DrSclafani answers some questions

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

Re: IVUS

Postby Cece » Thu Apr 28, 2011 5:04 pm

WeWillBeatMS - how exciting - I hope you see many improvements. To piggyback on your question about restenosis rates, there is Dr. Cumming's thought that durability of the procedure is something that needs to be improved, hopefully in the next year. Right now I don't see how this can be improved. The whole point of the extra-large balloons was to reduce restenosis and if the risk of the vein collapsing is too high, it is too high. Are there any other ideas out there right now to improve durability? Will we end up coming back to stents as the best option in cases where the vein will not stay open? I have disagreed with the use of stents in medical tourism where there is no follow-up with the patients but perhaps there is a role for them with the right aftercare regimen and close follow-up?
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Re: Two weeks before Liberation Procedure with you

Postby drsclafani » Thu Apr 28, 2011 8:52 pm

WeWillBeatMS wrote:Dr Sclafani,

I'm two weeks out from flying up to Brooklyn for the testing and procedure with you and I'm getting a little concerned (to say the least) about restenosis. What are the restenosis rates that you are seeing for people now? Also, daily I take 2,000 IU D3 daily, 500 MG of DHA (fish oil) Nordic Natural pills, 81 mg aspirin twice a day, and I do pretty good eating healthy. Are there any things you would recommend I do in these last few weeks to help my chances of not restenosing?

thank you,

WeWillBeatMS


Let me explain why i cannot give a good answer for this question. It is based upon the misfortune I had when the hospital stopped my program.

The vast majority of my patients have been done after a six month hiatus brought about when the hospital forbade me to perform the procedure. I resumed on weekends in November, so the vast majority of my patients have been treated in the past six months with most of those in the past four months. According to Zamboni, most restenosis occurs after the seventh month after treatment. Therefore my data is not old enough to give a good reflection of restenosis.

Let's review the cumulative restenosis rate described by Zamboni

Image

In this chart, he evaluates the percentage of patients who are patent over time. You can see that there is an overall progressive increase in the number of patients who restenosed


If we look at the chart we seen that most of the restenosis occurs between 8 and 16 months.

Image
You can see with time the percentage of patients who did not restenose went from 100% to 47% at 18 months.
At 90 days about 90% had not restenosed. (orange)
at 180 days about 85% had not restenosed (yellow)
At 210 days about 65% are stenosis free (green)
At one year about 55% have no stenosis (purple
at 18 months only 47% of patients have not restenosed.(red)

So we can expect that at least half of patients will restenose. Reducing intimal damage by procedural and medical manuevers, by healthy living practices such as cessation of smoking, better nutrition, etc MAY prolong the interval to restenosis. Surveillance by ultrasound mayhave value.

This restenosis seems to be an inevitable occurence in the majority of patients. We have to live with it until new devices, new medical therapies and new techniques reduce this problem.

This is very common in medical practice. People get infections. they get treated. they get another infection. Diabetics blood sugar goes up, is treated, come down, goes up again.

Face it, we are partners for a long time

S
Last edited by drsclafani on Fri Apr 29, 2011 8:17 pm, edited 2 times in total.
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Postby Liberation » Fri Apr 29, 2011 5:13 am

It is an old news on Dick Cheney from 2001. I am just wondering how the probability of scarring might differ in case of IJV and azygos today.


While doctors have gotten better at clearing out clogged arteries, keeping them from closing back up remains a stumbling block for a significant number of heart patients, including Vice President Dick Cheney.

"The Achilles' heel of angioplasty and intercoronary stenting is the problem that Vice President Cheney experienced today -- the narrowing related to scar tissue," said Dr. Ralph Brindis, a cardiologist at Kaiser Permanente Medical Center in San Francisco and clinical professor of medicine at the University of California at San Francisco.

About 20 percent of patients develop scar tissue in their blood vessels after angioplasty, a procedure in which a tiny balloon is inserted into the artery and inflated, squashing the built-up plaque that is blocking blood flow.
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Re: Two weeks before Liberation Procedure with you

Postby Liberation » Fri Apr 29, 2011 5:42 am

drsclafani wrote:So we can expect that at least half of patients will restenose. Reducing intimal damage by procedural and medical manuevers, by healthy living practices such as cessation of smoking, better nutrition, etc MAY prolong the interval to restenosis. Surveillance by ultrasound mayhave value.

This is very common in medical practice. People get infections. they get treated. they get another infection. Diabetics blood sugar goes up, is treated, come down, goes up again.

Face it, we are partners for a long time

S


Dr Sclafani, I was just wondering what the implications of repeated angioplasty could be. I read that approximately 20% of patients get scarring after coronary angioplasty. Wouldn't this risk grow by repated angioplasty in our case (IJV and azygos)? Can we do anything against it? Have you experienced better figures with using ivus?
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Postby Rici » Fri Apr 29, 2011 5:49 am

During my meeting with Doz. Kielar in Medicover Hospital in Warsaw I asked him about the daughter of a lady with whom I am in contact. I met them both women when they were in Medicover Hospital to perform the tests. I got then a CD with the MRI results and I forwarded it to Dr. Schelling. Dr. Schelling then confirmed – based on the test results of a very high quality – that the reason for MS of Miss K. were vein deformations. Dr. Schelling saw also the results of the angiography – MRV – where exactly these deformations are. He showed tem to Doz. Kielar when they met in Katowice during the congress. But Doz. Kielar told me, that the deformations of the veins are caused by the vertebrae of the spine. The vein is in close contact with the spine and also an angioplastic operation would not help. It looks like a soft hose lying on the ground. The stent for women is out of the question for the high risk of foetal asphyxia (Miss. K. is 23 years young). In Medicover the implants of stents for women are completely excluded. Neurologists in Poland are taking advantage of this fact (for instance citing in Poland the percentage number of no improvements after CCSVI treatments), and they refer to this statistic. I am of the opinion that angioplastic surgery is not recommended to anyone, and the same for the stent implantation, if from the beginning it is clear that it would not help and even make the situation worse. I know of such cases. Many patients have claims to me, when I directed them to Euromedics as their first CCSVI patient in Poland, and now they are feeling worse after the treatment. It cannot be good if women get a thrombosis only after a few weeks of feeling better. I am sorry for this happening.
What is your comment on stent exclusions for women? Is this reasonable?
Thank you for an answer and best regards

Rici
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Postby drsclafani » Fri Apr 29, 2011 7:47 pm

Liberation wrote:It is an old news on Dick Cheney from 2001. I am just wondering how the probability of scarring might differ in case of IJV and azygos today.


While doctors have gotten better at clearing out clogged arteries, keeping them from closing back up remains a stumbling block for a significant number of heart patients, including Vice President Dick Cheney.

"The Achilles' heel of angioplasty and intercoronary stenting is the problem that Vice President Cheney experienced today -- the narrowing related to scar tissue," said Dr. Ralph Brindis, a cardiologist at Kaiser Permanente Medical Center in San Francisco and clinical professor of medicine at the University of California at San Francisco.

About 20 percent of patients develop scar tissue in their blood vessels after angioplasty, a procedure in which a tiny balloon is inserted into the artery and inflated, squashing the built-up plaque that is blocking blood flow.


First we must clarify VP Cheney's cardiac history. He has had six heart attacks beginning in the late 1970s, he has had a quadruple coronary bypass. He never had angioplasty he always has coronary stenting and this was done in vessels that had been sutured together.

so was the scarring related to the surgical anastomoses?, was it related to the stents?, both are far more likely than from the angioplasty.

But this coronary artery angioplaty and stenting really cannot be extrapolated into the venous angioplasties that we do.
We do not know how these veins will respond in the long run. That the only long term followup showed that 50% of patients will develop restenosis suggests only that narrowing recurs.

If you believe, as I do that the vein wall is not the problem but that the valves are the problem, we have to consider that the valves have restenosed, or formed adhesions or sticky connections to the points of prior fusion. That is far different than angioplasty of arteries with restenosis is an environment of arteriosclerotic plaque and disease up and down the vessel.

So i think that we cannot make judgments regarding restenosis at this time. I will continue to quote Zamboni but my gut is telling me that i am likely going to have less restenosis that 50% at 18 months.

But time will tell
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Postby Cece » Fri Apr 29, 2011 7:59 pm

drsclafani wrote:If you believe, as I do that the vein wall is not the problem but that the valves are the problem, we have to consider that the valves have restenosed, or formed adhesions or sticky connections to the points of prior fusion. That is far different than angioplasty of arteries with restenosis is an environment of arteriosclerotic plaque and disease up and down the vessel.

Really interesting.
Any thought on what might cause formerly fused leaflets to form these adhesions again? Is it a healing response, where it grows back together?
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Postby drsclafani » Fri Apr 29, 2011 8:06 pm

Cece wrote:
drsclafani wrote:If you believe, as I do that the vein wall is not the problem but that the valves are the problem, we have to consider that the valves have restenosed, or formed adhesions or sticky connections to the points of prior fusion. That is far different than angioplasty of arteries with restenosis is an environment of arteriosclerotic plaque and disease up and down the vessel.

Really interesting.
Any thought on what might cause formerly fused leaflets to form these adhesions again? Is it a healing response, where it grows back together?


i speculate that the valves are often elongated and may just end up adhering to each other. However they could also be formed long and tubular. Opening such veins might lead to long trailing leaflets that might eventually come in contact and ultimately fuse.

BUt i am not stating fact. I suspect that if my postulate is correct, then restenosis should not be 50% at 18 months if appropriately sized balloons are used.

speaking of sizing

Today i used a 12 mm balloon in the jugular vein and an 18 mm balloon in the azygous. Another azygous very much underrepresented by venography and graphically displayed on IVUS.... incredible. and IVUS allowed me to use such a monstrous balloon in the aygous with confidence that i was n ot going to blow up the vein.

i will show this when the pix are rady.
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Postby pklittle » Fri Apr 29, 2011 9:42 pm

Good evening Dr.,
How many valves do we have in each internal jugular? And the azygous?
thanks
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Postby Cece » Sat Apr 30, 2011 11:56 am

Pklittle, last spring, he posted an image of someone with three valves in the azygous but that was not at all normal...my own right jugular had two valves but, again, I don't think this is normal...funny how normal goes out the window when it comes to CCSVI.

i speculate that the valves are often elongated and may just end up adhering to each other. However they could also be formed long and tubular. Opening such veins might lead to long trailing leaflets that might eventually come in contact and ultimately fuse.

It's very different from elastic recoil, though, isn't it. Nor is it intimal hyperplasia or thombosis. Refusion of the valves....

And I accept that this is just speculation. Very interesting and provocative speculation. :)
Today i used a 12 mm balloon in the jugular vein and an 18 mm balloon in the azygous

Quite the reverse there!
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Postby pklittle » Sat Apr 30, 2011 2:03 pm

It seems so much with ccsvi is a moving target.. so that is why I ask the Dr. today how many valves are in each, since his present thinking is that the problems are with the valves, not the vein walls.
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Postby drsclafani » Sun May 01, 2011 1:01 am

pklittle wrote:Good evening Dr.,
How many valves do we have in each internal jugular? And the azygous?
thanks
Pam


I have been told that the azygous vein is valveless, yet I see valves there not uncommonly. I have seen three or more on occasion.

the internal jugular vein usually has one, but 15% of cadaver studies had none but two or more is not very uncommon.
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Postby drsclafani » Sun May 01, 2011 1:48 am

Rici wrote:During my meeting with Doz. Kielar in Medicover Hospital in Warsaw I asked him about the daughter of a lady with whom I am in contact. I met them both women when they were in Medicover Hospital to perform the tests. I got then a CD with the MRI results and I forwarded it to Dr. Schelling. Dr. Schelling then confirmed – based on the test results of a very high quality – that the reason for MS of Miss K. were vein deformations. Dr. Schelling saw also the results of the angiography – MRV – where exactly these deformations are. He showed tem to Doz. Kielar when they met in Katowice during the congress. But Doz. Kielar told me, that the deformations of the veins are caused by the vertebrae of the spine. The vein is in close contact with the spine and also an angioplastic operation would not help. It looks like a soft hose lying on the ground.

Rici, there are venous compressions by the vertebra and by the carotid artery. it is usually at the second vertebral transverse process high near the skull base. Dr Zamboni warned me about this trick finding in 2009 and I have been lecturing about this since then. I use IVUS, intravascular ultrasound, at the time of the venogram to evaluate these narrowings. most of them are phasic and you can see distension followed by collapse multiple times. I saw one in a patient i treated today. I did not perform angioplasty or stenting for it. Occasionally one can get an organic fixed stenosis in that area,often it is a focal hypoplasia. it is often associated with collaterals draining around the stenosis. This i try to treat by angioplasty. I have a dramatic improvement in one patient.

The stent for women is out of the question for the high risk of foetal asphyxia (Miss. K. is 23 years young). In Medicover the implants of stents for women are completely excluded. Neurologists in Poland are taking advantage of this fact (for instance citing in Poland the percentage number of no improvements after CCSVI treatments), and they refer to this statistic. I am of the opinion that angioplastic surgery is not recommended to anyone, and the same for the stent implantation, if from the beginning it is clear that it would not help and even make the situation worse. I know of such cases.

i am not familiar with the risk of fetal asphyxia from stents for CCSVI. Can you explain and provide reference for me? Thanks.

i agree that treatment for problems that are not likely to be helped should be withheld. Stents are a problem for me and i withhold stents except for complications the only stents i have placed have been to treat complications of stenting performed by other physicians. I have never put a stent on the first treatment

Many patients have claims to me, when I directed them to Euromedics as their first CCSVI patient in Poland, and now they are feeling worse after the treatment. It cannot be good if women get a thrombosis only after a few weeks of feeling better. I am sorry for this happening.
What is your comment on stent exclusions for women? Is this reasonable?
Thank you for an answer and best regards

Rici


i know of no evidence which precludes stents being used in women. Certainly not in CCSVI. However i do not believe in stents except in rare circumstances.
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mega azygous vein

Postby drsclafani » Sun May 01, 2011 1:59 am

30 year old man with PPMS for several years with worsening spasticity and weakness.

ultrasound confirmed CCSVI

Venography was performed.

please review the following image

Image

can anyone tell me if and where there is an abnormality

ciao
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Postby joge » Sun May 01, 2011 7:13 am

Is this the earlier mentioned '' 18 mm balloon - azygos'' ?
I'm ready, I'm ready !
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