DrSclafani dialogues w other doctors re:CCSVI interventions

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

Postby drsclafani » Tue Mar 08, 2011 9:46 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 would be shocked if a ten millimiter balloon had any significant effect on these malformations. I would have started with 14 or 16 mm balloon depending upon what IVUS showed.
User avatar
drsclafani
Family Elder
 
Posts: 3156
Joined: Fri Mar 12, 2010 3:00 pm
Location: Brooklyn, New York

Advertisement

Postby drsclafani » Tue Mar 08, 2011 9:50 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.


you know my position on that deal!

i recently retreated someone treated by a trialist before the beginning of the trial.

. A collateral was mistaken for and treated as if it were the right jugular vein, the left jugular vein was dilated ABOVE the stenosis but not at the valve , the azygous valve malformation was missed and the femoral vein was thrombosed apparently by excessive force and time of compression.

sort of proves how dangerous and ineffective this treatment is if this case had been part of a trial
User avatar
drsclafani
Family Elder
 
Posts: 3156
Joined: Fri Mar 12, 2010 3:00 pm
Location: Brooklyn, New York

ivus on dr to dr thread

Postby dan46 » Fri Apr 22, 2011 8:33 pm

bump
User avatar
dan46
Getting to Know You...
 
Posts: 11
Joined: Mon Aug 02, 2010 2:00 pm

Postby Johnnymac » Thu May 12, 2011 2:42 pm

Hate to see this thread die down, here are a couple of pictures of my wife's azy which was recently treated by Dr S.

Great thread docs!

ImageImage
User avatar
Johnnymac
Family Elder
 
Posts: 213
Joined: Wed Oct 18, 2006 2:00 pm

Postby Nunzio » Sat May 14, 2011 7:42 am

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.
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.

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.
Image
Because of that Dr. Sclafani treated me in March; He found re-narrowing and fusion of the valve leaflets by IVUS.

Image
He re-dilated the area with a 16 mm balloon:
Image
With resulting improvement of flow.
Image
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.
Image
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
Everybody here brings happiness, somebody by coming,others by leaving.  PPMS since 2000<br />
User avatar
Nunzio
Family Elder
 
Posts: 254
Joined: Thu Jan 14, 2010 3:00 pm
Location: South Florida

Postby drsclafani » Sat May 14, 2011 8:15 pm

Nunzio wrote:
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.
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.

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.
Image
Because of that Dr. Sclafani treated me in March; He found re-narrowing and fusion of the valve leaflets by IVUS.

Image
He re-dilated the area with a 16 mm balloon:
Image
With resulting improvement of flow.
Image
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.
Image
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


nunzio, lets hope this improves things. please let me know.

the case itself is humbling for me.

i agree with the use of self expanding stent. The rigid nature of the balloon expandible stent would have been problematic in an areas with bony compression and motion.
User avatar
drsclafani
Family Elder
 
Posts: 3156
Joined: Fri Mar 12, 2010 3:00 pm
Location: Brooklyn, New York

Postby Nunzio » Sun May 15, 2011 4:50 am

drsclafani wrote:nunzio, lets hope this improves things. please let me know.

the case itself is humbling for me.

i agree with the use of self expanding stent. The rigid nature of the balloon expandible stent would have been problematic in an areas with bony compression and motion.

Thanks Sal for your kind words.
The reason I was suggesting Balloon-expandable stents was that I was relying on the recently published paper on the subject by Dr. Ludyga/Simka group, which, as you know, are the ones with the most experience in stents in CCSVI since they use them in 44% of their patients.
Below is a quote from their paper:http://phleb.rsmjournals.com/cgi/content/full/25/6/286

Similar to the angioplastic balloons, different sized stents, which were tailored to the occluding lesion, were used. The diameter of the stents varied from 4 to 16 mm and the length from 18 to 80 mm. Balloon-expandable stents (OmnilinkTM, Abbott, Abbott Park, IL, USA; and NeptunTM, Balton, Warsaw, Poland) were used for the management of stenotic valves in the ostium of the IJV with no signs of stenosis cranially to the level of junction of the IJV with the facial vein.

Since they use self-expanding stents in any other area of the IJV there might be a specific reason to use a different kind of stent at the base of the IJV, possibly their resistance to radial pressure.
Everybody here brings happiness, somebody by coming,others by leaving.  PPMS since 2000<br />
User avatar
Nunzio
Family Elder
 
Posts: 254
Joined: Thu Jan 14, 2010 3:00 pm
Location: South Florida

Renal Vein & CCSVI

Postby MarkW » Thu Sep 01, 2011 5:15 am

Hello Dr S and other CCSVI practitioners,
The post below was posted by Dania without comment in a new thread.
I disagree with Mike Arata because at such an early stage of CCSVI diagnosis it is illogical to exclude the renal vein. Very few diagnoses have been performed on the renal vein with IVUS and a web could be present. This may only occur at 1 in 10,000 patients but who knows until more IVUS diagnosis is performed.
Your thoughts please,
MarkW

===========================
Renal veins and CCSVI
by Mike Arata on Tuesday, August 30, 2011 at 2:16pm

I have been asked to share my thoughts on renal veins.

The jugular and azygous veins are the veins responsible for CCSVI. In the vast majority of cases this is from a malformed valve. When the flow in these veins is blocked the body has natural alternatives for draining the blood. In the jugular system the thyroidal and external jugular are the major alternative draining veins. The supreme intercostal vein and lumbar veins are the alternative veins for the azygous system. Less commonly the left renal vein provides alternative drainage. When the left renal is an alternative it is almost always in the setting of hemiazygos vein compression.

The important points are A)The renal veins do not directly cause CCSVI. B) The left renal vein is rarely involved with CCSVI, as an alternative. C) the left renal vein drainage is most often seen with hemiazygos vein compression.

Pathology of the left renal vein is quite unusual. Based on my evaluation with IVUS and review of literature it is not associated with a valve problem. Left renal vein abnormalities are caused by compression of the vein. When present it may cause flank pain or blood in urine.

Renal vein abnormalities are rare. I feel safe stating that I have treated as many hemiazygos compressions as anyone. In my experience hemiazygos compression is rare. Finding a patient with hemiazygos compression AND left renal vein compression is like finding the proverbial needle in a haystack!

So how would one identify when the renal vein is play a role, any role in ccsvi. Well first of all it would be evaluated last. What I mean by that is, you evaluate the azygous and hemiazygos veins. You correct any problems found in these veins. After treating the azygos and hemiazygos if you still have left renal drainage it means one thing. Blood is finding it easier to flow in the renal rather than the azygous. Logically one would try and search for the lesion blocking azygos/hemiazygos flow. If not found are able to be corrected I suppose one could make sure the left renal was wide open. Intuitively, this would be known since venous blood always flows in the direction of lowest pressure. The azygos blood draining into the left renal IMPLIES a normal renal.

For the sake of argument that all these rare events all came together in a single patient. Azygos/hemiazygos abnormality that could not be correct and alternative drainage into a left renal...that is abnormal. Well the treatment would be to stent the compressed renal vein. Balloon angioplasty of a compressed vein is not the standard of care for 2011.

So in summary. Renal vein involvement in CCSVI intuitively impossible and if it actually occurs exceedingly rare. If it ever were found it would be discovered after thorough treatment of the azygos/hemiazygos sytem. (renal vein treatment prior to azygos/hemiazygos should not EVER occur). In the off chance all this occurs, treatment of the left renal vein would be using a stent, NOT a balloon.

This is my opinion on renal veins and CCSVI. If another physician has a different opinion. I welcome a rebuttal on this page.
================================
Mark Walker - Oxfordshire, England. Registered Pharmacist (UK). 11 years of study around MS.
Mark's CCSVI Report 7-Mar-11:
http://www.telegraph.co.uk/health/8359854/MS-experts-in-Britain-have-to-open-their-minds.html
User avatar
MarkW
Family Elder
 
Posts: 1151
Joined: Thu Oct 19, 2006 2:00 pm
Location: Oxfordshire, England

Postby Cece » Fri Sep 02, 2011 4:17 pm

Do you have a link? I don't.want to respond in the doctors thread but this one is killing me! He has it backwards. He is talking about the renal as an alternate drainage for azygous but the problem is the azygous serving as alternate drainage for the renal vein.
Cece
Family Elder
 
Posts: 9054
Joined: Mon Jan 04, 2010 3:00 pm

CCSVI Practitioners Views

Postby MarkW » Sat Sep 03, 2011 2:06 am

Hello Cece,
I made my brief comments from the many 'Arata' threads posted by Dania (you could resort to fb for his actual words). For me the basis of treating a syndrome is you diagnose using the best available tools (IVUS to be included) and treat what you find. The pharma industry makes billions each year by doing just this, so lets do this for CCSVI. Theorising about CCSVI syndrome is dangerous as we have too little data and it will take years to prove anything.
I hope Dr S will comment later in the month when he returns from holiday (UK english for vacation), or other docs sooner.
Kind regards,
Mark
Mark Walker - Oxfordshire, England. Registered Pharmacist (UK). 11 years of study around MS.
Mark's CCSVI Report 7-Mar-11:
http://www.telegraph.co.uk/health/8359854/MS-experts-in-Britain-have-to-open-their-minds.html
User avatar
MarkW
Family Elder
 
Posts: 1151
Joined: Thu Oct 19, 2006 2:00 pm
Location: Oxfordshire, England

Re: CCSVI Practitioners Views

Postby drsclafani » Sat Sep 03, 2011 6:00 am

MarkW wrote:Hello Cece,
I made my brief comments from the many 'Arata' threads posted by Dania (you could resort to fb for his actual words). For me the basis of treating a syndrome is you diagnose using the best available tools (IVUS to be included) and treat what you find. The pharma industry makes billions each year by doing just this, so lets do this for CCSVI. Theorising about CCSVI syndrome is dangerous as we have too little data and it will take years to prove anything.
I hope Dr S will comment later in the month when he returns from holiday (UK english for vacation), or other docs sooner.
Kind regards,
Mark


At the moment
we are treating based upon logics
the next phase will be based upon data

So I treat renal vein stenoses based upon the anatomical logic of collateral flow of kidney blood flow into the hemiazygous vein into the azygous vein. Very logical

Next will come analysis of outcomes of patients to see whether the logic results in clinical improvements.

Generally, there are confounding variable like veno/valvuloplasty of the jugulars and azygous vein

That is what makes my one patient who had treatment ONLY of the renal vein stenosis during my session with proof that the treatments of the jugulars and the azygous in India remained patent.

The fact that vision and balance clinically improved after isolated stenting of the nutcracker syndrome is the best data i have. I await longer term followup.
User avatar
drsclafani
Family Elder
 
Posts: 3156
Joined: Fri Mar 12, 2010 3:00 pm
Location: Brooklyn, New York

Previous

Return to Chronic Cerebrospinal Venous Insufficiency (CCSVI)

 


  • Related topics
    Replies
    Views
    Last post

Who is online

Users browsing this forum: No registered users


Contact us | Terms of Service