aree scientifiche

ABSTRACT

CHIVA was introduced by Claude Franceschi in 1988. This technique is based on analysis of the venous circulation; a small number of ligatures follow, which cause a volume discharge of the superficial (and deep) veins. The aim is to reduce the circulating volume in these veins, sparing the saphenous trunks and their drainage through perforators. Prospective studies that include 695 patients with 3-year follow-up have been published. In the past 2 years, three prospective randomized studies of CHIVA versus stripping, with follow-ups of 5-10 years, have been done (750 legs) and have been partially published (250 legs). They are summarized and discussed in this article. Treatment costs were lower for CHIVA. Subjective and objective results were either significantly better or equal to stripping, and a lower rate of recurrence was found. In the 10-year follow-up, the recurrence rate was double in the stripping group. CHIVA has become widespread particularly in Spain, where half of the interventions on veins are done using this technique. In France and Italy, CHIVA is covered by health insurance.

2) D. KELLEHER, T R A Lane, I J Franklin and A H Davies : Treatment options, clinical outcome (quality of life) and cost benefit (quality-adjusted life year) in varicose vein treatment

Phlebology 2012;27 Suppl 1:16–22. 

Conventional surgery

Standard surgery for varicose veins was firstdescribed over 100 years ago, and is still considered the gold standard against which other treatment modalities are tested. The results of surgery are good and patients are generally satisfied. Surgery is associated with an improvement in QOL in most patients. However, there is a significant rate of minor complications. Rates of morbidity vary from series to series.

New techniques that have arisen interrupt the reflux haemodynamics while preserving the long saphenous vein and include the ASVAL and CHIVA techniques. These provide minimally invasive treatments performed under tumescent local anaesthesia, and have produced good results. One single-centre series has shown that while CHIVA offers improved recurrence rates compared with open stripping in experienced hands, it has a steep learning curve and can lead to worse

Conclusion

Varicose veins have a multitude of treatment options, all of which provide excellent improvements in QOL at a cost-effective level. Overall costs have fallen dramatically despite material requirements, and no patient should be without a treatment option. The treatment of varicose veins is one of the few treatments that offer low morbidity for large improvements in QOL. Importantly, despite the higher incidence of varicose veins in older patients, a high percentage of patients are of working age when health improvements are most cost-effective.

3) MENDOZA E.: Primum non nocere

Veins and Lymphatics, 2017, 6(2)

4) AGUS G.B.:  Thirty years of new venous hemodynamic concept and teaching 

Acta Phlebologica 2019 mese;20(0):000–000 

DOI: 10.23736/S1593-232X.20.00458-0 

Conclusion

Finally, thanks to hundreds of studies, some RCTs and a Cochrane review by various authors over Europe, CHIVA is today validated as more successful than destructive method and the more recent international meta-analysis concluded that CHIVA seemed to have superior clinical benefits on long-term efficacy comparing different therapeutic procedures for treating varicose veins.11-13  The efficacy of this approach was based on a better physiological process, and this revolutionary approach should be widely applied in clinics. However, the conclusion still needs additional trials for supporting evidence. 

5) FRANCESCHI C.: CHIVA 30 years later. Scientific and ethical considerations

Veins and Lymphatics, 2019 – pagepressjournals.org

6) CAMPBELL B. , Ian J Franklin3 and Manj Gohel4

Editorial: The choice of treatments for varicose veins: A study in trade-offs

Phlebology 0(0) 1–3 2020

CHIVA AND PELVIC LEAK POINTS

FRANCESCHI C. and BAHININI A.: Treatement of loower extremity venous insufficiency due to pelvic leak points in women

Annals of Vascular Surgery April 2005

DELFRATE R., BRICCHI M., FRANCESCHI C.: Minimally-invasive procedure for pelvic leak points in women. 

Veins and Lymphatics 2019; vol 8: 7789

Abstrac

Pelvic leak points (PLP) may be responsible for vulvar, perineal and lower limb varicose veins, in women during and/or after pregnancy. The accurate anatomical and hemodynamic assessment of these points, the perineal (PP), inguinal (IP) and clitoral points (CP) and their surgical treatment under local anesthetics as defined by Claude Franceschi is a new therapeutic option. The aim of this study was to assess the reliability and durability of the PLP reflux ablation using a minimally-invasive surgical disconnection at the PLP level in women with varicose veins of the lower limbs fed by the PLP. In this open-label trial 273 pelvic leak points free of pelvic congestion syndrome, with at least a 12-month follow- up, were assessed. 273 PLP treated: PP (n=177), IP (n =91) and CP (n=5). Followup: Period =12 to 92 months (mean =30.51 months). Age from 29 to 77 years (mean=45). The only 3 patients over 70 years (71, 74, 77) showed a high-speed reflux from a I point that fed symptomatic varicose veins of the lower limb. Exclusion criteria: pelvic congestion syndrome, BMI>24, venous malformations, a post thrombotic varicose vein. Diagnosis was performed using echo duplex and PLPs selected for treatment when refluxing at Valsalva + Paraná + squeezing maneuvers. A surgical skin marking of the PLP had been performed using echo duplex before surgery. Surgery consisted of minimally invasive dissection and selective division and ligation with non-absorbable suture of the refluxing veins and fascias at the PP, IP and CP pelvic escape points, under local anesthesia in a single center. The follow-up consisted of an echo duplex ultrasound, searching for reflux at the PLP treated thanks to the Valsalva maneuver, within 2 weeks, after 6 and 12 months and then yearly. The main endpoint of the study was the immediate elimination of the reflux at the PLP treated. The second endpoint was the long-term durability of the reflux ablation at the PLP treated. 267 (97.8%) without PLP reflux redo. 6 (2.2%) PLP reflux recurrences (PP=4, IP=1, CP 1). 3 patients with PLP reflux recurrence undergo a redo surgery (1.1%) where PP=2 (0.7%) and IP=1 (0.3%). This study shows the feasibility and durability of reflux ablation at the PLP level thanks to a minimally-invasive surgical treatment of the PLP and it demonstrates that there is no need for pelvic varicose embolization in patients without clinical signs of pelvic congestion syndrome. The accurate ultrasound assessment of each specific pelvic leak as well as a special surgical technique (vein division, non-absorbable suture of veins and fascias) seems to be the key for satisfactory outcomes.

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