PATIENTS AND CAREGIVERS DISCUSS THE PHYSICIAN DISCUSSION

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

Postby L » Sat Jan 22, 2011 2:00 pm

Cece wrote:
L wrote:
drsclafani wrote:
Cece wrote:Still looking forward to Dr. Sclafani posting the "after" images of his case when he is back from iset, but thank you Dr. Cumming for giving us something to look at in the meantime.


its posted now, cece. Other doctors are also joining. If you knew who some of them were you would be very much surprised


Dr. Mark Freedman??

It's good that my family is in the basement and I am on the second floor because it can be embarrassing when I burst out laughing like that. :D


Imagine! He seems like a bit of a dark horse, I wouldn't be at all surprised Cece..
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playing along at home

Postby Cece » Sat Jan 22, 2011 7:52 pm

Dr. Cumming's example is mystifying. If there was an audible pop but the vein is still showing narrowing in that place...the pop would seem to indicate that the annulus is broken. What about looking at it with IVUS and seeing if it will expand under any conditions? If not, then it is not broken. It's more interesting if it is...why would a stenosis with a broken annulus still persist. Could there be something that was missed lower down that is reducing the overall blood flow? Collateral system would be in place above the broken-annulus stenosis, thus the narrowing there?

:oops: I am a little embarrassed to be playing along, standard disclaimer that I am no doctor and expect to often be wrong....
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Postby NZer1 » Sat Jan 22, 2011 8:57 pm

I am finding the imaging a challenge, I wonder what other options there are? Dr Haacke's input would be valuable?
Dr.S if you see this, is there any way of knowing if the volume of blood that is passing is changed before and after?
The comment the was made earlier about the flow spreading to the other side has me wondering what is being achieved, it seems like there may be a balancing or flow between each side, does that mean that the flow has improved in total though?
It would be interesting to know the flow volume capability at different exercise levels. The flow must change at different rates of exercise and if the physical blockages are changing the ability of blood to flow because of blockages may help in answering what is happening at these static moments whilst on the theater table.
The flow capabilities and improvement during exercise, could give some insights to what benefit could happen through CCSVI treatment. If the flow is not improved at exercise there may be more problems than first thought.
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Re: playing along at home

Postby drsclafani » Mon Jan 24, 2011 12:24 am

Cece wrote:Dr. Cumming's example is mystifying. If there was an audible pop but the vein is still showing narrowing in that place...the pop would seem to indicate that the annulus is broken. What about looking at it with IVUS and seeing if it will expand under any conditions? If not, then it is not broken. It's more interesting if it is...why would a stenosis with a broken annulus still persist. Could there be something that was missed lower down that is reducing the overall blood flow? Collateral system would be in place above the broken-annulus stenosis, thus the narrowing there?

:oops: I am a little embarrassed to be playing along, standard disclaimer that I am no doctor and expect to often be wrong....


drcummings shows a stenosis that did not resolve at 14 mm, but when he increased idamteter to 16, he got the pop and the vein no longer had a waist
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Re: playing along at home

Postby Cece » Mon Jan 24, 2011 6:12 am

drsclafani wrote:drcummings shows a stenosis that did not resolve at 14 mm, but when he increased idamteter to 16, he got the pop and the vein no longer had a waist

But did the stenosis then go away? From the initial description of the case, he stated that the tight waists resolved at 15-18 atms but there was still severe recoil and little improvement in stenosis. That is the part I am confused on - why the stenosis persisted after some waisting was broken. And if the pop was then or if the pop came later. It is ok if I stay confused on these matters! :oops:

From what you have said, is it that the pop came later at 16 diameter and that the stenosis was indeed fully resolved and somewhere (not posted) there are the beauty shots of a free-flowing vein....
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Postby DrCumming » Mon Jan 24, 2011 8:45 am

See the images of the right and my desciption. Hopefully the explanation makes some sense.
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Postby Cece » Mon Jan 24, 2011 9:05 am

Thank you. :oops:

Even after the pop there was little improvement! There must be something else going on there? No point in continuing to dilate the same spot after it is popped, I don't think? Again as a complete nonMD "playing along at home" I would want to look lower for something causing diminished overall flow and look with IVUS (to see if the popped stenosis can expand if the flow is strong).

Love the images, thank you for showing the sequence, it is very clear.
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Postby pairOdime » Mon Jan 24, 2011 10:03 am

Thank you for the fabulous images Dr. Cumming. As a non-medical person the narrowing is intriguing. All sources of potential vessel compression ruled out? Is it possible that very high lumen collagen content in that section of the vein could present in this manner...interesting. Thanks to all the IRs and vasc docs for their expertise.
It's a paradigm shift
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Postby NZer1 » Mon Jan 24, 2011 11:38 am

DrCumming wrote:See the images of the right and my desciption. Hopefully the explanation makes some sense.

I wonder in these examples where there is a pop all that is happening is that the wall area where the valve attaches has a memory, and the leaflets of the valve are what is popping as they partly detach from the wall. The wall of the vein has 'torn' but when it heals it recreates its original shape/structure like a finger print, which has the flapping pieces of valve still attached as well? which may create thrombosis as they attempt to either heal or decompose?
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Postby Cece » Mon Jan 24, 2011 11:55 am

The analogy has been that elastic recoil is like stretching a tight rubber band and then it re-takes its old shape. But that when you hear the pop, it's like tearing the rubber band.

For Dr. Sclafani's case, it's similar to another hypoplastic jugular that he posted in his thread a few weeks ago in which thrombus formed during the procedure. This might end up being among the expected complications of treating hypoplastic jugulars in that way. So far thrombectomy during the procedure seems to be working fine, but these clots could travel and cause a PE or be resistant to thrombectomy? I agree with what he said in his thread previously, that the vein is already hypoplastic so not much to lose, might as well try.
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Postby NZer1 » Mon Jan 24, 2011 1:32 pm

Being able to visualize what the pop is doing?
We are assuming what is happening, and we know how that can create an ass!
Although there is a pop, there is no way of knowing what has happened, maybe experimenting with cadaver veins? and seeing what the possibilities are from multiple outcomes?
The torn vein walls and flapping valves are unknowns. Future issues?
Each situation could be different and have different long term outcomes.
I'll have a look at my crystal ball and let you know. :lol:
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Postby Rokkit » Tue Jan 25, 2011 8:25 am

DrCumming, the image you posted of the incompletely opened stent is horrifying. I don't see how the stent could even be helping much with the waist still present. It seems it could have just been ballooned properly in the first place with no stent required. Can it be ballooned now or is the patient just stuck with it?
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Postby DrCumming » Tue Jan 25, 2011 8:31 am

Rokkit wrote:DrCumming, the image you posted of the incompletely opened stent is horrifying. I don't see how the stent could even be helping much with the waist still present. It seems it could have just been ballooned properly in the first place with no stent required. Can it be ballooned now or is the patient just stuck with it?


I am hoping we can try and dilate and get it open. And yes, the stent never should have been placed. The vein was not properly dilated the first time. Very disappointing to see this being done.
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Postby HappyPoet » Tue Jan 25, 2011 8:51 am

Dr. Cumming,
This case breaks my heart, but thank goodness the patient sought further treatment. The dark, grainy image showing the stent with the waist is sobering to say the least -- I almost couldn't believe what my eyes were seeing! Is there any chance this is a case of stent failure? Do you have a new image of the waisted stent you can show?
Thank you very much for sharing the case with us.
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Postby DrCumming » Tue Jan 25, 2011 9:01 am

HappyPoet wrote:Dr. Cumming,
This case breaks my heart, but thank goodness the patient sought further treatment. The dark, grainy image showing the stent with the waist is sobering to say the least -- I almost couldn't believe what my eyes were seeing! Is there any chance this is a case of stent failure? Do you have a new image of the waisted stent you can show?
Thank you very much for sharing the case with us.


I think this is simply a case of failing to properly dilate the vein. I do not know what they tried in terms of balloons or technique to get the vein open. Probably not much given the case was done in 30 minutes.
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