jgalt2009 wrote:Dr. Sclafani, I have two questions.
1. You state that, when you have a chance, you look in the vertebral veins, and you also stated that you now routinely check the dural sinuses. Do you have a "basic" playbook for the procedure, and adjust it based on circumstances or available time or other criteria?
time never really is a criteria for what i do. i take as much time as necessary to get the job done.
the basic playbook keeps being enhanced.
it is as follows
2 time out
4 lidocaine anesthesia
5 ultrasound detection of the saphenous vein at the saphenofemoral junction
6 micropuncture access
7 sequential dilatation to 10 French
8 introduction of 80 cm 10 French sheath and placement in the superior vena cava
9 selective catheterization in whatever sequence makes sense of the right internal jugular vein, the left internal jugular vein and the azygous vein over a 0.014 inch platinum tipped guidewire.
10 after fentanyl analgesia, in each jugular first advance catheter into the transverse sinus and do Frontal and Lateral views of the dural sinuses into the jugular bulb
11 then do jugular venogram
12 then do ivus
13 then if appropriate measure cross sectional area of IJV above and below stenosis
14 then select balloon 50-100% larger in cross sectional area than vein balloon using ivus images depending upon location and size of the vein
15 give more fentanyl
16 inflate balloon to nominal pressure and identify 'waist"
17 position balloon shoulder at the waist
18 inflate to 10 Atmospheres.
19 if waist still present, inflate balloon up to 20 atmospheres slowly and incrementally to pressure that effaces the waist, moving shoulder of balloon to effect most stretching .
20 keep inflated for 15 second
21 check for elastic recoil, if none remove balloon
22 repeat venography and IVUS
23 if ok, move on to next vessel
24 azygous same basic principles but techniques and views different
25 after these three vessels are completed, move into abdomen,
26 catheterize and venogram of left renal vein
27 if stenosis, angioplasty and stenting
28 then IVC gram.
29 if may thurner angioplasty and stenting
30 then ascending lumbar venogram.
31 after everything completed remove catheter
32 manual compression of puncture site
33 pressure bandage
34 recovery for one hour
35 write report
26 discharge patient
it is my understanding is that the azygous vein serves to exfiltrate blood from the vertebral plexuses on the right side, and the hemiazygous and accessory hemiazygous exfiltrates blood from the left side of the v-plex. If this is correct, why not catheterize the hemiazygous and accessory hemiazygous while you are down in the azygous?
these veins are all one system and they can be assess quite nicely by injections of the azygous.
i dont quite agree with your assessment though, there are branches that interconnect all the way through the system.
I'm thinking that when you get two flat tires, if you only fix one flat, the car will still perform poorly.
These veins are progressively smaller. there comes a time when angioplasty is only going to get you in trouble.