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COMPARISON BETWEEN CHIVA METHOD
AND ASVAL TREATMENT
Stefano Ermini MD
Firenze
A Ablation
S Selective
V Varices … sous
A Anestesie
L Locale
Paul Pittaluga
ASVAL Phisiopathologic assesment
1. Ascending Theory
2. “Reservoire” effect
ASVAL Strategy
1. Tributary compression test
L...
Phisiopahologic presuppositions : Ascending theory
1-Dr Pittalugua: “That is the explanation of the « aspirating effect » ...
What the “reservoir” effect is in Phisiology ?
Reservoire venoso:
Sistema di
ammortizzamento delle
variazioni di pressioni...
The “Reservoir” effect, invented from the ascending theory
followers , would be that a large varicose veins volum capacity...
∂gh
Leukocyte adhesion in the valve sinus
M.A. Elsharawy et al. Interactive
Cardiovascula and Thoracic Surgery 6 (2007)
21...
3° Commento
Daily practice:
Rare Finding of enlarged veins not refluxing
Frequent findings of not enlarged refluxing veins...
4° Comment
A DUS documentation of proximal reflux extension is possible?
Answer = NO
No Competent valves
No retrograde Flo...
Strategy
 ASVAL : Extensive phlebectomy of
the incomtent tributary
 CHIVA : adapted to shunt type and
to systolic cartho...
La Strategia
ASVAL strathegy : provides an extensive phlebectomy of the incompetent thigh
tributary when the compression t...
Note that …
The compression re-entry test has been
described by Claude Franceschi 23 years ago
and publied by Marc Bailly ...
Which Kind of Hemodynamic Pattern can give origin to
this GSV thigh tributhary ?
GSV
SSV
Giacomini
Deep Veins
Competent
In...
1° variable aspect :
a. The escape point can exists or not
b. The escape point location
Whithout escape point Whit an esca...
Possible Escape Points
Incompetent SFJ
Pelvic escape point
Hunter Perforator
Zamboni : 80%
recidive a 3 anni
2° variable aspect :
The saphenous axe below the tributary origin ( competent/incompetent/absent)
Competent Incompetent Ab...
With Saphenous Incompetence
With Competent GSV
below the tributary
With Incompetent GSV
below the tributary
Shunt Type 2A ...
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 p...
ASVAL provides the saphenous trunk
stripping or Laser ablation when the
saphenous reflux reappers after
phlebectomy
What p...
Why do centrifugal flow reappears in a shunt type 2 after
tributary flush ligation ( including or not an extensive
phlebec...
Is extensive phlebetomy mandatory??
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Differences between CHIVA strategy and ASVAL treatment.

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Differences between CHIVA strategy and ASVAL treatment.

  1. 1. COMPARISON BETWEEN CHIVA METHOD AND ASVAL TREATMENT Stefano Ermini MD Firenze
  2. 2. A Ablation S Selective V Varices … sous A Anestesie L Locale Paul Pittaluga
  3. 3. ASVAL Phisiopathologic assesment 1. Ascending Theory 2. “Reservoire” effect ASVAL Strategy 1. Tributary compression test La Strategia CHIVA 1. Tributary compression test 2. Systolic carthography CHIVA Phisiopathogic assesement All theories
  4. 4. 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 2009 Feeding tributary effect in 2013
  5. 5. 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
  6. 6. 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
  7. 7. ∂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
  8. 8. 3° Commento Daily practice: Rare Finding of enlarged veins not refluxing Frequent findings of not enlarged refluxing veins Prospective epidemiological study on the beginning of varicose veins. Schultz-Ehrenburg and al. Phlebologie 2009; 38: 17–25 Longitudinal 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 reflux Studio Schulz-Ehrenburg = Reflux precedes dilation
  9. 9. 4° Comment A DUS documentation of proximal reflux extension is possible? Answer = NO No Competent valves No retrograde Flow Incompetent tributary Competent Valve
  10. 10. Strategy  ASVAL : Extensive phlebectomy of the incomtent tributary  CHIVA : adapted to shunt type and to systolic carthography
  11. 11. 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
  12. 12. 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. Bailly Carthographie CHIVA EMC - Paris 1995
  13. 13. Which Kind of Hemodynamic Pattern can give origin to this GSV thigh tributhary ? GSV SSV Giacomini Deep Veins Competent Incompetent
  14. 14. 1° variable aspect : a. The escape point can exists or not b. The escape point location Whithout escape point Whit an escape point ( SFJ)
  15. 15. Possible Escape Points Incompetent SFJ Pelvic escape point Hunter Perforator Zamboni : 80% recidive a 3 anni
  16. 16. 2° variable aspect : The saphenous axe below the tributary origin ( competent/incompetent/absent) Competent Incompetent Absent (US not detected)
  17. 17. 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
  18. 18. Possibilities with a refluxing SFJ - Terminal valve incompetent (positive Valsalva) Shunt Type 3 Shunt Type 1 + 2
  19. 19. Variables of Shunt Type 3 Shunt Type 3/a Shunt Type 3/b Shunt Type 3/c
  20. 20. Shunt Type 4 +II Pelvic escape point Shunt Type 5
  21. 21. Muscle Contractive Centripetal Flow in the Giacomini Vein that feeds a centrifugal flow in the GSV during the relaxation phase
  22. 22. 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 ?
  23. 23. 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
  24. 24. Is extensive phlebetomy mandatory?? Thanks for your attention Video perthes test
  25. 25. Thanks for your attention

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