DrSclafani answers some questions

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

Postby Cece » Sun May 01, 2011 7:43 am

snagit would come in handy for me....

There is a narrowing in the very lowest portion of the azygous, beginning about an inch from the bottom of the image.

Up at the top of the arch there is a point where it goes from bloated to less bloated. Like a snake that swallowed a mouse. But it's still quite big.
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Re: mega azygous vein

Postby scorpion » Sun May 01, 2011 8:04 am

drsclafani wrote:can anyone tell me if and where there is an abnormality
ciao


I can't tell if or where there is an "abnormality" but since research is ongoing as to whether there is a significant connection between CCSVI and MS I am not sure why stating "this gentleman had PPMS for thirty years" is significant.
Last edited by scorpion on Sun May 01, 2011 8:16 am, edited 1 time in total.
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Postby Algis » Sun May 01, 2011 8:10 am

since research is ongoing as to whether there is a significant connection between CCSVI and MS I am not sure why stating this gentleman had PPMS for thirty years is significant


Maybe because this website is about MS and that this thread is about CCSVI?

But don't take my word for it :roll:
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Postby Cece » Sun May 01, 2011 8:43 am

Because in Dr. Zamboni's research, he found pattern 'D' in 9 out of 10 pwPPMS?

www.direct-ms.org/sites/default/files/Z ... S%2009.pdf

Type D pattern (18%) is characterized by the multilevel
involvement of the AZY and lumbar systems. Association
with the IJVs was observed in approximately 50%
and caused an additional obstruction in these patients.
It was observed in two of 35 RR patients, in one of 20
SP patients, and in nine of 10 PP patients.
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Re: mega azygous vein

Postby Trish317 » Sun May 01, 2011 9:50 am

scorpion wrote:I can't tell if or where there is an "abnormality" but since research is ongoing as to whether there is a significant connection between CCSVI and MS I am not sure why stating "this gentleman had PPMS for thirty years" is significant.


It doesn't say "this gentleman had PPMS for thirty years". It says "30 year old man with PPMS for several years"....
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Re: mega azygous vein

Postby scorpion » Sun May 01, 2011 10:00 am

Trish317 wrote:It doesn't say "this gentleman had PPMS for thirty years". It says "30 year old man with PPMS for several years"....


Ok. So I guess I have the same question accept the "30 year old man" part. All I am saying is language like this frames the discussion to make it appear that there is a definite connection between CCSVI and MS.
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Re: mega azygous vein

Postby drsclafani » Sun May 01, 2011 10:33 am

scorpion wrote:Ok. So I guess I have the same question accept the "30 year old man" part. All I am saying is language like this frames the discussion to make it appear that there is a definite connection between CCSVI and MS.


scorpion
give it a rest.

i am not going to debate you

do you see an abnormality?
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Postby AJMcE » Sun May 01, 2011 12:28 pm

drsclafani wrote: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.



Dear Dr S
Assuming valves are the main problem, do we know enough to tell how well do they cope with repeat procedures?

Are multiple procedures less likely to be successful when valves are involved?
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follow-up ultrasound in Canada...

Postby kkala » Sun May 01, 2011 1:16 pm

My mother had the liberation treatment done by Dr. Simka last June (2010).

She has had follow-up ultrasounds here in Ontario, but of course there is nobody who will deal with anything around CCSVI here.

The first follow-up at six months was fine, another done two weeks ago looks not so great (restenosis?)

"The internal jugular stent appears patent with internal hyperechoic echos. Venous insufficiency was evident with reflux in the internal jugular vein at 0 and 90 degrees. Conclusion: Patent left IJV stent, with partial thrombus/or fibrointoimal hyperplasisl and venous reflux."

Any advice? Is this basically saying "need CCSVI round 2" ?

Many thanks,

Kariné
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Re: mega azygous vein

Postby scorpion » Sun May 01, 2011 3:13 pm

drsclafani wrote:scorpion
give it a rest.

i am not going to debate you

do you see an abnormality?


I have not the slightest clue if there is an "abnormality" but even if I was an experienced vascular specialist I put money that my interpretation is different then yours. This is not because either one of us is right or wrong but because it seems the "specialists" do not themselves know what defines a "normal" venous system and what does not or even if a normal one exists. Wasn't this experiment tried on here one other time and every single doctor on this board had a different interpretation? The answer you are looking for is what you see of course but I would be VERY interested to see what others in your field of expertise say about your interpretation of the image. That said I don't want to argue either so I will take leave of your thread!
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Re: mega azygous vein

Postby Nunzio » Sun May 01, 2011 3:46 pm

Cece wrote:snagit would come in handy for me....

There is a narrowing in the very lowest portion of the azygous, beginning about an inch from the bottom of the image.

Up at the top of the arch there is a point where it goes from bloated to less bloated. Like a snake that swallowed a mouse. But it's still quite big.

Not to contradict Cece but I think the only normal part is the one at the bottom of the page. The rest looks dilated to me. Usually this indicate a blockage near the junction with the Brachiocephalic vein. IVUS will tell.
Everybody here brings happiness, somebody by coming,others by leaving.  PPMS since 2000<br />
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Re: mega azygous vein

Postby Nunzio » Sun May 01, 2011 4:11 pm

drsclafani wrote: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

Cece wrote:Up at the top of the arch there is a point where it goes from bloated to less bloated. Like a snake that swallowed a mouse. But it's still quite big.

Hi Cece, I see the mouse or is it a rat? But do you see the bird beak?

Image
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Postby Cece » Sun May 01, 2011 4:20 pm

My own azygous was rather mega! Being big does not have to mean being dilated?
Image

:)
Usually i see skinny little candy canes! There is indeed a very elegant bird's beak on the one drsclafani posted. Perhaps it is the azygous of a zoologist.
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Re: mega azygous vein

Postby drsclafani » Sun May 01, 2011 10:46 pm

Yes, well. There was a reason that i mentioned the PPMS. As we know, ppms is supposed to have a higher incidence of azygous disease.

The internal jugular veins were imaged. The right side was normal by venography and IVUS.

Here is an image of the left internal jugular vein.
Image
There is a stenosis at the confluens on the venogram (yellow oval). Note near the skull the collateral veins in the perivertebral plexus. There is thickened valvular material (curved orange arrows) on the IVUS that points to the cause of the narrowing of the LIJV as being valvular in nature. After angioplasty (orange arrow) the lumen looked great, and flow was improved.
Also it has been said to be uncommon to have only one vein obstruction in ccsvi.

So with one normal ijv and one abnormal ijv, we have to look carefully at the aygous vein. this Azygous is the mother of all azygous. on IVUS it measured 18 mm. well beyond the usual range of 8-12 mm

I can think of several reasons for enlargement of the azygous vein
1. obstruction of both jugular veins
2. obstruction of the left renal vein
3. obstruction of the left iliac vein
4 high flow arteriovenous fistula that drains into the aygous vein
5. obstruction of the outflow drainage of the aygous vein.

some of the group answere my question, talking about the large expansion of the arch and dr sossi talks about the ascending azygous also being enlarge. The ascending vessel measured about 9.5 mm. This is somewhat large but nowhere near the dimension of the arch.

But do we see a beak like narrowing at the orifice of the vein, to the left in the image? No. Do we see filling defects in the contrast column? no.

So lets proceed to look at the pelvis. Obstructions of flow from the leg into the inferior vena cava, the large main vein that carries blood from the lower half of the body into the heart, force that blood to seek alternate pathways back to the heart. These pathways cross from left to right through collaterals in the pelvis and through the ascending lumbar vein into the hemiazygous vein and finally into the aygous vein.

in this patient we see a stenosis of the external iliac vein

ImageThis was treated by balloon angioplasty. the results are good. Note also on the film on the right that there is a duplication of the common iliac vein. I did not dilate that segment.

The cause of the stenosis is nicely shown by IVUs to be a septum in the vein (small curved arrows)

Image

Another cause of enlargement of the aygous vein is drainage of the left kidney's venous blood into the azygous vein. This can happen when there is an obstruction of the renal vein by stenosis or occlusion. Then blood can shunt up the ascending lumbar vein, into the hemiazygous vein and into the azygous vein. The left kidney accounts for at least 10% of blood flow.

The renal venogram shows nonocclusion of the left renal vein.
Image

i will review the azygous vein tomorrow
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Postby drsclafani » Sun May 01, 2011 10:55 pm

AJMcE wrote:
drsclafani wrote: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.



Dear Dr S
Assuming valves are the main problem, do we know enough to tell how well do they cope with repeat procedures?

Are multiple procedures less likely to be successful when valves are involved?


Since i think that most of the stenoses are valvular problems, i would suspect that the history of current treatment of stenosis is representative. However if valve stenosis is treated, then there is hope that we can improve restenosis rates in the long run because we may not need to stretch the normal vein resulting in injury that goes on to stenosis.
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