DrSclafani answers some questions

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Re: DrSclafani answers some questions

Postby NHE » Tue May 21, 2013 9:59 pm

drsclafani wrote:Any questions?


The last photo of the RIJV in the May 18th series looks like the flow is still getting caught up even in the presence of a stent. Is this correct? Did you use IVUS and, if so, what did it show?
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Re: DrSclafani answers some questions

Postby Robnl » Wed May 22, 2013 4:47 am

drsclafani wrote:Any questions?

DrSclafani

Hi Doc,

Exactly the same problems at the second treatment or were there additional problems ( in same or other veins)??
Sometimes i think that a reduced bloodflow could have impact on veins 'down he line'......if the bloodflow is suddenly restored; can that 'stress' (maybe not the right word) veins that have been less used before?

Rgds,

Robert
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Re: DrSclafani answers some questions

Postby CureOrBust » Wed May 22, 2013 6:11 am

Did the second treatment also provide similar benefits as the first?
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Re: DrSclafani answers some questions

Postby drsclafani » Wed May 22, 2013 6:16 am

NHE wrote:
drsclafani wrote:Any questions?


The last photo of the RIJV in the May 18th series looks like the flow is still getting caught up even in the presence of a stent. Is this correct? Did you use IVUS and, if so, what did it show?


one cannot tell from a static single image whether the contrast media is caught up. I put up an image to filled the stent. Rest assured that there was no reflux or hang up of the contrast.

I did not use IVUS during this procedure. We were trying to reduce the costs. The IVUS catheter itself costs almost US$1000
i use the prior IVUS for its information and most of the time it is sufficient. If I thought it would be critical information I would have used it.

However, please understand that IVUS does not measure flow. It is not a doppler devce.
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Re: DrSclafani answers some questions

Postby drsclafani » Wed May 22, 2013 6:21 am

Robnl wrote:
drsclafani wrote:Any questions?

DrSclafani

Hi Doc,

Exactly the same problems at the second treatment or were there additional problems ( in same or other veins)??
Sometimes i think that a reduced bloodflow could have impact on veins 'down he line'......if the bloodflow is suddenly restored; can that 'stress' (maybe not the right word) veins that have been less used before?

Rgds,

Robert


Robert, the anatomical problems were identical to those seen in the first treatment.
I think the explanation is that the fibrous bands that are holding the valve closed are very strong and while the first treatment resulted in their stretch (like a rubber band), the bands were not broken and recoiled back into the stenotic position. I think it happens sometimes. Balloon selection is challenging. A larger balloon may have injured the vein and resulted in a thrombosis.

I am not sure about this stenting issue but perhaps such cases will be a reason to stent. No clarity yet. I just havent done this enough times to know the efficacy.
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Re: DrSclafani answers some questions

Postby dlynn » Wed May 22, 2013 6:54 am

Dr. Sclafani,
If these venous abnormalities are congenital, is it possible that restenosis could occur mainly because the veins and/or
valves are assuming the position they have known since birth? I had much relief of many symptoms, fatigue, balance etc.,
from my procedures, the fourth lasting the longest, approx. 1yr. I chose not to have stents because of uncertainty. So are you saying that you haven't placed stents "enough times to know the efficacy"?
thank you
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Re: DrSclafani answers some questions

Postby drsclafani » Wed May 22, 2013 7:09 am

CureOrBust wrote:Did the second treatment also provide similar benefits as the first?


The patient was treated only five days ago. Upon discharge he was feeling like sensation was beginning to improve. However he has been traveling home and i have not yet been in contact with him.

I shared the case now because of the visualization of an omohyoid compression, because I hadn't shown such an early restenosis before and because of the use of a stent. I will share outcome when i have it.
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Re: DrSclafani answers some questions

Postby drsclafani » Wed May 22, 2013 7:17 am

dlynn wrote:Dr. Sclafani,
If these venous abnormalities are congenital, is it possible that restenosis could occur mainly because the veins and/or
valves are assuming the position they have known since birth? I had much relief of many symptoms, fatigue, balance etc.,
from my procedures, the fourth lasting the longest, approx. 1yr. I chose not to have stents because of uncertainty. So are you saying that you haven't placed stents "enough times to know the efficacy"?
thank you

in a sense, i would agree that these valvular restenoses occur because the valves are stiff and can recoil back into the established shape and position. There are also bands that prevent the valve from changing position in some. This is usually overcome by sufficient balloon size and enough pressure to overcome the resistance to change.

How can you be sure that treatment of renal vein compression did not have impact on the durability of the CCSVI improvements?

I have not used early restenosis as an indication for stenting the internal jugular vein very commonly because of concerns about stenting the jugular vein. This was a difficult decision between patient and me. Such cases are landmarks for me and i think that they are very important

i have great confidence in the efficacy of stenting the renal vein compression syndrome.

DrS
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Re: DrSclafani answers some questions

Postby Ernst » Wed May 22, 2013 7:23 am

Sir Sclafani,

Thank you very much for your case raports, most interesting. I was wondering about those external (muscle) compressions - is it possible that they are related to re-stenosis? Some new studies were published lately about external compression to jugulars and they were very interesting.
My wife's 3 yrs post video: http://www.youtube.com/watch?v=eLeqLps8XR8

Our family: http://www.youtube.com/watch?v=p_QCKxeQAlg
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Re: DrSclafani answers some questions

Postby drsclafani » Wed May 22, 2013 7:35 am

Ernst wrote:Sir Sclafani,

Thank you very much for your case raports, most interesting. I was wondering about those external (muscle) compressions - is it possible that they are related to re-stenosis? Some new studies were published lately about external compression to jugulars and they were very interesting.


It is possible that they are related in the sense that decreased flow from above the valvular stenosis may facilitate restenosis of the valves. But there is no firm evidence.

These case reports are interesting but they do little to clarify the relevance of such compressions. One study was a case report where an omohyoid muscle compression was treated surgically but the patient did not imporove, rather worsened. However the patient may well have had an overwhelming sclerosis load and was progressing in disability rapidly. The other case report did show clinical improvement. However that patient had both venoplasty and omohyoid muscle release. I cannot tell from the report what caused the positive effect. The venoplasty? or the muscle release? or both?

Another recent paper looked at compressions by the carotid bulb and the second vertebra on the jugular vein, They found that such compression was common in PwMS. However there were no controls to help determine whether these compressions are also seen in patients without MS

For the moment, I am in a watch and wait for more information stage.

DrS
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Re: DrSclafani answers some questions

Postby dlynn » Wed May 22, 2013 8:41 am

Dr. Sclafani,
I can't be sure how it (stenting my renal vein) impacted the durability of CCSVI improvements. My fourth angioplasty
was 3-16-2012, NCS was treated 12-28-13, I had a bad fall 2-14-13, xrays showed stents were fine and no broken bones.
Restenosis occured 2 times after a 2.5 hr. flight, I'm not sure if this is a coincidence but recently I visited at a higher
altitude then my symptoms returned, fatigue, headaches... I've not been tested but I don't know that my veins are open
considering the symptoms I'm experiencing. So at this time I don't know what could be causing/helping what. If the veins
are left untreated, will more damage occur , or more disability?
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Re: DrSclafani answers some questions

Postby Cece » Fri May 24, 2013 6:47 am

drsclafani wrote:I think the explanation is that the fibrous bands that are holding the valve closed are very strong and while the first treatment resulted in their stretch (like a rubber band), the bands were not broken and recoiled back into the stenotic position. I think it happens sometimes. Balloon selection is challenging. A larger balloon may have injured the vein and resulted in a thrombosis.

I am not sure about this stenting issue but perhaps such cases will be a reason to stent. No clarity yet. I just havent done this enough times to know the efficacy.
Generally, I prefer to give angioplasty a second try as the next manuever. I prefer to withhold stenting after the first restenosis because some patients respond quite nicely to a second angioplasty and stenting can be avoided.

This seems similar to what occurred with my left jugular (a J3 physiological stenosis, a J1 valvular stenosis that required early retreatment). A second ballooning led to the vein staying open and a stent was avoided.
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Re: DrSclafani answers some questions

Postby Cece » Fri May 24, 2013 7:09 am

drsclafani wrote:but i need better evidence before I would recommend surgical release of muscles. This is not intuitive and it is phasic. I like the possibility of using botox as a provocative test of effect of release of the muscle. wish i knew how to use botox
In the U.S., each state governs who can legally administer Botox treatments. Some states allow only licensed physicians to inject Botox. Examples of exceptions are New York, Florida, Texas, California and Oklahoma where other health care professionals are allowed to treat clients under the supervision of a doctor.
http://www.shape.com/latest-news-trends ... your-botox
I wasn't sure who could legally administer botox. At least it's limited to health care professionals, it's not quite anyone and everyone.
Perhaps you could collaborate with someone who is experienced with botox.
I like the idea of botox in these cases. It's a way to see if it works for individuals without the permanence of the surgical release.
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Re: DrSclafani answers some questions

Postby drsclafani » Sat May 25, 2013 12:15 pm

Cece wrote:
drsclafani wrote:but i need better evidence before I would recommend surgical release of muscles. This is not intuitive and it is phasic. I like the possibility of using botox as a provocative test of effect of release of the muscle. wish i knew how to use botox
In the U.S., each state governs who can legally administer Botox treatments. Some states allow only licensed physicians to inject Botox. Examples of exceptions are New York, Florida, Texas, California and Oklahoma where other health care professionals are allowed to treat clients under the supervision of a doctor.
http://www.shape.com/latest-news-trends ... your-botox
I wasn't sure who could legally administer botox. At least it's limited to health care professionals, it's not quite anyone and everyone.
Perhaps you could collaborate with someone who is experienced with botox.
I like the idea of botox in these cases. It's a way to see if it works for individuals without the permanence of the surgical release.


there are nearby important structures that might be affected by doing this including the muscles of breathing and swallowing. My brother is a plastic surgeon so there is no reason not to do this except continued questions about its risks
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Re: DrSclafani answers some questions

Postby Cece » Sat May 25, 2013 12:41 pm

http://books.google.com/books?hl=en&lr= ... &q&f=false
Caution should be observed when both sternocleidomastoid muscles are injected as dysphagia can occur and is more common with bilateral injections (3).
Keeping it unilateral might reduce the risk.

Googling sternocleidomastoid and botox in googlescholar turned up many entries. Omohyoid and botox turned up fewer. A case report:
http://onlinelibrary.wiley.com/doi/10.1 ... ated=false
Omohyoid muscle syndrome has a characteristic feature of a protruding lateral neck mass during swallowing. We present a case of omohyoid muscle syndrome diagnosed based on the clinical presentation and a dynamic imaging study. Botulinum toxin was injected into the inferior belly of one omohyoid muscle, and the neck mass resolved.
Your brother is a plastic surgeon, lol. Ok that works.

edited: the anterior belly of the omohyoid is treated in cases of oromandibular dystonia, specifically jaw opening not jaw closing dystonia, so that might be the research to check for the risks of botox in this muscle
http://neurologyindia.com/article.asp?i ... st=Muthane
Oromandibular dystonias are difficult to treat without causing dysphagia and should only be done by well-trained and experienced clinicians with adequate experience in use of neurotoxins.
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