The saphenous vein is the longest vein in the human body. It Has its origin on the ankle, runs in the inner part of the leg and thigh to the inguinal region where it enters the femoral vein leading to the superficial flow of the leg to the deep system. It is not a purely subcutaneous vein, because in most people it has a subcutaneous fascia around it that functions as an elastic stocking. This Natural Elastic Sock makes the saphenous even if sick (reflux) does not increase its diameter greatly and neither become tortious. Thus, most of the veins that we see in varicose patients with venous insufficiency are the ancillary collateral veins and not the saphenous vein itself.
The function of the saphenous is to carry the blood from the surface toward the deep system where it will reach the heart. It receives numerous smaller veins along the leg and takes the flow of these veins to the deep system. The deep System is below the fascias near the muscles in the leg and thigh and inside the abdomen. The deep system in the leg has an intermediate position and functions as a large reservoir of blood. The deep system binds to the superficial in the legs at the entrances of the saphenous veins and through perforating veins (pierce the muscle fascia). The function of these blood inputs from superficial to deep is essential for the maintenance of adequate venous circulation. If the superficial system is not functioning properly, it receives more blood than it should and becomes more involved as a reservoir, which causes several clinical manifestations of mild to severe venous insufficiency.
The importance of the saphenous vein goes beyond drainage in the venous drainage of the leg. The vein can be removed from the leg and used in cardiac and vascular surgeries that often save the person’s life. Saphenous Bridges for coronaries and lower limb arteries are common procedures and other substitutes that the saphenous vein often does not obtain the same results. The lack of this saphenous vein can oblige changes of plan in future procedures whose effects are not desirable.
Another still poorly defined factor and the effect of saphenous withdrawal on varicose vein recurrence in the long term. Some animal studies have shown that ligation of a vein causes an effect on the organism to try to supplant that obstacle and create more veins as a consequence. Clinical Studies have shown that the chance of varicose veins returning was higher in patients who had all the inguinal veins connected (closed) than in patients who had only the saphenous ligated (closed) in the surgical procedure. In fact, some clinical trials suggest that CHIVA had a lower recurrence than stripping (removing the vein) as we will discuss afterwards.
The treatments usually performed in patients with the patient’s saphenous disease are diverse and their application depends on the place of accomplishment, clinical case, patient’s expectations, physician’s experience among others. There are several scientifically proven treatments, including thermal ablation of saphenous (Laser and radiofrequency), safenectomy by Phleboextraction (stripping), injection sclerotherapy (foam or glue) and the hemodynamic technique (CHIVA). Among these, except for the hemodynamic technique, the others eliminate in different ways the saphenous vein (burn, irritation by injection, adhesion by glue or withdrawal).
The result of CHIVA has already been scientifically evaluated in randomized clinical trials and a systematic review of trials. The systematic review of the data shows low recurrence rate and low index of cutaneous nerve injury (probably by local anesthesia) and fewer hematomas than in the stripping technique. The technique proved to be superior to compression alone in patients with venous ulcer. Comparisons with Endolaser and radiofrequency there are few, a retrospective study showed that CHIVA patient reported less pain and needed fewer sessions of complementary sclerotherapy in the treatment that patient post-endolaser of the saphenous.
In Summary, the ideal technique for treating varicose veins is not yet defined. No technique is able to avoid totally problems such as recurrence, blemishes, aesthetic problems, edema and other symptoms. We chose CHIVA as the first choice in cases of saphenous disease due to the above reasons.
In the opinion of the European consensus for the treatment of chronic venous insufficiency, CHIVA (recommendation 54) can be made in these patients if performed by a physician specializing in the technique.
We have an article written along with colleagues in which we do a review of the technique published in Jornal Vascular Brasileiro if you have interest in more scientific information enter the link.
Randomized Clinical Trials and Cochrane Meta-Analysis CHIVA versus conventional surgery
Pares JO, Juan J, Tellez R, Mata A, Moreno C, Wants FX, et al. Varicose vein surgery: Stripping Versus the CHIVA method: a randomized controlled trial. Ann Surg. APR 2010; 251 (4): 624 – 31.
Carandina S, Mari C, De Palma M, Marcellino MG, Cisno C, Legnaro A, et al. Varicose vein stripping vs. Haemodynamic correction (CHIVA): A long term randomised trial. Eur J Vasc Endovasc Surg. Feb 2008; 35 (2): 230 – 7.
Bellmunt-Montoya S, Escribano J, Dilme J, Martinez-Zapata M. CHIVA method for the treatment of chronic venous insufficiency. Cochrane Database of Systematic Reviews 2015, Issue 6. Art. No.: CD009648. DOI: 10.1002/14651858. CD009648. pub3
Why not resect the veins? The increase in the appearance of new vessels
GM Glass. Neovascularization in recurrence of varices of the great saphenous vein in the groin: phlebography. Angiology. 1988 July; 39 (7 Pt 1): 577 – 82.
Pfisterer L, Kön G, Hecker M, Korff T. Pathogenesis of Varicose veins – lessons from biomechanics. Vasa 2014; 43 in: 88 – 99
Recent scientific Publication of our group in Jornal Vascular Brasileiro (link in photo)
