newlywed4ever wrote:This is exciting, Dr Cumming! I am in Michigan's U.P. and will need follow-up care at 1,3,6,9 & 12 mos. I was initially treated by Dr Siskin in August, have an appt with Dr Sclafani the end of January (I believe I've restenosed) and have not been successful in finding follow-up care locally (meaning within a day's drive). Would you be willing to provide follow-up care?
Cece wrote:Welcome to the forum, Dr. Cumming, what a surprise!
It is great to hear that the eleven procedures so far have gone well. When I was tested by MRV, I was number four, and at that time every one of us had shown CCSVI. Have those odds held up, are you seeing CCSVI in every MS patient who comes in?
Last winter when I first looked into this, it was that alone that was very intriguing and convincing: with very few exceptions, how could every last one of us be showing up with the predicted jugular and azygous malformations....
Btw, if I say that you know me as "Jeff's wife," my identity is revealed?
Cece wrote:I was highly impressed with him as well.
Dr. Cumming, if you're available to answer, what are your thoughts on some of what we've been hearing about tearing the annulus as opposed to just stretching it and having it recoil back in a month or two? Or on high pressure balloons or on IVUS or on any of the various techniques that the various doctors are using? Everything I know I learned in Dr. Sclafani's thread, he is very convincing....
mjc701 wrote:Its complicated And its all theory at this point (as you know).
First, we need to be clear about where in the jugular vein that we are talking about. Most lesions are proximal (near where the jugular joins the subclavian) so we'll deal with them. I really like the concept that these lesions are congenital (vs acquired) and that there are a variety of causes (see the paper the from George Washington).
One cause of these proximal lesions is an annulus of residual mesenchymal tissue. To treat this, you will need to disrupt (tear) the tissue. I believe that if you get a good venographic result, then you probably have been successful doing this. If the balloon was undersized, then you probably will see immediate recoil. So, this raises the question of balloon sizing and inflation pressures. The larger the balloon the greater the injury to the vein wall. While this may give a better immediate venographic improvement, long term it may cause a more aggressive healing response resulting in restenosis. So, my approach, at this point, is to start with a balloon similar in size to the more normal vein above and to only use a larger balloon (or cutting technique) if that does not give an good venographic result. At this time, I do not think that aggressively over dilating the vein will give a better long term result. Hopefully we will be able to learn more about balloon sizing from current studies.
Other proposed causes of narrowing include webs and stuck valve leaflets. These lesions (in my limited experience) tend to require less force to successful treat. And in these situations, I definitely do not think the balloon should be over sized (unless required). I think the goal should be to minimize the amount of intimal injury.
As for high pressure balloons, we use them, but only inflate them to the pressure require to get the balloon to completely open. These balloons are what we call non compliant versus compliant. I don't think there is much role for the use of compliant balloons in this situation.
We have IVUS but have not used it for these procedures. Some of the imaging I have seen from IVUS looks interesting and may turn out to be useful in making treatment decisions.
So, in summary, my approach to dilating, is big enough and aggressive enough to get the job done with the secondary goal of minimizing the amount of injury to the vein wall and to the surrounding normal veins.
Two of the most important questions that need to be answered are:
1. Does treating CCSVI improve the symtoms of MS.
2. Does treating CCSVI stop or slow disease progression.
Of course there is the more basic question of what is the relationship of CCSVI to patients with MS (and possibly other neurological disorders) and if the concept of CCSVI is even valid. I believe it is, but, of course, I might be wrong. The science is coming. Its going to be a turbulent and exciting journey.
Happy New Year!
Brainteaser wrote:I'm not sure Cece is correct regarding the 3 month restenosis timeframe. Some patients are being retreated after only a couple of weeks.
Stenosis from intimal hyperplasia is often difficult to treat. Unlike soft atheromatous plaques, these stenoses are firm and require prolonged high inflation pressures to dilate with a balloon. The stenoses often recur; repeated dilatation causes repeated intimal injury and perpetuates the intimal healing response.
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