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                                                             Veins and Lymphatics 2017; volume 6:6646

                                       [Veins and Lymphatics 2017; 6:6646]                                                        [page 35]

Primum non nocere
Erika Mendoza
Venenpraxis, Wunstorf, Germany

Dear Editor,

Thank you for the editorial pointing out
the possibility of sparing saphenous veins in
Phlebology.1 You are right pointing out, that
the innovation in Phlebology goes ahead
and looking at the last 20 years one could
think, that everything might be possible to
deal with varicose veins. 

Of course, surgical ablation of great
saphenous veins (GSV) has the longest his-
tory and so the procedure is carved in stone
in many National Health Services (NHS) as
the Gold Standard (so still in Germany!!)
and in many brains of lots of honorable
chiefs of department. But there is another
point to be taken into consideration: Other
than in Spain and Italy, where Department
chiefs and surgeons are employed by the
NHS and earn their money independently of
the sales – in lots of countries the Health
Professionals’ income depends on their per-
formance. The higher the income for a pro-
cedure, the higher the personal financial
benefit. In poorer countries foam sclerother-
apy is the best option. In high sophisticated
places, the more the cost, the better the
treatment, the better the income.
Endoluminal heat treatments were intro-
duced as a way to do stripping without a
knife. So the idea from the very beginning
included heating the complete refluxive
segment of the saphenous vein. 

In the recently published study, CHIVA

with endoluminal procedures: LASER ver-
sus VNUS,2 it could be demonstrated, that
the short term results of CHIVA with both
methods (LASER or VNUS Closurefast)
were identical and both methods showed no
statistical differences to another cohort of
surgically treated CHIVA patients: 104
patients were investigated before and 3-6
months after the treatment of GSV with
CHIVA strategy using enoluminal heat
techniques to close the groin segment
[VNUS Closurefast or LASER (1470 nm,
Intros radial)]. General data (age, sex, BMI)
and phlebological data (QoL as reflected in
VCSS, clinics as C(CEAP), diameters of
GSV at the groin and proximal thigh, as
well as diameters of the common femoral
vein were not different among both groups.
As a result, we found a significant reduction
of diameters of GSV at proximal thigh from
6.5 +/-1.6 to 3.7 +/-1.1 and VFC from 15.2
+/-2.3 to 14.8 +/-2.2 were recorded, as well
as reduction of clinical scores (VCSS from
5.6 +/-3.1 to 2.2 +/-2 and C(CEAP) from
3.2 +/-1 to 2.1 +/-1.1. Results are compara-
ble to those achieved after surgical crossec-
tomy and published in other series. 

In this publication, we do not only open
CHIVA to other techniques, but we also
show that even applying high technology
(endoluminal heat and possibly glue) it is
not necessary to sacrifice the complete
length of the saphenous vein. 

If those patients with reflux in GSV but
competentterminal valve would be treated
withouth high ligation but with CHIVA
(flush ligation of the tributary) or
Müller/ASVAL and in those with incompe-
tent terminal valve only a short segment
would be closed with endoluminal devices,

we could spare far more than 50% of saphe-
nous veins. As a Bypass? As a drainage
path? As an option to treat the vein in the
future – when possibly even more gentle
techniques are available? As a tribute to our
maximal objective in medicine: Primum
non nocere?

References
1. Zamboni P. 2016: The year of

Phlebological Olympic Games. Veins
and Lymphatics 2016;5:6249.

2. Mendoza E. CHIVA performed with
endoluminal heat technique: laser versus
VNUS Cross treatment of the great sape-
nous vein. Phlebologie 2017;46:5-12. 

Correspondence: Erika Mendoza, Venenpraxis,
Speckenstrasse 10, 31515 Wunstorf, Germany. 
Tel.: 05031.912781. 
E-mail: erika.mendoza@t-online.de

Conflict of interest: the author declares no
potential conflict of interest.

Received for publication: 13 February 2017.
Accepted for publication: 27 February 2017.

This work is licensed under a Creative
Commons Attribution 4.0 License (by-nc 4.0).

©Copyright E. Mendoza, 2017
Licensee PAGEPress, Italy
Veins and Lymphatics 2017; 6:6646
doi:10.4081/vl.2017.6646

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