DrSclafani answers some questions

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

Postby David1949 » Mon Nov 22, 2010 10:52 am

Cece wrote:
drsclafani wrote:whew
that was a lot of posting

i might take off the rest of the night, although i might sneak a look while watching the football game tonite. :wink:

Go Giants!

What is all this talk of football, tonight is "The Walking Dead" night.

Go humans! :D


"The Walking Dead" ? Holloween movie? Dancing with the stars maybe?

Anyway I think I'll opt for football too.
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Postby Cece » Mon Nov 22, 2010 8:56 pm

David1949 wrote:"The Walking Dead" ? Holloween movie? Dancing with the stars maybe?

Anyway I think I'll opt for football too.

It's a new zombie apocalypse series on AMC, as I said by pm since I wasn't sure whether taking up time in this thread with the words zombie apocalypse was, um, right. 8O

Nunzio wrote:Hi Cece, I agree with you, and that was dr. Sclafani point that maybe they were just looking and not treating these lesions even though I know they treated at least one renal narrowing with significant improvement in blood flow as shown in Dr. Galeotti presentation.

I've been following your posts on this with interest, it would be good if we can know for sure what they are or aren't treating.
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Postby drsclafani » Tue Nov 23, 2010 4:39 am

CCSVIhusband wrote:
CCSVIhusband wrote:Dr. Sclafani

(sorry to double post).

My next question is valves of the hemi-azygos and accessory hemi-azygous ... from my very limited reading of anatomy books trying to learn here --- each of these veins has a valve at the end of them where they drain into the azygos vein?

Do you look at those valves when in there to see if they are functioning properly?

Also ... do you go into either of those veins? (do you consider them separate veins, or when you talk azygos - does that include one or both of those)?


I didn't see an answer to this, if you don't mind Dr. Sclafani. I know these pages go by fast, so thought I'd re-ask.


these veins have inconstant valves. they are not always present.
We do not go into these veins to study them directly. when we image the azygos vein we look to see whether there is reflux into these veins which there occasionally is.

Like the vertebral veins, ascending lumbar veins and other smaller veins, we are no t pursuing treatment on these veins yet. There is much to learn and we should focus on the main veins for the time being
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Postby drsclafani » Tue Nov 23, 2010 4:47 am

sbr487 wrote:Dr. S,

Some questions pertaining to blood pressure, reflux and ccsvi -

Supposing there is a reflux eventually resulting in less consumption of oxygenated blood by brain, does heart actually adjust and start puming out less blood? Quite a few people have reported that they have low blood pressure.

That supposition is not correct. slower venous outflow may slow arterial inflow and that might lead to increased oxygen extraction from the red blood cells. Further if there were inadequate oxygen delivery, the reflexes would tend to increase blood flow not lessen it until derangement resulted in dysfunction.

If this is the case, is it not possible that due to reduced blood pressure, the level of reflux itself can reduce and hence can show up as non existent in the scans?

it is n ot the case and the physiology you suggest is not likely

Do you think a test like fMRI can come handy under such situations?
For example, normal & abnormal fMRI response ...

dr hubbard is investigating this.I am no expert and would defer to him

On a personal note though - I seem to be exact opposite of many MS patients. I have high BP and take medicine as a precaution.


important to do so. hypertension leads to cardiovascular disease. patients with ms do worse if they have cardiovascular disease.
Last edited by drsclafani on Wed Nov 24, 2010 2:26 pm, edited 1 time in total.
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Postby Donnchadh » Tue Nov 23, 2010 7:58 am

drsclafani wrote:
Image

The image on the left is a internal jugular vein excised from a patient with multiple sclerosis.

You can see how closely the venogram resembles in some ways the anatomical specimen.

The yellow straight arrow shows a narrowing of the vein. There is no scar tissue at all. The curved orange arrow points to the abnormal valve.




Dr. Sclafani,

Questions----

if you were to use an IVUS for internal imaging of the veins,

.....would the region of stenosis appear different from healthy vein tissue?

.....does scar tissue caused by a trauma appear different from a stenosis originating from a congenital cause?

I am asking the above questions from the internal perspective made possible by the IVUS imaging.

Also, judging from the external images above, it would seem that the region of stenosis has some different type of tissue compared to healthy veins.

What exactly is that difference?

Is it thicker?

Donnchadh
Kitty says, "Take that, you stenosis!"

Got MS?.....Get Liberated!
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Postby Cece » Tue Nov 23, 2010 10:24 am

I am still upset to learn that not all IVUSes are created equal. (After Dr. Sclafani's comment in another thread that he had used two from different manufacturers with very different results.)

When you are able to treat again, will you have access to the better of the two IVUSes?

and also:
drsclafani wrote:Image
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

These are beautiful images. In both jugulars of this patient the breaking point came at 18 mm at 14 atmospheres for the stenosis to be overcome. Is this highly individualized or might this turn out to be the standard size and pressure needed?
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Postby Bear2 » Wed Nov 24, 2010 6:22 pm

[quote="drsclafaniI 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


Image
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"



Image
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



Image
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



Image
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.[/quote]


Dr Sclafani,

Those are beautiful images. Is the use of high pressure ballons common. Are those images from someone local? I really want to meet this gal or guy.

Jim
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Postby drsclafani » Wed Nov 24, 2010 10:30 pm

Donnchadh wrote:
drsclafani wrote:
Image

The image on the left is a internal jugular vein excised from a patient with multiple sclerosis.

You can see how closely the venogram resembles in some ways the anatomical specimen.

The yellow straight arrow shows a narrowing of the vein. There is no scar tissue at all. The curved orange arrow points to the abnormal valve.




Dr. Sclafani,

Questions----

if you were to use an IVUS for internal imaging of the veins,

.....would the region of stenosis appear different from healthy vein tissue?

.....does scar tissue caused by a trauma appear different from a stenosis originating from a congenital cause?

I am asking the above questions from the internal perspective made possible by the IVUS imaging.

On IVUS, the region of the stenotic area would be different in appearance, but in a coarse way. If the valves were malformed, one would see that abnormality. One could see some of the collateral veins, duplications and septae. However the current technology does not do a great job of tissue characterization in MS. One of the manufacturers does color code different tissue characteristics, but it did that by analysis of actual tissue. This has been done for atherosclerosis but it has not been done for veins with cCSVI

Also, judging from the external images above, it would seem that the region of stenosis has some different type of tissue compared to healthy veins.

What exactly is that difference?

Is it thicker?

Donnchadh


The tissue appears to have smooth muscle cells in the outer layers of the vein rather than closer to the flowing blood. Also the type of collagen in the wall is stiffer, resulting in reduced distensability. One does not see on that case any evidence of scar tissue or inflammation of the vein
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Postby drsclafani » Wed Nov 24, 2010 10:44 pm

Cece wrote:I am still upset to learn that not all IVUSes are created equal. (After Dr. Sclafani's comment in another thread that he had used two from different manufacturers with very different results.)

When you are able to treat again, will you have access to the better of the two IVUSes?


cece, do you need an answer?

and also:
drsclafani wrote:Image
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

These are beautiful images. In both jugulars of this patient the breaking point came at 18 mm at 14 atmospheres for the stenosis to be overcome. Is this highly individualized or might this turn out to be the standard size and pressure needed?


cece, i think that there will be a range of balloon diameters depending upon the size of the vein. my assessment is that most will be in the 14mm to 20 mm range for jugulars. Pressure is interesting. I have seen success at 8 atmospheres to 20 atmospheres. I suspect that the most common numbers with be an 18 mm balloon at 14 atmospheres but not enough data.
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Postby drsclafani » Wed Nov 24, 2010 10:51 pm

Image
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.



Dr Sclafani,

Those are beautiful images. Is the use of high pressure ballons common. Are those images from someone local? I really want to meet this gal or guy.

Jim


jim
are you referring to the doctor or the patient :wink:

I do not think that the use of high pressure balloons is common. They are 2 or 3 times more expensive
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Postby Cece » Thu Nov 25, 2010 12:12 am

drsclafani wrote:
Cece wrote:I am still upset to learn that not all IVUSes are created equal. (After Dr. Sclafani's comment in another thread that he had used two from different manufacturers with very different results.)

When you are able to treat again, will you have access to the better of the two IVUSes?


cece, do you need an answer?

I connected some dots but was not happy with the picture that resulted....
I suspect that the most common numbers with be an 18 mm balloon at 14 atmospheres but not enough data.

We never have enough data, that's ok. It's exciting to be on the right path.

Happy thanksgiving.
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Postby drsclafani » Thu Nov 25, 2010 7:39 am

Cece wrote:
drsclafani wrote:
Cece wrote:I am still upset to learn that not all IVUSes are created equal. (After Dr. Sclafani's comment in another thread that he had used two from different manufacturers with very different results.)

When you are able to treat again, will you have access to the better of the two IVUSes?



cece, do you need an answer?

I connected some dots but was not happy with the picture that resulted....



Cece
I will use whatever I think it takes to get the best results.That means i will use the best IVUS available, use the most high pressure balloons and treat fewer patients per day than some others if i think i will get better results. I will change what i do as soon as i see a better solution

I suspect that the most common numbers with be an 18 mm balloon at 14 atmospheres but not enough data.

We never have enough data, that's ok. It's exciting to be on the right path.

Happy thanksgiving.


cece
all the data of all the cases done everywhere would be a great load of data. The problems include the secret treaters whose data is not accumulated or shared; data that has been contaminated by variation in practice, a necessary evil during startup; i am sure i can think of others.

trial data is helpful
registry data is valuable
reported data is often stimulating, enlightening and provocative
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Postby burg » Thu Nov 25, 2010 9:18 am

CONGRATULATIONS DR. S !!!!!!!!!!!!!!!!!!!!!!!!!!!!

Which American Access are you going to be with?? Brooklyn??

GREAT NEWS FOR MS!!!!!!!
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Postby drsclafani » Thu Nov 25, 2010 9:51 am

burg wrote:CONGRATULATIONS DR. S !!!!!!!!!!!!!!!!!!!!!!!!!!!!

Which American Access are you going to be with?? Brooklyn??

GREAT NEWS FOR MS!!!!!!!


The plan is to develop a dedicated ccsvi center in manhattan. in the meantime, i will work mostly in brooklyn but whereever i can schedule time among their new york centers while the ccsvi concept is developed
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Postby Cece » Thu Nov 25, 2010 9:55 am

drsclafani wrote:Cece
I will use whatever I think it takes to get the best results.That means i will use the best IVUS available, use the most high pressure balloons and treat fewer patients per day than some others if i think i will get better results. I will change what i do as soon as i see a better solution

whew
Since you posted in the other thread, I'd wondered if you'd ended up with the lesser IVUS.

Again I'm struck that your patients are very fortunate to be your patients. And we are very conscious of it.

CCSVI@aac-llc.com, quickly, everyone....
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