jgalt2009 wrote:Dr. Sclafani,
I am fascinated by the categorization of CCSVI by location of blockage. While nobody wants to have any of the types, type D (multi-level azygous and lumbar blockages) seems to be heavily correlated with PP (and thus, the diagnosis one would least want to receive).
1. Has this association held up in the sample population of patients that you have treated?
No. I have found no pattern to be associated with any particular type of MS. This multilevel azygous and lumbar blockage pattern to be very uncommon. I am skeptical about multilevel azygous findinigs. I do most of my azygous imaging in deep inspiration. I do not see such findings very often. I think bilateral jugular stenosis is more common in PPMS than type 4.
when i perform azygous imaging during expiration i often find narrowing in the middle of the ascending azygous vein. On IVUS this seems to be phasic. I believe that the so called candy wrapper stenosis depends upon the phase of respiration. I do not treat it unless it is seen in all phases of respiration.
Lumbar hypoplasia seems very common among MSers of all types.
2. Is it possible that the upward venous drainage through the "intrarachidean" circle exacerbates lesion formation because of the constant turbulent flow of blood flowing against gravity (up-flow during cardiac systole, down-flow due to gravity during cardiac diastole, resulting in expression of surface adhesion molecules, etc.)?
it's possible. I have no opinion.
3. IF (2.) is true, wouldn't it be wise for patients with type D CCSVI to sleep in a slight declining orientation (head below feet) in order to decrease turbulence during sleep?
I dont know. I wouldnt recommend putting the head below the feet without proof of your conjecture.
4. Since type 4 CCSVI is characterized primarily by multiple azygous blockages, and angioplasty of the azygous has the greatest long-term patency, are you surprised by the lack of significance in QoL measurement for PPMS patients (I would have expected the best scores at the 18 mo. follow-up)? Do you have a hypothesis to explain this?
perhaps it's just a different disease that involves areas of the spine critically and that treatment of ccsvi has no effect on the spinal lesions. Also I do not think that you can make any meaningful conclusions about PPMS in Zamboni's paper, The patient numbers were far too few and the followup was far too short.
The more i treat this, the more I believe that i am not treating MS at all, but most of the time treating ccsvi.
Thanks so much for your time, and forgive me for the misuse of any medical terms. I received my medical license from the University of Wikipedia.
Well, professor of Wikipedic surgery: i am most impressed by your questions.