1. CHIVA TODAY 2014
From theory to scientific evidence
C. Franceschi (Paris France Cremona ITALY)
2. To raise new questions, new possibilities, toTo raise new questions, new possibilities, to
regard old problems from a new angle,regard old problems from a new angle,
requires creative imagination and marks realrequires creative imagination and marks real
advance in scienceadvance in science
Albert EinsteinAlbert Einstein
5. CHIVAâS STORY
-An hemodynamic pattern
proposed 26 years ago.
-Proved 20 years later by
Controlled Randomized Trials
and COCHRANE review
6. Friedrich TRENDELENBURG 1890
Benjamin BRODIE 1846
Tomaso RIMA 1775- 1843
Everard HOME 1799
Ambroise PARE 1509-1590
CHIVA Precursors
Georg Clemens PERTHES 1900
William HARVEY 1578-1657
7. 1788-1899: Ligation of Saphena
Vein
Trendelenburg
1988: CHIVA
Varicocentric
Ablative
1906 Stripping Mayo
Babcok
1947 Sclerosis
2000 RF, Laser, Foam
Short Story
90 years90 years
blackoutblackout
Varicocentric
Ablative
Emodinamicocentric
Conservative
9. HEMODYNAMIC
CONCEPTS PUBLISHED
IN 1988.
Varicose veins and trophic changes are not the
cause but the effect of overloading pressure/flow
The consequent treatment consists of correcting
this hemodynamic impairment in order to collapse
the varicose veins, restore the tissue health and
reduce the varicose recurrence thanks to
overloading flows disconnection and draining
veins conservation, included varicose.
11. HEMODYNAMIC CONCEPTS
1-Dynamic Fractioning of the Hydrostatic Pressure
2-Closed and Open Shunts
3-Vicarious Varicose Recurrence
4-Saphena Conservation for Future Arterial By-pass
5-Anato-functional Mapping.
12. i P
o P
p P
c P
s g P
ig P
i P
o P
p P
c P
gs P
g s P
20032003
Identification of pelvic leak points: Inguinal (IP) Perinaeal (PP), Clitorudian (CP) Obturator OP) Gluteal
( SGP and IGP)
Franceschi C, Bahnini A. Treatment of lower extremity venous insufficiency due to pelvic leak points in
women. Ann Vasc Surg. 2005 Mar;19(2):284-8
ANATOMIC LOCATION OF PELVIC LEAK POINTS
17. CHIVA cure :
1/Hydrostatic Pressure column fractionning :
restore the dynamic fractionning of the hydrostatic
column during walking
2/Closed and deviated shunts disconnection :
suppresses flow/pressure overloading supplied by
the VM Pump during walking
3/Draining Veins conservation: avoids residual
pressure excesses responsible for spider veins
and varicose recurrence
4/ Venous Capital Conservation for future
possible need of arterial by-pass
22. CHIVA is not only avaricose treatment
CHIVA is also the treatment of the cause of
the venous insuficiency
i.e the TMP excess.
When TMP is reduced to normal, all signs
and symptoms are cured: Varicose veins,
Edema, Hypodermitis, Ulcer
23. CHIVA doesnât depend on
the direction of the
varicose progression ,
downwards or upwards
25. 1- Varicose Vein Surgery Stripping versus the CHIVA method:
a Randomized
Controlled Trial Josep oriol
Pares and al Annals
of Surgery * Volume 251, Number 4, April 2010 [ISRCTN52861672].[ISRCTN52861672]. (international(international
standard randomised controlled trial number )www.controlled-trials.comstandard randomised controlled trial number )www.controlled-trials.com
2- Minimally Invasive Surgical management of primary venous Ulcer vs.
Compression Treatment: a randomized Clinical Trial
P.Zamboni and all
Eur J vasc Endovasc Surg 00,1 6 (2003)
3- Clinical and random study comparing two, surgical techniques for varicose
vein treatment : immediate results
Iborra and all
Angiologia 2000:6, 253-258
4-Varicose Vein Stripping vs Haemodynamic Correction (CHIVA):
a Long Term Randomised Trial.
Carandina, C. and al.
Eur J Vasc Endovasc Surg xx, 1e8 (2007)
doi:10.1016/j.ejvs.2007.09.011
26. 1- Varicose Vein Surgery Stripping versus the CHIVA method:
a Randomized
Controlled Trial Josep oriol
Pares and al Annals
of Surgery * Volume 251, Number 4, April 2010 [ISRCTN52861672].[ISRCTN52861672]. (international(international
standard randomised controlled trial number )www.controlled-trials.comstandard randomised controlled trial number )www.controlled-trials.com
2- Minimally Invasive Surgical management of primary venous Ulcer vs.
Compression Treatment: a randomized Clinical Trial
P.Zamboni and all
Eur J vasc Endovasc Surg 00,1 6 (2003)
3- Clinical and random study comparing two, surgical techniques for varicose
vein treatment : immediate results
Iborra and all
Angiologia 2000:6, 253-258
4-Varicose Vein Stripping vs Haemodynamic Correction (CHIVA):
a Long Term Randomised Trial.
Carandina, C. and al.
Eur J Vasc Endovasc Surg xx, 1e8 (2007)
doi:10.1016/j.ejvs.2007.09.011
27. 0
10
20
30
40
50
60
70
464 465 459 453 458 457
6m 12m 24m 36m 48m 60m
%
Ph-M
Ph-ED
TC
St -MC
St -ED
TC
5ans. 550 Patients
Up to 18 months: NO differenceUp to 18 months: NO difference
Difference increases with time after 2 yearsDifference increases with time after 2 years
CHIVA
Stripp. Duplex guided
Stripp. Clinical
5 years follow up : Recurrence rate:5 years follow up : Recurrence rate:
CHIVA vs strippingCHIVA vs stripping
28. 0
10
20
30
40
50
60
70
464 465 459 453 458 457
6m 12m 24m 36m 48m 60m
%
Ph-M
Ph-ED
TC
St -MC
St -ED
TC
5ans. 550 Patients
Duplex Guided Vs Clinical : NO differenceDuplex Guided Vs Clinical : NO difference
Duplex is USLESS for strippingDuplex is USLESS for stripping
CHIVA
Stripp. Duplex guided
Stripp. Clinical
5 years follow up : Recurrence rate:5 years follow up : Recurrence rate:
CHIVA vs strippingCHIVA vs stripping
29. 1- Varicose Vein Surgery Stripping versus the CHIVA method:
a Randomized
Controlled Trial Josep oriol
Pares and al Annals
of Surgery * Volume 251, Number 4, April 2010 [ISRCTN52861672].[ISRCTN52861672]. (international(international
standard randomised controlled trial number )www.controlled-trials.comstandard randomised controlled trial number )www.controlled-trials.com
2- Minimally Invasive Surgical management of primary venous Ulcer vs.
Compression Treatment: a randomized Clinical Trial
P.Zamboni and all
Eur J vasc Endovasc Surg 00,1 6 (2003)
3- Clinical and random study comparing two, surgical techniques for varicose
vein treatment : immediate results
Iborra and all
Angiologia 2000:6, 253-258
4-Varicose Vein Stripping vs Haemodynamic Correction (CHIVA):
a Long Term Randomised Trial.
Carandina, C. and al.
Eur J Vasc Endovasc Surg xx, 1e8 (2007)
doi:10.1016/j.ejvs.2007.09.011
30. KAPLAN-MEIR ESTIMATIONKAPLAN-MEIR ESTIMATION
1.01.0
0.80.8
0.60.6
0.40.4
0.20.2
00
1.01.0
0.80.8
0.60.6
0.40.4
0.20.2
00
00 250250 500500 500500750750 10001000
TIME (days)TIME (days)
CHIVACHIVA
compressioncompression
Minimally invasive surgical management of primary venousMinimally invasive surgical management of primary venous
ulcers vs. compression treatment: a randomized clinical trial..ulcers vs. compression treatment: a randomized clinical trial..
Zamboni Pand al A.Zamboni Pand al A. EJ V E S. 2003EJ V E S. 2003
31. 1- Varicose Vein Surgery Stripping versus the CHIVA method:
a Randomized
Controlled Trial Josep oriol
Pares and al Annals
of Surgery * Volume 251, Number 4, April 2010 [ISRCTN52861672].[ISRCTN52861672]. (international(international
standard randomised controlled trial number )www.controlled-trials.comstandard randomised controlled trial number )www.controlled-trials.com
2- Minimally Invasive Surgical management of primary venous Ulcer vs.
Compression Treatment: a randomized Clinical Trial
P.Zamboni and all
Eur J vasc Endovasc Surg 00,1 6 (2003)
3- Clinical and random study comparing two, surgical techniques for varicose
vein treatment : immediate results
Iborra and all
Angiologia 2000:6, 253-258
4-Varicose Vein Stripping vs Haemodynamic Correction (CHIVA):
a Long Term Randomised Trial.
Carandina, C. and al.
Eur J Vasc Endovasc Surg xx, 1e8 (2007)
doi:10.1016/j.ejvs.2007.09.011
32. Clinical and random study comparing two, surgical techniques for varicose vein
treatment : immediate results
Iborra and all
Angiologia 2000:6, 253-258
immediate results: NO DIFFERENCE
In accordance with O.Pares where
CHIVA vs Stripping difference starts
after the 18th month!
33. 1- Varicose Vein Surgery Stripping versus the CHIVA method:
a Randomized
Controlled Trial Josep oriol
Pares and al Annals
of Surgery * Volume 251, Number 4, April 2010 [ISRCTN52861672].[ISRCTN52861672]. (international(international
standard randomised controlled trial number )www.controlled-trials.comstandard randomised controlled trial number )www.controlled-trials.com
2- Minimally Invasive Surgical management of primary venous Ulcer vs.
Compression Treatment: a randomized Clinical Trial
P.Zamboni and all
Eur J vasc Endovasc Surg 00,1 6 (2003)
3- Clinical and random study comparing two, surgical techniques for varicose
vein treatment : immediate results
Iborra and all
Angiologia 2000:6, 253-258
4-Varicose Vein Stripping vs Haemodynamic Correction (CHIVA):
a Long Term Randomised Trial.
Carandina, C. and al.
Eur J Vasc Endovasc Surg xx, 1e8 (2007)
doi:10.1016/j.ejvs.2007.09.011
37. Retrospective study CHIVA vs LASER
.
Chan, C.-Y.a , Chen, T.-C.b , Hsieh, Y.-K.a , Huang, J.-
H.c
Retrospective comparison of clinical outcomes between
endovenous laser and saphenous vein-sparing surgery
for treatment of varicose veins (2011) World Journal of
Surgery, 35 (7), pp. 1679-1686.
Conclusion: The CHIVA patients had less pain
postoperatively and a significantly higher sclerotherapy-free
period compared to patients in the EVL group.
38. GUIDELINES
âą The care of patients with varicose veins and associated chronic venous
diseases: Clinical practice guidelines of the Society for Vascular Surgery and
the American Venous Forum
âą Peter Gloviczki, MD, and al. JVS 2011
âą Results with preservation of the saphenous vein. Results with CHIVA. Two
RCTs188,191 compared standard treatment(compression or high ligation, stripping,
and phlebectomy) with CHIVA approaches with specific anatomic patterns of reflux
(types I and III shunts). For the specific venous anatomy evaluated in these
trials, such techniques were better than compression in preventing ulcer
recurrence and were at least equivalent to stripping of varicose veins. Although
the first two RCTs focused on a small group of patients with varicose veins, the trial of
Pares et al deserves credit for including the full spectrum of patients with primary
varicose veins. CHIVA is a complex approach, and a high level of training and
experience is needed to attain the results presented in this RCT. However, the
results achieved by a few outstanding interventionists does not support offering this
procedure to all practitioners.Although CHIVA has called attention to the importance
of directing surgical procedures toward the patientâs venous anatomy and function, it
still requires considerable education of venous interventionists willing to learn
this approach.
39. CHIVA requires considerable education of venous
interventionists willing to learn this approachâ (Peter
Gloviczki, MD, and al. JVS 2011) because it relies on new
hemodynamic concepts of the venous pathophysiology and
a proper DUS assessment method. CHIVA performed by
who doesnât know enough about them is not CHIVA and
leads to failure as a study demonstrated it (Milone M,
Salvatore G, Maietta P, Sosa Fernandez LM, Milone
Recurrent varicose veins of the lower limbs after
surgery. Role of surgical technique (stripping vs.
CHIVA) and surgeon's experience.F. G Chir. 2011 Nov-
Dec;32(11-12):460-3).So, conservation is possible in all
the patients and CHIVA
40. âŠ..today, treatments are
performed in accordance
with the evidence based
medicine supplied by
Randomized Controlled
Trials âŠ.and after a
comprehensive
information and consent
of the patient.
President of
Medicine
Academy
41. CHIVA preserves the GSV for future arterial bypass
Optimal management of infrainguinal arterial occlusive disease
Authors: Pennywell DJ, Tan TW, Zhang WW
Full text: available on http://www.dovepress.com/article_18926.t34346121
Risk factors:Age is the most important, nonmodifiable risk factor for PAD, with a
prevalence of 0.9% in people under age 50 and 23.2% in people over the age of
80.1
Open reconstruction:The most important determinant of success of an
Infrainguinal lower extremity bypass (LEB) is the type and quality of conduit
selected.2,17,52 Autogenous vein is superior to synthetic graft as conduit for
LEB,2,53â55 and the great saphenous vein (GSV) is superior to other
autologous alternatives.2,55,56 An essential step in preoperative planning is
evaluation of the GSV with duplex mapping and identification of alternative vein
conduits, if needed. An ideal vein conduit should be soft, compressible, at least 3
mm in diameter, and should not be calcified or sclerotic. If the ipsilateral GSV is
unsuitable or unavailable, the contralateral GSV should be used.
Conclusion
Open infrainguinal bypass remains the gold standard for revascularization
in CLI, especially for patients at appropriate surgical risk and with suitable bypass
conduit.
42. Is it professional not to give the best
scientifically proved treatment to the
patient?
Is it honest to tell the patient his
saphena wouldnât be usefull in case of
arterial by-pass necessity?
Hinweis der Redaktion
Chap12 Fig 6 Ulcer recurrences a 3 years after CHIVA I or CHIVA I+II performed for venous ulcers, straight line, and by standard compression, interrupted line.
Chap12 Fig 11 Hobbs score (best 1 worse 4) was significantly better after 10 years in the haemodynamic CHIVA group ( 1.9 vs 2.2 , P< 0.038).