How do you see the future of Varicose Veins surgery?

Traditionally, the saphenous vein has always been considered as the origin of the varicose disease since it is affected first (dilation and reflux). Then, the disease spreads from the saphenous vein termination (with the inguinal fold for the great saphenous vein and with the popliteal fossa for the small saphenous vein), progresses on by the saphenous trunk on the thigh then on the calf, up to the peripheral collaterals on which the varicose veins develop.

The traditional theory has considered the saphenous vein responsible for the varicose veins development, leading to it systematic ablation for a “radical” solution.

This principle has been applied since 1907 when the American surgeons Dr. Babcock and Dr. Mayo described the varicose veins treatment by ablation of the saphenous vein. This principle remains the same, 100 years later.

Several elements led us – Dr. Chastanet and Dr. Pittaluga – to wonder on the saphenous vein responsibility and the corollary principle of it systematic ablation: 

  • The recurrence frequency of varicose veins after saphenous vein ablation (30% to 70% according to studies). How could we explain varicose veins return after the saphenous vein removal? 
  • Patient cases presenting varicose veins without an affected saphenous vein. 
  • The existence of only one type of intervention (Saphenous Vein Ablation by stripping) whatever the age, symptoms and localisation of the varicose veins.

We co-created the ASVAL Method in late 2003. 

The ASVAL Method is based on a concept opposite to the traditional one. The varicose disease starts from the peripheral veins, from the bottom up; the smallest and superficial veins, whose wall are most fragile, would be the first to be dilated (heredity, traumatism, pregnancy, aging…). Evolution would remain initially in the subcutaneous plan near the skin, creating a superficial venous network dilated and flowing back. This flowing back superficial network would end up creating an aspiration effect in the saphenous vein, generating a backward flow initially reversible.

The saphenous vein is the superficial vein of which the wall is the thickest, protected in addition by the unfolding of the subcutaneous fascia in which it progresses. Therefore, it will be the last one to be degraded.

The physiopathological conception of the A.S.V.A.L. method led to preserving the saphenous vein, with two principles:

1/ The early treatment of varicose veins protects the saphenous vein as long as it is not refluxing.

2/ Varicose veins ablation without ablation of the saphenous vein, even refluxing. Recent studies show that the saphenous vein recovers a satisfactory hemodynamics in 91% of the cases after varicose veins ablation. Saphenous vein ablation would be indicated only in situations where the saphenous vein damage seems irreversible.

Saphenous vein preservation has several interests:

 Physiological: even if it is known that the saphenous vein drains only 10% lower limb venous blood overall, it has certainly a major role for subcutaneous drainage.

• Anatomical: the great saphenous vein is used for bypass heart surgeries or peripheral surgeries on the lower limbs. In certain cases, no other material than the patient vein can be used to carry out a bypass operation.

 The idea of the A.S.V.A.L. method is thus a selective management of the superficial venous refluxes, according to the clinical and haemodynamic context suitable for each patient situation.

Advantages of the ASVAL method:  

1/ Softer Surgery:

All of the surgical gestures of the A.S.V.A.L. method are guided by the respect of tissues. The ablation of collateral varicose is made by meticulous phlebectomy with a hook according to Müller’s technique. The principle is to withdraw the longest possible segment of the vein through several incisions, without rupture, to decrease bleeding. The incisions of phlebectomy are micro-incisions, of less than two millimeters. Generally, all gestures are as atraumatic as possible, in particular during the hooks handling. It requires precise gestures, from there the importance of location by a rigorous preoperative cartography.

2/ Lighter anaesthesia:

Except for exceptional case, the anaesthesia always purely local, is very diluted. This mode of anaesthesia has several advantages: reduction of the anaesthetic risk, major reduction of surgical bleeding by the effect of vasospasm and tumescence, early ambulation (thus prevention of venous thrombosis and lesser disability).

3/ Simpler postop course:

The patient can leave one hour after the intervention, and walking is advised as much as possible. No activity is formally prohibited in the following days, apart from prolonged trampling, a long sitting travel or an intensive sport.

Studies show that less aggressive surgical and anaesthetic techniques reduce in a very important way postoperative pains (92% of patients do not take any antalgic treatment in the first eight postoperative days) and the interruption of work duration (93% of patients returned to work on the following day).

We founded the Riviera Vein Academy. Since 2010, the Academy has been a leading Venous Surgical Training Center in vascular surgery.

Riviera Vein Academy has welcomed doctors and surgeons from all over the world, providing practical personalized training for varicose veins treatment.

We will be hosting several course sessions on varicose vein treatments to share our expertise on the ASVAL technique, but also on Endothermal ablation and on the general management of the patient.

Attendees will spend 2 full days in the operating room and in the consultation room where we will share our tips & tricks.

We would be delighted to welcome you to the French Riviera for this course. To join us, please click here:

Posted by Sylvain Chastanet Paul Pittaluga

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