1. i frequently find unrecognized problems in patients who have undergone treatment in the past by others.
2. missed valvular stenoses are the most common, nutcracker syndrome is another, high jugular stenoses that were not part of the prior venography,
3. i try to see the images from prior procedures for ccsvi, some patients do not have copies and sometimes i cannot load their disks. It is very helpful to have a sense of what was done. I learn a lot from what was not done the first time.
4. I didnt think that there was much discussion of new techniques. I worry that I am getting satisfied with my technique now!
I think that renal vein compression is a very important topic for ccsvi. It is grossly understood and underestimated. most IRs do not look for this. That it can cause spinal symptoms was described more than forty years ago but the entire idea is foreign to most. I encourage you to ask questions in this forum about this topic.
so, can you please describe what is the patient's profile and symptoms with renal vein compression?
There are several profiles of patients with renal compression (nutcracker)
1. no symptoms. 10-20% of humans have some degree of renal vein compression. The majority of them have no symptoms and renal vein compression is then called Nutcracker phenomenon.
2. symptoms related to renal vein compression in children: This is a common cause of chronic fatigue in childhood. These patients have symptoms of vascular congestion of the kidney manifested by protein in the urine and microscopic or gross hematuria. They may also have other symptoms listed below as seen in adults.
3. Symptoms related to reflux into the veins of the ovary or the testicle. In women this manifests as some of the following: chronic pelvic pain unrelated to menstrual cycle, pelvic floor fatigue and pain (especially on standing and relieved by lying down), frequent bouts of cystitis, hemorrhoids, rectal pain, varicose veins of the upper thigh and the external female genitalia. In men infertility with low sperm count and immobility of sperm, and varicose veins in the testicle are common.
4. Symptoms of the midline congestion syndrome described by Scholbach: a constellation of symptoms related to organs and structures that are located in the mid-line of the abdomen, including the spinal cord and vertebrae, the bowel, uterus, bladder, and genitalia. Symptoms include headaches (including migraine headaches), abdominal pain, back and flank pain, diarrhea, bloody bowel movements, painful sex, urinary pain and cystitis and rectal pain
5. In the 1970's Albouker reported on myelopathy resulting from renal vein compression. He stated that he found, among 60 patients treated for renal vein compression, that other venous obstructions, involving jugular, brachiocephalic, azygos and iliac veins were common. (sounds like CCSVI to me)
I contend that since jugular and azygos vein obstructions are so common in patients with MS, things are strongly affected by renal vein compression. When jugular veins are obstructed, epidural venous drainage provides an accessory collateral outflow draining into the superior vena cava through the azygos vein. When the azygos vein is also obstructed, azygos flow decompresses through the hemiazygo-left renal trunk into the renal vein and inferior vena cava. But if that renal vein is obstructed, it has a doubly negative effect. Not only is the collateral flow inhibited, but the flow from the renal vein is partially redirected INTO the hemiazygos vein back into the spine resulting in increased congestion of the spinal cord and worsening overload of the spinal circuits. The only remaining spinal vein is the ascending lumbar vein but we know that this vein is commonly hypoplastic in patients with MS. So that is not useful as a decompressing vein.
Scholbach thinks that congestion of the vertebral plexus of veins results in displacement of CSF upward and he suggests that resultant intracranial CSF overload can cause headaches. This may be compounded by the retardation of CSF outflow in the presence of jugular vein obstructions.
I must add that most IRs to do not focus on this at all.