DrSclafani answers some questions

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Re: DrSclafani answers some questions

Postby drsclafani » Wed Nov 06, 2013 8:40 pm

pelopidas wrote:
drsclafani wrote:
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.


Let's think about the possible scenario of an adult, 55 yo, a relative of mine, never suffered from MS, but suddenly appears to have an Acute Cerebrospinal Venous Insufficiency (?)
If this patient undergoes a venography, should we expect first a Nutcracker phenomenon and an asymptomatic azygos blocked?
Then somehow the jugulars were blocked by an accident?

I know it sounds impossible, but this healthy person for a lifetime, suddenly suffers from cerebrospinal venous insufficiency


it appears that neurological symptoms in patients with NCS likely also have other silent obstructions of the IJVs or azygos.

I would ask what the symptoms were. cognitive? sensory motor? balance, fatigue.

i would not be able to guess from the information you have handed me

DrS
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Re: DrSclafani answers some questions

Postby drsclafani » Wed Nov 06, 2013 8:44 pm

lety wrote:Dear dr. Sclafani

you have still not received an answer ? :sad:




lety, i asked again. consultant was away. promised to review it soon

i hope
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Re: DrSclafani answers some questions

Postby drsclafani » Wed Nov 06, 2013 8:45 pm

erinc14 wrote:I've had stents for almost 3 years . is there still a risk of migration ? thanks .

Late migrations of stents are rare but have been reported.Which veins?
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Re: DrSclafani answers some questions

Postby pelopidas » Thu Nov 07, 2013 12:06 am

drsclafani wrote:
pelopidas wrote:
drsclafani wrote:
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.


Let's think about the possible scenario of an adult, 55 yo, a relative of mine, never suffered from MS, but suddenly appears to have an Acute Cerebrospinal Venous Insufficiency (?)
If this patient undergoes a venography, should we expect first a Nutcracker phenomenon and an asymptomatic azygos blocked?
Then somehow the jugulars were blocked by an accident?

I know it sounds impossible, but this healthy person for a lifetime, suddenly suffers from cerebrospinal venous insufficiency


it appears that neurological symptoms in patients with NCS likely also have other silent obstructions of the IJVs or azygos.

I would ask what the symptoms were. cognitive? sensory motor? balance, fatigue.

i would not be able to guess from the information you have handed me

DrS

The symptoms appeared almost 15 months ago :

Cog fog, extreme fatigue, blurred speech, blurred vision, loss of balance, headaches, anger

Difficulty in swallowing and choking are often

Heat intolerance was present during summer

The patient seems clumsy and disoriented most of the time

He falls down often, his gait is not good

It all seems like venous insufficiency, right?
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Re: DrSclafani answers some questions

Postby erinc14 » Thu Nov 07, 2013 8:23 am

drsclafani wrote:
erinc14 wrote:I've had stents for almost 3 years . is there still a risk of migration ? thanks .

Late migrations of stents are rare but have been reported.Which veins?

one in each jugular vein .
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Re: DrSclafani answers some questions

Postby drsclafani » Thu Nov 07, 2013 1:00 pm

pelopidas wrote:
Let's think about the possible scenario of an adult, 55 yo, a relative of mine, never suffered from MS, but suddenly appears to have an Acute Cerebrospinal Venous Insufficiency (?)
If this patient undergoes a venography, should we expect first a Nutcracker phenomenon and an asymptomatic azygos blocked?
Then somehow the jugulars were blocked by an accident?

I know it sounds impossible, but this healthy person for a lifetime, suddenly suffers from cerebrospinal venous insufficiency


it appears that neurological symptoms in patients with NCS likely also have other silent obstructions of the IJVs or azygos.

I would ask what the symptoms were. cognitive? sensory motor? balance, fatigue.

i would not be able to guess from the information you have handed me

DrS[/quote]
pelopidas wrote: The symptoms appeared almost 15 months ago :

Cog fog, extreme fatigue, blurred speech, blurred vision, loss of balance, headaches, anger

Difficulty in swallowing and choking are often

Heat intolerance was present during summer

The patient seems clumsy and disoriented most of the time

He falls down often, his gait is not good

It all seems like venous insufficiency, right?


My position is that these symptoms, commonly seen in patients with MS, may be the result of impaired neural transmission due to ms or be the result of venous obstructions. When symptoms are improved significantly within a day, one must consider that something other than demyelinization has caused the problem. It is difficult So it is clear to me that acutely improved symptoms after venous angiopalsty is likely the result of improved circulation and CSF hydrodynamics.

In any given patient the acute symptoms could be caused by demyelinization as well. only time and angioplasty tells us what is causative.

but yes, the majority of the symptoms you describe in this patient are often the symptoms that improve after angioplasty.
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Re: DrSclafani answers some questions

Postby drsclafani » Thu Nov 07, 2013 1:03 pm

erinc14 wrote:
drsclafani wrote:
erinc14 wrote:I've had stents for almost 3 years . is there still a risk of migration ? thanks .

Late migrations of stents are rare but have been reported.Which veins?

one in each jugular vein .


endthelium and matrix grow over the stent metal, in essence incorporating the stent within the wall of the vein. I think it is unlikely that such stents would migrate.
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Re: DrSclafani answers some questions

Postby Lety » Fri Nov 08, 2013 2:25 am

drsclafani wrote:
lety wrote:Dear dr. Sclafani

you have still not received an answer ? :sad:




lety, i asked again. consultant was away. promised to review it soon

i hope



Thank you, I really hope he will review it as soon as possible.


I have a question, do you and your valuable employees already tried to search after a muscle compression ? if you are convinced of the translated study, will you perform this investigation in your future and your former patients (with unsuccessful dilation) ?.
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Re: DrSclafani answers some questions

Postby drsclafani » Fri Nov 08, 2013 12:20 pm

drsclafani wrote:
lety wrote:Dear dr. Sclafani

you have still not received an answer ? :sad:




lety, i asked again. consultant was away. promised to review it soon

i hope


lety, below is the opinion of my vascular surgical consultative colleague on reading the paper you sent me regarding omohyoid muscle compression. New techniques can look promising, but they must have reasonable experience and volume to truly understand outcome effectiveness and safety. My consult is saying that it may be interesting but that there is not enough experience to really tabulate risk and the length of followup is too short to determine effectiveness.

consultant surgeon wrote:Sal,

Sorry, it took so long. Definitely an interesting hypothesis at this time. However, sample size small. 23 pts with SP, 6 with RR and one with PP. Follow up short as well. Will give you more detail to follow.
Unlikely something Bill or I would do.. I think more in line with a University institution.

Regards
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Re: DrSclafani answers some questions

Postby drsclafani » Fri Nov 08, 2013 12:23 pm

Lety wrote:

I have a question, do you and your valuable employees already tried to search after a muscle compression ? if you are convinced of the translated study, will you perform this investigation in your future and your former patients (with unsuccessful dilation) ?.


I am not convinced at this time that compressions should be treated. Today i had a patient who had compression in J3 at the level of the stylohyoid compression. When the patient flexed the neck the compression went away. When he coughed it also went away.

At this time i would defer to a university center that is performing this surgery.
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Re: DrSclafani answers some questions

Postby Squeakycat » Fri Nov 08, 2013 3:31 pm

Interesting new study that shows a link between a set of venous abnormalities and the type of MS:
No significant difference was found in the distribution of these miopragic veins with regard to MS duration. There was a strong association between the CCSVI scores and the complexity of jugular morphological types (Χ2 [9, N = 313] = 75.183, p < 0.001). Wall miopragia was mainly observed in MS patients with SP (59.3%) and PP (70.0%) clinical forms, compared to RR (48.3%) forms (p = 0.015).

They also linked these newly found morphological differences to the severity of CCSVI:
In a per patient analysis, we also correlated the IJV morphological types with the CCSVI scores (Table 5). A strong association was observed between the IJV morphological types and the CCSVI scores (Χ2 [9, N = 313] = 75.183, p < 0.001). In fact, the patients with isolated VDs [VD = Valvular defect] had a median CCSVI score of two, those with hypoplasia plus VDs or miopragia plus VDs had a median score of three, and the patients with hypoplasia of an IJV and miopragia plus VDs of the other IJV had a median score of four.

In their conclusion, they state that these findings suggest certain cases in which venoplasty would be contraindicated.

Comment?

Source URL: http://www.ncbi.nlm.nih.gov/pubmed/24188184
PMID: 24188184
DOI: http://dx.doi.org/10.1186/1471-2377-13-162
Journal Title: BMC neurology
Journal Date: 5 Nov 2013
Journal Issue: 1
Journal Volume: 13
Journal First Page: 162
Abstract URL: http://www.ncbi.nlm.nih.gov/pubmed/2418 ... t=abstract
Article Title: Cross-sectional area variations of internal jugular veins during supine head rotation in multiple sclerosis patients with chronic cerebrospinal venous insufficiency: a prospective diagnostic controlled study with duplex ultrasound investigation.
Article Authors: Massimiliano Farina,Eugenio Novelli,Raffaello Pagani

Conclusions
The reconstruction of longitudinal echographic scans of IJVs provides a full view of vessels, thereby enabling the identification of a new morphological type with an hourglass appearance, which was not detected in the HCs. This type of vein shows a unique behaviour with the SCM stretching manoeuvre, most likely because of a condition of wall miopragia, the congenital nature of which was clearly shown by our study, but the meaning of which will have to be investigated further. This dynamic approach, applied to the conventional static ultrasound screening for CCSVI, allowed us to introduce the first selective criterion for angioplasty. In fact, it would be unthinkable to treat miopragic veins; balloon angioplasty would most likely fail because of the increased distensibility of the venous wall. Obviously, further histochemical studies will be needed to confirm whether jugular collapse, found in MS patients, could be the expression of dysregulation of collagen synthesis.
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Re: DrSclafani answers some questions

Postby Squeakycat » Fri Nov 08, 2013 4:03 pm

And another new study which suggests a way to predict the outcome of venoplasty:

Source URL: http://www.jvir.org/article/S1051-0443(13)01393-6/abstract
DOI: 10.1016/j.jvir.2013.08.024
Journal Title: Journal of Vascular and Interventional Radiology
Abstract URL: http://www.ncbi.nlm.nih.govhttp://www.j ... 51-0443(13)01393-6/abstract
Article Title: Internal Jugular Veins Outflow in Patients with Multiple Sclerosis: A Catheter Venography Study

Internal Jugular Veins Outflow in Patients with Multiple Sclerosis: A Catheter Venography Study

Pierfrancesco Veroux, MD, Alessia Giaquinta, MD, Debora Perricone, MD, Lorenzo Lupo, MD, Flavia Gentile, MD, Carla Virgilio, MD, Anna Carbonaro, MD, Concetta De Pasquale, MD, Massimiliano Veroux, MD, PhD
Abstract

Purpose

To investigate an examiner-independent catheter venography protocol that could be used to reliably diagnose venous outflow abnormalities in patients with multiple sclerosis (MS) and chronic cerebrospinal venous insufficiency and to determine whether venous angioplasty is effective in the treatment of these abnormalities.

Materials and Methods

A total of 313 patients with MS and 12 patients with end-stage renal disease underwent echo-color Doppler sonography and catheter venography of the internal jugular veins (IJVs) to evaluate contrast medium clearance time. In patients with venous outflow anomalies, balloon angioplasty of the IJVs was performed.

Results

A contrast medium clearance time cutoff value of 4 seconds or less provided the maximal combination of sensitivity and specificity for the right IJV (sensitivity, 73.4%; specificity, 100%) and left IJV (sensitivity, 91.4%; specificity, 100%). IJVs with a clearance time between 4.1 and 6 seconds had moderate delayed flow (MDF), and IJVs with a clearance time longer than 6 seconds had severe delayed flow (SDF); 89% of patients showed MDF/SDF through at least one IJV, 79% showed MDF/SDF through both IJVs, and only 5% showed normal flow in both IJVs. Balloon angioplasty was immediately able to improve flow in at least one IJV in 69% of patients, but venous flow was normalized in both veins in only 37% of patients; SDF persisted after angioplasty in 32% of patients.

Conclusions

There is a high prevalence of abnormal delayed flow through the IJVs in patients with MS. Venous angioplasty was effective in only a minority of patients with SDF.

Comment?
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Re: DrSclafani answers some questions

Postby Cece » Fri Nov 08, 2013 4:38 pm

Squeakycat wrote: Balloon angioplasty was immediately able to improve flow in at least one IJV in 69% of patients, but venous flow was normalized in both veins in only 37% of patients; SDF persisted after angioplasty in 32% of patients.
Underdilatation?

This type of vein shows a unique behaviour with the SCM stretching manoeuvre, most likely because of a condition of wall miopragia

Squeakycat, do you have the full article? What do they mean by SCM stretching maneuver?
I thought this one might be the authors seeing the hourglass shape of the IJVs and explaining it as miopragia, instead of looking with IVUS and seeing intraluminal abnormalities and explaining it thusly.
The vein right above the valve can be highly distensible but I don't think that has any effect on the outcome of angioplasty since that is not the area being ballooned.
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Re: DrSclafani answers some questions

Postby Squeakycat » Fri Nov 08, 2013 6:51 pm

Cece wrote:Squeakycat, do you have the full article? What do they mean by SCM stretching maneuver?


The full article.

http://www.biomedcentral.com/content/pd ... 13-162.pdf
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Re: DrSclafani answers some questions

Postby Lety » Sat Nov 09, 2013 1:12 am

drsclafani wrote:
drsclafani wrote:
lety wrote:Dear dr. Sclafani

you have still not received an answer ? :sad:




lety, i asked again. consultant was away. promised to review it soon

i hope


lety, below is the opinion of my vascular surgical consultative colleague on reading the paper you sent me regarding omohyoid muscle compression. New techniques can look promising, but they must have reasonable experience and volume to truly understand outcome effectiveness and safety. My consult is saying that it may be interesting but that there is not enough experience to really tabulate risk and the length of followup is too short to determine effectiveness.

consultant surgeon wrote:Sal,

Sorry, it took so long. Definitely an interesting hypothesis at this time. However, sample size small. 23 pts with SP, 6 with RR and one with PP. Follow up short as well. Will give you more detail to follow.
Unlikely something Bill or I would do.. I think more in line with a University institution.

Regards



Thank you Dr. Sclafani

I hope there will be soon more experience and case study for this muscle compression.
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