DrSclafani answers some questions

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

Postby bestadmom » Fri Apr 01, 2011 6:57 pm

Cece, from what I was told, it was done in lieu of a stent.
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Postby Cece » Fri Apr 01, 2011 7:24 pm

Cryoplasty balloons in addition to mechanical remodeling of the stenotic lesion, reduce the temperature of the surrounding tissue to −10°C resulting in apoptosis of smooth muscle thereby reducing restenosis rates. Some published data show reduction in restenosis by 82% at the end of one year.[21]

www.ncbi.nlm.nih.gov/pmc/articles/PMC2768636/
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Postby David1949 » Sun Apr 03, 2011 2:11 pm

As I understand it, one of the problems with valves is that they are sometimes inverted such that they would cause the blood to flow in the wrong direction. Is it possible to invert a valve back to normal by dragging a balloon through it in the direction of blood flow?
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Postby drsclafani » Sun Apr 03, 2011 8:23 pm

Cece wrote:
Liberation wrote:I tried to put the images of my veins on the page, but somehow only the addresses of them got there :(

I use photobucket, it has a list of choices by the image, one of them is the img code. Clicking it automatically copies it. Not sure if sendspace is the same.

Thanks for the update on Dr. Sinan's methods. When Dr. Sclafani mentioned the possibility of a genetic difference among Kuwaiti patients, that is not implausible, particularly since Kuwaiti has a historically low rate of MS that has gone dramatically up in the last 10-20 years, as compared to other populations that have a historically high rate of MS.

Of note: we have yet another conference starting! The SIR meeting, in Chicago, technically underway already but the excitement starts tomorrow with Dr. Sclafani's CCSVI workshop and then Monday with a full panel of presenters. I don't think our researchers have any more surprises left, do you? They gave us everything and then some at ISNVD.


I would agree with that. I thought the meeting was about introducing ideas to many generalists who were starting to hear about this.I do not think that there was much in the way of breakthrough here.

It was good to spend some time with some of the players who did not get to isnvd. but i have to tell you, the isnvd was for people serious about this problem and treatment.

i really needed a break. between isnvd and sir, there was a lot of preparation for the lectures and stuff. I am pretty tired. Needed to pull away for a while

now back to treatments full time yeah!
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Postby drsclafani » Sun Apr 03, 2011 8:29 pm

Liberation wrote:One more time :)

Dear dr Sclafani,
I am wondering what is your opinion about my IJVs and azygos, I went through the procedure in December and they found problem only with my right IJV. They did the dilation with a very small ballon, 6x20. The procedure took only circa 30 minutes. As I have ppms with motoric function problems, Iam wondering if there is more there.

I know you are those very few doctors who care about examining lumbar veins. You mentioned that you met or talked to dr Salvi recently. If I remember correctly he as a neurologist was pretty much interested in finding an association between ccsvi and ppms. Do they have more on this?

You mentioned tha last time that dr Zamboni reports that PPMS is associated with hypoplasia or atresia of the lumjbar veins. however at the current time it is not possible to treat these. Dr zamboni also noted that azygous veins were commonly narrowed in patients with ppms. Do you have more on this? The implication of lumbar veins are always likely with ppms or azygos itself can cause this problem too?
thx

Image

Image

Image


your images DO NOT show the upper parts of the jugular veins. This is a real problem. I have a sneaking suspicion that you may have problems in both veinshigher up in addition to the narrowings you see

with respect to lumbar vein hypoplasia, i see it not uncommonly is all types of MS, not just ppms.

One vein involved? hard to accept that. unfortunately, while you have been successful in posting your images, they are not of diagnostic quality at all.
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Postby drsclafani » Sun Apr 03, 2011 8:31 pm

MegansMom wrote:Dear Dr Sclafani,

I read on another thread that they have to prove that CCSVI is connected to the plaque formation to tie it all together. And maybe someday soon this will occur.

But could another way to prove a connection be if post- venoplasty plaques shrink or disappear and remyelination occurs. Seems to me that that would prove the impaired flow influences the course of the disease process.

This would probably happen in the patients with short term disease as opposed to long term but who knows?

Just wondered your thoughts on this?


personally, i suspect that there are ms symptoms and there are ccsvi symptoms. it may be possible to use MRI as a marker of pregression or regression of the disease.
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Postby drsclafani » Sun Apr 03, 2011 8:31 pm

Liberation wrote:
MegansMom wrote:Dear Dr Sclafani,

I read on another thread that they have to prove that CCSVI is connected to the plaque formation to tie it all together. And maybe someday soon this will occur.

But could another way to prove a connection be if post- venoplasty plaques shrink or disappear and remyelination occurs. Seems to me that that would prove the impaired flow influences the course of the disease process.

This would probably happen in the patients with short term disease as opposed to long term but who knows?

Just wondered your thoughts on this?


That is a good point. Dr Sinan told me that they observed reduction in the laesios 3 months after the operation in all patients.


All?

I am skeptical
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Postby drsclafani » Sun Apr 03, 2011 8:33 pm

1eye wrote:
But could another way to prove a connection be if post- venoplasty plaques shrink or disappear and remyelination occurs. Seems to me that that would prove the impaired flow influences the course of the disease process.


Dr. Zamboni's MRI work is not duplicated yet, as far as I know. Too bad, because we might find they are a good indicator of areas that have improved vs. not, and whether or not more treatment is needed. They might also be indicators of hypo-perfusion or hypoxia, or they might indicate that although veins are better, an immune attack is still happening, or the BBB is still breached. Many possibilities.


I think that manny mehta has duplicated good results in a quality study. Not RCT yet but a good start.
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Re: Membrane and Valves

Postby drsclafani » Sun Apr 03, 2011 8:33 pm

Jason wrote:Hi Dr Sclafani
Have you ever herd of Membrane working in cojunction with a valve causing a reflux?
I think both can cause reflux. why not both causing reflux.
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Re: Occasional dull pain in my chest after procedure

Postby drsclafani » Sun Apr 03, 2011 8:37 pm

NotFound wrote:Dear Dr. Sclafani,

After having had the stent placed in my Azygous (at Pacific Interventionalists)
I have been having intermittent (not very frequent either) dull pains where I think my azygous is.

Somewhat below / at the level of the heart?

Pain is not debilitating or anything, however it has me concerned.

I had the procedure done on December 14 2010 (3+ months ago). I have been diligently on blood thinners (Warfarin, after getting my INR stabilized between 2 and 3 by injections).

I was not given nor told to take any blood thinners prior to the procedure (not even aspirin). It took more than 10 days for the INR to get to the "therapeutic" level post procedure.

According to the operating Doctor, even if my azygous were to completely clog up, I would not be any worse off (his words, not mine), because my occlusion (which was due to azygous twisted about itself) was greater than 90%.

Can I please hear your take on this?
What can the pains be due to?


In my understanding to check the status of the stent will involve going in through the veins again and Doppler is no help here.

Thank you in advance.



i would think that the pain is likely caused by the stretching of the azygous as well as by the continued radial force of the stent

i have skepticism about these azygous stenoses.I think lots of them are phasic changes in th positionof the azygous. for example I have never seen a candhy wrapper.At this point you would think i would be seeing them too. Perhaps the difference is in the phase of respiration i image the azygous? Ivus also shows that many narrowings are phasic in the azygous

you are correct that the azygous is not measured by noninvasive imaging very well
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Postby drsclafani » Sun Apr 03, 2011 8:46 pm

griff wrote:
drsclafani wrote: we had a great informal session saturday night, speaking about things like anticoagulation, balloon size and my percussion hammer :lol:

i got a sense that the giant balloons were out of favor. While no one mentioned the thrombosis issue, i think that many had instances of it when using very large. balloons we may never get a comparison on that idea....it was probably overstated

Dr Sclafani, what do you mean by "it was probably overstated"? Do you mean the results of the giant balloons were overstated or the thrombosis issue?


I THINK BOTH ARE OVERSTATED.
Another issue regarding balloon size: isn't the size of the stretch depends on two things, one is the size of the narrowing/stenoses and the other is the size of the balloon? So, by increasing the balloon size I increase potential damage to the vein walls, but if the stenoses is greater (very narrow vein) I can dilate only with greater damage to the vein walls? So, all in all, I can only mitigate the damage done to the vein wall by using the appropriate size of balloon, but I can not have any impact on the other factor, the original size of the stenoses. Why can we not scale the size of the balloon used based on the Doppler us?


It is possible to size the balloon correctly but i think only with IVUS. The vessel above the stenosis is often dilated. if you select that size for the balloon you will overdilate. If you think that the narrowing is due to scar tissue you will try to overdilate intentionally about20% to maximize the stretch of the scar. IVUS shows you that the vein is not narrowed in most cases. The valve is fused and the opening is narrowed.I try to stay pretty close in diameter to the measurement of the narrowed area.
How about scarring and intimal hyperplasia? Are they mostly associated with stents or also with damage caused by balloon? Is the any documented data on these issues?

scarring and intimal hyperplasia is mostly caused by stents and the dilatation itself.
What did dr Zamboni change in his original techniques? As far as I know he used smaller balloons and he did not tear up annulus at the beggining. Did he change that?


Drs Zamboni and Galeotti used relatively small balloons and low pressure because that is what they had. Their restenosis rate is 53%. Many of us are trying to find a better result that 53% restenosis.
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Postby drsclafani » Sun Apr 03, 2011 8:48 pm

griff wrote:
Cece wrote:
We have never treated by angioplasty a disease like this. pure valvular obstructions i am not sure we need to continue to think that restenosis is an essential component of this. We just have to figure out how to do this properly.

It would be tremendous if you are right about that! It's been said that angioplasty is not durable anywhere in the body, why should it be durable here, but if you are right that this is an entirely new sort of disease (pure valvular obstructions) than we should not be limited by the success or failure of other types of angioplasty.


Sorry for the silly question, but I am not that familiar with the backgorund of the CCSVI. Do you mean that the stenoses is caused by the valve problems (narrow annulus, leaflets fusions, etc.) so we have to treat only the valve?


It is generally my approach after a hundred cases of IVUS. there are other problems such as hypoplasia, outflow obstruction of the dural sinuses, but mostly i think that this is predominantly fuse or malformed valves
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Postby drsclafani » Sun Apr 03, 2011 8:50 pm

erinc14 wrote:hi,

i have a question

my jugulars we're stented but not the azygos . why not?

thanks , Erin


i am asking "why was anything stented"
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Postby drsclafani » Sun Apr 03, 2011 9:19 pm

bestadmom wrote:Dr. S,

I heard someone's CCSVI was treated this week by cryoplasty vs a stent. It wasn't her first treatment. Was there talk of this method at ISNVD or SIR? What does the "freezing" do to the vein wall?


i am perplexed by this treatment. for a valvular stenosis. makes no sense to me.
any idea who is doing this?
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Postby drsclafani » Sun Apr 03, 2011 9:23 pm

David1949 wrote:As I understand it, one of the problems with valves is that they are sometimes inverted such that they would cause the blood to flow in the wrong direction. Is it possible to invert a valve back to normal by dragging a balloon through it in the direction of blood flow?


I do not think one can change the direction of the valve by balloon angioplasty. it might actually be one of the reasons to put a stent in: to hold that valve open
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