Stefano Ricci
AbstractThe Office based (OB) – CHIVA (Conservative and Hemodynamic treatment of Venous Insufficiency in Outpatients) is a slightly modified CHIVA strategy designed to use some technical facilities adopted in ablative procedures. Currently available choices for CHIVA crossotomy are: section ligature, isolated ligature, the clip and the triple saphenous flush ligation (TSFL) technique. The OB-CHIVA was introduced in order to reduce the required resources and generic surgical risk, especially risks associated with CHIVA crossotomy. In addition, OB-CHIVA tries to answer the often faced but never solved issue of a minimally invasive surgical CHIVA intervention. It is not only a technical but rather a conceptual variation of CHIVA, thus the two methods cannot be considered the same thing. The essential difference is the reduced length of saphenous treatment, which is much shorter than the length generally treated in laser procedures. Unlike CHIVA but similar to LASER and RF, OB-CHIVA leaves some tributaries of the arch and uses them as washing vessels (draining crossotomy). The research protocol includes only OB-CHIVA cases with crossotomy performed with alternative methods (LASER, RF, and steam). Chemical agents were excluded. The prerequisite for treatment is SFJ terminal valve incompetence; thus, we need to know: |
Words by the Master: La Cure CHIVA est conservatrice et se pratique en ambulatoire (CHIVA treatment is conservative and is performed in office).1 If in the method definition the procedure is office based, it may be questioned why a group of CHIVA fans try to find a way of making the same method office based. Moreover, I know for sure that at least two of the Authors of the paper already practice their CHIVA treatment in office. Probably the Authors try to change traditional CHIVA crossotomy (a quite demanding operation) in a more easy operation, employing commonly used tools (Laser, RF, etc) in the attempt to popularize the method, but in this way, they commit the capital sin of accepting an incomplete SFJ interruption, something that Claude Franceschi (one of the Authors) would have never accepted in the past. Going more through the protocol analysis, one may wonder why the simple GSV interruption at 3-4 cm from the junction by stab extraction, ligation (at two cm) and section - like suggested and practiced by several French colleagues and by myself - has not been included, although being easily performed in office, in local anesthesia, at a very low cost compared to the suggested methods. Somebody could see in the suggested association of two methods (i.e., CHIVA + LASER) a better reimbursement mechanism, which is surely not in the intent of the Authors. Furthermore, the GSV anatomy of the last centimeters reveals many variations so that the given protocol should be revised as far as the SFJ tributaries are concerned.2 In fact, a punctual Laser vein closure seems at least unpredictable, while no date are available about the minimum length of the saphenous stem needed to maintain obstructed the vein. Concerning devalvulation, no indications are given about the treatment of consequent thrombosis, an event that commonly occurs after the procedure, according to Franceschi (personal communication). Finally, the costs of the suggested protocol execution will rise highly, while the purpose of an office based procedure should be simplification and cost saving.
Thanks for the very interesting criticism.
A short premise about the reasons why to implement OB CHIVA:
• CHIVA uses a difficult diagnostic assessment and operators have a generally long learning curve;
• OB CHIVA uses some simple diagnostic maneuvers and a flow chart provides a computer-aided decision, to help everyone to perform the diagnostic/strategic step;
• CHIVA requires a traditional Day Surgery environment, more complex than actually required by all the ablative endovascular procedures;
• OB CHIVA is a completely Office Based procedure;
• CHIVA is performed essentially by surgeons, excluding all phlebologists not trained in surgical procedures;
• OB CHIVA can be performed also by phlebologists with a limited surgical knowledge, but experienced in endovascular procedures.
Detailed answers.
[...] If in the method definition the procedure is office based, it may be questioned why a group of CHIVA fans try to find a way of making the same method office based...
This issue isn’t specific of CHIVA but is common to all venous ablative procedures as they all were and are today more and more applied in outpatients and in Day Surgery environments. A common trend for them is to search for more simple procedures declared as Office Based. For instance, the famous CX Vascular Meeting in London dedicated in the last years (and still in the next 2014 program) several sessions to the Office Based venous procedures, as they were a new treatment behavior.
Maybe the explanation is that the old term ambulatorial was referred to simple operating rooms, while the modern office based term requires a much smaller number of resources for the intervention.
[...] the Authors try to change traditional CHIVA crossotomy in a more easy operation, employing commonly used tools (Laser, RF, etc) in the attempt to popularize the method...
Why not? Shifting to Endovascular procedures can be a natural extension, in a world that is practically dominated by these devices.
[...] capital sin of accepting an incomplete SFJ interruption, something that Claude Franceschi (one of the Authors) would have never accepted in the past...
And in the present Claude Franceschi thinks the same too! More than one page in the paper is used to explain that CHIVA and OB CHIVA are two different strategies, which use also different tactics. However, this depends on the actual technology and on the future developments, because the greatest aim of OB CHIVA is to be never more a different strategy, but only one of the tactics employed in CHIVA.
[...] why the simple GSV interruption at 3-4 cm from the junction by stab extraction, ligation (at two cm) and section - like suggested and practiced by several French colleagues and by myself - has not been included, although being easily performed in office, in local anesthesia, at a very low cost compared to the suggested methods...
We were not aware of this method so it was not included, though it could.
Nevertheless, the real difference is the need of planning the trunk interruption (using washing and draining vessels), searching for a personalized intervention instead of a standardized one, everywhere and for everyone.
In addition, 3-4 cm from the SFJ can be a long distance. Depending on the length and the type of tributaries, leaving a long patent stump will sometimes transform the intervention in an old-style bad practiced crossotomy, leaving almost all the tributaries of the arch. The least important requirement in OB CHIVA is to use washing vessels at the junction. They are tolerated because SFJ flush treatment is hardly afforded by endovascular procedures, while they could be simply not used if SFJ would be treated surgically with a flush ligation (not as an Office Based procedure).
[...] suggested association of two methods (i.e., CHIVA+ LASER) a better reimbursement mechanism...
It depends on the country. For instance in some European countries, traditional surgical and endovascular procedures are included in the same category of reimbursement, while in USA instead the endovascular approach has a better reimbursement.
[...] the GSV anatomy of the last centimeters reveals many variations so that the given protocol should be revised as far as the SFJ tributaries are concerned...
Though not written clearly in our paper, refluxing tributaries of the arch cannot be used as washing vessels. Independently of the presence/absence of the valves, washing vessels feed the junction in the anterograde direction and draining vessels in a retrograde fashion. This occurs by definition owing to the pre-requisite of the SFJ intervention in OB CHIVA, i.e. the incompetence of TV and PTV. In case of treatment of high arch refluxing tributaries (AASV) using LASER or mini-surgical approach, the method is already Office Based and the OB CHIVA protocol has nothing new to add.
[...] In fact, a punctual Laser vein closure seems at least unpredictable, while no data are available about the minimum length of the saphenous stem needed to maintain obstructed the vein...
Agree! One of the aims clearly declared in the paper is the study of the evolution of the SFJ stump and the relationship between the GSV closure persistence and the length of the treated segment, which was never investigated before. Thus the research protocol faces this issue and as soon as data will show a clear success/failure of the reduced length procedure, the protocol will be changed/discontinued in favor of one or the other method.
[...] Concerning devalvulation, no indications are given about the treatment of consequent thrombosis, an event that commonly occurs after the procedure...
Classical devalvulation is already Office Based, performed during a flush phlebectomy of the tributary. Using the wire-guided method or the virtual dissection variant is only a tactical change. No indication is given about thrombosis after devalvulation, because post-devalvulation thrombosis and its evolution and treatment are already described for classical CHIVA interventions.
[...] the costs of the suggested protocol execution will rise highly, while the purpose of an office based procedure should be simplification and cost saving.
The Office Based environment aims essentially to simplify the procedures, though very often cost saving proceeds together.
However, a reduction of costs occurs also owing to a reduced number of resources comparing with mini-surgery/Day Surgery. For instance the reduced number of personnel required by sanitary law and surgical materials as sutures and medications.
1. Franceschi C, ed. Theorie et pratique dela cure CHIVA. Dijon: Editions de L’Armacon; 1988. p 106.
2. Dickson R, Hill G, Thomson IA, van Rij AM. The valves and tributary veins of the saphenofemoral junction: ultrasound findings in normal limbs. Veins and Lymphatics 2013;2:e18. [Full-Text]
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