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COMPARISON BETWEEN CHIVA METHOD AND ASVAL TREATMENT
Stefano Ermini MDFirenze
A AblationS SelectiveV Varices … sous A AnestesieL Locale
Paul Pittaluga
ASVAL Phisiopathologic assesment1. Ascending Theory2. “Reservoire” effect
ASVAL Strategy1. Tributary compression test
La Strategia CHIVA1. Tributary compression test2. Systolic carthography
CHIVA Phisiopathogic assesementAll theories
Phisiopahologic presuppositions : Ascending theory
1-Dr Pittalugua: “That is the explanation of the « aspirating effect » of the varicose reservoir on the saphenous vein” : Vasculab 2009. He changed this explanation 4 years later in “We talk about "filling effect" rather than "aspirating effect". The dilatation begins on the tributaries at the bottom (where the hydrostatic pressure is higher) because of the weakness of the vein wall and the absence of protection by the fascia”. VASCULAB Feb 2013
Aspirativ effect in 2009Feeding tributary effect in 2013
What the “reservoir” effect is in Phisiology ?
Reservoire venoso:Sistema di
ammortizzamento delle variazioni di pressioni nel
sistema venoso grazie alla compliance della
parete che consente un aumento di volume
importante con aumento di pressione debole
( almeno fino al raggiungimento della massima distensione).
Reservoire cardiaco:Svolto dalle vene
muscolari
The “Reservoir” effect, invented from the ascending theory followers , would be that a large varicose veins volum capacity
alone is capable of creating a “passive”aspirative effect..
Only that a liquid movement may be created only by "active"forces, like that of gravity or a pump.
MotionEquation of a Generic Volume (Base of Hydrodynamics)
Force acting on the unit mass
Therefore this concept is contrary to the physic fluids law
∂gh
Leukocyte adhesion in the valve sinus
M.A. Elsharawy et al. Interactive Cardiovascula and Thoracic Surgery 6 (2007) 219-224(ONO T. et al. J. Vasc. Surgery 1998 Jan; 27 (1):158-166)
2° Comment
3° Commento
Daily practice:Rare Finding of enlarged veins not refluxingFrequent findings of not enlarged refluxing veins
Prospective epidemiological study on the beginning of varicose veins. Schultz-Ehrenburg and al. Phlebologie 2009; 38: 17–25Longitudinal study . 740 pupils 10-12 to 18-20. “The manifestation of a truncal VV is preceded by a VR in the same vein (p = 0.039). “
ASVAL = Dilation precedes refluxStudio Schulz-Ehrenburg = Reflux precedes dilation
4° CommentA DUS documentation of proximal reflux extension is possible?
Answer = NO
No Competent valvesNo retrograde Flow
Incompetent tributary
Competent Valve
Strategy
ASVAL : Extensive phlebectomy of the incomtent tributary
CHIVA : adapted to shunt type and to systolic carthography
La Strategia
ASVAL strathegy : provides an extensive phlebectomy of the incompetent thigh tributary when the compression test is positive.If saphenous reflus reappears , ASVAL provides the saphenous trunk stripping or Laser ablation“Penso” che da questo è nato lo stripping senza crossectomia, per trattare la ricomparsa del reflusso in caso di valvola terminale continente.
In conclusion ASVAL is only the new “Muller” phlebectomy justified by the ascending theory
CHIVA Strategy : Never provides the saphenous trunk ablation
Note that …The compression re-entry test has been
described by Claude Franceschi 23 years ago and publied by Marc Bailly in 1995
J.M. BaillyCarthographie CHIVAEMC - Paris 1995
Which Kind of Hemodynamic Pattern can give origin to this GSV thigh tributhary ?
GSV
SSV
Giacomini
Deep Veins
Competent
Incompetent
1° variable aspect : a. The escape point can exists or notb. The escape point location
Whithout escape point Whit an escape point ( SFJ)
Possible Escape Points
Incompetent SFJ Pelvic escape pointHunter Perforator
Zamboni : 80% recidive a 3 anni
2° variable aspect : The saphenous axe below the tributary origin ( competent/incompetent/absent)
Competent Incompetent Absent (US not detected)
With Saphenous Incompetence
With Competent GSV below the tributary
With Incompetent GSV below the tributary
Shunt Type 2A Shunt Type 2B Shunt Type 2C
Possibilities without escape point (negative Valsalva)Shunt Type 2
Without Saphenous Incompetence
Possibilities with a refluxing SFJ - Terminal valve incompetent (positive Valsalva)
Shunt Type 3 Shunt Type 1 + 2
Variables of Shunt Type 3
Shunt Type 3/a Shunt Type 3/b Shunt Type 3/c
Shunt Type 4 +II
Pelvic escape point
Shunt Type 5
Muscle Contractive Centripetal Flow in the Giacomini Vein that feeds a centrifugal flow in the GSV during the relaxation phase
ASVAL provides the saphenous trunk stripping or Laser ablation when the
saphenous reflux reappers after phlebectomy
What percentage do you think ASVAL will be a saphenous sparing surgery
treatment?
Less then 20% in shunt type 3 and about 50% in shunt type 2/b and 5
?
Why do centrifugal flow reappears in a shunt type 2 after tributary flush ligation ( including or not an extensive
phlebectomy) ?
Saphenous trunk
Tributary
Tributary
Desappearing of diastolic centrifugal flow
No flow is detectable A Centripetal flow persists
Saphenous trunk
Desappearing of diastolic centrifugal flow
Is extensive phlebetomy mandatory??
Thanks for your attention
Video perthes test
Thanks for your attention