Review Article

Split Viewer

Ann Phlebology 2023; 21(1): 1-4

Published online June 30, 2023

https://doi.org/10.37923/phle.2023.21.1.1

© Annals of phlebology

The Teupitz Shunt Classification for CHIVA Strategy

Sangchul Yun, M.D., Ph.D.1 and Mi-Ok Hwang, RVT2

1Department of Surgery, Soonchunhyang University Seoul Hospital, 2Thrombosis Clinic, Soonchunhyang University Seoul Hospital, Seoul, Korea

Correspondence to : Sangchul Yun, 59 Daesakwan-ro, Yongsan-gu, Seoul 04401, Korea, Department of Surgery, Soonchunhyang University Seoul Hospital
Tel: 02-710-3240, Fax: 02-709-0449
E-mail: ys6325@schmc.ac.kr

Venous hypertension, caused by venous reflux, often leads to heaviness, swelling, and pain in the legs. However, the hemodynamics of venous flow are complex and incomprehensible, with a frequently unclear correlation between reflux and symptoms. Regarding treatment options, removal of saphenous veins (SVs) based on a few seconds of reflux can adversely affect patients. Further, indiscriminate removal of SVs in aging populations may complicate future treatment of arterial diseases. Patients should be treated selectively based on ultrasound examinations and hemodynamic principles. The CHIVA strategy, which involves treating patients without removing SVs, is a potential treatment option for patients with mild chronic venous insufficiency. In this context, we introduce the Teupitz shunt classification, which forms the basis for hemodynamic correction.

Keywords Chronic venous insufficiency, Reflux, CHIVA

Varicose veins may be surgically treated by either of two main approaches: endovenous ablation and removal. The CHIVA (Cure Conservatrice et Hémodynamique de l’Insuffisance Veineuse en Ambulatoire) techniques present an alternative treatment approach, aiming to preserve veins during treatment (1). This minimally invasive technique was first introduced by Dr. Claude Franceschi, a French physician, in the late 1980s (2), and aims to correct underlying hemo-dynamic abnormalities that cause varicose veins. The technique involves selective ligature or interruption of abnormal veins and their connections while preserving healthy veins, thus maintaining normal venous circulation; it is recommended for selected patients and performed by experienced physicians (3). Suitable candidates for these techniques must be carefully assessed and selected. This involves identifying and addressing specific sites of venous reflux or shunting in the venous system.

The connection between different structures is known as a shunt. The venous system of the leg is divided into three compartments (Network, N; Réseau, R): N1 (R1), N2 (R2), and N3 (R3) corresponding to the deep, saphenous, and superficial veins, respectively. Normally, blood flows from the outside to the inside and from bottom to top; hence, it flows in the order of N3, N2, and N1 (4). In the CHIVA strategy, reflux is defined not solely as a temporary backward flow lasting for a few seconds, but rather as a change in the centripetal hierarchy within the venous system. This strategy aimed to restore normal antegrade (forward) N3-N2-N1 flow, converting it into physiological drainage rather than pathological reflux.

To implement the CHIVA strategy, hierarchy of venous flow in the leg must be assessed using Doppler ultrasono-graphy. Various patterns of saphenous reflux have been previously described; (5,6) these patterns are useful for guiding saphenous ablation therapy. In the CHIVA strategy, Teupitz shunt classification is used to categorize flow patterns in saphenous veins (7). Each hierarchy was scored from 0∼6 and examined individually.

Shunt 0: The saphenofemoral junction (SFJ) or sapheno-popliteal junction (SPJ) is competent. Segmental reverse flow occurs in the saphenous vein, re-entering the deep vein at a re-entry point (RP). Here, the N3-N2-N1 hierarchy was maintained, and this was classified as shunt 0. Reverse flow was observed; however, physiological drainage was maintained, and pathological reflux was not considered. Surgery in shunt 0 was not required to eliminate reflux (Fig. 1).

Fig. 1. Shunt type 0.

Shunt 1: Reflux from deep vein to saphenous vein (N1–N2). The reflux flows into the deep vein through a perforator vein serving as an RP without connecting to the tributary veins (TVs) (Fig. 2).

Fig. 2. Shunt type 1.

Shunt 2: No reflux is observed in deep veins. Reflux occurs from the saphenous vein to the TV (N2–N3); it then connects to the deep vein through a perforator, or flows to the SSV or GSV (Fig. 3).

Fig. 3. Shunt type 2.

Shunt 1+2: Here, shunts 1 and 2 coexist and reflux occurs from the deep vein to the saphenous vein through the SFJ or SPJ (N1–N2). Venous drainage occurs in the deep vein from the saphenous vein through an RP, whereas reflux to TVs drains into the deep vein through a different RP (Fig. 4).

Fig. 4. Shunt type 1+2.

Shunt 3: Reflux from the deep vein to the saphenous vein (N1–N2), passing through the saphenous vein to the TV (N2–N3) and draining into the deep vein through an RP (N3– N1). No direct RP drains flow from the saphenous vein into the deep vein (Fig. 5).

Fig. 5. Shunt type 3.

Shunt 4, 5: Shunt 4 and 5 were similar to shunts 1 and 3, respectively; however, the primary reflux point originated from the pelvic point or perforator vein. The SFJ or SPJ remains competent (Fig. 6).

Fig. 6. Shunt type 4, 5, 6.

Shunt 6: The perforator vein is the primary reflux point, and the reverse flow drains directly into the perforator vein through TVs without passing through the saphenous veins (Fig. 6).

Mixed shunts were commonly observed in patients with deep vein occlusion (Fig. 7).

Fig. 7. Mixed shunt type.

Hemodynamic correction based on Teupitz shunt classi-fication can improve venous symptoms by preserving saphenous veins while reducing hydrostatic pressure. In the CHIVA strategy, reverse flow was less important than maintenance of antegrade and centripetal blood circulation and ambulatory venous pressure. Ablating saphenous veins based on the presence of reverse flow for a few seconds is a harsh approach that does not consider hemodynamics. Patients requiring treatment based on hemodynamic ultrasound examinations should be carefully selected.

The authors declare no potential conflict of interest.

  1. Onida S, Davies AH. CHIVA, ASVAL and related techniques--concepts and evidence. Phlebology. 2015;30(2 Suppl):42-5.
  2. Franceschi C. The conservative and hemodynamic treatment of ambulatory venous insufficiency. Phlebologie. 1989;42:567-8.
  3. De Maeseneer MG, Kakkos SK, Aherne T, Baekgaard N, Black S, Blomgren L, et al. Editor's Choice - European Society for Vascular Surgery (ESVS) 2022 clinical practice guidelines on the management of chronic venous disease of the lower limbs. Eur J Vasc Endovasc Surg. 2022;63:184-267.
  4. Yun S. Ultrasound-based topographic analysis of tributary vein connection with the saphenous vein during ambula-tory conservative hemodynamic correction of chronic venous insufficiency. J Vasc Surg Venous Lymphat Disord. 2019;7:356-63.
  5. Labropoulos N, Kim H. Patterns of saphenous vein reflux and treatment plan. Annals of Phlebology. 2022;20:52-7.
  6. Qureshi MI, Gohel M, Wing L, MacDonald A, Lim CS, Ellis M, et al. A study to evaluate patterns of superficial venous reflux in patients with primary chronic venous disease. Phlebology. 2015;30:455-61.
  7. Franceschi C, Cappelli M, Ermini S, Gianesini S, Mendoza E, Passariello F, et al. CHIVA: hemodynamic concept, strategy and results. Int Angiol. 2016;35:8-30.

Review Article

Ann Phlebology 2023; 21(1): 1-4

Published online June 30, 2023 https://doi.org/10.37923/phle.2023.21.1.1

Copyright © Annals of phlebology.

The Teupitz Shunt Classification for CHIVA Strategy

Sangchul Yun, M.D., Ph.D.1 and Mi-Ok Hwang, RVT2

1Department of Surgery, Soonchunhyang University Seoul Hospital, 2Thrombosis Clinic, Soonchunhyang University Seoul Hospital, Seoul, Korea

Correspondence to:Sangchul Yun, 59 Daesakwan-ro, Yongsan-gu, Seoul 04401, Korea, Department of Surgery, Soonchunhyang University Seoul Hospital
Tel: 02-710-3240, Fax: 02-709-0449
E-mail: ys6325@schmc.ac.kr

Abstract

Venous hypertension, caused by venous reflux, often leads to heaviness, swelling, and pain in the legs. However, the hemodynamics of venous flow are complex and incomprehensible, with a frequently unclear correlation between reflux and symptoms. Regarding treatment options, removal of saphenous veins (SVs) based on a few seconds of reflux can adversely affect patients. Further, indiscriminate removal of SVs in aging populations may complicate future treatment of arterial diseases. Patients should be treated selectively based on ultrasound examinations and hemodynamic principles. The CHIVA strategy, which involves treating patients without removing SVs, is a potential treatment option for patients with mild chronic venous insufficiency. In this context, we introduce the Teupitz shunt classification, which forms the basis for hemodynamic correction.

Keywords: Chronic venous insufficiency, Reflux, CHIVA

INTRODUCTION

Varicose veins may be surgically treated by either of two main approaches: endovenous ablation and removal. The CHIVA (Cure Conservatrice et Hémodynamique de l’Insuffisance Veineuse en Ambulatoire) techniques present an alternative treatment approach, aiming to preserve veins during treatment (1). This minimally invasive technique was first introduced by Dr. Claude Franceschi, a French physician, in the late 1980s (2), and aims to correct underlying hemo-dynamic abnormalities that cause varicose veins. The technique involves selective ligature or interruption of abnormal veins and their connections while preserving healthy veins, thus maintaining normal venous circulation; it is recommended for selected patients and performed by experienced physicians (3). Suitable candidates for these techniques must be carefully assessed and selected. This involves identifying and addressing specific sites of venous reflux or shunting in the venous system.

The connection between different structures is known as a shunt. The venous system of the leg is divided into three compartments (Network, N; Réseau, R): N1 (R1), N2 (R2), and N3 (R3) corresponding to the deep, saphenous, and superficial veins, respectively. Normally, blood flows from the outside to the inside and from bottom to top; hence, it flows in the order of N3, N2, and N1 (4). In the CHIVA strategy, reflux is defined not solely as a temporary backward flow lasting for a few seconds, but rather as a change in the centripetal hierarchy within the venous system. This strategy aimed to restore normal antegrade (forward) N3-N2-N1 flow, converting it into physiological drainage rather than pathological reflux.

To implement the CHIVA strategy, hierarchy of venous flow in the leg must be assessed using Doppler ultrasono-graphy. Various patterns of saphenous reflux have been previously described; (5,6) these patterns are useful for guiding saphenous ablation therapy. In the CHIVA strategy, Teupitz shunt classification is used to categorize flow patterns in saphenous veins (7). Each hierarchy was scored from 0∼6 and examined individually.

TEUPITZ SHUNT CLASSIFICATION

Shunt 0: The saphenofemoral junction (SFJ) or sapheno-popliteal junction (SPJ) is competent. Segmental reverse flow occurs in the saphenous vein, re-entering the deep vein at a re-entry point (RP). Here, the N3-N2-N1 hierarchy was maintained, and this was classified as shunt 0. Reverse flow was observed; however, physiological drainage was maintained, and pathological reflux was not considered. Surgery in shunt 0 was not required to eliminate reflux (Fig. 1).

Figure 1. Shunt type 0.

Shunt 1: Reflux from deep vein to saphenous vein (N1–N2). The reflux flows into the deep vein through a perforator vein serving as an RP without connecting to the tributary veins (TVs) (Fig. 2).

Figure 2. Shunt type 1.

Shunt 2: No reflux is observed in deep veins. Reflux occurs from the saphenous vein to the TV (N2–N3); it then connects to the deep vein through a perforator, or flows to the SSV or GSV (Fig. 3).

Figure 3. Shunt type 2.

Shunt 1+2: Here, shunts 1 and 2 coexist and reflux occurs from the deep vein to the saphenous vein through the SFJ or SPJ (N1–N2). Venous drainage occurs in the deep vein from the saphenous vein through an RP, whereas reflux to TVs drains into the deep vein through a different RP (Fig. 4).

Figure 4. Shunt type 1+2.

Shunt 3: Reflux from the deep vein to the saphenous vein (N1–N2), passing through the saphenous vein to the TV (N2–N3) and draining into the deep vein through an RP (N3– N1). No direct RP drains flow from the saphenous vein into the deep vein (Fig. 5).

Figure 5. Shunt type 3.

Shunt 4, 5: Shunt 4 and 5 were similar to shunts 1 and 3, respectively; however, the primary reflux point originated from the pelvic point or perforator vein. The SFJ or SPJ remains competent (Fig. 6).

Figure 6. Shunt type 4, 5, 6.

Shunt 6: The perforator vein is the primary reflux point, and the reverse flow drains directly into the perforator vein through TVs without passing through the saphenous veins (Fig. 6).

Mixed shunts were commonly observed in patients with deep vein occlusion (Fig. 7).

Figure 7. Mixed shunt type.

CONCLUSION

Hemodynamic correction based on Teupitz shunt classi-fication can improve venous symptoms by preserving saphenous veins while reducing hydrostatic pressure. In the CHIVA strategy, reverse flow was less important than maintenance of antegrade and centripetal blood circulation and ambulatory venous pressure. Ablating saphenous veins based on the presence of reverse flow for a few seconds is a harsh approach that does not consider hemodynamics. Patients requiring treatment based on hemodynamic ultrasound examinations should be carefully selected.

ACKNOWLEDGEMENTS

None.

CONFLICTS OF INTEREST

The authors declare no potential conflict of interest.

Fig 1.

Figure 1.Shunt type 0.
Annals of Phlebology 2023; 21: 1-4https://doi.org/10.37923/phle.2023.21.1.1

Fig 2.

Figure 2.Shunt type 1.
Annals of Phlebology 2023; 21: 1-4https://doi.org/10.37923/phle.2023.21.1.1

Fig 3.

Figure 3.Shunt type 2.
Annals of Phlebology 2023; 21: 1-4https://doi.org/10.37923/phle.2023.21.1.1

Fig 4.

Figure 4.Shunt type 1+2.
Annals of Phlebology 2023; 21: 1-4https://doi.org/10.37923/phle.2023.21.1.1

Fig 5.

Figure 5.Shunt type 3.
Annals of Phlebology 2023; 21: 1-4https://doi.org/10.37923/phle.2023.21.1.1

Fig 6.

Figure 6.Shunt type 4, 5, 6.
Annals of Phlebology 2023; 21: 1-4https://doi.org/10.37923/phle.2023.21.1.1

Fig 7.

Figure 7.Mixed shunt type.
Annals of Phlebology 2023; 21: 1-4https://doi.org/10.37923/phle.2023.21.1.1

References

  1. Onida S, Davies AH. CHIVA, ASVAL and related techniques--concepts and evidence. Phlebology. 2015;30(2 Suppl):42-5.
  2. Franceschi C. The conservative and hemodynamic treatment of ambulatory venous insufficiency. Phlebologie. 1989;42:567-8.
  3. De Maeseneer MG, Kakkos SK, Aherne T, Baekgaard N, Black S, Blomgren L, et al. Editor's Choice - European Society for Vascular Surgery (ESVS) 2022 clinical practice guidelines on the management of chronic venous disease of the lower limbs. Eur J Vasc Endovasc Surg. 2022;63:184-267.
  4. Yun S. Ultrasound-based topographic analysis of tributary vein connection with the saphenous vein during ambula-tory conservative hemodynamic correction of chronic venous insufficiency. J Vasc Surg Venous Lymphat Disord. 2019;7:356-63.
  5. Labropoulos N, Kim H. Patterns of saphenous vein reflux and treatment plan. Annals of Phlebology. 2022;20:52-7.
  6. Qureshi MI, Gohel M, Wing L, MacDonald A, Lim CS, Ellis M, et al. A study to evaluate patterns of superficial venous reflux in patients with primary chronic venous disease. Phlebology. 2015;30:455-61.
  7. Franceschi C, Cappelli M, Ermini S, Gianesini S, Mendoza E, Passariello F, et al. CHIVA: hemodynamic concept, strategy and results. Int Angiol. 2016;35:8-30.
AP
Vol.21 No.2 Dec 31, 2023, pp. 53~98

Share

  • line

Related Articles

Annals of Phlebology