A Systematic Reflection on Methodology, Risk, Downward Standard Shifts, and Future Directions
This article is reproduced from the personal blog of Dr. Qiang Zhang and is intended solely for medical education and the sharing of professional information. It does not constitute medical diagnosis or treatment advice, nor can it replace in-person consultation with a qualified physician. Patients are advised to seek individualized medical care from a professional doctor based on their specific condition.
At first glance, the concept of “endovenous CHIVA” or combining endovenous ablation with CHIVA appears reasonable: it seems to merge the “no-incision” advantage of ablation techniques with CHIVA’s core philosophy of hemodynamic correction and vein preservation. Conceptually, this is often presented as a natural upgrade.
However, in reality, this idea remains far removed from what CHIVA truly represents.
Why is it methodologically difficult to integrate endovenous ablation with CHIVA?
What hidden risks are often overlooked behind this hybrid approach?
Why does this concept repeatedly emerge in clinical practice?
And what is the truly reasonable future direction for CHIVA?
1. The Core Issue Is Not “Which Technique Is Better,” but “Which Therapeutic Logic Is Applied”
The fundamental difference between endovenous ablation and CHIVA lies in their starting logic.
The logic of endovenous ablation is straightforward:
by thermal, chemical, or adhesive means, the vein lumen is irreversibly closed in order to eliminate reflux pathways.
The logic of CHIVA is fundamentally different:
based on a comprehensive hemodynamic assessment, it seeks to understand how reflux originates and how pressure is transmitted within the venous system. Treatment aims to correct abnormal reflux pathways while preserving venous structures as much as possible.
This is not a difference in “extent of intervention,” but a difference in methodological level.
Therefore, any discussion about “combining” the two must begin with an acknowledgment that they do not belong to the same logical framework.
2. “Ablating Only a Short Segment” Does Not Resolve the Methodological Conflict
A common argument in favor of “ablation-based CHIVA” is:
“We only ablate a very short segment, not a large portion of the vein.”
From a medical logic perspective, however, the length of ablation does not change its destructive nature. More importantly, endovenous ablation lacks the precision required to address complex hemodynamic patterns.
Within CHIVA, even when ligation or interruption is performed, it is always applied with extreme precision, serving a strategic role in protecting the saphenous vein and restoring physiological blood flow.
Once “vein closure” becomes the primary corrective tool, the therapeutic pathway has already shifted into an ablation-based system, no longer belonging to the methodological framework of CHIVA.
3. Underestimated but Critical Risks: Thrombosis and Deep Complications
Endovenous ablation is not inherently “lower risk”; rather, the type of risk is shifted.
Compared with flow-oriented or incision-based surgical approaches, endovenous ablation more readily introduces:
- Endothelial injury
- Thermal or chemical damage to adjacent nerves, deep veins, or arteries
- Incomplete closure
- Neovascularization
These factors may increase:
- Endothermal Heat-Induced Thrombosis (EHIT) extending into deep veins, leading to deep vein thrombosis
- The need for additional anticoagulation and long-term surveillance
- Recanalization and neovascularization-associated recurrence
These risks do not disappear simply because the procedure is “percutaneous and incisionless.” In many cases, they are underestimated or overlooked.
4. Altered Recurrence Patterns and Potentially Higher Long-Term Recurrence Rates
Attempting to achieve CHIVA-like outcomes through short-segment endovenous ablation may lead to:
- Artificial shortening of physiological flow pathways, increasing closure failure and recanalization rates
- Inflammatory responses and extensive neovascularization triggered by thermal ablation
Recurrence under these conditions often manifests as:
- Compensatory collateral vein dilation
- Increased hemodynamic burden on non-target venous systems
- More complex anatomical and flow patterns
Such recurrences are not easily managed with simple repeat interventions. Instead, they narrow future treatment options. For patients seeking long-term hemodynamic stability through CHIVA, this outcome directly contradicts the original intent.
5. Conceptual Dilution: When “Endovenous CHIVA” Becomes a Misleading Label
When terms such as “endovenous CHIVA” are used as vague and appealing labels, the real danger lies not only in the technology itself, but in the dilution and misuse of medical concepts.
Without clear boundaries:
- Any ablation-dominant approach can be labeled as CHIVA
- Patients cannot clearly understand which treatment philosophy they are receiving
- CHIVA’s rigorous methodological principles are gradually obscured
Ultimately, patients may undergo an entirely different treatment pathway under the name of “CHIVA.”
6. Learning Curve and Economic Incentives: The Real Drivers of Lowered Standards
One frequently overlooked reality is the steep learning curve of hemodynamic-based treatment.
Proper implementation of CHIVA requires physicians to possess:
- A systemic understanding of venous hemodynamics
- The ability to identify reflux origins, propagation pathways, and pressure gradients
- Long-term training integrating ultrasound assessment, clinical decision-making, and surgical execution
This is a highly cognition-driven, experience-dependent methodology that is difficult to standardize or rapidly replicate.
In contrast, endovenous ablation offers:
- Highly standardized, pipeline-like procedures
- Lower learning thresholds
- Clear economic incentives supported by mature commercial systems
When a demanding methodology like CHIVA coexists with a simpler, more profitable alternative without strict boundaries, a dangerous tendency emerges:
rather than elevating skill levels to meet CHIVA standards, easier techniques are repackaged as a diluted form of “CHIVA.”
7. An International Context: When Technology Replaces Professional Competence
In some countries and regions, physicians treating venous disease may not possess comprehensive surgical training or full operative qualifications. Under such circumstances, endovenous ablation—requiring fewer traditional surgical skills—becomes more readily adopted.
In certain cases, this leads to a concerning trend:
not because ablation aligns better with CHIVA principles, but because the standards required for true CHIVA are considered too high and are therefore deliberately lowered.
Using ablation to replace complete CHIVA while retaining the CHIVA name represents a downgrade of methodology, not genuine medical innovation.
8. Economic Drivers and the Unnecessary Use of High-Value Consumables
Endovenous ablation is heavily dependent on disposable high-cost devices and equipment. Without methodological constraints, economic incentives may lead to:
- Preferential use of ablation when not strictly necessary
- Replacement of complex, individualized hemodynamic assessment with device-based workflows
- Marketing optional approaches as “more minimally invasive”
This is not a critique of individual physicians, but a structural risk repeatedly observed in healthcare systems. Ultimately, patients bear the consequences.
9. Looking Forward: Non-Endovenous Approaches as a More Reasonable Evolution of CHIVA
Highlighting the limitations of endovenous ablation does not imply rejecting technological progress. CHIVA does not oppose innovation; rather, it imposes higher standards on technology:
- Does it serve hemodynamic reconstruction?
- Does it avoid irreversible damage to the venous lumen?
- Can it achieve precise modulation while preserving venous pathways?
Under these criteria, more promising directions include non-endovenous, low-destructive technologies, such as:
- High-intensity focused ultrasound (HIFU), delivering extracorporeal focused energy to specific reflux points without intraluminal damage
- Modulatory techniques used as adjuncts to flow reconstruction, rather than simply closing entire veins
The key question is not whether a vein is closed, but whether the intervention is reversible, adjustable, and subordinate to a global hemodynamic strategy.
10. A Clear and Responsible Conclusion
Endovenous ablation and CHIVA can coexist in the treatment of varicose veins. However, within current theoretical and practical frameworks:
Endovenous ablation cannot function as an integral component of the CHIVA methodology.
What deserves vigilance is not any single technology, but the lowering of medical standards and conceptual confusion driven by learning costs, economic incentives, and rhetorical packaging.
More than a decade ago in Europe, similar approaches were explored by a small number of practitioners. In contexts where physicians lacked full surgical training and CHIVA’s demands on hemodynamic understanding and surgical execution were high, endovenous ablation was attempted as a substitute to lower the implementation threshold.
In practice, several unavoidable outcomes quickly emerged:
First, complication risks did not decrease and, in some respects, increased. Thrombosis-related risks, nerve injury, and irreversible intraluminal changes associated with ablation did not disappear simply because the ablation segment was shorter.
Second, long-term outcomes failed to meet CHIVA’s goal of stable hemodynamic reconstruction. Permanent vein closure forced blood flow redistribution, leading to more complex recurrence patterns and reduced future treatment options—contrary to CHIVA’s emphasis on systemic adaptability and long-term stability.
Third, and most critically, such approaches did not align with CHIVA’s core methodology and were therefore never accepted into the CHIVA academic system.
For this reason, these attempts were not sustained in Europe and never entered mainstream CHIVA consensus. They remained isolated practices rather than recognized methodological extensions.
This historical experience already provides a clear answer:
the concept of “endovenous ablation plus CHIVA” is not a novel, untested idea, but a pathway that has been examined, found inconsistent with CHIVA’s core values, and ultimately abandoned.
When similar narratives re-emerge today, the essential questions are not how attractively they are packaged, but whether we are repeating a path already proven unsustainable, whether economic incentives are influencing decisions, and whether venous hemodynamics are being studied and respected with sufficient rigor.