Abstract
When I first thought of conducting my thoughts and practical experience regarding the treatment of certain venous insufficient cases with the CHIVA saphenous sparing technique, I could not imagine that this manuscript would draw the attention of the most famous and renowned surgeons in the field, which I feel very proud of. 1
I am tremendously honoured to receive the response, suggestions and fruitful criticism by the very inventor of the method, Dr Franceschi, who defends the method, supporting that the notion to simplify theoretical and practical aspects of it, spares physicians for valuable hemodynamic details which should be taught and adapted in their full spectrum, avoiding devaluation of the method. Yet, unsurprisingly, the response-manuscript carries repeatedly the word “elite”.
While the recent Cochrane systematic review in 2021 by Bellmunt-Montoya et al. recorded sufficient technical and clinical results with acceptable recurrence rates (i.e., making little or no difference) comparing CHIVA to either stripping or thermal ablation, another recent network meta-analysis exhibited enhanced performance of CHIVA in terms of lower recurrence rates.2,3 Yet, both studies strongly highlight the limitation of small number of CHIVA studies, implicating a high risk of bias. Characteristically, while 3448, 3063 and 2406 cases encountered for EVLA, stripping and RFA respectively, the CHIVA cases were only 95 in the recent meta-analysis by Juhani et al. 3 So, no matter how satisfied I may feel guarding the original concept, I tend to believe that increasing the number of cases for the proficient operators leaves us again with the under-appreciation of the CHIVA philosophy to the general audience. So, I personally sense that we should not only widen the CHIVA spectrum to a narrow “elite” audience but also encourage the introduction of a narrow spectrum of cases to a widened audience! Moreover, taking advantage of the incorporation of new technology to the CHIVA approach revolutionizes the method: CHIVA is not just a targeted-ligation technique, but an applied philosophy of focused intervention, not only supporting and justifying the Riobamba technique but also modifying the newest techniques, as recently tried with high-intensity focused ultrasound (HIFU).4,5
Lastly, the inspirer of us all, Dr Franceschi, reminds us of the great saying by Einstein: “keep it simple, don’t simplify it.” Yet, when I vision the evolution of a surgical technique, I tend to remind myself another quotation by Charles Darwin: “It is not the strongest that survives, or the most intelligent. It is the one that is the most adaptable to change”.