Franceschi教授来信：目前"腔内CHIVA"不符合CHIVA治疗原则

亲爱的SMILE：

CHIVA策略包含两个层面。第一，从血流动力学角度看，它旨在恢复一种符合生理的引流层级（physiological drainage hierarchy），具体包括：
1）保留静脉通路，尤其是大隐静脉（GSV）；
2）断开分流（shunts）；
3）分散重力性静水压（fractionating gravitational hydrostatic pressure）。

第二，保留浅静脉系统（SSG）的另一个原因，是它在未来一旦需要静脉旁路移植时，可能具有关键作用。

因此，所采用的战术必须与这一战略保持一致。迄今为止，微创外科性断离（minimally invasive surgical disconnections）可以实现这一目标。

与该战略相兼容的非手术性战术当然是值得期待的，但尚未出现。目前提出的热消融CHIVA（Hot CHIVA）和腔内技术，并不符合上述两个战略目标。

在隐股连接处存在逃逸点（saphenofemoral escape point）的情况下，这类方法所做的分流断开，并不是在紧贴股静脉处完成，而是在瓣膜弓（valvular arch）之下进行，并且闭合长度达到5到10厘米。

因此，这种不符合血流动力学原则的断离以及过度闭塞，都不符合CHIVA的血流动力学战略，也不符合对大隐静脉的完整保留。

（在欧洲）在大多数情况下，这些“腔内CHIVA”的做法都是由无权限进行手术操作的非外科医生实施的；也有一些外科医生出于追求“更简单、更吸引人”的操作方式，而采用这些方法，并把它们包装为“非侵入性”和“创新技术”。

但他们没有说明的是：非侵入性并不等于安全；同时，他们也忽视了一个事实：技术进步并不必然意味着在认识、诊断和治疗上的科学进步。而在静脉病学领域，人们恰恰常常存在这种误解。

原文如下：（2026年3月13日）

Dear Smile：

The CHIVA strategy is twofold. First, from a hemodynamic perspective, it aims to restore a physiological drainage hierarchy by: 1- preserving venous pathways, particularly the great saphenous vein (GSV); 2- disconnecting shunts; and 3- fractionating gravitational hydrostatic pressure. Second, it preserves the SSG for an additional reason: its potentially crucial role in the event of a need for venous bypass. The tactics implemented must be consistent with this strategy. To date, minimally invasive surgical disconnections make it possible to achieve this. Non-surgical tactics compatible with the strategy are desirable but remain to be discovered. Hot CHIVA and endovenous techniques are proposed, but they do not meet the two strategic objectives. In the case of a saphenofemoral escape point, the shunt disconnection is performed under the valvular arch instead of being performed flush with the femoral vein, with a closure length of 5 to 10 cm. Thus, non-hemodynamic disconnection and excessive occlusion are not consistent with hemodynamic strategy and the complete preservation of the great saphenous vein. In most cases, these practices are implemented by non-surgical phlebologists, who are not authorized to operate on the saphenofemoral junction, and by surgeons who favor "simpler and more appealing" procedures, presented as non-invasive and innovative technologies. They fail to mention that non-invasive does not equate to safe and ignore the fact that technological advances are not necessarily synonymous with scientific progress in understanding, diagnosis, and treatment, contrary to a common misconception in phlebology.

点评：射频热消融对于大部分不具备血流动力学知识的医生，或者是没有外科资质的医生，是一项不错的技术选择。但是，对于掌握血流动力学的外科医生看来，把腔内消融套上CHIVA的外衣，并包装成号称“更微创”的技术，是医疗耗材利益驱动的行为，违背CHIVA的治疗原则和伦理。