Brainteaser wrote:Thank you Dr Sclafani and Cece regarding your responses concerning restenosis. If I understand the situation clearly, problems can be addressed, in a nutshell as follows -
a. elastic recoil - by using larger balloons and longer balloon times
conjecture, no evidence yet
b. thrombosis/clotting - by 3 weeks of arixtra, post angioplasty
extrapolated from data from other indications and used in CCSVI. Fondaparinux has no increase in risk, better anticoagulation, longer half life, better safety profile, but is more expensive and not universally available and not well known by many physicians.
c. intimal hyperplasia - by monitoring and perhaps using cryoplasty, but also drug eluting stents are starting to be used.
Almost all the evidence for intimal hyperplasia both clinical and experimental is from vein to artery grafts where pressure differentials and high flow lead to intimal hyperplasia. There is little written about pure vein intimal hyperplasia. Angioplasty alone of Budd Chiari venous stenosis has mid term and long term patency. vein to vein anastomoses in liver transplants may have stenosis from a different cause.
Also venous stenosis from intimal hyperplasia should occur later than we are seeing restenosis after ccsvi angioplasty. Thus, i am unclear about the role of intimal hyperplasia right now and have not added antiplatelet drugs such as aspirin or clopidogrel (plavix) to my post procedure regimen
But i am surely no expert in all of this.
Am I correct in assuming that a. and b. can be better managed than c? Intimal hyperplasia seems very problematic and is likely to show up several months after CCSVI treatment and hence the need for an active aftercare program. Some docs are not using larger balloons in order to reduce the risk of intimal hyperplasia at the expense of better short term results.
big assumptions. we dont have these answers yet.
Arixtra can't be used with aspirin and therefore seems to be a better option than aspirin.
This is not accurate. It can be used with aspirin. Pharmacological studies have shown that the antiplatelet effects of aspirin and the anti-thrombin activities of fondaparinux are not altered by simultaneous use.
Fondaparinux should not be used by patients who:
weigh less than 110 pounds (50 kilograms); have kidney disease; have active bleeding; have a low level of platelets in the blood; or have bacterial endocarditis (infection of the heart).
Fondaparinux may be risky in patients with high blood pressure; a bleeding or blood clotting disorder; a prosthetic heart valve; need to have (or have recently had) surgery or another invasive procedure; stomach bleeding or ulcers; eye problems due to diabetes; a history of a low level of platelets in the blood during treatment with heparin; or liver disease.
Individual judgments must be made in such circumstances.
Is this all about right in terms of the current state of play?
The game is still on