DrSclafani answers some questions

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

Re: CCSVI Aftercare aspirin

Postby drsclafani » Tue Jun 07, 2011 1:03 pm

fraser wrote:Hi!

Just wondering if you think it's absolutely 100% necessary to take low dose aspirin after the Liberation Procedure? My husband has been on it for a year, since the procedure, but starting to wondering if it's interfering with his sleep. Things have been good since the procedure, and his symptoms have improved, but the broken sleep is causing havoc. He wakes in the middle of the night, unable to get back to sleep. He is on prescription sleep medication which is causing longterm problems...and still waking in the night. He can hardly function at work most days.

I know he'd be in fantastic shape if only he could sleep.

Would going off the aspirin be a dangerous move?

Also I've read reports that taking longterm aspiring may lead to pancreatic cancer. It was once believed that it could prevent this type
of cancer - what is your take on this?

Thanks!


this is a difficult question to answer. I am not sure that it is appropriate for me to provide anything but fact and my own opinion at this point. If your husband was not treated by me, i think it would make the most sense to have your questions answered by his treating physician. If he was treated by me, please lets do a proper discussion one on one

That being said, i do not think that aspirin is dangerous as a carcinogen.

read also the following abstract:

Effect of daily aspirin on long-term risk of death due to cancer: analysis of individual patient data from randomised trials
Original TextProf Peter M Rothwell FMedSci a , Prof F Gerald R Fowkes FRCPE b, Prof Jill FF Belch FRCP c, Hisao Ogawa MD d, Prof Charles P Warlow FMedSci e, Prof Tom W Meade FRS f
Summary
Background
Treatment with daily aspirin for 5 years or longer reduces subsequent risk of colorectal cancer. Several lines of evidence suggest that aspirin might also reduce risk of other cancers, particularly of the gastrointestinal tract, but proof in man is lacking. We studied deaths due to cancer during and after randomised trials of daily aspirin versus control done originally for prevention of vascular events.
Methods
We used individual patient data from all randomised trials of daily aspirin versus no aspirin with mean duration of scheduled trial treatment of 4 years or longer to determine the effect of allocation to aspirin on risk of cancer death in relation to scheduled duration of trial treatment for gastrointestinal and non-gastrointestinal cancers. In three large UK trials, long-term post-trial follow-up of individual patients was obtained from death certificates and cancer registries.
Results
In eight eligible trials (25 570 patients, 674 cancer deaths), allocation to aspirin reduced death due to cancer (pooled odds ratio [OR] 0·79, 95% CI 0·68—0·92, p=0·003). On analysis of individual patient data, which were available from seven trials (23 535 patients, 657 cancer deaths), benefit was apparent only after 5 years' follow-up (all cancers, hazard ratio [HR] 0·66, 0·50—0·87; gastrointestinal cancers, 0·46, 0·27—0·77; both p=0·003). The 20-year risk of cancer death (1634 deaths in 12 659 patients in three trials) remained lower in the aspirin groups than in the control groups (all solid cancers, HR 0·80, 0·72—0·88, p<0·0001; gastrointestinal cancers, 0·65, 0·54—0·78, p<0·0001), and benefit increased (interaction p=0·01) with scheduled duration of trial treatment (≥7·5 years: all solid cancers, 0·69, 0·54—0·88, p=0·003; gastrointestinal cancers, 0·41, 0·26—0·66, p=0·0001). The latent period before an effect on deaths was about 5 years for oesophageal, pancreatic, brain, and lung cancer, but was more delayed for stomach, colorectal, and prostate cancer. For lung and oesophageal cancer, benefit was confined to adenocarcinomas, and the overall effect on 20-year risk of cancer death was greatest for adenocarcinomas (HR 0·66, 0·56—0·77, p<0·0001). Benefit was unrelated to aspirin dose (75 mg upwards), sex, or smoking, but increased with age—the absolute reduction in 20-year risk of cancer death reaching 7·08% (2·42—11·74) at age 65 years and older.
Interpretation
Daily aspirin reduced deaths due to several common cancers during and after the trials. Benefit increased with duration of treatment and was consistent across the different study populations. These findings have implications for guidelines on use of aspirin and for understanding of carcinogenesis and its susceptibility to drug intervention.
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Re: case of the week

Postby drsclafani » Tue Jun 07, 2011 1:07 pm

Cece wrote:
drsclafani wrote:We have previously spoken about the scenario of this week's case of the week: A procedure totally done using IVUS for diagnosis and intervention.

wow!
Yes, I remember discussing this, and in the very same situation, regarding a patient who had reaction to the contrast dye. Back then you thought it might be something you'd try only if the patient had RR MS, because then she would be more likely to benefit. Now with more procedures under your belt, you would not hold to such a restriction?

As we cannot predict who will benefit most, i will not restrict. This is the patient we discussed previously.

Image
and
Image[/img]
I am not sure what we're seeing in the top left image, it looks triangular?
Bottom left image, bingo! Two white lines are the fixed leaflets?

i will answer after others have had a chance to look and to comment.
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Postby Cece » Tue Jun 07, 2011 1:53 pm

#6 and #7 show another vein merging, is it the EJV?

The very last image, I cannot read the vertical readout because I don't yet understand them, but there is a bright bump in it.

What do you think, dear others? Would you trust Dr. Sclafani to do a procedure on you with IVUS only?
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Postby Cece » Tue Jun 07, 2011 2:19 pm

drsclafani wrote:
jacksonsmommy wrote:I recently heard of someone that had a life threatening reaction to the contrast dye while on the table. They had to stop the procedure immediately.

This person now knows that they have serious stenosis, but have been told that they will never be able to get it treated now unless a new type of dye is invented.

Ever heard of this? Is there seriously no workaround?


Life threatening contrast (dye) reactions occur with an estimated frequency of 1:140,000 to 1:1,000,000. Prior allergic reactions predisposes to another one. Life threatening reactions include anaphylactic reaction, irreversible asthma or bronchospasm, edema of the throat so bad the airway cannot be secured. It is generally considered an absolute contraindication to further imaging with contrast media.

risk analysis does not favor performing this procedure. While we believe that the liberation procoedure has great potential benefits compared to general risk estimates, in this particular patient risk may out weigh benefit.

the only alternative i can think of is to perform the procedure under IVUS alone. that would be quite a challenge. However, with prior venogram completed, it is not without some merit.

i would only consider it, however, in the group where benefit is most compelling, namely RRMS

www.thisisms.com/ftopicp-144654.html#144654
Prior conversation on this matter. Just in case drsclafani thinks I never quote him anymore.... :D
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Postby drsclafani » Tue Jun 07, 2011 2:25 pm

Cece wrote:#6 and #7 show another vein merging, is it the EJV?

The very last image, I cannot read the vertical readout because I don't yet understand them, but there is a bright bump in it.

What do you think, dear others? Would you trust Dr. Sclafani to do a procedure on you with IVUS only?


#6 and #7 are the same, just to provide continuity. That vein merging into the internal jugular vein is the facial vein. the facial vein demarcates the junction of the J3 and the J2 segments of the IJV. The external jugular vein does not merge directly with the internal jugular vein. it is a separate vein that drains into the subclavian vein.

but good thinking...

look carefully at #11. See the two white lines? they are progressively narrowing from the two lines in 10. this is the stenosis! I will show some arrows
Last edited by drsclafani on Tue Jun 07, 2011 4:35 pm, edited 1 time in total.
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Postby Cece » Tue Jun 07, 2011 2:37 pm

drsclafani wrote:look carefully at #11. See the two white lines? they are progressively narrowing from the two lines in 10. this is the stenosis! I will show some arrows

I saw those lines but didn't think they were anything. Huh!

What an accomplishment, for this woman to get the procedure when she'd been told she never would.
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Postby Johnson » Tue Jun 07, 2011 5:06 pm

Cece wrote:Would you trust Dr. Sclafani to do a procedure on you with IVUS only?


Absolutely and unreservedly.

With one eye closed, even.
My name is not really Johnson. MSed up since 1993
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Re: case of the week

Postby Cece » Tue Jun 07, 2011 6:26 pm

drsclafani wrote:The next few minutes became unclear to the patient and she developed anaphylactic shock requiring resuscitation. Resuscitation was successful but the procedure was terminated. The patient returned to Canada, alive, knowing that there was some stenosis but untreated.

She and her husband persisted., seeking a way to undergo another attempt, but obviously unable to have standard venography or venographic guidance to treatment. They tried MR venography. There is no cross reactivity between venographic dye and MR dye. They are separate, different compounds with nothing in common. There is no association of allergic reactions between the two. Nonetheless she had an allergic reaction. They were investigating the use of carbon dioxide gas as a contrast agent, something researched extensively by Irwin Hawkins and Jim Caridi in Florida.

I have a lot of respect for this patient and her husband right now. Gotta admire those who persist in the face of such obstacles.
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Re: case of the week

Postby Cece » Tue Jun 07, 2011 6:38 pm

drsclafani wrote:I told her that I would be willing to attempt the procedure without the use of any dyes and use fluoroscopy and IVUS for guidance, diagnosis and treatment. Fluoroscopy would give me landmarks. The bones visible on fluoroscopy would enable me to know where the trouble was. Finding the trouble would require the use of IVUS to show me stenoses and valvular abnormalities.

I am not familiar with what fluoroscopy shows. You say it would give you the landmarks, such as the bones. You could not see the veins at all? What could you see? The guidewire advancing?
Catheterization began from the left saphenous vein just before it entered the femoral vein. The sheath was placed in the superior vena cava thus avoiding any further instrument placement through the heart. At this time i then administered intravenously benadryl, an antihistamine which promptly caused the heart rate to rise to greater than 160 beats/minute. This was treated and the pulse returned to 80 ppm. Blood sugar had dropped to 53 so 50% dextrose was given. Finally things returned to her steady state and we resumed the procedure.

I bet that was a scare for her, after what she'd been through before.
Selective catheterization of the right internal jugular vein was performed first. I knew i was in the jugular vein because of the guidewire went into the dural sinuses.

Did you get the jugular vein on your first try?
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Postby Cece » Tue Jun 07, 2011 6:43 pm

drsclafani wrote:
Cece wrote:Hi, Dr. Sclafani! Are you back from Italy yeeeet? There has been much excitement over in the ISNVD thread, what a conference. How did your ivus presentation go? What ideas did you find most intriguing over there?


it was a candy store of ideas

The ivus was enjoyed. during the week several on the podium supported the ivus value
a couple of people actually tnink that IVUs may be the gold standard ond eayh. I am thinking to try to use IVUS as the primary diagnostic tool in a few cases, to correlate in reverse, from the ivus to the venogram....see how that works.

Had you tried this (using IVUS as the primary diagnostic tool, correlating to venogram) before this most recent case? Were there any stenoses that showed on venogram that did not show on IVUS?
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Re: case of the week

Postby drsclafani » Tue Jun 07, 2011 8:02 pm

Cece wrote:
drsclafani wrote:I told her that I would be willing to attempt the procedure without the use of any dyes and use fluoroscopy and IVUS for guidance, diagnosis and treatment. Fluoroscopy would give me landmarks. The bones visible on fluoroscopy would enable me to know where the trouble was. Finding the trouble would require the use of IVUS to show me stenoses and valvular abnormalities.

I am not familiar with what fluoroscopy shows. You say it would give you the landmarks, such as the bones. You could not see the veins at all? What could you see? The guidewire advancing?


Fluoroscopy is the viewing of the body through a fluoroscope. Xrays are passed through the body and are attenuated and absorbed on their way through. What reaches the other side of the body is then recorded as energy that is received by a detector and amplified electronically before being transformed into pixels on a TV monitor.
So what we see are those things that attenuate and absorb the xray more or less than water, such as bones, gas, fat and catheters and guidewires, IVUS devices or balloons filled with contrast media.

We always use fluoroscopy during angiography.

We know for example that the renal veins are going to be at the level of the first and second lumbar vertebrae and that the jugular vein is going to be at a certain location, etc.

Catheterization began from the left saphenous vein just before it entered the femoral vein. The sheath was placed in the superior vena cava thus avoiding any further instrument placement through the heart. At this time i then administered intravenously benadryl, an antihistamine which promptly caused the heart rate to rise to greater than 160 beats/minute. This was treated and the pulse returned to 80 ppm. Blood sugar had dropped to 53 so 50% dextrose was given. Finally things returned to her steady state and we resumed the procedure.

I bet that was a scare for her, after what she'd been through before.


for patient AND doctor


Selective catheterization of the right internal jugular vein was performed first. I knew i was in the jugular vein because of the guidewire went into the dural sinuses.

Did you get the jugular vein on your first try?


yup :D
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Postby drsclafani » Tue Jun 07, 2011 8:03 pm

Johnson wrote:
Cece wrote:Would you trust Dr. Sclafani to do a procedure on you with IVUS only?


Absolutely and unreservedly.

With one eye closed, even.


you want me to work with one eye closed?

actually i do all my procedures with my eyes closed :D
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Postby drsclafani » Tue Jun 07, 2011 8:05 pm

Cece wrote:
drsclafani wrote:
Cece wrote:Hi, Dr. Sclafani! Are you back from Italy yeeeet? There has been much excitement over in the ISNVD thread, what a conference. How did your ivus presentation go? What ideas did you find most intriguing over there?


it was a candy store of ideas

The ivus was enjoyed. during the week several on the podium supported the ivus value
a couple of people actually tnink that IVUs may be the gold standard ond eayh. I am thinking to try to use IVUS as the primary diagnostic tool in a few cases, to correlate in reverse, from the ivus to the venogram....see how that works.

Had you tried this (using IVUS as the primary diagnostic tool, correlating to venogram) before this most recent case? Were there any stenoses that showed on venogram that did not show on IVUS?


while there are uncommonly cases that show nothing on ivus and something on venography, it is much more common to identify things on IVUS that are not visible on venography

patient and husband understood that risk before we started.
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Postby Thekla » Wed Jun 08, 2011 12:47 am

"you want me to work with one eye closed?
-----actually i do all my procedures with my eyes closed"

Now we know your secret! You are a Jedi master! 8)
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Re: case of the week

Postby drsclafani » Wed Jun 08, 2011 4:59 am

Image
and
Image[/img]
I am not sure what we're seeing in the top left image, it looks triangular?
Bottom left image, bingo! Two white lines are the fixed leaflets?

i will answer after others have had a chance to look and to comment.[/quote]

The first image that struck me as unusual is #2. Here is a close-up:Image
This is in the dural sinuses. The bright reflections do you see the tissue with reflections at about "9 o'clock?
i was wondering what this was. I have never seen anything like that before on IVUS. Could it be a clot?

I surmised that it represented Arachnoid granulations. These are SF-filled meningothelial-lined protrusions that are filled with CSF. They
extend into the venous sinuses through openings in the
dura. They filter CSF and drain it into central venous circulation.

it is important to differentiate them from dural sinus thrombosis and tumor. It was in a typical location for arachnoid granulations.
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