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.
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 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