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Q4 2023 Penumbra Inc Earnings Call

Participants

Adam Elsesser; Co-Founder, Chairman, President & CEO; Penumbra, Inc.

Jason Richard Mills; EVP of Strategy; Penumbra, Inc.

Jee Hamlyn-Harris; IR Officer; Penumbra, Inc.

Maggie S. Yuen; CFO; Penumbra, Inc.

David Kenneth Rescott; Senior Research Analyst; Robert W. Baird & Co. Incorporated, Research Division

Joanne Karen Wuensch; MD; Citigroup Inc., Research Division

Lei Huang; Associate Analyst; Wells Fargo Securities, LLC, Research Division

Macauley Healy Kilbane; Research Analyst; William Blair & Company L.L.C., Research Division

Michael Anthony Sarcone; Equity Analyst; Jefferies LLC, Research Division

Michael Stephen Matson; Senior Analyst; Needham & Company, LLC, Research Division

Philip Chickering; Research Analyst; Deutsche Bank AG, Research Division

Richard Samuel Newitter; Research Analyst; Truist Securities, Inc., Research Division

Robert Justin Marcus; Analyst; JPMorgan Chase & Co, Research Division

Samantha L. Kurtz; Research Analyst; Piper Sandler & Co., Research Division

William John Plovanic; MD of Life Science Research; Canaccord Genuity Corp., Research Division

Presentation

Operator

Good afternoon. My name is Audra, and I will be your conference operator today. At this time, I would like to welcome everyone to Penumbra's Fourth Quarter and Year-end 2023 Conference Call. (Operator Instructions). I would like to introduce Ms. Jee Hamlyn-Harris, Investor Relations for Penumbra. Ms. Hamlyn-Harris, you may begin your conference.

Jee Hamlyn-Harris

Thank you, operator, and thank you all for joining us on today's call to discuss Penumbra's earnings release for the fourth quarter and full year 2023. A copy of the press release and financial tables, which includes the GAAP to non-GAAP reconciliation, can be viewed under the Investors tab on our company website at www.penumbrainc.com.
During the course of this conference call, the company will make forward-looking statements pursuant to the safe harbor provisions of the Private Securities Litigation Reform Act of 1995, including statements regarding our financial performance, commercialization, clinical trials, regulatory status, quality compliance and business trends. Actual results could differ materially from those stated or implied by our forward-looking statements due to certain risks and uncertainties, including those referenced in our 10-K for the year ended December 31, 2023, which is scheduled to be filed with the SEC on February 22, 2024. As a result, we caution you against placing undue reliance on these forward-looking statements, and we encourage you to review our periodic filings with the SEC, including the 10-K previously mentioned, for a more complete discussion of these factors and other risks that may affect our future results or the market price of our stock. Penumbra disclaims any duty to update or revise our forward-looking statements as a result of new information, future events, developments or otherwise.
On this call, certain financial measures are presented on a non-GAAP basis. The corresponding GAAP measures and a reconciliation of GAAP to non-GAAP financial measures are provided in our posted press release. Non-GAAP operating expenses exclude the amortization of acquired intangible assets and a onetime expense associated with the acquisition of IPR&D and adjusted EBITDA excludes a onetime expense associated with the acquisition of IPR&D and stock compensation.
Adam Elsesser, Penumbra's Chairman and CEO, will provide a business update. Maggie Yuen, our Chief Financial Officer, will then discuss our financial results for the fourth quarter and full year 2023; and Jason Mills, our executive Vice President of Strategy, will discuss our 2024 guidance. With that, I would like to turn over the call to Adam Elsesser.

Adam Elsesser

Thank you, Jee. Good afternoon. Thank you for joining Penumbra's Fourth Quarter and Full Year 2023 Conference Call. Our total revenues for the fourth quarter were $284.7 million, a year-over-year increase of 28.7% as reported and 27.9% on a constant currency basis. For the full year 2023, our total annual revenues were $1,058.5 million, representing growth of 25% as reported and 24.7% in constant currency over full year 2022.
During the fourth quarter, our global thrombectomy business achieved record revenue of $190.8 million, growing 42.4% as reported and 41.6% in constant currency on a year-over-year basis. Our global embolization and access revenue was $93.9 million, representing increasing 7.6% as reported and 6.7% in constant currency over the same period a year ago. Our U.S. thrombectomy business continued driving outsized growth, increasing 46.4% compared to the same quarter a year ago, driven by continued growth with our computer-assisted vacuum thrombectomy or CAVT products in U.S. vascular thrombectomy. We also delivered more than 20% year-over-year growth in stroke thrombectomy in the U.S. with RED 72 with SENDit technology continuing to set the standard for the market in aspiration catheters and laying the groundwork for Thunderbolt.
We expanded our gross margins in the fourth quarter to 65.7%. We expect to continue expanding gross margins in 2024, owing to favorable product mix and increasing productivity.
While we are making important investments to sustain strong growth into the future, we're also delivering increasing profitability. We delivered another record quarter of profitability in the fourth quarter. Non-GAAP operating income was $37.4 million, representing 13.1% of revenue. We posted record adjusted EBITDA of $53.4 million or 18.8% of total revenue, and we grew our operating cash balance by $40.3 million sequentially. We expect to expand our operating profitability in 2024 and beyond, all while we pursue the significant opportunity ahead of us in thrombectomy.
2023 was a watershed year for thrombectomy technology. The defining characteristic about this moment in time in thrombectomy is a confluence of CAVT true second-generation thrombectomy technology and physicians' broadening recognition that this unique platform technology can now successfully treat the majority of both VTE and arterial clot patients. Over the past several months, our expanded base of customers have communicated to us a desire to work together with their hospital systems to expand the pathways of care for their thrombectomy patients. In other words, following 20 years of innovation in thrombectomy technology, now is the time for Penumbra to start doing the next phase of the important work with the health care community to help the vast majority of clot patients who are not yet getting this treatment.
To fulfill the promise of this opportunity for our patients and physicians, we are focused on 3 areas of work, which I began laying out on our third quarter earnings call. They are innovation, internal readiness and market access. These areas of interconnected work are critical to our mission to reach all of these patients. Starting with innovation, Lightning Flash and Lightning Bolt 7 changed the trajectory of treatment in VTE and arterial thrombectomy in the United States during 2023. As many new customers work through the submission process for these transformational products late in the year, we saw the trajectory of our U.S. vascular thrombectomy business accelerate in late November. Coupled with the growth of our commercial team in the U.S., we see this new trajectory as sustainable, as reorder rates for both Flash and Bolt remain as high as any product we've ever launched in thrombectomy.
As we look into 2024 and beyond, the innovation that delivered Flash and Bolt remains at the core of Penumbra. We recently received FDA clearance for Flash 2.0, the first of our 4 new CAVT products expected over the next 15 months. Flash 2.0 raises the already high bar established just a year ago by Lightning Flash in VTE thrombectomy as 2.0 further optimizes the advantages of CAVT in PE and DVT procedures. Further, the next 3 products will expand the breadth of CAVT's utility to more areas of the body and will enhance the safety, speed and simplicity with which CAVT tackles the variety of clot morphology. In addition, Thunderbolt is progressing very well in THUNDER study, and we are excited to bring the advantages of CAVT to stroke thrombectomy as well, especially with our increasing market share in stroke aspiration catheters.
Further on the innovation front, we are advancing our strategy to leverage the fact that we have a computer chip in every case, dedicated to each individual procedure. Through this important work, we will integrate new technology into the platform that can seamlessly collect valuable information, both procedural and patient specific. This information will be utilized by physicians in real time and in reflection to further enhance treatment and produce efficiencies in patient care that could pay dividends for patients, physicians and hospital systems for many years to come.
Moving to internal readiness. The fourth quarter was a very important moment in time for Penumbra. The momentum in CAVT with Flash and Bolt in 2023 gave us the opportunity to bring more focus on thrombectomy as well as more scale and efficiency to our vascular sales team. We augmented the capabilities of the team in some areas and increased the size of the team overall. Much of this hiring was accomplished during the fourth quarter with continued hiring and significant training taking place throughout the current quarter.
In addition to our commercial team in the U.S., we continue to make significant progress on efficient manufacturing at scale, which would benefit our gross margins going forward. Given how early we are in the penetration curve for CAVT and thrombectomy, this internal readiness work is timely, important and will continue to evolve.
The third area of work for us is market access through which we are developing additional evidence to validate the clinical benefit of our CAVT platform and health economic data with which hospital systems can make more informed decisions on treatment paradigms. We believe there are at least 800,000 arterial and VTE thrombectomy patients in the U.S. each year.
In order to reach the majority of these patients over the next 5-plus years, our market access work with large hospital systems is critical. With hospital systems partners, we are collecting and analyzing real-world data on an increasing number of CAVT procedures compared to traditional therapies. These initiatives will focus on DVT, PE, arterial and stroke. We believe this work will validate that getting the clot out by optimizing safety, speed and simplicity with CAVT is advantageous to the patient, physician and the hospital system in terms of both clinical outcomes and health economics.
The benefits from the work we are doing in these 3 areas in 2024 will accrue primarily to our U.S. thrombectomy business. Given that Flash and Bolt 7 have already built momentum, the new products in CAVT are coming first to the U.S. and reimbursement is in place for these procedures. In 2024, we project our U.S. thrombectomy business will deliver 27% to 30% year-over-year growth. While displacing traditional therapies in first-generation mechanical products will drive part of our growth, we believe the work I just described across these 3 areas will move more patients into the system to receive CAVT therapy in 2024 and build even more momentum in the U.S. over the next few years.
Outside the U.S., our opportunity with CAVT is also compelling for future years, and we are well into the work with regulatory and reimbursement bodies in Europe, Asia Pacific and Latin America to bring the entire CAVT portfolio to patients outside the U.S. as well. We think we will begin to see the positive impact to our international thrombectomy business in 2025. This strategy and the timing associated with it allows us to not only focus on sustaining long-term revenue growth but also increasing profitability.
For the last 20 years, the Penumbra team has worked very hard to continuously innovate and in so doing, has built what has become the largest thrombectomy company in the world, removing blood clot from head to toe. This innovation has led to the CAVT platform.
Now is the time to start the next phase of the strategy, which we have outlined in detail again today. Our successful execution of this strategy will make our technology available to everyone who can benefit. This work will be hard and will not always be a straight line. However, it will be profound and extremely motivating.
The company is in the best position we've ever been. The Penumbra team is stronger than at any point in our history. And over the next few years, our CAVT products can positively impact the vast untreated patient population in ways no other technology platform has been able to before.
I'll now turn the call over to Maggie to go over our financial results for the fourth quarter and full year 2023.

Maggie S. Yuen

Thank you, Adam. Good afternoon, everyone. Today, I will discuss the financial results for the fourth quarter and full year of 2023. Financial results on this call for revenue and growth margin are on a GAAP basis, while operating expenses and operating income are on a non-GAAP basis. The corresponding GAAP measures and a reconciliation of GAAP to non-GAAP financial measures are provided in our posted press release.
For the fourth quarter ended December 31, 2023, our total revenues were $284.7 million, an increase of 28.7% reported and 27.9% in constant currency compared to the fourth quarter of 2022. Our geographic mix of sales for the fourth quarter 2023 was 71.5% U.S. and 28.5% international.
For the fourth quarter 2023, our U.S. region reported growth of 29.6%, primarily driven by 46.4% year-over-year growth in U.S. thrombectomy. Our international regions increased 26.4% reported and 23.5% in constant currency. The sequential growth in our total revenue of 5.1% was primarily driven by an increase in our global vascular thrombectomy business of $12.2 million or 10.1%.
Moving to revenue by products. Starting this quarter, we are providing new revenue disclosures that better align with our business. As presented in our press release, we are providing detailed revenue results of our thrombectomy business and our embolization and access business, respectively, in the United States, international and globally. Revenue from our global thrombectomy business grew to $190.8 million in the fourth quarter of 2023, an increase of 42.4% reported and 41.6% in constant currency compared to the same period last year. Revenue from our embolization and access business was $93.9 million in the fourth quarter of 2023, an increase of 7.6% reported and 6.7% in constant currency compared to the same period a year ago.
Before turning to our income statement, I will provide fourth quarter revenue results in the format we have previously used before we transition to the new disclosure format going forward. On a global basis and compared to the fourth quarter of last year, revenue from our vascular thrombectomy was $133.4 million, an increase of 64%, neuro thrombectomy was $57.4 million, an increase of 9%. Vascular embolization was $51.5 million, an increase of 7.3%. Neuro access was $33.2 million, an increase of 18.3%. Neuro embolization was $5.9 million, a decrease of 33.8%, and other revenues were $3.3 million, an increase of 46.3%.
U.S. thrombectomy was our primary growth driver in the fourth quarter and will be in 2024. And we are also being disciplined with our commercial strategy for our embolization portfolio. In sum, we are focused on driving both strong revenue growth and increasing profitability going forward.
Turning to gross margin. Gross margin for the fourth quarter of 2023 is 65.7% compared to 62.6% for the fourth quarter of 2022 and 65.6% last quarter. The 300 basis point improvement compared to prior year are driven by higher thrombectomy product mix while cost savings and improvement and productivity and volume leverage have offset labor inflation and material price increases. In 2024, we target improvements of 100 to 150 basis points expansion in gross margin, which reflects continued favorable thrombectomy product mix, investment to support new product launches and variation in regional and distributor mixes.
Now on to our non-GAAP operating expenses, non-GAAP operating income and margins and adjusted EBITDA. Total operating expense for the quarter was $149.6 million or 52.5% of revenue compared to $131.2 million or 59.3% of revenue for the same quarter last year, and $144.5 million or 53.3% of revenue for last quarter. Our research and development expenses for Q4 2023 were $21.9 million compared to $18 million for Q4 2022 and $21 million for last quarter. SG&A expenses for Q4 2023 were $127.6 million or 44.8% of revenue compared to $113.3 million or 51.2% of revenue for Q4 2022 and $123.5 million or 45.6% of revenue last quarter. Increases in the fourth quarter were driven by an increase in headcount for our U.S. commercial team.
We recorded operating income of $37.4 million or 13.1% of revenue in the fourth quarter of 2023 compared to an operating income of $7.2 million or 3.3% of revenue for the same period last year and operating income of $33.2 million or 12.3% of revenue last quarter.
We continue to focus on innovation of our products, commercial evolution of our U.S. sales team to address the increased opportunity in front of us and market access programs in DVT, stroke, arterial and PE, all of which supports an increased number of patients treated. While we continue to spend on these long-term projects that will allow us to scale our organization into the future, we also continue to exercise self-discipline in our other spend in the present. In 2024, we target improvement of 100 to 200 basis point expansion in our operating margin.
We posted record adjusted EBITDA of $53.4 million or 18.8% of total revenue compared to 10.5% in the fourth quarter last year.
I will now summarize our full year performance for the full year of 2023. Our total revenue for the year was $1,058.5 million, which represents an increase of 25% reported and 24.7% in constant currency compared to full year 2022. Our geographic mix of sales in the year were 71.5% U.S. and 28.5% international. For the full year 2023, U.S. reported growth of 28%, primarily driven by growth from our vascular thrombectomy business of 45.2%, and our international regions increased 18% reported and 17.3% in constant currency.
Revenue from our global thrombectomy business for the full year of 2023 was $677.3 million, an increase of 32.5% reported and 32.3% in constant currency. Revenue from our global embolization and access business, for the full year of 2023 was $381.2 million, an increase of 13.4% reported and 13.2% in constant currency. Revenue from our vascular business for the full year of 2023 was $652.4 million, an increase of 30.6% reported and 30.6% in constant currency. Revenue from our neuro business for the full year of 2023 was $406.1 million, an increase of 16.8% reported and 16.3% in constant currency.
Our gross margin for the year was 64.5% of revenue compared to 63.2% of revenue for the full year 2022. We had non-GAAP operating income for the full year of $101.3 million compared to a non-GAAP operating income of $14.4 million for 2022. Our adjusted EBITDA is $170.6 million or 16.1% of total revenue compared to 7.7% last year.
Turning to cash flow and balance sheet. We ended the fourth quarter with cash, cash equivalents and marketable securities balance of $289.2 million and no debt, which is an increase of $40.3 million from last quarter. We expect positive operating cash flow trend to continue in 2024.
And now I'd like to turn the call over to Jason to discuss our guidance.

Jason Richard Mills

Thank you, Maggie, and good afternoon, everyone. For 2024, we introduced guidance for total revenue in the range of $1.230 billion to $1.270 billion, representing year-over-year growth of 16% to 20% compared to $1,058.5 million in total revenue in 2023. Primarily based on currently forecasted orders from our international distributors and timing of new product launches, we expect global revenue growth in the first half of the year to be in the mid-teens range. Then, we expect growth to accelerate to the high end of our 16% to 20% guidance range or above in the second half of the year.
We guide to U.S. thrombectomy revenue growth in the range of 27% to 30% year-over-year. We expect growth in U.S. thrombectomy to be consistently strong in this range throughout the 4 quarters of the year. We expect our U.S. embolization and access business to contribute low double-digit growth in 2024. And therefore, in total, we expect our U.S. business to deliver strong, consistent growth in the 22% to 25% range throughout the year.
From a geographical distribution perspective, we expect our U.S. business to represent 73% to 75% of our global revenue in 2024. Outside the United States, we have worked the past 2 years to expand the foundation for thrombectomy in our international markets with our legacy products and have made significant progress. In 2024, more of our focus will be on regulatory, reimbursement and market access initiatives to bring our CAVT products to patients outside the United States. As we do this work this year, we expect our international thrombectomy revenue in 2024 to grow modestly over 2023 levels. And as these initiatives come through, we expect to accelerate our international thrombectomy growth in 2025.
Also, on the international front, we are focusing more on driving profitable growth. We plan to continue to be disciplined with our commercial strategy in the near term for our embolization and access products in certain international markets, where prices do not currently reflect the value of our products. At the same time, we are continuing our work with international regulatory and reimbursement agencies with our new products in these areas. In sum, we expect our total international revenue in 2024 to be similar to 2023 levels, and we think our international revenue will accelerate to double-digit growth in 2025.
As a final thought, as we look beyond the current year, as Adam mentioned, we believe our CAVT products will sustain strong growth for the company over the ensuing years.
Operator, we can now open the call for questions for the next 35 or 40 minutes.

Question and Answer Session

Operator

(Operator Instructions) We'll go first to Joanne Wuensch at Citi.

Joanne Karen Wuensch

Wanted to ask -- I'm curious -- I'm going to ask 2. One, we're hearing about increased payer scrutiny on mechanical thrombectomy. I'm curious how that may or may not be impacting you. And then number two, how do we think about sort of ongoing profitability metrics. I'm finding that comes up more and more on several stocks and medtech, sort of an LRP longer-term view on gross and operating margins.

Adam Elsesser

Yes. First of all, thanks for the good questions. We, in fact, did not -- on mechanical thrombectomy, particularly as we see it, we have not seen the type of, what you're calling, scrutiny. That shows up in other types of procedures that aren't clot, removing blood clots in the cases. So we haven't really seen that. In fact, we saw the opposite this year. In arterial, there were some increases, particularly interesting increases related to hospital outpatient use. So I think we're seeing the opposite.
As it relates to sort of how we think about profitability, we've outlined, the beginning on this call, our thoughts and plans around how we want to continue to accelerate that by focusing on certain areas where we're not seeing the same sort of price value for some of our embolization access business. So we're going to be disciplined about it. We sort of have, if you will, the luxury of being disciplined about that because we don't need every last dollar revenue when we have the growth of CAVT in the U.S. and coming to the rest of the world in out years.
So I think you'll see more and more focus on that without taking away focus on the growth. And I think that's an important -- you're seeing the beginning of that in the last couple of quarters, and I think you'll see that continue pretty strong.

Operator

And we'll go next Lei Huang.

Lei Huang

This is Lei calling in for Larry Biegelsen from Wells Fargo. Can you hear me okay?

Adam Elsesser

Yes.

Lei Huang

My question is around the 2024 guidance, the 16% to 20% growth, the midpoint being at 18%. That's quite a bit of deceleration. And thank you for the color on the breakdown. Can you talk a little bit about how to think about the sales cadence through the year just given there are so many different dynamics running through the different segments? And I have a follow-up.

Adam Elsesser

Yes. Absolutely, Lei. Let me start by first thing, I -- we stand by our comment that we made actually at your conference last September when our -- and our overall guidance reflects our confidence by projecting that we think 20% growth is achievable. I want to emphasize, though, that we also added a lot more transparency, which you alluded to, by providing guidance of our U.S. thrombectomy business where we project 27% to 30% growth. And that's probably the most important -- the more important number right now since it focuses on our CAVT platform, which is only right now in the U.S. And it also allows us to prepare our international markets in 2024 for our CAVT platform in the future, so we can have similar accelerated growth throughout the world in following years.
And that's how we're thinking about the business. And I acknowledge that there's a lot to digest because we've given you a lot of different numbers and talked about our business in a slightly different way, but it's also how we're managing the business. That's how we see the growth. That's where the growth is. That's what the excitement around the opportunity to finally do what we set out to do 20 years ago, which is with this platform, we have visibility. We have the strategy around making sure we can bring this to everyone who has clot in their body from head to toe. We're hearing that from large hospital systems. We're hearing that from customers. We're seeing that in the cases.
So we're trying to focus our energies on that opportunity, and it takes some discipline because that hasn't always been the sole focus of the company. So you're seeing that in how we're thinking about our international business, our coil and access business with that focus right now. But again, what we're thinking about is the other parts of our business matter, but the 27% to 30% growth in U.S. thrombectomy is our focus. And Jason can follow up.

Jason Richard Mills

Yes. Lei, just to follow up on that with respect to the cadence, so a couple of things I just want to repeat and go over again. We commented about that 27% to 30% in U.S. thrombectomy as well as the entire U.S. business at 22% to 25% delivering pretty consistent growth in that range through the year. So the cadence quarterly is primarily based on distributor order timing to which we have very good visibility as well as timing of product launches as well, to which we have, again, really good visibility, we believe.
And so as Adam mentioned, we think that the U.S. thrombectomy number is the number to really look at primarily, and we've commented also that our international business should accelerate in 2025. We have a high degree of confidence in that as well.

Lei Huang

That's helpful. Just a clarification on what you just said, Jason. So U.S. growth overall is pretty consistent, so it's really the OUS where you're talking about the distributor timing that's driving the mid-teens growth in first half versus second half at 20% or higher. Is that the message there?

Jason Richard Mills

That's correct. And we have very good visibility into the timing. It's just how they land throughout the year.

Lei Huang

And just for my follow-up, can you talk about your assumptions for the U.S. vascular thrombectomy market growth in terms of what's assumed in your guidance for both venous and arterial?

Adam Elsesser

Yes. We won't give specific breakdowns between those 2, but the assumption -- the fundamental basis of that is what I've alluded to now for the last month or so -- or 2 that we saw a notable uptick in our trajectory in late November, and that has been consistent. It didn't -- it wasn't a onetime event. It went up, and it stayed at a different level, which gives us the confidence not only in those projections but also in the consistency throughout the year.
And the reason for that is what we've been saying throughout most of 2023, which is we had a lot of new customers. We saw a lot of them come through at the end -- the last -- very last days of November and into December, and that's continued. And I think that momentum is continuing, which is why you hear the confidence we have right now in this platform and in this business.
You add into it the dialogues we're having with hospital systems and physicians, which is just nothing we've ever been able to have before. It gives us an awful lot of confidence that we're headed in the right direction.

Jason Richard Mills

Lei, just to add to that a little bit, in referencing again the U.S. thrombectomy growth of 27% to 30%, we -- that includes VTE, arterial, coronary and stroke. And while we're really excited about cataracts in our stroke portfolios, those -- the growth rates implied for those thrombectomy franchise in the U.S. are lower than that range. VTE and arterial are expected to grow well above that range.
Part of that strong growth is market growth, which is healthy. Again, market growth is best observed in arrears, I think, but it's still healthy growth. And in addition to that, we expect, of course, to add to our share throughout the year.

Operator

We'll go next to Bill Plovanic at Canaccord Genuity.

William John Plovanic

Just some clarity here. So as we look at the U.S. thrombectomy, you launched Flash starting early last year. You launched Bolt soon thereafter. So as we go into the first half of the year, it's actually pretty easy comps as you keep the growth going. It sounds like you're going to keep the growth going and then in the back half of '24, at least in the U.S., it's the sales force changes that really kind of help that growth continue in terms of the market access and all the work you've done on that. Am I thinking about that correctly? And then I have a follow-up.

Jason Richard Mills

Yes. Bill, it's Jason. I'll start and maybe Adam can chime in. I -- we had a really strong first quarter last year with Flash, especially early on with our existing customers, and we actually had quite a bit of success with new customers early in that launch as well. Of course, that continued. So I don't know if there are any particular comps to point out that -- 1 quarter outweighing another. And that's why we have pretty good confidence in the consistency with which those grow.
The other thing I would point out is launching Lightning Flash 2.0. Likely a full launch later this quarter really won't impact things until you get into the second quarter. And the other product launches, we're not factoring in too much through the year just to sort of be conservative on that as well.

William John Plovanic

And then on just Thunderbolt, I think some comments you made, I think, earlier in the year. Is that now pushing into 2026 in terms of contributing to the U.S. thrombectomy business?

Adam Elsesser

Yes, Bill, it's a great question. Obviously, I'm going to be careful to give any kind of specificity on a trial that's still ongoing. I think I learned my lesson the last time, so I'm going to resist. The trial is going well. We're enrolling well. The cases are going well.
We said during that time when we were resetting expectations around the timing of Thunderbolt that we have not put in our number for '24 or '25 any Thunderbolt revenue. And so that was what we said then. That's still true. Whether or not it comes or not, we'll deal with that at the time. But we're not counting on Thunderbolt revenue until '26 anyway, and I said that over a year ago or whenever that last was. So that's stayed consistent.
So this is -- the growth that we're talking about is -- in CAVT is on -- with Flash and Bolt and the new products going forward. And obviously, our stroke growth, which was -- if I want to -- it's significant in the fourth quarter. We continue to take share. A lot of that is really just on the extraordinary success, continued success of Red 72 with SENDit, which is, as I said, just setting the standard.
That is the catheter of choice now. We've gained more and more share, and I think it's setting the table for Thunderbolt because, again, you need that catheter first, and then you can use Thunderbolt afterwards. So again, we remain very optimistic about the sort of 1-2 punch there with those 2 products.

William John Plovanic

And a point of clarification on international if I could. Is -- are you going to discontinue selling some products in some countries in the first half of this year? Is that what some of the delays and kind of the downdraft in OUS?

Adam Elsesser

What we said was that in our embolization and access business, there are certain countries where reimbursement pricing just isn't commensurate with sort of the value of the product, and we're not -- it's not a profitable business. So we are using this opportunity, if you will, with the success that we're having, where we don't need to do that, and they can use products that are more commensurate with what they want to pay for. And so yes, the answer is there are certain areas and countries that, that is true, so we are going to focus on profitability in those markets.

Operator

We'll take our next question from Robbie Marcus of JPMorgan.

Robert Justin Marcus

I want to ask -- and I don't want to belittle 29% growth at all because it's a great growth rate, but this is the first time you've missed Street numbers since the IPO. And I would say at our conference in January, you didn't comment on the quarter, but you did sound pretty robust. So what happened during the quarter that you ended up missing the midpoint of your guidance range and the sell-side numbers?

Adam Elsesser

Yes. What you just said is true, but our Q4 revenue number, it was within our guidance, but obviously, it's still just shy of the consensus number. However, what led to my excitement at your conference, what led to my excitement every single day since then into now is the very -- sort of the fact that -- and I said it again today day. We saw a notable uptick in our trajectory in late November, and that's continued since then, which gives us the visibility, Robbie, and the confidence to guide our U.S. thrombectomy business to see a 27% to 30% growth in the U.S. this year.
What's not to like about that? That gives us an extraordinary amount of confidence about 2024 and beyond with the success of this. And we were waiting for this moment. All these new accounts were coming. They were -- and we saw that sort of moment happen. So what's not to be liked? And yes, I acknowledge, without a doubt, that there's a couple of million dollars short from the consensus, still within our guide. But I will assure you, our entire team here is totally focused on 2024 and succeeding with the CAVT platform.

Robert Justin Marcus

Great. And maybe to follow up on a question from before about cadence. The U.S., you said, should be within the guidance range pretty much throughout the year. OUS, lower at the beginning, higher at the end due to stocking. How do we think about the amount of stocking that were in the different quarters? Because when we just look from the outside, we see much more difficult comps in the back part of the year versus the first and higher dollar values. So how do we think about what the amount of stocking is, so we could get a sense of underlying volume?

Adam Elsesser

Yes, it's a great question. Let me just make sure our terminology is sort of right if you will. We don't really do stocking as that word is sort of sometimes considered and used. What we're talking about in most of these international markets, not all because we're direct in parts of Europe and so on, but is really distributor orders.
Distributors tend to order -- they are slightly different. Some have different ordering patterns. We've seen this now. They're not linear. They don't order every week. They order, most of the time, quarter-by-quarter, but sometimes even less than that. And then they get -- they then go sell it. We get those orders and those forecasted orders from them. We don't give them numbers. We get those in advance. And from those projected, forecasted orders, we then put it into our number.
All -- on the thrombectomy side, all of those folks -- I should say, the vast majority of those folks know that CAVT is coming. So obviously, they're going to be careful and not order as much product when they know a better generation is coming because they don't want to be left with excess inventory. That's just obvious and common sense. So we're taking that into account and being thoughtful about it.
The other part of it relates to the coil business, the embolization and access business. And I've already sort of addressed that, that this is an opportunity now with us to focus that business in a way that allows us to retain our growth and profitability without really losing anything in the long, long run. So some of those are sort of dipping away, are negative, and we're just putting that into a lot of transparency, which, again, brings me back to the best measure is our latest technology and the growth curve that we're having because not only are we going to continue to have that for number of years, we think, in the U.S. We think that will be replicated in the international markets when those products get there. That's really the good thing. So we're getting the business ready to go in those international markets where we can have that kind of growth, too.

Robert Justin Marcus

And Adam, if I could just sneak in the size of those discontinued country sales.

Adam Elsesser

When you add it all up, it gets you to the numbers that we were alluding to. I don't think by calling out each country is -- and the size feels right on a public call. Those are great partners and great countries, and I think we can get to the same number without calling them out country by country. But I appreciate the question.

Operator

We'll move next to Pito Chickering at Deutsche Bank.

Philip Chickering

One quick clarification. Just looking at the comments from sort of 3Q of at least 20% growth for 2024 and then guidance today, is the only difference between your commentary previously and where we are today is just slower international growth because you're focused on profitability? Or is there anything else?

Jason Richard Mills

Yes. I think you've got it. That question implies you're really focusing on both the 27% to 30% growth in U.S. thrombectomy as well as taking that a step further with the entire portfolio of neuro access, embolization, et cetera, at 22% to 25% growth.
And yes, the discipline we've talked about here with respect to certain international markets and timing is something we've been working on now for a little while and we've seen a little bit of as well in 2023. So we have pretty good visibility into this, but I think that is the difference that you've noted.

Philip Chickering

And then can you talk about the sales force for a minute? How many sales guys have you hired? What was the cadence of that hiring throughout the last 12 months? Where is the sales force, those new reps ramping up versus the demand? And do you have the right sales force today in order to meet your '24 guidance? Or do you need to hire more? And then last question, are you seeing any churn of seasoned sales force because of the new adds? Or is it looking pretty good?

Adam Elsesser

I tried to write them all down. There's a long list of questions, so let me -- if I missed one of the specific ones, please reask it. As I said in the prepared remarks, most but not all of the hiring is done. The majority of it is. Now we're focused on getting them all trained and operated.
I will tell you from years of doing this, this was the most seamless as it related to moving around territories, bringing in new folks than any other expansion we've had. And that's in large part because our team, I think, very maturely and sort of as a professional understood that they will actually benefit more in the long run as will our patients by having the ability to focus on less accounts.
We have a lot to do. We have very large territories, much larger than our competitors, which is also why we don't give out our sales force numbers. And that has been part of our advantage. It stays that way. But with all of the work ahead and these 2 big launches and the growth ahead, we just needed more people. We probably should have done it a day or 2 earlier. Had that happened, it would have turned out differently. But it's gone really, really well, and it's been a sort of a remarkable sort of integration.
The other thing and part of the reason for that is we have attracted the sort of most talented, most seasoned sales reps from other peripheral vascular companies that we've ever attracted. And I think part of that is just on the success of the CAVT products and what they know and hear so that the professionalism, the ability to move in and pick up quickly has been pretty remarkable.
So it's gone well. It obviously takes some effort to train them and get them started and so on. We've had training classes and all that. But in the long run, I think it's been one of the easiest things.
As it relates to our current projected growth, this is the team that will get us there. Obviously, as that continues to go, and the market access projects that we're working on bear fruit, we might need to evolve that as well. But for now through this year, I think we're in really good shape.

Operator

We'll take our next question from Matthew O'Brien at Piper Sandler.

Samantha L. Kurtz

This is Samantha on for Matt. I guess, first, I would like to touch on -- go back and touch on guidance a bit. So I guess the lower end of the revenue guidance, the 16%, what does that scenario consider or bake in compared to the top end of the range?

Jason Richard Mills

Yes, I'll start, and then Adam can join in. Obviously, we have a range for U.S. thrombectomy where there's a low end and a range for our U.S. business, which would contemplate our expectations for what U.S. embolization and access, too, that also has a low end, 27% and 22%, respectively. And it's probably hard on a call where we have finite time to go through every detail on what drives the lower, the higher end or above of each one of those numbers. But in every event, it is market growth. It is things like that. Internationally, I think we have pretty good visibility, but of course, you let the year play out. So I don't think there's anything demonstrable to point out between the low or upper end. It's just execution at the end of the day.

Samantha L. Kurtz

And then one thing -- I guess, one of the bright spots for us this quarter was the EBIT was higher than we were expecting. I guess where do you kind of see the margins moving in the long term?

Maggie S. Yuen

I think, yes, we're very pleased with our profitability this year. I mean it kind of demonstrate that we can scale and continue to invest at the same time. Our gross margin, we're continuing seeing favorable product mix. So we are on track to our longer-term 70-plus percent margin target. And I'm pretty sure that we'll pull through to the bottom line. And we will continue to invest, but I think we are setting up for very good infrastructure to scale.

Operator

We'll take our next question from Michael Sarcone at Jefferies.

Michael Anthony Sarcone

So just for the first one, do you think you can give us an update on the status of the VAC processes that you're working through with Flash and Bolt? I would just love to get an update there.

Adam Elsesser

Yes. It's a great question. So obviously, the uptick that we saw starting in late November and continuing assumes that more -- a lot more of those customers have come onboard and started using the products. So we're just like we said we were in the third quarter, i.e., we're getting through a lot of those. We still have some to go. We're not obviously in every account in the country, and we have more coming. But a big bolus of those came in late November and into December, which is what we had hoped for. And now we're seeing the benefit of that. And as we continue, the focus now is, yes, on continuing getting the remainder but really focuses on moving to getting the physicians up and running and using the product on a regular basis.
So it's a really good phase. Some of that administrative part is done and derisked. And now we're just enjoying the early text cases -- we get texts from reps in the early cases and how they're all going and pictures of clot and excitement and so on. So we're moving into that phase, which is a lot more fun than the heavy burden of the administrative load there.

Michael Anthony Sarcone

And then just last one for me. Could you give us any more color on the different bells and whistles you've added to the Flash 2.0? I think you said it optimizes the advantages of CAVT. But anything that could help us crystallize that more?

Adam Elsesser

Yes, I think you would frame it the following way. We get more clot out faster with even less blood loss than before.

Operator

And next, we'll move to Richard Newitter at Truist Securities.

Richard Samuel Newitter

Maybe just on the guidance and the philosophy there, Adam, Jason. The 2024 guide, particularly with respect to the U.S., you're kind of very accountable on the metrics there, the revenue breakdown. Thank you for that. I guess what I'd like to know, going off Robbie's question earlier, what philosophically is your approach to guidance this year, last year and in the fourth quarter? You came close, but it wasn't necessarily upside relative to the guide or the consensus.
So how should we think about your approach to this year? And I'm particularly talking about the U.S. thrombectomy numbers because that's where I think you're going to be graded the hardest. Is this aspirational? Is this a floor? What can you give us in terms of how much cushion is built in and how you set your -- up for better expectations, management and execution?

Adam Elsesser

So I would comment that we're running out of time on your pun, the fact that our guide is aspirational, and that's the products we sell. I don't think you intended that pun, but I appreciate the effort if you did. The fact is this. We learned a lot. Last year was a great year for us. We learned a lot. We have not had a year that had the scale of growth and excitement around our product in our company's history. And so it was really hard to figure that out. How do we get the kind of information that can give proper guidance and so on. And we came really close, and I'm pretty proud of that given the scale of growth in the transformational aspect of last year.
Obviously, better to hit the number and move on, but in the long run, it is not as important as having the foundation to continue to grow from year-over-year. So we've learned a lot, and I think we're going to be more careful, thoughtful about it. We understand these products better. We understand the rhythm of them, the level of interest. We're further into it. So we have a lot more information. So our philosophy is to not guide aspirationally, to use your term, but to really guide with the kind of clarity and information that we've done in the past. And again, I think you'll see that in 2024.

Operator

We'll go next to David Rescott at Baird.

David Kenneth Rescott

Two questions. I'll ask them both upfront. First, I heard you call out Flash 2.0. I think maybe specifically, you talked a little bit about expanding to more areas in the body. So just wondering specifically what some of those comments kind of mean? And then should we think about maybe a Bolt 2.0?
And then my second question, just on international. It sounds like obviously 2024 is the big investment. I think I heard you call out seeing that accelerate in 2025 to a double-digit range. Just wondering if that growth outlook into 2025 for international is something that would be maybe accretive or just maybe more supportive of the total top line growth of the company?

Adam Elsesser

Let me start and then Jason can sort of touch on the question around '25 and so on. The products, I'm not going to be more specific than I have been about where we think -- what these products are going to do. What I can tell you is the following. I've had the opportunity to hear about them, to see them, to talk to the folks who are designing them and playing with them. I'm really excited about it. The goal again is simple.
We want to be able to go after every kind of clot in as much of the body as we can go. These new products do that. They expand that opportunity to get different types of clots in different parts of the body. And sometimes both. Sometimes just one of those. That's the goal. And I can't wait. I think we now have understood this. This platform of CAVT has totally changed how we're thinking about this, what we think we can go after, how we can continue to improve the algorithms.
And so the goal here is to be able to go after clot in any part of the body with a lot of confidence that we can get it out, and that's what those products bring us even closer to. When those are done, we're not going to be done. We're going to keep adding. We'll keep innovating. We'll keep adding 3.0, 4.0 because that's how great technology works. And I think we're set up for a pretty nice run here.

Jason Richard Mills

Yes. And David, thanks for your second question. In my prepared remarks, I talked about the international business, and I mentioned 2025, and you're right. We did say in those prepared remarks that we thought that international revenue could accelerate into the double digits in 2025.
And then the next comment that we made was about our CAVT products and sustaining strong growth because the reality is, even hitting our guidance this year in U.S. thrombectomy and doing really well, the market penetration rate we have, the number of patients we will have helped is still really, really low penetration levels. We will have a long ways to go.
So that comment that I made right on the heels of making the comment about international was intended to talk about the fact that this is, as Adam has mentioned several times in the past, growth that can extend over the next ensuing years, a number of years. And so while I'm not going to quantify what we think 2025 looks like yet, we're pretty optimistic about 2024 and beyond.

Operator

We'll go next to Mike Matson at Needham & Company.

Michael Stephen Matson

I guess, first, with the efforts outside the U.S. to get the CAVT products on the market, I just want to understand -- I know it probably varies by country and whatnot, but it sounds like, generally, you feel like there's a need to get some reimbursement in place. Is it -- or is it just that there's reimbursement there and it's just not enough to cover the cost of the products?

Adam Elsesser

Yes. Mike, that's a good question. We're talking about large geographies, many different countries in Europe that have different reimbursement schemes country by country, same in Latin America and Asia Pacific. So each one is obviously very different. There are going to be cases in which reimbursement is there for the most basic sort of catheter and syringe type system, which is not an expensive reimbursement. And then more sophisticated stuff is not yet reimbursed because they've never seen it. They don't know what it is. And we have to go through that effort. And then in other cases, there's really no reimbursement yet for that procedure at all. So it's a little of each. And obviously, we're focusing on some of the larger areas first, and then we'll continue to do that effort.
Not different, just to give some context to what we did in stroke many, many years ago. Stroke was not reimbursed at all and ironically, still is not in certain countries, and we've been doing that work for the better part of almost 20 years now. So I think we know how to do it. It just takes time, and we want to do it right and make sure because we don't need to rush this because we have the benefit now of growth, particularly in the U.S.

Michael Stephen Matson

Okay. Got it. And then just as far as the distributor ordering forecast or patterns you're expecting in 2024, I was wondering, in the commentary around exiting certain markets and certain product categories due to lower pricing, is China a factor in either of those things, either distributor ordering patterns or the markets you're exiting? Because I know there has been some VBP over there in the neurovascular area.

Adam Elsesser

Yes, Mike, that's a really important question. I'm glad you asked it. I just want to maybe remind you and everyone else that we have 3 different buckets of revenue from China. We have license fees, royalties and distribution. So that structure, as you know has sometimes created a funny quarter-by-quarter movement that we've talked about over the last couple of years in the past that on a longer-term basis, that same structure has provided us, I think, a lot of protection from some of the current climate in China.
So we feel pretty good about it. Going forward, we have a really incredible partner in Genesis. And we believe that our products, particularly the CAVT platform, can ultimately have an important place in the Chinese market. We've got a lot of work to do, but I think we're really set up for that, and we're pretty excited about it.

Operator

We'll take our final question today from Margaret Kaczor at William Blair.

Macauley Healy Kilbane

This is Macauley on for Margaret. I appreciate you squeezing me in here. Just to kind of put 2 questions into one. I know you mentioned the 20% growth in U.S. stroke, large part of that obviously SENDit. But as we look towards 2024, do you expect SENDit to be able to bridge that gap within neuro? Or I guess how should we think about the rollout in terms of adoption compared to Flash and Bolt, which, to your point, might have a longer tailwind? And then to throw in the second, just any update in terms of THUNDER time line on the trial -- on the THUNDER trial?

Adam Elsesser

Yes. So let me -- I'll start with the last one. I've sort of answered that question around the Thunderbolt trial. It's going well. Enrollment continued. We aren't counting any of that revenue until 2026, so we've got a ways off, but the trial is going well.
So what we did is greater than 20%, not 20%. That business is really strong. And we don't yet have 100% of the market, and so we're going to continue to go after those physicians. Word of mouth is now really strong as people -- more and more physicians have used it and the platform to get to the place of clot, we're seeing more and more conversion to it. So yes, I think 2024 is going to be a good year for our stroke business, and we're going to continue to see some growth there.
Obviously, that will continue and get even more when Thunderbolt comes. But in the meantime, it stands as an anticipation of Thunderbolt because, again, you've got to have the catheter there first. Then, you can use Thunderbolt. So the setup is really kind of perfect for us.

Operator

And that does conclude the question-and-answer session. I'll turn the conference back over to Ms. Hamlyn-Harris.

Jee Hamlyn-Harris

Thank you, operator. On behalf of our management team, thank you all again for joining us today and for your interest in Penumbra. We look forward to updating you on our first quarter call.

Operator

And this concludes today's conference call. Thank you for your participation. You may now disconnect.

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