Chiva today 2014

CHIVA TODAY 2014From theory to scientific evidence

C. Franceschi (Paris France Cremona ITALY)

To raise new questions, new possibilities, to To 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 real requires creative imagination and marks real advance in scienceadvance in science

Albert EinsteinAlbert Einstein

CHIVA cure-Conservative -Hemodynamic-Venous Insufficiency -Ambulatory Treatment

CHIVA’S STORY

-An hemodynamic pattern proposed 26 years ago.

-Proved 20 years later by Controlled Randomized Trials

and COCHRANE review

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

1788-1899: Ligation of Saphena Vein

Trendelenburg

1988: CHIVA

Varicocentric

Ablative

1906 Stripping Mayo Babcok

1947 Sclerosis

2000 RF, Laser, Foam

Short Story

90 years 90 years blackoutblackout

Varicocentric Ablative

Emodinamicocentric Conservative

19771986

CHIVA was possible thanks to diagnosis improvement based on Ultrasound Duplex Scan

1988

2009

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.

HEMODYNAMIC CONCEPTS PUBLISHED

IN 1988.

AND BY THE WAY preservation of the

saphena veins, possibly vital in case of necessary arterial

bypass

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.

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

Hemodynamic aspects of Venous Insufficiency

Diagnosis and Treatment

Signs: Edema, Varices, trophic changes, Ulcer

ONE cause

TransMural Pressure Excess

TMP

Venous Insufficiency Disease

TMP

=Pressure

Extra-Venous Extra-Capillary

Pressure Endo-VenousEndo-Capillary

minus

TPM is increased by

1-Hydrostatic Pressure Overloading ( gravitational)

Causes

Valve Incompetence, flow block

2-Residual Pressure Overloading ( micro-circulation)

3-M.Pump Pressure Overloading ( shunts)

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

CHIVA doesn’t depend on the varicose veins

evolution, downwards or upwards

Treatments

Venous Sysytem Impairment

Venous Blocks P.Residual P↑

Valve Incompetence Hydrostatic P ↑

Shunts VM Pump P ↑

Hemodynamic Disfunction Trans Mural Pressure PTM

↑

causes

Genetic Malformazioni Biological Infezione

Flebiti Infiamazione

Iatrogenic Veins ablation

EffectsDilation Venous

Varicose Veins

Draiange Impairement Edema Hypodermitis

Ulcer

Vicious Circle

PTM↓

Posture Compression

Veinblock: liberation, by-pass

Valve repair

CHIVA

Venous Hypertension posture, obesity

according to the cause

Varico Centric Hemodinamico Centric

TMP REDUCTION TMP REDUCTION

P ExtraVenous Pressure IncreaseP ExtraVenous Pressure Increase

-Compression-Compression

IntraVenous Pressure DecreaseIntraVenous Pressure Decrease

-Posture-Posture

-Liberation-Liberation

VEINS ABLATIONVEINS ABLATION

-Phlebectomy-Phlebectomy

-Sclerosis-Sclerosis

-Laser-Laser

-Radio Frequency -Radio Frequency

IMPAIRS the DRAINAGE IMPAIRS the DRAINAGE Tissue sufferingTissue suffering

Vicarious Recurrence Vicarious Recurrence

Destruction of the VENOUS Destruction of the VENOUS CAPITALCAPITAL

CHIVACHIVA

-HP Fragmentation -HP Fragmentation -Shunt Disconnection-Shunt Disconnection--Drainage respect Drainage respect -Venous capital preservation-Venous capital preservation

TREATMENTS

OOSSOO

SFSF

vv aa

MM

Flow/pressurFlow/pressure overloade overload

Vicarious Vicarious flowflow

Fistole Fistole Artéro-Artéro-Venosus Venosus fistulefistule

Closed Closed shuntshunt

Venous Venous malformationmalformation

TMPTMP increases with flow and pressure overload due to increases with flow and pressure overload due to various causesvarious causes

Hydrostatic Hydrostatic Pressure Pressure excessexcess

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

CHIVA doesn’t depend on the direction of the

varicose progression , downwards or upwards

CHIVA cure

- EVIDENCE BASED MEDICINE

- Randomized Controlled Trials

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 allEur 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 allAngiologia 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

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 stripping CHIVA vs stripping

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 stripping CHIVA vs stripping










doi:10.1016/j.ejvs.2007.09.011

KAPLAN-MEIR ESTIMATIONKAPLAN-MEIR ESTIMATION1.01.0

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

0000 250250 500500 500500750750 10001000

TIME (days)TIME (days)

CHIVACHIVA

compressioncompression

Minimally invasive surgical management of primary venous Minimally 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










doi:10.1016/j.ejvs.2007.09.011

Clinical and random study comparing two, surgical techniques for varicose vein treatment : immediate results


immediate results: NO DIFFERENCE In accordance with O.Pares where

CHIVA vs Stripping difference starts after the 18th month!










doi:10.1016/j.ejvs.2007.09.011

1,75

1,8

1,85

1,9

1,95

2,05

2,1

2,15

2,2

2,25

2

P<0.038

Stripping

CHIVACHIVA

BEST SCORESBEST SCORES

18%

35%

0

5

10

15

20

25

30

35

CHIVA Stripping

RECIDIVE1O years follow up : Recurrence rate: 1O years follow up : Recurrence rate:

CHIVA vs stripping CHIVA vs stripping Objective evaluation

S.Carandina, and alS.Carandina, and al. . E J V E Surg. 2008E J V E Surg. 2008

CHIVAStripping

1 COCHRANE REVIEWCHIVA vs Stripping

Less recurrences, less complications

Bellmunt-Montoya S, Escribano JM, Dilme J, Martinez-Zapata MJ. CHIVA method for the treatment of chronic venous insufficiency. Cochrane Database of Systematic Reviews 2012 , Issue 2 . Art. No.: CD009648. DOI:10.1002/14651858.CD009648 .

EVIDENCES Level Grade meta-analyses de RCT

Ia A Strong

Au moins un RCT Ib

Au moins une étude clinique bien conduite sans randomisation

IIa B Mid

Au moins un autre type d’étude clinique bien programmé et quasi expérimental

IIb

Au moins un autre type d’étude clinique bien programmée et non expérimentale

III

Opinions de comités d’experts ou expérience d’autorités reconnues

IV C Weak

Other venous technics at this level????

Stripping still Gold standard? CHIVA ?

CHIVA (4 RCT)CHIVA (4 RCT)

+ Cochrane Library REVEW

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.

GUIDELINES• 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

• Peter Gloviczki, MD, and al. JVS 2011 • 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 patient’s venous anatomy and function, it still requires considerable education of venous interventionists willing to learn this approach.

CHIVA requires considerable education of venous interventionists willing to learn this approach” (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 doesn’t 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

…..today, treatments are performed in accordance with the evidence based medicine supplied by Randomized Controlled Trials ….and after a comprehensive information and consent of the patient.

President of Medicine Academy

CHIVA preserves the GSV for future arterial bypassOptimal management of infrainguinal arterial occlusive diseaseAuthors: Pennywell DJ, Tan TW, Zhang WWFull text: available on http://www.dovepress.com/article_18926.t34346121Risk 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 80.1Open 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,2,53–55 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.ConclusionOpen infrainguinal bypass remains the gold standard for revascularization in CLI, especially for patients at appropriate surgical risk and with suitable bypass conduit.

Is it professional not to give the best scientifically proved treatment to the patient?

Is it honest to tell the patient his saphena wouldn’t be usefull in case of arterial by-pass necessity?

Chiva today 2014

Health & Medicine

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