DrSclafani answers some questions

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

Postby joana123 » Sat Jul 31, 2010 6:49 am

Dear Doctor,
forgive me for boring you, but I pray to you to give me your opinion based on my letters to the release from the hospital.
Thank you

This is a letter from the hospital
43 years old patient, admitted for additional evaluation.
In June this year was the hospital treated at our institute, when the planned flebografy dilatation and eventual left jugular vein. Then, after ultrasound and scanner processing, and made diagnostic and partial dilatation, ie. venous confluence of both sides were dilated, and the middle segment of the left jugular vein was not successfully dilated due to anatomical anomalies, or pressure on the veins of the bulbus of the carotid artery.
During the procedure, then, there was bradycardia and hypotension. The patient is in serious condition, it is about multiple sclerosis, slowly progressive type, can not to independently walk.
Upon receipt at our institution, patients and exposed to an extended vascular-neurological council, where it was decided to further interrventne procedures do not try because the above-mentioned position bulbus carotid artery and jugular vein to the left keeping in mind that during the last dilatation occurred hypotension and bradycardia.
Therefore, forgive the patient departments.
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Re: all Cece's questions....

Postby Cece » Sat Jul 31, 2010 6:53 am

drsclafani wrote:
Cece wrote:* What did you think of the question asked to Dr. Salvi, I believe, about diabetes (?) research from the 90s that showed that when blood flow was cut off to nerves, their functioning decreased and when it was restored, it improved? This is relevant to what is being found with immediate improvements in CCSVI, isn't it?


i am going to have to review the videotape before i make comments on that one.


Here is what I'm referring to:
<shortened url>

It is research on rats, not humans. And it's peripheral nervous system, not CNS.

I am not sure if this is the research being referenced, I think it might be:
http://www.ncbi.nlm.nih.gov/pubmed/1858864
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PROCEDURE

Postby THEGREEKFROMTHED » Sat Jul 31, 2010 7:01 am

Dr S,
curious if the Dr's at the symposium who are actively treating had made notice of lumbar veins and or vertebral septums or any other abnormal findings that could not be treated at this juncture including malformed valves and such?
Also in terms of stenting it seems Dr Siskin is comfortable doing so but was there any other opinions relative to that?
Lastly have they run into situations where a vein doesnt dilate but rather just seems to tear and not respond to ballooning? Sound familiar?
Last edited by THEGREEKFROMTHED on Sat Jul 31, 2010 7:36 am, edited 1 time in total.
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Postby girlgeek33 » Sat Jul 31, 2010 7:14 am

Not a question, Dr. S, I will send you a flash drive with copies of all of my video files. I am willing to do the same for anyone who would like copies. But, send me a private message and you can send me a drive with enough space to hold over 9gb of files and please include self addressed, stamped envelope... I gave up on online limitations...
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also

Postby THEGREEKFROMTHED » Sat Jul 31, 2010 7:36 am

Also wanted to ask if through treatments are any patterns starting to emerge or develop? For instance do all the guys seem to have such and such here or there and the girls something similiar or opposite. Any other ethnic patterns like all the Greek veins seem to be really a mess?
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Postby drsclafani » Sat Jul 31, 2010 8:32 am

HappyPoet wrote:Hello Dr. Sclafani,

It seems I owe you a question. :wink:

Here is the question I owe you:

drsclafani wrote:
Cece wrote:Lately with the emergence of so many more docs on the field, they all have different strategies. I know of a doc doing unilateral ballooning, so if both jugulars need ballooning, he schedules them for different days. (This is quite cautious?)

this is quite proposterous!

Now I'm quite terrified! Can you please be more specific?
Thank you.

~HP


Let me put it simply:
you have to go to shopping mall where that are two stores that are next door to each other and from which you want to purchase some items at both. You walk, chair or drive to one store, buy what you need, then go home without visiting the other store. Then the next day you do the same thing to go to the second store.

a waste of energy, double the risk of a car crash, etc, and maybe the second store will not have the item the second day
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Postby drsclafani » Sat Jul 31, 2010 8:41 am

joana123 wrote:Dear Doctor,
forgive me for boring you, but I pray to you to give me your opinion based on my letters to the release from the hospital.
Thank you

This is a letter from the hospital
43 years old patient, admitted for additional evaluation.
In June this year was the hospital treated at our institute, when the planned flebografy dilatation and eventual left jugular vein. Then, after ultrasound and scanner processing, and made diagnostic and partial dilatation, ie. venous confluence of both sides were dilated, and the middle segment of the left jugular vein was not successfully dilated due to anatomical anomalies, or pressure on the veins of the bulbus of the carotid artery.
During the procedure, then, there was bradycardia and hypotension. The patient is in serious condition, it is about multiple sclerosis, slowly progressive type, can not to independently walk.
Upon receipt at our institution, patients and exposed to an extended vascular-neurological council, where it was decided to further interrventne procedures do not try because the above-mentioned position bulbus carotid artery and jugular vein to the left keeping in mind that during the last dilatation occurred hypotension and bradycardia.
Therefore, forgive the patient departments.


Patients do not bore me...inactivity bores me

bradycardia means slow heart rate of a significant degree leading to hypotension, meaning low blood pressure.

This is a risk of dilating the carotid impression. There are nerve fibers in that region of the carotid artery (the carotid bulb) that regulate heart rate. Inflating the balloon in that area can result in stimulation of the vagus nerve and its fibers that results in bradycardia and shock.

THIS IS ONE OF THE MAJOR REASON I AM RELUCTANT TO DILATE THIS AREA OF THE VEIN WITHOUT BEING SURE THAT THE CAROTID IMPRESSION IS REAL STENOSIS. THE OTHER REASON IS THAT THIS IS OFTEN PHYSIOLOGICAL AND SHOULD BE DEFERRED UNTIL THE EFFECTS OF VENOPLASTY ON LOWER AREAS OF THE VEIN ARE SHOWN BY DELAYED IMAGING OR BY IVUS.

I am happy for you that it was, as is often the case, of a temporary transient nature.

now my turn for a question: how are you feeling. Did you get any relief by liberation?
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Re: PROCEDURE

Postby drsclafani » Sat Jul 31, 2010 8:54 am

THEGREEKFROMTHED wrote:Dr S,
curious if the Dr's at the symposium who are actively treating had made notice of lumbar veins and or vertebral septums or any other abnormal findings that could not be treated at this juncture including malformed valves and such?

There was mention of lumbar veins by me, salvi and siskin. but there was no consensus, nor would we expect any. Remember that these docs were reporting independent concepts and i thought we were all learning from each other.
I do not think that anyone is treating lumbar veins yet.

Also in terms of stenting it seems Dr Siskin is comfortable doing so but was there any other opinions relative to that?


I think we are all comfortable stenting veins. Some, like zamboni, sinan and me want to explore the limits of angioplasty before stenting. Some like siskin and petrov are not averse to stenting but usually reserved the stenting for occlusions and undilatable stenosis.


Lastly have they run into situations where a vein doesnt dilate but rather just seems to tear and not respond to ballooning? Sound familiar?

not familiar at all. if you speak about a person who likes mortadella, he had a tiny perforation necessary to get the vein opened but the vein did respond. As we reach the limits of venoplasty, there will be perforations as dilation occurs.

Also wanted to ask if through treatments are any patterns starting to emerge or develop? For instance do all the guys seem to have such and such here or there and the girls something similiar or opposite. Any other ethnic patterns like all the Greek veins seem to be really a mess?


i dont think anything like that has occured. we will have to wait for more data and lots of reports before a metaanalysis of these reports or review of the registries can find any trends. But greek are notorious for being a mess :D
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Re: all Cece's questions....

Postby drsclafani » Sat Jul 31, 2010 9:06 am

Cece wrote:* What did you think of the question asked to Dr. Salvi, I believe, about diabetes (?) research from the 90s that showed that when blood flow was cut off to nerves, their functioning decreased and when it was restored, it improved? This is relevant to what is being found with immediate improvements in CCSVI, isn't it?


This research is not linking diabetes and CCSVI. it is using some work that shows that diabetics with reduced arterial blood flow have diminished nerve conduction postulated to be due to reduced oxygen getting to the nerves. Diabetes results in thickening of the wall of small blood vessels and this reduces the inner diameter of the blood vessels.

It is important if we can show that arterial flow reduction in the brain is the result of outflow obstruction of the veins. Perhaps if that is correct, then it can explain some of the dramatic improvements in nerve functions seen after liberation.
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Postby drsclafani » Sat Jul 31, 2010 9:12 am

girlgeek33 wrote:Not a question, Dr. S, I will send you a flash drive with copies of all of my video files. I am willing to do the same for anyone who would like copies. But, send me a private message and you can send me a drive with enough space to hold over 9gb of files and please include self addressed, stamped envelope... I gave up on online limitations...


squeakycat, algis and L have volunteered their services to improve the quality and availability of the professional videos that were created. hopefully they will be available soon.

patience my dear self :twisted:
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Postby Nunzio » Sat Jul 31, 2010 9:36 am

drsclafani wrote:
girlgeek33 wrote:Not a question, Dr. S, I will send you a flash drive with copies of all of my video files. I am willing to do the same for anyone who would like copies. But, send me a private message and you can send me a drive with enough space to hold over 9gb of files and please include self addressed, stamped envelope... I gave up on online limitations...


squeakycat, algis and L have volunteered their services to improve the quality and availability of the professional videos that were created. hopefully they will be available soon.

patience my dear self :twisted:

If you upload your files to Megashares.com which is a free service with a 10 gigabites limit, they will send you a url that you can share with the forum and everybody will be able to download the file at their convenience without using the postal service which is so 20th century.
http://www.megashares.com/
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Re: Unilateral disease

Postby concernedwife » Sat Jul 31, 2010 9:41 am

drsclafani wrote:I always assume that there is more than i can see. those just starting, more likely to miss things.
It is a familiar story, the group probably knows it by heart now.....the narrowing that was seen, was probably the impression of the carotid artery. it is usually a physiological narrowing caused by obstruction to flow further down. ..of course there are real narrowings there, including a muscle compression. But was IVUS done? how many views? was full strength contrast media used or diluted.

We should all assume there is more than meets the eye because the eye is not prepared to see everything.

I do not know where the impression that MRV is the standard came from? did your husband get a ultrasound ala zamboni?



Dr. Sclafani:
I read your article in EV Today. Below is the quote which I think applies to my husband's scenario which is similar to what you mentioned above:

"As a result, many of the narrowings seen in CCSVI are caused by compression of a collapsed system by external forces rather than due to stenoses. This may lead to unnecessary angioplasty. The common areas of questionably physiological stenosis seen on MR venography are located at the skull base, adjacent to the carotid bulb, or where strap muscles exert compression."

I'm a physician (not radiology), so I have a descent understanding of anatomy, etc. What do you mean by "physiologic"? Do you mean clinically not significant or not pathological?
I discussed our venography result with our IR doctor, who is very experienced, although his experience is likely limited with CCSVI like most. He is quite sure, however, that the compression is not from the carotid. It is somewhere at the level of C1 so his feeling is that it may be the transverse process or ? the muscle (I watched the venogram, the compression was large, smooth border ~ 3-4 cm). When he balooned it, the jugular moved anteriorly. There was a 3-4 mmHg pressure gradient across the area of the compression which he considered significant give the venous system.

Any input you may have is greatly appreciated.
To your questions above, we did a straight venography, no IVUS, no doppler. There was no dilution of the contrast.

Thank you very much.
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Postby Cece » Sat Jul 31, 2010 9:54 am

drsclafani wrote:now my turn for a question: how are you feeling. Did you get any relief by liberation?

Here are her previous posts, if this helps:

joana123 wrote:Thank you for your reply.
I don't know what to do, the doctor did not want to redo the balloon angioplasti: said that it makes no sense, and sent me home. I am desperate, is there any hope for me?
What can be done in my case?

With respect.
A.

joana123 wrote:Thank you for your reply. I am from Bosnia and Herzegovina, and balloon dilatation have made in Serbia, in Belgrade Dedinje hospital. I'm sending you a discharge summary from the hospital, which is visible from my situation.

joana123 wrote:Good day everyone,

Please can you answer. How do you solve CCSVI if arteries supports the jugular vein? I have baloon angioplastic, it was not successfully i was a restenosis. I'm desperate.

Thanks, A.

joana123 wrote:I'm sorry for my bad english.
The doctor said that the situation - specific reason because the artery pushing jugular vein.
Can you tell me is installation stent in my case is posible?

Thank you,
whit respect,
A.
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Postby joana123 » Sat Jul 31, 2010 12:54 pm

Thank you for your reply.

I feel like even before the liberation treatment, no changes have not felt at all and I doubt that the veins were enlarged because on the the control Doppler doctor found that nothing had been done and called the doctor who performed the surgery to explain the situation.
What I have passed, that was a ''horror''. I hope my pain will get done, because i have a scheduled appointment in Bulgaria in early September this year.
I guess there will be more lucky!

With respect, A.
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Re: Unilateral disease

Postby drsclafani » Sat Jul 31, 2010 3:13 pm

concernedwife wrote:
drsclafani wrote:I always assume that there is more than i can see. those just starting, more likely to miss things.
It is a familiar story, the group probably knows it by heart now.....the narrowing that was seen, was probably the impression of the carotid artery. it is usually a physiological narrowing caused by obstruction to flow further down. ..of course there are real narrowings there, including a muscle compression. But was IVUS done? how many views? was full strength contrast media used or diluted.

We should all assume there is more than meets the eye because the eye is not prepared to see everything.

I do not know where the impression that MRV is the standard came from? did your husband get a ultrasound ala zamboni?



Dr. Sclafani:
I read your article in EV Today. Below is the quote which I think applies to my husband's scenario which is similar to what you mentioned above:

"As a result, many of the narrowings seen in CCSVI are caused by compression of a collapsed system by external forces rather than due to stenoses. This may lead to unnecessary angioplasty. The common areas of questionably physiological stenosis seen on MR venography are located at the skull base, adjacent to the carotid bulb, or where strap muscles exert compression."

I'm a physician (not radiology), so I have a descent understanding of anatomy, etc. What do you mean by "physiologic"? Do you mean clinically not significant or not pathological?
I discussed our venography result with our IR doctor, who is very experienced, although his experience is likely limited with CCSVI like most. He is quite sure, however, that the compression is not from the carotid. It is somewhere at the level of C1 so his feeling is that it may be the transverse process or ? the muscle (I watched the venogram, the compression was large, smooth border ~ 3-4 cm). When he balooned it, the jugular moved anteriorly. There was a 3-4 mmHg pressure gradient across the area of the compression which he considered significant give the venous system.

Any input you may have is greatly appreciated.
To your questions above, we did a straight venography, no IVUS, no doppler. There was no dilution of the contrast.

Thank you very much.


The veins are quite compliant, they distend and collapse based on the volume within them. When there is outflow obstruction, usually from stiff valves or central stenosis of the ijv, then the majority of blood flows via the vertebral veins and thus the IJVs collapse, much like they do when you stand up.

Three areas which appear to naturally cause narrowing of the undistended vein are ar the C2 transverse process, at the carotid bulb and where the strap muscles of the neck can compress the jugular vein in the region of the thyroid gland.

it always looks so impressive, doesnt it. but dr zamboni asserts that it is a physiological narrowing due to low volume. I have used IVUS to show how dynamic this area of the vein is. Dr. Sinan of kuwait says that if he waits an hour after lower stenoses, these upper narrowing get smaller or go away.
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