Venous Disease – Not So Black and White

By: Windsor Ting, MD. 
Division of Vascular Surgery, Icahn School of Medicine at Mount Sinai

Close to 30% of Americans are described as minorities, a number that will reach 40% by 2030.  Hispanic Americans currently account for 15%, African Americans 12%, and Asian Americans 7% of the U.S population1.  Two of these population groups, Hispanic Americans and Asian Americans, are projected to increase significantly during the next few decades2.   

The impact of race on disease prevalence, presentation, and treatment has been investigated in many different health conditions but almost none pertains to chronic venous insufficiency (CVI)3,4.  Sam et al reported that Asian men in England were significantly less likely to undergo vein surgery than Caucasians and that this difference was not due to a low disease prevalence5.   This physician who has treated a large number of Asian Americans with vascular disease in New York City over many years observed that while the true prevalence of CVI in Asian Americans is unknown, venous disease appears common in this population and the introduction of endovascular approaches to venous disease has removed many barriers to treatment.   

In a study at the John Hopkins Hospital of 1541 patients who underwent thoracoabdominal aortic aneurysmal surgery, Hispanics had significantly higher mortality independent of preoperative comorbidities and postoperative complications6.   Reports such as this seemingly reinforce the kind of myths that I have heard from my Asian American patients that the hospital is a place of death.  This physician was advised early in his career that it is best to complete the entire vascular evaluation expeditiously in one or two office visits before the patient elopes and to avoid referring patients to the hospital for tests.  In reality, I can recall very few patients within my practice experience who had a large aortic aneurysm but declined endovascular or open repair, or someone with a significant carotid artery stenosis who refused endarterectomy, or a patient with ischemic rest pain but left the hospital prior to recommended treatment.  Despite fear and ignorance, the overwhelming number of patients, English-speaking or not, seems to recognize a life-threatening condition and more often than not, will make a rational decision in their best interests.  Is this equally true for CVI, a condition that is not life threatening?

Durazzo et al reported that non-white individuals were significantly less likely than white individuals to undergo revascularization prior to amputation in critical lower extremity ischemia7.  There may be many reasons for this finding.  In carotid artery disease, aortic aneurysm and most peripheral artery disease, the underlying vascular pathology is not apparent to the patient.  A primary care physician usually makes the initial diagnosis of these vascular conditions.  In contrast, the patient with CVI presents very differently.  In my experience, these CVI patients have a distinctly different referral pattern.  Unlike other vascular conditions, varicose veins are immediately noticeable to the patient.  While some patients with CVI are asymptomatic, most have some symptoms but frequently the mere presence of bulging veins will prompt someone to seek medical attention.  Furthermore, patients attribute any symptoms, venous or not, in their lower extremities to their varicose veins.  Not surprisingly, many patients with CVI in my practice have been self-referrals and even among those referred by a primary care physician the referral is frequently self-initiated by the patient.  In CVI, no translation is needed for someone to point out the bulging veins in their legs.  Among these non-English speaking patients of mine, I found having an office close to the community and having an office staff that speak the same native language has lowered the barrier and greatly facilitated the initial evaluation of patients with CVI.   Because I have two separate offices where I see patients, I have been able to evaluate patients with similar vascular diseases but from significantly different demographics.  While I have observed a trend toward more advanced stages of CVI among my Asian American patients, it is difficult to attribute this to anything more than the unique referral pattern of a medical practice.   Worthy of mention, however, is the impact of work on treatment that may be especially pronounced when certain types of occupation are more common in a specific community.  Current treatment recommendations frequently include a trial of medical therapy with compression stocking prior to endovascular surgery.  While the use of compression stocking is beneficial in CVI, it may be problematic in such occupations as those in restaurants, constructions, and farms.        

During the past decade, endovascular treatment approaches have evolved into the standard of care for varicose veins.  Endovenous thermal ablation of varicose veins is presently a procedure that can be easily performed in an office setting.  This evolution has helped virtually all patients but especially the non-English speaking patients in several ways.  Firstly, patients no longer have to navigate the hospital milieu for these procedures, avoiding the many trips for blood testing, preoperative medical clearance, the pre-surgical anesthesia visit, and the actual procedure.  I have come to realize that for these non-English speaking patients, a trip to the hospital is difficult not only for the complexity of the hospital but also because of the very difficult task of finding and arranging for an English-speaking family member or friend to accompany them to the hospital.  These patients seem partial to a treatment approach that requires no incision and minimal or no anesthesia.  This less invasive and ambulatory treatment approach seems especially attractive to individuals who are not familiar with our health care system.  Finally, I have observed over the years that many of my Asian-American patients have employments that provide little or no sick days.  That endovenous thermal ablation necessitates minimal convalescence also means that these patients can return to work promptly.  For selected patients, returning to work on POD 1 is a real possibility and among other patients, they are usually able to work within one week.           

In conclusion, CVI is different from other vascular disease in many ways.  The development of endovascular treatment for CVI has helped all patients and has lowered the barrier to treatment for the non-English speaking patients.

 

Reference

  1. Projections of the populations of the United States: 1982 to 2050.  United States’ Census, U.S. Dept. of Commerce
  2. Population projections of the United States, by age, sex, race, and Hispanic origin 1993 to 2050.  United States’ Census, U.S. Dept. of Commerce
  3. Davis TM.  Ethnic diversity in type 2 diabetes.  Diabet Med 2008;supple 2:52-6.
  4. Quan H, Chen G, Walker RL et al.  Incidence, cardiovascular complications and mortality of hypertension by sex and ethnicity.  Heart 2013;99(10):715-21
  5. Sam RC, Hobbs SD, Darvall KA, et al.  Chronic venous disease in a cohort of healthy UK Asian men.  Eur J Vasc Endovasc Surg. 2007;34(1):92-6.
  6. Arnaoutakis DJ, Propper BW, Black JH 3rd et al.  Racial and ethnic disparities in the treatment of unruptured thoracoabdominal aortic aneurysms in the United States.  J Surg Res. 2013;184(1):651-7.
  7. Durazzo TS, Frencher S, Gusberg R.  Influence of race on the management of lower extremity ischemia: revascularization vs. amputation.  JAMA Surg. 2013;148(7):617-23.

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