Comment to: Diameter reduction of the great saphenous vein and the common femoral vein after CHIVA long-term results by Mendoza E. Phlebologie 2013;42:65–69.

Stefano Ricci

Abstract

The diameters of the veins are considered to be an indicator of the severity of venous disease. The present paper examines as a retrospective evaluation, the development of the diameter of the GSV and common femoral vein, as well as the small saphenous vein in the patients who were originally enrolled in the long-term investigation on CHIVA versus stripping and who spontaneously attended the practice over the further course after conclusion of the three-year study. The diameters of the veins were evaluated at the following points: i) common femoral vein immediately distally of the junction of the great saphenous vein; ii) great saphenous vein 15 cm distally of its junction; iii) small saphenous vein 5 cm distally of the knee fold. In addition, the C from the CEAP and the refilling time after muscle pump (light reflection rheography, were evaluate. A total of 43 patients presented, 15 men and 28 women. The mean follow-up period was 5.36 years (±1.63 years, range 3–8.6 years). The patients had been operated on the great saphenous vein in 28 cases and on the small saphenous vein in 15 cases.
A greater diameter of the common femoral vein was seen preoperatively in the case of disease of the great saphenous vein than in the case of disease of the small saphenous vein [CFV with pathology of the GSV: 16.1 mm (±2.7), CFV with pathology of the SSV 14.1 mm (±3.1)]. The reduction in diameter of the CFV after treatment of the GSV ran from 16.1 mm preoperatively via 15.3 mm after 8 weeks (not significant) to 14.3 mm after 5 years (significant compared with preoperatively and with 8 weeks postoperatively). A significant reduction in diameter results between the preoperative finding and the two postoperative measurements with pathology of the great saphenous vein: the diameter decreased from 7.0 mm (±2.0) preoperatively via 5.0 mm (±1.15) after 8 weeks to 4.4 mm (±1.4) after 5 years. After treatment of the GSV, the C value decreased significantly from 2.6±0.6 preoperatively to 1.8±1.2 postoperatively and was stable after 5 years. The initially significant reduction in the highest C value after treatment of the SSV (from 3.0±1.0 to 1.1±1.0) increased after 5 years (not significant) to 1.6±0.8. The refilling time was only measured in 17 patients with treatment of the great saphenous vein. The values developed from an average of 15.9 s (±6.6) preoperatively to 18.5 s after 8 weeks (±6.5) and further to 21.7 s (±10) after 5 years.
In people with healthy veins, a mean diameter at the proximal thigh of 3.7±0.9 mm was demonstrated (Mendoza E, Blättler W, Amsler F. Great saphenous vein diameter at the saphenofemoral junction and proximal thigh as parameters of venous disease class. Eur J Vasc Endovasc Surg 2012;45:76–83. See abstract and comments on Bybliolab 2013:1). The values for the great saphenous vein after 5 years, at an average of 4.4 mm, were within the standard deviation of the people with healthy veins. These data demonstrate that hemodynamic correction after CHIVA does not place an excessive strain on deep leg veins and that their diameters remain stable or continue to decrease, even after long-term observation.


Comment by Stefano Ricci

This interesting study is a further step by the same Author on analysis of GSV calibers as a parameter of its clinical status. It is demonstrated now that CHIVA method is able to achieve long-term stable hemodynamic balance (at least in a good number of cases) independently of the inherited evolution tendency of the disease. Unfortunately, in the paper all data concerning the shunt classification of pretreated patients are missing and, consequently, the type of operation employed.
It is not clear: i) whether all the considered patients (defined as having disease of the GSV) had a crossotomy or alternatively had a tributary disconnection; ii) whether the crossotomy was immediate or has been performed in a second phase; iii) the length of the saphenous incompetence, as well as possible post-operatory phlebitis (recanalized) of the GSV; iv) if all the above-mentioned conditions can have different effects on the GSV behavior.
By the way, the treatment of the SSV (junction ligation?) cannot be considered a proper CHIVA operation. Finally, it would be of great interest knowing the specific data related to the 8 patients who received the recommendation of undergoing an intervention, in order to verify the importance of the GSV diameter indication.

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