful opportunity for adjusted gross margin expansion that also translates to a compelling level of adjusted operating margin expansion. Taken together, we expect to drive a double-digit adjusted EPS CAGR.
Finally, there is confidence in our cash generation with our robust cumulative free cash flow generation of at least $1.7 billion during the long-range plan, enabling us to execute on our capital allocation priorities. That concludes the comments for today. I would like to turn the meeting back over to Larry to facilitate our last Q&A session.
Take this. Just bring these chairs. Okay. Thank you. All right. Just grab. Yeah. Any questions back here? Okay. Thank you, Tom.
Yep.
We will now begin our final Q&A session of the day. For the live audience, please raise your hand if you'd like to ask a question, and we'll have someone bring over a mic. Again, please state your name and the name of your firm before asking your question, and please limit yourself to one question. If you'd like to ask an additional question, you can certainly raise your hand again. For those of you on the live webcast, there is an option to submit questions, and we will take any questions that come in from virtual attendees if there's time permitting at the end of the Q&A session. With that, let's kick off. Shagun?
Thank you. Shagun Singh from RBC. Tom, this question's for you. What are you assuming for inflationary headwinds in your LRP? Any color you can provide on the cadence of it during the LRP period, you know, the impact on gross margins versus operating margins? And then, just a question on 2022.
You know, you'd previously discussed a bridge between, 2021 and 2022 EPS and two factors in there, that were causing a headwind was FX and inflation. Can you just comment on where you stand on those two items? And are you more comfortable at the middle, bottom, or upper end of EPS range for 2022? Thank you.
Sure. As we think about inflation, we are expecting that inflation will continue throughout the LRP timeframe, although at a moderating rate relative to what we saw in 2022. I think the best way to think about it is in the context of the gross margin. You know, we had mentioned 250 to 350- basis points of margin expansion. You know, a big piece of that is gonna be coming from mix. We also have restructuring savings.
But importantly, we have a number of cost improvement programs going on in the plants that will continue for the next number of years. We're gonna add new ones to it. And that combined with a modest level of pricing, we expect to be able to offset the inflationary pressures in our LRP.
Essentially, you know, we've got a continued expectation for inflation and, you know, we have programs in place as well as pricing that we believe we can offset. It really allows us then to deliver the savings from mix and the restructuring programs as an expansion in the margin.
You had also asked about the bridge for 2021 to 2022 with some headwinds from FX and inflation. As we spoke about, you know, kicking off the year, we mentioned that we are expecting incremental inflation of about $20 million or $0.35 in earnings. I think it's $0.33 in earnings. We're largely tracking to that expectation. You know, as we see it right now, we think we're kind of well-aligned with that expectation going forward.
As we look at FX, as we entered the year, you know, we saw a $0.20 headwind from foreign exchange. Our biggest exposure is related to the euro-US dollar. Since that point in time we've seen a strengthening of the US dollar. There is, you know, additional inflationary pressure relative to when we first provided the guidance. Now I will say that we've reaffirmed our guidance with knowledge of where the FX rate is.
You know, there's a number of things when you're running a business, a number of pluses, a number of minuses. You know, FX was actually favorable in the first quarter relative to our plan assumption. It's now turned negative. You know, I think it's been very volatile. We'll have to see where it goes.
While that may be turning negative, you know, we've also seen favorability in OpEx and some other areas. As we think about our ability to offset that, we had a strong close to the first quarter, with our performance, you know, really stronger than we were expecting as we closed out that quarter. We've got some favorability in OpEx, and we also have the discretion to moderate our investment levels to help compensate for FX or other issues.
Thank you.
Yep. Mike.
All right. Mike Matson, Needham & Company. Just want to ask about the UroLift guidance. At 15%, you know, given that you're going into a lot of OUS regions, would that sort of imply that the US growth is gonna be below the 15%? And then, you know, just maybe talk about how conservative you think that 15% number is overall and the puts and takes there.
Yeah. First of all, I'll reiterate what I said a little earlier. You know, super confident on the 6% to 7% overall. Really confident on the 14% to 15% in the high-growth portfolio. And part of that high-growth portfolio is UroLift. But it's not just UroLift alone carrying the flag for Teleflex anymore. You've got our PICC's in there, you've got our hemostats in there, you've got intraosseous in there, and you've got MANTA in there. The 15% growth for UroLift, the dollar value, the heavy lifting is still gonna be in the United States.
If we look overseas at the overseas markets, the two key markets I think we're focused on, and I would encourage investors and analysts to focus on, is Japan and China. They're gonna carry the bulk of the weight for overseas markets.
Now clearly, overseas is going to grow faster percentage-wise than the United States simply because it's off a really low base. Again, super confident on being able to deliver a 15% CAGR over the three-year period for UroLift. Also bear in mind, using percentages in a high-growth portfolio is a little bit dangerous cause the denominator keeps getting bigger and bigger and bigger. The opportunity to grow at 15% over the three years gets us to that 6% to 7%.
If overseas does better, that's great. We all benefit from it. If one of those markets overseas catch fire, that's great. What we wanted to lay out was a super confident growth rate for UroLift over a three-year horizon of 15%. Matt? Yeah.
Hey. Matt O'Brien, Piper Sandler. Just on the R&D spend side of things, I think that's where a majority of the incremental or kind of deleveraging from gross margin to operating margin comes from. Correct me if I'm wrong. But what areas as far as the spend goes on the R&D side should we think about? Is it higher ASP products, kind of outside of some areas where you're really strong right now? Where is that investment going in and how impactful could it be as we get later in the year, later in the LRP cycle? Thanks.
There are three real buckets I would focus on, and Tom will obviously comment as well. R&D growth over the LRP is growing faster than our revenue. Clearly we're investing, and Jay outlined some of the key products that we're investing behind, in order to fuel the top-line growth. Our anticipation is that we will see incremental improvement in revenue generated from new products over the three-year horizon, and we'll shorten the time to market. The second bucket of investment is behind our high growth portfolio.
We are investing heavier behind that 14% to 25% of our portfolio that is growing 14% to 15%. By the end of the LRP period, we would anticipate that portfolio would be almost a third of Teleflex without adding anything else into it, Matt.
The other areas, we're investing behind our people. Inflation is not just on raw materials and freight, so we are investing behind our people to ensure that we have an organization that's driven to that top line growth expectation. Yeah, that's right. In terms of the investment, you're investing in R&D as well as SG&A. In addition to that, you know, we're making some investments to build brands, DTC, and all of that. also putting in systems and capabilities to really allow and provide the infrastructure for a greater international expansion. There is some investment that's going on in the SG&A area as well.
Great. Matt Mishan, KeyBanc. I wanted to start with OnControl. It was one of the six key product areas. Going back a couple of years, I remember that being, you know, intuitively a great product, great for the patient, but it didn't necessarily have the reimbursement to drive penetration. Has reimbursement changed around that to where you actually can drive, like, significant growth there?
It's covered under a general DRG in the hospital. It doesn't have a specific reimbursement code in the outpatient setting. The growth in that profile hasn't been impacted by the lack of a specific reimbursement code. The key factor here with OnControl is ultimately the speed of the procedure when you're using an electronic device as regards a manual device, and obviously the quality of the sample as well.
It's incredibly painful to get a sample from bone marrow. Doing it once is painful enough without asking somebody to go back in and have it done 3x or 4x because the sample wasn't appropriate. Reimbursement, specific outpatient reimbursement, has not been a barrier to the growth of this product, and it's in our high-growth profile that encompasses some of that 14% to 15% growth.
Okay. Excellent. For EZ-Plas, was that included as part of the long-term guidance? What's your level of confidence that when you do the resubmission of the BLA, that you're gonna be able to get that through to the finish line?
Obviously, for those not aware, EZ-Plas is a freeze-dried plasma product, $100 million market, $25 million in military, $75 million in civilian. We are on a fast-track BLA submission. Would never like to be on a slow track if this is a fast track. In any regard, we are confident that the data. The good news is they haven't asked for any additional clinical data. It's simply documentation that we need to follow up with the FDA.
In fairness to the FDA, they have been very collaborative with us. We are confident that we will get it through this process. We know exactly what they want, and we're building out. Just to be clear, we have not built in any revenue in our LRP.
We will layer that in time when we get the approval. As you all know, or most of you will know, the military tender where we will start is worth to a value of about $3.2 million over a 12 to 18-month period. We'll pivot to air ambulance cause that's the next biggest segment.
Vik?
Vik Chopra, Wells Fargo. Thanks for taking the questions. I guess, Tom, first one, do you see the 6% to 7% growth rate as being consistent throughout the LRP over 2023 to 2025? How should we think about the margin ramp? I had a follow-up for Liam. What impact is the contrast shortage having on procedures, and do you expect any impact in second quarter? Thanks.
I'll address the contrast shortage.
Sure. Okay
First, Tom, you can take the other piece. Obviously, for those not aware, the biggest provider of contrast, they have a facility in Shanghai. That facility has been closed. As you heard from the clinician, Dr. Summers, when he was up here, he's not anticipating any significant impact of that contrast shortage. We believe that it will get addressed with a ramp-up of supply coming from Europe. Now, it's early days, but from talking to clinicians, that's their expectation.
They also can become more efficient at the amount of contrast they use in different procedures, as you, again, heard from Dr. Summers. If there is going to be an impact, I think it's going to be pretty short term. Don't forget, these are procedures that are very difficult to postpone. They will have an adverse event for the patient. Just building on what Dr. Matthew Summers say, I it's early days. Difficult to see a large impact, and if it is, I think it'll be short-lived.
Then in terms of the ramp of revenue and margins, you know, really what we're here to talk about today is, you know, what we expect to do over the next three years. We expect 6% to 7% revenue growth and achieve the margin targets that we outlined of 250 to 350 on gross margin. You know, we'll obviously provide detailed specifics on each individual year as we get to that point in the cycle. You know, we'll talk about 2023 at the end of this year.
Right now what we want you to take away is that, you know, this business has got the capability of delivering 6% to 7% revenue with really healthy margin expansion, despite it being an inflationary environment.
Rich?
Great. Thank you. Rich Newitter, Truist. Thanks for taking the questions and hosting the day. Liam, just going back to UroLift, I think you provided a 15% CAGR for the global franchise over the 2022 to 2025 timeframe. I'm just curious, you know, I appreciate that, you know, there's an international contribution that's going to probably increase as we move through the latter part of that timeframe. Just on an annual basis, should we be thinking about UroLift as a sustainable annual year-over-year 15% grower? It, you know, what I'm really just getting at is can the US continue to sustain, you know, close to that mid-teens% or what's the floor for what we should be thinking about North America being from a growth standpoint in 2022, 2023, maybe even 2024?
Yeah. I think, for UroLift, if you take a step back for a minute, and you work out a 15% CAGR on our jump-off from this year, 2022, it's gonna be a $600 million franchise as we exit at the end of 2025. Well on the way to being the $1 billion that we always thought that it could be. I think this is a real positive growth story for UroLift. What we're trying to do here, as Tom said earlier, we're trying to lay out a three-year horizon for the investment community.
We'll get into individual years as we give guidance for the individual years. What I want investors to take away is we're really confident on the 6% to 7%. We're really confident of the high growth portfolio doing 14% to 15%, and we're really confident on Europe being able to deliver a 15% CAGR over that horizon.
Well, thank you. Cheers.
Hi. Kevin [inaudible] with Morgan Stanley. Can you just walk us through your growth outlook for the durable core portfolio versus the outlook you provided at your last analyst day, and how we should think about the shift in the growth opportunities as well as, you know, the potential for global expansion moving forward?
I think the last LRP is very similar to this one, quite frankly, from a growth perspective. The last time we outlined a 6% to 7% CAGR, we were well on path to execute against that, until the coronavirus hit. If you look at that algorithm in the past, you know, the idea was that we would do 4% to 5% from the core business, and we would do 2% from some of the M&A we had recently added. I think that investors should feel a lot more confident in this 6% to 7%. It's not as dependent on one product. Now, if that one product does better than we expect, we're all winners.
We're not as dependent on one product to drive the top-line growth as we probably were in the past. Again, that algorithm for 25% of our portfolio in 2021 growing at 14% to 15%, driving the majority of the growth and a lot of the margin expansion.
The products within the high-growth portfolio that we've outlined a couple of times, the margins there are accretive to overall Teleflex, which is why Tom is incredibly confident in portraying a 250 to 350 gross margin expansion because that mix shift that happens back to our philosophy within Teleflex, that not all growth is equal, will allow us to get margin expansion on the gross line and then on the operating line over the horizon. I think the algorithm is very similar to three years ago with less dependence on one single product category.
Jayson?
Two questions. I'll ask the first one and then I'll wait for an answer. Liam, in your initial commentary, you mentioned that the supply chain challenges will exist for some time. It sounded like transportation costs are tempering a bit here if we want to include that in supply chain. I don't want to get too granular here, but what are the key supply chain challenges that you're seeing in the business today, and how long do you think they'll last?
I think thankfully, we're not reliant on chips for any of our product. We have two products that require a chip, so I'm glad that we're not in that category. The challenges that we see are the ones that you outlined, which is predominantly freight costs and the time to move product, in particular from Asia to Europe and the United States.
T he time lag to bring product on the ocean has grown quite considerably. That has a knock-on effect with some of your resin suppliers are also moving product through sea lanes, and they're actually raising some. There's some price pressure there. We caught all of that in 2022 with the 70- basis points of inflation that we built into our 2022 guidance.
On top of that, we're heading into the three-year horizon, eyes wide open when it comes to inflation and that disruption. We're not expecting it to reduce over the three-year horizon. We're expecting inflation to continue to rise and some of that disruption to stay there. I think that our global supply chain team is managing this exceptionally well, and we're hearing that from our customers as well, that we're managing this environment really, really well. Our customer satisfaction scores are actually going up in this disruption, which is very, very encouraging.
Just quickly on capital deployment. I appreciate that you want to observe discipline here, but you know, does the current market environment lead you to accelerate your M&A cycle a little bit here and take on a bit more risk?
I think that the way I would look at that is we have the most important thing you need when you want to do M&A, firepower. At 1.7x levered, we have probably the capability. I'm not saying we're gonna do this, but we have the capability to spend up to $2 billion on M&A right now. We will maintain our disciplined approach.
My mother had a great saying, "Act in haste, repent at leisure." I think we'll be very focused on bringing the right asset into Teleflex, and I think we'll also be very focused on sticking to our strategic criteria. Now, are there assets out there right now that meet our financial and strategic criteria? Yes, there are.
Okay. Before we conclude, we'll just take one question for Tom from Craig Bijou of Bank of America. The question, Tom, is the margin expansion range correlated in the LRP with the revenue growth range? The second part of the question is, to hit the high end of the margin expansion range, do you need to hit the high end of revenue growth range?
Okay. Well, if we think about, you know, what's gonna drive our margin, let's start with kind of establishing what's gonna hit the low end of the range. You know, really what we're looking at is. Favorable mix will drive the majority of it. If we're looking at the low end, 250- basis points, we're anticipating mix to account for more than 200- basis points of that. We'll pick up another 70- basis points from the restructuring programs that have been currently announced.
As mentioned, our expectation is that, you know, the manufacturing cost improvement programs, as well as a little bit of modest pricing in the plan, can largely offset inflation. That's how we're establishing kind of the low end of the guidance range, and that's probably at the 6% level of revenue.
Now, how do we get to the upper end of the range is more revenue and more revenue with more favorable high-mix products. Our expectation between the upper and lower end of the range is really that it's a mix-driven, volume-driven equation. Revenue does play a component into getting us to the top end of the range.
Okay, terrific. We will conclude the Q&A. Liam, I will turn it back to you for some closing comments.
Thank you, Larry. I will close by saying that we remain very excited about the future opportunities for Teleflex as we build upon the strong foundation that has been established. We continue to view Teleflex as a company with room for further evolution over time as our corporate strategy continues to play out.
From my perspective, we are somewhere in chapter three or four of a 10-chapter novel. At the heart of our growth objectives are the efforts of our more than 14,000 employees that make it their mission to be relevant to our customers and the patients they serve. We will continue to live by our diversity, equity, and inclusion values, fortify our culture, and be good stewards of the environment. We are excited about the future for Teleflex. Thank you to everyone who took the time to participate in our 2022 Analyst and Investor Day.
At this time, we will move to our scheduled breakout session with various members of our corporate leadership team. For those interested in participating in this session, I'd ask you to please join us down the hall in the Kennedy Room. Thank you all for your attention today, and we really appreciate your interest in Teleflex. Thank you.