CHIVA vs. Stripping: A Decade of Evidence Supporting Hemodynamic Preservation in Varicose Vein Surgery

Introduction

Varicose veins, a prevalent manifestation of chronic venous disease (CVD), are often treated surgically when symptomatic. While traditional approaches involve the removal (stripping) of the great saphenous vein (GSV), the CHIVA (Conservatrice Hémodynamique de l’Insuffisance Veineuse en Ambulatoire) method presents a non-ablative, hemodynamic strategy designed to preserve the venous anatomy while correcting reflux patterns. This long-term randomized controlled trial (RCT) conducted by Carandina et al. is one of the landmark studies comparing these two approaches over a 10-year period, offering invaluable insight into recurrence, clinical outcomes, and patient satisfaction.

Study Design & Methodology

• Study Type: Prospective randomized controlled trial
• Sample Size: 150 patients with primary varicose veins (CEAP class C2–C6)
• Intervention Groups:
  • Group A: Traditional GSV stripping
  • Group B: CHIVA technique
• Duration of Follow-up: Mean 10 years
• Evaluation Tools:
  • Clinical assessment: Hobbs clinical score
  • Imaging: Duplex ultrasound
  • Primary endpoint: Recurrence of varicose veins
  • Secondary endpoints: Complications, patient-reported outcomes, SFJ reflux recurrence

CHIVA Technique Overview

CHIVA is based on mapping and redirecting venous flow to reduce hydrostatic pressure without removing veins. It involves selective interruption of reflux points while maintaining vein patency for physiological drainage. This technique contrasts with stripping, which physically removes the saphenous trunk, thus eliminating reflux but also compromising the native venous structure.

Key Findings

🔹 Recurrence Rates

• CHIVA: 18%
• Stripping: 35%
• Statistical significance: P < 0.04 (Fisher’s exact test)
• Odds Ratio for recurrence with stripping: 2.2 (95% CI: 1.0–5.0)

🔹 Clinical Improvement (Hobbs Score)

• No statistically significant difference between the two groups, indicating that both procedures improved symptoms effectively.

🔹 Reflux at the SFJ

• Recurrence of reflux at the sapheno-femoral junction was not significantly different between the groups, implying that the mechanism of recurrence may not be solely related to SFJ incompetence.

🔹 Patient Tolerance and Satisfaction

• CHIVA was generally well-tolerated, with less invasiveness and preservation of venous structures offering a favorable long-term perception.

Clinical Implications

1. Recurrence Prevention:
   The significantly lower recurrence rate in the CHIVA group suggests that preserving the GSV and correcting reflux dynamically may prevent compensatory mechanisms that often lead to new varicose formations post-stripping.
2. Minimally Invasive Strategy:
   CHIVA avoids unnecessary tissue damage and preserves venous return pathways, reducing trauma and potentially improving long-term venous physiology.
3. Re-evaluation of Ablative Therapies:
   This trial invites a paradigm shift away from purely ablative methods toward functional correction in selected patients.
4. Training & Standardization Needed:
   Despite its benefits, CHIVA requires precise hemodynamic mapping and surgical expertise, which may limit widespread adoption without structured training programs.

Limitations of the Study

• Loss to Follow-Up: 26 patients were lost, which, while acceptable for a 10-year study, might influence statistical robustness.
• Operator Dependency: The CHIVA technique’s success is highly dependent on the surgeon’s training and accurate mapping.
• Lack of Blinding: Due to the nature of the intervention, patients and providers were not blinded, which may introduce reporting bias.

Conclusion

This study represents one of the most rigorous long-term comparisons between stripping and CHIVA. It demonstrates that CHIVA offers equivalent symptom relief with significantly lower recurrence rates, likely due to the preservation of venous structures and correction of hemodynamic faults rather than destruction. These findings validate the CHIVA strategy as a viable, conservative, and function-preserving alternative to traditional surgery in varicose vein treatment.

Reference

Carandina S, Mari C, De Palma M, Marcellino MG, Cisno C, Legnaro A, Liboni A, Zamboni P. Varicose vein stripping vs haemodynamic correction (CHIVA): a long-term randomized trial. Eur J Vasc Endovasc Surg. 2008 Feb;35(2):230-7. doi:10.1016/j.ejvs.2007.09.011.
🔗 PubMed Link