Invited Commentary regarding: Hemodynamics-based treatment of varices: a therapeutic concept counteracting the intrinsic tendency of varicose veins to recur

The hemodynamic aspect of venous disorders has rarely received independent serious review despite publication of many excellent clinical guidelines regarding the management of venous disorders. The hemodynamic concepts have remained largely unexplored mainly due to their complicated nature and the lack of depth of understanding of hemodynamic processes. Recently, however, interest in the hemodynamic aspect of venous disorders has been rekindled based on new hemodynamic information obtained through advanced technology. ¹

‘The tenacious tendency of varicose veins to recur' continues to be a challenge, occurring in up to 80% of cases despite various measures that attempt this problem, an enigma the author correctly points out. ²

The author, a world renown scholar in venous hemodynamics, who has contributed tremendously over many years has kindly shared his view on pathogenesis with a novel hemodynamic interpretation based on the ‘ambulatory pressure gradient'. The author interpreted the intrinsic tendency of varicose veins to recur as a ‘hemodynamic paradox' via a newly generated ‘ambulatory pressure gradient' at the level of the thigh following the abolition of reflux at the saphenofemoral junction (SFJ).

After high ligation at the SFJ, for example, the ambulatory pressure in the femoral vein does not decrease so that an ambulatory pressure difference arises between the femoral vein and the incompetent superficial thigh veins allowed to drain into deep lower leg veins during calf pump activity. Hence, the author believes the abolition of saphenous reflux generates this unique condition and serves as preconditions for the development of ‘recurrent reflux' because the dividing line of the ambulatory pressure gradient is now transferred up into the thigh, triggering the process leading to reflux recurrence. ³

The author called this unique phenomenon the ‘hemodynamic paradox', and proposed to eradicate this iatrogenically created relocation of the dividing line of the ambulatory pressure gradient and to prevent the lower pressure extending from the deep lower leg veins into the superficial thigh veins to generate an ambulatory pressure gradient triggering venous reflux, resulting in the recurrence. ⁴

It is a fascinating hemodynamic interpretation regarding the recurrence of varicose veins following crossectomy/crossotomy at SFJ, based on the rationale of the hemodynamic change along the superficial and deep veins above the level of the thigh. It is a bold new concept as saphenous sparing option together with CHIVA strategy and actual outcome of this new approach would need to be verified.

CHIVA is an acronym for “Cure Conservatrice et Hemodynamique de l’Insuffisance Veineuse en Ambulatoire” (hemodynamic correction of venous insufficiency in outpatients). The rationale of this strategy is based on restoring drainage of flow from the most superficial to deepest venous networks of the lower limb while maintaining the re-entry perforating vein along the saphenous trunk and sparing of the main saphenous trunks. ⁵

Recently, we reviewed these two strategies, especially CHIVA, through the UIP commissioned Consensus of Venous Hemodynamics of lower extremity, with over 70 invited faculties. Both concepts were thoroughly reviewed in the Consensus. ¹

Both saphenous sparing options share a substantial portion of the hemodynamic interpretation of ‘refluxing patterns' through the leaking and re-entry points, although they also differ substantially. While CHIVA relies on continuous reflux through the entire great saphenous vein (GSV) to drain into the re-entry calf perforating veins as physiological retrograde flow, ⁶ this new approach advocates the arrest of further retrograde flow from thigh veins across the knee into lower leg at the popliteal level to prevent/reduce the ambulatory pressure gradient and thus avoid the vicious cycle of the ‘hemodynamic paradox'. ¹

It would be interesting to compare this with the CHIVA strategy which seems to be on the same side of the coin in terms of the hemodynamic cause of varicose vein. Together with CHIVA principles, this new interpretation could become an irreplaceable counter approach as to stand together against the current hemodynamic concept that supports ablation of the GSV itself.

However, I must point out that this new interpretation on the pathogenesis of recurrence, based on hemodynamic observations through ambulatory pressure gradients represents only one hemodynamic aspect. I am sure there are many peers with different views, especially regarding CHIVA. Further evidence to reinforce this concept with more specific refluxing hemodynamic patterns would provide a foundation for better understanding of the ‘hemodynamic paradox'.