This Is MS Multiple Sclerosis Community: Knowledge & Support

This question seems to be coming up frequently.

what are the reasons to have a second procedure?
1. incomplete study
2. equivocal findings
3. missed diagnoses
4. fleeting improvements
5. recurrent symptoms
6. suspicion of thrombosis
7. recurrent CCSVI ultrasound findings?
8. a simple desire to have a second look
9. a mistrust of the first operator
10. feeling worse after the procedure.

if anyone has other ideas, please share them here so we can start to look at why second procedures are done.

I would think, (my conjecture) that reflux would be common after angioplasty because the valves are opened by angioplasty. Perhaps reflux can come from the heart toward the brain by an incompetent valve?
can valve thickening be caused by balloon angiopastly?

The questions about the ultrasound screening are intriguing to me. I intend to ask quite a few questions during the consensus panel discussions on ultrasound at the ISNVD meeting on March 13-15 in Ferrara Italy. they will focus upon the value and interpretation of the postprocedural ultrasound.

i think that it is likely that you were incompletely dilated or had a lot of elastic recoil. i think second or even third treatments m ay be beneifical.

i have started to consider whether second venograms and possible an;gioplasties should be done sooner than later as a routine

Dear Dr. Sclafani,

Unfortunately I fall under "6" as I have a blood clot in my stent in the jugular.

What would your approach be towards the blood clot? Would you try to take it out or do clots fall into the "don't poke the mama bear" category?

Thanks for the answer.

Do you require an MS diagnosis?

How exciting. We are not there yet but we are getting further. What a gift to have minds like yours and the other investigators at work on this.

I am curious, what percentage of the patients you've been treating are first time patients (no previous ccsvi treatment)?

Dr
for someone new to the idea of ccsvi procedure and declining quickly would you have any advice based on the recent results of your procedures?

Also have you noticed any correlation with the degree of stenosis relative to disability?

thanks

I should say (and with the information that runs on the Internet today is a little hard to brag) that I report up to now very few restenosis. So far I have retreated only a single patient for that. I think the technique used is very important . From the beginning I made a very forceful balloon dilatation using much larger balloons (often two at once) than those used by many other operators, being often able to break the valve at the base of the jugular and that we are becoming increasingly aware this is the main reason for the block of the flow. Dilating the valve without the necessary force allows an increased passage of blood for a limited time. With the regeneration of the valve, the flow tends to return to the same as before, and we tend to define (wrongly?) that restenosis. In my opinion it is simply a sub-optimal dilatation. Once fully open the valve has no chance to recover as fully open in different parts, completely separated from each other. The adoption of this technique has brought me so far (but we definitely need a longer time of observation) to avoid the high number of restenosis observed by other doctors. We need to clarify some other points.
The diagnosis of restenosis is mainly clinical. The patient returns to have the same symptoms than before surgery, then having lost most or all of the benefits. There are ecodopler experts mistaking physiologic reflux (such as those in pre-stenotic dilation that does not disappear even after the effective reopening of the vessel) for disease. Some of my patients without any loss of benefits reported diagnosis of restenosis on Doppler, which turned out later to be non-existent by Doppler performed at my confidence. And I mean Doppler technician running the Doppler on my patients in the angiography suite in contemporary with the angioplasty intervention. This way they can see in real-time with venography at the same time the probe is on the patient's jugular and we are studying, then realizing what is really what they are observing with the echo color Doppler.
Running in the angiography suite the Doppler and the angioplasty at the same time is leading increasingly to identify artifacts and false negative / positive by both methods. There are some parameters that those who have never executed the Doppler in the angiography suite during venography may be very difficult to recognize. So it is true that it is important to adopt a correct surgical technique but it is equally important an experience "in the field" of the Doppler technician. Probably this will reduce the diagnosis of restenosis.
Finally it is important to note that even Dr. Simka reported that some patients may tend to lose some benefits over time despite the jugular being open. Now this could be due to a sort of "addiction" if you will of the benefits at the time of the dilation but may also depend on the fact that the jugular veins were partially closed, and maybe just the Doppler has not been able to assess this small difference. Ultimately they were open but immediately after the intervention they were open even more.
And here we come at a very delicate point, however,it is increasingly finding a solid foundation based on my personal experience. Even jugular with very little stenosis or that appear normal once dilatated seem to lead to benefits for the symptoms of the disease in the patient.I have few reported cases in which the patient seemed completely normal to flow venography but after forced dilatation of the jugular some benefits have appeared (sometimes important). It 's like a jugular expanded even more, even if of normal diameter, however, could lead to increase in flow inside, resulting in improvements. This would mean that CCSVI is present in virtually all MS patients (and not only that, I treated CCSVI successfully in cases of ALS, polymyalgia rheumatica, autoimmune polyneuropathy, etc.)
and that the data of patients without the famous five to the Zamboni Doppler parameters could not mean that the patient does not respond to dilatation (indeed, sometimes in these patients we have seen very good responses). There is only one patient in whom I have not found CCSVI and it so happens (it will be a coincidence?) that he did not show any symptoms characteristic of CCSVI.
I conclude that some patients in spite of everything, fortunately a minority, have little or no improvement from angioplasty. And this is probably now the problem more difficult to interpret.
When we have more data with appropriate statistical analysis we will certainly be more precise on several points.

That was a fascinating piece of reading! Apparently he has a forum with a section dedicated to CCSVI. In my browser I was able to ask for a translation to English. There are a number of interesting questions/answers.

http://embolizzazione.forumup.it/forum- ... zione.html

Great find!

From the beginning I made a very forceful balloon dilatation using much larger balloons (often two at once) than those used by many other operators, being often able to break the valve at the base of the jugular and that we are becoming increasingly aware this is the main reason for the block of the flow.

Performing doppler during venoplasty is brilliant. It's even more fusion than the fusion (doppler+MRI) that I think is what Dr. Zamboni has been discussing, at ISET and upcoming at ISNVD. Dr. Cumming discussed on-table ultrasound in the doctors' thread, I'd have to check back to see what was said. If as this Italian doctor seems to be saying, it is not to benefit the patient on the table but to improve the ability of those doing the doppler to benefit all future patients, this would add some radiation time to the patient on the table at no gain. But, still, brilliant.

The other point that I have not seen mentioned before is that he performs doppler during angiography and that helps with artifact and false positive /negative of both procedures.
.

He mention "both procedure" so I think he means that there is an advantage also on the venography side possibly to verify the valve has been properly disrupted but maybe IVUS is good for that too.