DrSclafani answers some questions

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

Postby Cece » Sat Jul 30, 2011 12:50 pm

drsclafani wrote:The woman then consulted me. Ultrasound showed residual valvular deformities and reflux only in the supine position. The test was equivocal. I expected no significant treatment options.

In general, have you found ultrasound to be accurate in determining restenosis? In this one, we can say that it was not accurate, if the test was equivocal but the venogram found three areas in need of treatment.

ok you just answered this question before I asked it, in the post to vlpg! That was quick. (answer = not a perfect correlation)
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Postby Cece » Sat Jul 30, 2011 1:05 pm

drsclafani wrote:Then on to the Azygous.

Image


The venogram on the left shows a really nice open Azygous arch. No stenosis, no webs, no valves, nothin.

But IVUS shows a severely narrowed vein with about a 75% stenosis. The arrows point to intraluminal tissue that results in the narrowing. It is also visible on the sagittal reconstruction.

It's amazing to see such a bad stenosis completely hidden on the venogram. I am guessing that this is due to flow passing down the funnel at the valve itself and then backfilling under the cusps? But I would still think there would be some sign of it on the venogram. Your images prove me wrong.
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Postby Cece » Sat Jul 30, 2011 1:22 pm

drsclafani wrote:So before we talk about restenosis, we need to be assured that the angioplasty was adequate.

I think you are right about this.

Finally, there is no evidence that angioplasty causes injury. Again, there is NO evidence of vein wall injury after TWO angioplasties.

With this case, the balloons were undersized, I would not expect vein wall injury. I worry still for people getting treated with oversized balloons.
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Postby NZer1 » Sat Jul 30, 2011 1:53 pm

Hi everyone,
What I am now understanding is that IVIS it giving far more information to someone with your experience and skills and that is making a major difference in 'finding' previous undetected issues, which will give better long term symptom benefit. This brings me to be belief that IVIS is going to be necessary to provide lasting results.

Is it possible that IR's who frequently use IVIS are giving better service?

Do you think IVIS will be a gold standard test?

Dr. is there any reliable feed back from the IR's who were using big balloons in the earlier treatments?

Regards Nigel
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DrSclafani answers some questions

Postby tinajo » Sat Jul 30, 2011 4:24 pm

Dear Dr. Sclafani,
I have a big decision to make and I am in need of your advice.
I recently had a doppler US in Arizona with Eric Feigenbutz. I basically have oversized, floppy valves/leaflets in my IVJ.
So, I was considering travel to NY to see you- however Dr. Makris is much closer and no flying.

My questions are:
Are your discoveries shared with the other AAC doctors?
especially dilation size and length and type of anti-coagulants.
If I am treated now- and plan on staying around another 40 + years will my veins be able to hold up to future tune ups or do I risk damaging them for future improvements in treatment. I realize this is a difficult question- but I would like your thoughts on this.

Thank you for everything- I can't truly express the gratitude I feel for your willingness to make yourself available to us- I was having such anxiety over this until I discovered you on TIMS. You made it all so real to me.

Best Regards,
Tina
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Postby drsclafani » Sat Jul 30, 2011 5:58 pm

NZer1 wrote:Hi everyone,
What I am now understanding is that IVIS it giving far more information to someone with your experience and skills and that is making a major difference in 'finding' previous undetected issues, which will give better long term symptom benefit. This brings me to be belief that IVIS is going to be necessary to provide lasting results.

Is it possible that IR's who frequently use IVIS are giving better service?

do you want my conjecture or facts? I think that IVUS adds value to the procedure but at a cost, some of which gets borne by the patient. You get what you pay for. It is not for free.

Do you think IVIS will be a gold standard test?

I think that at the current time IVUS and Venography leads to improved diagnosis and refined treatment decisions. FOR ME the combo is my gold standard

Dr. is there any reliable feed back from the IR's who were using big balloons in the earlier treatments?

Regards Nigel


Nigel, do you hear anyone else talking about their problems?
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Postby drsclafani » Sat Jul 30, 2011 5:59 pm

Cece wrote:
drsclafani wrote:So before we talk about restenosis, we need to be assured that the angioplasty was adequate.

I think you are right about this.

Finally, there is no evidence that angioplasty causes injury. Again, there is NO evidence of vein wall injury after TWO angioplasties.

With this case, the balloons were undersized, I would not expect vein wall injury. I worry still for people getting treated with oversized balloons.


Agreed.now all we have to do is decide what is oversized.

i guess oversized is a balloon that leads to tears and thromboses

Oops, cant determine that AFTER treatment, can we.
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Postby Cece » Sat Jul 30, 2011 6:17 pm

drsclafani wrote:
Cece wrote:
drsclafani wrote:So before we talk about restenosis, we need to be assured that the angioplasty was adequate.

I think you are right about this.

Finally, there is no evidence that angioplasty causes injury. Again, there is NO evidence of vein wall injury after TWO angioplasties.

With this case, the balloons were undersized, I would not expect vein wall injury. I worry still for people getting treated with oversized balloons.


Agreed.now all we have to do is decide what is oversized.

i guess oversized is a balloon that leads to tears and thromboses

Oops, cant determine that AFTER treatment, can we.

It's not pretty but it has come down to trial and error this past year, by all of the treating doctors. I feel deeply for those who experienced the errors.
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Postby Cece » Sat Jul 30, 2011 6:24 pm

HappyPoet wrote:
drsclafani wrote:Perhaps the 16 mm balloon will be judged to be too small but i calculated that the 16 mm balloon is about 50% greater in surface area than the cross sectional area of these veins. I am dilating to 50-80% increase in cross sectional area measurement.

If a patient wanted a conservative procedure, is balloon sizing an area where a patient could ask for you to dilate only to a 50% increase in cross sectional area measurement as opposed to 80%?

To piggyback on this question, it could be asked more broadly: what changes would you make if a patient specifically requested a very conservative treatment?
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Postby Cece » Sat Jul 30, 2011 6:56 pm

drsclafani wrote:Patient has previously been treated by a well known and respected interventionalist. The first treatment revealed a right sided stenosis that was treated with a 12 mm balloon. The left side was thought to be an insignificant stenosis. There were improvements in several symptom complexes. The symptoms gradually returned over the next couple of months.

A second procedure done a few months after the first showed that the right IJV was not restenosed, but the left IJV was felt to be significantly stenosed and was treated with a 14 mm balloon. Again with clinical improvements and yet again with gradual deterioration back to baseline.

This then might be the clinical profile of undertreatment? Although it might vary from patient to patient. Gradual deterioration of improvements.
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Postby Cece » Sat Jul 30, 2011 7:05 pm

drsclafani wrote:Image



The image on the left is a right dural venogram. Note the contrast in the left dural sinuses and in the left internal jugular vein. This is not normal. The area of the confluens (second image from the left) shows an irregular outline. I believe that some of this represents reflux into a collateral.

Huh! I've wondered about those irregular outlines when we've seen them.
Angioplasty (third from the left) was performed. Upon nominal inflation two annular narrowings were identified. They went away with 14 Atm of pressure. The end result ( far right) looks pretty good).

The end result looks great. And the irregular outline is much more regular looking.
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Postby Cece » Sat Jul 30, 2011 7:11 pm

drsclafani wrote:So I used the same 16 mm balloon to dilate the confluens of the right IJV.

A cost-saving measure? ;)
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Postby drsclafani » Sat Jul 30, 2011 8:27 pm

HappyPoet wrote:Hi Dr. Sclafani,


I'm puzzled by the reflux of contrast into the L-DS after venography of the R-TS. What path did the contrast take and what accounts for this reflux? Do you have video of this as it's happening that you can show (maybe youtube)?


Sorry, i dont have it. The dural sinuses for the most part are a continuous circuit of venous drainage that allows flow from one to the others. In this case the contrast flows from one transverse sinus to the other and then down into the left jugular vein Why would this happen? Because there is more resistance to flow on the same side as there is to the other side.



HappyPoet wrote:So, at this point in time, all appears well with the once-treated R-IJV. The once-treated L-IJV venous wall, though, appears intact, as if only temporarily stretched with too small a balloon--which accounts for both the temporary improvement in symptoms and no permanent injury to the vein wall above the stenosis. Could it be, though, that the vein wall, itself, was never dilated, that the balloon shoulder had been placed against just the valvular stenosis and not the vein wall at all, eccentrically ala Sclafani?

Yes that is possible. The problem is that the valvular stenosis was not effectively dilated to remain open for a long time. My point is twofold, choosing a balloon size that will adequately stretch the stenosis while minimizing the stretch of the normal vein.

HappyPoet wrote:How does the number of times the balloon is inflated and the length of time the balloon is inflated fit into the overall equation that also includes the atmospheres of pressure used/required and the size of balloon chosen, ala Sclafani IVUS Balloon-sizing Method discussed below?


frequency of inflation: each inflation imparts stress to the vein wall and the stenosis, sometimes several stretches allow gradual stress rather full stress during one inflation

duration of inflation
longer duration may allow prolonged stretch of the stenosis; however it increases the time that intimal gets no oxygen

amount of pressure applied
The more pressure the greater the forces applield to expand the tissue. Highly resistant tissues require higher pressure to stretch it

size of the balloon
balloon size determines how much stretch is applied. undersizing results in inadequate stretch, oversizing risks overwhelming the structure integrity of the structure




HappyPoet wrote:If a patient wanted a conservative procedure, is balloon sizing an area where a patient could ask for you to dilate only to a 50% increase in cross sectional area measurement as opposed to 80%?


I can only speak personally. I value my expertise and judgment. As such I am willing to hear patients' desires, but ultimately the physician should be responsible to meet the goal of the patient in a safe and responsible way. I would feel uncomfortable deferring years of training to the less educated directions of a patient. Actually there is the possibility of malpractice in certain situations.

Also it is my responsibility to educate my patients so that they understand what i am doing and why i am doing it



HappyPoet wrote:Where did you place the shoulder of the balloon? Was there a valve at the confluens? Was this decision difficult?


there are two shoulders upper and lower. I use both shoulders depending upon the anatomy. I try to place the majority of the balloon in the area that is largest so that there is less stretch on the balloon. For the most part the vein above the stenosis is usually smaller than below the stenosis. That means that I would place the upper shoulder at the stenosis and the rest of the balloon would trail into the larger more central vein. In those circumstances were the vein above was more dilated, i would use the lower shoulder at the stenosis and let the remainder of the balloon flop into the upper dilated segment.




HappyPoet wrote:Again, I'm puzzled. Will this angioplasty stop blood from flowing/refluxing down the L-DS and L-IJV?

If the obstructions at the valve are overcome and the resistance is reduced by enlargement of the stenosis sufficiently, then flow should go to the path of least resistance down the jugular.
This is the primary purpose of the angioplasties

HappyPoet wrote:By "annular narrowings," do you mean the two areas seen had an actual annulus with no valve flaps? Was there a "pop" heard when the annular narrowings went away?

annular stenosis is a bad term, sorry. Zamboni used it to describe a short focal circumferential stenosis. Ironic, then, that the majority of the stenoses occur at the annulus, which is the scaffold of hard collagen tissue that provides support for the attached valves

i no longer like to hear the pop...i try slower and repeated dilatations to stretch rather than fast. I have learned from my mistakes. :cry:


HappyPoet wrote:This shows the value of IVUS.

I honestly don't see anything on the sagital reconstruction where the arrow is pointing near the thin, green horizontal line. What does the large shift in signal represent far above the arrow?


the large shift represents movement of the tissue during normal breathing,and pulsations.

i would consider the green line to be vertical. It represents the plane of the ivus device. to the right of the green lines one sees some white longitudinal speckles. There represent sound reflections off the narrowed valvular area.



HappyPoet wrote:This makes sense; how does an IR tell the difference between thrombosis, and/or intimal hyperplasia, and/or valvular or intraluminal tissue that is either not staying pressed into the vein wall or is a defect?

All of this is VERY interesting. :)

ultrasound can usually tell the difference. The hemodynamics might be misleading but the anatomical visualization is pretty good and one should be able to differentiate these problems for the most part.

HappyPoet wrote:Please forgive my cogfog, but I don't get this--what about restenosis?


in this case, i believe that this patient was undertreated rather than restenosed. I am just making the point that all instances where patient loses improvements are not the result of restenosis. Thus repeating procedures in this circumstance is essential and not an overzealous repeated angioplasty.

HappyPoet wrote:Thank you, DrS!


thank you. Your questions were very good. I am impressed.
i thank you because your questions and those of others have helped guide my thinking and formulate my answers to patients.
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Postby HappyPoet » Sat Jul 30, 2011 8:47 pm

Dr. Sclafani, I guess I got carried away inside your case. Please take my previous post only as evidence of how great a teacher you are--you taught me everything I know about CCSVI venoplasty and make me want to learn and understand more.

For this case, Cece zeroed in on the important issues (thank you, Cece). She has mastered how to approach your cases--the right comments with the right questions in separate posts. Well done, Cece. From now on, I'll sit back and let you two teach. I am a motivated learner. :)
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Postby drsclafani » Sat Jul 30, 2011 9:04 pm

HappyPoet wrote:Dr. Sclafani, I guess I got carried away inside your case. Please take my previous post only as evidence of how great a teacher you are--you taught me everything I know about CCSVI venoplasty and make me want to learn and understand more.

For this case, Cece zeroed in on the important issues (thank you, Cece). She has mastered how to approach your cases--the right comments with the right questions in separate posts. Well done, Cece. From now on, I'll sit back and let you two teach. I am a motivated learner. :)


I DISAGREE
you asked great questions. dont lurk
s
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