DrSclafani dialogues w other doctors re:CCSVI interventions

A forum to discuss Chronic Cerebrospinal Venous Insufficiency and its relationship to Multiple Sclerosis.

Postby drsclafani » Fri Jan 21, 2011 8:41 pm

DrCumming wrote:New case.

53 yo female with relapsing remitting MS.

Venography showed severe bilateral IJ stenosis and azygous stenosis.

Azygous responded to venoplasty. Both IJ's initially dilated to 14mm. Tight waists in the balloon resolved at 15-18 ATM. Repeat venography showed severe recoil. Multiple repeat dilations, use of a cutting wire and upsizing to 16mm balloon done. Still little improvement in stenosis. Images from left IJ only shown. No clinical improvement at 1 month.

Patient does not want stents (and neither do I).

Thoughts? Options? What would others do differently?



Left IJ preballooning

Image


Cutting wire (after several prolonged conventional balloonings)

Image

Post venoplasty. Severe recoil.

Image

if 14 mm allows elastic recoil, i would consider increasing balloon size. Routinely 14-18 mm in woman and 16-20 in men are endpoints before giving up. when angioplsty is successful, the pressure in the balloon drops precipitiously, the waist disappears and an audible pop is heard.

i have found that you can stretch but not disrupt the valve annulus at 14 mm so that the waist on the balloon appears to disappear. but when the rest of the vein continues to distend with a larger balloon, the stenosis waist "reappears" before it is disrupted.

i would give a try of a larger balloon.
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Postby drsclafani » Fri Jan 21, 2011 8:43 pm

phlebologist wrote:
uprightdoc wrote:
DrCumming wrote:Sal, I think the left IJ maybe occluded at the skull base. ..........................

As for stents versus angioplasty, I wasn't advocating either. I was merely pointing out the permanency of certain curvature problems that will most likely cause restenois to occur sooner rather than later due to chronic extravascular musculoskeletal stress. It seems logical that more durable stents would maintain patency longer.



We have very bad experience with the stents implanted in the upper (cranial) part of IJV. Such a procedure was nearly always associated with a problem (usually, an occlusion, but also: accessory nerve injury, or dislocation of the stent) if not immediately - a problem occured after some time. Now we never stent such lesions, we either use cutting balloons or perform balloon angioplasty in 2 (or more) steps. Importantly, poor INFLOW is a common finding in these (i.e. with stenotic upper IJV) patients.


i have received so many consults of patients treated with stents with bad outcomes either thrombosis or intimal hyperplasia.

i agree that stents should be avoided at almost all circumstances
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Postby drsclafani » Fri Jan 21, 2011 8:52 pm

drsullivan wrote:How many times did you inflate the balloon, and for how long? I am routinely inflating each stenosis three times, with 2 minute for each inflation.


kevin, i was doing the same thing, but i have found that once there is a POP, then the stenosis is broken and second dilatation does not show the waist.

do you think that repeated dilatation increases risk of injury to the NORMAl vessel? i worry about that.

the more i learn, the more i dont know :cry:
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Postby DrCumming » Fri Jan 21, 2011 8:53 pm

I did go upto 16 and the waist in the ballloon definitely released at 16 or so ATM. 16 was is a fair bit larger than the size of the vein.

Did 3 inflations with a 14 mm, 2 inflations with 16 and then 3 inflations with 16 plus cutting wire. All inflations for 2 or so minutes.

18 certainly would be over dilating. 16 definitely treated the stenosis - repeat dilations showed no further waist.

I am not aware of any published reports on patency between nitonal or stainless steel stents in the venous system. Reference?

This case is a good example of what is a reasonable end point when you have recoil. How much do you oversize before stopping. This was at least a 20% oversize.
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Postby DrCumming » Fri Jan 21, 2011 8:55 pm

drsclafani wrote:
drsullivan wrote:How many times did you inflate the balloon, and for how long? I am routinely inflating each stenosis three times, with 2 minute for each inflation.


kevin, i was doing the same thing, but i have found that once there is a POP, then the stenosis is broken and second dilatation does not show the waist.

do you think that repeated dilatation increases risk of injury to the NORMAl vessel? i worry about that.

the more i learn, the more i dont know :cry:


i definitely got a POP in this case... :)

agree, the more i see and do the more i realize what needs to learned.
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Postby phlebologist » Sat Jan 22, 2011 6:48 am

DrCumming wrote:

I am not aware of any published reports on patency between nitonal or stainless steel stents in the venous system. Reference?


not many articles published but we've experienced clear difference between steel and nitinol stents. Thus far, no of steel stent occluded (at least, we have no information about such an event), only some insignificant narrowings, while there were many severe narrowings inside of nitinol stents, and some of them completly occluded.
here is the paper on stents implanted to carotid arteries.

http://journals.lww.com/investigativera ... tid.4.aspx

Of course, you can find many studies with opposite results (favoring nitinol stents) but these stents were implanted into leg artieries where flexibility may play a role.
I think that many studies have not been published - due to financial reasons. Interestingly, company engineers know that nitinol is not a good material for veins (personal communication)
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Postby drsclafani » Sat Jan 22, 2011 7:51 am

DrCumming wrote:I did go upto 16 and the waist in the ballloon definitely released at 16 or so ATM. 16 was is a fair bit larger than the size of the vein.

Did 3 inflations with a 14 mm, 2 inflations with 16 and then 3 inflations with 16 plus cutting wire. All inflations for 2 or so minutes.

18 certainly would be over dilating. 16 definitely treated the stenosis - repeat dilations showed no further waist.

I am not aware of any published reports on patency between nitonal or stainless steel stents in the venous system. Reference?

This case is a good example of what is a reasonable end point when you have recoil. How much do you oversize before stopping. This was at least a 20% oversize.

mike, this is a good question and one that we will have to really explore. That vein distends tremendously it is so compliant. Actually, i have started to come DOWN in size and UP in pressure. i use ivus to assess luminal diameter, taking measurements at end expiration when flow is greatest. I will start with balloon diameter equal to vein diameter. Afterall, there is nothing wrong with the vein, it is with the confluens/annulus that is the problem.I will use the smallest diameter to "pop" the valve or stenosis.
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Postby drsclafani » Sat Jan 22, 2011 12:12 pm

phlebologist wrote:
drsclafani wrote:.

Image

i do not know what to name it.



I wonder if the vein actually has its anatomical name, I don't think it is the facial vein, it might be one of deep cervical veins, but also it might be an originally very small vessel transformed within years of pathologic outflow conditions into a larger conduit (look at its tortuosity), for sure it is a compensatory outflow route from the IJV and maybe also (is it joining intracranial veins?) from the brain - otherwise it will not fill with contrast.
In Italy or France it will be called a vicarious shunt (I'm not sure if American doctors are familiar with this term)


Sorry, i couldnt finish this case before leaving for ISET.
Allow me to show the rest of the story and i will be happy to let you all tear it apart.
Eventually i decided that that large bulbous vein was the IJV and ultimately was able to catheterize it. There was a second obstruction above (blue circle) . which i was able to cross.
Dilation of the lower stenosis required 25 atm with a 12 mm high pressure balloon.
The upper area was really a hypoplasia. so i used a long balloon of 8 mm to open the vein.

Unfortunately, thrombus started to form despite patient being on fondaparinux 5 mg for about three hours which should have been therapeutic level for this patient.


Image

Unfortunately, during subsequent imaging thrombus began to form, Despite patient being on fondaparinux 5mg for three hours. Thrombectly was performed and final images looked like image on right.

Image

you may now begin the thrashing
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Postby DrCumming » Mon Jan 24, 2011 9:37 am

Sal,

I am not sure if that was due to anticoagulation choice or making a hypoplastic vein too big. There is why I am not keen on aggressive over dilation. Too much intimal injury.

How did you perform the thrombectomy?
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Postby DrCumming » Mon Jan 24, 2011 9:43 am

Follow up on the first case I posted. Here is the right side. I am showing this so that the non MD's following this in the other thread can understand the sequence of what we see.

First image is the venogram showing the severe stenosis. The blue circle on the second image shows the 'waist' in the balloon. We see this as we begin to inflate the balloon. Third image shows the balloon inflated to profile. This required fairly high pressure (18 ATM). Usually what happens is that as the pressure in the balloon increases, the tissue we are dilating releases (tears..) and the balloon comes up to full size. Ie the 'pop' we talk about. Last images shows little improvement (as occured on the left). This was after multiple prolonged dilations.

Image
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Another example of sub optimal work done at St. Elsewhere

Postby DrCumming » Tue Jan 25, 2011 8:30 am

I have had several patients come to see me in follow up treated elsewhere. Here is an example of an incompletely opened stent. The balloon waist never resolved on any of the images (at least no picture was included). Imaging is done on a cardiac room - ie no subtracted images. For this case, the images indicate a procedure time of under 30 minutes - very fast. The quality of the imaging was in general poor. Only 1 set of images of the azygous and right IJ.

Image

Image
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Postby drsclafani » Tue Jan 25, 2011 10:23 pm

DrCumming wrote:Sal,

I am not sure if that was due to anticoagulation choice or making a hypoplastic vein too big. There is why I am not keen on aggressive over dilation. Too much intimal injury.

How did you perform the thrombectomy?


thrombectomy was performed by gental Fogarty balloon. Final image showed no thrombus but continue slow flow.

i understand and share your concern regarding over-dilation. We actually didnt over dilate this annulus, using only a 12 mm balloon.

BTW I am surprised how much the J1 segment can dilate . Using IVUS it is possible to see how dynamic the distension can be. 14 mm is not uncommon with simple manuevers like activating the thoracic pump. but i agree one should not dilate any more than is requiring to break the stenotic annulus. Sometimes dilation to 14 mm is just not enough. so i am not sure what you believe overdilation is.

my assessment was that this hypoplastic vein was not really functional anyway: witness the web of collaterals. We decided that we would go for broke on the hypoplastic vein. The J1 segment valvular stenosis was relieved but i did not believe that it would remain open without improving the inflow from the upper vein. The upper segment was dilated with a relatively small balloon. If patient lived in Brooklyn, I would have brought her back over multiple treatments to more slowly effect "maturation". But in this circumstance i did sequential dilatation during one sitting.

I thought that perhaps the highest part of J3 was too small. I could not get the balloon as close to the skull base as i would have needed and even if i had, it would have required dilating higher than i would have felt comfortable with. . I chose not to stent and not to dilate the top of the J3 segment.

I believe it was a calculated risk and a great outcome was not anticipated but we went for it.

in the end the vessel occluded. The patient did not have adverse sequellae but did not benefit as much as we hoped.

here is the final image that shows the upper J3 vessel.


Image
The end result is disappointing. Does anyone think that pushing harder into J3 would have been valuable? In hindsight, what would others have done when confronted with this case.

Slam away, I can take it. After all, none of you detected the hypoplastic IJV in the first place
:wink:
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Postby drsclafani » Tue Jan 25, 2011 10:35 pm

DrCumming wrote:Follow up on the first case I posted. Here is the right side. I am showing this so that the non MD's following this in the other thread can understand the sequence of what we see.

First image is the venogram showing the severe stenosis. The blue circle on the second image shows the 'waist' in the balloon. We see this as we begin to inflate the balloon. Third image shows the balloon inflated to profile. This required fairly high pressure (18 ATM). Usually what happens is that as the pressure in the balloon increases, the tissue we are dilating releases (tears..) and the balloon comes up to full size. Ie the 'pop' we talk about. Last images shows little improvement (as occured on the left). This was after multiple prolonged dilations.

Image


mike
First and most importantly, a clinical effect was not achieved. I have shown a case on TIMS a couple of months ago where balloon distension was achieved at 14 mm but followup venography showed persistent collaterals and a slight persistent narrowing. When i used an 18 mm balloon one noted the waist again. and this clearly broke the stenosis and the followup venogram showed a widely patent lumen and no collateral visualization. AS i look at your case, I would have gone larger and wished i had a 2 cm high pressure balloon to try, but i would not have stopped with that residual stenosis. Now what? you have a patient with no improvement. Are you going to go back and try larger balloons or something else.

s
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Re: Another example of sub optimal work done at St. Elsewher

Postby drsclafani » Tue Jan 25, 2011 10:40 pm

DrCumming wrote:I have had several patients come to see me in follow up treated elsewhere. Here is an example of an incompletely opened stent. The balloon waist never resolved on any of the images (at least no picture was included). Imaging is done on a cardiac room - ie no subtracted images. For this case, the images indicate a procedure time of under 30 minutes - very fast. The quality of the imaging was in general poor. Only 1 set of images of the azygous and right IJ.

Image

Image


that one is pretty awful. What did you do about the stenotic stent?

Hopefully the patients do not have to go as far as they used to. As they get more choices they will do what they have always done, critically analyze, go viral about the bad guys and quality will win out.
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Postby Nunzio » Thu Jan 27, 2011 3:47 am

This case is similar to the one presented by DrCumming on top of page 5:
Patient is a 62 y/o male with PPMS.
Venogram done in the beginning of December showed an hyopoplastic RIJV and a narrowing at the base of the LIJV which was dilated with a 14 mm balloon. Pt reported immediate improvement that disappeared in few days.
Repeat venography showed renarrowing at the confluens with the brachiocephalic vein.
Image

dilation was performed with a14 mm balloon.
Image
Then using a 16 mm balloon.
Image
Image
The post dilation picture shows improvement but still some narrowing.
Image
The real question is to "pop" or not to "pop".
Assuming a redilation is needed should we go just for a larger balloon, i.e. 18 mm. or keep dilating until the patient feels a pop and the pressure drops in the line? This is an important question since there are a lot of patients that restenose and require retreatment. If it is determined that a break in the annulus is needed to prevent recurring stenosis that might save future return to the O.R.
Everybody here brings happiness, somebody by coming,others by leaving.  PPMS since 2000<br />
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