Saphenous sparing treatments: The ASVAL Method

Abstract

The ASVAL method is based on a bottom-up concept of the evolution of venous disease from the tributaries to the saphenous axes, as opposed to the traditional top-down theory where reflux, conversely, appears first on the saphenous axes and then spreads to the tributaries. The bottom-up evolution has led to a change in treatment paradigm, no longer based on effective suppression of saphenous reflux, but on reversibility of the latter by ablation of the varicose tributaries, eliminating the filling effect at the origin of the hemodynamic disturbance. As the ASVAL strategy has its limits, depending on the stage of progression of saphenous damage, it is necessary to establish the indications where it can be applied, before the saphenous vein is irreversibly damaged (diameter larger than 8 mm, multiple ectasia, extended reflux above and below knee), or the clinical staged too advanced (skin changes). Various authors have reported on these criteria for applying the ASVAL method in the right indications considering hemodynamic data (ostial reflux, extent of truncal reflux), anatomical data (saphenous diameter, reflux location, volume of varicose reservoir) and clinical data (age, nulliparity, trophic disorders, presence of symptoms). Complications and side effects are limited if the indications and principles of the miniphlebectomy technique are respected. All the cohort studies reported show that after treatment using the ASVAL method (removal of varicose tributaries and ad integrum respect for the saphenous vein), reflux abolition is achieved in between 50% and 80% of cases, depending on the patients selected. Above all, these studies show that improvement in symptoms and quality of life is systematic, whatever the result on the saphenous vein. A recent randomized controlled trial shows that endovenous laser and ASVAL are clinically equivalent, with a cost/effectiveness ratio in favor of ASVAL. In conclusion, The ASVAL method leads to an alternative concept of an ascending or multifocal evolution starting on the epifascial tributaries and enabling to set an individualized “à la carte treatment” since every patient has a different clinical and hemodynamic situation of the disease at the time of treatment, which cannot match to a “one size fits all” that represents the traditional strategy. We have now at our disposal simple tools to evaluate the patients, select the good indications and perform properly the ASVAL method by mini-phlebectomy.