This Is MS Multiple Sclerosis Community: Knowledge & Support

"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.


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.

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

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.


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


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



important to do so. hypertension leads to cardiovascular disease. patients with ms do worse if they have cardiovascular disease.

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!

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:

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?

[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



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.[/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

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



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

cece, do you need an answer?



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.

jim
are you referring to the doctor or the patient

I do not think that the use of high pressure balloons is common. They are 2 or 3 times more expensive

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

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

Happy thanksgiving.

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



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

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

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....