DrSclafani answers some questions

A forum to discuss Chronic Cerebrospinal Venous Insufficiency and its relationship to Multiple Sclerosis.

Postby drsclafani » Fri Mar 26, 2010 8:56 pm

As an 18 month old I underwent a heart operation for the closure of an ASD. It was a simple straightforward operation. I am now in my mid twenties.

Do you think that this will prevent me from undergoing balloon angioplasty of the internal jugulars?


as you know, i am reluctatnt to speak about specifics with just a little bit of information. My goal here is to educate.

an ASD is an atrial septal defect, or a hole in the septum that separates the right and left atria of the heart.

so the risk in this situation is that blood or small blood clots could go from one side of the heart to the other side of the heart through any residual hole. If tha air bubbles or blood clots went from the right heart (where we are working ) to the left side, it could flow into a vital organ such as a kidney the heart of the brain. That could case troubles that you do not want.

In such a situation i would think that a consultation with the cardiologist is important. an echocardiogram would be helpful for making that determineation in such a patient.

if the defect is still closed, then i would pursue
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Postby drsclafani » Fri Mar 26, 2010 9:02 pm

What is your view on the significance of pressure gradients across narrowings? Let's say, hypothetically, that the 40-50% narrowing of an internal jugular vein was accompanied by a small (i.e., close to 0) pressure gradient. Does that impact the decision on how to proceed?


I think that pressure gradients are not that important in this highly compliant part of the circulation. Pressures are usually low to begin with.
i think the more valuable concern is flow and resistance to flow.

i would balloon if i found even a 40% narrowing
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Postby drsclafani » Fri Mar 26, 2010 9:12 pm

"Because we are talking dissipating veins (is that the correct translation? Draining veins?). This is an area that we do not know much about. There is a lot of knowledge about using arteries and also about ballooning these arteries. Thats is a simple procedure and there is a lot of experience in it.

On the other hand, there is less experience in ballooning dissipating veins and no knowledge on what the effects in the long run will be."

My question is simple: is this true? Do we know less about dissipating veins and ballooning them? Is that really a different ballgame?
I am looking for facts to reply with.


i do not know what dissipating veins are. i suspect that your second translation, draining veins, is more accurate. we know a lot about veins, Our group has been doing angioplasty of the veins of the upper extremity for more than thirty years. True, they are different kinds of veins that jugular veins. jugular flow is higher, arm veins have higher pressures but are smaller. . we know that veins generally do not do as well with surgery as arteries. Clotting of veins happens more frequently than arteries when repaired after injury for example.
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Postby drsclafani » Fri Mar 26, 2010 9:23 pm

More and more of us MSers are going abroad to get treatment. What is the typical follow-up procedure after angioplasty, so we can educate our doctors after our trip overseas


Followup is clinical. if things are going well, i like to see the patients in six months as that is when the stenoses in dr zamboni's report started to develop restenosis. I am looking for a good test to noninvasively assess but currently do not like to rely upon them. I have not been treating patients that long yet so i have some time to think about it some more.

i would think that the only noninvasive test would be a doppler sonogram to look for flow changes. but i would probably do another vfenogram

it is good to educate and familiarize your doctors with what is happening. I think it might be a good idea for a group to find a few select imaging labs that all patients go to. This will allow a few to become expert rather than many missing the boat.
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Postby drsclafani » Fri Mar 26, 2010 9:28 pm

Dr. Sclafani, have you treated anyone yet who is in the early stages of m.s.? If so did you find the CCSVI to not be as bad as those in worse shape with the m.s. (or with higher EDSS scores)?



cece

i have treated relatively young and recently presenting ms patients. I have not noticed much difference in the character of their fein abnormalities. but the numbers are too small to make anything of it yet.

If as we think, this is a congenital malformation of these veins and their valves, then the process is not time related, except perhaps in the development of collateral veins, those veins bypassing the obstruction
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Postby drsclafani » Fri Mar 26, 2010 9:29 pm

Would you agree to updating, by posting here, your opinion, (occasionally) as it may change, (strengthen/weaken) as time (with increasing knowledge and experience) goes on?


of course.
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Postby drsclafani » Fri Mar 26, 2010 9:32 pm

It appears that the people who have had continued remission of symptoms are primarily the ones who were stented. Any thoughts??


there is only one paper peer reviewed to my knowledge
the rest is unverified. So we need more information
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Postby drsclafani » Fri Mar 26, 2010 9:38 pm

What is the number of MS patients you have looked for CCSVI in and what is the number you have found have CCSVI ? How many of these do you perform in a week?

Thought you could use a couple easy ones.


I would prefer not to get into that kind of detail on the forum.
shall i just say that i have found problems in every patient so far. some are very subtle findings.
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Postby Hopeful10 » Fri Mar 26, 2010 10:03 pm

Dr. Sclafani,

Thank you again for your noble willingness to educate us.
Last edited by Hopeful10 on Mon Apr 12, 2010 9:25 am, edited 1 time in total.
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Postby PCakes » Fri Mar 26, 2010 10:05 pm

Dr Sclafani,

If you were to find similar issues, insufficiencies, stenosis, occlusions, etc in a non-MS patient, would you suggest and perform treatment? If so, what would be the reasoning? Is it as simple as "you do not have sufficient circulation in your brain.. we need to fix that or ____ ?" ..your head will fall off comes to mind... 8O

I am sorry for the simplistic approach.. if we could only find something that would justify our right to treatment..sigh

You are a good person.
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Postby hope410 » Fri Mar 26, 2010 10:12 pm

drsclafani wrote:i do not know what dissipating veins are. i suspect that your second translation, draining veins, is more accurate. we know a lot about veins, Our group has been doing angioplasty of the veins of the upper extremity for more than thirty years. True, they are different kinds of veins that jugular veins. jugular flow is higher, arm veins have higher pressures but are smaller. . we know that veins generally do not do as well with surgery as arteries. Clotting of veins happens more frequently than arteries when repaired after injury for example.


I didn't realize that angioplasty of veins was not new. Is this for dialysis patients alone where the experience has come, or...? That gives me some comfort to know that IR's are familiar with manipulating veins to some degree and their expertise hasn't been limited to arteries alone.

If we know from the Buffalo research that a good percentage of healthy controls also have CCSVI, then was no one treating the stenoses in the jugulars or azygous before this potential association of CCSVI to MSer's was discovered?

So, for example, if a person was having a venogram or ultrasound or MRV for some other reason and a stenoses was found, would it have just been left alone before now? Or was identification of stenoses of these veins just never looked at before in anyone, it was never found?

I appreciate all your responses so much. I have not only found the questions posted to be superb, but your answers are extremely educational as well. Thank you for the "vein" lesson!

edited: sorry, PCakes, it looks like I was typing a similar question to yours as you were posting your own! :)
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Baloon Angioplasty

Postby Serendib » Sat Mar 27, 2010 4:36 am

Dr Sclafani

I have had MS for the last 6 years. In the third year I had a seizure (two) and I was put on Tegretol CR 200. My Neurologist said that the seizure may have neen caused by a tiny lession. After sometime he asked me to stop the Tegretol. I have not been taking Tegretol for the past 6 months and I am fine now.

Will this history of epileptic seizure preclude me from undergoing balloon angioplasty?

Thank you for your kind views on this matter.
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Postby drsclafani » Sat Mar 27, 2010 4:51 am

Will this history of epileptic seizure preclude me from undergoing balloon angioplasty?


There are no data on your question. However, i can think of no contraindication to venoplasty in a patient with a history of seizures.
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Postby Johnson » Sat Mar 27, 2010 4:53 am

Greetings Doctor Sclafani. It's me, again...

I was wondering if you might give a GENERAL impression of what you might do with this - my stenoses, of course, with the understanding that things might look different in a venogram.
My name is not really Johnson. MSed up since 1993
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Postby drsclafani » Sat Mar 27, 2010 5:00 am

I didn't realize that angioplasty of veins was not new. Is this for dialysis patients alone where the experience has come, or...? That gives me some comfort to know that IR's are familiar with manipulating veins to some degree and their expertise hasn't been limited to arteries alone.


In a generic sense, the procedure I am performing for ccsvi is angiography and angioplasty of veins. Venous angioplasty has been performed at our institutions since about 1979.; Our report (Glanz S, Gordon DH, Butt KM, Hong J, Adamsons R, Sclafani SJA: Treatment of stenotic lesions in upper extremity dialysis access fistulas by transluminal angioplasty: Four years experience. Radiology 152: 637-642, 1984) was among the first in the United States.

The most common indications are
1.the treatment of vein stenoses caused by hemodialysis catheters
2. the treatment of venous obstructions caused by cancers.
3. treatment of stenoses of jugular veins resulting from repeated dialysis catheterization and causing massive swelling of the head and face and microhemorrhages in the brain.
4. venous narrowings caused by malformations of veins, including Budd Chiari syndrome stenoses of the inferior vena cava and hepatic veins and the May Thurner syndrome, stenosis of the iliac vein.

Other types of venous malformations at our hospitals are treated by embolization and sclerotherapy.

In CCSVI (chronic cerebrospinal venous insufficiency) a malformation occurs mostly in the region of the confluens of the jugular vein and the subclavian vein. It has been shown that such veins and valves have an abnormal type of Actin. Fused valve leaflets, inverted valves, webs, septae and hypoplasia are seen. In 2009, the College of Phlebology, with representatives of more than fifty countries, voted unanimously to define this malformation.

It is often seen in patients with symptoms of multiple sclerosis, but is also seen in other patients without the diagnosis of MS. These patients have been found to have reduced cerebral blood flow and cerebral atrophy, potentially ischemic in nature, is postulated to be caused at least in part by the outflow problems.

Our procedure calls for percutaneous femoral vein catheterization under local anesthesia, followed by catheterization and angiography of the veins draining the brain and spinal cord, namely the jugular veins and the azygous veins. Occasionally catheterization of the vertebral veins is also performed. These procedures are comparable to the treatments for other venous malformations.

If venous stenoses, slow flow, reflux or collateral flow through the brain and spine are identified. angioplasty of the jugular veins or azygous vein is performed after confirmation of stenosis by intravascular ultrasound. Patient recovery is short with discharge about one hour after the procedure. No sedation is necessary.

As stated above, venous angioplasty is an accepted procedure with a very low complication rate. While no complications were reported by Zamboni, they do occur when venous angioplasty is performed in other veins, including thrombosis, perforation that are minor and usually self limited, and restenosis. Restenosis may have a role in management of restenosis, although the stents were not designed for ccsvi.

Stent placement is also a component of most other venous angioplasty procedures either as an adjunct, as a primary form of overcoming elastic recall or as a secondary procedure to reverse restenosis. These have been safe. There is one anecdotal report in the lay press of a migration of a stent from the jugular vein into the heart that required operative removal; stent migration has been reported during other venous stenting procedures but these are uncomomon.
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