Introduction: The Shift Toward Hemodynamic Conservation
Chronic venous insufficiency (CVI) and its clinical manifestation as varicose veins represent a significant global health burden, affecting millions of individuals and placing considerable strain on healthcare resources. For decades, the surgical gold standard was high ligation and stripping (HL/S), an approach rooted in the anatomical destruction of the insufficient vein. However, the emergence of the CHIVA method (Cure Conservatrice et Hémodynamique de l’Insuffisance Veineuse en Ambulatoire) has challenged this ‘ablate and destroy’ paradigm. CHIVA is a minimally invasive, hemodynamic-based strategy that aims to correct venous hypertension while preserving the superficial venous system.
Unlike thermal ablation or stripping, CHIVA focuses on redirecting blood flow from the superficial to the deep venous system by strategically disconnecting specific leak points. This approach preserves the saphenous vein, which may be crucial for future use in arterial bypass grafting. Recent high-level evidence, including Cochrane systematic reviews and large-scale network meta-analyses, provides a compelling case for the efficacy and safety of this hemodynamic strategy compared to conventional and endovenous thermal techniques.
The Mechanistic Foundation of the CHIVA Strategy
To understand the clinical utility of CHIVA, one must appreciate the underlying pathophysiology of CVI. The method is based on the premise that varicose veins are the result of hemodynamic disturbances—specifically, the failure of venous valves leading to closed-circuit refluxes and increased hydrostatic pressure. By performing precise preoperative ultrasound mapping, clinicians identify ‘shunts’ where blood escapes the deep system into the superficial system.
CHIVA involves targeted ligations to interrupt these shunts, thereby reducing the transmural pressure in the superficial veins without removing them. This preservation of the anatomical structure allows the vein to recover its diameter and function over time. The strategy requires high-level expertise in duplex ultrasound, making it a more cognitively and diagnostically demanding procedure than standardized thermal ablation.
Synthesizing the Evidence: The Cochrane Review Perspective
A pivotal 2021 Cochrane systematic review (Bellmunt-Montoya et al.) analyzed six randomized controlled trials (RCTs) involving 1,160 participants to compare CHIVA with alternative treatments. The review provided critical insights into the safety and long-term outcomes of the method.
Recurrence and Clinical Efficacy
The review found that CHIVA may result in little to no difference in the clinical recurrence of varicose veins when compared to conventional stripping (Risk Ratio [RR] 0.74; 95% CI 0.46 to 1.20). While the certainty of evidence was categorized as low due to the inability to blind surgical personnel, the results suggest that preserving the vein does not inherently increase the risk of recurrence. In comparisons with Radiofrequency Ablation (RFA) and Endovenous Laser Therapy (EVLA), CHIVA also demonstrated comparable recurrence rates, although data for these specific comparisons were derived from fewer trials.
Safety and Complication Profiles
One of the most significant findings from the Cochrane analysis was the superior safety profile of CHIVA regarding iatrogenic injury. Compared to stripping, CHIVA significantly reduced the risk of nerve injury (RR 0.14; 95% CI 0.02 to 0.98) and hematoma formation (RR 0.59; 95% CI 0.37 to 0.97). The Number Needed to Treat for an additional Harmful outcome (NNTH) for nerve injury was 9, indicating a clinically meaningful reduction in postoperative morbidity. These findings underscore CHIVA’s role as a tissue-sparing intervention that minimizes the trauma associated with traditional surgical approaches.
Network Meta-Analysis: A Broader Comparative View
Recent data from a frequentist network meta-analysis (Juhani et al., 2025) involving 12,196 patients across 75 studies has added further weight to the hemodynamic approach. Interestingly, this analysis suggested that CHIVA might actually outperform certain thermal techniques in terms of recurrence prevention. Specifically, CHIVA demonstrated a significantly lower recurrence rate compared to RFA (RR 0.35; 95% CI 0.15 to 0.79).
This finding is particularly relevant for health policy experts and clinicians who are weighing the long-term cost-effectiveness of various interventions. While thermal ablation has gained widespread popularity due to its procedural simplicity, the hemodynamic durability of CHIVA suggests that a more nuanced, individualized approach to venous reflux may yield superior long-term results for specific patient cohorts.
Technological Innovations: HIFU and Hybrid Methods
As the field moves toward entirely non-invasive solutions, the principles of CHIVA are being integrated with cutting-edge technology. A notable development is the use of High-Intensity Focused Ultrasound (HIFU) via the SONOVEIN system.
The SONOVEIN-CHIVA Synergy
A 2025 study by Izquierdo Lamoca et al. evaluated HIFU treatment specifically applied under the CHIVA strategy. In a study of 204 limbs, researchers targeted specific leak points for non-invasive thermal occlusion. The results were impressive, with primary leak point occlusion rates reaching 95.5% at 24 months. This approach eliminates the need for even the small incisions used in traditional CHIVA, further reducing the risk of infection and skin damage. The study highlights HIFU as a potentially disruptive technology that aligns perfectly with the hemodynamic goals of the CHIVA method.
Hybrid Echosclerotherapy
In addition to HIFU, hybrid methods combining EVLA with ultrasound-guided foam sclerotherapy (UGFS) have shown high technical success. A study of 200 patients (Hauzer et al., 2021) reported a 98% efficiency rate at 12-month follow-up using this hybrid approach. By combining the thermal occlusion of the main trunk with the chemical obliteration of collateral branches, clinicians can achieve high patient satisfaction and low relapse rates, mirroring the comprehensive nature of the CHIVA mapping strategy.
Expert Commentary and Clinical Considerations
Despite the robust data supporting CHIVA, its adoption remains heterogeneous globally. This is largely due to the steep learning curve associated with hemodynamic mapping. Unlike ‘plug-and-play’ endovenous devices, CHIVA requires the surgeon to be a master of ultrasound anatomy and hemodynamics.
However, in an era of value-based healthcare, the benefits of CHIVA are difficult to ignore. The preservation of the great saphenous vein is not merely an anatomical preference; it is a clinical safeguard for patients who may eventually require coronary or peripheral artery bypass. Furthermore, the reduction in nerve injuries and hematomas translates to faster recovery and lower secondary care costs.
Limitations in current evidence, such as the high risk of bias due to lack of blinding in surgical trials, must be acknowledged. Nevertheless, the consistency of the findings across different meta-analyses suggests that CHIVA is a highly viable alternative to both stripping and thermal ablation.
Conclusion: A Personalized Future for Venous Care
The management of chronic venous insufficiency is transitioning from a one-size-fits-all anatomical approach to a personalized hemodynamic one. The CHIVA method, supported by Cochrane-level evidence and modern network meta-analyses, offers a safe, effective, and conservative alternative to traditional surgery. With the integration of non-invasive technologies like HIFU and the refinement of hybrid sclerotherapy, the principles of hemodynamic correction are set to become a cornerstone of modern phlebology. For the clinician, the challenge lies in mastering the diagnostic mapping required to deliver these superior outcomes; for the patient, the benefit is a less invasive journey with preserved vascular options for the future.
References：
Bellmunt-Montoya S, Escribano JM, Pantoja Bustillos PE, Tello-Díaz C, Martinez-Zapata MJ. CHIVA method for the treatment of chronic venous insufficiency. Cochrane Database Syst Rev. 2021 Sep 30;9(9):CD009648. doi: 10.1002/14651858.CD009648.pub4 IF: 9.4 Q1 . PMID: 34590305 IF: 9.4 Q1 ; PMCID: PMC8481765 IF: 9.4 Q1 .
Hauzer W, Gnus J, Rosińczuk J. Endovenous laser therapy with echosclerotherapy as a hybrid method for chronic venous insufficiency: experience in 200 patients and literature review. Eur Rev Med Pharmacol Sci. 2021 Dec;25(24):7777-7786. doi: 10.26355/eurrev_202112_27624 . PMID: 34982439 .Izquierdo Lamoca LM, Reyero Postigo T, Morán Escalona S, Giráldez Arranz JF, Aguinaco Acosta A. 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. J Vasc Surg Venous Lymphat Disord. 2025 Jul;13(4):102233. doi: 10.1016/j.jvsv.2025.102233 IF: 3.0 Q1 . Epub 2025 Mar 19. PMID: 40118271 IF: 3.0 Q1 ; PMCID: PMC12018035 IF: 3.0 Q1 .
Juhani AA, Abdullah A, Alyaseen EM, Dobel AA, Albashri JS, Alalmaei OM, Salem Alanazi YM, Almutairi DR, Alqahtani LN, Alanazi SA. Interventions for great saphenous vein insufficiency: A systematic review and network meta-analysis. Vascular. 2025 Oct;33(5):983-998. doi: 10.1177/17085381241273098 IF: 0.9 Q4 . Epub 2024 Aug 16. PMID: 39148483 IF: 0.9 Q4 .
