Penumbra, Inc. (PEN) Earnings Call Transcript & Summary

All right. Afternoon, everybody. Thanks so much for joining us. Matt O'Brien, I cover Medtech here at Piper. Very, very fortunate to have the Penumbra team with us today. We've got Adam, who's the CEO and then Jason, who is Vice President of IR and biz dev. I think Cecilia is in the audience as well as far as folks from Penumbra that are here. So I really do appreciate you guys coming all the way across country.

Yes. Thanks for having us.

Excellent. So let's start with Q3, which is really good, especially on the peripheral side. The peripheral business did really well. The thing that was interesting was how well it did, but I don't think you really got the benefit from the 600 companies that got -- 600 hospitals that got through the back committees. So just maybe talk a little bit about what you saw in Q3 and then the excitement that you're feeling from all these different hospital customers as we head into Q4.

Yes. So maybe a step back even from that question is sort of how we're seeing and thinking about our business as we go into the next couple of years. As everyone knows, we've been at this for the better part of 20 years, trying to continue to iterate and iterate and make products better and better at removing blood clot in all parts of the body. And that's sort of the starting point. And we're now finally at a point, and we said this on the earnings call, where the idea of CAVT or catheter assisted vacuum thrombectomy is really gaining sort of traction is the wrong word, but sort of the perception that this is the technology that sort of will -- is second generation at the latest conference. That was what lots of people were talking about, both on the podium and in the hallways. So that's sort of how we are framing and thinking about the work we have in front of us. So the new accounts that are coming, and we've talked about that, I tried to give more detail around that, that broadens the base of customers that we have, more than doubles the customers that we've had over time. And once we get them up and going, we also have the work we have to do with them and our existing customers to go deeper and get all of the cases and patients that are able to be treated successfully with our products. Those are different tasks. They require different things, but we laid that out also on the earnings call as part of our access -- our market access work ahead. So the 3 big things we got to keep innovating, and we talked about new products coming in the next 18 months for CAVT as well as sort of technology that will integrate into the CAVT system. We talked about the evolution of our sales force to meet this challenge, which is underway. And we've talked about the market access. So if we can do all that work over the next period of time, we're going to be in a really good position to treat as many of those possible patients, whether it is arterial or DVT or PE as possible. And in addition, a shameless plug, today, we put out a press release announcing our first patient enrolled in the STORM-PE study, which is a randomized trial against our technology against antiquagulation, the first trial to do that, which I think will be critical. It's bringing along the physicians and the rest of the community that we should be looking at treating PE a little broader than we are today.

Got it. Okay. And that, excuse me, kind of dovetails into the next question, which is this market is lightly penetrated, right? DVT, PE, you name it, slightly penetrated. Is it devices you guys are bringing that are going to grow the market? Or is it data that's really needed to grow the market?

It's both.

Which one is more important to you?

Oh, my god. They're both essential. We only are at this stage because the technology has gotten better and better. And I think I used the term on the earnings call, little incremental successes have led to this sort of moment -- this transformational moment. And that's just constantly iterating and fine-tuning and getting the products better and better. So technology does matter. Otherwise, we wouldn't still be here 20 years after we started Penumbra, talking about new technology. It would have been solved years and years ago. And it's really hard. It's kind of ironic. You would think getting blood clot out of an artery or vein isn't as hard as some of the other bigger challenges that we have solved in medicine, but it really is. So technology does matter. But also getting the health care system, if you will, the larger systems, hospital systems and all to rally behind this idea and say, "Oh, this is how we should be doing this. This is good for us, good for patients. That is critical, and data plays an important part of that. What data matters is different depending on what the question is. In the PE study that we're running, the question is important, how do we justify and answer the question of what patients should be getting mechanical thrombectomy, that's a very particular question. In other areas, it's less relevant to have that type of data and more relevant to look at data that really is looking at the question of patient -- treating patients, health economics, the viability of expanding the number of patients that we're treating.

Okay. Great. I appreciate it. So let's talk about the acute stuff, which I'm sure you also want to talk about. But the 600 new hospital accounts that you have, can you just give us a sense for what they look like in terms of like are they a big chunk of them super high-volume centers? Or is it just like a mix of them? Or like how does that look versus customers you have?

It's a good question. The best way I would answer that question is because they're -- if you look at our market share, particularly in venous, we don't have 100% market share. And so it's a mixture. Some are big, very active centers. Others are smaller centers. It's customers we didn't have before. That's primarily on the venous side. On the arterial side, it's also customers we didn't have -- you have to think about that a little differently because those patients, again, are being treated in those hospitals, but they're being treated either with lytic or open surgery in terms of mechanical devices, we don't have a ton of competition on that side -- on the arterial side. So some are quite busy. Some are smaller. It mirrors probably the best way to frame it, mirrors our existing client base -- customer base pretty accurately.

Okay. All right. All right. Appreciate that. And then the supply chain commentary that you had in terms of getting through that with your customers, what's the gating factor? Or -- and I don't think you guys have a lot in terms of stocking. I don't think you stock a lot.

Yes, we don't stock a ton. We usually can stock literally one product, buy one and use it and get started on it. It's really just time and effort like anything, a lot of things in life is I think takes time and effort. We have a lot to do and everyone else is busy and getting the codes loaded and getting them ordered and also doing everything else. I did allude to needing to evolve our sales team as well. Some of that is just we've done a lot this year. If you think back to the beginning of this year and where we are now, the business has grown, obviously, much greater on the vascular side than it's grown in many, many years. And we also have our embolization business. So again, I'm not making excuses, it's just time and effort. And frankly, that's exciting because we control a lot of that.

Okay. Understood. What about some of your customers that were newer to Penumbra that came on board because of Flash. How have you seen them grow because the thing that's been interesting in some of the limited dock calls that we've done is the initial yes, I'll try it. And okay, I'll do a couple more. And then all of a sudden, they kind of like the light goes off and then they just [indiscernible]. Are you seeing that still in some of the earlier adopters and given the latest cohort that's coming on?

Yes. The product, Flash and Lightning both really work. So that calls have generated -- I mean let's go back to early spring where expectations had gotten pretty high. Those calls aren't different now. The product does work like that and it's just a question of getting there and getting them started and getting them operating. Everyone's path is -- they come with their own biased physicians. I want to use it for X or I want to use it for Y. And it then takes sometimes a moment or two to like, "Oh, I could use it for this and that, too. Like anything, there's probably a little bit of a, I call it learning curve, but just getting used to it. If you haven't used computer orchestrated or aided vacuum thrombectomy, you're going to need like what is the -- what do the sounds mean? What does the lights mean? But again, that's not a huge hurdle, most people can get through that pretty quickly after a case or two. And I think we've gotten better at training around those. So it's pretty exciting. We were at the VEITH Conference just 2 weeks ago here in New York. And the conversations with physicians were very different rather than me getting involved in, hey, you should try the benefit of this. I didn't have to do that to anyone. That was already sort of known. People came to those discussions with that already -- even if they weren't using our product yet because it's not yet through their system, they already expected that. They already knew that they would like it. And then the conversations were about some of the more interesting things around market growth and how do we go after their systems who have built-in barriers, not purposeful, but just that are stopping the flow of patients, and then how do we break through that. And that's an amazing opportunity to have the conversations with people and validate the work that we already started knowing that, that will have a huge impact on their practices and the patients they treat.

Got it. What do you think we should expect in terms of market growth for DVT and PE going forward?

Well, it's going to be significant. Can I get away with that? It was worth a try. I think we're going to wait like we said on the earnings call to give formal guidance, but the growth of both arterial and DVT and PE will be where most of -- the majority is -- the biggest part of our growth for the next few years for sure. Okay.

Yes. Market growth has been really quite good in both arterial and on the venous side. Venous, I think, has been growing as a market in terms of procedures a little faster. What we did see, though, with arterial is arterial sort of saw an acceleration with the launch of Lightning Bolt 7 because of the outcomes that were being generated. But I guess if you take a step back and you know this, Matt, the number of patients that are not some fantasy target market, but a true serviceable number of patients in each one of those is maybe anywhere from 6% to 12% of those patients are being treated with mechanical intervention. So by definition, if we're doing our job right, which is innovating and providing the initiatives for market access, market will grow.

To that point, Jason, I mean, back on the neuro side, MR CLEAN, obviously massive accelerant. Do you think STORM-PE or any other data can be a massive accelerant to adoption? And it seems like some of the teams are in place, especially in PE for the market to really accelerate, but just thoughts around that.

Yes. I think so it depends on the 3 vascular beds. We'll start with PE since you talked about STORM-PE. STORM-PE definitely is the necessary trial. You have to show you have pulmonologists who are responsible for these patients who currently are the ones who typically would administer anticoagulants that there's something better. And that's exactly what the concept is, MR CLEAN and Swift Prime and the other studies had to show and opened up that field. The difference, and this is really important to point out is unlike in stroke, where we had the added issue post those trials of moving patients, getting them to the right place that we spent a lot of time laying out and talking about we don't really have in PE because they're already at a place that can be treated. So I think once that's opened up, we're going to see that grow significantly. That being said, I think the other 2 areas, arterial and DVT have slightly different trajectories. Those patients on PE -- I'm sorry, on arterial already in the hospital. Those are acute events. They come in and they're with our current one of the types of doctors, whether it's an interventional cardiologist, interventional radiologist, or vascular surgeon to be treated. So then it's a little bit different. You're not having to show and prove something as much as this is better. And we heard some very well-known vascular surgeons make this comment at VEITH that now with Lightning Bolt that is the front line for their thinking versus, oh, maybe if it looks like a tricky case, I would do a mechanical thrombectomy, but otherwise, an open surgery is still the standard of care. We're starting to see that shift and then pretty significant viewpoint. So we have to build on that on the arterial side. And then on the DVT side, there's work done -- needing to be done that we're starting that we've alluded to around market access because there, the patient is still with their general practitioner, has to come to the hospital in a timely manner to be treated. So that's the kind of work that hospitals and hospital systems want to do once they understand and have the data that this is good for the patient and good for them as a hospital system to go out there and help drive that pathway.

Okay. Okay. Understood. And I don't want to pick on neuro at all, which we had a really strong first half of the year, and it did decel a little bit in Q3 on a 2-year stack basis, still good. It did decel a little bit there. I thought SENDit was really getting a lot of traction. Did it slow down a little bit in Q3. We need to call out specifically in neuro.

So I'll take that, and you can add on to it. Actually, to your point on SENDit in the United States only, and the United States neuro business stroke specifically had another quarter. I think we called it out in our prepared remarks, grew strong double digits again. At the beginning of the year, and maybe it's a little bit of our fault in not giving more granular guidance to the way that you guys model the business neuro versus vascular. I'll get to that in a second, the neuro versus vascular conception probably isn't the way to look at it going forward. But what we said at the beginning of the year, when we gave original guidance of $1 billion or more, we said neuro for the full year, globally would grow slower than corporate average and vascular would grow faster. And we didn't change that notwithstanding in the first half of the year, you saw neuro grow a little bit faster. And it was just -- there's a bunch of things that go into that. First of all, international business, we've had a neuro product portfolio for a lot longer. So our international business in total has more neuro in it than the global business. In neuro internationally, we knew distributors variances were going to be more heavily weighted first half versus the second half, and you have more seasonality in Europe in the third and fourth quarters, primarily the third, given that neuro is a bigger part of the business, you have those nuances. So actually, the neuro business performed slightly above our expectations in the third quarter specifically.

Okay. What about -- talking about '24 when we think about those 2 buckets because you said, I think, at least 20% for next year on the top line. How much of that is dependent on obviously the vascular business with all of these new hospital accounts and then going deeper in those accounts? How do you kind of deconstruct getting to that 20%, knowing that neuro is probably going to be smaller, but slower.

Yes. So we'll give formal guidance. Obviously, we typically give it on our fourth quarter earnings call. Adam was asked the question in the earnings call, we were asked again about it and what we said -- what he said in September at the investor conference and what we reiterated on our earnings call was we thought that 20% plus growth was achievable. And obviously, there's a lot that goes into that. What we're going to talk about more and what we talk about now, but we'll give everyone more granularity in terms of our business historically, so you can see it, is thrombectomy versus embolization and access. And thrombectomy is obviously peripheral thrombectomy in neuro, and you'll get those pieces as well. But thrombectomy, as I'm sure you're already modeling is growing significantly faster globally and in the United States versus embolization and access. So I think it'd be helpful to understand those 2 components of the business. With a little bit more disclosure and granularity not just in the worldwide global market, but we're going to provide those numbers historically and then guidance going forward for both the U.S. and international. So you can understand, I think, the business a little bit better. People can see and then model a little bit better. And that's been our fault in the past, I think. But clearly, without giving guidance, official guidance now, just predicated on what we've said here to for, thrombectomy will grow faster than whatever guidance range we give or expected to grow faster -- and likely, the United States will grow faster than international markets because that's where we have these products, and we're seeing the momentum from the computer-assisted vacuum thrombectomy platform.

Okay. Appreciate that color. That's really helpful. Trying to figure out how to ask you this question, Adam. But the thing that caught my attention on the call was these 4 new products coming, and you've got people listening right now that want to hear all about them. What I'm really curious about is how revolutionary or evolutionary, are they versus what you already have, which are really good products.

Yes. Well, first of all, that's a great question. And we're going to -- I'm going to be careful only for competitive reasons like, hey, here's what we're doing. What I will say is the following. Our current products, Flash and Bolt are great. When you look at the I'd call it, ambition or thought that we're the only company now or we're the largest company that takes clot out of every part of the body head to toe. How do we bring CAVT to all of those places in a format that is really, really valuable to ultimately patients through their physicians. Then one can start to look at some of the gaps where CAVT is not as evolved or as used from head to toe and that's the best way to frame. So we're not fixing anything. We're expanding the offerings throughout the entire body.

You make the catheter size bigger on Flash.

Why?

Just heard that from some people like I want a bigger catheter.

Yes. You've also heard from a lot of people they want a smaller catheter because they're much safer. So you have to balance both those 2 people.

I'll add on to that. I understand the question, and I appreciate it. It's a good one. It's one we get a lot. Just to take a step back, the fundamental premise of taking clot out of the body are threefold. And we've talked about it over and over and over again because it's true. Safety, simplicity of platform and speed. That's it, right? And so the reason why we have the privilege of potentially by the middle of next year, doubling the number of customers using our thrombectomy products versus any point in the company's history, is because those doctors are recognizing safety, simplicity and speed. Now the reason we're doing -- continuing to innovate is to augment our platform's ability to try to get close to perfection, like this country, we're always aspiring for a perfect union. Trying to aspire to the perfection is what we will continue to do, but it's really in those 3 areas. Now to go back to a previous question you asked about the VACs and accounts and getting through that -- having that privilege is an important step, right, having double the number of people that are ordering your products. To go from 6% to 12% penetrated depending on what vascular that you're talking about to much higher, i.e., more patients getting the benefit of our computer-assisted vacuum thrombectomy, we need to -- and it's different in different areas, we need to provide the health economics and clinical evidence so that the broader cohort of physicians, both managing them and treating them understand the way forward and what's best for their patient. And that is going to be an important work for us to do. And that's the 2 general areas -- 3 general areas we're working on.

Got it. Okay. Last one, I've got a million more, but I can't get to them all. Thunderbolts. We've done work on it. We think it's a game changer. How much -- what are your thoughts on Thunderbolt as you introduce that product? Is it going to be a faster ramp than you've seen with Flash? And then is it the revolutionary technology that can really take over that market, and I think it is.

Yes. It's a really good question. So Thunderbolt with RED 72 with SENDit is. Without RED 72 and SENDit, we would have had the dilemma of that's great, but I don't know if I can get -- I don't like your catheter, I can't get it there. With SENDit, that excuse goes away. So you really have to talk about Thunderbolt in the context of the catheter that goes with it, which is a little bit different dynamic than in the other areas. That being said, yes, the thing works really well. And unlike when we started talking about Thunderbolt a couple of years ago, we now have thousands of lightning bolt cases, thousands and thousands done. It's similar technology, slightly different size catheter. We know how it works. We also know how the trial is going. So yes, we're really excited about it. But we don't -- we're not waiting for it to grow. We're growing in stroke right now in the U.S. with SENDit, and we have a great setup. As I said earlier on the earnings call, we have -- excuse me, I'm losing my [indiscernible]. We have 55% estimated market share. 28 catheters are competing for the other 45%. The field is crowded in the bottom, they're fighting for that share. I think we're in a really good spot. And I think from where we are sitting, and then continue to grow that share. And let's hope the market continues to grow as well.

Got it. Got it. Okay. Well, I've kept us longer, so we'll have to cut it off there. Adam, Jason, thank you so much for you time.

Thanks. Appreciate it.