DrSclafani answers some questions

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

Postby David1949 » Wed Dec 29, 2010 3:10 pm

Dr. Sclafani
Do jugular veins need internal pressure to keep them open? Would they collapse like a fire hose without internal pressure?
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Postby drsclafani » Thu Dec 30, 2010 12:50 am

CD wrote: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.


so sorry you had stents placed. Do you know why there were put in? I wish you the best.

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?

no, i dont think that would be an explanation. Most plausible is simple dehydration resulting in concentration of your blood.

2. In my left jugular, I had many thick webs, and a large tissue flap. What is a flap?

this is not a term that we use as one of the findings of ccsvi. flap is often used to describe a piece of the wall of the blood vessel that gets unroofed. it can be flow limiting.especially if the flap is attached distally to flow, in which circumstances flow tends to push the flap down into the flow of blood. perhaps that is why a stent was used. I find that it is usually possible to press a flap back into the wall and avoid a stent
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Re: ISNVD meeting in March

Postby drsclafani » Thu Dec 30, 2010 12:51 am

SickButHappy2 wrote: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?


i am not sure. it could be that they will satellite components of the meeting INTO the conference hall
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Postby drsclafani » Thu Dec 30, 2010 12:52 am

David1949 wrote:Dr. Sclafani
Do jugular veins need internal pressure to keep them open? Would they collapse like a fire hose without internal pressure?


they need a little pressure to drive forward but going toward the heart not much pressure is necessary. More to the point they need volume. if there isnt liquid going through they collapse
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MRV is quite useful

Postby hwebb » Thu Dec 30, 2010 2:17 am

Hi Dr S,

just wanted to contribute an MRV picture to the forum. I have a similar jugular scenario to your 61 year old - a hypoplasmic left jugular and normal sized right jugular with suspicious looking valve (I also had an obstructed azygos, which was fixed early on). Just wanted to point out that when you look front on at this right vein...you can see a "ghost" stenosis (not real...puffs out when I breath in a certain way). Also, the valve looks a bit swollen front on, but when you look at the axial view in the MRV - it is very obviously severely pinched:

[img][img]http://farm6.static.flickr.com/5290/5306137152_f77489fe48.jpg[/img]
axial jugular image by anatomical, on Flickr[/img]

This was missed during an early venogram, but picked up recently after scrutinizing the MRV. The valve was treated, and the symptoms on the right side of my body receded.
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Postby SickButHappy2 » Thu Dec 30, 2010 6:44 am

Caught that on FB
"I saw one mexican clinic advertising that they use the anti-restenosis drug impregnated balloons. maybe that is what they mean. Dr Ponec in San Diego said he is going to be a beta test site for those balloons soon. They are not yet FDA approved, but are approved and used in Europe.

Dr Ponec also speculated that future stents for CCSVI might be drug impregnated and dissolvable. but this is just a concept now, not yet made."

Heard anything about that?
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Postby Cece » Thu Dec 30, 2010 9:48 am

SickButHappy2 wrote:Caught that on FB
"I saw one mexican clinic advertising that they use the anti-restenosis drug impregnated balloons. maybe that is what they mean. Dr Ponec in San Diego said he is going to be a beta test site for those balloons soon. They are not yet FDA approved, but are approved and used in Europe.

some more information on this in this thread: http://www.thisisms.com/ftopict-15080.html
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.
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Postby elliberato » Thu Dec 30, 2010 10:15 am

Dr S
curious in these various cases you are posting if you have seen any dramatic positive results??Or any results at all including changes in function??
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Postby drsclafani » Thu Dec 30, 2010 11:03 am

elliberato wrote:Dr S
curious in these various cases you are posting if you have seen any dramatic positive results??Or any results at all including changes in function??


I dont want to get into dramatics. I think the changes depend upon where you are coming from and the dramatics depend on your point of view.

If you cant breathe, then a little less spasm in your intercostal muscles is pretty dramatic.
if you choke on your food and can swallow just a bit btter, that is pretty dramatic

But that is philosophy....

and the answer to your question is yes, i have seen impressive positive results.

But also some not so impressive results.

i am still trying to get my hands around this...Speak to me after three hundred procedures and six months followup, once i figure out the best way to do the procedure technically.
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Postby Cece » Thu Dec 30, 2010 12:21 pm

When you mentioned many disappointments, back in your healthy skepticism post, I have kept that in mind, how emotionally charged and hopeful we all are going into this and, with a doctor who cares, how the disappointments must affect you too.

You'll get to 300 before the end of 2011, won't you? I am looking forward to all of it.
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Postby drsclafani » Thu Dec 30, 2010 8:13 pm

Cece wrote:When you mentioned many disappointments, back in your healthy skepticism post, I have kept that in mind, how emotionally charged and hopeful we all are going into this and, with a doctor who cares, how the disappointments must affect you too.

You'll get to 300 before the end of 2011, won't you? I am looking forward to all of it.

Said quite truly cece

each disappointment pains me

all the more after reading the testimonials to the question i asked.
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Re: MRV is quite useful

Postby drsclafani » Thu Dec 30, 2010 8:18 pm

hwebb wrote:Hi Dr S,

just wanted to contribute an MRV picture to the forum. I have a similar jugular scenario to your 61 year old - a hypoplasmic left jugular and normal sized right jugular with suspicious looking valve (I also had an obstructed azygos, which was fixed early on). Just wanted to point out that when you look front on at this right vein...you can see a "ghost" stenosis (not real...puffs out when I breath in a certain way). Also, the valve looks a bit swollen front on, but when you look at the axial view in the MRV - it is very obviously severely pinched:

[img][img]http://farm6.static.flickr.com/5290/5306137152_f77489fe48.jpg[/img]
axial jugular image by anatomical, on Flickr[/img]

This was missed during an early venogram, but picked up recently after scrutinizing the MRV. The valve was treated, and the symptoms on the right side of my body receded.


thanks. I appreciate someone else sharing images with the group. it is so hard for me to comprehend how the MRvenogram could be more definitive for a valvular problem than a catheter venogram. Can you post a venogram view? only then can we really decide if the MRV was necessary.
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thanks for comment :)

Postby hwebb » Fri Dec 31, 2010 4:12 am

yes Dr S,
I will post the images from my recent venogram when I get hold of them (I was treated just before x-mas...and it may be hard to get a copy of the images for a week...silly season).

During the earlier venogram inspection - an image was not taken of the right jugular as it was deemed to look OK. I did see the images on the screen during the earlier venogram though...and the "ghost stenosis" area visible in the MRV mid-vein was not present during the venogram (and the doctor even stood me upright and rotated me around to get different beam angles). I had increasing symptoms on the right side of my body...so was convinced there was some subtle obstruction there. I thought perhaps the wire was keeping a veinous flap open or something during the actual venogram - maybe that's why it was missed. I'm yet to get a copy of my IR's latest report, to read what the problem actually was. I felt him balloon in two parts of the right vein when he treated me though. Will post more info when I have it :)

Helen
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Postby hope410 » Fri Dec 31, 2010 4:35 am

Cece wrote:When you mentioned many disappointments, back in your healthy skepticism post, I have kept that in mind, how emotionally charged and hopeful we all are going into this and, with a doctor who cares, how the disappointments must affect you too.



I imagine a lack of significant results, particularly if the restenosis rate remains high and complications or difficult cases continue to present themselves that frustrate, confound and take up extra time, this may affect IR's willingness or interest in even getting or continuing to be involved and practicing in this particular area? It may not seem worth the risks and headaches for many doctors.

That is a concern of mine. I heard that a neuro up here in Canada said that his discussions with vascular surgeons here indicated that they weren't particularly interested in this new area. I fear that if success isn't evident and repeats and complications are high, the interest from even our strongest vascular specialist supporters will wane as well. If continuing patient demand or disappointment, especially from already treated patients, becomes too much given what doctors feel they can realistically deliver or do to help, I hope we don't see doctors dropping out and less taking it up. I worry about that.
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Postby drsclafani » Fri Dec 31, 2010 7:52 am

hope410 wrote:
Cece wrote:When you mentioned many disappointments, back in your healthy skepticism post, I have kept that in mind, how emotionally charged and hopeful we all are going into this and, with a doctor who cares, how the disappointments must affect you too.



I imagine a lack of significant results, particularly if the restenosis rate remains high and complications or difficult cases continue to present themselves that frustrate, confound and take up extra time, this may affect IR's willingness or interest in even getting or continuing to be involved and practicing in this particular area? It may not seem worth the risks and headaches for many doctors.

That is a concern of mine. I heard that a neuro up here in Canada said that his discussions with vascular surgeons here indicated that they weren't particularly interested in this new area. I fear that if success isn't evident and repeats and complications are high, the interest from even our strongest vascular specialist supporters will wane as well. If continuing patient demand or disappointment, especially from already treated patients, becomes too much given what doctors feel they can realistically deliver or do to help, I hope we don't see doctors dropping out and less taking it up. I worry about that.


There are vascular doctors who practice endovascular techniques, there are vascular doctors who treat with medications, there are vascular doctors who treat with surgery.

our focus must be firstly on those doctors who are dedicated to angioplasty for at the moment it seems like the best alternative for this anatomic disease.Surgery may have a role, but not the predominant one.

So its the interventionalists who treat veins that are our focus. They are largely interventional radiologists and they will grow in number. it is what they do most of the time.
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