Cece wrote:drsclafani wrote:Cece
this is a case where the azygous venogram showed reflux but NOTHING in two views to sugest the cause. . However IVUS easily showed a grossly abnormal valve posterior to the arch.
Have a look:
There is a frontal and 70 degree oblique view.The image of IVUS shows thickened valves, outlined with orange arrows . These valves during the movie do not move. the final image on the right shows the waist of the balloon at the valvular obstruction.
I am glad for the orange arrows, because even with them I am having trouble finding the valve. What's fascinating is that you are right, it is hard to see anything in the venogram to indicate it even now that we know it is there.
I have seen this happening too often; even Dr. Galeotti showed a video where the jugular vein looked normal on venogram but they knew there was a problem at the valve level from the previously performed Doppler US.
My proposal is to use a compliant low pressure balloon in the Jugular and Azygous veins even if they look normal; that would have evidentiated the problem in the above case as shown on the picture to the right.
A compliant balloon doesn't need any special equipment and only add a little time to the procedure.
I hope any IR that doesn't have an IVUS available will use this technique.
drsclafani wrote: This is a substantial expense and we must prove its value.
The most important test would be to determine whether patients have a better outcome when IVUS is used. That is a five year study of durability and clinical outcome.
A less valuable test could be to do an "intent to treat" study. have a treatment plan based upon venography. then reveal the IVUS to the IR being studied (i will bet you guys like that one) to see whether the treatment plan changes.
Of course, we can documenet what percentage of vessels have something uncovered by IVUs, not uncovered by venography. By the way, there are other cases where ivus does not show what venography does.
My 5 year study would than compare IVUS vs. Venography with compliant balloon. I cannot visualize any lesion that would be missed by the compliant balloon and picked up only by the IVUS. The real advantage of the IVUS is in understanding how the valve leaflets move and in helping with the use of a valvulotome instrument when it will be available and knowledge is power.