jgalt2009 wrote:Dr. Sclafani,
I have a few questions, but before getting to them, I want to express, not just my appreciation for you, but WHY I appreciate you so much.
In any normal environment, I only get to speak with my doctor when I have an appointment. If I am properly prepared, I can usually get my most pertinent questions answered. However, follow-up questions, "what-if" questions, distractions, impatience by the doctor, my knowledge that he has 20 people to see after me... all of this leads to me feeling frustrated after the visit.
By making yourself available in this forum to answer our questions, you have taken time out of your very busy life and donated it to a large number of people that you have never met (and in most cases, never will). I find this act to be generous and lovely. With deepest appreciation, I salute you.
i appreciate the sentiments.
And I'll try not to waste any of your time with stupid questions. Hopefully these are worthy:
the only unworthy question is one that is not voiced
1. When you encounter a resistant stenosis, what demographic factors do you consider in your treatment plan? Specifically, do you treat differently based on patient age, race or gender (e.g. do you test African-american patients for a proclivity to hypertrohic scarring; are 50 y.o. IJV's more prone to distress than 25 y.o.; etc.)?
when i encounter a resistant stenosis i wonder how much pressure i will apply to the balloon. I stress about exceeding the pressure limits of the balloon and worry about balloon rupture. Pressures as high as necessary often exceed the pressure transmitted by a high power rifle. So ultimately we come down to failure to break the stenosis and then anguish about how to address both the persistent stenotic lesion and the injury of the vessel, or worse, the damage caused by balloon rupture.
I dont think too much about keloid formation. I have only treated two african americans, who seem to abhor this disease as much as I do.
At this stage i havent really found any proclivities toward resistant stenoses. Not age, sex, degree of stenosis, race, location type of MS...nothing.
2. When you (hopefully rarely) encounter injury resulting from vascular ballooning:
a. is the correct term for the injury intimal hyperplasia, thrombosis, or something else?
the correct term for injury is "injury". Injuries include intimal crush, intimal tears, mural ruptures which can all lead to hematoma and thrombosis, mural dissections where the intimal and part of the media pulls away from the rest of the wall and may cause compromise to flow, are a few of the things that can occur
b. do you know if the injury is from stretching of the endothelia along the expanding circumference of the lumen, or from compression of the endothelia between the balloon and the Tunica media?
most injuries are caused by stretching the wall of the vessel, rather than crush of the intimal.
3. IF the limiting factor on achieving a patent IJV (that has a resistant stenosis) is stretching of the intima (and not compression), would it be possible to encase the exterior of the IJV with a sleeve to allow much higher pressures during the ballooning process (I've read about vascular sleeves for aneurysm mitigation)?
if you are going to do that, you might as well resect the problem and see what happens. I think that we need to patent the tissue that can exceed 30 atmospheres of pressure. would put kevlar out of business.
