DrSclafani answers some questions

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

Postby pklittle » Sun Apr 03, 2011 9:36 pm

I am online reading here as you post. It is late.

WAVING HI TO YOU DR.SCLAFANI !!! :)

I have no questions, I am still on hold.
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Re: Occasional dull pain in my chest after procedure

Postby NotFound » Sun Apr 03, 2011 10:13 pm

drsclafani wrote:
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


Thank you.

Although I feel rather bad realizing that I might have a 6cm stent now that was absolutely not necessary :( One would think IR doctors would know about dynamic positioning of the veins.
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Re: Occasional dull pain in my chest after procedure

Postby drsclafani » Sun Apr 03, 2011 10:19 pm

NotFound wrote:
drsclafani wrote:
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


Thank you.

Although I feel rather bad realizing that I might have a 6cm stent now that was absolutely not necessary :( One would think IR doctors would know about dynamic positioning of the veins.


its an ivus thing

not many are using it yet.
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Postby drsclafani » Sun Apr 03, 2011 10:20 pm

pklittle wrote:I am online reading here as you post. It is late.

WAVING HI TO YOU DR.SCLAFANI !!! :)

I have no questions, I am still on hold.


it is late. i promised my self that i wouldnt do this any more. it really is exhausting.

so off to bed i go
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to wait or not to wait

Postby jak7ham9 » Mon Apr 04, 2011 5:18 am

Dear Dr. S
Hi I had the procedure done by you last march patient 10 barbara with cutting balloon. I am quite sure I restenosed but after viewing so much questions and changes in the operation and how it is done I am wondering should I get it done again or should I wait. I feel my mobilility is somewhat less than before I had operation (deffinately less than week after). I want to improve but I don't want to do any harm. So confusing. It just seems that there are not a lot of improvements for many people . Then of course I read of patients with scarring or clots..... I keep using my hbot in hopes the o2 will at least slow progression in the mean while.) Drugs have never been helppful. I really would love some kind of direction. b
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Postby bestadmom » Mon Apr 04, 2011 8:19 am

drsclafani wrote:
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?


Dr. Montague in Tampa used this last week on someone I know. It wasn't her first procedure.
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Postby Cece » Mon Apr 04, 2011 8:58 am

drsclafani wrote:now back to treatments full time yeah!

double yeah :)

drsclafani wrote: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.

Didn't know you could stretch scar tissue in these veins. That is encouraging as well.
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Postby pklittle » Mon Apr 04, 2011 12:59 pm

drsclafani wrote:
pklittle wrote:I am online reading here as you post. It is late.

WAVING HI TO YOU DR.SCLAFANI !!! :)

I have no questions, I am still on hold.


it is late. i promised my self that i wouldnt do this any more. it really is exhausting.

so off to bed i go


Perhaps we should look into having this forum shut down after midnight.

Dr. Sclafani, in all honestly, you need to take care of yourself first. We know you care for all of us and want to help us so badly, but remember we all care about you too! Do not exhaust yourself. :(

ok, off my soapbox now.... :)
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Postby Liberation » Mon Apr 04, 2011 2:28 pm

drsclafani wrote:
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.


First I thought that the RIJV has a narrow annulus where the vein gets real thin in a very small segment and that is why the long part above is stenosed, but then souldn't there be a bulge above the narrow annulus? As far as I know they dilated the valve and the vein with a small balloon (6x20mm) but they did not break the annulus. So a few weeks later the lower part got restenosed (1cm) then a week ago I got another Doppler and the IR saw the whole full section got back where it was. I guess this would be an elastic recoil. However, the second time the IR told me that he sees some drifting piece there. If there is a narrow annulus, souldn't be enough to break that and then the vein sould get normal? Of course, if there is no thickening of the wall.

As for the two other veins I do not see major obstacles. Dr Sinan told me he would dilate the valves there. I am not sure if saw specific problem there or he always do that. As far as I know he always enters the veins with a balloon to see whether he encounters any problem there. Would ivus be a better way exploring these problems? Would a problem be better identified with ivus or entering by balloon would have some merits?

That is true that the upper parts are not indicated in the images. Could it be that they did not see those parts? On the other hand if my recollection is right, Dr Cumming just said a day before that using an extra large balloons in the upper part of the IJVs can cause big problems as it did a full occlusion with Winni's IJV. Could it be? What should be done if those parts are stenosed? Are there valves in those segments that can cause the problems or there is a vein problem? If I understand correctly mostly valves are the cause of stenosis.
I try to get the MRV images that were prepared half a year before my operation those should be much better quaility.
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Postby drsclafani » Tue Apr 05, 2011 7:01 am

Cece wrote:
drsclafani wrote:now back to treatments full time yeah!

double yeah :)

drsclafani wrote: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.

Didn't know you could stretch scar tissue in these veins. That is encouraging as well.


cece
just because you think that the narrowing is scar tissue, doesnt mean it is. In fact, i do not think it is when the narrowing is in the vicinity of the valves.
i was just making the statement that most IRs believe it is scar until proven otherwise and thus are over dilating.

I think it is not and have backed off on sizeing balloons to conform to the diameter of the vein to start.
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Postby drsclafani » Tue Apr 05, 2011 7:34 am

First I thought that the RIJV has a narrow annulus where the vein gets real thin in a very small segment and that is why the long part above is stenosed, but then souldn't there be a bulge above the narrow annulus? As far as I know they dilated the valve and the vein with a small balloon (6x20mm) but they did not break the annulus. So a few weeks later the lower part got restenosed (1cm) then a week ago I got another Doppler and the IR saw the whole full section got back where it was. I guess this would be an elastic recoil. However, the second time the IR told me that he sees some drifting piece there. If there is a narrow annulus, souldn't be enough to break that and then the vein sould get normal? Of course, if there is no thickening of the wall.


i am sorry, Liberation, in truth, the images that you show are so bad that one cannot really make accurate comments about them. There do appear to be segmental narrowings (?hypoplasia) but the area of the valve is not visible at all. Also you state that a 6x20 balloon was used. seems rather short, possibly rather thin. Might i guess that your IR was a cardiologist? just a guess and with no bias intended.

you cannot tell wall thickness from a venogram. A venogram only shows the inner part of the vein, a "lumenogram"

As for the two other veins I do not see major obstacles.

Liberation, i dont see any "major" obstacle either....the problem is I don't think that i see anything there. You have to accept that what you are showing us does not meet standards. One cannot make ANY comments at all. And what is "MAJOR"? That is still under debate.

Dr Sinan told me he would dilate the valves there. I am not sure if saw specific problem there or he always do that. As far as I know he always enters the veins with a balloon to see whether he encounters any problem there. Would ivus be a better way exploring these problems? Would a problem be better identified with ivus or entering by balloon would have some merits?


i prefer NOT to inflate a balloon until I have found some reason to inflate it. Inflating balloons to find lesions is something many physicians do. It can damage intima. That is one of the reasons that I use IVUS which is less traumatic and more accurate in so many ways than inflating a balloon.

That is true that the upper parts are not indicated in the images. Could it be that they did not see those parts?

I think we should always try to see the ENTIRE vein, and, ideally, see the connection between the dural sinuses in the head and the jugular veins in the neck. Just last week i had a case of segmental hypoplasia which did not show reflux into the head. I sent the patient for a BRAIN MRV (not MRV of neck) and it showed clearly a number of dural sinus stenoses.

On the other hand if my recollection is right, Dr Cumming just said a day before that using an extra large balloons in the upper part of the IJVs can cause big problems as it did a full occlusion with Winni's IJV. Could it be? What should be done if those parts are stenosed? Are there valves in those segments that can cause the problems or there is a vein problem?


perhaps you are misunderstanding dr cumming
I agree that one should not use extra large balloons in the upper IJV because it will be a mis-sizing and ballooning may cause more harm that good WITH A BALLOON THAT IS TOO LARGE. Doesnt mean that using a properly sized balloon cannot improve flow in the vein.

If I understand correctly mostly valves are the cause of stenosis.
I try to get the MRV images that were prepared half a year before my operation those should be much better quaility.


ok. but perhaps your scan of your venogram is the problem. do you have the images? or do you have paper prints?
MRV just isnt as good as venography, but perhaps that will help us all understand what you are trying to show us.

Based upon what you have said and shown us here, my opinion is that we cannot provide you with any clarity, sorry.
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Postby Cece » Tue Apr 05, 2011 7:51 am

drsclafani wrote:cece
just because you think that the narrowing is scar tissue, doesnt mean it is. In fact, i do not think it is when the narrowing is in the vicinity of the valves.
i was just making the statement that most IRs believe it is scar until proven otherwise and thus are over dilating.

I think it is not and have backed off on sizeing balloons to conform to the diameter of the vein to start.

I see what you were saying, you were talking about the original stenoses.

In a different scenario, we are hearing reports of patients who have scarring as a result of the procedure. Depending on what is exactly going on with those patients, as long as the vein does not close completely, it can still be ballooned again? I had thought scarring sounded so severe, this would not be possible.
sent the patient for a BRAIN MRV (not MRV of neck) and it showed clearly a number of dural sinus stenoses.

What next, for such a patient? Will the dural sinus stenoses be treated and by whom?
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Postby HappyPoet » Tue Apr 05, 2011 12:39 pm

Hi Dr. Sclafani,

A very happy update for you! :D

My follow-up US showed strong flow throughout my left femoral vein which had been occluded by clot [from 1st procedure, different doctor].

Your post-procedure protocol of using Arixtra dissolved the very scary clot (DVT) and saved my leg and my life for which my family and I can never thank you enough. You will be forever in our hearts.

Thank you for everything, Superstar.
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Postby Liberation » Tue Apr 05, 2011 1:53 pm

i am sorry, Liberation, in truth, the images that you show are so bad that one cannot really make accurate comments about them. There do appear to be segmental narrowings (?hypoplasia) but the area of the valve is not visible at all. Also you state that a 6x20 balloon was used. seems rather short, possibly rather thin. Might i guess that your IR was a cardiologist? just a guess and with no bias intended.


Almost, the head of the CCSVI program is a vascular surgeon. :) I have a great respect for him, just like I do for you. :) I just heard from him that they try to do dilation four times a year to avoid stenoses.

That is true that the upper parts are not indicated in the images. Could it be that they did not see those parts?

I think we should always try to see the ENTIRE vein, and, ideally, see the connection between the dural sinuses in the head and the jugular veins in the neck. Just last week i had a case of segmental hypoplasia which did not show reflux into the head. I sent the patient for a BRAIN MRV (not MRV of neck) and it showed clearly a number of dural sinus stenoses.


It seems to me me that they not treated the upper part of the IJV in the past as I just heard that they start dilating IJW all the way from now. Was it thought more dangerous treating the upper part? I guess there must have been a reason why they did not do it in the past.

If I understand correctly mostly valves are the cause of stenosis.
I try to get the MRV images that were prepared half a year before my operation those should be much better quaility.


ok. but perhaps your scan of your venogram is the problem. do you have the images? or do you have paper prints?
MRV just isnt as good as venography, but perhaps that will help us all understand what you are trying to show us.


Yes, I only got the print of it and the bad quality is due to my scanning. I have the MRV of the brain and the cervical. I can send you an access to a link where you can look at the full CD. Your help is greatly appreciated :)
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Postby Cece » Tue Apr 05, 2011 2:54 pm

HappyPoet wrote:Your post-procedure protocol of using Arixtra dissolved the very scary clot (DVT) and saved my leg and my life for which my family and I can never thank you enough. You will be forever in our hearts.

Thank you for everything, Superstar.

Hooray, HappyPoet!! What a relief.
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