DrSclafani answers some questions

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

Postby kaboodah » Tue Aug 10, 2010 4:45 pm

Ok I really cannot believe this is possible, but ever since my ultrasound last Tuesday, I have been getting headaches... Everyday. I NEVER get headaches. I really can't believe that the test caused this, but that is one heck of a coincidence. Anyone have any ideas?
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Postby Cece » Tue Aug 10, 2010 9:04 pm

Zeureka wrote:Sorry, no question Dr Sclafani

The questions are back on pages 197 & 198 if he's in want of them. :)

Zeureka and annad, glad to hear of your fatigue improvements, it gives us all hope.
"However, the truth in science ultimately emerges, although sometimes it takes a very long time," Arthur Silverstein, Autoimmunity: A History of the Early Struggle for Recognition
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Postby drsclafani » Wed Aug 11, 2010 12:00 am

Nunzio wrote:Image
Hi Dr. Sclafani,
this is a side view of my jugular veins. The right one(on the left side of the picture) is obviously narrower.What concern me is that there are 2 collateral veins that take over right after the jugular vein exit the bony ostium.
I think they are collaterals because they insert at 90 degrees to the main vein.
1: Do you agree that they are collaterals?
2: Is it safe to balloon collaterals considering they usually are smaller and more fragile veins? Have you seen a similar situation in the past?
Thanks again for your expert opinion.


Dr Sossi:
those may be the vertebral veins.
i remain unclear what these mrv images of the jugulars represent when they show discontinuity of opacification, or apparent occlusions, or even narrowings. I think there is a flow phenomenom confusing the issue and I often cannot be sure whether I am seeing thrombosis, stenosis or the appearance of veins that have slow or sluggish flow. I have seen these abnormalities come to nothing on venography, so remain cautious and unclear about their meaning.

With regard to the collateral veins, they may be valuable. I have not yet dilated any in ccsvi, but i have done so in patients on dialysis. but if a patient had occluded main flow vessels, i would consider dilating these veins. smaller vessels means using smaller balloons. I have one patient who comes to mind that i have thought about this seriously and may do it soon. however no publications yet on the subject
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Postby drsclafani » Wed Aug 11, 2010 12:39 am

TMrox wrote:Dear Dr Sclafani,

Have you read the German and Swedish studies commented in the Wall Street Journal?

http://online.wsj.com/article/SB1000142 ... 10380.html

Did these studies use the doppler ultrasound with the right protocols?


It is regretful that Drs. Doepp and co-authors’ attempt to reproduce Professor Zamboni’s discovery of a link between multiple sclerosis and disturbance of the outflow veins of the brain and spine has been unsuccessful. It is particularly unfortunate that the authors’ misunderstanding of Dr. Zamboni’s publications about this subject have led to their conclusions that “No cerebrocervical venous congestion in patients with multiple sclerosis" exists

The authors mis-state several of the criteria for a positive ultrasound examination. They state that reflux must be present in both internal jugular veins or both vertebral veins. This is not accurate. Reflux in any one of these veins was considered a positive criteria by Zamboni.

It appears to me that Dr Doepp and colleagues have tried to elicit reflux by testing for incompetent valves in the lower jugular vein. Incompetent valves result in reversal of blood flow from the heart back up into the jugular veins. They used the Valsalva maneurer, a technique to increase pressure in the chest that reverses blood flow. However, Zamboni explicitly states that one should assess flow “never in (by) a forced condition such as the Valsalva manoeuvre.”

That the authors’ attempts were unsuccessful is not surprising. The ultrasound examination used by Zamboni is a simple one but the description of the technique has not been fully elaborated in his papers. Thus performance of the ultrasound by some investigators is often at variance and this may lead to differences of results. At my own institution, we were surprised that non-invasive testing by ultrasound did not correlate with the very obvious obstructive phenomena seen on catheter venography, which remains the Gold Standard of assessing veins. We also had difficulty identifying CCSVI on ultrasound, initially using the Valsalva maneuver during out testing. In fact we were able to find an obstruction in only one patient of twenty. It was only after being shown how to correctly perform this simple screening test by the Zamboni team during a visit to Ferrara, that we have become facile in detecting these abnormalities. It is clear that there is a learning curve to the use of this technique.

Nor does this paper refute the concept of CCSVI. Doppler ultrasound is only a screening test for CCSVI. When Doppler shows signs of CCSVI, the gold standard test of catheter venography is indicated to detect the sites of potential obstruction. Doppler is not the definitive test of CCSVI because it cannot assess the azygous vein, an important contributor to cerebrspinal venous outflow resistance. Catheter venographies routinely show evidence of outflow obstructions. Sluggish flow, reversal of flow, extensive collateral veins, strictures, duplications, reversed valves, thickened incompletely opening valves and misplaced valves are among the many abnormalities seen in MS patients that we never see in patients without MS.
The paper by Sundstrom and coauthors similarly rejected the CCSVI hypothesis by performing MR venograms and flow quantification in the neck. MR venography is suboptimal as a screening test because it underestimates and overestimates stenoses quite regularly. One can see from their illustrations two MRV images. It is noteworthy that neither image shows the portion of the jugular vein where lesions causing flow resistance are usually found: behind the clavicle as the vessel enters the chest. Both images show considerable collateral vasculature suggestive of CCSVI. Moreover the image on the right on page 258 purports to show a stenosis with an arrow. It is well known that most of the narrowings referred to by the white arrow are a common transient, non-stenotic narrowing caused by a true narrowing below the clavicle. Catheter venography shows abnormalities that cannot be detected by MRV.

I was struck by the rapidity of publication of both articles. Surprising! Both papers were accepted within six weeks. I have never had such rapid decision, editing and publication of any of my more than 120 publications.

This debate is going to be a challenging one. One side wants randomized prospective trials to prove efficacy. However while many proceduralists have noted sometimes impressive gains for patients, these proceduralists need to evaluate nuances of techniques before consensus can be built regarding the best approach to therapy. Only then can intelligent, carefully designed randomized prospective trials begin. Some who commonly perform randomized trials will try to reduce the work of those who will try to develop the best practices because they are not randomized. However, in my view this is a necessary initial step toward the final trials.
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Postby drsclafani » Wed Aug 11, 2010 12:44 am

AlmostClever wrote:Hiya Doc!

Been working my way through the symposium vids and had a few questions:

Doc Siskin mentions they developed their own "flared" stent.

[color=blue]Is the use of flared stents going to be the standard and how much of a flare are we talking about? Flared which way - up or downstream? Can other docs do this?

it is a nice technique. I am not sure it will be shown to be of value in keeping these veins open or in preventing migration.

Is it possible to stent around a curve?

yes, but how well depends upon the angles and the type of stent used.

What keeps the wire from damaging the inside wall of the vein? How do you steer? How thick is the wire?

Thanks!

A/C

There might be some damage from pressure and this may lead to some inflammation that results in narrowing. but the wire is polished and smooth. You do not steer a stent. It is loaded on a catheter and the catheter goes over a guidewire. when the stent is in position, it is deployed
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Postby drsclafani » Wed Aug 11, 2010 12:46 am

Cece wrote:
drsclafani wrote:to be honest, as i hope i will always be with you, i did not suspect that such abnormalities were common in the azygous. Sinan used the balloon as a diagnostic tool to "feel" around in the vein. the narrowings were impressive. It was one of the major points i took away from the meeting

Any other major points that we have yet to touch on?



yes, fabrizio is a great guy. i thoroughly enjoyed spending the weekend with him at my home. He is filled with passion for the work. we could not stop talking about what we do
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Re: Video (with good sound) from symposium

Postby drsclafani » Wed Aug 11, 2010 12:50 am

japentz wrote:Forgive the question here, but was their a professional video done of the July 26th symposium?

Videos were posted on YouTube by DrBartman, but the sound and voices are hard to hear and the visuals in the presentations were not in these videos.

sorry for this being in the wrong place, but I figured it was a question to Dr. Sclafani, who has been so very kind.

Thanks
Judy


judy, beautiful animal picture.

the video is completed and was sent to L who is doing some sound engineering to improve quality of the speakers voices (the quality of their ideas and presentations was first class)
not sure how long it will take. it might be superfluous now. things move so fast in ccsvi :cry:
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Postby Stacemeh » Wed Aug 11, 2010 12:53 am

I was struck by the rapidity of publication of both articles.



Hmmm, I wondered about this as well. Do you know if these papers were peer reviewed?
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Postby drsclafani » Wed Aug 11, 2010 12:53 am

hope410 wrote:Doctor, why is there such diversity regarding the use, if at all and for how long, of blood thinners/anti-coagulants after the procedure?

Is this kind of disparity typical, i.e., when docs have done angioplasty on arteries or veins in the past, is there this kind of difference in opinion on post-treatment meds that has always existed? Or is this unique to CCSVI treatment that there's such a difference in post-tx meds? Thanks. I think many of us are worried about the risks of blood thinners versus the risks of thrombosus, and feel insecure with the differences in medical opinion on tx & for how long and with what vs. no tx. With stents, should blood thinners ALWAYS be used because of the higher risk of clots? Is it absolutely indicated where no stents are used?

Please enjoy a wonderful holiday and thank you for putting on such a successful symposium!


i think it is pretty typical when treating veins to have coagulation a bit inhibited by anticoagulants.

there are many opinions and options. if angioplasty alone is done, i favor short term anticoagulation as does dr zamboni. others try antiplatelet drugs, others use both

stents require anticoagulation because of the foreign material encourages clot formation
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Postby drsclafani » Wed Aug 11, 2010 12:54 am

girlgeek33 wrote:
AlmostClever wrote:
Doc Siskin mentions they developed their own "flared" stent.

[color=blue]Is the use of flared stents going to be the standard and how much of a flare are we talking about? Flared which way - up or downstream? Can other docs do this?

A/C


So this doesn't confuse issues, because FDA approval gets involved in brand new medical devises, he didn't develop a new stent. He is using multiple size stents together to come up with this effect. Great creativity to work with existing devices to solve issues!


thanks girlgeek. you are correct
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Postby drsclafani » Wed Aug 11, 2010 1:00 am

logic wrote:
drsclafani wrote:
JohnJoseph wrote:Dear Dr S,
Many thanks for The Symposium a week ago!

Another technical question, I don't think it has been much discussed so far:
- What pressure is being applied to the balloons - are there different cathegories of baloons based on pressure?


pressures generated are between 8 and 30 atmospheres. That is the equivalent of the pressure of the ocean on top of you 1000 feet under the surface. It is a lot of pressure. Fortunately it is contained within the balloon.



Hi Dr. Sclafani. I have been studying scuba for three years. I am now 12 years old. My mom is bluesky63 and I am very glad that you are helping her. My mom showed me this after her venogram.

I hope you won't mind if I point out that your example of pressure was not quite accurate because in that depth the perception would be more like density squeezing you more tightly, not like the weight of the ocean, plus the pressure would crush you. It's not a solid object that would press down on you. It's liquid but it has less oxygen at that depth, which makes it more solid, but still not solid, and the farther you descend, the greater the density. Do you have a different and more realistic example that I could understand?

Thanks for your time!


dear logic
your mom must be very proud of you. As far as i know, you are the first kid i have interacted with on this site. Thanks for your disagreement with me. helps keep me honest.

I was trying to explain that the pressure in that balloon was the equivalent of the amount of pressure exerted at 30 atmospheres

sorry, i always use this example and i cannot think of another one.

lets say that the pressure is an enormous amount of force stretching the vein

thanks for joining
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Re: ultrasound

Postby drsclafani » Wed Aug 11, 2010 1:03 am

THEGREEKFROMTHED wrote:Sal,
question regarding doppler ultrasound. The technician who performed my ultrasound worked for a vascular surgeon and was quite familiar with venous system and IJV's. She commented on the reflux at the base of my neck as "interesting" but said that she typically will see some reflux in normal subject and considered it as such. Is some degree of reflux normal? How does one measure the degree of reflux with regard to abnormality?


one can occasionally have reflux but not for as long as is necessary to diagnose significant reflux

zamboni's criteria require reflux lasting 0.88 seconds
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Postby drsclafani » Wed Aug 11, 2010 1:06 am

Cece wrote:More questions, quick:

* When googling high pressure catheter balloons, it brings up differently shaped balloons: dogbone, square, etc. Would there be any use in CCSVI for balloons of a different shape? I have no idea what they're for.

do not know of these shapes. "dogboning" is a term i never used but reminds me of the shape of a balloon at the site of stenosis before the pressure causes it to stretch.

* Did Dr. Sinan talk any more about valvulotomy? Does it seem like valvulotomy is acceptably safe?


no, the talk was about "cutting balloons" more than valvulotomy balloons. I do not have any experience with that balloon.
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Re: TODAY'S DISCOVERY

Postby drsclafani » Wed Aug 11, 2010 1:10 am

drbart wrote:
drsclafani wrote:
drbart wrote:
drsclafani wrote:Today I added a cutting ballloon to my amamentarium of tools for use in liberation. This balloon has some sharp edges of metal attached to the balloon. When the balloon is opened, the metal presses into the tissues. it creates a indentation. After creating the creasing of the vein or valve, I then went to my usual 14 millimeter high pressure balloon and the vein dilated so easily and smoothly. it was like buttah! and created a very large venous confluens.


a friend had his second angioplasty thursday. his stenosis was a very tight thing (dunno the label) high enough into his skull that he had trouble finding an IR who would work on it.

initial reports are that it wasn't quite like buttah, or even i-can't-believe-it's-not-buttah. they wound up using "the wire", which i gather is a pre-balloon thing that sounds even creepier than the cutting balloon animation i saw elsewhere.

<shortened url>

can you comment? are you still a CB fan?


i am but i havent used it in two months :cry:

i am not sure i would have used a cutting balloon that high. There are some important things up there.
into the skull? i have my own trepidation doing that. Thankfully i havent had the opportunity to meet that critter yet.


so it was interesting to see dr siskin report on this case, and his observation that the vein's reaction to the cutting balloon was to close up even tighter than before.

have you and he had subsequent discussions about cutting balloons?


would love to see exactly where in the vein you are speaking about.
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Postby drsclafani » Wed Aug 11, 2010 1:14 am

1eye wrote:Maybe, if veins are really floppy, a bit softer approach is required, than in arteries. My speculation (actually I was in a haze of valium when I got my stents, so the speculation would not be legal testimony anyway) would be that only the more rigid deformation would be required, and not even that, if you stressed the walls enough, for long enough.

Maybe if you just waited a few more minutes (15?), you might get more of the vein's attention and convince it not to restenose right away. I like the idea of multiple inflations, too. But I'm not someone you would be wise to consult, having not much prospect of ever needing to decide.

What do you think, Dr. Sclafani? Will it weaken a stricture better with multiple inflations? Would more time inflated be as good? Or a cutter with a special, duller, vein blade? I know there are so many of us that the quicker way is probably better.



these cutting balloons are not exactly like specialized japanese cooking knives. the really mostly crease or score wall before a larger balloon is used for further dilatation.I do not think they are very sharp.

i like the idea of longer and repeated dilatation.
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