Sergio Gianesini, MD PhD FACS
University of Ferrara (ITALY)
Uniformed Services University of Health Sciences (Bethesda, USA)
President of the venous-lymphatic World International Network (v-WIN) foundation
President-elect of the World Union of Phlebology (International Union of Phlebology)
The treatment of varicose veins involves a first strategic choice: to remove the diseased vessel or rather to repair it. The subject offers the opportunity to underline the difference between "technique" and "strategy". This aspect is of fundamental importance in a scientific and technological era characterised by a constant market supply of innovative instrumentation. The innovation in question in fact refers to an aspect of "technique" and is characterised by a continuous attempt to improve the minimal invasiveness of the procedure. This, however, does not correspond to a strategic innovation, since the therapeutic orientation remains the removal of the vessel, similarly to surgical stripping.
While the therapeutic "strategy" can therefore be defined as "the selection between removal and repair of the vessel", the technique rather represents "the instrumentation used to carry out the strategy selected pre-operatively". The main repair strategy is known as CHIVA, an acronym standing for the "Conservative Haemodynamic treatment of venous Insufficiency in an Ambulatory setting"
Haemodynamic treatment according to the CHIVA strategy is based on the concept of transforming venous reflux into a physiological drainage flow. This objective is achieved by closing the "taps" that feed the pathological flow within a vein, allowing the vein itself to drain into normally functioning circuits (Gianesini S, et al. CHIVA strategy in chronic venous disease treatment: instructions for users. Phlebology Journal 2015).
The strategic option of not removing a refluxing vein but rather of restoring its physiological drainage had already been elegantly described in 1971 by Fegan's group (Quill RD, Fegan WG. Reversibility of femorosaphenous reflux. Br J Surg. 1971).
In 2019 an important review of the literature confirmed the possibility of reducing the rate of recurrence of varicose veins thanks to the CHIVA approach, with related benefits also in terms of quality of life and complications (Guo L et al. Long-term efficacy of different procedures for treatment of varicose veins: A network meta-analysis. Medicine (Baltimore). 2019).
Since this is a procedure designed for the specific case of each individual patient, as already published in 2011, it is essential to consider the operator's experience, particularly in the context of haemodynamic treatments (Milone M. Recurrent varicose veins of the lower limbs after surgery. Role of surgical technique (stripping vs. CHIVA) and surgeon's experience. G Chir. 2011).
The latter in fact represent a type of procedure performed to the patient's precise haemodynamic "measurements", thus requiring significant ultrasound experience aimed at the correct identification of the anatomical segments warranting treatment.
In conclusion, CHIVA treatment, despite the difficulty for the surgeon in learning it, represents an opportunity to evolve not only in technological development in the form of increasingly minimally invasive instrumentation, but also in the strategic option tailored to the patient's specific case, improving not only its minimal invasiveness but also clinical performance as well as procedural time.
Over the last decade it has then been demonstrated that this approach can also be performed with the most modern endovenous tools, further minimising invasiveness for the patient and optimising the aesthetic result, free of surgical scars (Gianesini S. Segmental saphenous ablation for chronic venous disease treatment. Phlebology. 2021).