tzootsi wrote:Dr Sclafani,
Because of the difficulties detecting azygos problems, I'm starting to hear of routine ballooning of the azygos during the procedure, even when no problem is seen. Do you think this is a good idea? Are there any negatives?
The Azygos venous system results from a"deconstruction/reconstruction" of the cardinal veins of the embryo. It results in the azygos and hemiazygos veins, and the jugular veins. The truncal areas are commonly involved with abnormalities in patients with CCSVI. One could make the case that these abnormalities are the result of malformation of those veins as the cardinal venous system changes to the mature jugular azygos system.
In addition to the truncal areas, it is also possible to develop malformations in the azygos vein proper, not just in the valvular area. This results in webs and tissue formation in the azygos veins, that might be a remnant of the immature cardinal system.
These webs are extremely difficult to see because they are small and easily obscured by the contrast media in the main channel. Some practicioners routinely use a semicompliant balloon to interrogate the vein. These balloons have "waists" or indentations when they are inflated because of the resistance to distension resulting from the webs. Thus the contrast media within the balloon is not spherical. This is a sign of webs.
Inflating the balloon to higher pressures results in angioplasty of those veins.
So yes, I think it is an interesting technique but requires balloons that do not exert too much pressure on the wall, ie...semicompliant balloons. A compliant balloon would be preferable but I have not found one in the right shape and length as a product offering.
I like this idea because the webs create pockets of resistance to flow. Failure to diagnose and treat these malformations may reduce successful outcome. However there is always risk of inflation, although it is not common. I would anticipate that there is a risk of thrombosis.Rupture of the vein is unlikely because pressures are not too high.