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There is considerable debate in the literature with relation to the best method to treat patients with chronic venous disease (CVD). CHIVA is an office-based treatment for varicose veins performed under local anesthesia. The aim of the technique is to lower transmural pressure in the superficial venous system and avoid destruction of veins. Recurrence of varicosities, nerve damage, bruising and suboptimal aesthetic results are common to all treatments for the disease. This paper evaluates and discusses the characteristics and results of the CHIVA technique. We conclude that CHIVA is a viable alternative to common procedures that is associated with less bruising, nerve damage, and recurrence than stripping saphenectomy. The main advantages are preservation of the saphenous vein, local anesthesia, low recurrence rates, low cost, low pain, and no nerve damage. The major disadvantages are the learning curve and the need to train the team in venous hemodynamics.
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REVIEW ARTICLE
ISSN 1677-7301 (Online)
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Faccinietal. J Vasc Bras. 2019;18:e20180099. https://doi.org/10.1590/1677-5449.009918
CHIVA to treat saphenous vein insuciency in chronic venous
disease: characteristics and results
CHIVA para tratar insuficiência de veia safena em doença venosa crônica:
características e resultados
Felipe Puricelli Faccini1,2 , Stefano Ermini3 , Claude Franceschi4,5
Abstract
ere is considerable debate in the literature with relation to the best method to treat patients with chronic venous
disease (CVD). CHIVA is an oce-based treatment for varicose veins performed under local anesthesia. e aim of the
technique is to lower transmural pressure in the superficial venous system and avoid destruction of veins. Recurrence
of varicosities, nerve damage, bruising and suboptimal aesthetic results are common to all treatments for the disease.
is paper evaluates and discusses the characteristics and results of the CHIVA technique. We conclude that CHIVA
is a viable alternative to common procedures that is associated with less bruising, nerve damage, and recurrence than
stripping saphenectomy. e main advantages are preservation of the saphenous vein, local anesthesia, low recurrence
rates, low cost, low pain, and no nerve damage. e major disadvantages are the learning curve and the need to train
the team in venous hemodynamics.
Keywords: CHIVA; saphenous sparing; local anesthesia; varicose vein; chronic venous disease.
Resumo
Existe uma grande discussão na literatura sobre o tratamento da doença venosa crônica (DVC). A cura conservadora
e hemodinâmica da insuficiência venosa em ambulatório (CHIVA) consiste no tratamento ambulatorial de varizes
sob anestesia local. O objetivo da técnica é diminuir a pressão transmural no sistema venoso superficial para evitar
a destruição das veias, incluindo as veias safenas. Recorrência de varizes, lesão de nervos, hematomas e resultado
estético abaixo do ideal são uma constante em todos tratamentos de varizes. O objetivo desta revisão é avaliar e
discutir a técnica CHIVA quanto a suas características e resultados. A CHIVA é uma alternativa válida frente aos outros
procedimentos, apresentando menos hematomas, recorrência e lesão nervosa que a safenectomia. Preservaç ão da veia
safena, anestesia local, baixa taxa de recorrências, baixo custo, pouca dor e ausência de lesões ner vosas são as principais
vantagens. A longa curva de aprendizado para treinar a equipe em hemodinâmica venosa é a principal desvantagem.
Palavras-chave: CHIVA; preservação safena; anestesia local; varizes; doença venosa crônica.
How to cite: Faccini FP, Ermini S, Franceschi C. CHIVA to treat saphenous vein insuciency in chronic venous disease:
characteristics and results. J Vasc Bras. 2019;18:e20180099. https://doi.org/10.1590/1677-5449.009918
1 Cirurgia Vascular, Hospital Moinhos de Vento, Porto Alegre, RS, Brasil.
2 Instituto de Cardiologia, Porto Alegre, RS, Brasil.
3 Veneinforma, Grassina, Florence, Italy.
4 Centre Marie érèse, Hôpital Saint Joseph Paris, Paris, France.
5 Hôpital Salp êtrière, Paris, France.
Financial support: N one.
Conflicts of interest: No conflicts of interest declared concerning the publication of this article.
Submitted: October 16, 2018. Accepted: November 28, 2018.
e study was carried out at Hospital Moinhos de Vento and Instituto de Cardiologia, Porto Alegre, RS, Brazil.
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INTRODUCTION
CHIVA is the French acronym for “Cure conservatrice
et Hemodynamique de l’Insusance Veineuse en
Ambulatoire” (Conservative and Hemodynamic
treatment of Venous Insuciency in the Oce). It is a
saphenous-sparing therapeutic approach to lower limb
chronic venous disease (CVD) based on hemodynamic
concepts proposed by Claude Franceschi in 1988.1-6
The rationale behind this hemodynamic approach to
treating the disease is that increased transmural pressure
(TMP) is responsible for progression of the signs and
symptoms of CVD, such as varicosities, edema, pain,
itching, dermatitis and ulcers. Transmural pressure
is elevated in supercial venous disease because of
the higher hydrodynamic pressure caused by absence
of orthodynamic pressure fractionating and presence
of closed shunts.7
The CHIVA strategy aims to restore near-normal
physiological ow with no destruction or ablation of
the veins involved. The mainstay of this approach is a
correct hemodynamic evaluation. A complete duplex
scan is performed to correctly determine the source
of pressure overloads.8 The strategy uses ligatures
targeted to interrupt escape points and fractionate
hydrostatic pressure. The number and position of these
ligatures depend on duplex scan ndings and every
operation is tailored to each patient’s reux pattern.
No phlebectomies are performed and reduction of
TMP causes the varicose veins to reduce in size,
as shown in preoperative and postoperative images
(Figures 1 and 2).
The procedure is performed under local anesthesia
and can be conducted in the oce with immediate
patient discharge. The great and small saphenous
veins are left in place and are available in the
future for bypass surgery and to channel the ow
of varicose recurrence, if this occurs. All collateral
veins are preserved and return to their normal size
in a few months after the hemodynamic result is
achieved. This is particularly interesting because the
postoperative period after phlebectomy can be painful
and may be complicated by pigmentations and red
telangiectasias that are dicult to treat. Additionally,
studies suggest that extensive resection of veins may
result in higher recurrence rates over the long term.9
Recently, saphenous sparing techniques have been
increasingly discussed in the literature and are being
considered as a promising approach to treatment of
CVD patients.10
The objective of this review article is to briey
describe the CHIVA technique and present the results of
a technique that is a possible cost-eective alternative
to the usual venous ablative/resective procedures.
Figure 1. Preoperative image of a CHIVA patient.
Figure 2. Postoperative image after CHIVA - No phlebectomy,
sclerotherapy, laser or any other treatment was performed. Veins
disappear due to lower transmural pressure.
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DISCUSSION
Several dierent procedures for treatment of
varicose veins are possible and oer good results.
The CHIVA strategy is based on venous system
hemodynamics and aims to maintain the venous
system in place while correcting imbalances created
by shunts between the deep and supercial venous
systems.
3
The main characteristics of the procedure are:
1) local anesthesia; 2) day-clinic surgery; 3) immediate
return to activities; 4) low pain scores; 5) avoidance
of removal of collaterals causing fewer skin marks;
and 6) preservation of the saphenous trunks in place
for future bypass use and to receive ow from any
new escape points or recurrence (making them easier
to treat).
e CHIVA strategy: basic principles
The objective of treatment is to maintain the
saphenous vein and collaterals draining to the deep
venous system, independently of the direction of
ow. In some cases, the saphenous vein will recover
and the ow will be directed upwards. However,
in other cases, in which the vein is too large or the
saphenofemoral junction is the primary source of reux,
ow will be directed downwards and reenter the deep
system via the perforators. This downward ow is
not pathogenic and is associated with venous system
stability and good long term results. The technical
approach employed in CHIVA depends on the shunts
identied in each patient. Basically, the escape point
(start of reux) should be treated, usually by ligation.
The reentry point is preserved (where reux enters the
deep system after its supercial course). Collaterals
found along the course of reux that might maintain
or create reux should be also interrupted. Collaterals
and saphenous veins should not be left without
reentry points because of the risk of thrombophlebitis.
For example, in a type I or I+II shunt, the reuxing
saphenous vein has direct drainage to a perforator,
as have the collaterals involved. On the other hand, a
type III shunt has no direct saphenous ow drainage
to a perforator; rather, the sequence is saphenous vein
– collateral – perforator (Figure 3). In the rst case
(type I+II shunt), ligation of the collateral will reduce
diastolic reux and TMP in the saphenous vein. In the
second case (type III shunt) ligation of the escape
point and disconnection of the tributary will result
in absence of ow in the saphenous trunk. This can
cause saphenous thrombosis that will be recanalized
as soon as a new reentry point develops. Further
strategy possibilities, such as devalvulation, use of
tributary perforators or CHIVA in 2 steps (CHIVA 2)
oer adequate treatment for such cases. The 2-step
CHIVA strategy consists of an initial ligature of a
collateral, leaving the saphenous vein untouched in
the rst procedure. Disconnection of the tributary
in a type III shunt eliminates the centrifugal ow,
decreasing the saphenous caliber due to the reduced
ow rate. The energy of a shunt from the escape point
is not always stable or predictable and centrifugal
ow in the GSV trunk can reappear if a new reentry
point occurs. In this case, a second CHIVA step is
performed to treat the escape point. This second
procedure is planned in advance and is not considered
a reoperation, but rather the completion of the rst.
This is commonplace with the CHIVA approach,
but is often erroneously considered a reoperation by
surgeons unfamiliar with the technique.11
Characteristics of CHIVA
Nerve damage
One of the biggest advantages of CHIVA compared
to other venous procedure modalities is the absence
of nerve damage, particularly in the modern context
in which nerve damage and malpractice claims are
becoming a common problem. During a CHIVA
procedure, performed under local anesthesia, the patient
warns the surgeon if the sural or saphenous nerves are
touched, which they cannot do with general, axial, or
tumescent anesthesia, because the nerve or response
are blocked. The nerve is therefore susceptible to
damage by the mechanical or burning energies used
in most common procedures such as vein stripping
and thermal ablation. Two previously published
randomized clinical trials comparing stripping to
CHIVA found evidence of no cases of nerve damage in
286 CHIVA procedures compared to 26 nerve damage
cases in 383 (6.7%) stripping procedures.12,13 A study
of litigation claims after vascular surgery showed
that nerve damage is responsible for nearly a third of
malpractice claims that are successful in the courts
Figure 3. Types of Shunts. Shunt I, reentry straight from the
saphenous vein. Shunt I + II, reentry from the saphenous vein
below the collateral and the collateral itself. Shunt III, no reentry
from the saphenous vein, only from the collateral.
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after venous operations. This British study showed
a 61% success rate of malpractice claims related to
varicose veins operations.14 Mean compensation for
damage was €100,000 and in some cases awards
were higher. In Brazil, there is no transparency in
the courts and the healthcare system per se (both
insurance and public) is usually left out of these
trials. We do not have clear data on success rates or
a direct evaluation of the nancial burden these trials
impose on doctors. Current knowledge suggests that
compensation awards are lower than in the British
study, but the completely free justice system (without
no cost to the plainti in the case of an unsuccessful
claim) makes the number of malpractice suits much
higher than in England. We consider that the CHIVA
technique causes near zero nerve damage and may be
advantageous for avoiding such mishaps.
Future use of the saphenous vein
The importance of preservation of the saphenous
veins in venous operations is a matter of great debate.
Possible advantages include maintaining the vein for
further use in bypass surgeries, reducing surgical
trauma to prevent remodeling, and retaining the
saphenous trunk to receive ow in case of a recurrence.
With regard to bypass surgery, use of the saphenous
vein in both coronary and peripheral bypass surgery
is well established in the literature.
15,16
The prevalence
of coronary disease varies according to population.
In Brazil, from 2005 to 2007, a total of 63272 coronary
artery bypasses were performed, equating to a total
of 1 operation for every 2900 inhabitants in the
general population.17 Another study showed that in
Rome one coronary bypass was performed for every
1424 inhabitants over the age of 35 years during the
late nineties.18 Recent studies show that harvesting
the saphenous vein using no touch techniques is
reliable and has a long term patency comparable to
the internal thoracic artery.
18,19
Concerning peripheral
bypass for limb ischemia, a national study in the United
States found that 1.6% of patients with peripheral
artery disease underwent a peripheral bypass.
19
Surgical removal or ablation of the saphenous vein
may decrease the likelihood of treatment success in
patients needing such bypasses.20
Patients who present with deep vein thrombosis or
leg trauma after a venous operation may need the great
saphenous vein for adequate venous return. If the vein
has not been destroyed previously, a vicarious shunt
may form in such patients, improving symptoms.
Recurrence of varicose veins
Recurrence of varicosities is a constant concern
in patients undergoing venous operations and places
considerable burden on patients over the long term.
There are recent biochemical and clinical studies
suggesting that excessive venous resection may
cause more recurrence. Biochemical and animal
studies show that increases in the pressure on veins
and chronic shear stress on the vein wall are linked
to venous remodeling and may lead to recurrence.
21,22
Animal studies have shown that transcription factor
activator protein 1 (AP-1) appears to be a prerequisite
for venous remodeling/proliferation and MMP-2
(matrix metalloproteinase) expression. MMP-2
expression and venous proliferation are stimulated
by sudden interruption of the ear vein in rats.
21,22
Additionally, a clinical study showed that ligation
of all junctional saphenous tributaries is associated
with a higher risk of varicose vein recurrence.
This study compared recurrence in two groups after
high ligation of the saphenofemoral junction, with
or without ligation of all tributaries. The group that
had all tributaries ligated had a sevenfold increase
in recurrence.9 These data suggest that an approach
with less resection may help reduce recurrence.
Indeed, in the CHIVA strategy, the approach to SFJ
incompetence consists of sectioning/ligating the
saphenous arch at the common femoral vein junction,
preserving the collaterals draining into the saphenous
arch. Furthermore, we should remember that chronic
venous disease is a lifelong disease and recurrence is
a constant problem. The longer the follow-up periods
of clinical trials, the better the knowledge they oer
about the long-term results.
With regard to the results and safety of CHIVA, there
are several studies and some randomized clinical trials
(RCT) comparing CHIVA with stripping/compression
in dierent subtypes of patients. Zamboni studied
severe cases and ulcer patients in a RCT comparing
healing and recurrence of ulcers in two groups of
patients (CHIVA and compression therapy).
23
The study
showed that CHIVA had a higher healing rate than
compression (100% versus 96%) and less ulcer
recurrence over a 3-year period (9% versus 38%).
The study showed that CHIVA is a safe and eective
treatment for venous ulcers with better results than
compression therapy.
There are also some RCTs comparing CHIVA to
stripping for chronic venous disease without ulcers and
several studies conrming its ecacy and reporting
good results.
5,24,25
Iborra-Ortega et al.
12
published
the results of a randomized trial comparing CHIVA
with stripping in 100 patients over a 5-year follow-up
period. This study found no dierence between the
CHIVA and stripping groups in recurrence, reoperation,
or aesthetic results. Carandina et al.26 randomized
150 patients and followed stripping and CHIVA
groups for up to 10 years. This study found a twofold
higher recurrence rate in the stripping group. It also
showed that recurrence was signicantly higher
after stripping (in both stripping groups; a group in
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which veins were marked clinically and a group in
which veins were marked using duplex scanning)
than in the CHIVA group (odds ratio 2.64 and 2.01
respectively). In an RCT, Parés et al.13 showed that
recurrence up to ten years’ follow-up was 31.1% for
the CHIVA method, compared to 50.3% for stripping.
The RCTs investigating CHIVA were open and did
not blind participants or personnel to which group
participants were assigned to, because it is easy to
recognize the type of operation, since anesthesia,
incisions, and duplex ndings make identication
of groups possible.
A Cochrane systematic review including clinical
trials evaluating CHIVA compared to stripping
showed signicantly less nerve damage, fewer
bruises, and less recurrence.27 The results favored
the CHIVA approach, although the review authors
suggested further studies are needed to corroborate
ndings. The authors considered the lack of blinding
of patients and personnel to be a possible source of
bias. They recommended further trials using quality
of life endpoints and comparing CHIVA to other vein
surgery modalities.
There are several treatment alternatives for recurrent
varicose veins and a high incidence of recurrence is
commonplace. A Brazilian study presented good results
after open correction for groin recurrence, although
complications such as skin infection, lymphedema,
and recurrence are a matter of concern.
28
Sclerotherapy
has a good success rate and is being increasingly used
worldwide, but deep vein thrombosis and recurrence
are possible complications. Recurrence is common
after saphenous stripping and tends to increase with
time elapsed after the operation. Recurrence after
endovenous laser ablation (EVLA) of the saphenous
vein seems to be similar to the rate of recurrence
after stripping. Rasmussen et al.29 showed that
clinical recurrence rates after EVLA and stripping
were 46.6% and 54.7% respectively and reoperation
rates were 38.6% and 37.7% at 2 years. In this study,
there were no statistical dierences in recurrence or
reoperations between EVLA and stripping. There
are few published RCTs comparing recurrence after
CHIVA and EVLA, although Chan et al.
30
showed that
CHIVA patients exhibited less pain and less need for
sclerotherapy after operations than EVLA patients.
The issue of recurrence is also a problem after foam
treatment and no long term results are available for
adequate comparison with other techniques.31,32 These
data suggest that there is no conclusion concerning
which is the best method to avoid recurrence. There
is one RCT investigating the CHIVA technique with
10 years’ follow-up in which it was associated with
less recurrence than the stripping technique, making it
a good option for treating patients with saphenous vein
insuciency. Gloviczki et al.
33
published a guideline
for chronic venous disease and considered the results
of preservation of the saphenous vein with CHIVA.
The conclusion was that the results were better than
compression for preventing ulcer recurrence and at
least equivalent to stripping of varicose veins.
Bruises and aesthetic results
Most patients who undergo varicose vein operations
have high expectations and skin marks, bruises,
and brown spots are common patient complaints.
The aesthetic results of CHIVA have been compared
to those of stripping operations. Parés et al.13 found
signicantly fewer bruising marks after CHIVA (45%)
than after saphenous vein stripping (76%). Aesthetic
improvements were assessed in terms of participants’
opinions in two trials and no signicant dierences
were found.12,26 Aesthetic improvements as assessed
by the investigator were recorded in one trial and no
signicant dierence was found between CHIVA
and stripping.12 Parés et al.13 reported a signicant
dierence in favor of CHIVA in relation to postoperative
bruises, with 240 out of 334 patients (71%) exhibiting
bruising after stripping compared to 76 out of 167
(45%) CHIVA patients. This is probably because
most veins are left in place and less subcutaneous
blood remains to stain the skin. We conclude that
the CHIVA technique causes less bruising than the
stripping technique, probably because no phlebectomies
are conducted. No signicant dierences in patients’
aesthetic impressions were observed.
Learning curve
The CHIVA technique demands that the surgeon
has expertise in venous hemodynamics. The learning
curve is long and is extremely important to achieve
good results. Surgeons who are not specically skilled
in CHIVA may have high supercial thrombophlebitis
incidence rates,
34
because of excessive ligature
of draining collaterals or failure to recognize
disproportionate calibers in dierent regions of the
saphenous vein. The incidence of this complication
diminishes with training, experience, and correct
planning of the procedure. For example, in one RCT,
Parés et al.,13 observed a 1.3% phlebitis rate in the
CHIVA group and there was no signicant dierence
between this group and the stripping patients. In our
experience, the learning curve is long and appropriate
duplex scanning skills that are not covered in the
usual teaching units are required. The incidence of
supercial phlebitis at our clinic (Brazilian author) is
below 2% of cases, all cases were asymptomatic and
diagnosed by duplex scan. No case of symptomatic
phlebitis has been observed to date. A trial comparing
CHIVA and stripping found that CHIVA performed
by experienced surgeons had a signicantly lower
recurrence rate and better results than stripping, but
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CHIVA patients operated by non-specialized surgeons
had worse results.35 The authors point out that the
several dierent possibilities in the CHIVA technique
make it less repeatable than stripping and demand more
training. Gloviczki et al.
33
concluded that CHIVA is a
complex approach and that high levels of training and
experience are needed to achieve the results reported
by RCTs. Venous interventionists willing to learn this
approach require considerable education.
Postoperative GSV thrombosis is due to the absence
of centrifugal ow and occurs more commonly after
treatment of type III shunts. This phlebitis is due to a
hemodynamic cause, rather than endothelial trauma, as
occurs in foam sclerotherapy or endovenous ablation.
The dierence is that this thrombosis will recanalize
as soon as a new ecient reentry point develops,
generally from 1 to 6 months after surgery. With
the CHIVA strategy, GSV thrombosis is an event of
low signicance and cannot be considered a failure
of the technique, since the majority of thrombosed
GSVs regain ow in a few months and cause no
symptoms. This is common to other saphenous-sparing
techniques. For example, Ferracani et al.36 presented
a saphenous-sparing laser remodeling procedure
associated with a 10.5% rate of saphenous thrombosis;
half of these patients had spontaneous recanalization
within a few weeks.
Postoperative duplex scan
Another important point that is pivotal to physicians
performing duplex scans and surgeons who do not
perform the CHIVA is the concept of postoperative
reux. The usual approach to reux soon after
stripping or EVLA is to consider this a treatment
failure. The purpose of CHIVA is to keep the veins
draining and reuxing veins might recover upward
ow or continue to drain reux. Many patients remain
with a continuously draining reverse ow without a
compartment change (the saphenous diameter decreases),
classied as a type 0 shunt.
3
This is considered a good
treatment result, fullling the ultimate objective of a
CHIVA procedure.
e cost of CHIVA
The cost of CHIVA is low if compared to newer
techniques that use expensive industry technology.
This can be particularly advantageous in developing
countries and for clinics/doctors that earn similar
fees irrespective of the technique used. On the other
hand, the method does not attract funding for clinical
trials and publicity because the procedure does not
involve expensive industry equipment. The CHIVA
surgeon spends more time with the patient than
with other techniques and must perform duplex
scans to diagnose, mark the skin and follow-up
the patient. The extra duplex examinations and
additional surgeon time with the patient should be
also considered. Zmudzinski et al.37 published a trial
showing good early results of CHIVA, but pointed to
obstacles to disseminating the technique related to
the need for detailed duplex scans, the existence of
accessible alternatives such as EVLA/stripping, and
insurance-related problems. Nevertheless, the study
concluded that several investigators have achieved
good results and suggested keeping an open mind
with regard to CHIVA.
CONCLUSION
CHIVA is a cost-eective method for treating
CVD patients. The possible advantages are no nerve
damage, preservation of the saphenous vein (both for
bypass and to receive ow from recurrent varicosities),
a low recurrence rate, local anesthesia, and reduced
bruising. The main disadvantage is the long learning
curve needed to master the technique.
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Correspondence
Felipe Puricelli Faccini
Centro Clínico Ramiro, Hospital Moinhos de Vento
Rua Ramiro Barcelos, 910, sala 903 - Auxiliadora
CEP 90035-001 - Porto Alegre (RS), Brasil
Tel.: +55 (51) 3312-4389
E-mail: felipefaccini@yahoo.com
Author information
FPF - MSc, Universidade Federal do Rio Grande do Sul (UFRGS);
Vascular surgeon, Hospital Moinhos de Vento and Instituto de
Cardiologia.
SE - MD, private practice, Veneinforma.
CF - Angiology consultant, Centre Marie érèse, Hôpital Saint
Joseph; Professor, Diplôme de Pathologie Vasculaire,
Hôpital Salpêtrière.
Author contributions
Conception and design: FPF, SE, CF
Analysis and interpretation: FPF, SE, CF
Data collection: FPF, SE, CF
Writing the article: FPF, SE, CF
Critical revision of the article: FPF, SE, CF
Final approval of the article*: FPF, SE, CF
Statistical analysis: N/A.
Overall responsibility: FPF
*All authors have read and approved of the final version of the article
submitted to J Vasc Bras.
... As treatment methods, ambulatory selective varices ablation under local anaesthesia (ASVAL), Cure Conservatrice et Hemodynamique de l'Insuffisance Veineuse en Ambulatoire strategy (CHIVA), and external valvuloplasty (eVP) have been described. [11][12][13] eVP is a reconstructive surgical method aimed at repairing the function of the terminal and preterminal valve. 14 In our department, we achieve this by implanting a u-shaped patch at the saphenofemoral junction, 15 although other devices can be used. ...
Article
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Objectives External valvuloplasty (eVP) is a reconstructive surgical method to repair the function of the terminal and preterminal valves. We evaluated the 6-month outcomes of eVP regarding the diameter of the great saphenous vein (GSV). Methods Patients from five vein centres were included in this observational study. Follow-up involved detailed duplex sonography of the GSV. The venous clinical severity score (VCSS) and the C class of the clinical, aetiologic, anatomic and pathophysiologic (CEAP) classification were recorded. Results We enrolled 210 patients, with a follow-up rate of 58%; eVP was sufficient in 95.24% of the patients. The GSV diameters decreased significantly from 4.4 mm (standard deviation (SD): 1.39) to 3.9 (SD: 1.12), 4 cm distal to the saphenofemoral junction (SFJ); from 3.7 mm (SD: 1.10) to 3.5 mm (SD: 1.02) at the mid-thigh; from 3.6 mm (SD: 1.14) to 3.3 mm (SD: 0.94) at the knee and from 3.1 mm (SD: 0.99) to 2.9 mm (SD: 0.78) at the mid-calf. VCSS decreased significantly from 4.76 (SD: 2.13) preoperatively to 1.77 (SD: 1.57) 6 months postoperatively. Conclusions GSV function can be restored by eVP; diameters over the total length of the GSV decreased significantly.
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Pourquoi ce livre ? L’approche hémodynamique m’a conduit à revisiter les concepts classiques de la physiopathologie veineuse. Elle a abouti à une nouvelle modélisation, proposant de nouveaux concepts physiopathologiques qui ont abouti à une sémiologie plus raffinée et une stratégie thérapeutique appelée CHIVA qui leur est diamétralement opposée
Article
Patients with varicose veins can be treated with conservative or surgical approaches based on the clinical conditions and patient preferences. In the recent decade, the recommendations for managing symptomatic varicose veins have changed dramatically due to the rise of minimally invasive endovascular techniques. The literature was systematically searched on Medline without language restrictions. All papers on the treatment of varicose veins and venous insufficiency with different procedures were included and reviewed. Endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) both are same safe and effective in terms of occlusion rate, and time to return to normal activity. In comparison with RFA or EVLT, Cure conservatrice et Hemodynamique de l'Insufficience Veineuse en Ambulatoire (CHIVA) may cause more bruising and make little or no difference to rates of limb infection, superficial vein thrombosis, nerve injury, or hematoma. In terms of recurrence of varicose veins, there is little or no difference between CHIVA and stripping, RFA, or EVLT. Great saphenous vein recanalization is highest in the ultrasound-guided foam sclerotherapy (FS) group (51%) during 1 year of follow-up. The 2013 National Institute for Health and Care Excellence clinical guidelines recommend surgery as a third-line therapeutic option after EVLA or RFA and sclerotherapy. Although the mechanochemical endovenous ablation (MOCA) is a non-thermal, non-tumescent option and appears to be of similar efficacy to stab avulsion with no potential risk of nerve damage, the overall success rate of MOCA is lower than those of other procedures such as EVLA, RFA, or high ligation and stripping. EVLA is the most cost-effective therapeutic option, with RFA being a close second for the treatment of patients with varicose veins. Endovenous thermal ablation (EVLA or RFA) is recommended as a first-line treatment for varicose veins and has substituted the high ligation of saphenofemoral junctional reflux and stripping of varicose veins. Ultrasound-guided FS is associated with a high recurrence rate and can be used in conjunction with other procedures. MOCA and cyanoacrylate embolization appear promising, but evidence of their effectiveness is required.
Article
Background: CHIVA is a conservative outpatient treatment strategy for chronic venous disease (CVD) that preserves the superficial venous system. A modified twostage strategy is used in patients with a great saphenous vein (GSV) diameter ≥ 9 mm with the goal to decrease the risk of symptomatic superficial vein thrombosis (SVT), as the risk of complications is higher when first and second stage simultaneously is performed. Methods: We conducted a retrospective observational study of 111 patients with CVD and a GVS diameter ≥ 9 mm treated with two possible stages of the CHIVA strategy, between January 2010 and December 2019. The goal of the first stage is to interrupt the main reflux escape point (incompetent saphenofemoral junction), thereby lowering the venous pressure and achieving a sufficient reduction in GSV diameter to enable, if necessary, a second stage that consist of disconnection of secondary reflux exit point (incompetent saphenous tributaries), with a lower risk of symptomatic SVT when patients do not show significant clinical improvement. Reductions in GSV diameter, postoperative complications and clinical improvement were analyzed. Results: There were 60 men (54.1%) and 51 women (45.9%) with a mean age of 57±11.9 years. All patients undergone first surgical stage, and this interruption of the saphenofemoral junction was the single procedure in 77.5% of cases (86 patients). Mean follow-up time was 19.8 months. The second stage was performed in 25 patients (22.5%). Mean preoperative GSV diameter was 10.2±1.1 mm and this decreased to 7.1±1.5 mm after the first surgery (mean reduction, 3±1.5 mm, p<0.001). Six patients (5.4%) experienced recurrence due to recanalization of the reflux point and 16 patients (14.4%) developed SVT, which was symptomatic in 12 cases (10.8%). Conclusions: Interruption of the main reflux escape point as a single procedure in patients with a GSV diameter ≥ 9 mm led to a significant reduction in diameter and sufficient clinical improvement in almost 80% of cases.
Article
In this article, the CHIVA and ASVAL methods are assessed from the hemodynamic point of view. The CHIVA method comprises complicated, unusual terminology and new perceptions, such as closed and open shunts, fractionation of the hydrostatic pressure, subdivision of the venous network. The principal part of the CHIVA theory is the drainage of venous blood from the thigh saphenous system into the deep lower leg veins through the preserved saphenous trunk after high ligation at the saphenofemoral junction, which is considered as a beneficial, physiological phenomenon. In reality, this is recurrent reflux producing ambulatory venous hypertension. The main impact of the CHIVA procedure is the elimination of the saphenous reflux by high ligation at the saphenofemoral junction; thus it can be presumed that the CHIVA procedure yields similar results like the crossectomy. The ASVAL procedure is de facto the modification of the old Madelung method that was the prevalent surgical procedure before the Trendelenburg era in the 19th century. The results after ASVAL were not checked by plethysmography; there is a good case to suppose that the results after the ASVAL method would comply with those after sclerotherapy.
Article
Objectives To assess the postoperative pain and midterm results of patients undergoing internal perivenous compression with internal compression therapy (ICT) for venous insufficiency at the saphenofemoral junction (SFJ) Materials and Methods Patients managed with ICT between April and October 2019 for grade 4 venous reflux at the SFJ were retrospectively evaluated. The venous clinical severity score (VCSS) was calculated preoperatively and 1, 3, and 6 months postoperatively. Postoperative pain was assessed with the visual analog scale (VAS). Control Doppler ultrasound imaging was performed 6 months postoperatively. Results Forty-five patients [14 (31%) males and 31 (69%) females; mean age, 47 ± 13 years] were included. The median preoperative VCSS was 7 (5–8.5). The median VCSS at 1, 3, and 6 months postoperatively was 6 (4–7.5), 4 (3–5.5), and 3 (2–4), respectively, and these values were significantly lower than the preoperative score (p = 0,001, p < 0.001, and p < 0.001, respectively). The postoperative VAS score was 0 in 6 patients (13%), 1 in 17 patients (38%), 2 in 6 patients (13%), 3 in 15 patients (33%), and 4 in 1 patient (2%). At 6 months, reflux was absent in 9 (20%), grade 1 in 20 (44%), and grade 2 in 16 (36%) patients. A vena saphena magna diameter of >6.7 mm predicted grade >1 reflux at 6 months [87.5%, with an area under the curve of 0.78 (p < 0.001)]. No complications occurred. Conclusion ICT alleviated symptoms and reduced reflux grade in patients with venous insufficiency at the SFJ. This therapy can be applied with satisfactory patient comfort.
Article
Background: 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 (in French '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. This is the second update of the review first published in 2013. Objectives: To compare the efficacy and safety of the CHIVA method with alternative therapeutic techniques to treat varicose veins. Search methods: The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, AMED, and the World Health Organisation International Clinical Trials Registry Platform and ClinicalTrials.gov trials registries to 19 October 2020. We also searched PUBMED to 19 October 2020 and checked the references of relevant articles to identify additional studies. Selection criteria: We included randomized controlled trials (RCTs) that compared CHIVA to other therapeutic techniques to treat varicose veins. Data collection and analysis: Two review authors independently assessed and selected studies, extracted data, and performed quantitative analysis from the selected papers. A third author solved any disagreements. We assessed the risk of bias in included trials with the Cochrane risk of bias tool. We calculated the risk ratio (RR), mean difference (MD), 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). We evaluated the certainty of the evidence using GRADE. The main outcomes of interest were the recurrence of varicose veins and side effects. Main results: For this update, we identified two new additional studies. In total, we included six RCTs with 1160 participants (62% women) and collected from them eight comparisons. Three RCTs compared CHIVA with vein stripping. One RCT compared CHIVA with compression dressings in people with venous ulcers. The new studies included three comparisons, one compared CHIVA with vein stripping and radiofrequency ablation (RFA), and one compared CHIVA with vein stripping and endovenous laser therapy. We judged the certainty of the evidence for our outcomes as low to very low due to inconsistency, imprecision caused by the low number of events and risk of bias. The overall risk of bias across studies was high because neither participants nor personnel were blinded to the interventions. Two studies attempted to blind outcome assessors, but the characteristics of the surgery limited concealment. Five studies reported the outcome clinical recurrence of varicose veins with a follow-up of 18 months to 10 years. CHIVA may make little or no difference to the recurrence of varicose veins in the lower limb compared to stripping (RR 0.74, 95% CI 0.46 to 1.20; 5 studies, 966 participants; low-certainty evidence). We are uncertain whether CHIVA reduced recurrence compared to compression dressing (RR 0.23, 95% CI 0.06 to 0.96; 1 study, 47 participants; very low-certainty evidence). CHIVA may make little or no difference to clinical recurrence compared to RFA (RR 2.02, 95% CI 0.74 to 5.53; 1 study, 146 participants; low-certainty evidence) and endovenous laser (RR 0.20, 95% CI 0.01 to 4.06; 1 study, 100 participants; low-certainty evidence). We found no clear difference between CHIVA and stripping for the side effects of limb infection (RR 0.83, 95% CI 0.33 to 2.10; 3 studies, 746 participants; low-certainty evidence), and superficial vein thrombosis (RR 1.05, 95% CI 0.51 to 2.17; 4 studies, 846 participants; low-certainty evidence). CHIVA may reduce slightly nerve injury (RR 0.14, 95% CI 0.02 to 0.98; NNTH 9, 95% CI 5 to 100; 4 studies, 846 participants; low-certainty evidence) and hematoma compared to stripping (RR 0.59, 95% CI 0.37 to 0.97; NNTH 11, 95% CI 5 to 100; 2 studies, 245 participants; low-certainty evidence). For bruising, one study found no differences between groups while another study found reduced rates of bruising in the CHIVA group compared to the stripping group. Compared to RFA, CHIVA may make little or no difference to rates of limb infection, superficial vein thrombosis, nerve injury or hematoma, but may cause more bruising (RR 1.15, 95% CI 1.04 to 1.28; NNTH 8, CI 95% 5 to 25; 1 study, 144 participants; low-certainty evidence). Compared to endovenous laser, CHIVA may make little or no difference to rates of limb infection, superficial vein thrombosis, nerve injury or hematoma. The study comparing CHIVA versus compression did not report side effects. Authors' conclusions: There may be little or no difference in the recurrence of varicose veins when comparing CHIVA to stripping (low-certainty evidence), but CHIVA may slightly reduce nerve injury and hematoma in the lower limb (low-certainty evidence). Very limited evidence means we are uncertain of any differences in recurrence when comparing CHIVA with compression (very low-certainty evidence). CHIVA may make little or no difference to recurrence compared to RFA (low-certainty evidence), but may result in more bruising (low-certainty evidence). CHIVA may make little or no difference to recurrence and side effects compared to endovenous laser therapy (low-certainty evidence). 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, and the results were imprecise due to the low number of events. New RCTs are needed to confirm these results and to compare CHIVA with approaches other than open surgery.
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Most patients with chronic venous disease (CVD) and reflux in the saphenous vein are treated with saphenous stripping or ablation. The venous hemodynamics approach offers the possibility of treating saphenous reflux without eliminating the saphenous vein. We present 2 cases in which venous reflux was eliminated while preserving the great saphenous vein, after treatment with hemodynamic sclerotherapy using a protocol of synergic use of Dextrose and long pulse Nd YAG 1064 laser. These cases show that treating the tributaries responsible for saphenous reflux can correct hemodynamic imbalances and restore normal flow in the great saphenous vein with improvements in symptoms and esthetics. Long-term results are still uncertain.
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Purpose of review: Chronic venous insufficiency is found to some extent in a large proportion of the world's population, especially in the elderly and obese. Despite its prevalence, little research has been pursued into this pathology when compared to similarly common conditions. Pain is often the presenting symptom of chronic venous insufficiency and has significant deleterious effects on quality of life. This manuscript will describe the development of pain in chronic venous insufficiency, and will also review both traditional methods of pain management and novel advances in both medical and surgical therapy for this disease. Recent findings: Pain in chronic venous insufficiency is a common complication which remains poorly correlated in recent studies with the clinically observable extent of disease. Although lifestyle modification remains the foundation of treatment for pain associated with chronic venous sufficiency, compression devices and various pharmacologic agents have emerged as safe and effective treatments for pain in these patients. In patients for whom these measures are insufficient, recently developed minimally invasive vascular surgical techniques have been shown to reduce postsurgical complications and recovery time, although additional research is necessary to characterize long-term outcomes of these procedures. This review discusses the latest findings concerning the pathophysiology of pain in chronic venous insufficiency, conservative and medical management, and surgical strategies for pain relief, including minimally invasive treatment strategies.
Book
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This book is designed to equip the reader with a detailed knowledge of the pathophysiology of chronic venous disease and an understanding of the clinical benefits of restoring venous drainage by saphenous vein-sparing procedures, including minimization of invasiveness and reduction of the recurrence rate. All of the techniques currently available for vein-sparing strategies, including novel endovenous options, are clearly described and illustrated, with explanation of the role and value of recent technical innovations. The reader is guided through the entire management process, starting from diagnosis and proceeding through evaluation of the individual patient’s needs to the successful implementation of appropriate treatment. In addition, the literature on relevant diagnostic and therapeutic protocols is thoroughly reviewed, covering all significant publications to the present day. The content is kept as simple as possible to help those new to the field. At the same time, the deep insights into theoretical and technical aspects will support even the most advanced specialists in their everyday practice.
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Resumo A maior causa de recidiva das varizes dos membros inferiores é a inadequada dissecção da crossa da safena interna, com a ligadura não rente da junção safenofemoral. O acesso direto ao tecido cicatricial de uma cirurgia prévia deve ser evitado ao máximo pelo elevado risco de sangramento e de lesões linfáticas. O acesso proximal ao tecido cicatricial, abordando inicialmente a veia femoral comum acima da junção safenofemoral, seguindo-a em direção caudal até a crossa da safena, mostrou-se uma técnica eficiente e relativamente simples quando comparada às abordagens medial, lateral e direta.
Article
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Background: Femoro-popliteal bypass is implemented to save limbs that might otherwise require amputation, in patients with ischaemic rest pain or tissue loss; and to improve walking distance in patients with severe life-limiting claudication. Contemporary practice involves grafts using autologous vein, polytetrafluoroethylene (PTFE) or Dacron as a bypass conduit. This is the second update of a Cochrane review first published in 1999 and last updated in 2010. Objectives: To assess the effects of bypass graft type in the treatment of stenosis or occlusion of the femoro-popliteal arterial segment, for above- and below-knee femoro-popliteal bypass grafts. Search methods: For this update, the Cochrane Vascular Information Specialist searched the Vascular Specialised Register (13 March 2017) and CENTRAL (2017, Issue 2). Trial registries were also searched. Selection criteria: We included randomised trials comparing at least two different types of femoro-popliteal grafts for arterial reconstruction in patients with femoro-popliteal ischaemia. Randomised controlled trials comparing bypass grafting to angioplasty or to other interventions were not included. Data collection and analysis: Both review authors (GKA and CPT) independently screened studies, extracted data, assessed trials for risk of bias and graded the quality of the evidence using GRADE criteria. Main results: We included nineteen randomised controlled trials, with a total of 3123 patients (2547 above-knee, 576 below-knee bypass surgery). In total, nine graft types were compared (autologous vein, polytetrafluoroethylene (PTFE) with and without vein cuff, human umbilical vein (HUV), polyurethane (PUR), Dacron and heparin bonded Dacron (HBD); FUSION BIOLINE and Dacron with external support). Studies differed in which graft types they compared and follow-up ranged from six months to 10 years.Above-knee bypassFor above-knee bypass, there was moderate-quality evidence that autologous vein grafts improve primary patency compared to prosthetic grafts by 60 months (Peto odds ratio (OR) 0.47, 95% confidence interval (CI) 0.28 to 0.80; 3 studies, 269 limbs; P = 0.005). We found low-quality evidence to suggest that this benefit translated to improved secondary patency by 60 months (Peto OR 0.41, 95% CI 0.22 to 0.74; 2 studies, 176 limbs; P = 0.003).We found no clear difference between Dacron and PTFE graft types for primary patency by 60 months (Peto OR 1.67, 95% CI 0.96 to 2.90; 2 studies, 247 limbs; low-quality evidence). We found low-quality evidence that Dacron grafts improved secondary patency over PTFE by 24 months (Peto OR 1.54, 95% CI 1.04 to 2.28; 2 studies, 528 limbs; P = 0.03), an effect which continued to 60 months in the single trial reporting this timepoint (Peto OR 2.43, 95% CI 1.31 to 4.53; 167 limbs; P = 0.005).Externally supported prosthetic grafts had inferior primary patency at 24 months when compared to unsupported prosthetic grafts (Peto OR 2.08, 95% CI 1.29 to 3.35; 2 studies, 270 limbs; P = 0.003). Secondary patency was similarly affected in the single trial reporting this outcome (Peto OR 2.25, 95% CI 1.24 to 4.07; 236 limbs; P = 0.008). No data were available for 60 months follow-up.HUV showed benefits in primary patency over PTFE at 24 months (Peto OR 4.80, 95% CI 1.76 to 13.06; 82 limbs; P = 0.002). This benefit was still seen at 60 months (Peto OR 3.75, 95% CI 1.46 to 9.62; 69 limbs; P = 0.006), but this was only compared in one trial. Results were similar for secondary patency at 24 months (Peto OR 4.01, 95% CI 1.44 to 11.17; 93 limbs) and at 60 months (Peto OR 3.87, 95% CI 1.65 to 9.05; 93 limbs).We found HBD to be superior to PTFE for primary patency at 60 months for above-knee bypass, but these results were based on a single trial (Peto OR 0.38, 95% CI 0.20 to 0.72; 146 limbs; very low-quality evidence). There was no difference in primary patency between HBD and HUV for above-knee bypass in the one small study which reported this outcome.We found only one small trial studying PUR and it showed very poor primary and secondary patency rates which were inferior to Dacron at all time points.Below-knee bypassFor bypass below the knee, we found no graft type to be superior to any other in terms of primary patency, though one trial showed improved secondary patency of HUV over PTFE at all time points to 24 months (Peto OR 3.40, 95% CI 1.45 to 7.97; 88 limbs; P = 0.005).One study compared PTFE alone to PTFE with vein cuff; very low-quality evidence indicates no effect to either primary or secondary patency at 24 months (Peto OR 1.08, 95% CI 0.58 to 2.01; 182 limbs; 2 studies; P = 0.80 and Peto OR 1.22, 95% CI 0.67 to 2.23; 181 limbs; 2 studies; P = 0.51 respectively)Limited data were available for limb survival, and those studies reporting on this outcome showed no clear difference between graft types for this outcome. Antiplatelet and anticoagulant protocols varied extensively between trials, and in some cases within trials.The overall quality of the evidence ranged from very low to moderate. Issues which affected the quality of the evidence included differences in the design of the trials, and differences in the types of grafts they compared. These differences meant we were often only able to combine and analyse small numbers of participants and this resulted in uncertainty over the true effects of the graft type used. Authors' conclusions: There was moderate-quality evidence of improved long-term (60 months) primary patency for autologous vein grafts when compared to prosthetic materials for above-knee bypasses. In the long term (two to five years) there was low-quality evidence that Dacron confers a small secondary patency benefit over PTFE for above-knee bypass. Only very low-quality data exist on below-knee bypasses, so we are uncertain which graft type is best. Further randomised data are needed to ascertain whether this information translates into an improvement in limb survival.
Article
Objective: The aim of this study was to compare the recurrence rate after high ties performed with or without sparing of the saphenofemoral junction tributaries. Methods: There were 867 lower limbs enrolled. All patients underwent a high tie with (group A) or without (group B) ligation of all the junctional tributaries for a great saphenous vein reflux (C2-5EpAsPr). A duplex ultrasound examination detected recurrences. Results: Median follow-up was 5 years (interquartile range, 3-8 years). Group A had a higher recurrence rate than group B (odds ratio, 7.52; P < .001). Group A recurrences (7.4%), compared with group B (1.1%), presented with a more frequent direct stump reconnection (3.7% vs 0.2%; P < .001) or newly developed pelvic shunts (3% vs 0.5%; P < .001). No significant difference was reported between the two groups in newly incompetent perforating veins. Conclusions: Ligation of the junctional tributaries is associated with a higher recurrence risk. Further investigations are needed to determine the hemodynamic role of each single junctional tributary.
Article
This is the protocol for a review and there is no abstract. The objectives are as follows: To compare the effectiveness of endovenous LASER ablation therapy (EVLA), radiofrequency ablation (RFA) and ultrasound-guided foam sclerotherapy (UGFS) versus conventional surgery in the management of short saphenous vein varices.
Chapter
Background: Short (or small) saphenous vein (SSV) varices occur as a result of an incompetent sapheno-popliteal junction, where the SSV joins the popliteal vein, resulting in reflux in the SSV; they account for about 15% of varicose veins. Untreated varicose veins may sometimes lead to ulceration of the leg, which is difficult to manage. Traditionally, treatment was restricted to surgery or conservative management. Since the 1990s, however, a number of minimally invasive techniques have been developed; these do not normally require a general anaesthetic, are day-case procedures with a quicker return to normal activities and avoid the risk of wound infection which may occur following surgery. Nerve injury remains a risk with thermal ablation, but in cases where it does occur, the injury tends to be transient. Objectives: To compare the effectiveness of endovenous laser ablation (EVLA), radiofrequency ablation (RFA) and ultrasound-guided foam sclerotherapy (UGFS) versus conventional surgery in the treatment of SSV varices. Search methods: The Cochrane Vascular Information Specialist searched the Specialised Register (last searched 17 March 2016) and the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 2). We searched clinical trials databases for details of ongoing or unpublished studies. Selection criteria: We considered all randomised controlled trials (RCTs) comparing EVLA, endovenous RFA or UGFS with conventional surgery in the treatment of SSV varices for inclusion. Data collection and analysis: We independently reviewed, assessed and selected trials that met the inclusion criteria; any disagreements were resolved by discussion. We extracted data and used the Cochrane's tool for assessing risk of bias. When the data permitted, we performed either fixed-effect meta-analyses with odds ratios (ORs) and 95% confidence intervals (CIs) or random-effects meta-analyses where there was moderate to significant heterogeneity. Main results: We identified three RCTs, all of which compared EVLA with surgery; one also compared UGFS with surgery. There were no trials comparing RFA with surgery. The EVLA versus surgery comparison included 311 participants: 185 received EVLA and 126 received surgery. In the UGFS comparison, each treatment group contained 21 people. For several outcomes in the EVLA comparison, only a single study provided relevant data; as a result, the current review is limited in its ability to demonstrate meaningful results for some planned outcomes. The quality of evidence according to GRADE was moderate to low for the outcome measures in the EVLA versus surgery comparison, but low for the UGFS versus surgery comparison. Reasons for downgrading in the EVLA versus surgery comparison were risk of bias (for some outcomes, the outcome assessors were not blinded; and in one study the EVLA-surgery allocation of 2:1 did not appear to be prespecified); imprecision (data were only available from a single small study and the CIs were relatively wide); indirectness (one trial reported results at six months rather than one year and was inadequately powered for SSV varices-only analysis). Reasons for downgrading in the UGFS versus surgery comparison were imprecision (only one trial offered UGFS and several participants were missing from the analysis) and a limitation in design (the study was inadequately powered for SSV participants alone).For the EVLA versus surgery comparison, recanalisation or persistence of reflux at six weeks occurred less frequently in the EVLA group than in the surgery group (OR 0.07, 95% CI 0.02 to 0.22; I(2) = 51%; 289 participants, 3 studies, moderate-quality evidence). Recurrence of reflux at one year was also less frequent in the EVLA group than in the surgery group (OR 0.24, 95% CI 0.07 to 0.77; I(2) = 0%; 119 participants, 2 studies, low-quality evidence). For the outcome clinical evidence of recurrence (i.e. presence of new visible varicose veins) at one year, there was no difference between the two treatment groups (OR 0.54, 95% CI 0.17 to 1.75; 99 participants, 1 study, low-quality evidence). Four participants each in the EVLA and surgery groups required reintervention due to technical failure (99 participants, 1 study, moderate-quality evidence). There was no difference between the two treatment groups for disease-specific quality of life (QoL) (Aberdeen Varicose Veins Questionnaire) either at six weeks (mean difference (MD) 0.15, 95% CI -1.65 to 1.95; I(2) = 0%; 265 participants, 2 studies, moderate-quality evidence), or at one year (MD -1.08, 95% CI -3.39 to 1.23; 99 participants, 1 study, low-quality evidence). Main complications reported at six weeks were sural nerve injury, wound infection and deep venous thrombosis (DVT) (one DVT case in each treatment group; EVLA: 1/161, 0.6%; surgery 1/104, 1%; 265 participants, 2 studies, moderate-quality evidence).For the UGFS versus surgery comparison, there were insufficient data to detect clear differences between the two treatment groups for the two outcomes recanalisation or persistence of reflux at six weeks (OR 0.34, 95% CI 0.06 to 2.10; 33 participants, 1 study, low-quality evidence), and recurrence of reflux at one year (OR 1.19, 95% CI 0.29 to 4.92; 31 participants, 1 study, low-quality evidence). No other outcomes could be reported for this comparison because the study data were not stratified according to saphenous vein. Authors' conclusions: Moderate- to low-quality evidence exists to suggest that recanalisation or persistence of reflux at six weeks and recurrence of reflux at one year are less frequent when EVLA is performed, compared with conventional surgery. For the UGFS versus conventional surgery comparison, the quality of evidence is assessed to be low; consequently, the effectiveness of UGFS compared with conventional surgery in the treatment of SSV varices is uncertain. Further RCTs for all comparisons are required with longer follow-up (at least five years). In addition, measurement of outcomes such as recurrence of reflux, time taken to return to work, duration of procedure, pain, etc., and choice of time points during follow-up should be standardised such that future trials evaluating newer technologies can be compared efficiently.