CHIVA method for the treatment of chronic venous insufficiency

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.

Foam sclerotherapy for patients with Klipple-Trenaunary syndrome complicated by frequent cellulitis of lower extremity: A case report

RATIONALE

Klipple-Trenaunary Syndrome (KTS) complicated by frequent cellulitis of lower extremity seriously affects a patient quality of life. The hemodynamic characteristics of the disease are still unclear. Direct skin incision or puncture to remove malformed veins at the lesion site carries the risk of non-healing of the surgical incision. Our aim is to explore initial management strategies based on the hemodynamic characteristics of this disease.

PATIENT CONCERNS

A 29-year-old Manchu man was affected by KTS from childhood, characterized by an increase of the circumference and superficial varicose veins of the lower extremity. In the past 5 years, he suffered from frequent cellulitis in the left leg every 15 days or so.

DIAGNOSES

KTS complicated by frequent cellulitis of lower extremity.

INTERVENTIONS

The clinical and hemodynamic characteristics of KTS were evaluated by Doppler ultrasonography (DUS) combined with CT venography (CTV), and foam sclerotherapy and postoperative elastic bandage compression were performed accordingly.

OUTCOMES

Based on evaluations, the reason for frequent cellulitis was the continuous increase of venous hypertension in the calf caused by the malformed superficial vein and its penetrating vein. After 3 operations, the patient had no recurrence of cellulitis of the leg. Follow-up for 1 year showed no recurrence of left leg cellulitis.

LESSONS

This report emphasizes that foam sclerotherapy can significantly improve the clinical symptoms of KTS, such as cellulitis, and provide a safe skin environment for the implementation of other surgical methods, based on the evaluation of the pathological characteristics of KTS by DUS combined with CTV.

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.

The Analysis of Selected Morphological and Hemodynamic Parameters of the Venous System and Their Presumable Impact on the Risk of Recurrence after Varicose Vein Treatment

INTRODUCTION

The current treatment of venous disease is focused on reflux elimination in main venous trunks, especially in the saphenous vein. However, a high recurrence rate, independent of the method of treatment, suggests that the reason of low effectiveness may be due to a strategy focused on symptoms, without considering their origin.

METHOD

The aim of study was the comparison of retrospective data from 535 women with venous disease, either after treatment (n = 183) or not treated before (n = 352). The analysis concerned clinical symptoms and the results of the extended diagnostics, including the examination of the lower limb, pelvic and abdominal veins either using duplex-doppler ultrasound as well as venography with computed tomography or magnetic resonance.

RESULTS

The comparison of selected venous system parameters revealed more advanced disease progression in previously treated patients, compared to non-treated individuals (e.g., ipsi- or bilateral incompetence of sapheno-phemoral junction-29.5% vs. 20.4%, at P < 0.05 and 13.6% vs. 7.7% at P < 0.05, respectively). This difference could be explained by post-treatment alterations in the venous system, an older age and the higher number of pregnancies in the recurrence group. However, both groups did not differ in regards to the symptoms of pelvic venous insufficiency or the frequency of relevant variants/abnormalities in venous system.

CONCLUSIONS

Based on the aforementioned findings, we postulate the revision of treatment strategy, which should consider abdominal and pelvic veins as the source of reflux in many female subjects.

Development of a Minimum Data Set Registry for Chronic Venous Insufficiency of the Lower Limbs

The purpose of this study was to develop a minimum data set (MDS) registry for the prevention, diagnosis and treatment of chronic venous insufficiency (CVI) of the lower limbs. We designed the instrument in two phases, comprising a literature review and an e-Delphi study to validate the content. We obtained a total of 39 documents that we used to develop a registry with 125 items grouped in 7 categories, as follows: Patient examination, venous disease assessment methods, diagnostic tests to confirm the disease, ulcer assessment, treatments to manage the disease at all its stages, patient quality of life, and patient health education. The instrument content was validated by 25 experts, 88% of whom were primary healthcare and hospital nurses and 84% had more than 10 years' experience in wound care. Using a two-round Delphi approach, we reduced the number of items in the MDS-CVI to 106 items. The categories remained unchanged. We developed an MDS for CVI with seven categories to assist healthcare professionals in the prevention, early detection, and treatment history of CVI. This tool will allow the creation of a registry in the primary care setting to monitor the venous health state of the population.

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.

Studies on the relationship between perforating vein insufficiency and iliac compression syndrome

OBJECTIVE

To study correlation among number(n), diameter (D), and blood reflux time(t) and the left common iliac vein stenosis degree of the expansion of perforating veins, so as to guide the clinical formulation and adjust the treatment plan.

METHODS

Retrospective analysis of 45 PVs patients with left common iliac vein in different degrees of compression in our hospital from 2010 to 2012 was performed. Left common iliac vein was divided into 50%-69%, 70%-99%, 30%-49% and occlusion of the stenosis to avoid the error of the left iliac vein stenosis. Pearson's correlation analysis among the number, diameter, and blood reflux time of perforating veins and left common iliac vein was performed.

RESULTS

Pearson's correlation analysis among the number, diameter, and blood back flow time of perforating veins, and the degree of stenosis was performed, and these results showed that correlation coefficients among the number, diameter, and blood return the PVs between flow time and the degree of stenosis were rp-n = 0.784, rp-d = 0.893, rp-t = 0.845 (P < .001), respectively. The two variables exist positive correlation and correlation was significant.

CONCLUSION

With the increase in left common iliac vein stenosis, the number of perforating veins and the diameter increased, and the time of blood flow were prolonged.

The calendar of cytokines: Seasonal variation of circulating cytokines in chronic venous insufficiency

Objectives

To assess if in chronic venous insufficiency, there is a seasonal variation of cytokines levels which could explain the typical worsening of symptoms during Spring and Summer.

Participants

From 193 chronic venous insufficiency patients, we selected 32 patients in clinical stage C2–C3 of the Clinical–Etiology–Anatomy–Pathophysiology classification.

Design

A prospective, comparative and blinded cytokines assessment in two different seasons.

Setting

We sorted patients by two homogenous groups, 17 Autumn Group and 15 Spring Group. A complete clinical and haemodynamic assessment and laboratory analysis of 22 circulating cytokines were performed on each patient.

Main outcome measures

Circulating cytokines levels assessment.

Results

The two groups resulted homogenous for age, gender, clinical class, and haemodynamic parameters. Comparing cytokines expressions in Autumn Group vs. Spring Group, we found a significant difference of 11 out of 22 circulating cytokines (p < 0.05). Particularly Eotaxin, Interleukin-8, Monocyte Chemoattractant Protein-1, Tumour Necrosis Factor-α and Vascular Endothelial Growth Factor were increased in Autumn compared to the Control Group (p < 0.001); while significantly reduced in Spring, within the normal range (p, not significant).

Conclusions

Symptoms of chronic venous insufficiency are self-reported by patients more intense during warm seasons. Surprisingly, in our study, cytokines levels were significantly higher during Autumn and downregulated in Spring. These variations show for the first time the presence of a ‘Calendar of Cytokines’ in chronic venous insufficiency, which needs to be further investigated.