CHIVA method for the treatment of chronic venous insufficiency
Angiology, Vascular and Endovascular Surgery, Hospital de la Santa Creu i Sant Pau, IBB Sant Pau, Sant Quinti No. 89, Barcelona, Spain, 08041. Cochrane database of systematic reviews (Online)
(Impact Factor: 6.03).
07/2013; 7(7):CD009648. DOI: 10.1002/14651858.CD009648.pub2
Many surgical approaches are available to treat varicose veins secondary to chronic venous insufficiency. One of the least invasive techniques is the ambulatory conservative hemodynamic correction of venous insufficiency method (cure conservatrice et hémodynamique de l'insuffisance veineuse en ambulatoire (CHIVA)), an approach based on venous hemodynamics with deliberate preservation of the superficial venous system.
To compare the efficacy and safety of the CHIVA method with alternative therapeutic techniques to treat varicose veins.
The Trials Search Co-ordinator of the Cochrane Peripheral Vascular Diseases Group searched the Specialised Register (November 2012), CENTRAL (2012, Issue 10) and clinical trials databases. The review authors searched PubMed and EMBASE (December 2012). There was no language restriction. We contacted study authors to obtain more information when necessary.
We included randomized controlled trials (RCTs) that compared the CHIVA method versus any other treatments. Two review authors independently selected and evaluated the studies. One review author extracted data and performed the quantitative analysis.
Two independent review authors extracted data from the selected papers. We calculated the risk ratio (RR), mean difference (MD), the number of people needed to treat for an additional beneficial outcome (NNTB), and the number of people needed to treat for an additional harmful outcome (NNTH), with 95% confidence intervals (CI) using Review Manager 5.
We included four RCTs with 796 participants (70.5% women) from the 434 publications identified by the search strategy. Three RCTs compared the CHIVA method with vein stripping, and one RCT compared the CHIVA method with compression dressings in people with venous ulcers. We judged the methodological quality of the included studies as low to moderate. The overall risk of bias across studies was high because neither participants nor outcome assessors were blinded to the interventions. The primary endpoint, clinical recurrence, pooled between studies over a follow-up of 3 to 10 years, showed more favorable results for the CHIVA method than for vein stripping (721 people; RR 0.63; 95% CI 0.51 to 0.78; I(2) = 0%, NNTB 6; 95% CI 4 to 10) or compression dressings (47 people; RR 0.23; 95% CI 0.06 to 0.96; NNTB 3; 95% CI 2 to 17). Only one study reported data on quality of life and these results presented graphically significantly favored the CHIVA method.The vein stripping group had a higher risk of side effects than the CHIVA group; specifically, the RR for bruising was 0.63 (95% CI 0.53 to 0.76; NNTH 4; 95% CI 3 to 6) and the RR for nerve damage was 0.05 (95% CI 0.01 to 0.38; I(2) = 0%; NNTH 12; 95% CI 9 to 20). There were no statistically significant differences between groups regarding the incidence of limb infection and superficial vein thrombosis.
The CHIVA method reduces recurrence of varicose veins and produces fewer side effects than vein stripping. However, we based these conclusions on a small number of trials with a high risk of bias as the effects of surgery could not be concealed. New RCTs are needed to confirm these results and to compare CHIVA with approaches other than open surgery.
Available from: Paolo Zamboni
- "In a recent work, we have shown a correlation between the PDGF-BB released by patient-derived vein endothelial cell (VEC) cultures and relevant hemodynamic parameters measured in vivo into the venous segments from which the VEC was isolated upon surgical ablation . On these bases, to elucidate the link between systemic inflammation and altered hemodynamic forces, the primary aim of this study was to evaluate the effect of a saphenous sparing surgical correction (CHIVA strategy)  on the levels of circulating factors related to inflammation and angiogenesis characterizing CVI in order to identify a panel of biological markers able to correlate with the disease that might complement the standard procedures for diagnosis and posttreatment follow-up of CVI patients. "
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ABSTRACT: The expression of proinflammatory cytokines/chemokines has been reported in
in vitro/ex vivo
settings of chronic venous insufficiency (CVI), but the identification of circulating mediators that might be associated with altered hemodynamic forces or might represent innovative biomarkers is still missing. In this study, the circulating levels of 31 cytokines/chemokines involved in inflammatory/angiogenic processes were analysed in (i) CVI patients at baseline before surgical hemody namic correction, (ii) healthy subjects, and (iii) CVI patients after surgery. In a subgroup of CVI patients, in whom the baseline levels of cytokines/chemokines were analyzed in paired blood samples obtained from varicose vein and forearm vein, EGF, PDGF, and RANTES were increased at the varicose vein site as compared to the general circulation. Moreover, while at baseline, CVI patients showed increased levels of 14 cytokines/chemokines as compared to healthy subjects, 6 months after surgery, 11 cytokines/chemokines levels were significantly reduced in the treated CVI patients as compared to the CVI patients before surgery. Of note, a patient who exhibited recurrence of the disease 6 months after surgery, showed higher levels of EGF, PDGF, and RANTES compared to nonrecurrent patients, highlighting the potential role of the EGF/PDGF/RANTES triad as sensitive biomarkers in the context of CVI.
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Recurrence rates after varicose vein surgery of 6–80 % are frequently reported without any additional specifications. Such generalizations do not define the complex problem of recurrence of varicose veins. In addition, the quality of evidence of a large number of publications is limited by small numbers of events, indirectness (use of substitute results) and short-term follow-up.
The incidence of recurrence of varicose veins depends on many variables, such as the time of follow-up, drop-outs, diagnostic procedures, benchmarks for pathological duplex ultrasound values, neovascularization with or without concomitant varicose veins, assessment of recurrence, chosen classification of recurrence, definition of recurrence and clinical importance. Short-term follow-up is not adequate for detecting the real recurrence rate of varicose veins. In long-term follow-ups the number of lost patients increases; therefore, the reliability of results is questionable. The diagnostic method affects the results.
The aim of the study was to identify the variables accountable for such varying recurrence rates of 6-80% in varicose veins surgery.
Material and methods
The authors evaluated the results of own research and the data in the literature in order to identify the different variables for the rrecurrence rates of varicose veins after surgery.
Clinical investigations only underestimate the incidence whereas duplex ultrasound overestimates the incidence of clinically relevant recurrence. Considering these two methods separately distorts the results. A consistent data collection and interpretation is lacking. The symptomatics of recurrence is rarely considered. Duplex benchmarks vary from 2 mm to 5 mm in defining pathological vein diameters and ultrasound detected refluxes are considered pathological after 0.5, 1 or even 3 s. Te recurrence rates differ accordingly. The variety of the techniques performed and the lack of description of the underlying pathology at the first operation hinder an objective overview. Diagnostics and classification as well as the clinical importance of neovascularization are still under discussion. The multitude of classifications of recurrence of varicose veins is also confounding. A revision and a standardization of the different types of classification would be desirable.
The authors propose a different nomenclature with the aim of substituting the umbrella term recurrence of varices after surgery (REVAS) with varices after therapy (VAAT), reserving the term recurrent for true recurrences and adopting the term residual for varices remaining after the previous operation and the term new or progressive for varices due to natural disease progression. The progression of the underlying disease is not generally considered by the authors. Given the variety of variables and considering differences in data collection and interpretation as well as the advent of endovascular procedures, hemodynamic surgery and foam sclerotherapy, there is a need for a novel consensus conference. A standardization of data collection and interpretation for objective comparisons and meta-analyses are also necessary.
Available from: Manjunath M Shenoy
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