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Surgical Treatment of Varicose Veins with the CHIVA Method

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Surgical Treatment of Varicose Veins with the CHIVA Method Review Operative Behandlung der Varikose nach der CHIVA-Methode Surgical treatment of varicose veins with the CHIVA method Autoren Erika Mendoza Institut und Spanien durchgesetzt, im Moment hält es seinen Einzug in Venenpraxis, Wunstorf China und in den osteuropäischen Ländern, primär dort, wo der Duplex als Grundlage für die phlebologische Diagnostik zählt Schlüsselwörter und eine kostengünstige Herangehensweise vom Gesundheits- Chronische venöse Insuffizienz, Saphenareflux, Venenerhalt, wesen gefordert wird. CHIVA Das Verfahren kann bei jeder Ausprägung der Varikose und jedem Stadium der chronischen venösen Insuffizienz ange- Key words wendet werden, wobei der Erhalt einer postthrombotisch ver- chronic venous insufficiency, reflux in saphenous vein, änderten Stammvene nicht anstrebenswert erscheint. Eine vein preservation, CHIVA Metaanalyse (Cochrane-Review) bescheinigt CHIVA weniger Rezidive bei gleichwertigem Erstergebnis und weniger Neben- eingereicht 09.11.2018 wirkungen im Vergleich zum Stripping, wobei weitere Studien akzeptiert ohne Revision 14.03.2019 mit höheren Patientenzahlen gefordert werden. Die neuen Techniken, wie endoluminale (Hitze-) Verfahren Bibliografie und schallgesteuerte Schaumverödung haben das Verfahren DOI https://doi.org/10.1055/a-0877-8781 noch minimal-invasiver gemacht, sodass die ohnehin geringe Online Publikation: 02.05.2019 Komplikationsrate und die kurze Arbeitsunfähigkeitszeit noch Phlebologie 2019; 48: 153–160 verkürzt werden kann. © Georg Thieme Verlag KG Stuttgart · New York ISSN 0939-978X ABSTRACT Korrespondenzadresse In 1988, just after the upcoming of duplex ultrasound, the Dr. Erika Mendoza French vascular surgeon and angiologist Claude Franceschi de- Venenpraxis veloped a hemodynamic strategy to treat venous insufficiency Speckenstr. 10 on ambulatory patients. He gave the treatment the name of 31515 Wunstorf the French acronym. CHIVA. E-Mail: [email protected] The strategy is based on the preservation of draining path- ways, specially the saphenous veins. The first step consists in an analysis of the recirculation pathway, which was classified by Englische Version unter: https://doi.org/10.1055/a-0877-8781 Franceschi into veno-venous shunts, depending on the reflux source and the drainage. Each shunt type requires a special way ZUSAMMENFASSUNG of treatment to achieve the best result and to avoid superficial thrombosis. The method has found its place in the treatment Im Jahr 1988, kurz nach der Einführung der Duplex-Sonogra- options in Spain and Italy, actually it is becoming popular in phie, entwickelte der französische Gefäßchirurg und Angiologe CHINA and the European Eastern Countries, especially in coun- Claude Franceschi ein venenerhaltendes Verfahren zur Behand- tries, where duplex is common in phlebology diagnostics and lung insuffizienter Stammvenen bei ambulanten Patienten – ein financial resources are small. Verfahren das er nach dem Akronym aus dem Französischen als The method can be applied in each degree of venous illness „CHIVA“ bezeichnete. and chronic venous insufficiency, excepting post-thrombotic Es handelt sich um eine Strategie zum Erhalt der Drainagewege, saphenous trunks, which might not need to be preserved. A insbesondere der Stammvenen, im Bein. Sie erfordert eine Ana- meta-analysis in a Cochrane review certifies that CHIVA pro- lyse der Rezirkulationkreise, die Franceschi je nach Ursprung duces less side effects and long term recidives with the same des Refluxes und seiner Drainagewege in Shunts einteilte. Jeder immediate results as stripping. Shunt bedarf einer eigenen Herangehensweise, um eine stabile New techniques, like endoluminal (heat) procedures and ultra- postoperative Situation zu erhalten und oberflächliche Venen- sound guided foam sklerotherapy help to make the procedure thrombosen zu vermeiden. Das Verfahren hat sich in Italien even less invasive in the future. Mendoza E. Operative Behandlung der ... Phlebologie 2019; 48: 153–160 153 Review Einleitung Bis in die 80-er Jahre des 20. Jahrhunderts gab es nur eine chirur- gische Technik zur Therapie von insuffizienten Stammvenen: das Stripping. Die strategische Überlegung hinter dem Stripping ist, die erkrankten Venen zu entfernen. Dies Verfahren wurde immer weiter verfeinert und durch das invaginierende Stripping und auch durch die Einführung des stadiengerechten Ansatzes durchaus schonender [1]. Die Duplexsonographie als diagnostisches Medi- um der Varikose änderte dann die Therapiemöglichkeiten der Tak- tik „Venenausschalten“, weil es die intratherapeutische Kontrolle ermöglichte. Ohne Ultraschall wäre die schallgesteuerte Sklerothe- a N2 N1 N2 b N2 N1 N2 rapie und die endoluminalen Wärmeverfahren nicht möglich ge- worden, ebenso wenig wie die extraluminale Valvuloplastie. Die Duplexsonographie änderte aber auch das Verständnis der Hämodynamik der Varikose, ermöglichte Einblicke in Flussrich- tung und die Analyse der Rezirkulationskreise, die zwar theore- tisch durch Trendelenburg und Hach erörtert worden waren aber niemals bis ins Detail und an jedem Patienten individuell nachvoll- ziehbar waren. Diese Analyse ermöglichte es Dr. Claude Franceschi die Rezirku- lationen entsprechend des Ursprungs des Refluxes, seines Weges c N2 N1 N2 d N2 N1 N2 und seiner Drainage in so genannte Shunts einzuteilen [2]. Seine Strategie war es dann, die Rezirkulationen zu unterbrechen ohne die Venen zu entfernen – mit dem Ziel, die Stammvenen funktions- ▶Abb. 1 Refluxquellen aus dem tiefen Venensystem (N1) in die Stammvenen, sei es über den sapheno-femoralen Übergang (a), tüchtig zu erhalten und der Drainage des venösen Blutes aus der über den saphenopoplitealen Übergang (b), über eine Perforans- Haut keine Abflusswege zu nehmen. vene in die V. saphena magna (c) oder in die V. saphena parva (d). Seit 1988 hat sich der erste theoretische Ansatz durch Erkennt- nisse aus der praktischen Anwendung immer weiterentwickelt. Ursprünglich kamen nur chirurgische Techniken zum Einsatz, im eine Perforansvene (N2 → N1, s. ▶Abb. 4a) oder den Abfluss des Lauf der Zeit wurden aber die anderen Techniken wie Verödung Refluxes über einen Seitenast zur tiefen Beinvene (N2 → N3 → N1) und endoluminale Hitzeverfahren mit hinzugezogen, sofern sie die (s. ▶Abb. 4b). Um zwischen beiden Drainagewegen zu unterschei- Stammvenen nicht zerstörten [3]. den, wurde von Cappelli und Franceschi der Reflux-Eliminations- In diesem Artikel sollen die Strategie und die möglichen chirur- Test entwickelt (s. ▶Abb. 4c) [5, 6]. gischen Techniken zum Umsetzen der Strategie erklärt werden. Die häufigsten Shunts sind die, bei denen der Reflux von der tiefen Beinvene (N1) direkt in die Stammvenen (N2) übertritt (N1 → N2), meist über den sapheno-femoralen oder sapheno-poplitea- Die Shunt Typen nach Franceschi len Übergang, seltener über Perforansvenen [5]. Durch die Sonographie wurde es ersichtlich, dass die Stammvenen Beim Shunt Typ 1 drainiert das Blut dann auch direkt wieder aus (V. saphena magna und parva) in einer Faszienloge verlaufen und der Stammvene direkt zur tiefen Beinvene über eine Perforansvene sich dadurch von den anderen oberflächlichen Beinvenen unter- (N2 → N1) (s. ▶Abb. 4a und ▶Abb. 4c, sowie ▶Abb. 5 oben links). scheiden. Franceschi teilte die Beinvenen in Netze ein – das tiefe Beim Shunt Typ 3 liegt auch ein Reflux N1 → N2 vor, jedoch ist fin- Venennetz (N1), die Stammvenen als das so genannte interfaszia- den wir keine drainierende Perforansvene auf der Stammvene. Der le Netz zwischen der Muskelfaszie und der Faszia saphena (N2) und Drainageweg benötigt einen Seitenast: N2 → N3 → N1 (s. ▶Abb. 4b die epifaszialen Venen (N3) [2, 4]. Üblicherweise fließt das Blut bei und ▶Abb. 4c, sowie ▶Abb. 5 oben rechts). der Drainage aus dem Bein von oberflächlich nach tief, sprich, von Liegt ein Reflux aus einem Venensternast oder über eine Perfo- einem hohen N (N3, oberflächliches Netz) zu einem kleinen N (in- ransvene und einen Seitenast in die Stammvene vor, sprich, ist zwi- terfasziales Netz N2 oder tiefes Netz N1). Kehrt sich diese Richtung schen der Refluxquelle und der Stammvene ein Seitenast geschal- um liegt ein Reflux vor. tet, sprechen wir von Shunt Typ 4 oder 5 – abhängig vom Draina- Franceschi unterteilte die Shunts je nach den beteiligten Net- geweg: Läuft er direkt über eine Perforansvene auf der Stammvene zen und der Reihenfolge, in der sie beteiligt sind, sprich nach Re- zur tiefen Vene (Typ 4, vgl. ▶Abb. 3) oder benötigt er einen drai- fluxquelle und Drainageweg. Als Refluxquellen betrachtet er den nieren den Seitenast (Typ 5, s. ▶Abb. 7) Reflux N1 → N2 (Reflux aus der tiefen Beinvene in die Stammve- nen, s. ▶Abb. 1) oder aus anderen Quellen (Reflux aus einer Per- foransvene in einen Seitenast (s. ▶Abb. 2) und dann in die Stamm- Behandlungsstrategie nach CHIVA vene (N1 → N3 → N2) oder aus pelvinen Refluxquellen (zum Bei- Bei CHIVA handelt es sich darum, den Rezirkulationskreislauf aus- spiel über Äste des Venensterns) (s. ▶Abb. 3). Als Drainageweg zuschalten, ohne die Stammvenen zu entfernen. Im Wesentlichen sah er den Abfluss aus der Stammvene in die tiefe Beinvene über erreicht man dieses Ziel durch Unterbrechung der Refluxquelle, 154 Mendoza E. Operative Behandlung der ... Phlebologie 2019; 48: 153–160 P P N3 N3 Perf. Perf. a N2 N1 N2 b a N2 N1 N2 b N2 N1 N2 ▶Abb. 2 Refluxquellen aus dem Tiefen Venensystem in Seitenäste ▶Abb. 3 Refluxquellen aus dem kleinen Becken bei inkompe- (N3) über Perforansvenen, entweder isoliert, häufig zum Beispiel an tentem pelvinen Venennetz mit Refluxpunkten zum Bein wie der der Oberschenkelrückseite
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