NZer1 wrote:Hi Dr. Is micro surgery a possibility for removing the valves from the veins when there is problems with restenosis occurring repeatedly?.
Some way of cutting them away or off the wall of the vein instead of ballooning to tear them?
I have no idea how small micro surgery is and if it is possible using catheter
thought that the vein will expand and contract from dilation, but the problem seems in some cases to be that the attachment area is the problem in that it has grater recoil and memory than even the cutting balloon or the larger balloons are unable to overcome.
Patience! we are exploring and there are more options. The larger balloon, higher pressure, prolonged dilatation technique is not fully explored, nor reported.
I have the feeling you are saying that having angio treatment on a repeated basis (like the example of the repeated esophagus patient) for some situations could be the only answer if the larger balloons do not work on a permanent basis?
I am not ready to say "only answer" to anything. We are still in a technical infancy.
I am disillusioned with the cutting balloon because the manufactured ones are too small and the home grown variety leave me disappointed so far. It am hopeful that high pressure balloon inflation might be really important.
I would like to illustrate this with some images from some procedures using high pressure large diameter balloons. I think that this technique can pull the stuck valve off the wall and allow freer flow.
let me illustrate with some images
The images below show a variety of attempts to open a couple of tight stenoses of the valvular area, using medium and large sized balloons under lower pressures, a poor man's cutting balloon and finally a high pressure balloon at medium and high pressures. The stenosis finally broke at high pressure when all other manuevers failed. I am optimistic that this might be a solution for this particular problem
The images above show attempts to dilate a jugular confluens stenosis causing stagnation of flow, collateral veins and and obvious venographic reflux. The XXL is a medium pressure balloon with a burst rating of 8 atmospheres of pressure. the dye in the balloon (black) conforms to the opening in the vein. The balloon on the left is obviously too small. The other two images show more characteristically the "waist" on the balloon representing the area of stenosis. The balloon in the middle image clearly did not overcome the elastic force of the narrowing. On the right one sees a wire between the balloon and the wall of the vein. While better, there remains a "waist"
In this set of images a high pressure balloon is used. The atlas has a burst pressure of more than 20 atmospheres. The waist remains at 8 atmospheres but the stenosis is overcome at 14 atmospheres
In the left jugular of the same patient, one sees the stenosis ("waist")
at 0 atmospheres and at 10 atmospheres, but the stenosis is overcome at a pressure of 14 atmospheres
Finally, the venogram after this angioplasty shows some filing defects but the flow was phenomenal. I believe the filling defect is a detached part of the valve.