drsclafani wrote:
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.
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.
I like to update everybody on my ongoing treatment.
As you recall I have an Hypoplastic RIJV which leaves me with only one functional Jugular vein; the Left one which in my case has a significant narrowing at the confluens with the brachiocephalic vein.
Dr. Arslan, in Tampa, FL dilated it initially with a 14 mm. balloon with subjective improvement on my part lasting less than a week.
Repeat treatment was performed with a 16 mm balloon a month later with similar results.
Because of that Dr. Sclafani treated me in March; He found re-narrowing and fusion of the valve leaflets by IVUS.
He re-dilated the area with a 16 mm balloon:
With resulting improvement of flow.
In addition he dilated my azygous in 2 places and my Left Iliac vein.
This time too, in spite of the extensive treatments confirmed by IVUS,
my improvements lasted only a couple of days.
At this point a change in plan was needed and being an impatient patient I elected to have a repeat venogram sooner than later and possible stent implant in case of re-narrowing. This was done by Dr. Arslan.
As you can see in the first picture there was obvious re-narrowing which was treated with an EV3 Protege GPS 14X30 mm. stent.
Technically the stent seems to be in perfect position.
My only concern was about the kind of stent used.
I would have preferred to have a balloon expandable stent because of their radial strength being superior to self-expanding stent, like the one used here, but I know they are not available in the diameter that I needed and Dr. Arslan is confident it will be able to withstand the outside force that tends to re-narrow my vein so quickly.
Let me know your thoughts.
Thanks
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