Hi Dr. Sclafani,
* What percentage of your patients have had the same, new, or no symptom improvement(s) after a second venoplasty?
* On average, do improvements from a second venoplasty last as long as from the first venoplasty?
* Which is the most common cause of restenosis two years post-venoplasty? Scar tissue? Or scar tissue and intimal hyperplasia? Or scar tissue, intimal hyperplasia, and blood clots?
* Are you more conservative during a second venoplasty than a first venoplasty, i.e., do you use less pressure, less time of dilation, and/or smaller balloons for the second venoplasty?
Thanks for this HappyPoet,
*I would add why is the second treatment or multiple treatments less likely to improve symptoms compared with the first treatment?
*Could this issue with multiple treatments be causing inflammation that is based on the vein having an infection rather than the vein healing process?
*If a vein was dilated in an area that had 'healthy' valves several times is it going to make it become thrombotic and stenosis occur?
*If an Artery was PTA'ed several times is there the same risk issues as you are finding or hearing about with CCSVI Veins?
*Does using anti-coagulants/thinners alter the healing process?
Firstly, I must admit that i have not had that many second treatments of my own patients. So the data set is not really very large. I have far more repeat procedures of patients who had their first, second or third procedure done somewhere else or by someone else. Of my own patients whom i have retreated, the results are currently pretty good, having gotten a lot of experience. Only a very small number of my patients have come to me for a third procedure. I am only aware of one who had another procedure elsewhere. That doesnt mean there havent been more, i just think that patients might now want to talk to me about it. I just do not know.
The indications for a repeat procedure can fall into a few categories and the outcomes of these second procedures depends very often on the indication for the second treatment.
1. The best results occur in patents with RRMS who had good improvements of clinical symptoms or reductions in the number of exacerbations after treatment and then deteriorated by developing new or recurrent symptoms or developing relapses. Most commonly results of second procedures are comparable to the initial treatments with improvements of similar clinical symptoms, but sometimes with added benefits. It is true that some do not regain all the improvements but many do.
2. Results in progressive MS are usually more modest during the first procedure, things such as reduced fatigue, improved balance and cognition can be regained but paralysis and weakness, ataxia, neurologic pain syndromes often do not respond as well to repeated procedures. I expect that this is the result of further progression of the MS.
3. Another category of repeat procedures involves clinical improvements in patients who have a long standing occlusion that occurred in 2010 and 2011. These lesions cannot easily be corrected. However I often find that patients have other lesions that were unrecognized, untreated or under-treated. These are associated with very resistant valvular lesions, often in patients who also have atypical non-valvular lesions superimposed on the valvular lesions. These are quite challenging. Treatment of these may give improvements , modest in nature, despite failure to recanalize the initial occlusion.
4. Many patients have come to me for a repeat procedure who just were not satisfied with the results of treatment elsewhere. These patients often show continued stenosis. Whether it is restenosis or under-treatment or under-recognition of the lesions is speculative. I often have patients attain improvements upon re-treatment, especially if there were short term improvements on prior treatments. As stated above, RRMS does better than progressive disease; imbalance, fatigue, cognition and memory, heat intolerance, improve more than other symptoms.
5. Finally, there are repeated treatments for severe long standing MS in patients who are really debilitated. Generally these treatments give little or modest clinical improvements. However in these situations, i do not make judgments about the quality of the improvements. I leave that to the patient and family to decide.
I know that is not a perfect answer but it is the one I can give right now.
With regard to the lesions detected on second procedures, the most common lesion is recurrent valvular stenosis or persistent valvular stenosis. It is not uncommon to find that the initial treatment seemed to use too small a balloon or that the waist on the balloon never was completely eliminated (inadequate pre, most likely).
A much smaller percentage of patients seem to have developed stricture of the vein, that is previously normal sized vein was now narrowed. These may be intimal hyperplasia but IVUS seems to show mostly just a narrow vein without much thickening of the intimal layer.
A still smaller percentage of patients develop stenosis around the prior angiopastly site but there seem to be webs or other echogenic material in the area that easily dilates with small amounts of balloon pressure. I am thinking that this represents some scar tissue or organized thrombus.
I generally treat my patients the second time around the same way i treated them the first time. Usually less pressure is needed to open the stenosis. I do not use smaller balloons.
I now anticoagulate my patients better with the newer oral thrombin A inhibitors and aspirin. I really think it is important to protect the wall from injury.
Nigel, why would anyone dilate a normal valve?
That is a long answer to long questions. I guess i deserved that for asking for questions.
for those who have not been reading this thread for a long time, please do not hesitate to ask for clarifications. No one will think less of you. As I have said in the past, the only dumb question is one that wasnt asked.