This article delves into the theoretical foundation and clinical benefits of venous-preserving treatments, with CHIVA (Conservatrice et Hémodynamique de l’Insuffisance Veineuse en Ambulatoire) as a prime example.
The Undervalued Importance of the Great Saphenous Vein as a Golden Graft Material
Due to its robust structure, optimal diameter, and adaptability, the great saphenous vein (GSV) is one of the most frequently used grafts in arterial bypass surgeries, whether for coronary revascularization or lower extremity arterial disease.
It is crucially important for below-knee bypasses. Prosthetic grafts have been shown to be inferior to autogenous conduits for infragenicular reconstructions【1,2】. The current guidelines of the European Society for Vascular Surgery outline that availability and quality of an autologous vein conduit are key for successful bypass surgery【3】. The guidelines of the European Society of Cardiology (ESC) on the diagnostics and treatment of peripheral artery disease (PAD) recommend the autologous saphenous vein as the conduit of choice for femoropopliteal bypass (Grade IA). Moreover, it is recommended to prefer the great saphenous vein (GSV) for infra-popliteal arteries bypass (Grade IA) 【4】. The latest guideline for the management of lower extremity peripheral artery disease of the American College of Cardiology also confirms this fact 【5】. This recommendation is based not only on the fact that the autologous vein shows better patency in the infra-inguinal position than prostheses but also because it is more resistant to postoperative infectious complications 【6】. An autologous vein graft from the GSV of the same limb shows the best patency and preservation of the limb compared to other autologous veins 【6】.
Figure 2: Peripheral arterial occlusive disease treated with saphenous vein bypass
However, there are several patients with critical limb ischemia who need an infra-inguinal bypass but do not have a GSV on the same limb. This is usually due to previous coronary artery bypass grafting (CABG), femoropopliteal proximal or distal bypasses that have already been performed [8]. The vein may have a small caliber or be damaged as a result of superficial thrombophlebitis. Overall, 20–45% of lower extremity arterial disease (LEAD) patients may have no GSV for bypass【7–9】.
One major reason for this unavailability is prior destructive treatments for varicose veins, such as thermal ablation【10,11】.
In the last two decades, the number of venous interventions performed on VVs patients has severely increased. The first to pay attention to this was P. Lawrence. His report showed that from 1996 to 2014, the number of venous ablation procedures in the USA increased by 4529% 【12,13】.
This trend has led to a growing population of young and middle-aged patients who may face challenges finding viable venous grafts when they age and require arterial surgery【14】.
Figure 3: From 1996 to 2014, the number of vein ablation procedures in the United States increased rapidly
French vascular surgery expert Professor Claude Franceschi noted in an editorial:
“The excessive removal of the great saphenous vein may result in a shortage of graft material for future arterial bypasses, increasing surgical risks and limiting treatment options.”
The GSV Is Not Just a "Redundant" Vessel
Traditional treatments for varicose veins, including stripping, laser ablation, and radiofrequency ablation, often adopt destructive approaches by eliminating refluxing veins. However, modern insights reveal that the venous system comprises multiple interconnected tiers, functioning in a carefully orchestrated balance. Veins are not merely redundant vessels; their structural integrity is essential for maintaining dynamic equilibrium. Disrupting this balance without evaluating hemodynamics can hinder venous drainage.
CHIVA: The Science and Practice of Venous Conservation
1. Core Principles of CHIVA Treatment
CHIVA treatment revolves around adjusting hemodynamics to preserve venous structures while restoring venous function【15】. Its therapeutic principles include:
• Identifying and eliminating pathological escape points (EP) that cause venous hypertension.
• Reconstructing healthy venous circulation while retaining intact venous segments.
• Avoiding unnecessary vein removal to maximize structural preservation.
2. Theoretical Basis of CHIVA
CHIVA’s approach is grounded in the understanding that venous hypertension, rather than simple valvular insufficiency, is the primary driver of varicose veins. Its treatment strategies focus on correcting abnormal pressure distribution to restore circulatory balance.
• Improved Venous Reflux: CHIVA optimizes hemodynamic adjustments to reduce deep venous pressure while preserving venous drainage function.
• Avoiding Chain Reactions: Traditional vein removal can lead to compensatory dilation of other veins. CHIVA prevents such issues by maintaining hemodynamic stability.
Figure 5: Reduction of venous pressure and promotion of vascular contraction through CHIVA
3. Clinical Outcomes of CHIVA: Preserving Structures and Optimizing Function
Recent studies have confirmed CHIVA’s long-term efficacy:
• Low Recurrence Rates: CHIVA demonstrates significantly lower recurrence rates than traditional stripping techniques (5-year recurrence rate <10%).
• Faster Recovery: CHIVA treatments are performed under local anesthesia, involve minimal postoperative pain, and allow patients to resume normal activities quickly without hospitalization【16】.
• High Vein Preservation Rates: Preserved GSVs show excellent long-term patency and functionality, serving as viable vascular grafts if needed in the future.
Protecting Venous Structures: A Trend and a Responsibility
In varicose vein treatment, preserving venous structures reflects a shift toward ethical, patient-centered care. It not only addresses immediate symptoms but also safeguards patients’ long-term health by offering future surgical options.
The Benefits of Venous Preservation:
1. Optimal Use of Medical Resources: Reducing excessive GSV removal ensures viable graft options for future bypass surgeries.
2. Improved Quality of Life: Preserving venous structures prevents complications associated with destructive procedures like stripping or ablation.
3. Promoting Personalized Treatments: Hemodynamic approaches such as CHIVA offer patients effective solutions while maintaining venous functionality.
Conclusion
When we talk about "Venous Conservation", we are not merely referring to minimizing surgical trauma. Instead, we are advocating for a proactive approach that reserves critical vascular resources for future health needs. As Professor Franceschi aptly noted, the GSV is not just a localized anatomical structure but a potential lifeline for patients. CHIVA exemplifies the best practices under this philosophy by addressing varicose vein pathophysiology while preserving vital venous networks.
As technology advances and clinical research deepens, the concept of venous preservation will become integral to mainstream varicose vein treatments, offering safer, more effective, and sustainable solutions for patients.
References:
1. Ambler, G.K.; Twine, C.P. Graft Type for Femoro-Popliteal Bypass Surgery. Cochrane Database Syst. Rev. 2018, 2018, CD001487.
2. Klinkert, P.; Schepers, A.; Burger, D.H.C.; Van Bockel, J.H.; Breslau, P.J. Vein versus Polytetrafluoroethylene in Above-Knee Femoropopliteal Bypass Grafting: Five-Year Results of a Randomized Controlled Trial. J. Vasc. Surg. 2003, 37, 149–155.
3. Conte, M.S.; Bradbury, A.W.; Kolh, P.; White, J.V.; Dick, F.; Fitridge, R.; Mills, J.L.; Ricco, J.-B.; Suresh, K.R.; Murad, M.H.; et al. Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia. J. Vasc. Surg. 2019, 69, 3S–125S.e40.
4. Aboyans, V.; Ricco, J.B.; Bartelink, M.L.E.L.; Björck, M.; Brodmann, M.; Cohnert, T.; Collet, J.P.; Czerny, M.; De Carlo, M.; Debus, S.; et al. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in Collaboration with the European Society for Vascular Surgery (ESVS): Document Covering Atherosclerotic Disease of Extracranial Carotid and Vertebral, Mesenteric, Renal, Upper and Lower Extremity ArteriesEndorsed by: The European Stroke Organization (ESO)The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vasc. Eur. Heart J. 2018, 39, 763–816.
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6. Klinkert, P.; Post, P.N.; Breslau, P.J.; van Bockel, J.H. Saphenous Vein versus PTFE for Above-Knee Femoropopliteal Bypass. A Review of the Literature. Eur. J. Vasc. Endovasc. Surg. 2004, 27, 357–362.
7. Chew, D.K.W.; Owens, C.D.; Belkin, M.; Donaldson, M.C.; Whittemore, A.D.; Mannick, J.A.; Conte, M.S. Bypass in the Absence of Ipsilateral Greater Saphenous Vein: Safety and Superiority of the Contralateral Greater Saphenous Vein. J. Vasc. Surg. 2002, 35, 1085–1092.
8. Taylor, L.M.; Edwards, J.M.; Brant, B.; Phinney, E.S.; Porter, J.M. Autogenous Reversed Vein Bypass for Lower Extremity Ischemia in Patients with Absent or Inadequate Greater Saphenous Vein. Am. J. Surg. 1987, 153, 505–510.
9. Norgren, L.; Hiatt, W.R.; Dormandy, J.A.; Nehler, M.R.; Harris, K.A.; Fowkes, F.G.R. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J. Vasc. Surg. 2007, 45, S5–S67.
10. Klinkert, P.; Schepers, A.; Burger, D.H.C.; Van Bockel, J.H.; Breslau, P.J. Vein versus Polytetrafluoroethylene in Above-Knee Femoropopliteal Bypass Grafting: Five-Year Results of a Randomized Controlled Trial. J. Vasc. Surg. 2003, 37, 149–155.
11. Kashyap, V.S.; Ahn, S.S.; Quinones-Baldrich, W.J.; Choi, B.U.; Dorey, F.; Reil, T.D.; Freischlag, J.A.; Moore, W.S. InfrapoplitealLower Extremity Revascularization with Prosthetic Conduit: A 20-Year Experience. Vasc. Endovasc. Surg. 2002, 36, 255–262.
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15.Bellmunt-Montoya S, Escribano JM, Dilme J, Martinez-Zapata MJ. CHIVA method for the treatment of chronic venous insufficiency. Cochrane Database Syst Rev. 2013;(7):CD009648.
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