Treatments for varicose veins (V): CHIVA and Müller’s phlebectomy

In this issue I’ll explain about two different surgical techniques for varicose veins, which can be both used separately or in a combined way.

The C.H.I.V.A. strategy was defined by Dr. Franceschi (a French Psychiatrist, actually) in 1988. In a free translation from French means “Conservative and Hemodinamical Ambulatory Cure of Venous Insufficiency”.

This treatment is based on one concept: the veins are not the disease themselves but just a consequence of a circulatory disorder that overloads the vein (usually referred to one of the saphenous veins). Therefore, a minimal surgery is performed just to eliminate the hyperpressure mechanism without removing the vein itself, which will remain inside the body.

The procedure involves preoperative marking of the skin with a pen using a Duplex Ultrasound to find the spots where the surgeon needs to act, and then – usually under local anesthesia – close the veins at the places where the insufficient valves are, forcing the blood to find other ways to return that are working properly. It would be similar to closing several of the possible ways of a maze, leaving open only one easy and fast route to the exit.

However, the dilated vein is not extracted. This makes it a less aggressive surgery and can be performed without hospital admission and with a much shorter recovery period.

There is considerable controversy among surgeons (“saphenectomy supporters” and “CHIVA Cure supporters”), being quite common that the surgeon who supports one of them is openly against the other one. The comparative scientific studies that have been performed until now are not totally conclusive because – according to the experts that analysed them – they do not provide enough methodological quality (they are not strictly well performed); sometimes this happens because those who have conducted the studies have a preference for one of the techniques over the other, and unconsciously favor its results (that is what in science we call “bias“).

Most likely, reality is that both techniques can potentially provide similar long-term results. Probably the wisest thing would be to appropriately select which patients are best candidates for every one of them, although it’s not frequent that the same surgeon is a supporter of both techniques. In any case the really important thing when selecting a technique is the surgeon having enough expertise in how to perform it: it’s far better a saphenectomy well performed by someone who knows how to do it than a CHIVA performed by someone inexperienced. And vice versa.

Finally, note that many of the advantages offered by the CHIVA cure (less aggressive, faster recovery and feasible as outpatient surgery, which means no need for in-hospital admission, all of them great marketing tools indeed) seem to have been surpassed in recent years by other minimally invasive techniques such as sclerotherapy or endovenous thermal ablation (laser or radiofrequency), which will be discussed later.

Müller’s phlebectomy is a simple and minimally invasive surgical technique that allows removal of side branches or small isolated varicose veins (tributary varicose veins) through tiny incisions (2 or 3mm). For small isolated veins it can be carried out under local anesthesia and on an outpatient basis, or it can be used to complement any of the other techniques (stripping, C.H.I.V.A., laser/ radiofrequency…) to remove the collateral branches.

Along the vein to be treated, these tiny incisions are performed at regular intervals (every 3-5 cm, approximately), and through them it is possible to “hook” and ligate (occlude) or remove it. The wounds are so small that they often do not even need stitches to close. After the procedure, as usual, compression stockings have to be worn for some time.

To illustrate this technique, below you’ll find a video showing how this easy procedure is carried out. The first part of this movie is an animation, but please be warned that the second part is actually a real surgical procedure (that could be disgusting for some sensible persons):

Should you be interested in getting to know this disease better, and its causes, consequences, how to treat them, and, even better, what can we do to prevent them, you can find it all well explained in the ebook VARICOSE VEINS: Truth & myths.

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Treatments for varicose veins (VI): sclerotherapy
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Treatments for varicose veins (IV): classic surgery / stripping

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