DrSclafani answers some questions

[newfie-girl]

Would someone be so kind as to post an e-mail or office numner for Dr. Sclafani? I have searched the posts and sticky for hours and can't find anything.

Thank you, appreciate your help

[Cece]

it's on page 2 of the thread: ccsviliberation@gmail.com

[Johnson]

nevermind

[newfie-girl]

Thanks guys, your the best.

Johnson, I'm lost, what do you mean "my handle"

[CureOrBust]

2. extrinsic compression by a duplicated vein.

Or in my case (http://www.thisisms.com/ftopicp-95066.html#95066), by:

There is focal indentation of the IJV by the internal carotid artery at the level you indicate, with 50% narrowing of the luminal diameter of the IJV at that level (9mm above & below, 4.5mm at the indentation). The ICA is not abnormally dilated at this level and has a normal internal contour.

I spoke with the radiologist, and he didn't know what a surgeon could do to fix this issue. It seems minor on the scale compared to others. But I wonder if anything could be done using key-hole surgery? I see the interventional radiologist at the end of this month.

[drsclafani]

radiologist wrote:
There is focal indentation of the IJV by the internal carotid artery at the level you indicate, with 50% narrowing of the luminal diameter of the IJV at that level (9mm above & below, 4.5mm at the indentation). The ICA is not abnormally dilated at this level and has a normal internal contour.

I spoke with the radiologist, and he didn't know what a surgeon could do to fix this issue. It seems minor on the scale compared to others. But I wonder if anything could be done using key-hole surgery? I see the interventional radiologist at the end of this month.

at the price of being considered redundant, I suspect that your jugular narrowing at the level of the carotid bulb is the result of reduced filling and is a secondary sign of outflow obstruction.I would look for your narrowing at the level of the confluens with the subclavian vein

[newlywed4ever]

Thanks, Doc - for spending your Saturday night with us! Who "woulda thunk it?" 30 yrs ago this would not have been my idea of a good time on a Sat. night But right now I am full of hope and quite happy to be on these forums educating myself!

[PCakes]

Posted by Mangio.. who i will hope is okay with this.. forwarding to inpsire and to remind you why we so appreciate what you do...

Mangio says.. A friend of mine just lost her daughter to ms in the fall and one of her grandchildren is very disabled from progressive ms. What can we tell her. She is so raw with emotion.

[Johnson]

Composite of intra-venous ultrasound showing false narrowing

I think these images will clarify to the group that the upper narrowings don't indicate need for venoplasty or stents

*posted on behalf of Dr. Sclafani

[CureOrBust]

at the price of being considered redundant

FARRRR from it. You would only have a glimmer of the appretiation we have for your time here.

I suspect that your jugular narrowing at the level of the carotid bulb is the result of reduced filling and is a secondary sign of outflow obstruction.I would look for your narrowing at the level of the confluens with the subclavian vein

This statement of course made me review all the images of my MRV again, with new interest, and "possibly" finding something. Not so much my left, but my right subclavian vein actuall does not "light up" on the MRV anywhere near as bright as the left (you can just see it fade out on the image in the link above). And even more questionable, is that the rights drainiage (into what I guess is the superior vena cava) appears possible less than maxed in any image of the MRV( ie no image on the mrv shows the joining between these two being as brightly lit up as the other veins). Or am I reading too much into the brightness aspect of the images?

[Johnson]

Something that I have wondered about venogram pictures (as seen in Dr. Sclafani's pictures above), is why the catheter often appears to be outside the vein.

Just idle curiosity, but does anyone know?

[drsclafani]

PostPosted: Sun Apr 04, 2010 4:19 pm Post subject: posted on behalf of Dr. Sclafani Reply with quote
Composite of intra-venous ultrasound showing false narrowing

Dr. Sclafani wrote:
I think these images will clarify to the group that the upper narrowings don't indicate need for venoplasty or stents



*posted on behalf of Dr. Sclafani

So lets do radiology 101....
There are six images in the componsite , going left to right

On the first image, the MRV shows narrowing of the upper left jugular vein. There are also collaterals near the midline indicating collaterals through the vertebral venous circulation.
On the second image, from a catheter venogram, these findings are confirmed. One could think that this is a stenosis that needs treatment by venoplasty.
The third column has two images of IVUS. The upper one shows the complete collapse of the vein. but the lower one, done during deep inspiration increases blood flow through the vessel and the vessel (the dark area is blood) is distended quite well. Thus One can say that this is not a fixed narrowing, because it has the capacity to enlarge. AND that venoplasty is not necessary.
The fifth image is a catheter venogram. It shows this bulge on the outside of the jugular vein. This represents a valve that is malplaced, dysfunctional and causing the outflow problem. This is not seen on the MRV at all (not surprising).
The last image shows the jugular vein after the venoplasty. Flow is great, the valve is not seen and the upper vein now looks normal.

Isnt that interesting! That is why I do IVUS as a key element of our diagnostics.

With regard to johnson's question about why the catheter looks like it is outside the blood vessel, we are seeing the contrast column in the center of the vessel, but the catheter is hugging the wall where there may be no contrast media.

So now you have seen more than most radiologists have about this!

when do you want to take your Boards?




The first, looking from left, is a MR venogram.jasmd

[ClaireParry]

Dr Sclafani,

Is it possible to cause damage to the femoral nerve during the angioplasty procedure?

Thanks

Claire

[drsclafani]

This statement of course made me review all the images of my MRV again, with new interest, and "possibly" finding something. Not so much my left, but my right subclavian vein actuall does not "light up" on the MRV anywhere near as bright as the left (you can just see it fade out on the image in the link above). And even more questionable, is that the rights drainiage (into what I guess is the superior vena cava) appears possible less than maxed in any image of the MRV( ie no image on the mrv shows the joining between these two being as brightly lit up as the other veins). Confused Or am I reading too much into the brightness aspect of the images?

I looked at your images. It was just another crappy MR venogram. The arteries are superimposed over the most critical area of the jugular vein and could easily be obscuring the "money". What I do see is quite large jugular veins and lots of collateral veins which are compatible with outflow obstructions......its just that the lower part of the vein is hidden from view.

Thus you need a catheter venogram to find the culprit. Nothing else will do.

dollars to donuts

ooops.....i broke my own rule about discussing a direct patient issue.

[drsclafani]

Dr Sclafani,

Is it possible to cause damage to the femoral nerve during the angioplasty procedure?

Thanks

Claire

YES

The orientation of the three structures is as follows from outside to inside (lateral to medial)

femoral nerve....femoral artery....femoral vein

I feel for the artery and place the needle to the inside of the artery. It is therefore more likely to accidentally put the needle into the artery than the nerve, but it is possible to do either.

usually it is quite obvious that it is punctures. the patient will imimediately experience a sharp shock-like pain shooting down the leg

if a thin needle is used to puncture, damage is usually limited. However in some patients pain may persist for some time after the procedure is over. Rarely does the pain persist long term.