drsclafani wrote:Thinking about the first three years of CCSVI management, i have noted with alarming frequency some of the errors that were made commonly by proceduralists. Today a very disappointing story illustrated this and points to some explanations for many of the fleeting improvements that many patient experience after angioplasty
The patient was a middle aged Canadian woman with relapsing remitting MS that had progressed into the secondary stage. Her symptoms included chronic debilitating fatigue, temperature intolerance, imbalance, problems with memory and cognition, numbness and tingling and weakness in the extremities and bladder difficulties.
In 2010 she was treated in a European facility. The venogram was interpreted as showing valvular stenosis of the left internal jugular vein at the inferior jugular bulb, and incorrectly diagnosed a normal right internal jugular vein and normal azygous vein. The angiography was poor with very minimal contrast media. However to my eye, valvular stenoses of both the right IJV and the Azygous arch were clearly evident. Angioplasty of the left IJV was performed with a stent that was too small for that vein. Not surprisingly follow up venography was interpreted as showing inadequate angioplasty. Instead of increasing balloon size, stenting was performed. The patient was given a few days of anticoagulation and discharged. some of her symptoms improved, others did not and then some of the improvements regressed.
In 2011 she went to another facility in Europe and imaging was repeated. This second interventionalist detected the right IJV valvular stenosis and treated that successfully. Extensive intimal hyperplasia of the stented left IJV had developed and this has resulted in a narrowing of the lumen in the stent by about 70%. The Left IJV was treated by angioplasty of the stent without additional stenting. Azygous venography again was misinterpreted as normal and again left untreated. Surprisingly, left renal venography was also performed. I saw reflux into the left ovarian vein and was consistent with the renal vein compression syndrome. No intervention was performed.
most would consider this patient to have failed venoplasty. In reality this has just been unsatisfactory treatment. it has take three session to diagnose the critical pathology and some of the lesions still have not been treated. Moreover an unnecessary stent has been ultilized and this will likely lead to a chronic stenosis of the left IJV
hopefully i can address some of these problems tomorrow
lets try to illustrate some of the problems of the prior treatments.
2010 First procedure
This image began the procedure in 2010. No definite abnormality is seen. HOWEVER, the upper two thirds of the internal jugular vein were not imaged. The catheter is nowhere near the upper portions of the jugular vein. The technique of venography was too slowly inject contrast so that transit time can be assessed. The result is limited contrast media that does not completely opacify the lumen and it does not adequately demonstrate pathology of valves or reveal stenoses. Subtraction technique may have revealed a stenosis but we do not know whether subtraction was actually performed.
Next the left internal jugular vein was imaged:
Figure 1 definitely shows a rounded end of the contrast column at the site of a stenosis.
Figure 2 shows added contrast on the left side of the stenosis indicative of contrast under a immobile valve. A slight jet may be seen on the right side of the end of the contrast media.
Figure 3. I think treatment was justified. However, I am not sure sufficient treatment was performed. The balloon is inflated but no waist is seen. A waist is seen when a balloon is stretching the obstruction. In this case the balloon may be too small or of insufficient pressure.
Figure 4. This followup study is just not sufficient to justify stenting. The contrast study is poor. the amount of contrast media is just inadequate to make a definitive diagnosis of stenosis. It might be present but this study is just indefinite. stenosis cannot be ruled out.
Figure 5. A 16mm stent is deployed. It may be considerably larger than the vein.
Azygous venography was performed.
figure 1. looks pretty good. But figure 2. shows reflux into accessory hemiazygous veins. Figure 4 shows contrast trapped underneath the valve leaflets (red circle and red arrow). This is indicative of an immobile valve. I consider this study to be diagnostic. Unfortunately, no treatment was performed.