DrSclafani answers some questions

[drsclafani]

now what?

Ok, assuming that accepting defeat is not the chosen option, how about:

There is a technique which attempts to progressively dilate underdeveloped veins as part of the creation of an arteriovenous fistula for hemodialysis. I have begun to explore this option for hypoplastic veins.

Progressive dilation would just mean dilating it again and again? All in a row or does the patient get a break between rounds?

depends if you are from canada or canarsie.
progressive dilatation is performed to mature arteriovenous fistulas for dialysis. dilatation of 2-4 millimeters is done at two week intervals.

In CCSVI we might be compelled to do it more quickly, based upon whether the patent ican easily return. Absent the practicality of return for additional dilatation, we have to dilate using a group of progresssively lsthrt snhioplsdy nslloond.

[drsclafani]

Well this oughta start a debate...

now what?

1. It appears the vein is not wanting to stay open, too small.
2. Re-opening via balloon only leads to more scarring and worse narrowing.
3. Every time you go back in it's further trauma to veins.
4. I vote covered stent.

Yes, it has issues of its own, including risk of clot, etc., and will have to be closely monitored but how else are you going to keep it open?

interesting choice. Not one i was thinking of. For lots of reasons
risk of thrombosis, migration of the stent, injury to the adjacent nerves, etc

[Johnson]

a group of progresssively lsthrt snhioplsdy nslloond

I interpreted that as progressively larger angioplasty balloons. Is that right?

I wonder what is the largest size that balloons come in. I have a 25mm RIJV, and an 18mm LIJV. Granted, the stenotic, or valvular regions may be smaller, but can you bust out a vein to those sizes? I would presume that you would have to surpass the desired circumference to account for recoil?

What would the difference be between venous hypoplasia and valvular incompetence? Do they fall under the same rubric?

[Opera]

Dear Dr Sclafani,

A medical doctor who takes an arms-length interest in CCSVI suggested to me that restenosis may be occurring because of the swelling of the veins as a result of infection by the bacterium Chlamydia pneumoniae.

He suggested that a course of antibiotics lasting one year may help to eradicate the bacterium and clear MS symptoms.

The antibiotics he suggested are:
doxycycline 200mg once daily
roxithromycin 300mg once daily (azithromycin 250mg three days a week is an alternative.)
Short courses of metronidazole to be added to this regimen.

More information and research papers can be found at www.davidwheldon.com.uk/ms-treatment

I know you are very busy but it would be nice if you can have a quick look and express an opinion.

With best wishes

[drsclafani]

There is a technique which attempts to progressively dilate underdeveloped veins as part of the creation of an arteriovenous fistula for hemodialysis.

First angioplasty, the doc used a 5mm balloon on my hypoplasic left jugular. The treatment of this vein was unsuccessful at this stage (immediate elastic recoil...I even relapsed). The next treatment, he used an 8mm balloon. I had sustained improvements after this treatment...though my vein is not as good as it was in the first few months after the 2nd angioplasty. I suspect the "annular" region of this hypoplastic vein is problematic also...but it's just too darn small for the doctor to closely inspect.

yes, i believe your doctor is going in the right direction. But why stop at 8 mm. When IRs do angioplasty to mature a hypoplastic vein for hemodialysis, they perform angioplasty 4-5 times at intervals of 2-3 weeks.

of course if the patient is coming from a backward country where angioplasty is not practiced, that will be quite a hardship and thus the progressive dilatation must be accelerated aggressively.

only time will tell if one practice has benefit over the other.

[drsclafani]

Dear Dr Sclafani,

A medical doctor who takes an arms-length interest in CCSVI suggested to me that restenosis may be occurring because of the swelling of the veins as a result of infection by the bacterium Chlamydia pneumoniae.

He suggested that a course of antibiotics lasting one year may help to eradicate the bacterium and clear MS symptoms.

The antibiotics he suggested are:
doxycycline 200mg once daily
roxithromycin 300mg once daily (azithromycin 250mg three days a week is an alternative.)
Short courses of metronidazole to be added to this regimen.

More information and research papers can be found at www.davidwheldon.com.uk/ms-treatment

I know you are very busy but it would be nice if you can have a quick look and express an opinion.

With best wishes

opera
i did attempt to review the reference you gave me. it is really very long and i cannot do justice to it two weeks before christmas. i am already toxically overextended

[drsclafani]

a group of progresssively lsthrt snhioplsdy nslloond

I interpreted that as progressively larger angioplasty balloons. Is that right?

You see, i told you i am toxically overextended. Did I really write that? I am a bit embarrassed. What other languages do you translate.

I wonder what is the largest size that balloons come in.

I have found angioplasty catheters up to 26 mm in diameter. however by La Place's law, the larger the diameter, the lower the burst pressure. And high pressure is really important.

I have a 25mm RIJV, and an 18mm LIJV. Granted, the stenotic, or valvular regions may be smaller, but can you bust out a vein to those sizes? I would presume that you would have to surpass the desired circumference to account for recoil?

unless your distend the annular constriction beyond its elasticity, you will not break the band and elastic recoil is the rule. Some of this tissue is really elastic and really high pressure is necessary. Yesterday, it required 25 atmospheres to overcome the tissue band causing the obstruction

The balloon however does not have to be larger than your vein. Once the annular constriction is broken, the constricted vein seems to distend in the area of the constriction. So I might try an 18 or 20 mm balloon on your vein.

[Neutralis]

Dear doctor,

I was diagnosed with hypoplastic left internal jugular vein last March. I had baloon dilatation performed, a process which required at least seven baloons of 12mm along the entire length of the vein. I see you used only one baloon to treat hypoplasia. Is there some reason for the one or the other choice?

By the way, I had some improvements, since blood flow was visible through doppler examination and remained visible for a month following the angioplasty (initially, we had not been able to detect blood flow in vertical position). Two months later, the return of some symptoms and a bad doppler sent me for venography, which showed that the vein was occluded from its middle part till its upper point.

Original width of the vein was only 2mm. I remain hypoplastic, plus partially occluded. Now what?

[drsclafani]

What would the difference be between venous hypoplasia and valvular incompetence? Do they fall under the same rubric?

lets clarify, valvular incompetence is a hemodynamic consequence. venous hypoplasia is a embryological anomaly.

so they are not the same rubric. Hypoplasia means underdevelopment of the diameter of the vein. it is not an inflammatory stricture.

[drsclafani]

Dear doctor,

I was diagnosed with hypoplastic left internal jugular vein last March. I had baloon dilatation performed, a process which required at least seven baloons of 12mm along the entire length of the vein. I see you used only one baloon to treat hypoplasia. Is there some reason for the one or the other choice?

By the way, I had some improvements, since blood flow was visible through doppler examination and remained visible for a month following the angioplasty (initially, we had not been able to detect blood flow in vertical position). Two months later, the return of some symptoms and a bad doppler sent me for venography, which showed that the vein was occluded from its middle part till its upper point.

Original width of the vein was only 2mm. I remain hypoplastic, plus partially occluded. Now what?

i want to be clear, that this is a work in progress. There is no definitive answer to the best way to address hypoplasia in multiple sclerosis. The model i am exploring is that used for hypoplastic veins needed for dialysis. Some of my AAC colleagues have written about it, and i am learning from them.

So i might continue treatments, not just do it once. The real buggers with this treatment plan are the low pressure of the venous flow, the long distance traveling patient and the out of pocket cost to uninsured patients.

[drsclafani]

Dear doctor,

I was diagnosed with hypoplastic left internal jugular vein last March. I had baloon dilatation performed, a process which required at least seven baloons of 12mm along the entire length of the vein. I see you used only one baloon to treat hypoplasia. Is there some reason for the one or the other choice?

By the way, I had some improvements, since blood flow was visible through doppler examination and remained visible for a month following the angioplasty (initially, we had not been able to detect blood flow in vertical position). Two months later, the return of some symptoms and a bad doppler sent me for venography, which showed that the vein was occluded from its middle part till its upper point.

Original width of the vein was only 2mm. I remain hypoplastic, plus partially occluded. Now what?

i want to be clear, that this is a work in progress. There is no definitive answer to the best way to address hypoplasia in multiple sclerosis. The model i am exploring is that used for hypoplastic veins needed for dialysis. Some of my AAC colleagues have written about it, and i am learning from them.

So i might continue treatments, not just do it once. The real buggers with this treatment plan are the low pressure of the venous flow, the long distance traveling patient and the out of pocket cost to uninsured patients.

[drsclafani]

how small does a vein need to be to fall into the hypoplastic category? My right IJV was 8mm at its largest (and was down to 7mm after one month) I have seen good improvements despite this small vein. (it took an 18mm balloonto open the stenosis that existed in the small vein)

I need to go look at my reports and images again to ask better questions.

there is no definitive diameter. i am thinking 2-4 mm.
pretty impressive and aggressive stretching done by your "liberator"
long term survival is the key.

i look at hypoplasia this way, the vein itself is practically useless as is. we are trying to create a function conduit. Go for broke! if it clots off, its a risk but not much to lose

[drsclafani]

There is a technique which attempts to progressively dilate underdeveloped veins as part of the creation of an arteriovenous fistula for hemodialysis.

First angioplasty, the doc used a 5mm balloon on my hypoplasic left jugular. The treatment of this vein was unsuccessful at this stage (immediate elastic recoil...I even relapsed). The next treatment, he used an 8mm balloon. I had sustained improvements after this treatment...though my vein is not as good as it was in the first few months after the 2nd angioplasty. I suspect the "annular" region of this hypoplastic vein is problematic also...but it's just too darn small for the doctor to closely inspect.

perhaps, and i am musing here in uncharted territory, continued dilatation is the way to go.

[Cece]

You see, i told you i am toxically overextended.

Please take care...if you were as kind to yourself as you are to us, that would be just about right...

[Nunzio]

Hi Dr. Sclafani,
I was reading a PDF presentation from Dr. Al-Omari from Jordan and I was intrigued by his statement on facial signs of CCSVI because I have exactly the same symptoms on my left lower lid: Please look from page 54 to page 57 of the link below.
Q:Is there any facial sings of CCSVI
 A:YES:
 Subcutaneous
Periorbital and frontal
Veins:
 Dilated Periorbital vein
in CCSVI patient
 Not uncommon clinical
finding
 Respond well to
liberation procedure

http://www.essentialhealthclinic.com/we ... -omari.pdf
I looked a bit more into it and I found the anatomical reason for it: those vein are branching off the anterior facial vein which originate from the Interior jugular vein as you can see from the picture below

So my question is if you noticed this too in some of your patients and if you noticed the disappearance of those vessels after a successful procedure.
Thanks a lot.