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Non-Commercial Use Only Veins and Lymphatics 2018; volume 7:7199 Who knows the rationale of the According to Cestmir Recek’s the strain refilling time measured by gauge measurements improved the plethys- Correspondence: Claude Franceschi, Centre mographic parameters as follows: de soins Marie Thérèse, Paris, France. plethysmography? After great saphenous vein (GSV) E-mail: [email protected] crossectomy, the mean of 30 measurements Key words: Plethysmography; venous patho- Claude Franceschi was: refill time t-90 by 24.5 s; t-50 by 10.6 physiology; chronic venous insufficiency; Centre de soins Marie Thérèse, Paris, s; refill volume by 0.94 mL/100 mL (a mean CHIVA; saphenous ablation; lower limb of 30 measurements).1 France drainage. After crossectomy and stripping, the mean of 18 measurements was: refill time t- This work is licensed under a Creative 90 by 26.2 s; t-50 by 10.8 s; refill volume by Commons Attribution 4.0 License (by-nc 4.0). Abstract 1.1 mL/100 mL.² The Recek’s conclusion was: the differ- ©Copyright C. Franceschi, 2018 This mini-review analyzes the patho- Licensee PAGEPress, Italy ences were minimal and the postoperative Veins and Lymphatics 2018; 7:7199 physiology significance of the refilling time results both after high ligation and after doi:10.4081/vl.2018.7199 (RT) assessed in limbs after exercise by the high ligation plus stripping were well in the means of plethysmographic techniques. range of normal values. Based on such a rationale the Author offers The hemodynamic analysis of these an interpretation of RT following suppres- results shows limitations and sometimes gery does not take into account all the sion of reflux points respectively achieved misinterpretations of the data. aspects of the venous insufficiency, particu- by CHIVA or by ablative techniques, show- Indeed, though very minimal in terms larly the hydrostatic pressure and the ing the pathophysiologic differences of figures, the RT difference after crossecto- drainage impairment. That is why in case of between two different and controversial my alone and crossectomy + stripping is SFJ and total GSV trunk incompetence (N2) strategies of managing chronic venous very relevant in terms of pathophysiology the column should be segmented twice, at insufficiency. and paradoxically not in favor of the sup- the groinonly and below the knee (flush below a posed best result, i.e after stripping. leg re-entry perforator). Most of the time, In fact, the improved RT reflects not the GSV trunk is incompetent at the thigh only the overloading reflux volume aboli- but competent below the knee and the Pathophysiology significance of tion, but it also inevitably reflectsuse the reflux reaches the ankle or the foot through the refilling time impairment of the physiologic superficial an incompetent tributary (N3). In that case, flow caused by stripping or any endovenous if there is an interposed re-entry perforator Let’s analyze the rationale of the refill- destructive procedure. on the GSV trunk, the second hydrostatic ing time (RT) in order to understand the In case of sapheno-femoral junction column segmentation is performed flush the related hemodynamics basis, as well as field (SFJ) and GSV total incompetence, the N2>N3 escape point, and stops at the same and borders of interest in the venous insuf- refilling time is shortened by the huge spill time the shunt II overload N2>N3. ficiency assessment. from the femoral vein (N1 network) into N1 In SHUNT III, there is no available Normally, the leg elevation as well as again but below the knee via the GSV (N2 interposed re-entry on the N2 trunk. Then, the calf pumping exhausts the calf blood network) then. This represents a typical the N2>N3 flush ligation is a first step of volume accumulated by the standing or sit- closed shunts (N1>N2>N1). the CHIVA 2 steps strategy. The one step ting still posture. Reclining down the leg or The GSV closed shunt disconnection at strategy is possible. It consists of both pumping stop reverses the pressure gradient the SFJ eliminates N1 flow, and leaves N1>N2 and N2>N3 flush ligation combined but not the flow because it closes the valves. behind N2 flow only, which achieves a nor- with a N2 devalvulation down to a re-entry The valves open again when the refilling of mal range RT1 despite a still reversed GSV perforator. the venous bed is achieved. The normal flow. As a matter of fact, the physiological This CHIVA strategy segments the plethysmographic RT by calf pumping drainage hierarchy is restored (N2>N1 superficial network in two distinct drained measured at the end of several freeNon-commercial foot instead of N1>N2>N1). Yet, the RT normal- territories (thigh and leg). Consequently, RT flexions and dorsi-flexions ranges between ization does not take account of a still too at the leg is improved, even if not as much 18 and >20 seconds. The venous bed is high foot-groin hydrostatic pressure though after stripping but for a better functional quicker refilled and consequently the RT shorter than the previous foot-heart height. result and less recurrence.3-9 time is shortened by the reflux due to the Stripping or saphenous endovenous abla- So the refilling time is fortunately deep and/or superficial valve incompetence tion not only suppress the foot-groin col- increased up to the normal range but less (Figure 1). Furthermore, RT is also propor- umn but increases RT even more because than after stripping or endo-venous ablative tional to the volume reduction achieved by the whole GSV physiological flow is also procedures. Furthermore, the concept of the previous calf pumping or leg elevation. ablated. This explains the slightly longer reflux should be revisited. Indeed, the nor- This reduction is obtained at maximum dur- refilling time after stripping2 i.e after abla- mal refilling time restore after crossectomy ing the elevation while it depends on the tion of most of the N2 volume flow. This or CHIVA crossotomy despite a still pump efficiency during the calf activation. last plethysmographic improvement reflects reversed flow (reflux) demonstrates that the So, due to the difference of volume reduc- in fact superficial drainage impairment. As reflux after CHIVA is not pathogenic flow tion, the expected RT will be longer after a matter of fact, stripping or any other endo because it is no more overloaded and drains elevation than after calf activation. The calf venous superficial ablative techniques the tissues according to the physiological pump efficiency can be impaired by several impair the skin drainage, which is responsi- hierarchy N3>N2>N1 or N3>N1. reasons, as valve incompetence, venous ble for reactive neo-angiogenesis, matting, Finally, as reported in one of the first obstacles, and defect of muscle volume, telangiectasias and varicose recurrence. prospective randomised study10 comparing strength or mobility. That is why RT interpretation following sur- CHIVA with compression in the treatment [page 8] [Veins and Lymphatics 2018; 7:7199] Brief Report namic correction (CHIVA): a long term randomised trial. Eur J Vasc Endovasc Surg 2008;35:230-7. 6. Bellmunt-Montoya S, Escribano JM, Dilme J, Martinez-Zapata MJ. CHIVA methodfor the treatment of chronic venous insufficiency. Cochrane data- base Syst Rev 2013;7:CD009648. 7. Chan C-Y, Chen T-C, Hsieh Y-K, Huang J-H. Retrospective comparison of clinical outcomes between endove- nous laser and saphenous vein-sparing surgery for treatment of varicose veins. World J Surg 2011;35:1679-86. 8.Wang H, Chen Q, Fei Z, et al. Hemodynamic classification and Figure 1. In case of venous incompetence, the diastolic refilling time will be quicker, less CHIVA treatment of varicose veins in than 20 seconds, fed by the venous reflux, in proportion to the valve incompetence rate. A: Emptying volume and time. B: Refilling volume and time in case of venous incompe- lower extremities (VVLE). Int J Clin tence: capillary ouflow + Relux flow. C: Refilling volume and time normal venous com- Exp Med 2016;9:2465-71. petence: capillary ouflow. 9. Mendoza E. Primum non nocere. Veins and Lymphatics 2017;6:6646. 10. Zamboni P, Cisno C, Marchetti F, et al. Minimally invasive surgical manage- of venous ulceration, the surgical group 2. Recek C. Saphena-Reflux als Ursache ment of primary venous ulcers vs. com- showed a sifnificant improvement of all der venösen Zirkulationsstörung bei onlypression treatment: a randomized clini- plethysmographic parameters except of primärer Varikose mit chronischer cal trial. Eur J Vasc Endovasc Surg ejection fraction, at 6 months. However, the Veneninsuffizienz. Acta Chir Austriaca 2003;25:313-8. Erratum in: Eur J Vasc reverse direction of the flow is not responsi- 1998. Endovasc Surg 2003;26:337-8. ble for inflammation but just its amount.11,12 3. Franceschi C, Cappelli M, Erminiuse S, et 11. Tisato V, Zauli G, Gianesini S, et al. al. CHIVA: hemodynamic concept, Modulation of circulating cytokine- strategy and results. Int Angiol chemokine profile in patients affected 2016;35:8-30. by chronic venous insufficiency under- References 4. Pares JO, Juan J, Tellez R, et al. going surgical hemodynamic correc- Varicose vein surgery: stripping versus tion. J Immunol Res 2014;2014: 1.Recek C, Karisch E, Gruber J. the CHIVA method: a randomized con- 473765. Veränderungen der Perforansvenen und trolled trial. Ann Surg 2010;251:624- 12. Zamboni P, Spath P, Tisato V, et al. tiefen Unterschenkelvenen nach 31. Oscillatory flow suppression improves Beseitigung des Saphena-Refluxes. 5. Carandina S, Mari C, De Palma M, et inflammation in chronic venous dis- Phlebologie 2000;29:37-40. al. Varicose vein stripping vs haemody ease. J Surg Res 2016;205:238-45. Non-commercial [Veins and Lymphatics 2018; 7:7199] [page 9].
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