Servier – Phlebolymphology

A SNAPSHOT FROM THE 11TH ANNUAL MEETING OF THE EUROPEAN
VENOUS FORUM (Antwerp, Belgium)

Michel PERRIN
E-mail: m.perrin.chir.vasc@wanadoo.fr

It was my privilege to serve as the first president at the 2000 inaugural European Venous Forum (EVF) meeting held in Lyon. Ten years later it seems logical to take stock of the present state of the EVF by analyzing the Antwerp congress. First of all in terms of the number of attendees. Attendance has increased from 160 founding members in Lyon to 320 in Belgium. More impressive is the number of participating countries: 38 in total this year covering the five continents.

Quality remains the EVF’s main criterion for presentations, which explains why just 29 papers were selected from the 85 submitted. From the beginning the EVF board decided that the time devoted to discussion should be equal to the presentation time, and this rule remains both crucial and fruitful.

To go back to the Antwerp meeting, which was remarkably organized by Marianne de Maeseneer—the first woman president of the EVF, the sessions were divided into 5 topics: clinical and basic research, deep venous problems, endovenous treatment of varicose veins, socioeconomic implications of chronic venous disease, and short miscellaneous venous subjects. Preceding the EVF paper sessions, the 7th North Sea meeting organized by the Benelux Society of Phlebology was devoted to long-term follow-up after varicose vein treatment, followed by 2 other topics selected by the EVF committee: prevention of venous thromboembolism in 2010 and its treatment. All 3 were high-quality sessions. Between the selected papers we had, as usual, invited presentations, including those of the winners of the American Venous Forum and EVF traveling fellowship. Following a lovely musical intermezzo, the meeting ended with the presentation of the EVF prizes.

To summarize, this was an outstanding EVF vintage.

PRINCIPLES OF VENOUS HEMODYNAMICS. FRANCESCHI C, ZAMBONI P
(EDITS). NOVA BIOMEDICAL BOOKS.2009. NEW YORK.
ISBN 978-1-606692-485-3

This 200-page hardback book in glazed paper is divided into 12 chapters, with a total of 284 references, and is prefaced by both E. Rabe, the current President of the Union Internationale de Phlébologie (UIP), and N. Morrison, the elected President of the next UIP Meeting. For readers unaware of the CHIVA procedure (in French “cure Conservatrice et Hémodynamique de l’Insuffisance Veineuse en Ambulatoire—Ambulatory Conservative Hemodynamic Management of Varicose Veins), this book will be quite a surprise both in terms of the terminology used and the concept of varicose vein treatment.

CHIVA was first described by Franceschi in 19881 and West European phlebologists are accustomed to the specific terms it uses, as Shunt 0, I, II, III, and IV, venous networks N1, 2, 3, 4, etc., as well as the hemodynamic principles, given that many publications on CHIVA have been published, mostly in European journals.^2-13

The first chapter is devoted to the physical principles of venous hemodynamics, a reminder of the correlation between pressure and energy and their influence on venous flow according to Castelli’s flow, Bernoulli’s principle, and Venturi effects.

The second chapter is very informative on ultrasound data and introduces the next one on venous compartments and their hierarchical order of emptying in accordance with the five phases initiated by the muscular pump in a healthy individual.

Chapters 4, 5, and 6 deal with pathophysiological mechanisms in chronic venous insufficiency* and develop the shunt concept, including pelvic shunts, which demands careful attention from the uninitiated. Happily, many figures and diagrams illustrate the different types or modalities of the “private circulation” or venous shunts according to CHIVA terminology. Understanding of this classification is crucial before reading the subsequent chapters.

Chapter 7 states the CHIVA goal strategy in detail:
• First, preservation of the superficial venous capital as a possible arterial substitute when treating coronary or peripheral arterial disease.
• Second, conservation of saphenous trunks ensures better drainage of the superficial compartment tissues.

Many examples of treatment are displayed according to the various patterns of varicose veins evaluated by careful preoperative duplex investigation.

Chapter 8 describes methods of measuring hemodynamic parameters and what specific information they provide. Chapter 9 entitled “How to perform a duplex mapping” (before CHIVA) is crucial reading if this procedure is to be used properly. The chapter includes 41 color figures as detailed illustrations of clinical cases.

Chapter 10 is illustrated by 46 figures and describes the technical procedures to be performed according to the identified pathophysiological patterns: high ligation, tributary disconnection, hook phlebectomy, etc.

The penultimate chapter presents the results of CHIVA, including clinical findings, duplex scanning results, and health-related quality of life assessment. The last chapter revisits the problem of so-called incompetent perforators.

The purpose of this book review is not to formulate an opinion of the value and effectiveness of the CHIVA procedure, but to provide information on Franceschi and Zamboni’s book. Nevertheless, I would say that whether or not you are a CHIVA supporter or user you will, like me, learn a lot on varicose veins by reading it.

REFERENCES
1. Franceschi C. Théorie et Pratique de la Cure Conservatrice et Hémodynamique de l’ Insuffisance Veineuse en Ambulatoire. Precy-sous-Thil, France: Editions de l’ Armancon, 1988.
2. Carandina S, Mari C, De Palma M, et al. Varicose Vein Stripping vs Haemodynamic Correction (CHIVA): a Long Term Randomised Trial. Eur J Vasc Endovasc Surg. 2007;35:230-237.
3. Zamboni P, Marcellino MG, Feo C, Berta R, Vasquez G, Pansini GC. When CHIVA treatment could be video-guided. Dermatol Surg. 1995;21:621-625.
4. Cappelli M, Molino L R, Ermini S, Turchi A, Bono G, Franceschi C. Comparison between the CHIVA cure and stripping in the treatment of varicose veins of the legs: follow-up of 3 years. J Mal Vasc. 1996;21:40-46.
5. Zamboni P, Feo C, Marcellino MG, Vasquez G, Mari C. Hemodynamic correction of varicose veins( CHIVA): an effective treatment. Phlebology. 1996;11:98-101.
6. Bahnini A, Bailly M, Chiche L, Franceschi C. Ambulatory conservative hemodynamic correction of venous insufficiency. Technique, results. [Article in French]. Ann Chir. 1997;51:749-760.
7. Zamboni P, Marcellino MG, Pisano L, et al. Saphenous vein sparing surgery: principles, techniques and results. J Cardiovasc Surg. 1998;39:151-162.
8. Cappelli M, Lova RM, Ermini S, et al. Ambulatory conservative haemodynamic management of varicose veins: critical analysis of results at 3 years. Ann Vasc Surg. 2000;14:376-384.
9. Maeso J, Juan J, Escribano JM, et al. Comparison of clinical outcome of stripping and CHIVA for treatment of varicose veins in the lower extremities. Ann Vasc Surg. 2001;13:661-665.
10. Zamboni P, Cisno C, Marchetti F, Quaglio D, Mazza P, Liboni A. Reflux elimination without any ablation or disconnection of the saphenous vein. Eur J Vasc Endovasc Surg. 2001;21:361- 369.
11. Zamboni P, Cisno C, Marchetti F, et al. Minimally invasive surgical management of primary venous ulcers vs. compression treatment: a randomized clinical trial. Eur J Vasc Endovasc Surg. 2003;25:313-318.
12. Escribano JM, Juan J, Bofill R, Maeso J, Rodriguez-Mori A, Matas M. Durability of reflux-elimination by a minimal invasive CHIVA procedure on patients with varicose veins. A 3-year prospective case study. Eur J Vasc Endovasc Surg. 2003;25:159-163.
13. Parés JO, Juan J, Tellez R, et al. Varicose vein surgery. Stripping versus the CHIVA method: a randomized controlled trial. Ann Surg. 2010;251:624-631.
14. Eklof B, Perrin M, Delis K, Rutherford R; VEIN-TERM Transatlantic Interdisciplinary Faculty. Updated terminology of chronic venous disorders: the VEIN-TERM Transatlantic Interdisciplinary consensus document. J Vasc Surg. 2009;48:498-501.