DrSclafani dialogues w other doctors re:CCSVI interventions

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

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

Postby DrCumming » Thu Jan 27, 2011 1:39 pm

drsclafani wrote: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.


haven't done anything yet. unfortunately, this is a Canadian patient. $15k to go to europe and now another chunk of cash to come here. i feel very frustrated for the patient.

not sure what to say about the operator in this case. this is from a high volume center in europe. i would have expected better from them. patients deserve better than that.
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Postby DrCumming » Thu Jan 27, 2011 1:54 pm

Nunzio wrote: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.


good question. in this case, the balloon did come up to profile. so the annulus was at least torn to that size. but how big to go is a problem and what is a good balloon result another. one lesson i have learned is that its very hard to undo something you done and but easy to come back and do more. so, i think its very resonable to dilate to what is felt to be a safe size and come back and do more latter if needed. obviously, we want to do the best we can for the patient in one setting but we have to balance maximizing benefit against risk. big as possible is not always better, at least the first time around.
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Postby DrCumming » Thu Jan 27, 2011 2:37 pm

drsclafani wrote: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:


I am always worried about how aggressive to be at the skull base. I think a rupture in this area could lead to problems.
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Postby DrCumming » Fri Jan 28, 2011 12:28 pm

Below is an example of a "twisting" type abnormality of the azygous. As expected, this did not respond to venoplasty. We (patient and I) elected to not stent at this time.

http://picasaweb.google.com/lh/photo/XKish3rdkPJet9EwOCbH1w

Anyone had success dilating these?
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Postby Nunzio » Sat Jan 29, 2011 12:03 pm

DrCumming wrote:
Nunzio wrote: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.


good question. in this case, the balloon did come up to profile. so the annulus was at least torn to that size. but how big to go is a problem and what is a good balloon result another. one lesson i have learned is that its very hard to undo something you done and but easy to come back and do more. so, i think its very resonable to dilate to what is felt to be a safe size and come back and do more latter if needed. obviously, we want to do the best we can for the patient in one setting but we have to balance maximizing benefit against risk. big as possible is not always better, at least the first time around.

I just noticed this picture that was taken few minutes after dilation of the left IJV to look at the Right hypoplastic vein.
In the picture you will notice that the catheter fits tightly into the vein and the dye ,instead of flowing down it goes toward the brain and then through the sinuses out on the left side.
Image
If you look at the valve on the left side it looks to me that it restenosed again to approximately 50% in diameter compared to the vein diameter a couples of inches above,which allows less then a quarter of the flow to go through. This might explain why the patient did not experience the improvements he experienced with the first procedure.
I think this is another care of elastic recoil.
Everybody here brings happiness, somebody by coming,others by leaving.  PPMS since 2000<br />
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Postby drsclafani » Sun Jan 30, 2011 12:32 am

DrCumming wrote:Below is an example of a "twisting" type abnormality of the azygous. As expected, this did not respond to venoplasty. We (patient and I) elected to not stent at this time.

http://picasaweb.google.com/lh/photo/XKish3rdkPJet9EwOCbH1w

Anyone had success dilating these?


i didnt even have success in viewing these images.

i have concern about this diagnosis. This narrowing may not even be, in many situations, a stenosis. I had one today , but IVUS showed it kept collapsing and distending, suggesting that perhaps this was a physiological dynamic state rather than a real stenosis. I do most of my imaging in end-expiratoin to maximize flow toward the heart. So i repeated in the angiogram inspiration and it totally disappeared.

when youinflated the balloon, did you see a rigid waist as balloon pressure increased?
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Postby drsclafani » Sun Jan 30, 2011 12:52 am

Nunzio wrote: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.

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.


nunzio, i think the real question is whether one is going to accept the incomplete dilatation seen on the final image. I consider it a disappointment. Look at all those collateral veins! i would prefer not to stop with that result

But what does such a narrowing represent? for me, the real question that needs be answered is "what is causing this narrowing?"It is inelastic collagen in the wall of the vein that cannot distend? Is it a narrowed annulus with more central collapse? Is it fused valve leaflets that are causing a funnel? or something else.

This is where i have found IVUS very helpful. Based upon my interpretation of IVUS, i think that these central stenoses represent valve dysfunction often associated with a narrow annulus. One sees that the valve never completely opens and the valve leaflets are thick and often fused.

So I am moving, (and for me, the treatment seems always to be a moving target,) toward angioplasty to a balloon size slightly larger than the peripheral (away from the heart) diameter as measured accurately by IVUS. I put the peripheral balloon shoulder just above the stenosis and inflate to high pressure. I am delighted if i hear a pop or have a nice drop in balloon pressure. if i do, then i perform venography to see what effect i have had on stenosis appearance and contrast flow. If i find a stenosis like nunzio shows, i repeat the IVUS to see what the problem is. If the abnormal valvular tissue has been disrupted, and flow looks good i may stop. if collaterals are still present or stasis of the contrast media persists, then i will go up to a larger baloon size and again use the peripheral shoulder to dilate the annulus. using the peripheral shoulder should stretch the native vessel the least . There is no good reason to stretch that part of the vessel.
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Postby DrCumming » Sun Jan 30, 2011 5:33 am

drsclafani wrote:
DrCumming wrote:Below is an example of a "twisting" type abnormality of the azygous. As expected, this did not respond to venoplasty. We (patient and I) elected to not stent at this time.

http://picasaweb.google.com/lh/photo/XKish3rdkPJet9EwOCbH1w

Anyone had success dilating these?


i didnt even have success in viewing these images.

i have concern about this diagnosis. This narrowing may not even be, in many situations, a stenosis. I had one today , but IVUS showed it kept collapsing and distending, suggesting that perhaps this was a physiological dynamic state rather than a real stenosis. I do most of my imaging in end-expiratoin to maximize flow toward the heart. So i repeated in the angiogram inspiration and it totally disappeared.

when youinflated the balloon, did you see a rigid waist as balloon pressure increased?


Sal, I agree. I am not sure that this is just not a positional finding. IVUS shows exactly what you describe. No significant waist on balloon.

Both IJ's were narrowed and ballooned. Patient was doing great at 48hr with improved fatigue, balance, and less spasticity.

Try this link to the venogram

http://picasaweb.google.com/ccsvimn/Azy ... rs5426jQE#
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Postby DrCumming » Fri Feb 04, 2011 3:23 pm

Another case,

69 yo male, main complaint is progressive loss of leg function. Treated in US at a center that has large experience with CCSVI.

Imaging showed mild R IJ stenosis and severe L IJ stenosis. Both ballooned. Azygous called normal.

Images below from L. Dilated with a 10mm balloon.

Image

Little improvement in symptoms.

The left side (in my opinion) has not been treated completely. At least I would not have stopped with that result. Current US shows very little antegrade flow on the left.

Would anyone have been satisfied with the result on the L?

Would it be reasonable to retreat the L side?
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Postby DrCumming » Tue Mar 01, 2011 11:46 am

Bumping this thread with another case.

28 yo male with RRMS, mild symptoms. Right dominate IJ. Treated with bilateral venoplasty for mild right and moderate left stenosis.

Some improvement in symptoms, particularly at night.

Follow US on right is good, but left shows complete occlusion. Patient was on lovenox for 1 month post procedure.

Pictures below show stenosis and good result post venoplasty. US shows occluded IJ. This is not an acute thrombosis. The vein looks more like a post EVLA picture. Its more like the vein collapsed and the walls scarred down together after the intimal injury from ballooning.

The question I have - is it worth going back and trying to open the left IJ? I think the odds achieving a good result are low with venoplasty only and in a 28 yo a stent is not a good choice either.



Image
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Postby drsclafani » Tue Mar 01, 2011 7:28 pm

DrCumming wrote:Bumping this thread with another case.

28 yo male with RRMS, mild symptoms. Right dominate IJ. Treated with bilateral venoplasty for mild right and moderate left stenosis.

Some improvement in symptoms, particularly at night.

Follow US on right is good, but left shows complete occlusion. Patient was on lovenox for 1 month post procedure.

Pictures below show stenosis and good result post venoplasty. US shows occluded IJ. This is not an acute thrombosis. The vein looks more like a post EVLA picture. Its more like the vein collapsed and the walls scarred down together after the intimal injury from ballooning.

The question I have - is it worth going back and trying to open the left IJ? I think the odds achieving a good result are low with venoplasty only and in a 28 yo a stent is not a good choice either.



Image


Mike
I would think that there are several considerations

1. Hypercoagulability?
2. what is the inflow like? Is there a high stenosis or foraminal narrowing?
3. How big was the balloon?
4. how was the balloon located? Where was the waist?
5. Was there a pop or a snap?
6. Does the patient have worsening symptoms?
7. How long has the occlusion been present?
8. Where does the patient come from? local or long distance?

I have had a few of these situations , two were due to heroic attempts to maturate a hypoplasia. one or two may be related overdilatation. Another I just dont have any idea why it should happen.

Based upon that experience, i have really relied upon IVUS to decide balloon size, location of balloon, and to monitor effects of angioplasty. I have not noted any wall collapses on IVUS. I believe that we must distinguish between annulus stenosis and valvular stenosis because treatments are different and outcomes different. I would guess that this is treatment of a stenosis of the annulus, more likely to thrombose

with regard to thrombectomy or thrombolysis in this case, i suspect that this is a subacute thrombosis, thus outcomes wont be great. . A stent is not a great option. Anticoagulate and see if a lumen develops and then treat if symptoms are worse.

But this is fefinitely unchartered territory and i empathize with you

sal
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Postby drsclafani » Tue Mar 01, 2011 8:30 pm

DrCumming wrote:Another case,

69 yo male, main complaint is progressive loss of leg function. Treated in US at a center that has large experience with CCSVI.

Imaging showed mild R IJ stenosis and severe L IJ stenosis. Both ballooned. Azygous called normal.

Images below from L. Dilated with a 10mm balloon.

Image

Little improvement in symptoms.

The left side (in my opinion) has not been treated completely. At least I would not have stopped with that result. Current US shows very little antegrade flow on the left.

Would anyone have been satisfied with the result on the L?

Would it be reasonable to retreat the L side?
i
i had this same case today. note the contrast accumulation under the cusps, suggesting that the valve leaflets are likely adherent and never open fully.

I think that you can dilate this up to the diameter of the proximal dilatation.
ten mm is grossly underdilated in my opinion. I would start with a high pressure balloon in that long narrowed segment. Not all of it is stenosed, but exactly where the valves are adherent or fused is difficult to assess .

i would inflate a high pressure balloon to 0-1 Atm and see where the waist is. then i would deflate the balloon and reposition so that the upper shoulder was just above the narrowed focus. Thus most of the normal vein would not be dilated and the pressure exerted would be focused on that narrowing. This wont work if you pick too large a balloon size as it will watermelon seed down below the stenosis. That often leads to persisting and centering the balloon on the stenosis. But you will end up dilating normal vein above the stenosis. Totally unnecessary

I would inflate to 10 Atm and hold there for about 20-30 seconds. If the waist is not effaced, then deflate and try again to 20-30 Atm depending upon balloon size, pain, etc. Generally the narrowed waist will resolve.

Maintain inflated pressure for a short time, then release the lock on the inflator. if a waist reveals itself, then you have elastic recoil and repeat dilatation. If necessary go up in size of balloon. . In this case I would probably start with a 16 mm.

Followup IVUS will show that the valve leaflets are mobile or torn after treatment. Obviously mobile valve leaflets is more desirable but not always possible.



if you dont have ivus, remember that the long narrowed segment that you see is hiding a funnel of valve tissue and that somewhere in that narrowing is an opening. The rest is just contrast filling the funnel

If i have ministerpreted the venogram and there is actually an annulus stenosis or hypoplasia, then you will see a very tight, focal and discrete annular narrowing that is resistant to dilatation even at high pressure. Minimal stretch will occur. You will then have to decide whether to push higher pressure and larger diameter to tear the annulus. Maybe its worth a try since a narrow annulus will just recur very quickly. Of course i think this is where many of the occlusions occur if pushed too far. I now have a discussion with the patient about the risks before proceeding further. I think they should be part of the decision.

Sorry for missing this case. i started the thread but lost track of it.
I appreciate your support
sal
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Postby DrCumming » Wed Mar 02, 2011 6:01 pm

drsclafani wrote:i
i had this same case today. note the contrast accumulation under the cusps, suggesting that the valve leaflets are likely adherent and never open fully.

I think that you can dilate this up to the diameter of the proximal dilatation.
ten mm is grossly underdilated in my opinion. I would start with a high pressure balloon in that long narrowed segment. Not all of it is stenosed, but exactly where the valves are adherent or fused is difficult to assess .

i would inflate a high pressure balloon to 0-1 Atm and see where the waist is. then i would deflate the balloon and reposition so that the upper shoulder was just above the narrowed focus. Thus most of the normal vein would not be dilated and the pressure exerted would be focused on that narrowing. This wont work if you pick too large a balloon size as it will watermelon seed down below the stenosis. That often leads to persisting and centering the balloon on the stenosis. But you will end up dilating normal vein above the stenosis. Totally unnecessary

I would inflate to 10 Atm and hold there for about 20-30 seconds. If the waist is not effaced, then deflate and try again to 20-30 Atm depending upon balloon size, pain, etc. Generally the narrowed waist will resolve.

Maintain inflated pressure for a short time, then release the lock on the inflator. if a waist reveals itself, then you have elastic recoil and repeat dilatation. If necessary go up in size of balloon. . In this case I would probably start with a 16 mm.

Followup IVUS will show that the valve leaflets are mobile or torn after treatment. Obviously mobile valve leaflets is more desirable but not always possible.



if you dont have ivus, remember that the long narrowed segment that you see is hiding a funnel of valve tissue and that somewhere in that narrowing is an opening. The rest is just contrast filling the funnel

If i have ministerpreted the venogram and there is actually an annulus stenosis or hypoplasia, then you will see a very tight, focal and discrete annular narrowing that is resistant to dilatation even at high pressure. Minimal stretch will occur. You will then have to decide whether to push higher pressure and larger diameter to tear the annulus. Maybe its worth a try since a narrow annulus will just recur very quickly. Of course i think this is where many of the occlusions occur if pushed too far. I now have a discussion with the patient about the risks before proceeding further. I think they should be part of the decision.

Sorry for missing this case. i started the thread but lost track of it.
I appreciate your support
sal


Sal, thank you for the thoughtful commentary. Agree with your thoughts and observations especially regarding technique using the balloon to identify the lesions and then reposition to avoid dilating more normal vein. Had a case like that today.

I believe this case was under treated. What concerns me is that this came from a CCSVI trial site. This could have an impact on outcomes. Not good for the cause of CCSVI.
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Postby drsclafani » Wed Mar 02, 2011 10:34 pm

DrCumming wrote:
drsclafani wrote:i
i had this same case today. note the contrast accumulation under the cusps, suggesting that the valve leaflets are likely adherent and never open fully.

I think that you can dilate this up to the diameter of the proximal dilatation.
ten mm is grossly underdilated in my opinion. I would start with a high pressure balloon in that long narrowed segment. Not all of it is stenosed, but exactly where the valves are adherent or fused is difficult to assess .

i would inflate a high pressure balloon to 0-1 Atm and see where the waist is. then i would deflate the balloon and reposition so that the upper shoulder was just above the narrowed focus. Thus most of the normal vein would not be dilated and the pressure exerted would be focused on that narrowing. This wont work if you pick too large a balloon size as it will watermelon seed down below the stenosis. That often leads to persisting and centering the balloon on the stenosis. But you will end up dilating normal vein above the stenosis. Totally unnecessary

I would inflate to 10 Atm and hold there for about 20-30 seconds. If the waist is not effaced, then deflate and try again to 20-30 Atm depending upon balloon size, pain, etc. Generally the narrowed waist will resolve.

Maintain inflated pressure for a short time, then release the lock on the inflator. if a waist reveals itself, then you have elastic recoil and repeat dilatation. If necessary go up in size of balloon. . In this case I would probably start with a 16 mm.

Followup IVUS will show that the valve leaflets are mobile or torn after treatment. Obviously mobile valve leaflets is more desirable but not always possible.



if you dont have ivus, remember that the long narrowed segment that you see is hiding a funnel of valve tissue and that somewhere in that narrowing is an opening. The rest is just contrast filling the funnel

If i have ministerpreted the venogram and there is actually an annulus stenosis or hypoplasia, then you will see a very tight, focal and discrete annular narrowing that is resistant to dilatation even at high pressure. Minimal stretch will occur. You will then have to decide whether to push higher pressure and larger diameter to tear the annulus. Maybe its worth a try since a narrow annulus will just recur very quickly. Of course i think this is where many of the occlusions occur if pushed too far. I now have a discussion with the patient about the risks before proceeding further. I think they should be part of the decision.

Sorry for missing this case. i started the thread but lost track of it.
I appreciate your support
sal


Sal, thank you for the thoughtful commentary. Agree with your thoughts and observations especially regarding technique using the balloon to identify the lesions and then reposition to avoid dilating more normal vein. Had a case like that today.

I believe this case was under treated. What concerns me is that this came from a CCSVI trial site. This could have an impact on outcomes. Not good for the cause of CCSVI.


imy opinion on this is in the records.

its been over a year and i still dont feel like i have maximized technique.

For example, has any body discussed access from a vein other than the femoral? I am just as concerned about femoral access as i am to jugular angioplasty in terms of restenosis.

how many punctures is going to be too many.

My next nuance is going to be access from the saphenous vein at the confluens with the femoral vein.

WE need to be tweaking, not trialing.
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Next case

Postby DrCumming » Tue Mar 08, 2011 2:25 pm

64 yo male with SPMS.

Both IJ's stenotic and treated.

Below are pictures of the azygous. At the time of the procedure, I elected to not below the "kink".

I do not think it is truely stenotic. No collaterals around the kink. IVUS shows some narrowing but nothing that seems significant.

Feedback? Should this be ballooned? My experience with these types of lesions is they are "mechanical" and will not improve without placement of a stent. It would be interesting to see how this lesion looks between the supine and erect position (I think Machan is looking at this in Vancouver).


Image
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