DrSclafani answers some questions

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

Postby Cece » Mon Dec 27, 2010 5:54 pm

Sara-sama, I hope so too, it is not without risk but others have successfully travelled for treatment despite advanced disability:
http://www.thisisms.com/ftopicp-146418.html#146418
http://www.thisisms.com/ftopicp-143901.html#143901

I feel for people in the caregiver role, such as in the "Christmas Miracle" linked there, who have to make this decision for their loved one.
drsclafani wrote:thirdly, the dural sinus anatomy ifs highly variable and i am not sure what exactly is pathological.

my group of neuroradiologists at the hospital will soon begin a retrospective analysis of the deep cerebral veins on cta performed for stroke in non MS stroke patients. more than jugular vein anatomay, dural sinus anatomy is quite variable.

Has this not been done before? It will be good to see what is within the range of normal if it helps to answer the question of what is pathological.

If a person has one jugular obstruction and one dural sinus obstruction, would that qualify as the two obstuctions necessary for CCSVI?
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Postby Cece » Mon Dec 27, 2010 6:16 pm

Another question 8)
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?

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.
...

Is a rendezvous procedure uncommon? Is it something most IRs have done for other conditions? I haven't heard about it in CCSVI before this. Also is what you said about sonolucency and compressibility common knowledge to IRs, so that anyone going in with suspected thrombosis after CCSVI treatment woud have this looked at in this way?
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Postby drsclafani » Mon Dec 27, 2010 6:23 pm

cece wrote:
DrSclafani wrote:my group of neuroradiologists at the hospital will soon begin a retrospective analysis of the deep cerebral veins on cta performed for stroke in non MS stroke patients. more than jugular vein anatomay, dural sinus anatomy is quite variable.

Has this not been done before? It will be good to see what is within the range of normal if it helps to answer the question of what is pathological.

If a person has one jugular obstruction and one dural sinus obstruction, would that qualify as the two obstuctions necessary for CCSVI?


Yes, it has. one of my neurointerventionalists has studied this question and he believes that the variation among normal is so great. This study will use existing CTangiograms and retrospectively review them . An exercise for my trainees; might help us here.

fundamentally i cant tell what is abnormal because of the variability. This type of retrospective analysis always has value in a teaching environment.

we better be damn sure before we much around up there
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Postby mo_en » Tue Dec 28, 2010 2:58 am

A question about valves again:
In what way is a valvular ring (anywhere in the body) distensible? Do leaflets have the necessary excess length so as to remain functional within an increased truncular diameter? Or is an insufficiency of a certain degree acceptable, provided that it doesn't last long?
Since valves, generally, operate as reflux guards, would it be logical to assume that the passage they guard has a fixed throughput?
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Postby drsclafani » Tue Dec 28, 2010 9:30 am

Cece wrote:Another question 8)
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?

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.
...

Is a rendezvous procedure uncommon? Is it something most IRs have done for other conditions? I haven't heard about it in CCSVI before this. Also is what you said about sonolucency and compressibility common knowledge to IRs, so that anyone going in with suspected thrombosis after CCSVI treatment woud have this looked at in this way?


rendevous is used when we cannot get a catheter from one side of an obstructionto another. It is used across ureteric obstructions, blocked bile ducts, arterial transections, venous problems of access such as this

and you thought IRs only did CCSVI!

Obviously I cannot promise that every IR will think of this when its time. Often rendevous comes at the end of a very long frustrating procedure that is not going very well. it is human to lose this trick in the presence of this much frustration. Often, it is done at a second procedure after the first fails.

i just hate to give up
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Postby drsclafani » Tue Dec 28, 2010 12:45 pm

mo_en wrote:A question about valves again:
In what way is a valvular ring (anywhere in the body) distensible? Do leaflets have the necessary excess length so as to remain functional within an increased truncular diameter? Or is an insufficiency of a certain degree acceptable, provided that it doesn't last long?
Since valves, generally, operate as reflux guards, would it be logical to assume that the passage they guard has a fixed throughput?


this is still a work in progress, and i have not vetted this by anyone yet, but IVUS is informative to me.

Image

This image shows IVUS interrogating three areas of the right jugular vein (IVUS images on the left corresponding to the normal areas of the vein (red arrows). In the J1 segment, one notes on venography a narrowing. The ivus shows the valve edges as bright signals (yellow curved arrows). One can see that the valve is the problem.

It is not that it is opening normally; on the contrary, it is failing to open normally and has created a funnel that restricts flow into the inominate vein.

The goal of treatment is not to stretch a normal annulus, but to tear the annulus and disrupt the funnel effect.

In this case i used high pressure large 18 mm balloons to disrupt the annulus and to tear the funnel apart. As you can see from the post procedure image, flow is excellent and the diameter is now normal

Image
Last edited by drsclafani on Tue Dec 28, 2010 12:48 pm, edited 1 time in total.
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Re: posted on behalf of Dr. Sclafani

Postby Cece » Tue Dec 28, 2010 12:48 pm

drsclafani wrote:i just hate to give up

y'know, I've noticed that :)

Johnson wrote:Composite of intra-venous ultrasound showing false narrowing

Image
Dr. Sclafani wrote:I think these images will clarify to the group that the upper narrowings don't indicate need for venoplasty or stents



*posted on behalf of Dr. Sclafani

Knowing now that your patients last spring were likely underdilated, when we look again at the last image in this series (posted back in April), is there any indication in the blood flow that it has been underdilated?
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Re: posted on behalf of Dr. Sclafani

Postby drsclafani » Tue Dec 28, 2010 12:53 pm

Cece wrote:
drsclafani wrote:i just hate to give up

y'know, I've noticed that :)

Johnson wrote:Composite of intra-venous ultrasound showing false narrowing

Image
Dr. Sclafani wrote:I think these images will clarify to the group that the upper narrowings don't indicate need for venoplasty or stents



*posted on behalf of Dr. Sclafani

Knowing now that your patients last spring were likely underdilated, when we look again at the last image in this series (posted back in April), is there any indication in the blood flow that it has been underdilated?


Looks pretty good to me where i dilated it. But i now worry more about the long narrowing at J2 and J3. I fear that i have underestimated hypoplasias higher in the vessel.

I think that the balloon can stretch the narrowings so that it looks good immediately. It is within a short time of weeks to months that the narrowing re-establishes itself.

Geez, i like transparency, but feel kind of naked when i realize that everything i have ever written can end up biting me in my bare ass.
Last edited by drsclafani on Tue Dec 28, 2010 3:12 pm, edited 1 time in total.
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Re: posted on behalf of Dr. Sclafani

Postby drsclafani » Tue Dec 28, 2010 1:00 pm

drsclafani wrote:
Cece wrote:
drsclafani wrote:i just hate to give up

y'know, I've noticed that :)

Johnson wrote:Composite of intra-venous ultrasound showing false narrowing

Image


*posted on behalf of Dr. Sclafani

Knowing now that your patients last spring were likely underdilated, when we look again at the last image in this series (posted back in April), is there any indication in the blood flow that it has been underdilated?


Cece, look at this case i just posted above.
if you look at the balloon dilatation see how much the stenosis dilates before it is completely disrupted. one can imagine that that stretch would look pretty good at first look.

Image
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Re: posted on behalf of Dr. Sclafani

Postby Cece » Tue Dec 28, 2010 1:17 pm

drsclafani wrote:Cece, look at this case i just posted above.
if you look at the balloon dilatation see how much the stenosis dilates before it is completely disrupted. one can imagine that that stretch would look pretty good at first look.

Thanks, it does look very stretched. I think I'm trying to see how easy it is for docs still on the learning curve to think it's been treated when it is not fully done.

Even being able to look at the images from April, which I never meant to embarrass you by reposting, my uneducated opinion was that it looked like good blood flow. It would've been better if there'd been something to see, then the docs would know to go further.

But the "something to see" is clearly the waisting, during the inflation itself.
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Re: posted on behalf of Dr. Sclafani

Postby drsclafani » Tue Dec 28, 2010 2:34 pm

Cece wrote:
drsclafani wrote:Cece, look at this case i just posted above.
if you look at the balloon dilatation see how much the stenosis dilates before it is completely disrupted. one can imagine that that stretch would look pretty good at first look.

Thanks, it does look very stretched. I think I'm trying to see how easy it is for docs still on the learning curve to think it's been treated when it is not fully done.

Even being able to look at the images from April, which I never meant to embarrass you by reposting, my uneducated opinion was that it looked like good blood flow. It would've been better if there'd been something to see, then the docs would know to go further.

But the "something to see" is clearly the waisting, during the inflation itself.


cece
if you undersized this balloon, you might not see the waisting.
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Postby NZer1 » Tue Dec 28, 2010 4:40 pm

Hi Dr., is it possible that you may need to dilate with large balloons the entire vein to high light where there is waists? It seems that with hindsight the restrictions can be multiple and that now you are using the larger balloons you are 'seeing' more areas that need attention.
Hope you had some time out at Xmas.
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Postby drsclafani » Tue Dec 28, 2010 9:51 pm

NZer1 wrote:Hi Dr., is it possible that you may need to dilate with large balloons the entire vein to high light where there is waists? It seems that with hindsight the restrictions can be multiple and that now you are using the larger balloons you are 'seeing' more areas that need attention.
Hope you had some time out at Xmas.

yes

it is quite possible and some have done this. I do not think there is an ideal balloon for this test, which some have mockingly called braile angiography. no comment

these h igh pressure ballons are not idea because they stretch athe vein and we want to have the balloon indented without stretching the vein. That is called a compliant balloon.....i just havent found one that fits the bill
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Postby CD » Tue Dec 28, 2010 11:02 pm

Hi Dr Sclafani, two questions if you don't mind please. I'm late night thinking.

1. I had the CCSVI procedure Dec 11, 2010. Because of stents I am on Warfarin. My INR is 2.7 which is good I believe, but my RBC has increased from 3.4 barely normal, to the middle of the reference range lab chart, as of last week's testing. I go again tomorrow for my next weekly test.

I was always just one point above the normal reference range for years. Now I am higher, middle level. My question is does the Iron disposition, in the brain around lesions, now drain down to be part of the total RBC? Is this possible that iron may now be added to the total blood volume for a short time? Or does it exit via the kidneys?

2. In my left jugular, I had many thick webs, and a large tissue flap. What is a flap?
Thank you.
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ISNVD meeting in March

Postby SickButHappy2 » Wed Dec 29, 2010 5:11 am

Hello there ;)

I saw on the web page of the conference: http://www.isnvdannualmeeting.org/
that it states "satellite courses"....

Wouldn't that be a good way to get local IR interested & involved without actually be there? Is this the purpose?
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