Letter to the Editor concerning the editorial by Efstratios Georgakarakos “CHIVA in Practice: Ready for a bold Rebranding?” published on Phlebology 2025,Vol 40(7),463-465

Letter to the Editor

The editorial by Efstratios Georgakarakos, “CHIVA in Practice: Ready for a bold Rebranding?” Phlebology 2025, Vol 40(7) 463-465, clearly demonstrates the difficulties in understanding and practicing the CHIVA treatment and calls for the following clarifications.

First, let us recall that CHIVA does not abolish venous reflux. Indeed, it does not change the direction of reflux, but rather eliminates its diastolic pressure and flow overload from the veins that constitute the veno-venous shunts and breaks up the gravitational hydrostatic pressure column. Although the flow direction remains reversed, this hemodynamic strategy restores physiological values for tissue drainage pressures and vein caliber, which has been validated, as demonstrated by short- and long-term clinical and paraclinical studies. It also allows the conservation of valuable potential arterial bypass material, particularly below the knee, in accordance with the first project of its author.^1–4 Curiously, the various recommendations issued by CHIVA do not value its evaluation for its conservative aspect of the GSV, eminent arterial bypass material, which drastically differentiates it from all ablative methods. ⁵ Further, preserving a draining saphenous vein with a low energy reflux makes the treated venous system hemodynamically more stable over time, with a lower incidence of recurrences. ⁶ The argument of aesthetic dissatisfaction of the article is not demonstrated by any study. It is quite obvious that the aesthetic results are not immediate, but require a variable time of a few days to a few weeks, the time for the remodeling of the veins. After this waiting period, the treatment can be completed with a few sclerotherapy sessions on the disconnected vessels that are still visible at a distance from the operation. This does not contradict the “conservative” aim of the CHIVA Cure, as the saphenous trunk is anyhow preserved.

These results are the result of progress in understanding and knowledge of hemodynamic venous pathophysiology thanks to the contribution of new or revisited concepts such as the three network levels (R1, R2, R3), the various configurations of open, closed, and open shunts by derivation, leakage and reentry points made up of perforators, saphenous junctions classically described^7,8 and more recently identified pelvic leakage points.^9–11 These advances are inseparable from the new data provided by venous echodoppler which has allowed, in addition to a better understanding of the pathophysiology, the establishment of topographical and hemodynamic maps and topographies essential to the strategy and tactics of CHIVA. Implementation requires compliance not only with the requirements of the strategy, but also with those of the specific tactic (technique) in order to avoid recurrences, re-canalizations, and neo-angiogenesis of the disconnections. ¹²

CHIVA is certainly performed by an elite in many countries, notably in the USA, but it is the dominant method in Spain. ¹³

The crucial point, even the limit of CHIVA would be the difficulty of understanding its revisited pathophysiological bases and the complexity of the study by ultrasounds which would be reserved for an elite of experts. The difficulty comes essentially from the intellectual effort required by the novelty of these concepts based on physical laws of hemodynamics often forgotten since university. Learning CHIVA and its hemodynamic foundations is to progress in the knowledge of venous pathophysiology, not only superficial, but also deep, ¹⁴ as it should be taught from university. We understand the desire to simplify CHIVA to make it accessible to all surgeons. Ricci proposes that “to achieve the objective of conservative treatment of the saphenous vein, a limited phlebectomy and a possible interruption of the junction can represent a simplified solution”. But on condition of not degrading the results. Yet this is confirmed by the poor results of practices that do not conform to CHIVA’s strategy or tactics, as Milone M. has pointed out, demonstrating the superiority or inferiority of CHIVA depending on whether it is practiced by “experts or non-experts. ¹⁵ ” Indeed, Einstein is credited with the saying: “keep it simple, don’t simplify it.” Would we entrust a passenger aircraft to a pilot trained using a “for dummies” method?

Yet, ethics and professionalism require knowing and offering the best to the patient, even at the cost of a study effort comparable to that required by university cardiology students to understand hemodynamic cardiac pathophysiology. CHIVA becomes easy and intellectually stimulating for those who have humbly and patiently “resumed their study of hemodynamic venous pathology,” as confirmed by the growing number of colleagues acquiring expertise around the world. Proposing a CHIVA “for dummies” would be contemptuous of colleagues and dishonest to patients. The dignity of our profession and the trust of patients deserve our efforts.