Varicose vein surgery: stripping versus the CHIVA method: a randomized controlled trial. Ann Surg. 2010;251:624-631. [PMID: 20224376 DOI: 10.1097/sla.0b013e3181d0d0a3]

CHIVA for dummies

BACKGROUND

Sparing the Great Saphenous Vein capital for possible arterial substitution and recurrence decrease may be an alternative to current ablation options for Varicose Veins treatment. Conservative surgery of varicose veins (CHIVA) was suggested in 1988 by Franceschi, by limited veins interruptions in strategic points. However, the method did not diffuse due to the need for high Duplex expertise to determine the procedure in every single patient.

METHOD

Evaluation of the literature regarding saphenous sparing, with special reference to CHIVA.

RESULT

It has been realized that basic Ultrasound expertise is sufficient for performing GSV conservation. Most of the time, only a few parameters are needed: a junction competence assessment and a re-entry perforator position.

CONCLUSION

For achieving the goal of saphenous conservative treatment, a limited phlebectomy and possible Junction interruption (crossotomy) may be a simplified solution.

Comparison between radiofrequency ablation and CHIVA procedure in patients with varicose veins

OBJECTIVE

Conservatrice et Hémodynamique de l'Insuffisance Veineuse en Ambulatoire, the French acronym for CHIVA, is a strategy aimed to convert a venous reflux into a physiological drainage. We compared CHIVA with radiofrequency ablation and determined its possible advantages.

METHODS

We retrospectively analyzed the clinical recurrence, ultrasound recurrence, quality of life scores, and complications. They were compared after propensity score matching.

RESULTS

212 limbs of 166 patients were included: 42 limbs underwent radiofrequency ablation and 170 limbs underwent CHIVA. The hospital stay was shorter in the CHIVA group. There was no difference in clinical, ultrasound recurrence, quality of life scores and complications between the two groups. The preoperative saphenous vein diameter was larger in the recurrence cases.

CONCLUSIONS

CHIVA showed comparable results to radiofrequency ablation. There was more ultrasound recurrence with larger vein diameters. The CHIVA appears to be a simple and more efficient treatment method when performed on select patients.

Assessment of the CHIVA and the ASVAL Method

In this article, the CHIVA and ASVAL methods are assessed from the hemodynamic point of view. The CHIVA method comprises complicated, unusual terminology and new perceptions, such as closed and open shunts, fractionation of the hydrostatic pressure, subdivision of the venous network. The principal part of the CHIVA theory is the drainage of venous blood from the thigh saphenous system into the deep lower leg veins through the preserved saphenous trunk after high ligation at the saphenofemoral junction, which is considered as a beneficial, physiological phenomenon. In reality, this is recurrent reflux producing ambulatory venous hypertension. The main impact of the CHIVA procedure is the elimination of the saphenous reflux by high ligation at the saphenofemoral junction; thus it can be presumed that the CHIVA procedure yields similar results like the crossectomy. The ASVAL procedure is de facto the modification of the old Madelung method that was the prevalent surgical procedure before the Trendelenburg era in the 19th century. The results after ASVAL were not checked by plethysmography; there is a good case to suppose that the results after the ASVAL method would comply with those after sclerotherapy.

Treatment of chronic venous disorder: A comprehensive review

Chronic venous disorder (CVD) is highly prevalent vascular disorder affecting up to 45% of the general population, with clinical manifestations ranging from teleangiectasias to venous leg ulcers (VLUs). We examined the currently available data in order to provide an updated, comprehensive review on treatment options of CVD. We searched MEDLINE, Cochrane, Scopus, EMBASE, ClinicalTrials, and OpenGrey databases for relevant articles in English published until November 2020. Compression treatment is the mainstay of conservative treatment. Pharmacological treatment can provide significant symptomatic relief and hence it should be considered as part of conservative treatment. Transcutaneous Lacer treatment (TCL) is a safe and effective alternative option to sclerotherapy for treatment of C1 stage. High ligation and stripping (HL/S), ultrasound-guided foam sclerotherapy (UGFS), endovenous thermal ablation (EVTA) systems and non thermal non tumescent ablation (NTNT) systems are safe and efficacious first-line options for treatment of saphenous insufficiency. Interventional treatment of co-existing incompetent perforator veins (IPVs) is not supported by contemporary evidence. Regarding deep venous insufficiency (DVI), treatment of symptomatic femoroiliocaval occlusive venous disease refractory to conservative treatment with percutaneous transluminal venoplasty stenting has produced encouraging results.

CHIVA method for the treatment of chronic venous insufficiency

BACKGROUND

Many surgical approaches are available to treat varicose veins secondary to chronic venous insufficiency. One of the least invasive techniques is the ambulatory conservative hemodynamic correction of venous insufficiency method (in French 'cure conservatrice et hémodynamique de l'insuffisance veineuse en ambulatoire' (CHIVA)), an approach based on venous hemodynamics with deliberate preservation of the superficial venous system. This is the second update of the review first published in 2013.

OBJECTIVES

To compare the efficacy and safety of the CHIVA method with alternative therapeutic techniques to treat varicose veins.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, AMED, and the World Health Organisation International Clinical Trials Registry Platform and ClinicalTrials.gov trials registries to 19 October 2020. We also searched PUBMED to 19 October 2020 and checked the references of relevant articles to identify additional studies.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that compared CHIVA to other therapeutic techniques to treat varicose veins.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed and selected studies, extracted data, and performed quantitative analysis from the selected papers. A third author solved any disagreements. We assessed the risk of bias in included trials with the Cochrane risk of bias tool. We calculated the risk ratio (RR), mean difference (MD), number of people needed to treat for an additional beneficial outcome (NNTB), and the number of people needed to treat for an additional harmful outcome (NNTH), with 95% confidence intervals (CI). We evaluated the certainty of the evidence using GRADE. The main outcomes of interest were the recurrence of varicose veins and side effects.

MAIN RESULTS

For this update, we identified two new additional studies. In total, we included six RCTs with 1160 participants (62% women) and collected from them eight comparisons. Three RCTs compared CHIVA with vein stripping. One RCT compared CHIVA with compression dressings in people with venous ulcers. The new studies included three comparisons, one compared CHIVA with vein stripping and radiofrequency ablation (RFA), and one compared CHIVA with vein stripping and endovenous laser therapy. We judged the certainty of the evidence for our outcomes as low to very low due to inconsistency, imprecision caused by the low number of events and risk of bias. The overall risk of bias across studies was high because neither participants nor personnel were blinded to the interventions. Two studies attempted to blind outcome assessors, but the characteristics of the surgery limited concealment. Five studies reported the outcome clinical recurrence of varicose veins with a follow-up of 18 months to 10 years. CHIVA may make little or no difference to the recurrence of varicose veins in the lower limb compared to stripping (RR 0.74, 95% CI 0.46 to 1.20; 5 studies, 966 participants; low-certainty evidence). We are uncertain whether CHIVA reduced recurrence compared to compression dressing (RR 0.23, 95% CI 0.06 to 0.96; 1 study, 47 participants; very low-certainty evidence). CHIVA may make little or no difference to clinical recurrence compared to RFA (RR 2.02, 95% CI 0.74 to 5.53; 1 study, 146 participants; low-certainty evidence) and endovenous laser (RR 0.20, 95% CI 0.01 to 4.06; 1 study, 100 participants; low-certainty evidence). We found no clear difference between CHIVA and stripping for the side effects of limb infection (RR 0.83, 95% CI 0.33 to 2.10; 3 studies, 746 participants; low-certainty evidence), and superficial vein thrombosis (RR 1.05, 95% CI 0.51 to 2.17; 4 studies, 846 participants; low-certainty evidence). CHIVA may reduce slightly nerve injury (RR 0.14, 95% CI 0.02 to 0.98; NNTH 9, 95% CI 5 to 100; 4 studies, 846 participants; low-certainty evidence) and hematoma compared to stripping (RR 0.59, 95% CI 0.37 to 0.97; NNTH 11, 95% CI 5 to 100; 2 studies, 245 participants; low-certainty evidence). For bruising, one study found no differences between groups while another study found reduced rates of bruising in the CHIVA group compared to the stripping group. Compared to RFA, CHIVA may make little or no difference to rates of limb infection, superficial vein thrombosis, nerve injury or hematoma, but may cause more bruising (RR 1.15, 95% CI 1.04 to 1.28; NNTH 8, CI 95% 5 to 25; 1 study, 144 participants; low-certainty evidence). Compared to endovenous laser, CHIVA may make little or no difference to rates of limb infection, superficial vein thrombosis, nerve injury or hematoma. The study comparing CHIVA versus compression did not report side effects.

AUTHORS' CONCLUSIONS

There may be little or no difference in the recurrence of varicose veins when comparing CHIVA to stripping (low-certainty evidence), but CHIVA may slightly reduce nerve injury and hematoma in the lower limb (low-certainty evidence). Very limited evidence means we are uncertain of any differences in recurrence when comparing CHIVA with compression (very low-certainty evidence). CHIVA may make little or no difference to recurrence compared to RFA (low-certainty evidence), but may result in more bruising (low-certainty evidence). CHIVA may make little or no difference to recurrence and side effects compared to endovenous laser therapy (low-certainty evidence). However, we based these conclusions on a small number of trials with a high risk of bias as the effects of surgery could not be concealed, and the results were imprecise due to the low number of events. New RCTs are needed to confirm these results and to compare CHIVA with approaches other than open surgery.

Outcomes of Saphenous Vein Intervention in the Management of Superficial Venous Incompetence: A Systematic Review and Network Meta-Analysis

OBJECTIVE

To determine the most effective modality of intervention to treat saphenous vein insufficiency.

SUMMARY BACKGROUND DATA

Endovenous therapies have instigated a paradigm shift in the management of superficial venous incompetence (SVI). When compared with open surgery, endovenous interventions (foam sclerotherapy (FS), radiofrequency ablation (RFA), endovenous laser ablation (EVLA), mechanochemical ablation (MOCA), and cyanoacrylate glue (CAE) closure) potentially offer reduced morbidity with similar procedural efficacy.

METHODS

A systematic review and series of network meta-analyses of randomized controlled trials (RCTs) were performed assessing risks of procedural failure (within 6-weeks) and recurrence (6-weeks to 5-years), defined by ultrasound, between the different SVI modalities. Treatment comparisons addressing risks of common adverse events, Venous Clinical Severity Score (VCSS) and pain were also performed.

RESULTS

A systematic search identified 51 articles, describing 36 RCTs, incorporating 7,576 limbs. Outcome data on ten modalities of intervention were analyzed up to five-year follow-up. CAE resulted in the lowest risk of procedural failure within six-weeks. Foam sclerotherapy had the highest risk of recurrence while high ligation with stripping (HLS) and CHIVA were ranked best to reduce long-term recurrence. No intervention increased risks of venous thromboembolism and there was minimal difference in morbidity between treatments. All interventions improved VCSS (Range -1.02 to -4.95), however RFA demonstrated the greatest improvement, followed by EVLA and HLS between two to five-years. EVLA was associated with the highest risk of pain, while MOCA offered the least.

CONCLUSION

While CAE offered the lowest risk of initial procedural failure, HLS resulted in lower rates of long-term recurrence without considerably increasing morbidity when compared with other endovenous options.

Management of Lower Extremity Pain from Chronic Venous Insufficiency: A Comprehensive Review

PURPOSE OF REVIEW

Chronic venous insufficiency is found to some extent in a large proportion of the world's population, especially in the elderly and obese. Despite its prevalence, little research has been pursued into this pathology when compared to similarly common conditions. Pain is often the presenting symptom of chronic venous insufficiency and has significant deleterious effects on quality of life. This manuscript will describe the development of pain in chronic venous insufficiency, and will also review both traditional methods of pain management and novel advances in both medical and surgical therapy for this disease.

RECENT FINDINGS

Pain in chronic venous insufficiency is a common complication which remains poorly correlated in recent studies with the clinically observable extent of disease. Although lifestyle modification remains the foundation of treatment for pain associated with chronic venous sufficiency, compression devices and various pharmacologic agents have emerged as safe and effective treatments for pain in these patients. In patients for whom these measures are insufficient, recently developed minimally invasive vascular surgical techniques have been shown to reduce postsurgical complications and recovery time, although additional research is necessary to characterize long-term outcomes of these procedures. This review discusses the latest findings concerning the pathophysiology of pain in chronic venous insufficiency, conservative and medical management, and surgical strategies for pain relief, including minimally invasive treatment strategies.

Segmental saphenous ablation for chronic venous disease treatment

BACKGROUND

Endovenous thermal ablation for chronic venous disease treatment is recommended over traditional surgery. The present investigation compares endovenous laser ablation (EVLA) with radiofrequency (RF) for segmental endovenous sapheno-femoral junction ablation.

METHODS

This is a retrospective study in which 79 patients underwent a 6 cm great saphenous vein ablation by RF or by EVLA.Primary outcome was occlusion rate. Secondary outcomes included Venous Clinical Severity Score (VCSS), Aberdeen Varicose Vein Questionnaire (AVVQ) score, peri-procedural pain, aesthetic satisfaction.

RESULTS

At 12 ± 1 months recanalization of shrunk tract was recorded in 5/85 (5.8%) cases (2 RF, 3 EVLA) [OR: 1.6; 95%CI: 0.2-10.4; P = 0.6689]. Two cases (1/44 RF group and 1/38 EVLA group) also showed reflux recurrence [OR: 1.0; 95%CI: 0.06-17.8; P = 1.0000]. No significant differences between groups were found in AVVQ, VCSS, peri-procedural pain, or aesthetic satisfaction.

CONCLUSION

Saphenous sparing is feasible and effective by means of both EVLA and RF, representing a possible alternative to surgery.

A randomized controlled noninferiority trial comparing radiofrequency with stripping and conservative hemodynamic cure for venous insufficiency technique for insufficiency of the great saphenous vein

OBJECTIVE

The quality of available evidence regarding new minimally invasive techniques to abolish great saphenous vein reflux is moderate. The present study assessed whether radiofrequency ablation (RFA) was noninferior to high ligation and stripping (HLS) and conservative hemodynamic cure for venous insufficiency (CHIVA) for clinical and ultrasound recurrence at 2 years in patients with primary varicose veins (VVs) due to great saphenous vein (GSV) insufficiency.

METHODS

We performed a randomized, single-center, open-label, controlled, noninferiority trial to compare RFA and 2 surgical techniques for the treatment of primary VVs due to GSV insufficiency. The noninferiority margin was set at 15% for absolute differences. Patients aged >18 years with primary VVs and GSV incompetence, with or without clinical symptoms, C2 to C6 CEAP (Clinical, Etiologic, Anatomic, Pathophysiologic) clinical class, and GSV diameter >4 mm were randomized with a 1:1:1 ratio to RFA, HLS, or CHIVA. The rate of clinical recurrence at 24 months was the primary endpoint and was analyzed using a delta noninferiority margin of 15%. Ultrasound recurrence, safety, and quality of life were secondary endpoints.

RESULTS

From December 2012 to June 2015, 225 limbs had been randomized to RFA, HLS, or CHIVA (n = 74, n = 75, and n = 76). Clinical follow-up and Doppler ultrasound examinations were performed at 1 week and 1, 6, 12, and 24 months postoperatively. No differences in postoperative complications or pain were observed among the three groups. RFA was noninferior to HLS and CHIVA for clinical recurrence at 24 months, with an estimated difference in recurrence of 3% (95% confidence interval [CI], -4.8% to 10.7%; noninferiority P = .002) and -7% (95% CI, -17% to 3%; P < .001), respectively. For ultrasound recurrence, RFA was noninferior to CHIVA, with an estimated difference of -34% (95% CI, -47% to -20%; noninferiority P < .001) at 24 months. However, noninferiority could not be demonstrated compared with HLS (5.9%; 95% CI, -4.1 to 15.9; P = .073). No differences were found in quality of life among the three groups.

CONCLUSIONS

RFA was shown to be noninferior in terms of clinical recurrence to HLS and CHIVA in the treatment of VVs due to GSV insufficiency.

The 2020 appropriate use criteria for chronic lower extremity venous disease of the American Venous Forum, the Society for Vascular Surgery, the American Vein and Lymphatic Society, and the Society of Interventional Radiology

BACKGROUND

Stimulated by published reports of potentially inappropriate application of venous procedures, the American Venous Forum and its Ethics Task Force in collaboration with multiple other professional societies including the Society for Vascular Surgery (SVS), American Vein and Lymphatic Society (AVLS), and the Society of Interventional Radiology (SIR) developed the appropriate use criteria (AUC) for chronic lower extremity venous disease to provide clarity to the application of venous procedures, duplex ultrasound imaging, timing, and reimbursements.

METHODS

The AUC were developed using the RAND/UCLA Appropriateness Method, a validated method of developing appropriateness criteria in health care. By conducting a modified Delphi exercise and incorporating best available evidence and expert opinion, AUC were developed and scored.

RESULTS

There were 119 scenarios rated on a scale of 1 to 9 by an expert panel, with 1 being never appropriate and 9 being appropriate. The majority of scenarios consisted of symptomatic indications were deemed appropriate for venous intervention. For scenarios with anatomically short segments of reflux and/or no symptoms, the indications were rated less appropriate. For the indication of edema, a wide dispersion of ratings was observed especially for short segments of saphenous reflux or stenting for iliac/ inferior vena cava disease, noting that there are multifactorial causes of edema, some of which could coexist with venous disease and possibly impact effectiveness of treatment. Several scenarios were considered never appropriate, including treatment of saphenous veins with no reflux, iliac vein or inferior vena cava stenting for iliac vein compression as an incidental finding by imaging with minimal or no symptoms or signs, and incentivizing sonographers to find reflux.

CONCLUSIONS

The AUC statements are intended to serve as a guide to patient care, particularly in areas where high-quality evidence is lacking to aid clinicians in making day-to-day decisions for common venous interventions. This may also prove useful when applied on a population level, such as practice patterns, and not necessarily to dictate decision making for individual cases. As a product of a collaborative effort, it is hoped that this could be utilized by physicians and multiple stakeholders committed toward improving patient care and to identify and stimulate future research priorities.

Association between venous reflux and diameter of great saphenous vein in lower thigh

OBJECTIVE

Venous reflux may occur in all parts of the great saphenous vein (GSV). The GSV diameter generally increases when venous reflux occurs, and the extent of venous dilation may be altered on the basis of size and location of the reflux within the GSV. We examined which part of the GSV is the most sensitive and dilated in association with venous reflux.

METHODS

We retrospectively evaluated the data of 99 patients (198 limbs) with signs and symptoms of venous insufficiency of both lower limbs from January 2016 to December 2016. We performed ultrasound to examine the venous reflux and to measure the diameter of the GSV. The GSV was divided into four locations: saphenofemoral junction, midthigh, lower thigh (LT), and below the knee. The patients were divided into two groups according to the presence or absence of reflux.

RESULTS

There were 87 limbs that had venous reflux and 111 limbs that had no reflux. The diameter of the GSV with reflux was significantly larger than that of GSVs without reflux only at the LT (4.7 mm vs 4.2 mm; P < .001), and the highest area under the receiver operating characteristic curve was 0.642 at the LT. The cutoff value of the LT diameter for association with reflux was 5 mm (P = .025).

CONCLUSIONS

The cutoff diameter of the LT was 5 mm. We recommend treatment of symptomatic reflux, and LT diameter may be useful for follow-up before and after treatment.

CHIVA to spare the small and great saphenous veins after wrong-site surgery on a normal saphenous vein: a case report

CHIVA (Cure Conservatrice et Hemodynamique de l’Insufficience Veineuse en Ambulatoire) is a type of operation for varicose veins that avoids destroying the saphenous vein and collaterals. We report a case of CHIVA treatment of two saphenous veins to spare these veins. The patient previously had a normal great saphenous vein stripped in error in a wrong-site surgery, while two saphenous veins that did have reflux were not operated. The patient was symptomatic and we performed a CHIVA operation on the left great and right small saphenous veins. The postoperative period was uneventful and both aesthetic and clinical results were satisfactory. This case illustrates that saphenous-sparing procedures can play an important role in treatment of chronic venous insufficiency. Additionally, most safe surgery protocols do not adequately cover varicose veins operations. Routine use of duplex scanning by the surgical team could prevent problems related to the operation site.

Ultrasound-based topographic analysis of tributary vein connection with the saphenous vein during ambulatory conservative hemodynamic correction of chronic venous insufficiency

OBJECTIVE

Preoperative mapping of great saphenous vein (GSV) escape points to tributary veins (TVs) and targeted intervention of escape points may reduce recurrence rates of varicose veins (VVs) after endovascular treatment of saphenous veins and prevent saphenous nerve complications. The aim of this study was to perform an analysis of cartography after Doppler ultrasound mapping of escape points in patients with VVs and to suggest one point that may prevent recurrence and nerve complications.

METHODS

Ultrasound assessment of VVs was performed from March 4, 2016, to July 15, 2016, specifically focusing on the locations of escape points from the saphenous vein to TVs. The collected data were reviewed retrospectively. The topographic distribution of escape points was as follows: from inguinal ligament to midthigh; from midthigh to knee; from knee to midcalf; and from midcalf to heel.

RESULTS

Thirty patients (41 legs) with VVs underwent ultrasound examination. All VVs were characterized by reflux at the GSV. Topographic analysis revealed a total of 79 escape points in all patients. The most common location for escape points was the third part of the leg (from knee to midcalf), where 65.8% of escape points were located; 82.3% of all escape points were located below the knee. The mean diameter of the GSV at 3 cm and 15 cm from the saphenofemoral junction was 6.8 ± 1.6 cm and 5.5 ± 1.5 cm, respectively. Mean diameter of TVs was 5.1 ± 1.9 cm. The diameter was not significantly different between saphenous veins and TVs. The mean number of escape points in each leg was 1.9 ± 1.0.

CONCLUSIONS

Most escape points (65.8%) are located from knee to midcalf (third part of the leg), and 82.3% of all escape points are located below the knee. The diameter of TVs near the escape point is about 90% of that of the GSV. Thermal ablations of below-knee saphenous vein have potential nerve damage. Ablation of saphenous veins above the knee alone may result in residual shunting and formation of persistent reservoirs in TVs. These persistent reservoirs may be removed effectively with sclerotherapy or miniphlebectomy, especially trying to remove TVs near the escape point. Direct ligation of a TV near the escape point from the saphenous vein, just like saphenofemoral junction ligation, could be performed. These approaches may be able to prevent residual shunting and may reduce recurrence rates and nerve injury.

CHIVA to treat saphenous vein insufficiency in chronic venous disease: characteristics and results

There is considerable debate in the literature with relation to the best method to treat patients with chronic venous disease (CVD). CHIVA is an office-based treatment for varicose veins performed under local anesthesia. The aim of the technique is to lower transmural pressure in the superficial venous system and avoid destruction of veins. Recurrence of varicosities, nerve damage, bruising and suboptimal aesthetic results are common to all treatments for the disease. This paper evaluates and discusses the characteristics and results of the CHIVA technique. We conclude that CHIVA is a viable alternative to common procedures that is associated with less bruising, nerve damage, and recurrence than stripping saphenectomy. The main advantages are preservation of the saphenous vein, local anesthesia, low recurrence rates, low cost, low pain, and no nerve damage. The major disadvantages are the learning curve and the need to train the team in venous hemodynamics.

Kaliberreduktion der V. saphena magna und der V. femoralis nach CHIVA

Einleitung: Die Durchmesser der V. saphena magna (VSM) und der V. femoralis communis (VFC) gelten als Hinweis auf den Schwere-grad der Venenerkrankung. Eine Kaliberreduktion 8 Wochen nach Operation nach CHIVA wurde bereits belegt (3), offen blieb die Langzeitwirkung.

Methode: Bei 43 Patienten wurde 5 Jahre nach einem Eingriff nach CHIVA an den Stammvenen der Durchmesser der VSM und der VFC, das C(CEAP) und die Wiederauffüllzeit im Vergleich zum präoperativen Wert erfasst.

Ergebnis: 43 Patienten (Durchschnittsalter 52,7 Jahre) stellten sich im Mittel 5,36 Jahre nach Operation nach CHIVA vor. Der Durchmesser der VFC verringerte sich von präoperativ 15,39 ± 2,93 mm über 15,11 ± 2,73 mm nach 8 Wochen auf 14,18 ± 2,56 mm (p<0,05), bei Behandlung der VSM verringerte sich der Durchmesser der VFC von 16,07 ± 2,65 mm über 15,29 ± 2,41 mm nach 8 Wochen auf 14,30 ± 2,81 mm (p<0,001). Der Durchmesser der VSM verringerte sich von präoperativ 7,13 ± 2,05 mm über 4,98 ± 1,49 mm nach 8 Wochen auf 4,38 ± 1,44 mm nach 5 Jahren (p<0,001). Das C reduzierte sich von präoperativ 2,77 ± 0,81 mm über 1,51 ± 1,19 mm nach 8 Wochen auf 1,72 ± 1,10 mm nach 5 Jahren (p = 0,007). Die Wiederauffüllzeit verlängert sich von präop. 15,24 ± 6,18 ± s über 17,9 ± 6,47 s nach 8 Wochen auf 21,61 ± 9,2 s nach 5 Jahren (p = 0,022).

Fazit: Auch in der Langzeitstudie nach CHIVA konnte keine Belastung der tiefen Beinvenen nachgewiesen werden.

The importance of great saphenous vein types and segmental aplasia in venous reflux

PURPOSE

To investigate the relationship among great saphenous vein (GSV) anatomic type, segmental aplasia, and reflux.

METHODS

Color Doppler ultrasonography (CDUS) was performed on 475 legs of 277 consecutive patients with venous symptoms between November 2015 and August 2016. Exclusion criteria were previous venous surgery and venous thrombosis. Five GSV types were identified based on the saphenous compartment at thigh level, and segment aplasia and reflux were investigated.

RESULTS

The most frequent GSV type was type A, ie, a single GSV extending within the saphenous compartment with no accompanying large parallel tributary (53%), and the least frequent type was type B, GSV duplication (1.3%). Patients with and without reflux showed similar distributions of GSV type (p = 0.389). Segmental aplasia was observed in 117 (24.63%) of 475 legs. The mean age of patients with GSV reflux was compared between patients with and without aplasia (p = 0.798).

CONCLUSIONS

The frequency of venous reflux was nearly identical across GSV types. The frequency of segmental aplasia was similar in patients with and without reflux. Despite these similarities, defining GSV type and identifying segmental aplasia can provide guidance for treatment. In particular, type D GSVs, defined by the presence of an anterior accessory branch, should be investigated when performing CDUS. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:332-336, 2017.

CHIVA - A prospective study of a vein sparing technique for the management of varicose vein disease

BACKGROUND

Varicose vein disease (VVD) affects approximately one third of adults. Cure Conservatrice et Hémodynamique de l'Insuffisance Veineuse en Ambulatoire (CHIVA) is a minimally invasive, vein sparing technique that is emerging as an alternative to ablative techniques for treating VVD.

METHODS

This prospective study assessed the rate of recurrence of venous reflux with CHIVA. We evaluated 150 primary procedures with clinical and duplex ultrasound examinations pre and post operatively. Patients were followed at <3 months and >1-year post-op. Recurrence was defined as reflux in the diseased vessel at the saphenofemoral junction on duplex examination.

RESULTS

There was no documented recurrence at the early follow up. To date, 58 legs have completed the late follow up and reflux was found in 5 legs resulting in a recurrence rate of 8.6%; 95% CI (2.4%, 19%).

CONCLUSION

Our results indicate that CHIVA appears to offer a promising alternative for the treatment of VVD.

Varicose Remodeling of Veins Is Suppressed by 3-Hydroxy-3-Methylglutaryl Coenzyme A Reductase Inhibitors

BACKGROUND

Despite the high prevalence of chronic venous insufficiency and varicose veins in the Western world, suitable pharmaceutical therapies for these venous diseases have not been explored to date. In this context, we recently reported that a chronic increase in venous wall stress or biomechanical stretch is sufficient to cause development of varicose veins through the activation of the transcription factor activator protein 1.

METHODS AND RESULTS

We investigated whether deleterious venous remodeling is suppressed by the pleiotropic effects of statins. In vitro, activator protein 1 activity was inhibited by two 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, rosuvastatin and atorvastatin, in stretch-stimulated human venous smooth muscle cells. Correspondingly, both statins inhibited venous smooth muscle cell proliferation as well as mRNA expression of the activator protein 1 target gene monocyte chemotactic protein 1 (MCP1). In isolated mouse veins exposed to an increased level of intraluminal pressure, statin treatment diminished proliferation of venous smooth muscle cells and protein abundance of MCP1 while suppressing the development of varicose veins in a corresponding animal model by almost 80%. Further analyses of human varicose vein samples from patients chronically treated with statins indicated a decrease in venous smooth muscle cell proliferation and MCP1 abundance compared with samples from untreated patients.

CONCLUSIONS

Our findings imply that both atorvastatin and rosuvastatin effectively inhibit the development of varicose veins, at least partially, by interfering with wall stress-mediated activator protein 1 activity in venous smooth muscle cells. For the first time, this study reveals a potential pharmacological treatment option that may be suitable to prevent growth of varicose veins and to limit formation of recurrence after varicose vein surgery.

CHIVA method for the treatment of chronic venous insufficiency

BACKGROUND

Many surgical approaches are available to treat varicose veins secondary to chronic venous insufficiency. One of the least invasive techniques is the ambulatory conservative hemodynamic correction of venous insufficiency method (cure conservatrice et hémodynamique de l'insuffisance veineuse en ambulatoire (CHIVA)), an approach based on venous hemodynamics with deliberate preservation of the superficial venous system. This is an update of the review first published in 2013.

OBJECTIVES

To compare the efficacy and safety of the CHIVA method with alternative therapeutic techniques to treat varicose veins.

SEARCH METHODS

The Trials Search Co-ordinator of the Cochrane Peripheral Vascular Diseases Group searched the Specialised Register (April 2015), the Cochrane Register of Studies (2015, Issue 3) and clinical trials databases. The review authors searched PubMed (April 2015). There was no language restriction. We contacted study authors to obtain more information when necessary.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that compared the CHIVA method versus any other treatments. Two review authors independently selected and evaluated the studies. One review author extracted data and performed the quantitative analysis.

DATA COLLECTION AND ANALYSIS

Two independent review authors extracted data from the selected papers. We calculated the risk ratio (RR), mean difference (MD), the number of people needed to treat for an additional beneficial outcome (NNTB), and the number of people needed to treat for an additional harmful outcome (NNTH), with 95% confidence intervals (CI) using Review Manager 5.

MAIN RESULTS

No new studies were identified for this update. We included four RCTs with 796 participants (70.5% women). Three RCTs compared the CHIVA method with vein stripping, and one RCT compared the CHIVA method with compression dressings in people with venous ulcers. We judged the quality of the evidence of the included studies as low to moderate due to imprecision caused by the low number of events and because the studies were open. The overall risk of bias across studies was high because neither participants nor outcome assessors were blinded to the interventions. The primary endpoint, clinical recurrence, pooled between studies over a follow-up of 3 to 10 years, showed more favorable results for the CHIVA method than for vein stripping (721 people; RR 0.63; 95% CI 0.51 to 0.78; I(2) = 0%, NNTB 6; 95% CI 4 to 10) or compression dressings (47 people; RR 0.23; 95% CI 0.06 to 0.96; NNTB 3; 95% CI 2 to 17). Only one study reported data on quality of life (presented graphically) and these results significantly favored the CHIVA method.The vein stripping group had a higher risk of side effects than the CHIVA group; specifically, the RR for bruising was 0.63 (95% CI 0.53 to 0.76; NNTH 4; 95% CI 3 to 6) and the RR for nerve damage was 0.05 (95% CI 0.01 to 0.38; I(2) = 0%; NNTH 12; 95% CI 9 to 20). There were no statistically significant differences between groups regarding the incidence of limb infection and superficial vein thrombosis.

AUTHORS' CONCLUSIONS

The CHIVA method reduces recurrence of varicose veins and produces fewer side effects than vein stripping. However, we based these conclusions on a small number of trials with a high risk of bias as the effects of surgery could not be concealed and the results were imprecise due to low number of events. New RCTs are needed to confirm these results and to compare CHIVA with approaches other than open surgery.

Divided saphenectomy for varicose vein in ambulatory surgery

We performed divided saphenectomy (DS) for varicose vein in ambulatory surgery with minimal incisions. Under tumescent local anesthesia, this procedure ligates all perforators in the thigh, preserving a route of venous drainage, and reduces bruising by ligating all tributaries. Also, DS does not need any special surgical instrument. Subcutaneous inguinal hemorrhage was observed in 4.9% (3/61), mild bruises were observed in 19.7% (12/61), and saphenous nerve neuralgia was 1.6% (1/61). Wound infection, deep venous thrombosis, and edema were not observed. DS is a minimally invasive, simple, and cost-effective procedure.

CHIVA strategy in chronic venous disease treatment: instructions for users

Along the years, scientific clinical data have been collected concerning the possible saphenous flow restoration without any ablation and according with the CHIVA strategy. Moreover, in 2013 a Cochrane review highlighted the smaller recurrence risk following a CHIVA strategy rather than a saphenous stripping. Nevertheless, the saphenous sparing strategy surely remains a not-so-worldwide-spread and accepted therapeutic option, also because considered not so immediate and easy to perform. Aim of this paper is to provide an easily accessible guide to an everyday use of a saphenous sparing strategy for chronic venous disease, highlighting how even apparently too complicated reflux patterns classifications can be fastly and successfully managed and exploited for a hemodynamic correction.

Modulation of circulating cytokine-chemokine profile in patients affected by chronic venous insufficiency undergoing surgical hemodynamic correction

The expression of proinflammatory cytokines/chemokines has been reported in in vitro/ex vivo settings of chronic venous insufficiency (CVI), but the identification of circulating mediators that might be associated with altered hemodynamic forces or might represent innovative biomarkers is still missing. In this study, the circulating levels of 31 cytokines/chemokines involved in inflammatory/angiogenic processes were analysed in (i) CVI patients at baseline before surgical hemody namic correction, (ii) healthy subjects, and (iii) CVI patients after surgery. In a subgroup of CVI patients, in whom the baseline levels of cytokines/chemokines were analyzed in paired blood samples obtained from varicose vein and forearm vein, EGF, PDGF, and RANTES were increased at the varicose vein site as compared to the general circulation. Moreover, while at baseline, CVI patients showed increased levels of 14 cytokines/chemokines as compared to healthy subjects, 6 months after surgery, 11 cytokines/chemokines levels were significantly reduced in the treated CVI patients as compared to the CVI patients before surgery. Of note, a patient who exhibited recurrence of the disease 6 months after surgery, showed higher levels of EGF, PDGF, and RANTES compared to nonrecurrent patients, highlighting the potential role of the EGF/PDGF/RANTES triad as sensitive biomarkers in the context of CVI.

The cutoff value of saphenous vein diameter to predict reflux

Purpose

Increased saphenous vein diameter is a common consequence of saphenous vein reflux. Until now, there have been no reports about the correlation between diameter and reflux of saphenous vein in Korea. The aim of this study was to investigate the correlation between saphenous vein reflux and diameter changes.

Methods

From April 2009 to August 2012, 777 patients were sent to the vascular laboratory for evaluation of venous reflux. The diameter of the saphenous vein was measured with B-mode imaging, and reflux was quantified based on valve closure time using Doppler spectral tracings. Receiver operating characteristics curve analysis was applied to determine the best saphenous vein diameter cutoff for predicting reflux.

Results

The mean diameters of normal great saphenous vein (GSV) and refluxed GSV were 5.0 ± 2.4 mm and 6.4 ± 2.0 mm, respectively. The mean diameters of normal small saphenous vein (SSV) and refluxed SSV were 3.1 ± 1.3 mm and 5.2 ± 2.7 mm, respectively. The diameter differences between the normal and refluxed GSV and SSV were 1.4 mm and 2.1 mm, respectively, and these differences were statistically significant (P < 0.0001). A GSV threshold diameter of 5.05 mm had the best positive predictive value for reflux. The sensitivity and specificity at 5.05 mm were 76% and 60%, respectively. The best SSV diameter for predicting reflux was 3.55 mm. The sensitivity and specificity at 3.55 mm were 87% and 71%, respectively.

Conclusion

GSV diameter of ≥5.05 mm had the best positive predictive value for pathologic reflux. For pathologic reflux of SSV, the best cutoff diameter was 3.55 mm.

CHIVA method for the treatment of chronic venous insufficiency

BACKGROUND

Many surgical approaches are available to treat varicose veins secondary to chronic venous insufficiency. One of the least invasive techniques is the ambulatory conservative hemodynamic correction of venous insufficiency method (cure conservatrice et hémodynamique de l'insuffisance veineuse en ambulatoire (CHIVA)), an approach based on venous hemodynamics with deliberate preservation of the superficial venous system.

OBJECTIVES

To compare the efficacy and safety of the CHIVA method with alternative therapeutic techniques to treat varicose veins.

SEARCH METHODS

The Trials Search Co-ordinator of the Cochrane Peripheral Vascular Diseases Group searched the Specialised Register (November 2012), CENTRAL (2012, Issue 10) and clinical trials databases. The review authors searched PubMed and EMBASE (December 2012). There was no language restriction. We contacted study authors to obtain more information when necessary.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that compared the CHIVA method versus any other treatments. Two review authors independently selected and evaluated the studies. One review author extracted data and performed the quantitative analysis.

DATA COLLECTION AND ANALYSIS

Two independent review authors extracted data from the selected papers. We calculated the risk ratio (RR), mean difference (MD), the number of people needed to treat for an additional beneficial outcome (NNTB), and the number of people needed to treat for an additional harmful outcome (NNTH), with 95% confidence intervals (CI) using Review Manager 5.

MAIN RESULTS

We included four RCTs with 796 participants (70.5% women) from the 434 publications identified by the search strategy. Three RCTs compared the CHIVA method with vein stripping, and one RCT compared the CHIVA method with compression dressings in people with venous ulcers. We judged the methodological quality of the included studies as low to moderate. The overall risk of bias across studies was high because neither participants nor outcome assessors were blinded to the interventions. The primary endpoint, clinical recurrence, pooled between studies over a follow-up of 3 to 10 years, showed more favorable results for the CHIVA method than for vein stripping (721 people; RR 0.63; 95% CI 0.51 to 0.78; I(2) = 0%, NNTB 6; 95% CI 4 to 10) or compression dressings (47 people; RR 0.23; 95% CI 0.06 to 0.96; NNTB 3; 95% CI 2 to 17). Only one study reported data on quality of life and these results presented graphically significantly favored the CHIVA method.The vein stripping group had a higher risk of side effects than the CHIVA group; specifically, the RR for bruising was 0.63 (95% CI 0.53 to 0.76; NNTH 4; 95% CI 3 to 6) and the RR for nerve damage was 0.05 (95% CI 0.01 to 0.38; I(2) = 0%; NNTH 12; 95% CI 9 to 20). There were no statistically significant differences between groups regarding the incidence of limb infection and superficial vein thrombosis.

AUTHORS' CONCLUSIONS

The CHIVA method reduces recurrence of varicose veins and produces fewer side effects than vein stripping. However, we based these conclusions on a small number of trials with a high risk of bias as the effects of surgery could not be concealed. New RCTs are needed to confirm these results and to compare CHIVA with approaches other than open surgery.

A rare case of acute compartment syndrome after saphenectomy

Saphenectomy is one of the most validated criteria to treat varicose veins of the lower legs. Although many complications were well described, little is known about compartment syndrome due to muscle ischemia caused by constrictive bandages applied after stripping of varicose veins. We presented a case of successful conservative treatment of compartment syndrome after saphenectomy. Rehabilitation was found effective in improving fatigue, stiffness and tenderness showing the effectiveness of the combined conservative-rehabilitative treatment. However conservative treatment could not be considered the treatment of choice in daily practice. A severity score assessment of compartment syndrome should be useful to assess to which patients is allowed to not perform fasciotomy.

Treatment of primary varicose veins has changed with the introduction of new techniques

New technologies have produced a revolution in primary varicose vein treatments. Duplex ultrasound is now used for preoperative diagnosis, postoperative surveillance, and during many procedures. Ultrasound has also altered our understanding of the pathophysiology of chronic venous disease. Laser and radiofrequency saphenous ablations are common. Classic techniques, such as sclerotherapy, high ligation, stripping, and phlebectomy, have been improved. Magnetic resonance venography, computed tomographic venography, and intravascular ultrasound have improved diagnostic capabilities. New strategies like ambulatory selective varices ablation under local anesthesia (ASVAL) and conservative hemodynamic treatment for chronic venous insufficiency (CHIVA) raise important questions about how to manage these patients.

Treatment Options, Clinical Outcome (Quality of Life) and Cost Benefit (Quality-adjusted Life Year) in Varicose Vein Treatment

Varicose veins are an extremely common condition causing morbidity; however, with current financial pressures, treatment of such benign diseases is controversial. Many procedures allow the treatment of varicose veins with minimal cost and extensive literature supporting differing approaches. Here we explore the underlying evidence base for treatment options, the effect on clinical outcome and the cost-benefit economics associated with varicose vein treatment. The method of defining clinical outcome with quality-of-life assessment tools is also investigated to explain concepts of treatment success beyond abolition of reflux.

Retrospective comparison of clinical outcomes between endovenous laser and saphenous vein-sparing surgery for treatment of varicose veins

BACKGROUND

The purpose of the present study was to compare management of varicose veins by endovenous laser ablation (EVL) and a vein-sparing procedure (CHIVA: Conservatrice et Hémodynamique de l'Insuffisance Veineuse en Ambulatoire) for management of varicose veins.

METHODS

Data from 82 consecutive patients with great saphenous vein (GSV) reflux and primary varicose veins presenting to the vascular clinic at the Far Eastern Memorial Hospital between June and December 2005 were reviewed. Of these, 74 who met the inclusion criteria were included in this study. CHIVA was performed by a double division of the refluxing saphenous vein (i.e., proximal and distal ligation), and EVL was performed using 10-14 W beginning approximately 4 cm below the saphenofemoral junction to the level of the knee. Phlebectomy for significant branch varicose veins on the leg was routinely performed in all patients. Outcome measures included postoperative thrombophlebitis, bruising, pain, assessment of ultrasonographic and clinical symptoms (measured by the Venous Clinical Severity Score [VCSS]) and comparison of quality of life survey scores obtained preoperatively and postoperatively (measured by the Aberdeen Varicose Veins Score [AVVQ] and RAND-36). Patients were examined one week post-procedurally and again at 1, 3, 6, and 12 months.

RESULTS

Endovenous laser ablation and CHIVA were performed on 54 and 20 patients, respectively. The EVL patients had significantly higher pain scores and bruising than the CHIVA group (p<0.001). The VCSS of varicose, edema, pigmentation, and inflammation were significantly reduced after both EVL and CHIVA; however, patients treated by EVL had significantly more pain postoperatively than those treated by CHIVA (p=0.003). Twenty-two of 54 (40.7%) and 3 of 17 (17.6%) patients in the EVL and CHIVA groups, respectively, required sclerotherapy for residual varicosities (p=0.026). Both groups benefited significantly from surgery in disease-specific perceptions.

CONCLUSIONS

The CHIVA patients had less pain postoperatively and a significantly higher sclerotherapy-free period compared to patients in the EVL group. Further follow-up studies to compare long-term results of various approaches to surgically managing varicose veins are needed.