DrSclafani answers some questions

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

Postby drsclafani » Thu Mar 03, 2011 8:01 am

Cece wrote:That's an interesting question. If a hypoplastic vein can be matured, why not a regular vein, even if it wasn't originally the IJV?


we havent shown that we can mature a hypoplastic vein. It is just theoretical. So far, it hasnt worked :cry:
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Postby DrCumming » Thu Mar 03, 2011 8:06 am

drsclafani wrote:
Cece wrote:That's an interesting question. If a hypoplastic vein can be matured, why not a regular vein, even if it wasn't originally the IJV?


we havent shown that we can mature a hypoplastic vein. It is just theoretical. So far, it hasnt worked :cry:


My experience as well. In fact, trying may be making things worse.
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Postby drsclafani » Thu Mar 03, 2011 8:07 am

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Perhaps this is a question for sonographers, but anyway, I shall ask:

Supposing a patient has only azygos (or hemiazygos) stenosis/membranes/etc, what is the sonographic evidence that an ultrasound examination may provide? Can these people be erroneously diagnosed as "healthy"?
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CCSVI ultrasound is not really simply an evaluation of the veins that are interrogated. It is a global view of the hemodynamic status of the cerebrospinal drainage. So if the azygous vein is obstructed, alternate pathways are necessary. Some of those include the vertebral venous plexus, so we might see reversal of flow in the vertebral venous system.
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Postby newlywed4ever » Thu Mar 03, 2011 8:13 am

drsclafani wrote:
newlywed4ever wrote:Since I have a LIJV that is occluded due to 1) scar tissue, 2) blood clot or 3) first angio was not actually in the IJV, I am wondering... does it make any sense to balloon maybe one of the larger collaterals if the IJV can't be treated?


if they are stenotic, it might make sense to improve the collateral veins. this is the reason for looking for the may thurner syndrome as an alternative pathway for drainage in the presence of azygous stenosis.

IT might make sense to look at your vertebral veins the next time you undergo venography.

But remember that the vertebral veins are small and vulnerable. the external jugular veins may also be collaterals but there are so many of them it would be quite challenging to figure this out.


I like your comment "next time" - we're going to have a long-term relationship, doc! Which is OK with me...just need to win the lottery :D
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Postby Cece » Thu Mar 03, 2011 10:01 am

drsclafani wrote:
Cece wrote:That's an interesting question. If a hypoplastic vein can be matured, why not a regular vein, even if it wasn't originally the IJV?


we havent shown that we can mature a hypoplastic vein. It is just theoretical. So far, it hasnt worked :cry:

I am really sorry to read that. I don't think you've had a chance yet with a patient who is local and can have a hypoplastic vein repeatedly treated, a little at a time? It's always been attempted all at once, in a single procedure? Dang it, though...there are a lot of patients with hypoplasia.

Have you seen any patients yet with hypoplasia in both jugulars? If a patient presents with hypoplasia on one side, is that a reason to be more cautious with the jugular on the other side (because it's essentially the only one and more is at stake if it is lost or damaged) or more aggressive (because if it's the only one, it needs to be open)?

DrCumming wrote:My experience as well. In fact, trying may be making things worse.

It really is depressing, I want these ideas to work out, and it seems like it should in theory. But trying could be making it worse.... Dr. Cumming, have you seen these hypoplastic veins? Was it CCSVI jugulars or prior experience with veins elsewhere in the body? Have you seen any that were treated elsewhere?

We've seen some good images immediately post-procedure, of hypoplastic veins that have increased in size. But what happens then? Clotting, possibly due to poor flow or extensive intimal damage. Could that be met with higher doses of blood thinners? If the vein does not clot but shrinks, could it be looked at with tissue characterization on ivus to see if it is in fact intimal hyperplasia is the problem?
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Postby sou » Thu Mar 03, 2011 10:30 am

drsclafani wrote:
sou wrote:Supposing a patient has only azygos (or hemiazygos) stenosis/membranes/etc, what is the sonographic evidence that an ultrasound examination may provide? Can these people be erroneously diagnosed as "healthy"?


CCSVI ultrasound is not really simply an evaluation of the veins that are interrogated. It is a global view of the hemodynamic status of the cerebrospinal drainage. So if the azygous vein is obstructed, alternate pathways are necessary. Some of those include the vertebral venous plexus, so we might see reversal of flow in the vertebral venous system.


This is completely understood. As far as I have read, the vertebral plexus'es flow evaluation is not part of the standard CCSVI diagnostic procedure. Of course, it could be evaluated through scanning the flow of the deep cerebral veins, but what about people having no sonographic window on their skull and these veins can not be scanned? Can the flow of the vertebral or the internal jugular veins reveal any information or an interventional venography is mandatory, in that case?
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Postby drsclafani » Thu Mar 03, 2011 12:08 pm

sou wrote:
drsclafani wrote:
sou wrote:Supposing a patient has only azygos (or hemiazygos) stenosis/membranes/etc, what is the sonographic evidence that an ultrasound examination may provide? Can these people be erroneously diagnosed as "healthy"?


CCSVI ultrasound is not really simply an evaluation of the veins that are interrogated. It is a global view of the hemodynamic status of the cerebrospinal drainage. So if the azygous vein is obstructed, alternate pathways are necessary. Some of those include the vertebral venous plexus, so we might see reversal of flow in the vertebral venous system.


This is completely understood. As far as I have read, the vertebral plexus'es flow evaluation is not part of the standard CCSVI diagnostic procedure. Of course, it could be evaluated through scanning the flow of the deep cerebral veins, but what about people having no sonographic window on their skull and these veins can not be scanned? Can the flow of the vertebral or the internal jugular veins reveal any information or an interventional venography is mandatory, in that case?


no, the vertebral flow is part of the fluid space and hemodynamics reflect derangements of the azygous vein. The ultrasound exam does interrogate the vertebral veins, in addition to the jugular and deep cerebral veins. . It is all one system
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Postby drsclafani » Thu Mar 03, 2011 12:11 pm

Cece wrote:
drsclafani wrote:
Cece wrote:That's an interesting question. If a hypoplastic vein can be matured, why not a regular vein, even if it wasn't originally the IJV?


we havent shown that we can mature a hypoplastic vein. It is just theoretical. So far, it hasnt worked :cry:

I am really sorry to read that. I don't think you've had a chance yet with a patient who is local and can have a hypoplastic vein repeatedly treated, a little at a time? It's always been attempted all at once, in a single procedure? Dang it, though...there are a lot of patients with hypoplasia.

Have you seen any patients yet with hypoplasia in both jugulars? If a patient presents with hypoplasia on one side, is that a reason to be more cautious with the jugular on the other side (because it's essentially the only one and more is at stake if it is lost or damaged) or more aggressive (because if it's the only one, it needs to be open)?

DrCumming wrote:My experience as well. In fact, trying may be making things worse.

It really is depressing, I want these ideas to work out, and it seems like it should in theory. But trying could be making it worse.... Dr. Cumming, have you seen these hypoplastic veins? Was it CCSVI jugulars or prior experience with veins elsewhere in the body? Have you seen any that were treated elsewhere?

We've seen some good images immediately post-procedure, of hypoplastic veins that have increased in size. But what happens then? Clotting, possibly due to poor flow or extensive intimal damage. Could that be met with higher doses of blood thinners? If the vein does not clot but shrinks, could it be looked at with tissue characterization on ivus to see if it is in fact intimal hyperplasia is the problem?


later
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Postby NZer1 » Thu Mar 03, 2011 12:50 pm

Has there been any talk in the industry of stents that are coated to prevent clotting, or dissolving stents?
Removable stents?
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Postby drsclafani » Fri Mar 04, 2011 4:53 am

Cece wrote:
drsclafani wrote:
Cece wrote:That's an interesting question. If a hypoplastic vein can be matured, why not a regular vein, even if it wasn't originally the IJV?


we havent shown that we can mature a hypoplastic vein. It is just theoretical. So far, it hasnt worked :cry:

Have you seen any patients yet with hypoplasia in both jugulars? If a patient presents with hypoplasia on one side, is that a reason to be more cautious with the jugular on the other side (because it's essentially the only one and more is at stake if it is lost or damaged) or more aggressive (because if it's the only one, it needs to be open)?


I should always be cautious with any vein. I treat them all with respect.
i have been aggressive with angioplasty of the hypoplastic vein because they are not worth much in the state they start from. The collaterals are usually larger. I have not seen hypoplastic veins on both sides in one patient. I would expect to see tremendous collaterals. The "S" word comes to mind.
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Postby drsclafani » Fri Mar 04, 2011 4:57 am


We've seen some good images immediately post-procedure, of hypoplastic veins that have increased in size. But what happens then? Clotting, possibly due to poor flow or extensive intimal damage. Could that be met with higher doses of blood thinners? If the vein does not clot but shrinks, could it be looked at with tissue characterization on ivus to see if it is in fact intimal hyperplasia is the problem?


They clot. In some, the hypoplasia extends higher than the balloon can go. So even when the vein is successfully dilated, the slow and meager flow from above is insufficient to maintain patency of the vein.

I dont think higher doses of anticoagulation will help. Perhaps long term anticoagulation would be more effective.

I think sometimes what happens is that we stretch beyond tolerance and the entire vein just "unzips". having no longer any wall strength, the thing just collapses and clots.
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Postby Cece » Fri Mar 04, 2011 8:36 am

drsclafani wrote:They clot. In some, the hypoplasia extends higher than the balloon can go. So even when the vein is successfully dilated, the slow and meager flow from above is insufficient to maintain patency of the vein.

I can't think of anything that can be done about that. I suppose get an interventional neuroradiologist involved to balloon the upper areas, but only if they thought it were safe and worth risking, which it doesn't seem to be.
I dont think higher doses of anticoagulation will help. Perhaps long term anticoagulation would be more effective.

If you're seeing clotting in the short-term, there really isn't any long-term for these veins....
I think sometimes what happens is that we stretch beyond tolerance and the entire vein just "unzips". having no longer any wall strength, the thing just collapses and clots.

That is awful.

How would you determine what is within tolerance and what is beyond tolerance? These hypoplastic veins could still be stretched a little, for a mm gain or two?
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Postby drsclafani » Fri Mar 04, 2011 5:47 pm

Cece wrote:
drsclafani wrote:They clot. In some, the hypoplasia extends higher than the balloon can go. So even when the vein is successfully dilated, the slow and meager flow from above is insufficient to maintain patency of the vein.

I can't think of anything that can be done about that. I suppose get an interventional neuroradiologist involved to balloon the upper areas, but only if they thought it were safe and worth risking, which it doesn't seem to be.
I dont think higher doses of anticoagulation will help. Perhaps long term anticoagulation would be more effective.

If you're seeing clotting in the short-term, there really isn't any long-term for these veins....
I think sometimes what happens is that we stretch beyond tolerance and the entire vein just "unzips". having no longer any wall strength, the thing just collapses and clots.

That is awful.

How would you determine what is within tolerance and what is beyond tolerance? These hypoplastic veins could still be stretched a little, for a mm gain or two?


i hate to admit it, but i would say trial, and error and experience
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hypo

Postby hwebb » Sat Mar 05, 2011 3:18 pm

there is a patient here in melbourne who has a hypoplastic left and right jugular. She gets benefit when treated, but it doesn't last. Surely someone in this state could benefit from stenting - risky yes...but the risk (to life) if left unattended is extreme.

Dr S - if you met her you'd want to help her. Doctors here have walked away from her case. I'm operating on the assumption that some medical treatment may be better than none for a patient in such a dire situation.
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Postby 1eye » Sat Mar 05, 2011 6:25 pm

What about that exoskeletal stent-tube idea? It would support the vein instead of pushing it outwards.
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