DrSclafani answers some questions

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

Postby pklittle » Mon Aug 08, 2011 9:36 am

Questions about the case for Dr. Sclafani:


1. re the implanted port for ms drugs - where was that located and what impact, if any, did it have on your procedure?

2. "after 30-40 minutes, I could not enter the right jugular vein. "
How do you try for that long to enter? Do you try different methods of entry?

3. "Catheterization was also very difficult and I was about to give up when I finally was able to enter the LIJV. Almost one hour had passed."
One hour on the left? wow, again, do you try different ways to enter?
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Postby Cece » Mon Aug 08, 2011 1:28 pm

drsclafani wrote:As usual I accessed the venous circulation via the left saphenous vein. I attempted right jugular catheterization first. However after 30-40 minutes, I could not enter the right jugular vein. So i moved on to the left internal jugular vein..

How often does it happen that a vein cannot be catheterized?
Catheterization was also very difficult and I was about to give up whenI finally was able to enter the LIJV. Almost one hour had passed.

About to give up! That is out of character for you....
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images from my procedure...

Postby dlb » Mon Aug 08, 2011 1:33 pm

Can anyone help me?
I have tried to look at the images from the 2 cds that I got from AAC but I can't - neither on my Mac or hubby's PC.
Have been on the go since my return from Brooklyn, but I tried a second time today and no luck - not that I'll likely make any sense of anything there anyways, but.... a PM works for me rather than cluttering this thread!

Thanks,
Deb
Last edited by dlb on Mon Aug 08, 2011 1:37 pm, edited 1 time in total.
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Postby Cece » Mon Aug 08, 2011 1:36 pm

The catheter was then withdrawn into the internal jugular vein.
Venography looked like this:

Image

Does she not have a right jugular? We see other things lighting up on that side but not a jugular.

A year ago you said that you'd heard people here on TIMS talk about having a missing jugular but had never seen it clinically nor heard about it from your colleagues. There was the possibility that it was not a missing jugular but a jugular that had been missed.

We'd heard about one confirmed case of agenesis. This was quite some time back. Here it is. It was in the doctors' thread:
www.thisisms.com/ftopicp-150051.html#150051

Phlebologist's findings would suggest that true agenesis is very rare but possible.

On a sidenote, it is interesting what he says about the cranial portion of the vein improving after the lower part of the vein is dilated and that he does not know what causes this because it is not flow. I wonder if this could be explained by changes in pressure? Or is there a better explanation?
Last edited by Cece on Mon Aug 08, 2011 7:23 pm, edited 1 time in total.
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Postby Cece » Mon Aug 08, 2011 1:43 pm


Image

The upper left image shows the area of stenosis (black curved arrow). Minimal contrast exits the IJV; Collaterals are seen crossing the midline to opacify the External jugular vein (EJV), the vertebral vein (VV) and the subclavian vein (SCV). Other collaterals are seen in the midline.

The Left bottom image is an IVUS image at the level of the probe. The valve was persistently closed. The dense white tissue represents the valve tissue, thickened and immobile.

That valve looks worse than usual.

And this is the image that really makes it doubtful that there is an IJV anywhere on the right side. If there was a 100% blockage up in the sinuses (assuming there's a sinus!) thus allowing other veins to light up but not the RIJV and a 100% blockage at the base, preventing entrance, then there could still be a RIJV?
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Postby Cece » Mon Aug 08, 2011 1:59 pm

This next sequence shows that decision in action.

Image

The uper row again shows the IVUS exam. The middle row (Left) shows the IVUS probe at the level of the valve stenosis. It is just below the second rib. I attempted to place the upper shoulder of the 14 mm balloon (note the black dot at the waist on the balloon) exactly at the valvular stenosis (MIDDLE). Unfortunately I cut it too close and the balloon slipped below the stenosis. (RIGHT) The balloon was deflated and repositioned.

The lower row shows the new position of the balloon. Thus there is a small amount of upper vein that will be subjected to a fairly large distension (double in cross sectional area). The waist on the balloon (indicative of resistance to dilation) was overcome with 18 atmospheres of pressure. The post dilatation venogram shows a really nice diameter.

Unfortunately, there was still slow flow....

But that is a story for another day

Any questions so far?

So the black dots mark the shoulders? I've noticed them before.

The banding is very thick and white. Really remarkable.

In the last image, lower right, why is there a big puff of contrast off to the side?

Why is there still slow flow? No other waists showed on the balloon. You've checked out the dural sinuses. You had already checked the upper vein by IVUS at this point?

I was seeing this patient as a candidate for on-the-table improvements, because of the severity of the blockage leading to a marked increase in blood flow when cleared. But now I am not as sure, with that mysterious slow flow....
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Postby Cece » Mon Aug 08, 2011 2:19 pm

pklittle wrote:
But what does the picture of the radiologist (included in the article) say about him?


Mad scientist?!? HA! :mrgreen:

:lol:
He's scruffy. Hasn't shaved. Probably overworked. Nice looking, though. Intense gaze. Gaze is important in radiology....
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Re: images from my procedure...

Postby drsclafani » Mon Aug 08, 2011 4:29 pm

dlb wrote:Can anyone help me?
I have tried to look at the images from the 2 cds that I got from AAC but I can't - neither on my Mac or hubby's PC.
Have been on the go since my return from Brooklyn, but I tried a second time today and no luck - not that I'll likely make any sense of anything there anyways, but.... a PM works for me rather than cluttering this thread!

Thanks,
Deb

\
deb

Set internet explorer to the default browser. Then load the cd. it will automatically boot.

Open internet explorer
go to tools
then go to programs
then set internet explore as default browser.

if you still have a problem, give a call.
not tonite

more importantly, how are you
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Postby HappyPoet » Mon Aug 08, 2011 4:34 pm

As I understand the procedure, the contrast dye is only sent down one side at a time; therefore, the venography of the L-IJV would not opacify the R-IJV. The Right VV (and other veins) are only visible (opacified) because they are connected by collateral veins. My guess is that there is a R-IJV that we haven't been shown (yet).
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Re: images from my procedure...

Postby dlb » Mon Aug 08, 2011 5:06 pm

drsclafani wrote:
dlb wrote:Can anyone help me?
I have tried to look at the images from the 2 cds that I got from AAC but I can't - neither on my Mac or hubby's PC.
Have been on the go since my return from Brooklyn, but I tried a second time today and no luck - not that I'll likely make any sense of anything there anyways, but.... a PM works for me rather than cluttering this thread!

Thanks,
Deb

\
deb

Set internet explorer to the default browser. Then load the cd. it will automatically boot.

Open internet explorer
go to tools
then go to programs
then set internet explore as default browser.

if you still have a problem, give a call.
not tonite

more importantly, how are you


Thanks for that info for viewing the images - will try that on the PC!

I'm doing very well. My balance is greatly improved - Doug just asked for a "heel to toe" walk again last night! It was a huge improvement - think I could walk indefinitely like that! Also, less bladder urgency and I'm still just amazed at my new ability to withstand heat. We just returned from Arizona (there for 8 days). At one point the car's outdoor temp said 117 degrees and I had no difficulty dealing with that heat. Wasn't indoors all the time & I think I can safely say that had we made this trip prior to my procedure, I don't think I could have handled that heat! What is the explanation for the ability to perspire & cope with temp, post-procedure? Whatever it is, I am absolutely thrilled with that!

Thanks again... for everything!
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Postby Cece » Mon Aug 08, 2011 6:40 pm

HappyPoet wrote:As I understand the procedure, the contrast dye is only sent down one side at a time; therefore, the venography of the L-IJV would not opacify the R-IJV. The Right VV (and other veins) are only visible (opacified) because they are connected by collateral veins. My guess is that there is a R-IJV that we haven't been shown (yet).

Could be. This makes me think to ask very specifically: by what route is the contrast getting from the LIJV to, say, the external jugular on the right side? My assumption had been that it went across the sinuses and, since the EJV and the VV on that side lit up, the IJV should've lit up too.

Busy busy drsclafani, come back and clarify! :D
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Postby Thekla » Tue Aug 09, 2011 6:39 am

On newer versions of internet explorer, like IE9, you may also have to go to Tools/Internet Options and then click on the "Advanced" tab. Scroll about 2/3 down to "Security" in Settings and make sure the first option: "Allow active content from CDs to run on my computer" is selected.

This is a new security default setting that older versions didn't have.
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Postby HappyPoet » Tue Aug 09, 2011 6:33 pm

Cece wrote:
HappyPoet wrote:As I understand the procedure, the contrast dye is only sent down one side at a time; therefore, the venography of the L-IJV would not opacify the R-IJV. The Right VV (and other veins) are only visible (opacified) because they are connected by collateral veins. My guess is that there is a R-IJV that we haven't been shown (yet).

Could be. This makes me think to ask very specifically: by what route is the contrast getting from the LIJV to, say, the external jugular on the right side? My assumption had been that it went across the sinuses and, since the EJV and the VV on that side lit up, the IJV should've lit up too.

Busy busy drsclafani, come back and clarify! :D

Cece, I think we might have been too busy looking at the trees that we didn't see the forest because in DrS's introduction to the case, he said that there is an R-IJV:

DrSclafani wrote:As usual I accessed the venous circulation via the left saphenous vein. I attempted right jugular catheterization first. However after 30-40 minutes, I could not enter the right jugular vein. So i moved on to the left internal jugular vein..

Catheterization was also very difficult and I was about to give up whenI finally was able to enter the LIJV. Almost one hour had passed.

The case is interesting because the IJVs are supposed to take control away from the VVs when the patient is in the supine position during the venography, BUT both VVs opacify (darken with dye) just like the IJV which means there's a blockage (valvular stenosis) causing reflux into the VVs. A major collatoral circle involved might be the intracranial condylar venous system.

I wonder if this woman is the patient who needed to come back the next day for more work. DrS spent twice as much time trying to find/create an opening in the L-IJV valve than he spent on the R-IJV valve, so maybe he wanted another crack at the stubborn R-IJV valve. Here's a radical idea: Via the dural sinuses, find/create an opening in the R-IJV valve from above the valve, then attempt normal venoplasty from below the valve.

Is this the first time we've seen a VV take on refluxed blood? Did the VVP receive refluxed blood, too? In CCVBP theory, the VVP is the route by which lesions are formed on the cord.
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Postby MikeInFlorida » Tue Aug 09, 2011 6:37 pm

Dear Dr. Sclafani,
I have a thousand questions, but I'm not sure how to start, so I'll start by "blurting" a few (probably unimportant questions) while I collect my thoughts.
1. Why did you start with the right instead of the left (this is pure curiosity)?
2. Why did you try for 15 minutes on the right, then for 45 minutes (or more if it had taken more) on the left? Were you expecting one of the two IJV's to be easier than the other? I guess I'm asking, is it unusual for both IJV's to be such a PITA (pain in the a$$)?
3. The emissary vein collateral... my anatomy book doesn't show it traversing the hypoglossal canal. The only pic I can find of the emissary vein is superior to the saggital sinus (Netter Atlas, plate 99 and 101).
4. How could the contrast dye possibly illuminate the right IJV? A previous commenter hypothesised that the right IJV does not exist because it was not illuminated by the refluxed dye injected into the left IJV. Do the right and left IJV's communicate throught the emissary veins?
5. I was about to hit the "submit" button, but saw the "mastoid emissary" in the general vicinity of the jugular bulb (the condylar emissary vein is also nearby). If either of these are the referenced collateral, please ignore #3 (but which one?). If not, please explain my confusion.
6. How much radiation is the patient exposed to during a nominal procedure?
7. How much are you and your staff exposed to radiation during a nominal procedure?

These are random, simple (blurted) questions. I am fascinated by this case, and I hope to have more and better questions soon. I look very much forward to hearing more about this.

Mike
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Postby Cece » Tue Aug 09, 2011 6:44 pm

MikeInFL, welcome! If you start off with that many good questions, we will expect more great things from you to come.
HappyPoet wrote:Here's a radical idea: Via the dural sinuses, find/create an opening in the R-IJV valve from above the valve, then attempt normal venoplasty from below the valve.

Do you mean cross from one dural sinus to the other?

This could also be done with a rendezvous procedure to stay out of the sinuses. Although I am still not convinced that there is a RIJV....

drsclafani wrote:I attempted right jugular catheterization first. However after 30-40 minutes, I could not enter the right jugular vein. So i moved on to the left internal jugular vein..

Catheterization was also very difficult and I was about to give up whenI finally was able to enter the LIJV. Almost one hour had passed.

I took this to mean that an hour in total had passed. Thirty to forty minutes on the right vein that was unsuccessful and twenty minutes on the left vein?
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