COMPARISON BETWEEN CHIVA METHOD AND ASVAL TREATMENT

Stefano Ermini MDFirenze

A AblationS SelectiveV Varices … sous A AnestesieL Locale

Paul Pittaluga

ASVAL Phisiopathologic assesment1. Ascending Theory2. “Reservoire” effect

ASVAL Strategy1. Tributary compression test

La Strategia CHIVA1. Tributary compression test2. Systolic carthography

CHIVA Phisiopathogic assesementAll theories

Phisiopahologic presuppositions : Ascending theory

1-Dr Pittalugua: “That is the explanation of the « aspirating effect » of the varicose reservoir on the saphenous vein” : Vasculab 2009. He changed this explanation 4 years later in “We talk about "filling effect" rather than "aspirating effect". The dilatation begins on the tributaries at the bottom (where the hydrostatic pressure is higher) because of the weakness of the vein wall and the absence of protection by the fascia”. VASCULAB Feb 2013

Aspirativ effect in 2009Feeding tributary effect in 2013

What the “reservoir” effect is in Phisiology ?

Reservoire venoso:Sistema di

ammortizzamento delle variazioni di pressioni nel

sistema venoso grazie alla compliance della

parete che consente un aumento di volume

importante con aumento di pressione debole

( almeno fino al raggiungimento della massima distensione).

Reservoire cardiaco:Svolto dalle vene

muscolari

The “Reservoir” effect, invented from the ascending theory followers , would be that a large varicose veins volum capacity

alone is capable of creating a “passive”aspirative effect..

Only that a liquid movement may be created only by "active"forces, like that of gravity or a pump.

MotionEquation of a Generic Volume (Base of Hydrodynamics)

Force acting on the unit mass

Therefore this concept is contrary to the physic fluids law

∂gh

Leukocyte adhesion in the valve sinus

M.A. Elsharawy et al. Interactive Cardiovascula and Thoracic Surgery 6 (2007) 219-224(ONO T. et al. J. Vasc. Surgery 1998 Jan; 27 (1):158-166)

2° Comment

3° Commento

Daily practice:Rare Finding of enlarged veins not refluxingFrequent findings of not enlarged refluxing veins

Prospective epidemiological study on the beginning of varicose veins. Schultz-Ehrenburg and al. Phlebologie 2009; 38: 17–25Longitudinal study . 740 pupils 10-12 to 18-20. “The manifestation of a truncal VV is preceded by a VR in the same vein (p = 0.039). “

ASVAL = Dilation precedes refluxStudio Schulz-Ehrenburg = Reflux precedes dilation

4° CommentA DUS documentation of proximal reflux extension is possible?

Answer = NO

No Competent valvesNo retrograde Flow

Incompetent tributary

Competent Valve

Strategy

ASVAL : Extensive phlebectomy of the incomtent tributary

CHIVA : adapted to shunt type and to systolic carthography

La Strategia

ASVAL strathegy : provides an extensive phlebectomy of the incompetent thigh tributary when the compression test is positive.If saphenous reflus reappears , ASVAL provides the saphenous trunk stripping or Laser ablation“Penso” che da questo è nato lo stripping senza crossectomia, per trattare la ricomparsa del reflusso in caso di valvola terminale continente.

In conclusion ASVAL is only the new “Muller” phlebectomy justified by the ascending theory

CHIVA Strategy : Never provides the saphenous trunk ablation

Note that …The compression re-entry test has been

described by Claude Franceschi 23 years ago and publied by Marc Bailly in 1995

J.M. BaillyCarthographie CHIVAEMC - Paris 1995

Which Kind of Hemodynamic Pattern can give origin to this GSV thigh tributhary ?

GSV

SSV

Giacomini

Deep Veins

Competent

Incompetent

1° variable aspect : a. The escape point can exists or notb. The escape point location

Whithout escape point Whit an escape point ( SFJ)

Possible Escape Points

Incompetent SFJ Pelvic escape pointHunter Perforator

Zamboni : 80% recidive a 3 anni

2° variable aspect : The saphenous axe below the tributary origin ( competent/incompetent/absent)

Competent Incompetent Absent (US not detected)

With Saphenous Incompetence

With Competent GSV below the tributary

With Incompetent GSV below the tributary

Shunt Type 2A Shunt Type 2B Shunt Type 2C

Possibilities without escape point (negative Valsalva)Shunt Type 2

Without Saphenous Incompetence

Possibilities with a refluxing SFJ - Terminal valve incompetent (positive Valsalva)

Shunt Type 3 Shunt Type 1 + 2

Variables of Shunt Type 3

Shunt Type 3/a Shunt Type 3/b Shunt Type 3/c

Shunt Type 4 +II

Pelvic escape point

Shunt Type 5

Muscle Contractive Centripetal Flow in the Giacomini Vein that feeds a centrifugal flow in the GSV during the relaxation phase

ASVAL provides the saphenous trunk stripping or Laser ablation when the

saphenous reflux reappers after phlebectomy

What percentage do you think ASVAL will be a saphenous sparing surgery

treatment?

Less then 20% in shunt type 3 and about 50% in shunt type 2/b and 5

?

Why do centrifugal flow reappears in a shunt type 2 after tributary flush ligation ( including or not an extensive

phlebectomy) ?

Saphenous trunk

Tributary

Tributary

Desappearing of diastolic centrifugal flow

No flow is detectable A Centripetal flow persists

Saphenous trunk

Desappearing of diastolic centrifugal flow

Is extensive phlebetomy mandatory??

Thanks for your attention

Video perthes test

Thanks for your attention