親愛(ài)的SMILE：

CHIVA策略包含兩個(gè)層面。第一，從血流動(dòng)力學(xué)角度看，它旨在恢復(fù)一種符合生理的引流層級(jí)（physiological drainage hierarchy），具體包括：
1）保留靜脈通路，尤其是大隱靜脈（GSV）；
2）斷開(kāi)分流（shunts）；
3）分散重力性靜水壓（fractionating gravitational hydrostatic pressure）。

第二，保留淺靜脈系統(tǒng)（SSG）的另一個(gè)原因，是它在未來(lái)一旦需要靜脈旁路移植時(shí)，可能具有關(guān)鍵作用。

因此，所采用的戰(zhàn)術(shù)必須與這一戰(zhàn)略保持一致。迄今為止，微創(chuàng)外科性斷離（minimally invasive surgical disconnections）可以實(shí)現(xiàn)這一目標(biāo)。

與該戰(zhàn)略相兼容的非手術(shù)性戰(zhàn)術(shù)當(dāng)然是值得期待的，但尚未出現(xiàn)。目前提出的熱消融CHIVA（Hot CHIVA）和腔內(nèi)技術(shù)，并不符合上述兩個(gè)戰(zhàn)略目標(biāo)。

在隱股連接處存在逃逸點(diǎn)（saphenofemoral escape point）的情況下，這類方法所做的分流斷開(kāi)，并不是在緊貼股靜脈處完成，而是在瓣膜弓（valvular arch）之下進(jìn)行，并且閉合長(zhǎng)度達(dá)到5到10厘米。

因此，這種不符合血流動(dòng)力學(xué)原則的斷離以及過(guò)度閉塞，都不符合CHIVA的血流動(dòng)力學(xué)戰(zhàn)略，也不符合對(duì)大隱靜脈的完整保留。

（在歐洲）在大多數(shù)情況下，這些“腔內(nèi)CHIVA”的做法都是由無(wú)權(quán)限進(jìn)行手術(shù)操作的非外科醫(yī)生實(shí)施的；也有一些外科醫(yī)生出于追求“更簡(jiǎn)單、更吸引人”的操作方式，而采用這些方法，并把它們包裝為“非侵入性”和“創(chuàng)新技術(shù)”。

但他們沒(méi)有說(shuō)明的是：非侵入性并不等于安全；同時(shí)，他們也忽視了一個(gè)事實(shí)：技術(shù)進(jìn)步并不必然意味著在認(rèn)識(shí)、診斷和治療上的科學(xué)進(jìn)步。而在靜脈病學(xué)領(lǐng)域，人們恰恰常常存在這種誤解。

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.

點(diǎn)評(píng)：射頻熱消融對(duì)于大部分不具備血流動(dòng)力學(xué)知識(shí)的醫(yī)生，或者是沒(méi)有外科資質(zhì)的醫(yī)生，是一項(xiàng)不錯(cuò)的技術(shù)選擇。但是，對(duì)于掌握血流動(dòng)力學(xué)的外科醫(yī)生看來(lái)，把腔內(nèi)消融套上CHIVA的外衣，并包裝成號(hào)稱“更微創(chuàng)”的技術(shù)，是醫(yī)療耗材利益驅(qū)動(dòng)的行為，違背CHIVA的治療原則和倫理。