DrSclafani answers some questions

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

Postby drsclafani » Mon Jan 03, 2011 9:29 pm

Cece wrote:
drsclafani wrote:you can join my residency program

That was nice, thank you.

CCSVIhusband, I think he is interested in generating discussion, so if you can weigh in, I would not hesitate to do so. Or are you familiar with this particular azygous?

Why do the middle two images have diagonal lines across them, while the first and last don't?


misregistration

something we will speak about another time.it has nothing to do with this case
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Re: AXYGOS findings

Postby drsclafani » Mon Jan 03, 2011 9:31 pm

CCSVIhusband wrote:
drsclafani wrote:ok class....

Today we review an azygos vein. This vein, which drains the spinal cord via intercostal veins and lumbar veins, enters the superior vena cava at the top, the renal vein in the middle and the ascending lumbar veins at the bottom.

The findings of malformations are
1. valvular problems of fixation, stiffness and fusion
2. Webs & septations running through the ascending component of the vein
3. twists and kinks

Let's have a look at this:

Image
1. on the left contrast media is injected at the tip of the catheter (red arrow). One notes that there is no dye flowing up toward the superior vena cava.
2. on the second image one sees that there is dye above the area of blockage (red arrows). This is flowing past the obstruction through a large feeding branch. (orange curved arrow)
3. On the third image the narrowed segment is quite obvious. For those readers who are not obvious and have real moral character, the red arrow points to the pointed narrowing.
4. Finally, the last image on the right SHOWS NO NARROWING. What could be the explanation?

Tomorrow we will continue this harrowing adventure.

This is Dr Whiplash, i am out to lunch.



I know, I know!!! I know the answer (so do you want me to answer? - I defer to the expert in this case, you of course Dr. Sclafani) ... I don't want to devalue that education and expertise you've been so kind to bring to this forum by using incorrect terminology.

I just hope you work hard and put some collective brain power together with some of these great doctor colleagues of yours (perhaps your friend who treated it the first time) ... and find a good, permanent "fix" ...

It was a pleasure sir. A true honor.


i am a follower of maimonides, who said, "he who saves a life, saves the whole world"

it is i who am honored to have that opportunity
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don't look too hard

Postby hwebb » Mon Jan 03, 2011 10:17 pm

I'm afraid to show my azygos venogram in case there's a hidden problem/duplicate there too!
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Postby CD » Mon Jan 03, 2011 11:33 pm

drsclafani wrote:
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 don't 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


Thank you Dehydration sounds like the answer to my first question.

Why I had a stent put in? Well..

I had a stent put in because I had a resist narrowing of the distal portion of the LJV at the level of
C-1.

In addition, I also had severe focal stenosis at the base of the LJV, near its confluence with the left subclavian vein, which opened okay.

And a "waist"was seen also in the middle of the vein but eliminated. Looking at it again after doing the RJV an apparent intraluminal flap of tissue was seen, possibly indicative of a dissection. Webs were ballooned also and I had a higher up reflux seen too. (sigh)

Angioplasty was repeated on the LJV and a more apparent intimal flap within the lumen of the distal internal jugular vein, which appeared to be flow limiting on serial imaging. A stent was placed which demonstrated marked improvement and flow, with no visualization of the intraluminal flap of tissue.

RJV had 2 blockages and the arch of the Azygos vein was blocked and two other places lower in the Azygos.

My LJV was a mess of blockages. Plavix did nothing to help. I then had recoil and clots form within three days. US showed no flow. Two more stents were needed to hold open the first stent and break up the clots. I have flow now. 10 shots of Lovenox later, then Warfarin for ??
Sorry you asked?

CD's are unreal. With all this finally behind me, please God, I am finding improvements each day. I have MS 30 years. So I have lots of odd, old junk to clean up. I am healing every day.

I had a lot of work done on me. I am glad I had the CCSVI procedure. I just started my balance, walking and stretching exercises, but in small increments each day.

I'm getting there, one day at a time. I started my LDN again. I stopped it one week before the procedure so I could have conscious sedation and have it work.
CD
Dr. Siskin is my MD


.
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Observation

Postby NormB » Tue Jan 04, 2011 7:40 am

This is in my mind a potential stupid observation or question.

When a vein is ballooned, why can it be not entertained to cook or slightly burn the vein surface at the location instead of using any kind of stents?
I know in this forum stents are discouraged but could'nt burn marks prevent restenosis by leaving solid surface indentation a bit like a cutting balloons would?

Just a random thought.

Regards,

Normb
'92 diag RR - '05 SP
On LDN since Sept. 2012 with better quality of life.
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Re: AXYGOS findings

Postby Cece » Tue Jan 04, 2011 8:00 am

drsclafani wrote:ok class....

Today we review an azygos vein. This vein, which drains the spinal cord via intercostal veins and lumbar veins, enters the superior vena cava at the top, the renal vein in the middle and the ascending lumbar veins at the bottom.

The findings of malformations are
1. valvular problems of fixation, stiffness and fusion
2. Webs & septations running through the ascending component of the vein
3. twists and kinks

Let's have a look at this:

Image
1. on the left contrast media is injected at the tip of the catheter (red arrow). One notes that there is no dye flowing up toward the superior vena cava.
2. on the second image one sees that there is dye above the area of blockage (red arrows). This is flowing past the obstruction through a large feeding branch. (orange curved arrow)
3. On the third image the narrowed segment is quite obvious. For those readers who are not obvious and have real moral character, the red arrow points to the pointed narrowing.
4. Finally, the last image on the right SHOWS NO NARROWING. What could be the explanation?

Tomorrow we will continue this harrowing adventure.

This is Dr Whiplash, i am out to lunch.

Are all the images taken from the same angle? If not, then perhaps the narrowing is hidden when seen from one angle. If they are from the same angle, then it is a dynamic obstruction? You mentioned twists and kinks as #3 up there. What could cause a kink to be dynamic?

here is what I could find on twisted veins in a quick search:
J Vasc Surg. 1989 May;9(5):651-5.

Effect of twist on flow and patency of vein grafts.
Endean ED, DeJong S, Dobrin PB.

Department of Surgery, Loyola University Medical Center, Maywood, Illinois.

Abstract
This article examines the effect of twist on flow through reversed vein segments in vitro and its effect on graft patency in vivo. Excised canine superficial femoral veins were perfused in vitro with normal saline solution or canine blood. Perfusion was carried out at five pressures and against three outflow resistances. Increasing increments of twist were applied to the outflow end of the vein. Flow was measured at each level of twist. With both saline solution and blood, flow was unaltered until twist reached 140 to 180 degrees. Flow then decreased sharply, stopping completely at 175 to 200 degrees of twist. In vivo experiments were then performed in 13 dogs. Reversed superficial femoral veins were used as end-to-end grafts to bypass the iliac arteries. Each graft was deliberately twisted 0, 45, 90, 135, or 200 degrees. All grafts were harvested 6 months after surgery. Eighteen of 20 grafts twisted 135 degrees or less remained patent. However, all five grafts twisted 200 degrees were thrombosed within 4 hours of surgery (p less than 0.05). These data suggest that in patients a slight amount of graft twist probably does not reduce flow;however, more than 135 degrees of twist will greatly reduce flow, leading to early graft thrombosis.
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Re: AXYGOS findings

Postby mo_en » Tue Jan 04, 2011 11:00 am

drsclafani wrote:ok class....

Today we review an azygos vein. This vein, which drains the spinal cord via intercostal veins and lumbar veins, enters the superior vena cava at the top, the renal vein in the middle and the ascending lumbar veins at the bottom.

The findings of malformations are
1. valvular problems of fixation, stiffness and fusion
2. Webs & septations running through the ascending component of the vein
3. twists and kinks

Let's have a look at this:

Image
1. on the left contrast media is injected at the tip of the catheter (red arrow). One notes that there is no dye flowing up toward the superior vena cava.
2. on the second image one sees that there is dye above the area of blockage (red arrows). This is flowing past the obstruction through a large feeding branch. (orange curved arrow)
3. On the third image the narrowed segment is quite obvious. For those readers who are not obvious and have real moral character, the red arrow points to the pointed narrowing.
4. Finally, the last image on the right SHOWS NO NARROWING. What could be the explanation?

Tomorrow we will continue this harrowing adventure.

This is Dr Whiplash, i am out to lunch.


A sci-fi approach: Halfway the yellow arrow of the right-most picture, just beneath the bridge-like structure between the two ascending branches, lies a pseudo-valve with its leaflets reversed, that is allowing only a downward flow.
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Re: AXYGOS findings

Postby THEGREEKFROMTHED » Tue Jan 04, 2011 11:12 am

Today we review an azygos vein. This vein, which drains the spinal cord via intercostal veins and lumbar veins, enters the superior vena cava at the top, the renal vein in the middle and the ascending lumbar veins at the bottom.

The findings of malformations are
1. valvular problems of fixation, stiffness and fusion
2. Webs & septations running through the ascending component of the vein
3. twists and kinks

Let's have a look at this:

Image
1. on the left contrast media is injected at the tip of the catheter (red arrow). One notes that there is no dye flowing up toward the superior vena cava.
2. on the second image one sees that there is dye above the area of blockage (red arrows). This is flowing past the obstruction through a large feeding branch. (orange curved arrow)
3. On the third image the narrowed segment is quite obvious. For those readers who are not obvious and have real moral character, the red arrow points to the pointed narrowing.
4. Finally, the last image on the right SHOWS NO NARROWING. What could be the explanation?

Tomorrow we will continue this harrowing adventure.

This is Dr Whiplash, i am out to lunch.[/quote]


SHIT Sal is this all you got? THis is easy, the last image is some other GUY.
Most likely me! With the malformed valve.
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Re: AXYGOS findings

Postby drsclafani » Tue Jan 04, 2011 6:54 pm

THEGREEKFROMTHED wrote:Today we review an azygos vein. This vein, which drains the spinal cord via intercostal veins and lumbar veins, enters the superior vena cava at the top, the renal vein in the middle and the ascending lumbar veins at the bottom.

The findings of malformations are
1. valvular problems of fixation, stiffness and fusion
2. Webs & septations running through the ascending component of the vein
3. twists and kinks

Let's have a look at this:

Image
1. on the left contrast media is injected at the tip of the catheter (red arrow). One notes that there is no dye flowing up toward the superior vena cava.
2. on the second image one sees that there is dye above the area of blockage (red arrows). This is flowing past the obstruction through a large feeding branch. (orange curved arrow)
3. On the third image the narrowed segment is quite obvious. For those readers who are not obvious and have real moral character, the red arrow points to the pointed narrowing.
4. Finally, the last image on the right SHOWS NO NARROWING. What could be the explanation?

Tomorrow we will continue this harrowing adventure.

This is Dr Whiplash, i am out to lunch.



SHIT Sal is this all you got? THis is easy, the last image is some other GUY.
Most likely me! With the malformed valve.[/quote]

Before the Greek gets completely ouzo'd, lets proceed.
Frankly i was befuddled by this schizoid vein. And i still don't know what exactly is the consequence of this , but suffice it to say that this patient had annular stenoses of both jugular veins that were treated by annuloplasty of 16 mm at 18-25 Atmospheres with pretty good flow after treatment.

So I went to my other tool, the IVUS. it was quite remarkable in detecting and confirming this narrowing and its phasic nature.

Image

Amazingly, when one interrogate the area of narrowing one could see that at end inspiration there was wide distension of the vein. However at expiration one saw marked narrowing of the vein, down to 2 millimeters which is about the size of the catheter. Not the entire vein, just the area of the narrowing!

Why would this happen. My gut tells me this is not a "kink". but this vein surely does not appear to have much in the way of strength when it collapses. How to treat? Good question. I didnt treat, because i didnt really have a clear solution short of something that would keep the vein open. And stents are not ready for prime time in my book.

So we will see what progress this patient makes and hope that it is good. If no effect from a technically good angioplasty of both jugular veins, we may decide to revisit this.

just another example of how much we don't yet know about what constitutes optimum treatment
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Re: AXYGOS findings

Postby Cece » Tue Jan 04, 2011 8:29 pm

drsclafani wrote:Image

I begin to feel that I say this a lot but dang those are excellent images.

Have you consulted with any of the other doctors to see if they've seen something like this before?
Last edited by Cece on Wed Jan 05, 2011 3:58 am, edited 1 time in total.
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Postby cheerleader » Tue Jan 04, 2011 11:41 pm

Hey Dr. S...
Great images!!
wondering if those images were taken with deep inspirations/open mouth. If so, I did some prior research on breathing and jugular hemodynamics (since Jeff's a trumpet player and had muscle compression of jugulars)
Maybe there's something in your patient related to external muscle compression by the omohyoid muscle.
check out this study.
http://baillement.com/echographie.html
best, cheer
Husband dx RRMS 3/07
dx dual jugular vein stenosis (CCSVI) 4/09
http://ccsviinms.blogspot.com
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Re: Observation

Postby drsclafani » Wed Jan 05, 2011 9:01 am

NormB wrote:This is in my mind a potential stupid observation or question.

When a vein is ballooned, why can it be not entertained to cook or slightly burn the vein surface at the location instead of using any kind of stents?
I know in this forum stents are discouraged but could'nt burn marks prevent restenosis by leaving solid surface indentation a bit like a cutting balloons would?

Just a random thought.

Regards,

Normb

normb
actually that much heat would really destroy the vein and leave it likely to thrombose. Freezing has been done to reduce intimal hyperplasia but i think that heat would be destructive.
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Re: AXYGOS findings

Postby Cece » Wed Jan 05, 2011 9:04 am

drsclafani wrote:Frankly i was befuddled by this schizoid vein. And i still don't know what exactly is the consequence of this , but suffice it to say that this patient had annular stenoses of both jugular veins that were treated by annuloplasty of 16 mm at 18-25 Atmospheres with pretty good flow after treatment.

I don't remember you going up to 25 atms before, not that you've mentioned.

hwebb wrote:I'm afraid to show my azygos venogram in case there's a hidden problem/duplicate there too!

But wouldn't that be exceedingly interesting, a patient with two incomplete duplications? :)

Although I personally hope to be a very dull and uninteresting patient, at least when it comes to my veins. Good ol' valve malformations at the usual spot, pop pop, out the door.

Helen, yes, we've seen so few azygous venograms, I can speak for myself at least as a frequent reader that I'd enjoy seeing it.
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Re: AXYGOS findings

Postby drsclafani » Wed Jan 05, 2011 9:04 am

Cece wrote:
drsclafani wrote:Image

I begin to feel that I say this a lot but dang those are excellent images.

Have you consulted with any of the other doctors to see if they've seen something like this before?

about 15 minutes ago, i shared with dr zamboni. he stated that it is common for the vein to change configuration and diameter during the respiratory cycle.
I returned that i agreed. We see it all the time in the jugular vein on surface ultrasound. What was different here was the focality of the collapse. Not a general collapse as much as a focal narrowing.

He said he had no experience with IVUS, but was impressed and was looking forward to using it when he gets one.

I will look more at the dynamics of vein distension and collapse in the azygos from now on.
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Re: AXYGOS findings

Postby Cece » Wed Jan 05, 2011 9:54 am

drsclafani wrote:about 15 minutes ago, i shared with dr zamboni.

How exciting.
Not a general collapse as much as a focal narrowing.

But what could cause that?
He said he had no experience with IVUS, but was impressed and was looking forward to using it when he gets one.

Even last spring, he was saying you should publish on your IVUS findings. In your spare time, I suppose. How long until the AAC registry obtains IRB oversight so that you can publish?
I will look more at the dynamics of vein distension and collapse in the azygos from now on.

It's fascinating stuff. And you haven't seen anything like this in a jugular? Do you think it's specific to the azygous? Could it be related to the azygous webs at all, since those are not seen in the jugulars, or to whatever is different in the embrological formation of the azygous compared to the jugular.
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