This Is MS Multiple Sclerosis Community: Knowledge & Support

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.






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.


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.


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

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


this MS is a real bugger, appetite suppression resulting from MS?...we should bottle it

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?

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.


\
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




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



hours, days and weeks after angio

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

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;

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?

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!!

_________________
It's a paradigm shift

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

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

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?

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?

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

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.

_________________
Everybody here brings happiness, somebody by coming,others by leaving.  PPMS since 2000<br />

wow - congrats!!