This document compares the CHIVA method and ASVAL treatment for varicose veins. It discusses their differing physiopathologic assessments and strategies. The ASVAL method is based on the ascending theory, which posits that reflux begins in the tributaries and causes dilation of the saphenous vein. Its strategy is to perform an extensive phlebectomy of any incompetent thigh tributary found on compression testing. Reflux persisting after this would be treated with saphenous trunk stripping or ablation. The CHIVA method considers multiple theories of pathogenesis. Its strategy is tailored to the identified shunt type and systolic cartography. It never performs saphenous trunk ablation, seeking to preserve the deep

1. COMPARISON BETWEEN CHIVA METHOD
AND ASVAL TREATMENT
Stefano Ermini MD
Firenze

2. A Ablation
S Selective
V Varices … sous
A Anestesie
L Locale
Paul Pittaluga

3. ASVAL Phisiopathologic assesment
1. Ascending Theory
2. “Reservoire” effect
ASVAL Strategy
1. Tributary compression test
La Strategia CHIVA
1. Tributary compression test
2. Systolic carthography
CHIVA Phisiopathogic assesement
All theories

4. Phisiopahologic presuppositions : Ascending theory
1-Dr Pittalugua: “That is the explanation of the « aspirating effect » of the varicose
reservoir on the saphenous vein” : Vasculab 2009. He changed this explanation 4
years later in “We talk about "filling effect" rather than "aspirating effect". The
dilatation begins on the tributaries at the bottom (where the hydrostatic pressure is
higher) because of the weakness of the vein wall and the absence of protection by the
fascia”. VASCULAB Feb 2013
Aspirativ effect in 2009
Feeding tributary effect in 2013

5. What the “reservoir” effect is in Phisiology ?
Reservoire venoso:
Sistema di
ammortizzamento delle
variazioni di pressioni nel
sistema venoso grazie
alla compliance della
parete che consente un
aumento di volume
importante con aumento
di pressione debole (
almeno fino al
raggiungimento della
massima distensione).
Reservoire cardiaco:
Svolto dalle vene
muscolari

6. The “Reservoir” effect, invented from the ascending theory
followers , would be that a large varicose veins volum capacity
alone is capable of creating a “passive”aspirative effect..
Only that a liquid movement may be
created only by "active"forces, like that
of gravity or a pump.
MotionEquation of a Generic Volume
(Base of Hydrodynamics)
Force acting on the unit mass
Therefore
this concept
is contrary to
the physic
fluids law

7. ∂gh
Leukocyte adhesion in the valve sinus
M.A. Elsharawy et al. Interactive
Cardiovascula and Thoracic Surgery 6 (2007)
219-224
(ONO T. et al. J. Vasc. Surgery 1998 Jan; 27
(1):158-166)
2° Comment

8. 3° Commento
Daily practice:
Rare Finding of enlarged veins not refluxing
Frequent findings of not enlarged refluxing veins
Prospective epidemiological study on the beginning of
varicose veins.
Schultz-Ehrenburg and al. Phlebologie 2009; 38: 17–25
Longitudinal study . 740 pupils 10-12 to 18-20.
“The manifestation of a truncal VV is preceded
by a VR in the same vein (p = 0.039). “
ASVAL = Dilation precedes reflux
Studio Schulz-Ehrenburg = Reflux precedes dilation

9. 4° Comment
A DUS documentation of proximal reflux extension is possible?
Answer = NO
No Competent valves
No retrograde Flow
Incompetent
tributary
Competent
Valve

10. Strategy
 ASVAL : Extensive phlebectomy of
the incomtent tributary
 CHIVA : adapted to shunt type and
to systolic carthography

11. La Strategia
ASVAL strathegy : provides an extensive phlebectomy of the incompetent thigh
tributary when the compression test is positive.
If saphenous reflus reappears , ASVAL provides the saphenous trunk stripping or
Laser ablation
“Penso” che da questo è nato lo stripping senza crossectomia, per trattare la
ricomparsa del reflusso in caso di valvola terminale continente.
In conclusion ASVAL is only the new “Muller”
phlebectomy justified by the ascending theory
CHIVA Strategy : Never provides the saphenous trunk ablation

12. Note that …
The compression re-entry test has been
described by Claude Franceschi 23 years ago
and publied by Marc Bailly in 1995
J.M. Bailly
Carthographie CHIVA
EMC - Paris 1995

13. Which Kind of Hemodynamic Pattern can give origin to
this GSV thigh tributhary ?
GSV
SSV
Giacomini
Deep Veins
Competent
Incompetent

14. 1° variable aspect :
a. The escape point can exists or not
b. The escape point location
Whithout escape point Whit an escape point ( SFJ)

15. Possible Escape Points
Incompetent SFJ
Pelvic escape point
Hunter Perforator
Zamboni : 80%
recidive a 3 anni

16. 2° variable aspect :
The saphenous axe below the tributary origin ( competent/incompetent/absent)
Competent Incompetent Absent
(US not detected)

17. With Saphenous Incompetence
With Competent GSV
below the tributary
With Incompetent GSV
below the tributary
Shunt Type 2A Shunt Type 2B Shunt Type 2C
Possibilities without escape point (negative Valsalva)
Shunt Type 2
Without Saphenous Incompetence

18. Possibilities with a refluxing SFJ - Terminal valve incompetent
(positive Valsalva)
Shunt Type 3 Shunt Type 1 + 2

19. Variables of Shunt Type 3
Shunt Type 3/a Shunt Type 3/b Shunt Type 3/c

20. Shunt Type 4 +II
Pelvic escape point
Shunt Type 5

21. Muscle Contractive Centripetal Flow in the Giacomini Vein that
feeds a centrifugal flow in the GSV during the relaxation phase

22. ASVAL provides the saphenous trunk
stripping or Laser ablation when the
saphenous reflux reappers after
phlebectomy
What percentage do you think ASVAL will
be a saphenous sparing surgery
treatment?
Less then 20% in shunt type 3 and
about 50% in shunt type 2/b and 5
?

23. Why do centrifugal flow reappears in a shunt type 2 after
tributary flush ligation ( including or not an extensive
phlebectomy) ?
Saphenous
trunk
Tributary
Tributary
Desappearing of diastolic
centrifugal flow
No flow is detectable A Centripetal flow persists
Saphenous
trunk
Desappearing of diastolic
centrifugal flow

24. Is extensive phlebetomy mandatory??
Thanks for your attention
Video perthes test

25. Thanks for your attention