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Minerva Medica Copyright® Anno: 2016 Lavoro: 3580-ANGY Mese: February titolo breve: CHIVA: hemodynamic concept, strategy and results Volume: 35 primo autore: FRANCESCHI No: 1 pagine: 8-30 Rivista: INTERNATIONAL ANGIOLOGY Cod Rivista: International Angiology , Copyright © 2016 @EDIZIONI MINERVA MEDICA International Angiology 2016 February;35 (1):8-30 ORIGINAL ARTICLE CHIVA: hemodynamic concept, strategy and results Claude FRANCESCHI 1, Massimo CAPPELLI 2, Stefano ERMINI 3, Sergio GIANESINI 4* Erika MENDOZA 5, Fausto PASSARIELLO 6, Paolo ZAMBONI 4 1Centre Marie Therese Hopital Saint Joseph, Paris, France; 2Private Practitioner, Florence, Italy; 3Private Practitioner, Grassina, Flor- ence, Italy; 4Vascular Diseases Center, University of Ferrara, Italy; 5Venenpraxis, Wunstorf, Germany; 6Diagnostic Centre Aquarius, Napoli, Italy *Corresponding author: Sergio Gianesini, Vascular Disease Center, University of Ferrara Italy, Via Aldo Moro 8, 44124 Loc Cona, Ferrara, Italy. E-mail: [email protected] ABSTRACT The first part of this review article provides the physiologic background that sustained the CHIVA principles development. Then the venous networks anatomy and flow patterns are described with pertinent sonographic interpretations, leading to the shunt concept description and to the consequent CHIVA strategy application. An in depth explanation into the hemodynamic conservative cure approach follows, together with pertinent review of the relevant literature. (Cite this article as: Franceschi C, Cappelli M, Ermini S, Gianesini S, Mendoza E, Passariello F et al. CHIVA: hemodynamic concept, strategy and results. Int Angiol 2016;35:8-30) Key words: Venous insufficiency - Hemodynamics - Saphenous Vein - Ultrasonography, Doppler, Duplex. HIVA is a French acronym for “Cure conservatrice sequently suppressing the pressure overload by tar- Cet Hemodynamique de l’Insuffisance Veineuse en geted ligations that are customized on each specific Ambulatoire” (Conservative and Hemodynamic treat- reflux pattern. ment of the Venous Insufficiency in an office based Detailed duplex ultrasound scanning (DUS) and pre- setting). It is a saphenous-sparing therapeutic approach operative mapping are essential to detect the exact reflux- for lower limb chronic venous disease (CVD) based on ing points to treat: a therapeutic act that can be obtained hemodynamic concepts proposed by Claude Franceschi by mini-invasive procedures under local anesthesia in an in 1988.1-6 The hemodynamic model takes into consid- office-based setting. eration the pressure overload occurring in the presence Apart from the possible vital role as arterial by- of valvular incompetenceMINERVA and/or a drainageCOPYRIGHT® obstacles. pass, 7-12MEDICA the saphenous sparing feature preserves a main The consequent pressure and flow overload leads to ves- conduit for the tissue drainage: a hemodynamic scenario sel dilation, tissue drainage impairment, onset of CVD that is considered as the basis for reducing the onset of signs and symptoms (edema, varicosities, skin changes recurrences. Several randomized trials compared CHI- and ulceration, pain, heaviness, itching). VA with Stripping 13-18 or compression.19 A Cochrane CHIVA strategy is aimed to restore a physiological review (2013) demonstrated the need for further inves- drainage by an accurate hemodynamic investigation, tigations but also summarized the evidence for a long without any venous ablation. Hemodynamic correc- term lower recurrence rate when the saphenous-sparing tion identifies the specific overloaded networks, sub- rather than the ablative strategy was used.20 8 INTERNATIONAL ANGIOLOGY February 2016 This document is protected by international laws.This document is protected by copyright No additional reproduction is authorized. of this Article. only one file and print only one copy and save use to download personal It is permitted for It is not permitted additional copies to make either printed purpose. or electronic) of the Article any for or systematically, (either sporadically of the article It is not permitted the electronic copy to distribute through online internetother file sharingelectronic mailing or any and/or intranet systems, access to the Article. allow means which may part The use of all or any Commercial Use is not permitted. of the Article any for works from the Article The creation of derivative is not permitted. personal or commercial use is The production of reprints for post on the Article. notices or terms may copyright the Publisher of use which or change any block, obscure, not permitted. trademark, overlay, logo It is not permitted techniques to enclose any or use framing to frame cover, It is not permitted to remove, or other proprietary of the Publisher. information Lavoro: 3580-ANGY titolo breve: CHIVA: hemodynamic concept, strategy and results primo autore: FRANCESCHI pagine: 8-30 , CHIVA: HEMODyNAMIC CONCEPT, STRATEGy AND RESULTS FRANCESCHI Figure 1.—Ankle venous pressure according to posture. Ankle venous pressure shows no differences among healthy and CVD cases, whatever the posture is. The difference appears only upon VMP action. Obstruction increases the ankle pressure whatever the posture is, particularly whenever walking (venous claudication). Hemodynamics principles ρv1²=p2+½ ρv2²=Cte); p+½ ρv² is the sum of Rep and VMP pressure. Tissue drainage, thermoregulation and heart fill- Intravenous lateral pressure (IVLP) is the static and ing are the three main functions of the venous system, hydrostatic part of IVP=p+ρgh. This hemodynamic inter- made of conduits and pumps that drain the tissues from pretation is accepted despite the facts that blood is not a the capillaries to the heart, according to a cardiopetal Newtonian fluid, the vessels are not ideal conduits and the venous pressure gradient (VPG) that drives the blood. system is not steady (in particular during VMP systole). VPG is represented by the pressure difference between ReP is the remnant after the arterial pressure loss the postcapillary residual pressure (ReP) and the right through the arteriolo-capillary resistance according atrial pressure (RAP), (VPG=(ReP-RAP)/ankle-heart to the Poiseuille Law. VMP pressure derives from the distance). The heart 21 and abdomino-thoracic 22 pumps plantar sole, calf and thigh muscle contraction (systole) act permanently, and the peripheral valvo-muscular /relaxation (diastole). GHP values varie with the height pump (VMP) occasionally. 23-25 of the blood column, i.e. the body posture. ReP, VMP and gravitational hydrostatic pressure IVLP acts on the venous wall and capillary determin- (GHP) constitute the MINERVAintravenous and capillaryCOPYRIGHT® pressure ing theMEDICA so called transmural pressure (TMP), expressed (IVP). as a difference among the IVLP and the external venous IVP=p+½ ρv²+ρgh=Cte (Bernouilli’s law) pressure (EVP) (represented by the atmospheric and tis- sue pressure). p=static pressure; ½ ρv²=dynamic pressure; ρgh= TMP determines venous calibre, according to GHP=gravitational hydrostatic pressure; ρ=density; the Tension (laplace law) and wall Compliance. v=flow velocity; g=gravity acceleration; h=height of Tension=Stretching force=TMP/vessel radius. Compli- the liquid. GHP varies only with the vertical height of ance is the venous vessel feature of dilation according the column h. ρgh1<ρgh2.q varies only with p (p1+½ to the TMP. Venous calibre=Compliance/Tension is Vol. 35 - No. 1 INTERNATIONAL ANGIOLOGY 9 This document is protected by international laws.This document is protected by copyright No additional reproduction is authorized. of this Article. only one file and print only one copy and save use to download personal It is permitted for It is not permitted additional copies to make either printed purpose. or electronic) of the Article any for or systematically, (either sporadically of the article It is not permitted the electronic copy to distribute through online internetother file sharingelectronic mailing or any and/or intranet systems, access to the Article. allow means which may part The use of all or any Commercial Use is not permitted. of the Article any for works from the Article The creation of derivative is not permitted. personal or commercial use is The production of reprints for post on the Article. notices or terms may copyright the Publisher of use which or change any block, obscure, not permitted. trademark, overlay, logo It is not permitted techniques to enclose any or use framing to frame cover, It is not permitted to remove, or other proprietary of the Publisher. information , FRANCESCHI CHIVA: HEMODyNAMIC CONCEPT, STRATEGy AND RESULTS Figure 2.—Venous pressure gradient determinants. VPG: venous pressure gradient; ReP: residual pressure; RAP: right atrial pressure; TAP: thoraco-abdominal pump; VMP: valvular-muscular pump; LV: left ventricle; CP: cardiac pump; MC: micro-circulation; r: arterioles radius; L: microvessels length; IVP: intra-venous pressure; EVP: external venous pressure; AP: atmospheric pressure; TP: tissue pressure; OpT: oncotic tissue pressure; OpV: oncotic venous pressure; LP: lateral pressure; HP: hydrostatic pressure. usually described by a sigmoid curve, related to Hook’s fact responsible for venous dilation, formation of vari- law of elasticity. Nevertheless, the variable compliance cosities and drainage impairment (edema, skin disor- of the venous wall makes the caliber variations not lin- ders, ulceration). CHIVA goals aim to suppress the flow ear.45 Another factor represented by the turbulences can and pressure overload, affecting the factors
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