DrSclafani answers some questions

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

Postby drsclafani » Tue Aug 16, 2011 5:11 am

Hopeful10 wrote: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!


sorry i missed your question.

i think that normal valves are almost impossible to see. only thick, immobile valves are visible.
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Postby drsclafani » Tue Aug 16, 2011 5:15 am

Cece wrote: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.... ;)


i thought about going into more detail, but held off because it is unclear whether ONLY obstructions can cause ccsvi. If there is absence of the valve there should be some problems with reflux. While this reflux between heart and jugular would occur, it is not clear whether it will cause ccsvi because there is easier relief from the reflux, although transient global amnesia is reported with jugular valve incompetency

very confusing, that is why i wanted to avoid this
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Re: IVUS Images

Postby drsclafani » Tue Aug 16, 2011 5:18 am

NHE wrote:
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


I know. I havent got a good answer yet
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Postby munchkin » Tue Aug 16, 2011 6:31 am

Dr.Sclafani

Understanding that the technology is still being tested on arteries do you think the dissolving stents may be of use to those of us who might be in need of stents?

Is there a difference in the structure of scar tissue if it is from actual damage to the vein or if it is intimal hyperplasia? Does this affect your decision on implanting a stent?

Thank you for all of the information you share with us.

Kim
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Postby Cece » Tue Aug 16, 2011 7:32 am

drsclafani wrote:i thought about going into more detail, but held off because it is unclear whether ONLY obstructions can cause ccsvi. If there is absence of the valve there should be some problems with reflux. While this reflux between heart and jugular would occur, it is not clear whether it will cause ccsvi because there is easier relief from the reflux, although transient global amnesia is reported with jugular valve incompetency

very confusing, that is why i wanted to avoid this

If such a patient made it to you, they would likely have an MS diagnosis. And they would show up as having reflux on the doppler ultrasound, just as patients may show up as having reflux on follow-up ultrasounds after the valves are ballooned.

I would suspect that this sort of absence-of-the-valve reflux would only contribute to CCSVI if there were other CCSVI abnormalities present in the vein or other veins. When you mention easier relief, it would suggest that reflux and venous congestion are needed, not reflux alone.

This is also the condition we may be left with after being treated for CCSVI, if the valves are obliterated. In my experience, this condition is far preferable to the condition I was in before my procedures.

Ok, we can avoid this conversation now. :)
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Postby NZer1 » Tue Aug 16, 2011 4:06 pm

Dr. S my guess is that focusing on a smaller area of lesion incidence such as the cervical spine would give more tangible info to expand on, and transfer the learning to other regions of the brain.
With the flow system in the area it is less confusing when changing variables with treatment in many systems as you know.
My assumption is that the primary blood flow is easier to assess and the areas that need to be flow tested are more defined. The other challenge is that there is CSF flows and function as well that could be 'causing' lesions. This is likely a multi-disciplinary task because of the function assessments and electrical as well as plumbing involved.

*Is this where Paulo is heading with his interest in the verts and Lumbars?

*Can the cervical flows be accurately assessed and have they been compared to normals?

I will have a look at what Dr Schelling had to say on spinal lesions.

My personal focus is this area because of my own MRI results, and of course when a skilled and trusted Dr. gets to look at my tubes I am wanting to know that that area of dysfunction is under the scope.
Dr Flanagan has just linked into a group using Upright MRI to focus on this region as well, so I would imagine this will produce some insights soon.
Ok back to work,
Regards Nigel
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Re: IVUS Images

Postby drsclafani » Wed Aug 17, 2011 9:20 am

NHE wrote:
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


nhe

here is the answer from the manufacturer's engineers

Greg -
This question was more up my alley than Ross’s so he passed it over to me.

I spoke with Engineering about this and got the following:
The ‘length’ (in ILD view) is variable and determined by pullback speed, catheter stretch, or other movements in the vessel.
Within a single slice (tomo view), the wedge angle is fixed, but actual chord dimension will vary with distance.
Within a single wedge, (and this appears to be the dimension of interest) the distance is determined primarily propagation speed.
The average value is 0.138mm, our maximum tolerance values are 0.170mm upper and 0.074mm lower.

If there is more detail required (for instance research paper, etc.), let me know and I will get the answer out of Engineering.

Thanks
-Jim


I hope that this answers your question.
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Postby soapdiva884 » Wed Aug 17, 2011 4:20 pm

Just popping in and waving hi to Dr. Sclafani ((((waving)))) Hope you are doing well and taking time for YOU!
Boyfriend dx'd 6-6-06!!! RRMS............CCSVI procedure done on Nov. 13, 2010 and March 7, 2011 by Dr. Sclafani!
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Postby drsclafani » Wed Aug 17, 2011 7:36 pm

munchkin wrote:Dr.Sclafani

Understanding that the technology is still being tested on arteries do you think the dissolving stents may be of use to those of us who might be in need of stents?


dissolving stents are not the issue. Stents have some inherent problems. like thrombosis and in-stent intimal hyperplasia. Will a dissolving stent obviate these, or will a drug eluting stent do the job. or other maneuvers.

I think that we know the problem, it is the solution that is taking a long time. The big problem is that the majority of devices are tested in the coronary arteries since these get the most play, and revenue. The coronary arteries are much much smaller than the jugular veins. So, once things are proven with small vessels, we need to develop their use for large veins.

But yes, perhaps they will help.

Is there a difference in the structure of scar tissue if it is from actual damage to the vein or if it is intimal hyperplasia? Does this affect your decision on implanting a stent?

Intimal hyperplasia usually is associated with stenting, more than angioplasty alone. Both can lead to resistant stenoses. although scar tissue is usually more problematic for dilatation. Intimal hyperplasia seems to dilate much better but, unless you stop the intimal hyperplasia, stenosis keeps recurring despite your best intentions or manuevers.
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Postby drsclafani » Wed Aug 17, 2011 7:38 pm

Cece wrote:
drsclafani wrote:i thought about going into more detail, but held off because it is unclear whether ONLY obstructions can cause ccsvi. If there is absence of the valve there should be some problems with reflux. While this reflux between heart and jugular would occur, it is not clear whether it will cause ccsvi because there is easier relief from the reflux, although transient global amnesia is reported with jugular valve incompetency

very confusing, that is why i wanted to avoid this

If such a patient made it to you, they would likely have an MS diagnosis. And they would show up as having reflux on the doppler ultrasound, just as patients may show up as having reflux on follow-up ultrasounds after the valves are ballooned.

I would suspect that this sort of absence-of-the-valve reflux would only contribute to CCSVI if there were other CCSVI abnormalities present in the vein or other veins. When you mention easier relief, it would suggest that reflux and venous congestion are needed, not reflux alone.

This is also the condition we may be left with after being treated for CCSVI, if the valves are obliterated. In my experience, this condition is far preferable to the condition I was in before my procedures.

Ok, we can avoid this conversation now. :)


i think it is reflux and stenosis that is the problem
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Re: IVUS Images

Postby Cece » Wed Aug 17, 2011 9:31 pm

drsclafani wrote:nhe

here is the answer from the manufacturer's engineers

Greg -
This question was more up my alley than Ross’s so he passed it over to me.

I spoke with Engineering about this and got the following:
The ‘length’ (in ILD view) is variable and determined by pullback speed, catheter stretch, or other movements in the vessel.
Within a single slice (tomo view), the wedge angle is fixed, but actual chord dimension will vary with distance.
Within a single wedge, (and this appears to be the dimension of interest) the distance is determined primarily propagation speed.
The average value is 0.138mm, our maximum tolerance values are 0.170mm upper and 0.074mm lower.

If there is more detail required (for instance research paper, etc.), let me know and I will get the answer out of Engineering.

Thanks
-Jim


I hope that this answers your question.

I don't understand all of this but I think it's excellent of you to have gone to that length for the answer. What amused me was the line, "If there is more detail required (for instance research paper, etc.)" because you can substitute in 'social media forum' in the 'etc.' We do like all the details here. :)

Hope your week is going well!
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Postby NZer1 » Wed Aug 17, 2011 10:10 pm

Seeing the comment about scar tissue reminds me.
If a person had been over ballooned would this be evident and obvious, I see that when scar tissue is present it creates more problem for you.
There was a time when large balloons were touted as being the best option for busting valves, I guess there is poetic license with the term 'large'. I remember watching Dr. Tarqins videos, thinking that the idea of 'big is good' is risky without knowing what the vein can cope with before damage occurs that will be problematic in future.

Is it possible the vein wall is 'diseased' and that that will also allow the BBB breach that is spoken of, the area would need to be within the skull I guess, so it would not be from PTA?

It is the term 'diseased' that I am interested in and how to identify it, and where it is found and why?

Is the vein wall the problem when over ballooned or is it the remains of the valve and anulus that remain present the problem?

Is it possible to identify when there is scar tissue? IVIS?

and how do you know when there is vein disease?

Thanks again,
Nigel
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ccsvi in the legs

Postby Robnl » Thu Aug 18, 2011 1:11 am

Hi Doc,

see
http://iamsickofms.blogspot.com/2011/08 ... swers.html

Globally, i'm in the same situation as Ginger.....i'm going to check the leg veins.

What do you think about ccsvi in 'other' places??
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Postby drsclafani » Thu Aug 18, 2011 5:31 am

MikeInFlorida wrote:
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.


mike
do you have the image yet?
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Re: IVUS Images

Postby NHE » Thu Aug 18, 2011 5:35 am

drsclafani wrote:nhe

here is the answer from the manufacturer's engineers

Greg -
This question was more up my alley than Ross’s so he passed it over to me.

I spoke with Engineering about this and got the following:
The ‘length’ (in ILD view) is variable and determined by pullback speed, catheter stretch, or other movements in the vessel.
Within a single slice (tomo view), the wedge angle is fixed, but actual chord dimension will vary with distance.
Within a single wedge, (and this appears to be the dimension of interest) the distance is determined primarily propagation speed.
The average value is 0.138mm, our maximum tolerance values are 0.170mm upper and 0.074mm lower.

If there is more detail required (for instance research paper, etc.), let me know and I will get the answer out of Engineering.

Thanks
-Jim


I hope that this answers your question.


Dr. Sclafani,
Thanks so much for sharing that information. I recall reading about pullback speed and the image stacks in the IVUS Made Easy book, but had forgotten the details. The book is now back at its home library 2270 miles away. The dimmensions quoted above at 74-170 µm help to put images such as this into perspective. In effect, although it appears that we're looking down at the valve, we're really looking at a cross section through the valve.

Thanks again, NHE
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