DrSclafani answers some questions

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

Postby MikeInFlorida » Mon Aug 15, 2011 5:45 am

drsclafani wrote:
MikeInFlorida wrote: I'll request the x-rays on Monday, and I'll post them as soon as I get them.
that will be very revealing.


Medical records department says it will be at least two days.
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Postby Cece » Mon Aug 15, 2011 12:11 pm

CureOrBust wrote:
Cece wrote:MS is in fact character building, even as it tears everything else down. ....A lost opportunity for character building?
What does not kill us, makes us stronger? too bad patience is considered a virtue...

It's surpising we'd even have that saying, in our society that values action so much.

Impatience can be a virtue too, can it not? It all depends on the situation.

btw your turn must be imminent, all the best wishes to you.
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Re: Stent Fracture

Postby NHE » Mon Aug 15, 2011 5:39 pm

MikeInFlorida wrote:2. I believe that stents are subject to metal fatigue/fracturing. If true, does it depend on the amount of movement at the placement site (I believe you have discussed this before)?


Last November, I ran across a pdf of a PowerPoint presentation that discussed stenting the superficial femoral artery (SFA). The presentation discussed the risk of stent fracture. The images are not pretty. Essentially, this doctor found that the longer the stent, the greater the risk of fracture. At the end of the presentation, he questioned whether or not it was even appropriate to stent the SFA due too the complications arising from stent fracture.

post141085.html#p141085

Here is Dr. Sclafani's reply.

post143475.html#p143475


NHE



PS - I should note that the use of the word "superficial" refers to the artery's location near the surface.
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Postby NZer1 » Mon Aug 15, 2011 5:53 pm

Dr is there any indication as yet about the percentages of external or compression causes for stenosis versus internal?
I am aware that the most common discussed issue is currently valves, it is of interest to me about the 'other' causes that could be from for example the development of muscle bulk because of postural issues or spine and skull alignment compensation issues.
There are a few people who are listing injury to spine for example from whiplash around the first attack of RRMS.
This in my humble opinion would be similar to a person re-stenosising.
It of course does not explain a progressive disease form and that is in my opinion is where we will find the that the disease and cause is quite different between the two.
Flow issues and aging may explain the progression over time seen in PPMS and SPMS, but it does not really explain the episodic nature of RRMS for instance where there is known underlying progression happening with all RRMS people, which in my opinion is misleading when the episodic nature is the focus and the progression seen on MRI (grey matter) is not talked about.
People do not go from PPMS and have episodic periods, so this in my opinion is another clue that there is differing causes that will be explained in the future why there are some who respond well to PTA and others who one would expect a good response do not.
I guess you worked this out ages ago and are waiting to find the it factor, sorry to steal your thunder .

:wink:
Regards Nigel
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Re: Stent Fracture

Postby MikeInFlorida » Mon Aug 15, 2011 6:41 pm

NHE wrote:Last November, I ran across a pdf of a PowerPoint presentation that discussed stenting the superficial femoral artery (SFA). The presentation discussed the risk of stent fracture. The images are not pretty. Essentially, this doctor found that the longer the stent, the greater the risk of fracture. At the end of the presentation, he questioned whether or not it was even appropriate to stent the SFA due too the complications arising from stent fracture.

http://www.thisisms.com/ftopicp-141085.html#141085

Here is Dr. Sclafani's reply.

http://www.thisisms.com/ftopicp-143475.html#143475

Thank you for that link. I vaguely remembered having read the referenced post. I wonder
a) if technological improvements OR Dr. S.'s accumulated experience during the past 10 months has changed his mind; and if not, then
b) are either of the stent placements considered for the current case disqualified based on the warnings sited by Dr. S?
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Postby Cece » Mon Aug 15, 2011 7:17 pm

One difference I see is that in the referenced post he was talking about jugular stents. In this case, there is a possibility of innominate and subclavian vein stents, but not jugular stents. There would be less motion stress in these areas than in the neck.
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Postby Hopeful10 » Mon Aug 15, 2011 7:53 pm

Dr. Sclafani,

I asked a question a little while back that I think got lost in an avalanche of subsequent questions. I hope you don't mind if I ask the question again. My recollection is that studies have shown that approximately 10-15% of the population has no valves in either one or both internal jugular veins. Since problematic valves seem to be a primary cause of CCSVI, I was wondering if you've had any CCSVI patients who have no valves in either one or both IJVs, and if so, (1) do those patients number approximately 10-15% of your total group of CCSVI patients and (2) have you noticed any differences between those patients and other CCSVI patients (in terms of CCSVI angioplasty treatment results or disability status prior to CCSVI treatment)?

Thanks!
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Postby Cece » Mon Aug 15, 2011 8:13 pm

That was a very interesting question, Hopeful10, I remember thinking so the first time too.

My prediction, not knowing Dr. Sclafani's answer, is that no, he wouldn't be seeing that high of a percentage at all. My guess would further be that if they had no valves, they have some other form of outflow obstruction (hypoplasia or azygous blockages or whatnot) and would be equal to the rest of us in terms of disability and possibly worse off in terms of outcome, since the valve malformations are more easily treated than some other conditions (hypoplasia, septums, duplications).

Dr. Sclafani, your turn.... ;)
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Postby eric593 » Tue Aug 16, 2011 12:41 am

Cece wrote:
CureOrBust wrote:
Cece wrote:MS is in fact character building, even as it tears everything else down. ....A lost opportunity for character building?
What does not kill us, makes us stronger? too bad patience is considered a virtue...

It's surpising we'd even have that saying, in our society that values action so much.

Impatience can be a virtue too, can it not? It all depends on the situation.

btw your turn must be imminent, all the best wishes to you.


For consistency:

drsclafani wrote:... this is not the discussion at hand. Look at the images and tell me what is normal about these veins.

please ask a question and i will answer it. please do start another thread that addresses your issues. This thread is supposed to allow DrSclafani to answser some questions

thanks
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Re: IVUS Images

Postby drsclafani » Tue Aug 16, 2011 4:45 am

drsclafani wrote:
NHE wrote:Hi Dr. Sclafani,
What is the thickness of the image slice in the IVUS cross sectional images that you post? I'm curious how much depth there is to the image.

Thanks, NHE


good question.
i must admit i do not know the answer to it.

i will explore

S


i am not sure this answers your question, but the manufacturer has told me that the resolution of the IVUS images in about 100 microns.

That certainly helps to explain the echoes I see on the edges of the valve.
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Re: IVUS Images

Postby drsclafani » Tue Aug 16, 2011 4:48 am

MikeInFlorida wrote:
drsclafani wrote:
NHE wrote:Hi Dr. Sclafani,
What is the thickness of the image slice in the IVUS cross sectional images that you post? I'm curious how much depth there is to the image.

Thanks, NHE


good question.
i must admit i do not know the answer to it.

i will explore

S


What does the "thickness of the image slice" mean?


every image represents depth. This is easier to understand with CT and MRI which capture data of a certain volume that has three dimensions.

that volume of data (called a voxel) is what allows reformation of the data in different views.
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Postby drsclafani » Tue Aug 16, 2011 4:59 am

NZer1 wrote:Dr is there any indication as yet about the percentages of external or compression causes for stenosis versus internal?
I am aware that the most common discussed issue is currently valves, it is of interest to me about the 'other' causes that could be from for example the development of muscle bulk because of postural issues or spine and skull alignment compensation issues.


That is very difficult to determine the incidence of compression because it is episodic, dynamic and positional. Whether one sees it depends upon circumstances. For example, we do not see it in some patients without turning the head into a particular position, something that we do not do during venography.

I question whether this is abnormal, actually. In the legs we expect the muscular contractions to propel the blood toward the heart. Is this also happening in the jugular veins??

I commonly see compression of the internal jugular vein by the carotid artery. IVUS shows me that this is phasic and that there is ample room for the jugular vein to distend "away" from the carotid, essentially ignoring the compression. I have noted compression at the second cervical vertebrae. whether one sees it depends upon performing a lateral view and whether the neck is flexed or extended.

i have noted the candy wrapper "stenosis" butonly see it when patients take a deep expiration, never in full inspiration.

episodic compression seems very common.

There are a few people who are listing injury to spine for example from whiplash around the first attack of RRMS.
This in my humble opinion would be similar to a person re-stenosising.
It of course does not explain a progressive disease form and that is in my opinion is where we will find the that the disease and cause is quite different between the two.


it is my guess is that this is coincidental


Flow issues and aging may explain the progression over time seen in PPMS and SPMS, but it does not really explain the episodic nature of RRMS for instance where there is known underlying progression happening with all RRMS people, which in my opinion is misleading when the episodic nature is the focus and the progression seen on MRI (grey matter) is not talked about.
People do not go from PPMS and have episodic periods, so this in my opinion is another clue that there is differing causes that will be explained in the future why there are some who respond well to PTA and others who one would expect a good response do not.
I guess you worked this out ages ago and are waiting to find the it factor, sorry to steal your thunder .

:wink:
Regards Nigel


geez, nigel

i am only a plumber.
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Re: Stent Fracture

Postby drsclafani » Tue Aug 16, 2011 5:06 am

MikeInFlorida wrote:
NHE wrote:
Here is Dr. Sclafani's reply.

http://www.thisisms.com/ftopicp-143475.html#143475

Thank you for that link. I vaguely remembered having read the referenced post. I wonder
a) if technological improvements OR Dr. S.'s accumulated experience during the past 10 months has changed his mind; and if not, then
b) are either of the stent placements considered for the current case disqualified based on the warnings sited by Dr. S?


Mike, discussing the possibility of stents is not more than that. I remind you that there were no stents placed in this patient. The first step was to see whether clinical improvements would occur with balloon angioplasty.
So far so good.

The reason for the two month followup is
1. to see whether angioplasty works and holds
2. allow time for patient and husband to get their hands around the ideas of stenting
3. for doctor to get other viewpoints from other expert physicians

my evolving thoughts include
1. at least one more try with angioplasty of the innominate vein to expand it better before considering a stenting
2. no stent will be necessary for the subclavian vein stenosis
3. other areas may need stenting but we have not discussed them yet.
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Postby drsclafani » Tue Aug 16, 2011 5:07 am

Cece wrote:One difference I see is that in the referenced post he was talking about jugular stents. In this case, there is a possibility of innominate and subclavian vein stents, but not jugular stents. There would be less motion stress in these areas than in the neck.


the clavicle is a area of high stress on stents
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Re: IVUS Images

Postby NHE » Tue Aug 16, 2011 5:09 am

drsclafani wrote:
drsclafani wrote:
NHE wrote:Hi Dr. Sclafani,
What is the thickness of the image slice in the IVUS cross sectional images that you post? I'm curious how much depth there is to the image.

Thanks, NHE


good question.
i must admit i do not know the answer to it.

i will explore

S


i am not sure this answers your question, but the manufacturer has told me that the resolution of the IVUS images in about 100 microns.

That certainly helps to explain the echoes I see on the edges of the valve.


Thanks. However, I'm not sure that answers my question. Resolution is usually the minimum distance that one can distinguish two objects as being separate. I was asking about how thick the image is in terms of the vein anatomy.

NHE
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