CHIVA Varicose Veins Surgery – Technique and scientific basis

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The saphenous vein is the longest vein in the human body. It has its origin in the ankle, runs in the inner part of the leg and thigh until the inguinal region where it enters the femoral vein taking the superficial flow of the leg to the deep system. It is not a purely subcutaneous vein, since in most people it has a subcutaneous fascia around it that acts as an elastic stocking. This natural elastic stocking makes the saphenous even though sick (reflux) does not increase its diameter greatly and does not become tortuous. Thus, most of the veins seen in varicose veins with venous insufficiency are the accessory side veins and not the saphenous vein itself.

The saphenous function is to carry blood from the surface into the deep system where it will reach the heart. It receives innumerable smaller veins along the leg and carries the flow of these veins into the deep system. The deep system lies below the fascias along the muscles in the leg and thigh and inside the abdomen. The deep leg system has an intermediate position and functions as a large reservoir of blood. The deep system connects to the superficial legs in the veins saphenous veins and through perforating veins (perforates the muscle fascia). The function of these blood inflows from the superficial to the deep is fundamental for maintaining adequate venous circulation. If it is not working well the superficial system 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 a person's life. Scalene bridges for coronary and lower limb arteries are common procedures and other surrogates that the saphenous vein often does not achieve the same results. The lack of this saphenous vein may necessitate changes of plan in procedures in the future whose effects are not desirable.

Another factor still not well defined and the effect of the saphenous vein removal in the recurrence of varices in the long term. Some animal studies prove that ligation of a vein causes an effect on the body to try to overcome that obstacle and create more veins accordingly. Clinical studies have shown that the chance of varicose veins returning was greater in patients who had all inguinal veins attached (closed) than in patients who only had the saphenous vein attached (closed) in a surgical procedure. In fact, some clinical trials suggest that CHIVA had less recurrence than stripping (as described below).

The treatments usually performed in the patients with the patient's saphenous vein are diverse and their application depends on the place of accomplishment, clinical case, patient's expectations, doctor's experience among others. There are a number of scientifically proven treatments, including saphenous thermal ablation (laser and radiofrequency), stripping safenectomy, injection sclerotherapy (foam or glue) and hemodynamic technique (CHIVA). Among these, except the hemodynamic technique, the others eliminate saphenous vein (burn, injection irritation, adhesion by glue or withdrawal) in different ways.

The results of CHIVA have already been scientifically evaluated in randomized clinical trials and a systematic review of trials. The systematic review of the data shows a low relapse rate and a low rate of cutaneous nerve injury (probably due to local anesthesia) and less bruising than in the stripping technique. The technique was superior to compression alone in patients with venous ulcer. Comparisons with endolaser and radiofrequency are few, a retrospective study has shown that CHIVA patients reported less pain and required fewer sclerotherapy sessions in the treatment than patient endolaser of the saphenous vein.

In summary, the ideal technique for treating varicose veins is not yet defined. No technique is able to totally avoid problems like relapse, blemishes, aesthetic problems, edema and other symptoms. We chose CHIVA as the first choice in cases with saphenous disease due to the reasons above.

In the opinion of the European consensus of treatment of chronic venous insufficiency CHIVA (recommendation 54) can be made in these patients if it is performed by a doctor specialized in the technique.

We have an article of ours written with colleagues in which we do a review of the technique published in the Jornal Vascular Brasileiro if you are interested in more scientific information between the link.