Less vain and more vein: Evaluating the perceptions of venous disease amongst the vascular surgery community

Our biases permeate the fabric of our very being, as they weave their way into our training and practice. It is clear that complex aortic work is definitely in vogue and ‘in’, and, well… treating veins gets a bad rap. While training, our staff perpetually complained about not only treating venous disease but not having the patience to sit and listen to these ‘complex’ patients. Current vascular surgery training paradigms focus significantly on arterial disease, and training programs rarely focus on venous disease management as part of the core curriculum.

It comes as no surprise that if those teaching the next generation of vascular specialists are not enthusiastic or motivated and possibly even deterring the pursuit of treating venous disease, the next generation will face similar sentiments. It is clear that not all vascular systems are created equal, but why? 

The management of venous disease is imperative, as it has been reported to be twice as prevalent as coronary heart disease and five times more prevalent than peripheral arterial disease (PAD). More than 25 million adults in the U.S. suffer from chronic venous insufficiency, with more than 6 million having advanced venous disease.² Further, venous disease cost of care is estimated to range from $3 to $10 billion annually.^2,4 However, there seems to be a discrepancy in its perceived importance among vascular surgery specialists. 

It has been proposed that there exists a lack of adequate, specific and practical training throughout the academic curriculum presented to future vascular surgeons, which has led to the view that venous pathology, compared to arterial conditions, is of secondary nature. 

In addition to this, themes such as less technical challenge, lower morbidity/mortality risk, ease of lifestyle, less institutional support for research or clinical programs, and fewer funding opportunities were highlighted as reasons for the existence of this perception in a survey on the topic Furthermore, the terms “ego” and “prestige” were mentioned when describing rationales for arterial work being more important than those in the field of venous disease.¹ 

Vascular surgeons continue to be the largest provider for venous disease care in both medical and surgical specialties.³ More than 17% of all medical and surgical venous care providers do not have active board certification. Therefore, it behooves our specialty to uphold best practices in venous disease and continue to better understand the venous disease population. Our versatility in open and endovenous surgical management provides our specialty the skillset to care for venous disease when compared to other specialties. 

Another important and complex layer involved in this perception of venous and arterial work differing in value is gender bias and disparity. There is a significant lack of literature in venous disease compared to arterial disease regarding healthcare disparities. 

Racial/ethnic, gender and socioeconomic disparities impact venous disease similarly to arterial disease, driving how we approach our patients’ care. Chronic venous insufficiency can involve a difficult disease pattern superimposed with various risk factors that vascular surgeons must navigate in a similar way as they do with arterial diseases. 

It cannot go unsaid that vascular surgery is a male-dominated specialization and that, interestingly enough, the perception that venous diseases are of less importance stemmed mainly from younger female respondents. It is difficult to disseminate clearly why this may be the case, but the survey data suggest that this disparity in perception paves the way for a key new body of research. An in-depth analysis of existing and potentially inherent gender-based values as drivers for framing systemic perceptions in vascular surgery could be a valuable step in reducing gender bias within the field. 

Above all, the scarce exposure of trainees to the array of levels of venous interventions that exist seems to have driven and deeply embedded this perception that venous work is less of a challenge, and, in turn, of less interest to vascular specialists. As vascular surgery residents and fellows have reported feeling deficient in venous training, this is logically a root cause in the lack of value it has been historically attributed. 

One could argue it is ironic, as venous diseases pathologies are often complex, even more so than arterial ones, yet lack of attention to this nature during training is a recurring theme. A shift in this perception, however, is necessary. Potential avenues for improving such a deficit could include various mandates with regard to trainee exposure to venous pathologies and interventions, as well as the inclusion of continuing education initiatives, similar to that of advanced aortic training and formal limb salvage. Addressing and reducing the gender bias in existing perceptions may also pave the way for a more equitable view of both venous and arterial work. 

References 

1. Kiguchi MM, Drudi LM, Jazaeri O, Smeds MR, Aulivola B, MacCallum K, et al. Exploring the perception of venous disease within vascular surgery. JVS: Venous and Lymphatic Disorders. 2023:11(5);1063–1069. 
2. Kim, Young, et al. Defining the human and healthcare costs of chronic venous insufficiency. Seminars in Vascular Surgery. Vol. 34, no. 1, Mar. 2021, pp. 59–64. DOI.org (Crossref), https://doi.org/10.1053/j.semvascsurg.2021.02.007. 
3. Gabel, Josh, et al. Who is treating venous disease in America today? Journal of Vascular Surgery: Venous and Lymphatic Disorders. Vol. 7, no. 4, July 2019, pp. 610–14. DOI.org (Crossref), https://doi.org/10.1016/j.jvsv.2019.03.009. 
4. O’Banion, Leigh Ann, et al. A review of the current literature of ethnic, gender and socioeconomic disparities in venous disease. Journal of Vascular Surgery: Venous and Lymphatic Disorders. Vol. 11, no. 4, July 2023, pp. 682–87. DOI.org (Crossref), https://doi.org/10.1016/j.jvsv.2023.03.006. 

Sarah Wells is a clinical research assistant at Centre Hospitalier de l’Université de Montréal (CHUM) in Montreal, Canada; Eric Pillado is an integrated vascular surgery resident at Northwestern Medicine in Chicago; and Laura Marie Drudi is an assistant professor of surgery at CHUM.