.

1. P. Pittaluga, S. Chastanet
Is the ASVAL technique really
overcoming the CHIVA limitations?

2. P. Pittaluga, S. Chastanet
Is the ASVAL technique really
overcoming the CHIVA limitations?
Two options for a saphenous sparing strategy

3. I do not have any relevant
financial relationships
with any commercial interest
DISCLOSURE OF INTEREST

4. 2 options for a saphenous sparing strategy
The ASVAL method
Is only the name different ?
The CHIVA cure

5. SIMILARITY

6. SIMILARITY

7. SIMILARITY
Franceschi C. Théorie et Pratique de la
Cure Conservatrice Hémodynamique de
l’Insuffisance Veineuse en Ambulatoire,
Percy sous thil, Editions de l’Armaçon,1988
CHIVA

8. SIMILARITY
Pittaluga P, Chastanet S,Rea B, Barbe R.
Phlébologie 2005;58:175-61
ASVAL

9. SIMILARITY

10. SIMILARITY
No need of device
No support from the industry

11. For all the rest, they are totally opposed !!!
The ASVAL methodThe CHIVA cure

12. THERAPEUTIC PRINCIPLE

13. CHIVA
Saphenous vein -> efficient way of drainage
THERAPEUTIC PRINCIPLE

14. CHIVA
Saphenous vein -> efficient way of drainage
THERAPEUTIC PRINCIPLE
 Fragmentation of the column
pressure & disconnection of the
venous shunts with ligations

15. CHIVA
Saphenous vein -> efficient way of drainage
 Perform a system well-drained
• All isolated superf. segment drained in deep
veins
THERAPEUTIC PRINCIPLE
 Fragmentation of the column
pressure & disconnection of the
venous shunts with ligations

16. ASVAL
Restore the saphenous vein competence
THERAPEUTIC PRINCIPLE

17. ASVAL
Restore the saphenous vein competence
THERAPEUTIC PRINCIPLE

18. INDICATIONS
CHIVA
Universal method +++

19. INDICATIONS
 All kind of reflux patterns have a CHIVA solution
• Precise preop echo-Duplex mapping
• Set a good strategy of treatment -> system well-drained
CHIVA
Universal method +++

20. INDICATIONS
 All patients from C1 to C6 can be treated
CHIVA
Universal method +++
 All kind of reflux patterns have a CHIVA solution
• Precise preop echo-Duplex mapping
• Set a good strategy of treatment -> system well-drained

21. INDICATIONS
 A failure is always consecutive to a bad performance
• Requires expert ultrasonographers and expert surgeons +++
 All patients from C1 to C6 can be treated
CHIVA
Universal method +++
 All kind of reflux patterns have a CHIVA solution
• Precise preop echo-Duplex mapping
• Set a good strategy of treatment -> system well-drained

22. ASVAL
Selected indications for ASVAL +++
INDICATIONS

23. ASVAL
Selected indications for ASVAL +++
 Hemodynamic or anatomical criteria
• Limited SV dilatation (<10 mm for GSV; 6mm for SSV)
• Competent junction, segmental SV reflux
• Voluminous varicose tributary at the thigh
• Reversibility test + (compression of the varicose tributary)
 Clinical criteria
• Nulliparity +++
• Young age
• Cosmetic concern, few symptoms
INDICATIONS

24. ASVAL
Selected indications for ASVAL +++
 Hemodynamic or anatomical criteria
• Limited SV dilatation (<10 mm for GSV; 6mm for SSV)
• Competent junction, segmental SV reflux
• Voluminous varicose tributary at the thigh
• Reversibility test + (compression of the varicose tributary)
 Clinical criteria
• Nulliparity +++
• Young age
• Cosmetic concern, few symptoms
 Worse hemodynamic or clinical stages
• There is still indications for saphenous ablation / stripping
• Represents only 20% of the cases
INDICATIONS

25. EVIDENCES

26. EVIDENCES
CHIVA

27. EVIDENCES
• Follow up 5 years
• CHIVA > stripping for recurrence
•(31.1% vs 52.7% P<0.001)
• Follow up 10 years
• CHIVA > stripping for recurrence
•(8% vs 35% P=0.0038)
• Follow up 3 years
• CHIVA > compression for ulcer healing
(100% vs 96% P<0.02) and ulcer recurrence
(9% vs 38% P<0.05)
CHIVA

28. EVIDENCES
ASVAL

29. EVIDENCES
ASVAL

30. EVIDENCES

31. ASVAL vs CHIVA: which is better ?
FIGHT

32.  Rigid theory
• Excludes all other techniques
• Locks up into a unique approach
• Difficult to apply to a chaotic system
CHIVA’s weaknesses
FIGHT
 Not obvious to understand
• Limited to a community of experimented physicians
 Worsens the disease if not well done
• Explains its failure to be spread during 90’s

33.  Intellectual attractiveness
• Smart theory
CHIVA’s strengths
FIGHT
 Ambulatory & cheap
 Strong community
• Big chief (Franceschi)
• Enables to conduct studies with different teams

34. ASVAL’s weaknesses
 Limited indications
• Further experiences/studies to confirm the good indications
 Requires thorough ablation of the varicose reservoir
• Multiple phlebectomies, boring for the physician
 Absence of strong community
• Open approach, no big chief
• More difficult to induce studies in other teams

35.  Simple to understand
ASVAL’s strengths
 Leaves a place to other techniques
• Open to a larger number of physicians
 Ambulatory & cheap
 Doesn’t worsen the disease when it fails
• Secondary phlebectomy/ablation possible

36. CONCLUSION
 CHIVA & ASVAL are two saphenous sparing strategies
 CHIVA and ASVAL have two opposite theoretical and
therapeutic principles
 ASVAL seems to us more likely to be performed by a
large number of physicians since ASVAL is easier to
understand and to perform, it doesn’t exclude other
techniques and it doesn’t worsen the disease if it fails
 CHIVA and ASVAL are supported by publications but
with a limited level of recommendation in the
guidelines because of a lack of strong scientific
evidences

37. Thank you for
your attention