1) CHIVA is a conservative, hemodynamic, and ambulatory treatment for venous insufficiency that was first proposed 26 years ago and proved effective through randomized controlled trials and a Cochrane review 20 years later. 2) Randomized controlled trials have shown CHIVA to have lower recurrence rates and fewer complications than stripping and to be as effective as compression treatment for venous ulcers over the long term. 3) A Cochrane review found CHIVA to have fewer recurrences and fewer complications than stripping.

1. CHIVA TODAY 2014
From theory to scientific evidence
C. Franceschi (Paris France Cremona ITALY)

2. To raise new questions, new possibilities, toTo raise new questions, new possibilities, to
regard old problems from a new angle,regard old problems from a new angle,
requires creative imagination and marks realrequires creative imagination and marks real
advance in scienceadvance in science
Albert EinsteinAlbert Einstein

3. CHIVA cure
-Conservative
-Hemodynamic
-Venous Insufficiency
-Ambulatory Treatment

5. CHIVA’S STORY
-An hemodynamic pattern
proposed 26 years ago.
-Proved 20 years later by
Controlled Randomized Trials
and COCHRANE review

6. Friedrich TRENDELENBURG 1890
Benjamin BRODIE 1846
Tomaso RIMA 1775- 1843
Everard HOME 1799
Ambroise PARE 1509-1590
CHIVA Precursors
Georg Clemens PERTHES 1900
William HARVEY 1578-1657

7. 1788-1899: Ligation of Saphena
Vein
Trendelenburg
1988: CHIVA
Varicocentric
Ablative
1906 Stripping Mayo
Babcok
1947 Sclerosis
2000 RF, Laser, Foam
Short Story
90 years90 years
blackoutblackout
Varicocentric
Ablative
Emodinamicocentric
Conservative

8. 1977
1986
CHIVA was possible thanks to diagnosis
improvement based on Ultrasound Duplex Scan
1988
2009

9. HEMODYNAMIC
CONCEPTS PUBLISHED
IN 1988.
Varicose veins and trophic changes are not the
cause but the effect of overloading pressure/flow
The consequent treatment consists of correcting
this hemodynamic impairment in order to collapse
the varicose veins, restore the tissue health and
reduce the varicose recurrence thanks to
overloading flows disconnection and draining
veins conservation, included varicose.

10. HEMODYNAMIC
CONCEPTS PUBLISHED
IN 1988.
AND BY THE WAY
preservation of the
saphena veins,
possibly vital in case
of necessary arterial
bypass

11. HEMODYNAMIC CONCEPTS
1-Dynamic Fractioning of the Hydrostatic Pressure
2-Closed and Open Shunts
3-Vicarious Varicose Recurrence
4-Saphena Conservation for Future Arterial By-pass
5-Anato-functional Mapping.

12. i P
o P
p P
c P
s g P
ig P
i P
o P
p P
c P
gs P
g s P
20032003
Identification of pelvic leak points: Inguinal (IP) Perinaeal (PP), Clitorudian (CP) Obturator OP) Gluteal
( SGP and IGP)
Franceschi C, Bahnini A. Treatment of lower extremity venous insufficiency due to pelvic leak points in
women. Ann Vasc Surg. 2005 Mar;19(2):284-8
ANATOMIC LOCATION OF PELVIC LEAK POINTS

13. Hemodynamic aspects of
Venous Insufficiency
Diagnosis and Treatment

14. Signs: Edema, Varices, trophic changes, Ulcer
ONE cause
TransMural
Pressure Excess
TMP
Venous Insufficiency Disease

15. TMP
=
Pressure
Extra-Venous
Extra-Capillary
Pressure
Endo-Venous
Endo-Capillary
minus

16. TPM is increased by
1-Hydrostatic Pressure Overloading ( gravitational)
Causes
Valve Incompetence, flow block
2-Residual Pressure Overloading ( micro-circulation)
3-M.Pump Pressure Overloading ( shunts)

17. CHIVA cure :
1/Hydrostatic Pressure column fractionning :
restore the dynamic fractionning of the hydrostatic
column during walking
2/Closed and deviated shunts disconnection :
suppresses flow/pressure overloading supplied by
the VM Pump during walking
3/Draining Veins conservation: avoids residual
pressure excesses responsible for spider veins
and varicose recurrence
4/ Venous Capital Conservation for future
possible need of arterial by-pass

18. CHIVA doesn’t depend on
the varicose veins
evolution, downwards or
upwards

19. Treatments
Venous Sysytem Impairment
Venous Blocks P.Residual P↑
Valve Incompetence Hydrostatic P ↑
Shunts VM Pump P ↑
Hemodynamic Disfunction
Trans Mural Pressure PTM
↑
causes
Genetic Malformazioni Biological
Infezione
Flebiti
Infiamazione
Iatrogenic
Veins ablation
Effects
Dilation Venous
Varicose Veins
Draiange Impairement
Edema
Hypodermitis
Ulcer
Vicious
Circle
PTM↓
Posture
Compression
Veinblock: liberation, by-
pass
Valve repair
CHIVA
Venous Hypertension
posture, obesity
according to the cause

20. Varico Centric Hemodinamico Centric
TMP REDUCTIONTMP REDUCTION
P ExtraVenous Pressure IncreaseP ExtraVenous Pressure Increase
-Compression-Compression
IntraVenous Pressure DecreaseIntraVenous Pressure Decrease
-Posture-Posture
-Liberation-Liberation
VEINS ABLATIONVEINS ABLATION
-Phlebectomy-Phlebectomy
-Sclerosis-Sclerosis
-Laser-Laser
-Radio Frequency-Radio Frequency
IMPAIRS the DRAINAGEIMPAIRS the DRAINAGE
Tissue sufferingTissue suffering
Vicarious RecurrenceVicarious Recurrence
Destruction of the VENOUSDestruction of the VENOUS
CAPITALCAPITAL
CHIVACHIVA
-HP Fragmentation-HP Fragmentation
-Shunt Disconnection-Shunt Disconnection
--Drainage respectDrainage respect
-Venous capital preservation-Venous capital preservation
TREATMENTS

21. OOSS
OO
SFSF
vv aa
MM
Flow/pressurFlow/pressur
e overloade overload
VicariousVicarious
flowflow
FistoleFistole
Artéro-Artéro-
VenosusVenosus
fistulefistule
ClosedClosed
shuntshunt
VenousVenous
malformationmalformation
TMPTMP increases with flow and pressure overload due toincreases with flow and pressure overload due to
various causesvarious causes
HydrostaticHydrostatic
PressurePressure
excessexcess

22. CHIVA is not only avaricose treatment
CHIVA is also the treatment of the cause of
the venous insuficiency
i.e the TMP excess.
When TMP is reduced to normal, all signs
and symptoms are cured: Varicose veins,
Edema, Hypodermitis, Ulcer

23. CHIVA doesn’t depend on
the direction of the
varicose progression ,
downwards or upwards

24. CHIVA cure
- EVIDENCE BASED
MEDICINE
- Randomized Controlled Trials

25. 1- Varicose Vein Surgery Stripping versus the CHIVA method:
a Randomized
Controlled Trial Josep oriol
Pares and al Annals
of Surgery * Volume 251, Number 4, April 2010 [ISRCTN52861672].[ISRCTN52861672]. (international(international
standard randomised controlled trial number )www.controlled-trials.comstandard randomised controlled trial number )www.controlled-trials.com
2- Minimally Invasive Surgical management of primary venous Ulcer vs.
Compression Treatment: a randomized Clinical Trial
P.Zamboni and all
Eur J vasc Endovasc Surg 00,1 6 (2003)
3- Clinical and random study comparing two, surgical techniques for varicose
vein treatment : immediate results
Iborra and all
Angiologia 2000:6, 253-258
4-Varicose Vein Stripping vs Haemodynamic Correction (CHIVA):
a Long Term Randomised Trial.
Carandina, C. and al.
Eur J Vasc Endovasc Surg xx, 1e8 (2007)
doi:10.1016/j.ejvs.2007.09.011

26. 1- Varicose Vein Surgery Stripping versus the CHIVA method:
a Randomized
Controlled Trial Josep oriol
Pares and al Annals
of Surgery * Volume 251, Number 4, April 2010 [ISRCTN52861672].[ISRCTN52861672]. (international(international
standard randomised controlled trial number )www.controlled-trials.comstandard randomised controlled trial number )www.controlled-trials.com
2- Minimally Invasive Surgical management of primary venous Ulcer vs.
Compression Treatment: a randomized Clinical Trial
P.Zamboni and all
Eur J vasc Endovasc Surg 00,1 6 (2003)
3- Clinical and random study comparing two, surgical techniques for varicose
vein treatment : immediate results
Iborra and all
Angiologia 2000:6, 253-258
4-Varicose Vein Stripping vs Haemodynamic Correction (CHIVA):
a Long Term Randomised Trial.
Carandina, C. and al.
Eur J Vasc Endovasc Surg xx, 1e8 (2007)
doi:10.1016/j.ejvs.2007.09.011

27. 0
10
20
30
40
50
60
70
464 465 459 453 458 457
6m 12m 24m 36m 48m 60m
%
Ph-M
Ph-ED
TC
St -MC
St -ED
TC
5ans. 550 Patients
Up to 18 months: NO differenceUp to 18 months: NO difference
Difference increases with time after 2 yearsDifference increases with time after 2 years
CHIVA
Stripp. Duplex guided
Stripp. Clinical
5 years follow up : Recurrence rate:5 years follow up : Recurrence rate:
CHIVA vs strippingCHIVA vs stripping

28. 0
10
20
30
40
50
60
70
464 465 459 453 458 457
6m 12m 24m 36m 48m 60m
%
Ph-M
Ph-ED
TC
St -MC
St -ED
TC
5ans. 550 Patients
Duplex Guided Vs Clinical : NO differenceDuplex Guided Vs Clinical : NO difference
Duplex is USLESS for strippingDuplex is USLESS for stripping
CHIVA
Stripp. Duplex guided
Stripp. Clinical
5 years follow up : Recurrence rate:5 years follow up : Recurrence rate:
CHIVA vs strippingCHIVA vs stripping

29. 1- Varicose Vein Surgery Stripping versus the CHIVA method:
a Randomized
Controlled Trial Josep oriol
Pares and al Annals
of Surgery * Volume 251, Number 4, April 2010 [ISRCTN52861672].[ISRCTN52861672]. (international(international
standard randomised controlled trial number )www.controlled-trials.comstandard randomised controlled trial number )www.controlled-trials.com
2- Minimally Invasive Surgical management of primary venous Ulcer vs.
Compression Treatment: a randomized Clinical Trial
P.Zamboni and all
Eur J vasc Endovasc Surg 00,1 6 (2003)
3- Clinical and random study comparing two, surgical techniques for varicose
vein treatment : immediate results
Iborra and all
Angiologia 2000:6, 253-258
4-Varicose Vein Stripping vs Haemodynamic Correction (CHIVA):
a Long Term Randomised Trial.
Carandina, C. and al.
Eur J Vasc Endovasc Surg xx, 1e8 (2007)
doi:10.1016/j.ejvs.2007.09.011

30. KAPLAN-MEIR ESTIMATIONKAPLAN-MEIR ESTIMATION
1.01.0
0.80.8
0.60.6
0.40.4
0.20.2
00
1.01.0
0.80.8
0.60.6
0.40.4
0.20.2
00
00 250250 500500 500500750750 10001000
TIME (days)TIME (days)
CHIVACHIVA
compressioncompression
Minimally invasive surgical management of primary venousMinimally invasive surgical management of primary venous
ulcers vs. compression treatment: a randomized clinical trial..ulcers vs. compression treatment: a randomized clinical trial..
Zamboni Pand al A.Zamboni Pand al A. EJ V E S. 2003EJ V E S. 2003

31. 1- Varicose Vein Surgery Stripping versus the CHIVA method:
a Randomized
Controlled Trial Josep oriol
Pares and al Annals
of Surgery * Volume 251, Number 4, April 2010 [ISRCTN52861672].[ISRCTN52861672]. (international(international
standard randomised controlled trial number )www.controlled-trials.comstandard randomised controlled trial number )www.controlled-trials.com
2- Minimally Invasive Surgical management of primary venous Ulcer vs.
Compression Treatment: a randomized Clinical Trial
P.Zamboni and all
Eur J vasc Endovasc Surg 00,1 6 (2003)
3- Clinical and random study comparing two, surgical techniques for varicose
vein treatment : immediate results
Iborra and all
Angiologia 2000:6, 253-258
4-Varicose Vein Stripping vs Haemodynamic Correction (CHIVA):
a Long Term Randomised Trial.
Carandina, C. and al.
Eur J Vasc Endovasc Surg xx, 1e8 (2007)
doi:10.1016/j.ejvs.2007.09.011

32. Clinical and random study comparing two, surgical techniques for varicose vein
treatment : immediate results
Iborra and all
Angiologia 2000:6, 253-258
immediate results: NO DIFFERENCE
In accordance with O.Pares where
CHIVA vs Stripping difference starts
after the 18th month!

33. 1- Varicose Vein Surgery Stripping versus the CHIVA method:
a Randomized
Controlled Trial Josep oriol
Pares and al Annals
of Surgery * Volume 251, Number 4, April 2010 [ISRCTN52861672].[ISRCTN52861672]. (international(international
standard randomised controlled trial number )www.controlled-trials.comstandard randomised controlled trial number )www.controlled-trials.com
2- Minimally Invasive Surgical management of primary venous Ulcer vs.
Compression Treatment: a randomized Clinical Trial
P.Zamboni and all
Eur J vasc Endovasc Surg 00,1 6 (2003)
3- Clinical and random study comparing two, surgical techniques for varicose
vein treatment : immediate results
Iborra and all
Angiologia 2000:6, 253-258
4-Varicose Vein Stripping vs Haemodynamic Correction (CHIVA):
a Long Term Randomised Trial.
Carandina, C. and al.
Eur J Vasc Endovasc Surg xx, 1e8 (2007)
doi:10.1016/j.ejvs.2007.09.011

34. 1,75
1,8
1,85
1,9
1,95
2,05
2,1
2,15
2,2
2,25
2
P<0.038
Stripping
CHIVACHIVA
BEST SCORESBEST SCORES
18%
35%
0
5
10
15
20
25
30
35
CHIVA Stripping
RECIDIVE
1O years follow up : Recurrence rate:1O years follow up : Recurrence rate:
CHIVA vs strippingCHIVA vs stripping
Objective evaluation
S.Carandina, and alS.Carandina, and al.. E J V E Surg. 2008E J V E Surg. 2008
CHIVA
Stripping

35. 1 COCHRANE REVIEW
CHIVA vs Stripping
Less recurrences, less complications
Bellmunt-Montoya S, Escribano JM, Dilme J, Martinez-
Zapata MJ. CHIVA method for the treatment of chronic
venous insufficiency. Cochrane Database of Systematic
Reviews 2012 , Issue 2 . Art. No.: CD009648.
DOI:10.1002/14651858.CD009648 .

36. EVIDENCES Level Grade
meta-analyses de RCT
Ia A Strong
Au moins un RCT
Ib
Au moins une étude clinique
bien conduite sans
randomisation
IIa B Mid
Au moins un autre type
d’étude clinique bien
programmé et quasi
expérimental
IIb
Au moins un autre type
d’étude clinique bien
programmée et non
expérimentale
III
Opinions de comités
d’experts ou expérience
d’autorités reconnues
IV C Weak
Other venous technics at this level????
Stripping still Gold standard? CHIVA ?
CHIVA (4 RCT)
CHIVA (4 RCT)
+ Cochrane Library REVEW

37. Retrospective study CHIVA vs LASER
.
Chan, C.-Y.a , Chen, T.-C.b , Hsieh, Y.-K.a , Huang, J.-
H.c
Retrospective comparison of clinical outcomes between
endovenous laser and saphenous vein-sparing surgery
for treatment of varicose veins (2011) World Journal of
Surgery, 35 (7), pp. 1679-1686.
Conclusion: The CHIVA patients had less pain
postoperatively and a significantly higher sclerotherapy-free
period compared to patients in the EVL group.

38. GUIDELINES
• The care of patients with varicose veins and associated chronic venous
diseases: Clinical practice guidelines of the Society for Vascular Surgery and
the American Venous Forum
• Peter Gloviczki, MD, and al. JVS 2011
• Results with preservation of the saphenous vein. Results with CHIVA. Two
RCTs188,191 compared standard treatment(compression or high ligation, stripping,
and phlebectomy) with CHIVA approaches with specific anatomic patterns of reflux
(types I and III shunts). For the specific venous anatomy evaluated in these
trials, such techniques were better than compression in preventing ulcer
recurrence and were at least equivalent to stripping of varicose veins. Although
the first two RCTs focused on a small group of patients with varicose veins, the trial of
Pares et al deserves credit for including the full spectrum of patients with primary
varicose veins. CHIVA is a complex approach, and a high level of training and
experience is needed to attain the results presented in this RCT. However, the
results achieved by a few outstanding interventionists does not support offering this
procedure to all practitioners.Although CHIVA has called attention to the importance
of directing surgical procedures toward the patient’s venous anatomy and function, it
still requires considerable education of venous interventionists willing to learn
this approach.

39. CHIVA requires considerable education of venous
interventionists willing to learn this approach” (Peter
Gloviczki, MD, and al. JVS 2011) because it relies on new
hemodynamic concepts of the venous pathophysiology and
a proper DUS assessment method. CHIVA performed by
who doesn’t know enough about them is not CHIVA and
leads to failure as a study demonstrated it (Milone M,
Salvatore G, Maietta P, Sosa Fernandez LM, Milone
Recurrent varicose veins of the lower limbs after
surgery. Role of surgical technique (stripping vs.
CHIVA) and surgeon's experience.F. G Chir. 2011 Nov-
Dec;32(11-12):460-3).So, conservation is possible in all
the patients and CHIVA

40. …..today, treatments are
performed in accordance
with the evidence based
medicine supplied by
Randomized Controlled
Trials ….and after a
comprehensive
information and consent
of the patient.
President of
Medicine
Academy

41. CHIVA preserves the GSV for future arterial bypass
Optimal management of infrainguinal arterial occlusive disease
Authors: Pennywell DJ, Tan TW, Zhang WW
Full text: available on http://www.dovepress.com/article_18926.t34346121
Risk factors:Age is the most important, nonmodifiable risk factor for PAD, with a
prevalence of 0.9% in people under age 50 and 23.2% in people over the age of
80.1
Open reconstruction:The most important determinant of success of an
Infrainguinal lower extremity bypass (LEB) is the type and quality of conduit
selected.2,17,52 Autogenous vein is superior to synthetic graft as conduit for
LEB,2,53–55 and the great saphenous vein (GSV) is superior to other
autologous alternatives.2,55,56 An essential step in preoperative planning is
evaluation of the GSV with duplex mapping and identification of alternative vein
conduits, if needed. An ideal vein conduit should be soft, compressible, at least 3
mm in diameter, and should not be calcified or sclerotic. If the ipsilateral GSV is
unsuitable or unavailable, the contralateral GSV should be used.
Conclusion
Open infrainguinal bypass remains the gold standard for revascularization
in CLI, especially for patients at appropriate surgical risk and with suitable bypass
conduit.

42. Is it professional not to give the best
scientifically proved treatment to the
patient?
Is it honest to tell the patient his
saphena wouldn’t be usefull in case of
arterial by-pass necessity?