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Saphenous Vein-Sparing
Strategies in
Chronic Venous Disease
Paolo Zamboni
Erika Mendoza
Sergio Gianesini
Editors
123
Saphenous Vein-Sparing Strategies
in Chronic Venous Disease
Paolo Zamboni
Erika Mendoza
Sergio Gianesini
Editors
Saphenous Vein-Sparing
Strategies in Chronic
Venous Disease
Editors
Paolo Zamboni
School of Vascular Surgery and
Vascular Diseases Center
University of Ferrara
Ferrara, Italy
Unit of Translational Surgery
AOU Ferrara
Ferrara, Italy
Sergio Gianesini
Translational Surgery Unit-Vascular
Disease Center
University of Ferrara Vascular
Disease Center
Ferrara
Italy
Erika Mendoza
Venenpraxis Wunstorf
Wunstorf
Niedersachsen
Germany
ISBN 978-3-319-70637-5 ISBN 978-3-319-70638-2 (eBook)
https://doi.org/10.1007/978-3-319-70638-2
Library of Congress Control Number: 2018935125
© Springer International Publishing AG, part of Springer Nature 2018
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
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The publisher, the authors and the editors are safe to assume that the advice and information in
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Printed on acid-free paper
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part of Springer Nature
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Foreword
https://t.me/med1917
During the 1970s and in the 1980s, we had more and more patients who
needed a saphena bypass wherein the saphenous vein was unfortunately
destroyed by a previous surgical or endovenous treatment. I was struck by our
schizophrenic behaviour which consisted of, on the one hand, the saphenous
vein destruction for the benign varicose disease and, on the other hand,
lamenting for its absence when we needed it to perform a venous bypass for
a critical or life- threatening arterial or coronary obstruction. So, as a former
psychiatrist, I decided to confront and treat my insanity.
In addition to conservative treatments as foot elevation, bandaging and use
of compression stockings, I tried to find a surgical treatment which could also
preserve the saphenous capital. My observations of the varicose veins’ disappearance when I lifted the feet of my patients combined with the Trendelenburg
and Perthes manoeuvres’ effects convinced me that the cause of the venous
insufficiency and its symptoms was just a haemodynamic impairment of
the venous flows and pressure control.
Then, from this basis and thanks to the studies of the venous pressure principally published by Bjordal and the revolutionary capability of recent echoDoppler ultrasound devices, I could better figure out the better haemodynamic
venous system and its anomalies. It resulted in proposals of venous pathophysiological haemodynamic principles as dynamic fractioning of hydrostatic
pressure, various venous shunt patterns, re-entry concept, transmural pressure
control as the target of any rational treatment, location of not yet individualized pelvic leak points, haemodynamic venous cartography, and finally the
necessary conservation of the venous network for a correct drainage of the
tissues and prevention of recurrence. These concepts were the basis of the
CHIVA cure (French acronym for “cure Hémodynamique et Conservatrice de
l’Insuffisance Veineuse en Ambulatoire”) published in 1988.
As conservation is a pillar, CHIVA was received as provocative nonsense
because, so far, the destructive paradigm was dominant. Indeed, for around a
century, research, studies and devices where focused on killing the veins because
the treatment failures and recurrences where attributed to the veins left behind.
Indeed, CHIVA is based on dramatically different pathophysiological rational.
Its concepts were verified by further experimental evidence. Thanks to hundreds
of studies, some RCTs and a Cochrane review, achieved by various authors over
Europe, CHIVA is today validated more successful than destructive methods
and reaches, at the same time, both targets of treating efficiently the venous
insufficiency and preserving the venous capital for future bypass.
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CHIVA is also a scientific and intellectual challenge which demands a
reconsideration of the mainstream knowledge and personal habits, a steep
learning curve of the appropriate venous haemodynamics and its related
duplex scan assessment. We cannot play a game of chess with the rules for
checkers even if the board is identical. The same is for CHIVA. The rules of
destructive methods cannot fit to the conservative CHIVA.
Conservative or ablative methods, as well as invasive and non-invasive or
laser and other advanced devices, are powerful marketing arguments but not
always medically fair. The conservative procedures are relevant only when
they are better than the ablative in terms of risks/benefits ratio. Non-invasive
procedures are not necessarily safe. CHIVA is feasible in outpatients with
mini-invasive surgery.
Patient information should point out the risks/benefits based on medical
evidence. That is like kicking down an open door if we refer to the Hippocratic
oath “I am following that system of regimen which, according to my ability
and judgement, I consider for the benefit of my patients, and abstain from
whatever is deleterious and mischievous”. Furthermore, the patient informed
consent obliges to inform the patient about the nature and purpose and risks
and benefits of the proposed treatment as well as the alternatives.
Unfortunately, reality is not so. Ignorance, cynicism, competition, greed
and conflicts of interest are still to be taken into account.
I would like this book to revive the fair Hippocratic oath by permitting the
phlebologist to better inform and treat the patient. Remind him that varicose
veins are usually benign and may be treated or not according to his cosmetic
or comfort expectation. In case of skin changes and ulcers, easy efficient
procedures on transmural pressure decrease are available. In addition, the
CHIVA concepts and strategy are applicable to deep venous diseases, particularly post-thrombotic, and also to venous malformations.
Many thanks and congratulations to the authors who are renowned world
experts as researchers and practitioners in phlebology. They report and
explain extensively and clearly the venous haemodynamic pathophysiology
with the relevant contribution of other eminent colleagues, who improved the
CHIVA strategy and tactics.
Foreword
Claude Franceschi
Preface
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Many phlebologists, surgeons and scientists were involved on the way that
led to the writing of this book. The idea of venous-sparing surgery rests on
the shoulders of these colleagues. Countless numbers of courses, meetings
and discussion groups allowed us to sharpen our minds about the open questions. We deeply thank all the colleagues around the world who have contributed scientifically and practically to the development of the saphenous-sparing
surgery and the underlying haemodynamics concepts.
We thank Dr. Kraemer, Heidelberg, for his support in starting this project, and
Mr. Dhanapal Palanisamy, for his help along the writing and finishing of the
book. Mr. William Barne translated some of the German texts which were supported financially by Dr. Hans-Jürgen Thomae and Bauerfeind (Zeulenroda).
This was an invaluable help to the project.
We wish to acknowledge all the patients who trusted us giving us the possibility to learn and become experienced, thereby providing the foundations
of this book.
As an introduction to one of his lectures, Claude Franceschi once said that
it is important to empty a truck before storing new cargo. In a similar way, we
would like to invite our readers to open up a free space in their minds to make
room for new ideas. We anticipate that they will profit from the contents and
that the information of the book will enrichen their professional life, as
venous-saving strategies did with ours.
Ferrara, Italy Paolo Zamboni
Wunstorf, Germany Erika Mendoza
Ferrara, Italy Sergio Gianesini
October 2017
vii
Contents
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Part I Background
1 Historical Background and Rationale . . . . . . . . . . . . . . . . . . . . . 3
Paolo Zamboni
2 Functional Anatomy of Leg Veins . . . . . . . . . . . . . . . . . . . . . . . . 9
Sergio Gianesini, Paolo Zamboni, and Erika Mendoza
3 Venous Reflux Patterns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Sergio Gianesini, Paolo Zamboni, and Erika Mendoza
4 Duplex Ultrasound of Superficial Leg Veins in the Context
of Saphenous Vein Sparing Surgery . . . . . . . . . . . . . . . . . . . . . . 75
Erika Mendoza and Erica Menegatti
5 Second-Level Imaging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Sergio Gianesini, Paolo Zamboni, and Erika Mendoza
Part II CHIVA
6 Saphenous Sparing Strategy in the CHIVA Context . . . . . . . . . 121
Erika Mendoza
7 CHIVA: Surgical Tips and Tricks . . . . . . . . . . . . . . . . . . . . . . . . 181
Sergio Gianesini, Roberto Delfrate, Massimo Cappelli, and
Erika Mendoza
8 Minimally Invasive Surgical Treatment of Pelvic
Leak Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
Roberto Delfrate and Erika Mendoza
9 Haemodynamic Management of Deep
Venous Insufficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
Sergio Gianesini, Erika Mendoza, and Paolo Zamboni
10 CHIVA: Results from Literature . . . . . . . . . . . . . . . . . . . . . . . . . 225
Erika Mendoza and Erica Menegatti
11 Perioperative Management in Saphenous Sparing Surgery . . . 239
Erika Mendoza
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Part III Other Venous Sparing Techniques
12 Ambulatory Selective Varices Ablation Under Local
Anaesthesia (ASVAL) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
Paul Pittaluga and Sylvain Chastanet
13 External Valvuloplasty of the Sapheno-Femoral Junction . . . . 265
Paolo Zamboni and Sergio Gianesini
Part IV How to Treat a Patient in a Modern Phlebologic Setting
14 Treatment Options Depending on the
Patient’s Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
Erika Mendoza
Contents
Contributors
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Massimo Cappelli, M.D. Office Surgery, Florence, Italy
Sylvain Chastanet, M.D. Riviera Veine Institut, Monaco, France
Roberto Delfrate, M.D. Responsible Surgery at Casa di Cura Figlie di San
Camillo, Cremona, Italy
Sergio Gianesini, M.D., Ph.D. Vascular Diseases Center, University of
Ferrara, Ferrara, Italy
USUHS University, Bethesda, MD, USA
Erika Mendoza, M.D., Ph.D. Venenpraxis, Wunstorf, Germany
Erica Menegatti, Ph.D. Vascular Diseases Center, University of Ferrara,
Ferrara, Italy
Paul Pittaluga, M.D. Riviera Veine Institut, Monaco, France
Paolo Zamboni, M.D. School of Vascular Surgery and Vascular Diseases
Center, University of Ferrara, Ferrara, Italy
Unit of Translational Surgery, AOU Ferrara, Ferrara, Italy
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