DrSclafani answers some questions

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

Postby drsclafani » Wed Dec 22, 2010 8:47 pm

AlmostClever wrote:Dr. Sclafani,

I had a venogram today which revealed my right IJV is completely occluded.

This vein was open a month ago, but the treating doctor could not get the wire through this time.

Any suggestions on how to treat a completely occluded vein like this one that was open a month ago?

Thanks for your help!

AlmostClever
AlmostClever: Can I assume that doppler and Bmode ultrasound was performed before the procedure? And why are you having a second procedure? did you have worsening of symptoms?

At any rate, ultrasound is very important when one cannnot get the guidewire to pass an obstruction. The differential diagnosis includes
1. complete thrombosis with hard thrombus,
2. high grade stenosis that prevents the entry of a wire or catheter
3. the catheter has gone into an incomplete duplication
4. not enough persistence.

Ultrasound is very important because we must diagnosis #1 or exclude it.

If the vein above the occlusion is not thrombosed, there will be sonolucency and compressibility of the jugular vein on ultrasound.In such circumstances the interventionalist can continue to try or failing a reasonable persistent attempt, one can attempt a rendevous procedure.

Allow me to demonstrate a rendevous procedure.This is about a forty year old woman with fatigue, weakness, temperature intolerance, the usual general symptoms

Doppler and B mode ultrasound of the neck and power doppler examination of the deep cerebral veins by ccsvi technique showed three positive signs.
Therefore venography was performed.

Examination of the right neck showed a single annular stenosis. This was treated by high pressure large balloons with wide expansion of the vein and good flow.



Image


subsequently cathterization of the left jugular vein was attempted. This proved impossible despite probing with several different catheter shapes and three different guidewires for almost one hour.

A rendevous procedure was then attempted. the left neck was prepped to sterility. A Bmode ultrasound readily visualized a small but pateent jugular vein in the region of J2. Using ultrasound guidance and micropuncture technique, the vein was accessed and a platinum tip guidewire was advanced easily into the central part of the IJ vein.
In a true rendovous procedure, one would grab the guidewire in the chest with a snare entering the neck puncture and pull the guidewire up into the higher jugular vein. Then the procedure could continue.

in this case we were able to track along the US placed neck guidewire and ultimately get a catheter up the neck.

Image
Figure A shows the catheter unable to advance. Contrast media ends blindly and does not go up into the upper jugular vein.
Figure B is after a rendevous manuever. The catheter is now in the upper jugular vein. Contrast media does not travel towards the chest (red arrow) because the 1.66 mm catheter blocks all flow. The orange curved arrow shows flow up into the dural sinus and finally down the recently fixed right jugular vein (white arrow)
Figure C shows that some drainage occurs down the enck via the vertebral veins (green arrow)
Figure D shows an anterior jugular collateral.

So a hypoplasia correction procedure was performed in one treatment.

Image
First 10 millimeter 8 cm long balloons were used to dilate the J3, J2 and J1 regions. 10 Atmospheres were sufficient to overcome all stenoses except annular stenosis at the confluens. Finally 14 mm balloons were used to overcome stenotic areas in J1.

the final image on the right shows the ultimate appearance of the veins. No collaterals were noted..

one would anticipate that this patient has notseen her last day in this department.

not a bad beginning but reconstruction may take more than one treatment. So we come to another question, should periodic dilatation be performed or is one treatment sufficient until restenosis. This is unanswered. at the momen
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Postby drsclafani » Wed Dec 22, 2010 8:55 pm

LisaAnn wrote:Hi Dr. Sclafani,

I too have considered calling a lawyer as my purple feet have almost completely disappeared!! About 80%! I have also lost the icy cold in my legs and feet!

Just when I thought my improvements had peaked or plateaued, I accidentally discovered yesterday that I could move my left hand. I was just about to bang my hand on my wheelchair when I had a fleeting thought to just raise my hand and low and behold, my hand moved! I haven't been able to voluntarily move my hands or fingers for over two years. Later that evening I was able to move both hands. It's not a large movement and it takes a great deal of effort but you can actually see the movement in my fingers, hands and arm muscles. I thought it was just a fluke but I am still able to move my hands today.
I guess time will tell if this is significant or not. It was definitely a surprise as I was focusing on trying to move my feet!

I haven't seen any one else report this but since the treatment I am physically hungry almost everyday. Normally I don't get hungry and have been eating about the same amount for a few years. Now I am hungry within two hours of eating. My appetite has not changed but feeling hungry every day is very strange for me. This started about two days after the procedure so it must be related.

No real questions here! Just wanted to give a quick update!

Keep up the healthy skepticism! We all need it. Never feel bad about Smelling the Coffee!

Merry Christmas!
Lisa


Lisa
what a wonderful christmas card you send me!
I feel like santa right now!!
:D :D :D :D

this MS is a real bugger, appetite suppression resulting from MS?...we should bottle it
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Postby CCSVIhusband » Wed Dec 22, 2010 8:58 pm

Dr. Sclafani, your statement about restenosis above makes me wonder ...

if expanding a vein via angioplasty - not stenting ... can you estimate the risk (rate) of clots forming?

the risk (rate I guess) of "restenosis" in general - and would that mean ... elastic recoil ... most of the time?



It seems you've found ways to overcome some of the hypoplasia you used to discuss ... is that a fair statement?

OH ... one more! When would elastic recoil occur? hours? days? weeks after angio?
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Postby drsclafani » Wed Dec 22, 2010 9:20 pm

CCSVIhusband wrote:Dr. Sclafani, your statement about restenosis above makes me wonder ...

if expanding a vein via angioplasty - not stenting ... can you estimate the risk (rate) of clots forming?

i think clots form based upon the extent of the "controlled" injury caused by angioplasty, the patient's inherent "clotability" , the duration of balloon inflation, the amount of anticoagulant on board.

can you estimate the the risk (rate I guess) of "restenosis" in general - and would that mean ... elastic recoil ... most of the time?

\
i think most restenosis is caused by elastic recoil, or fibrosis on the wall of the vein after the angioplasty. In my first few attempts at this, i would say my rate of restenosis was very high, likely secondary to using undersized balloons. The stenosis seemed to go away but must have easily recoiled.
now i am using really high pressures and large diameters. i am cautiously and skeptically optimistic



It seems you've found ways to overcome some of the hypoplasia you used to discuss ... is that a fair statement?

As i have said, my AAC colleagues have been doing this for small veins used in forming an arteriovenous fistula for dialysis. They bring patients back every couple of weeks for me maturation of the vein. I cannot wait to find some patients from brooklyn where using that approach is practical. Given that many of my patients are from other countries, i do not have that luxury

OH ... one more! When would elastic recoil occur? hours? days? weeks after angio?


hours, days and weeks after angio
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Postby AlmostClever » Wed Dec 22, 2010 9:38 pm

drsclafani wrote:AlmostClever: Can I assume that doppler and Bmode ultrasound was performed before the procedure? And why are you having a second procedure? did you have worsening of symptoms?



Dr. Sclafani,

As always, you are on top of your game!

This was actually my third procedure! My symptoms had worsened after the first procedure in August and so I was doing an ultrasound follow-up of a procedure done in November when it was discovered that my IJV's were closing up again.

Ballooning of the left proved unsuccessful at keeping it open so ultimately and unfortunately a stent had to be placed.

My interventionalist was unsuccessful at entry into the right and decided to wait on this issue.

I will share this information with him so hopefully we can give it another shot!

Thank you for your detailed answer! I am very grateful!

AlmostClever
If you can't explain it simply, you don't understand it well enough. - Al Einstein
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Time for the troops to act

Postby drsclafani » Wed Dec 22, 2010 10:24 pm

Time for the troops to act:

below is the first announcement of the first annual meeting of the isnvd, that is, the international society of neurovascular disease. With an emphasis on ccsvi, this meeting will bring together experts on ccsvi

please send this to doctors who are interested in learning m ore about the science and the techniques related to ccsvi

so get in someone's face/ . wwe need to put on a big meeting;

Image
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Postby sara-sama » Thu Dec 23, 2010 5:32 am

hi ..

I'm happy to join you and I hope to find Benefit with you ..

My sister have Als .. diagnosed 18 months ago
she did the doppler ultrasound .. Then Found stenosis 90% on both sides of the neck ..
When she Got"The Liberation Procedure" By the balloon Since 6 months ago
her face color became Normal .. movement of her hands more flexible .. Swallowing Better .. Speech is becoming more clarity ..and no depression
But all of this improvement was for only one Month and returned deteriorate ..
She lost the ability to movement, speech and swallowing within 18 months .. Now she wants to travel to angioplasty procedure again ,Do you support that.. Do you think that the health status allow it ..What is your advice?
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Postby pairOdime » Thu Dec 23, 2010 7:01 am

Dr. Sclafani,

What are your thoughts on this drug treated balloon mentioned below. This was reported by a facility treating outside of the United States.

new device as an alternative to stent placement, this type of balloon, one that is currently being used on coronary patients with restenosis risk. The balloon carries a drug that is used to prevent organ transplant rejection and deposits it in the walls of peripheral blood vessels which is the case of the jugulars.
These balloons are now certified in Europe and it is expected that they will be available in January, 2011.

I also found this device mentioned at this link
http://www.dicardiology.net/node/33160/

Thanks in advance Dr. Sclafani...Merry Christmas!!
Last edited by pairOdime on Thu Dec 23, 2010 11:20 am, edited 1 time in total.
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Postby Bizzy » Thu Dec 23, 2010 7:18 am

drsclafani wrote:
Cece wrote:Dr. Sclafani, I have been wondering about something I read in a patient's blog of her procedure done by you. She said she was asked to raise her hands over her head (or maybe straight up?) when the azygous was being imaged. Did this help you see better? Does it increase blood flow to the azygous? I thought it was an interesting detail.


the answer will amuse you,
when we take the xray of the azygos, the best views are a straight up lateral view from right to left. IF the arms are left at the side they block the view of the azygos. So in order to get an unobstructed view, i have the patient put their arms above their head, away from their side and out of the field of view.

i know, it might not be an uplifting answer (or is it?) , but at least it isnt toxic


Thanks for asking this question Cece, I was wondering why Dr. Sclafani had me lift my arms over my head!

It will also be 3 weeks tomorrow since I have been treated and although I have no major walking improvements, my energy level is amazing and my balance is much better. This is the best christmas present ever! Thank you Dr. Sclafani.

Sue
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Postby drsclafani » Thu Dec 23, 2010 11:48 am

sara-sama wrote:hi ..

I'm happy to join you and I hope to find Benefit with you ..

My sister have Als .. diagnosed 18 months ago
she did the doppler ultrasound .. Then Found stenosis 90% on both sides of the neck ..
When she Got"The Liberation Procedure" By the balloon Since 6 months ago
her face color became Normal .. movement of her hands more flexible .. Swallowing Better .. Speech is becoming more clarity ..and no depression
But all of this improvement was for only one Month and returned deteriorate ..
She lost the ability to movement, speech and swallowing within 18 months .. Now she wants to travel to angioplasty procedure again ,Do you support that.. Do you think that the health status allow it ..What is your advice?


i would guess that she has restenosis, likely caused by elastic recoil from an incomplete angioplasty.

her situation appears to be bad. she will have to make a decision to take a risk or not
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Postby mo_en » Thu Dec 23, 2010 1:27 pm

A very enlightening post it was about treating hypoplasia.
And now a riddle: 25 year old MS patient has effectively had her azygos, right and left jugular veins treated in three successive angioplasties. Her symptoms deteriorate. A fourth angiogram shows perfect flow to all three veins. Cortisone therapy has no effect. An MRI of head & neck shows no new or enhancing lesions. Her symptoms deteriorate again. Vertigo, numbness and balance issues.
What seems to be the problem? An unresolved stenosis? Venous back-jets through the valveless jugulars? Increased flow in vertebral plexus and subsequent load on spine lesions? Or just a roller coaster improvement?
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Postby sara-sama » Thu Dec 23, 2010 1:51 pm

drsclafani wrote:
sara-sama wrote:hi ..

I'm happy to join you and I hope to find Benefit with you ..

My sister have Als .. diagnosed 18 months ago
she did the doppler ultrasound .. Then Found stenosis 90% on both sides of the neck ..
When she Got"The Liberation Procedure" By the balloon Since 6 months ago
her face color became Normal .. movement of her hands more flexible .. Swallowing Better .. Speech is becoming more clarity ..and no depression
But all of this improvement was for only one Month and returned deteriorate ..
She lost the ability to movement, speech and swallowing within 18 months .. Now she wants to travel to angioplasty procedure again ,Do you support that.. Do you think that the health status allow it ..What is your advice?


i would guess that she has restenosis, likely caused by elastic recoil from an incomplete angioplasty.

her situation appears to be bad. she will have to make a decision to take a risk or not


what do u think of the possible risk ?
is it more risky than staying without doing any thing until......?

do u find special kinds of blocks in patient with ALS?
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Postby hopeful2 » Thu Dec 23, 2010 2:21 pm

Happy Holidays Dr. Sclafani. Your presence here on TIMS has been like a snowfall of presents every day!

You waxed rather poetic in your Dec 21 post about being hungry for miracles---I didn't know you wrote poetry in your spare time! You're a man of many talents. See you in 2011. :)

Patrice
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Postby Nunzio » Thu Dec 23, 2010 4:33 pm

drsclafani wrote:So a hypoplasia correction procedure was performed in one treatment.

Image
First 10 millimeter 8 cm long balloons were used to dilate the J3, J2 and J1 regions. 10 Atmospheres were sufficient to overcome all stenoses except annular stenosis at the confluens. Finally 14 mm balloons were used to overcome stenotic areas in J1.

the final image on the right shows the ultimate appearance of the veins. No collaterals were noted..

one would anticipate that this patient has notseen her last day in this department.

not a bad beginning but reconstruction may take more than one treatment. So we come to another question, should periodic dilatation be performed or is one treatment sufficient until restenosis. This is unanswered. at the momen

Hi Dr. Sclafani,
I am very impressed by the fact you were able to dilate a totally hypoplastic vein to a 14 mm. diameter in just one session. As you probably remember this is my case too so I am particularly interested in this subject.
My concern is that it might be difficult to dilate the IJV near the bony ostium because of the fixed stricture that might not allow the balloon to properly expand.
The other problem is that if there is poor flow from the sigmoid/transverse sinus then there is higher chance of thrombosis due to the low velocity of the blood traveling through the newly dilated vein.
Because it would be nice to have higher flow also to prevent re-narrowing,
I wonder if you have some insight on the possibility of dilating the sinuses.
This is a scary thought for me because of what is next to the sinus.
Thanks again and Buon Natale.
Last edited by Nunzio on Thu Dec 23, 2010 4:46 pm, edited 2 times in total.
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Postby Cece » Thu Dec 23, 2010 4:42 pm

LisaAnn wrote:Just when I thought my improvements had peaked or plateaued, I accidentally discovered yesterday that I could move my left hand. I was just about to bang my hand on my wheelchair when I had a fleeting thought to just raise my hand and low and behold, my hand moved! I haven't been able to voluntarily move my hands or fingers for over two years. Later that evening I was able to move both hands. It's not a large movement and it takes a great deal of effort but you can actually see the movement in my fingers, hands and arm muscles. I thought it was just a fluke but I am still able to move my hands today.
I guess time will tell if this is significant or not. It was definitely a surprise as I was focusing on trying to move my feet!

wow - congrats!!
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