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P. Pittaluga, S. Chastanet
Is the ASVAL technique really overcoming the CHIVA limitations?
P. Pittaluga, S. Chastanet
Is the ASVAL technique really overcoming the CHIVA limitations?
Two options for a saphenous sparing strategy
I do not have any relevantfinancial relationshipswith any commercial interest
DISCLOSURE OF INTEREST
2 options for a saphenous sparing strategy
The ASVAL method
Is only the name different ?
The CHIVA cure
SIMILARITY
SIMILARITY
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
SIMILARITY
Pittaluga P, Chastanet S,Rea B, Barbe R. Phlébologie 2005;58:175-61
ASVAL
SIMILARITY
SIMILARITY
No need of device
No support from the industry
For all the rest, they are totally opposed !!!
The ASVAL methodThe CHIVA cure
THERAPEUTIC PRINCIPLE
CHIVA Saphenous vein -> efficient way of drainage
THERAPEUTIC PRINCIPLE
CHIVA Saphenous vein -> efficient way of drainage
THERAPEUTIC PRINCIPLE
Fragmentation of the column pressure & disconnection of the venous shunts with ligations
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
ASVAL Restore the saphenous vein competence
THERAPEUTIC PRINCIPLE
ASVAL Restore the saphenous vein competence
THERAPEUTIC PRINCIPLE
INDICATIONS
CHIVA Universal method +++
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 +++
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
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
ASVALSelected indications for ASVAL +++
INDICATIONS
ASVALSelected 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
ASVALSelected 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
EVIDENCES
EVIDENCES
CHIVA
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
EVIDENCES
ASVAL
EVIDENCES
ASVAL
EVIDENCES
ASVAL vs CHIVA: which is better ?
FIGHT
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
Intellectual attractiveness• Smart theory
CHIVA’s strengths
FIGHT
Ambulatory & cheap
Strong community• Big chief (Franceschi)• Enables to conduct studies with different teams
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
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
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
Thank you for your attention