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What is CHIVA

The Evidence-Based Pathway of CHIVA Treatment for Varicose Veins: Evidence, Challenges, and Prospects

Introduction

Lower limb varicose veins are a common chronic venous insufficiency (CVI) disease that affects the quality of life for a large global population. Traditional treatment methods mainly include sclerotherapy and vein stripping, while in the past 20 years, technologies such as laser, radiofrequency ablation, and adhesive closure of the saphenous vein trunk have also been applied. However, in recent years, CHIVA (Conservative Hemodynamic Correction of Venous Insufficiency), an outpatient local anesthesia treatment based on hemodynamic analysis and vein preservation, has attracted significant attention for its advantages in reducing recurrence rates and improving patients’ quality of life.

Research Methods

Extensive literature searches were conducted in globally renowned databases including MEDLINE, Embase, and Cochrane. A total of over 39 RCT studies were identified, involving more than 6000 limbs, which were finally used for quantitative analysis.

Research Objectives

The study focuses on the long-term efficacy of different varicose vein treatment methods. Two objective indicators were selected for the final data synthesis analysis: successful treatment rate (STR) and recurrence rate (RR). STR is defined as anatomical and functional integrity, confirmed by ultrasound as complete ablation, closure, or stripping. RR is defined as the reappearance of any visible varicose veins or pathological reflux after the initial treatment.

Treatment Methods Analysis

The study explored ablation, CHIVA, sclerotherapy, ligation, and stripping, as well as four additional combined treatments (ablation + stripping, ablation + ligation, sclerotherapy + ligation, ligation + stripping). The results showed the success treatment rates as follows: CHIVA > sclerotherapy + ligation > ablation + stripping. Long-term recurrence rates (RR) were: CHIVA < ablation + stripping < stripping.

Discussion

Traditional Surgery

High ligation and stripping (HLS) of the saphenous vein was once considered the “gold standard” for varicose vein surgery. While it can improve quality of life and show efficacy in the short term post-operation, traditional surgery is more traumatic and carries risks of high complication and recurrence rates, potentially failing to maintain long-term clinical benefits. Studies have shown that the recurrence rate of traditional stripping surgery ranges from 20-50%, depending on the experience of the surgeon.

Minimally Invasive Techniques

Compared to traditional surgery, some minimally invasive techniques may cause less trauma and are considered safer. These techniques mainly include ablation (laser or radiofrequency) combined with surgical stripping and sclerotherapy, which have been proven to be safe and effective and are currently widely performed in many hospitals. However, despite the reduced trauma, ablation and sclerotherapy still involve vein elimination, which can lead to the destruction of the venous network and associated complications. For long-term follow-up, minimally invasive techniques cannot fundamentally prevent the recurrence of varicose veins. Studies have shown that the recurrence rate for ablation ranges from 10-20%, also depending on the surgeon’s experience.

CHIVA

The revolutionary aspect of CHIVA lies in its ability to treat varicose veins effectively while preserving healthy vein networks through precise hemodynamic assessment. In practice, CHIVA reduces venous pressure by blocking abnormal reflux, segmenting pressure columns, and preserving reflux points, causing varicose veins to gradually shrink while continuing to drain blood into deep veins. This revolutionary method overturns the traditional treatment concept centered on removing or destroying varicose veins, thereby addressing venous hypertension at its root and minimizing surgical trauma-related problems.

Although venous valve function damage is irreversible, CHIVA treatment allows the vein pathway to continue transporting blood and draining subcutaneous venous network blood, reducing interference with normal veins. This new balance further reduces the recurrence of varicose veins. These characteristics may be key factors in revealing why CHIVA treatment has better long-term clinical efficacy and lower recurrence rates.

Studies have shown that the recurrence rate of CHIVA treatment is between 5-10%, largely determined by the doctor’s experience. It is worth noting that almost all cases of recurrence after treatment can be corrected through hemodynamic methods (CHIVA).

The Importance of Standardizing CHIVA Data for Evidence-Based Results

High-quality and consistent data are crucial for evidence-based research on CHIVA. However, due to the complexity of the CHIVA technique and practice differences across regions, achieving data consistency is challenging. This may lead to reduced comparability of different study results, affecting the credibility of evidence-based medicine. Therefore, standardized data collection and reporting standards, along with the establishment of international data sharing platforms, will facilitate global data exchange and comparison, ensuring the accuracy and comparability of research results.

The global CHIVA training and certification project initiated by Dr. Smile Medical Group and Inteleos in the United States is an important step in enhancing doctors’ technical skills and promoting data standardization. Through systematic training and certification, doctors can master standardized CHIVA procedures, improving clinical outcomes and reducing the impact of technical differences. This project also promotes unified research standards and methods, ensuring more scientific and rigorous comparisons between CHIVA and traditional surgical methods.

The Significance of the Global CHIVA Project

The global CHIVA training and certification project not only helps enhance doctors’ technical skills and experience but also promotes the standardization and normalization of CHIVA techniques worldwide. This project can establish unified research standards and operational protocols, ensuring the comparability of data from different countries’ research institutions, thus providing more reliable evidence-based medicine. Additionally, the project promotes international data sharing and academic exchange, contributing to the global dissemination and application of CHIVA techniques.

Conclusion

CHIVA, as a minimally invasive treatment method that emphasizes hemodynamics, has demonstrated excellent long-term efficacy and safety in the treatment of varicose veins. Compared to traditional stripping and techniques such as laser and radiofrequency ablation, CHIVA offers lower recurrence rates and less trauma. However, CHIVA also has drawbacks, such as the high level of experience required for surgeons, who need to possess extensive hemodynamic knowledge and practical skills. Proper training and standardized procedures are essential to achieving optimal results.

Despite these limitations, the conclusion remains that CHIVA has superior long-term efficacy compared to other surgical methods. This revolutionary approach should be widely applied in clinical settings, becoming a preferred option for both patients and doctors.

The global CHIVA training and certification project initiated by Dr. Smile Medical Group and Inteleos is pivotal in promoting the standardization of the technique and enhancing evidence-based medicine. Through rigorous scientific research and high-standard clinical practice, CHIVA will continue to provide efficient, low-trauma treatment options for varicose vein patients and make significant contributions to global venous health.

Research on CHIVA

ARTICLES FOCUSING ON THE PRESENTATION OF CHIVA THERAPY

（Research literature on CHIVA）

  • Franceschi, C. (1989). The conservative and hemodynamic treatment of ambulatory venous insufficiency. Phlebologie, 42(4), 567.
  • FRANCESCHI,, & FRANCO, G. (1989). La cure CHIVA Discussion. Phlébologie, 42(4),567-568.
  • Mandolesi,, Ballo, M., Galeandro, I., Filippo, S., Migaldi, D., Spinelli, F., … & Passariello, (1990). The 1st national multicenter study of the CHIVA (Conservative Therapy and Hemodynamicsin Venous Insufficiency in Outpatient Departments) method of treatment of varices. One-year follow-up. Annali italiani di chirurgia, 61(4), 425-427.
  • CONSIGLIO L., GIORGI G.: Terapia di exeresi o conservativa?Minerva Ang. 1991;16, sup.1: pp. 442–3.
  • Melliere, D., Cales, B., Martin-Jonathan, C., & Schadeck, M. (1991). Necessity of reconciling the objectives of the treatment of varices and arterial surgery. Practical consequences. Journal des maladies vasculaires, 16(2), 171-178.
  • Franceschi C. La cure conservatrice hémodynamique de l’insuffisance veineuse ambulatoire (chiva) [Conservative hemodynamic ambulatory treatment of venous insufficiency]. Soins Chir. 1992;(133):29-31.
  • Franceschi La cure hémodynamique de l’insuffisance veineuse en ambulatoire (CHIVA) [Ambulatory and hemodynamic treatment of venous insufficiency (CHIVA cure)]. J Mal Vasc. 1992;17(4):291-300.
  • Bailly M. La cure hémodynamique de l’insuffisance veineuse en ambulatoire (CHIVA).Présentationd’un cas particulier [Ambulatory and hemodynamic treatment of venous insufficiency (CHIVA cure). Report of an atypical case]. JMalVasc. 1992;17(3):241-249.
  • Hugentobler JP, Blanchemaison P. La cure hémodynamique de l’insuffisance veineuse en ambulatoire (CHIVA). Etude de 96 patients opérés de juin 1988 à juin 1990 [Ambulatoryand hemodynamic treatment of venous insufficiency (CHIVA cure). Study of 96 patients operated on between June 1988 and June 1990]. J Mal Vasc. 1992;17(3):218-223.
  • Bailly, (1993). CartographieCHIVA.EncyclopédieMédico-Chirurgicale. Paris 43-161-B: 1–4.
  • Franceschi, (1993). La cure CHIVA et la critique: 14 réponses et 1 conclusion. STV. Sang thrombose vaisseaux, 5(7), 491-497.
  • ZamboniP, Murgia AP, Vasquez G, Zandi G, Mari C, Liboni  La chirurgia venosa videoassistita [Video-assisted venous surgery]. Ann Ital Chir. 1995;66(3):379-386.
  • Zamboni,, Feo, C. V., Marcellino, M. G., Vasquez, G., & Mari, C. (1996). Haemodynamic correction of varicose veins (CHIVA): An effective treatment?. Phlebology, 11(3), 98-101.
  • di Chirurgia Generale, U. O. ILTRATTAMENTO DELLE VARICI DEGLI ARTI INFERIORI MEDIANTE CHIVA 2. NOSTRA ESPERIENZA.
  • A BANHINI,C Franceschi, X Mouren, P Caillard et : Superficial venous insufficiency JOURNAL DES MALADIES VASCULAIRES, 1996
  • FRANCESCHI, C.: Physiopathologie hémodynamique de l’insuffisance veineuse des membres inférieurs (1997) Actualités Vasculaires Internationales, 22, pp. 17-27
  • FRANCESCHI C. La Cure Hemodynamique de l’Insuffisance Veineuse en Ambulatoire.: Journal des Maladies Vasculaires. 1997 ; 22 (2) :91-95
  • CAPPELLI et Al.: Criteri di scelta della Strategia CHIVA Arch. Soc. Ital. Chirurgia 4, 118, 1998
  • Cappelli, M., Lova, R. M., Ermini, S., Turchi, A., Bono, G., & Franceschi, C. (1999). POSTERS-Conservative surgery of the saphenous trunks. Journal des Maladies Vasculaires, 24, 103-103.
  • Mendoza, E. (2002). Einteilung der Rezirkulationen im Bein: anatomische und physiologische Grundlagen der CHIVA-Methode. Phlebologie, 31(01), 01-08.
  • Criado, E., Luján, S., Izquierdo, L., Puras, E., Gutierrez, M., & Fontcuberta, J. (2002, March). Conservative hemodynamic surgery for varicose veins. In Seminars in Vascular Surgery (Vol. 15, No. 1, pp. 27-33). WB Saunders.
  • Mendoza, (2002). CHIVA-Alternative oder Erganzung zum Stripping. VASOMED-BONN-, 14(1), 6-17.
  • Hach, (2002). Was ist CHIVA?. Gefässchirurgie, 7(4), 244-250.
  • Mendoza, E. (2002). Einteilung der Rezirkulationen im Bein: anatomische und physiologische Grundlagen der CHIVA-Methode. Phlebologie, 31(01), 01-08.
  • JUAN-SAMSO’ J.: Venous haemodynamic surgery in the treatment of varicose syndrome (2003) Angiologia, 55 (5), pp. 460-475.
  • Cappelli, M., Molino Lova, R., Ermini, S., Franceschi, C., & PERRIN, M. (2002). Nouvelle approche de la physiopathologie de l’insuffisance veineuse superficielle: Conséquences thérapeutiques. Discussion: Indications thérapeutiques et nouvelles techniques de traitement en phlébologie. Phlébologie, 55(1), 27-31.
  • Criado,, Juan, J., Fontcuberta, J., & Escribano, J. M. (2003). Haemodynamic surgery for varicose veins: rationale, and anatomic and haemodynamic basis. Phlebology, 18(4), 158-166.
  • Criado, E., Juan, J., Fontcuberta, J., & Escribano, J. M. (2003). Haemodynamic surgery for varicose veins: rationale, and anatomic and haemodynamic basis. Phlebology,18(4), 158-166.
  • PITTALUGA, P. (2008). MISE AU POINT CONCERNANT les COMMENTAIRES sur la CURE CHIVAdans l’ARTICLE des Drs P. PITTALUGA et S. CHASTANET:«TECHNIQUE et TRAITEMENT des VARICES: COMMENT CHOISIR?». Phlébologie, 61(4), 428-430.
  • Passariello, (2008). Suppression of the sapheno-femoral reflux by pure non-saphenous phlebectomy and anatomical structure of the reflux. Acta Phlebologica, 9(3), 105-7.
  • Franceschi, C. (2008). Hémodynamique de la maladie postphlébitique: conséquences diagnostiques et thérapeutiques. Journal des Maladies Vasculaires, 33, S5.
  • Franceschi, C. (2008). Hémodynamique de la maladie postphlébitique: conséquences diagnostiques et thérapeutiques. Journal des Maladies Vasculaires, 33, S5.
  • Mowatt-Larssen E, Shortell C. CHIVA. Semin Vasc Surg. 2010;23(2):118-122. doi:10.1053/j.semvascsurg.2010.01.008.
  • Mowatt-LarssenE, Shortell  Treatment of primary varicose veins has changed with the introduction of new techniques. Semin Vasc Surg. 2012;25(1):18-24. doi:10.1053/j.semvascsurg.2012.02.002
  • Casian, D. (2012). Metode contemporane de tratament al maladiei varicoase. Buletinul Academiei de Ştiinţe a Moldovei. Ştiinţe Medicale, 33(1), 319-322.
  • Onida, S., & Davies, A. H. (2015). CHIVA, ASVAL and related techniques–Concepts and evidence. Phlebology, 30(2_suppl), 42-45.
  • Gianesini, S., Occhionorelli, S., Menegatti, E., Zuolo, M., Tessari, M., Spath, P., … & Zamboni, P. (2015). CHIVAstrategy in chronic venous disease treatment: instructions for users. Phlebology, 30(3), 157-171.
  • Zamboni, P., & Gianesini, S. (2016). Surgical technique for deep venous reflux suppression in femoral vein duplication. EJVES Short Reports, 30, 10-12.
  • PUSKÁS A. et Al.:HAEMODYNAMIC MAPPING OF CHRONIC VENOUS INSUFFICIENCY:THECONCEPT OF SHUNTS VÉNÁK BETEGSÉGEI Érbetegségek,XXIII. évfolyam 4. szám, 2016/4.
  • Faccini FP, Arendt AL, Pereira RQ, de Oliveira AR. CHIVA to spare the small and great saphenous veins after wrong-site surgery on a normal saphenous vein: a case report. J Vasc Bras. 2019;18:e20180077. Published 2019 Jan 7. doi:10.1590/1677-5449.007718

ARTICLES CONCERNING SUBJECTES OF CHIVA PROCEDURE NOT IN TERMS OF RECURRENCES / CLINIC DATA BUT OF BIOCHEMICAL, HEMODYNAMIC PARAMETERS, THROMBOSES AND COMPLICATIONS

（Clinical data on biomechanics, hemodynamics, thrombosis, and complications of CHIVA treatment）

  • CAPPELLI et Al.: Considerazioni sul ruolo fisiopatologico delle perforanti nella varicosi essenziale, quale presupposto alla concezione terapeutica dell’intervento CHIVA Ospedali d’Italia – Chirurgia nov–dic 1991, vol. XLIV n°6, pp.425–438.
  • ZamboniP, Marcellino MG, Feo CV, et  Alternative saphenous vein sparing surgery for future grafting. Panminerva Med. 1995;37(4):190-197.
  • Mendoza, E. (2018). Perioperative Management in Saphenous Sparing Surgery. In SaphenousVein-Sparing Strategies in Chronic Venous Disease (pp. 239-250). Springer,
  • Zamboni P, Cisno C, Marchetti F, Quaglio D, Mazza P, Liboni A. Reflux elimination without any ablation or disconnection of the saphenous vein. Ahaemodynamic model for venous surgery. Eur J Vasc Endovasc Surg. 2001;21(4):361-369.
  • FRANCESCHI: CHIVA effectiveness score: the correct one is below.Eur J Vasc Endovasc Surg. 2012 Sep;44(3):351; author reply 352.
  • Maldonado-Fernández,, López-Espada, C., Martínez-Gámez, F. J., Mata-Campos, J. E., Galán-Zafra, M., & Sánchez-Maestre, M. (2010). Complicaciones postoperatorias de la estrategia CHIVA para el tratamiento de la insuficiencia venosa crónica. Angiología, 62(3), 91-96.
  • MENDOZA, BERGER V., ZOLLMANN C., BOMHOFF M., AMSLER F., Calibrereduction of great saphenous vein and common femoral vein after CHIVA Phlebologie, 2011, 40(2): pp. 73–78
  • MENDOZA, Diameter reduction of the great saphenous vein and the common femoralvein after CHIVA Long–term results, Phlebologie, 2013, 42: pp. 65–69
  • MENDOZA: Crossectomy of the great saphenous vein with the CHIVA method (2004) Vasomed, 16 (2), pp. 46-48.
  • DELFRATE, BRICCHI M., FRANCESCHI C., GOLDONI M., Multiple ligation of the proximal greater saphenous vein in the CHIVA treatment of primary varicose veins, Veins and Lymphatics, 2014, 3: pp. 19–22
  • MENDOZAE, AMSLER , CHIVA with endoluminal procedures: LASER versus VNUS –treatment of the saphenofemoral junction, Phlebologie, 2017, 46: pp. 5–12.
  • PASSARIELLO F. et: The office based CHIVA Journal of Vascular Diagnostics 26 September 2013 Volume 2013:1 Pages 13—20
  • Gianesini, S., Menegatti, E., Zuolo, M.,Tessari, M., Ascanelli, S., Occhionorelli, S., & Zamboni,  (2013). Short endovenous laser ablation of the great saphenous vein in a modified CHIVA strategy. Veins and Lymphatics, e21-e21.
  • Gianesini, S., Menegatti, E., Malagoni, M., Occhionorelli, S., & Zamboni, P. (2017). Mini-invasive high-tie by clip apposition versus crossectomy by ligature: Long-term outcomes and review of the available therapeutic options. Phlebology, 32(4), 249-255.
  • Gianesini, S., Menegatti, E., Malagoni, M., Occhionorelli, S., & Zamboni, P. (2017). Mini-invasive high-tie by clip apposition versus crossectomy by ligature: Long-term outcomes and review of the available therapeutic options. Phlebology, 32(4), 249-255.
  • Tisato, V., Zauli, G., Gianesini, S., Menegatti, E., Brunelli, L., Manfredini, R., … & Secchiero, P. (2014). Modulation of circulating cytokine-chemokine profile in patients affected by chronic venous insufficiency undergoing surgical hemodynamic correction. Journal of immunology research, 2014.
  • Gianesini,, Menegatti, E., Zuolo, M., Tessari, M., Spath, P., Ascanelli, S., … & Zamboni, (2015).Laser assisted strategy for reflux abolition in a-modified CHIVA approach. Veins and Lymphatics, 4(2).
  • Zamboni,, Spath, P., Tisato, V., Tessari, M., Dalla Caneva, P., Menegatti, E., … & Secchiero, P. (2016). Oscillatory flow suppression improves inflammation in chronic venous disease. Journal of Surgical Research, 205(1), 238-245.
  • Delfrate, R. (2019). Thanks to the CHIVAstrategy, may the histoarchitecture of great saphenous vein-sparing, make it suitable as graft for bypasses?. Veins and Lymphatics, 8(1).
  • ZAMBONI et Al.: Alternative saphenous vein sparing surgery for future grafting. Panminerva Med. 1995 Dec;37(4):190-7.
  • Mendoza, M. Cappelli : Sclerotherapy technique in CHIVA strategy Phlebologie 2017; 46(02): 66-74
  • FERRACANI: A Change of a Paradigm Under the Scope of a Cardiovascular Surgeon. Remodeling of the Great Saphenous Vein Instead of Ablation for Preservation of the Patient Anatomical Capital Cardiology December 30, 2019 ecronicon.com open access
  • MENDOZA : Does the suture material influence the outcome after high ligation of great saphenous vein? Vasa (2020), 49 (2), 153–155

ARTICLES CONCERNING THE RESULTS OF CHIVA PROCEDURE IN TERM OF RECURRENCES / CLINIC DATA WITHOUT COMPARISON WITH OTHER METHODS

（Non-controlled clinical studies on recurrence rates and clinical data of CHIVA treatment）

  • FICHELLEJM, Carbone P, Franceschi : Results of ambulatory and hemodynamic treatment of venous insufficiency (CHIVA cure) J Mal Vasc. 1992;17(3):224-8.
  • BAILLY: Resultats de la cure Chiva In techniqueset stratégie en chirurgie vasculaire. Jubilé de J.M. Cormier. Edition A.E.R.C.Paris 1992: 255-71
  • HUGENTOBLERP., BLANCHMAISON P.: CHIVA cure. Etude de 96 patients opres de juin1988 a juin 1990 J. Mal. Vasc., 1992, 17: pp. 218–23.
  • QUINTANA et Al.:The CHIVA cure of varices of the lower extremities. La Cure Conservatrice et Hemodynamique de l’Insuffisance Veineuse en Ambulatoire Angiologia. 1993 Mar-Apr;45(2):64, 66-7
  • ZAMBONI: When CHIVA treatment could be video guided. Dermatol Surg. 1995 Jul;21(7):621-5.
  • ZAMBONI et AL.: Angiovideo-assisted hemodynamic correction of varicose veins. Int Angiol. 1995 Jun;14(2):202-8.
  • BAHNINIA, Bailly M, Chiche L, Franceschi C.: Ambulatory conservative hemodynamic correction of venous insufficiency. Technique, results. Ann Chir. 1997;51(7):749-60.
  • CAPPELLI et Al.: I risultati della cura CHIVA. Osp Ital Chir 1998; 4: 615-8.
  • ZAMBONI, MARCELLINO M.G., CAPPELLI M., FEO C.V., BRESADOLA V., VASQUEZ G., LIBONI A., Saphenous vein sparing surgery: principles, techniques and results, J.. Cardiovasc. Surg., Torino 1998 Apr, 39(2): pp. 151–62.
  • CAPPELLI M. et Al. “Ambulatory conservative hemodynamic management of varicose veins: critical analysis of results at 3 years” ANNALS OF VASCULAR SURGERY 2000 Vol 14 n°4 pag 376-384
  • ESCRIBANOM., JUAN J., BOFILL R., MAESO J., RODRÍGUEZ–MORI A., MATAS M., Durability of reflux–elimination by a minimal invasive CHIVA procedure on patients with varicose veins. A 3–year prospective case study, Eur. J. Vasc. Endovasc. Surg., 2003, 25: pp. 159–63.
  • ZAMBONI P, ESCRIBANO JM.: Regarding ‘Reflux Elimination Without anyAblation or Disconnection of the Saphenous  A Haemodynamic Model for Venous Surgery’ and ‘Durability of Reflux-elimination by a Minimal Invasive CHIVA Procedure on Patients with Varicose Veins. A 3-year Prospective Case Study’. Eur J Vasc Endovasc Surg. 2004 Nov;28(5):567.
  • ESTEBAN-GRACIA et Al.: Application of the CHIVA strategy. A prospective study at one year Angiologia 2004, 56 (3), pp. 227-235.
  • LINARES-RUIZ, P., Bonell-Pascual, A., Llort-Pont, C., Romera, A., Lapiedra-Mur, O. : Mid-term results of applying the CHIVA strategy to the external saphenous vein. Angiologia 2004 , 56 (5), pp. 481-490.
  • ZAMBONI, GIANESINI S.,MENEGATTI E., TACCONI G., PALAZZO A., LIBONI A., Great saphenous varicose vein surgery without saphenofemoral junction disconnection, Br. J. Surg., 2010 Jun, 97(6): pp. 820–5.EVA et Al.: CHIVA – ECOGRAPHIC ASPECTS AND SURGICAL RESULTS
  • Maxilo-facial surgery volume 18 • issue 1 January / March 2014 • pp. 64-70EVA,, TIUTIUCA, R., & STANCIU, C. (2014). CHIVA-ECOGRAPHIC ASPECTS AND SURGICAL RESULTS. International Journal of Medical Dentistry, 18(1).
  • MALDONADO-FERNANDEZet : Clinical results of a new strategy (modified CHIVA) for surgical treatment of anterior accessory great saphenous varicose veins. Cir Esp. 2016 Mar;94(3):144-50.
  • ZMUDZINSKI M,MALO P, HALL C, HAYASHI , CHIVA – A prospective study of a vein sparing technique for the management of varicose vein disease, Am. J. Surg., 2017, 213: pp. 967–969.
  • FRANCESCHI C, Bahnini A, Cappelli M, Cuaranta RL, Dadon M, Delfrate R, Ermini S, Gianesini S, Mendoza E, Passariello F, Puskas  : Commentary on the article “A prospective study of a vein sparing technique for the management of varicose vein disease” by M Zmudzinski et al. Am J Surg. 2018 Nov;216(5):1035.
  • Faccini, F. P., Ermini, S., & Franceschi, C. (2019). CHIVAto treat saphenous vein insufficiency in chronic venous disease: characteristics and  Jornal Vascular Brasileiro, 18.

ARTICLES COMPARING CHIVA RECURRENCES / CLINICAL DATA WITH OTHER PROCEDURES EMPLOING NOT RANDOMIZED STUDIES

（Non-randomized studies comparing recurrence rates and clinical data of CHIVA with other surgical procedures）

  • Gorny, P., Blanchemaison, P., Chahine, D., Hutinel, B., & Chanvallon, C. (1995). Chirurgie conservatrice et ambulatoire: étude comparative entre Chiva et crossectomie chez 321 patients opérés de la saphène interne. Discussion. Phlébologie, 48(2), 255-259.
  • CAPPELLI,MOLINO LOVA R., ERMINI S., TURCHI A., BONO G., BAHANINI A.,FRANCESCHI C.I., La Cure CHIVA dans le traitement de la Maladie Variqueuse: analyse critique des résultats après trois ans, Ann. Chir. Vasc., 1996.
  • MAESO, JUAN J., ESCRIBANO J., ALLEGUEN.M.,DIMATTEO A.,GONZALEZE.,MATAS M.: Comparison of clinical outcome of stripping and CHIVA for treatment of varicose veins in the lower extremities Ann. Vasc. Surg., 2001, 15: pp. 661–5.
  • NOPPENEY, T., Noppeney, J., Kurth, I.: Results of standard varicose vein surgery (2002) Zentralblatt fur Chirurgie, 127 (9), pp. 748-751.
  • MARIA et Al. : Varicose disease of lower limbs: What kind of treatment? Personal experience Chirurgia 2008, 21 (4), pp. 195-198.
  • Solís, V., Ribé, L., Portero, J. L., & Rio, J. (2009). Stripping saphenectomy, CHIVA and laser ablation for the treatment of the saphenous vein insufficiency. Ambul Surg, 15(1), 11-4.
  • Franceschi, (2010). “Stripping versus the CHIVA Method” par Claude Franceschi. Angéiologie, 62(4).
  • MILONE, SALVATORE G.,MAIETTA P., SOSA FERNANDEZL.M.,MILONE F.,Recurrent varicose veins of the lower limbs after surgery. Role of surgical technique (stripping vs. CHIVA) and surgeon’s experience, G. Chir., 2011, p. 32.
  • CHANCY et : Retrospective comparison of clinical outcomes between endovenous laser and saphenous vein-sparing surgery for treatment of varicose veins. World J Surg. 2011 Jul;35(7):1679-86.
  • DKELLEHER, T R A Lane, I J Franklin and A H Davies: Treatment options, clinical outcome (quality of life) and cost benefit (quality-adjusted life year) in varicose vein treatment Phlebology 2012;27 Suppl 1:16–22.
  • DE FRANCISCIS S. et Al. : Hemodynamic surgery versus conventional surgery in chronicvenous disease: a multicenter retrospective  ACTA PHLEBOL. 2013; 14; 109-114
  • WANG, CHEN Q., FEI Z., ZHENG E., YANG Z., HUANG X., HEMODYNAMIC CLASSICATION AND CHIVA TREATMENT OF VARICOSE VEINS IN LOWER EXTREMITIES(VVLE) Int. J. Clin. Exp. Med., 2016, 9(2): pp. 2465–2471.

ARTICLES COMPARING CHIVA RECURRENCES / CLINICAL DATA WITH OTHER PROCEDURES EMPLOING RANDOMIZED STUDIES (RCT)

（Non-randomized studies comparing recurrence rates and clinical data of CHIVA with other surgical procedures）

  • ZAMBONI,CISNO C.,MARCHETTIF.,MAZZA P.,FOGATO L.,CARANDINA S.,DE PALMA M., LIBONI A., Minimally invasive surgical management of primary venous ulcers vs. compression treatment: a randomized clinical trial, Eur. J. Vasc. Endovasc. Surg., 2003 Apr, 25(4): pp. 313–8
  • CARANDINA, MARI C., DE PALMA M., MARCELLINO M.G., CISNO C., LEGNAROA., LIBONI A., ZAMBONI P., Varicose vein stripping vs haemodynamic correction (CHIVA): a long term randomised trial, Eur. J. Vasc. Endovasc. Surg., 2008 Feb, 35(2): pp.230–7.
  • IBORRA–ORTEGA, BARJAU–URREA E., VILA–COLL R., BALLÓN–CARAZASH.,CAIROLS–CASTELLOTE M.A., Estudio comparativo de dos técnicas quirúrgicas en el tratamientode las varices de las extremidades inferiores: resultados tras cinco años de seguimiento, ANGIOLOGÍA, 2006, 58(6): pp. 459-468.
  • PARÉSO., JUAN J., TELLEZ R., MATA A., MORENO C., QUER F.X., SUAREZ D.,CODONY I., ROCA J., Varicose vein surgery: stripping versus the CHIVA method: a randomized controlled trial, Ann. Surg., 2010 Apr, 251(4): pp. 624–31.

Cochrane Reviews and Meta-analyses

（Systematic reviews and meta-analyses on CHIVA）

  • BELLMUNT–MONTOYA S., ESCRIBANO J.M., DILME J., MARTINEZ–ZAPATA M.J. Title: CHIVA method for the treatment of chronic venous insufficiency. Source: Cochrane Database of Systematic Reviews, 2013 Jul 3, (7): CD009648.
  • BELLMUNT-MONTOYA S., ESCRIBANO J.M., DILME J., MARTINEZ-ZAPATA M.J. Title: CHIVA method for the treatment of chronic venous insufficiency. Source: Cochrane Database of Systematic Reviews, 2015 Jun 29, (6): CD009648.
  • GUO L., ET AL. Title: Long-term efficacy of different procedures for treatment of varicose veins: A network meta-analysis. Source: Medicine (Baltimore), 2019 Feb, 98(7): e14495.

ARTICLES OF GENERAL REVIEW

（General review articles on CHIVA）

  • Mendoza E. CHIVA 1988-2008: Review of studies on the CHIVA method and its development in different countries. Gefässchirurgie. 2008; 13(4): 249–256.

  • Agus GB. Thirty years of new venous hemodynamic concept and teaching. Acta Phlebologica. 2019 Aug; 20(2): 33–36.

  • Mendoza E. Primum non nocere. Veins and Lymphatics. 2017; 6(2): 6703.

  • Franceschi C. CHIVA 30 years later: Scientific and ethical considerations. Veins and Lymphatics. 2019; 8(2): 8243.

BOOKS and CHAPTERS OF OTHER BOOKS

（Books and Chapters in Professional Texts on CHIVA）

  • FRANCESCHI C. Title: Théorie et pratique de la cure conservatrice et hémodynamique de l’insuffisance veineuse en ambulatoire [CHIVA]. Source: Éditions de l’Armançon, 1988.
  • ZAMBONI P. Title: La chirurgia conservativa del sistema venoso superficiale. Source: Edizioni Minerva Medica, 1996.
  • CAPPELLI M., ERMINI S., MOLINO LOVA R. Chapter: La correzione emodinamica o cura CHIVA (pp. 431-456). Book: Trattato di Flebologia e Linfologia, Vol 1. Editor: Sergio Mancini. UTET, 2001.
  • MENDOZA E. Title: CHIVA: Ein Handbuch. Source: Wunstorf: Arrien Verlag, 2002.
  • CAPPELLI M., MOLINO LOVA R., ERMINI S. Chapter: Chirurgia conservativa emodinamica (pp. 177-187). Book: Chirurgia delle vene e dei linfatici. Editor: Giuseppe Genovese. Masson, 2003.
  • ESCRIBANO J.M. Title: Cirugía Hemodinámica en el tratamiento de la insuficiencia venosa superficial. Source: Doctoral Thesis, Universitat Autònoma de Barcelona, 2006.
  • FRANCESCHI C., ZAMBONI P. Title: Principles of Venous Hemodynamics. Source: Nova Biomedical Books, 2009.
  • DELFRATE R. Title: A new diagnostic approach to varicose veins: Haemodynamic evaluation and treatment. Source: Dioni, Lorena, 2014.
  • ZAMBONI P., MENDOZA E., GIANESINI S. Title: Saphenous Vein-Sparing Strategies in Chronic Venous Disease. Source: Springer, 2018.
  • JORDI JUAN SAMSÓ. Title: La cura CHIVA en el tratamiento de las varices primarias de las extremidades inferiores. Source: 2019.
  • Y. Pei et al. Title: Comparison between radiofrequency ablation and CHIVA procedure in patients with varicose veins. Source: Meta-analysis, 2023.
  • H.T. Kiziltan; S. Ermini; C. Franceschi. Title: CHIVA in the light of long-term studies and awareness of saphenous preservation. Source: Turkish Journal of Vascular Surgery, 2025.
  • L.M.I. Lamoca et al. Title: High-intensity-focused ultrasound treatment for the chronic venous disease based on the Cure Conservatrice et Hémodynamique de l’Insuffisance Veineuse en Ambulatoire (CHIVA) strategy. Source: JVS: Venous and Lymphatic Disorders / PubMed, 2025.
  • Stefano Ricci. Title: CHIVA for dummies. Source: Phlebology/Pubmed, 2024.
  • DELFRATE R., et al. Title: CHIVA strategy in the treatment of venous insufficiency. Source: JTAVR (Journal of Traditional and Alternative Vascular Review), 2023.
  • F.P. Faccini ∙ S. Ermini ∙ C. Franceschi. Title: CHIVA to Treat Saphenous Vein Insufficiency in Chronic Venous Disease: Characteristics and Results. Source: Journal of Vascular Surgery(JVS), 2020.
  • CASA DI CURA PIACENZA. Title: Legatura delle vene varicose CHIVA (Clinical Practice and Guidelines). Source: Casadicura.pc.it, 2024.
  • R.A. Bishara ∙ A. Gaweesh ∙ W. Taha ∙ M.M. Tolba ∙ J. Shalhoub. Title: Impact of great saphenous vein ablation on healing and recurrence of venous leg ulcers in patients with post-thrombotic syndrome: A retrospective comparative study. Source: Journal of Vascular Surgery: Venous and Lymphatic Disorders, 2024.
  • D. Curbelo ∙ I. Lancaster ∙ A. Yaylayan ∙ M. Krolick. Title: Extensive Collateral Venous Circulation and Anatomic Remodeling in Chronic Deep Vein Thrombosis. Source: Case Reports in Cardiology, 2026.