any IRs NOT focusing on the valves?

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

any IRs NOT focusing on the valves?

Postby Cece » Sun Feb 06, 2011 2:48 pm

I keep hearing talk about Dr. Arata's focusing on the valves, as if he is doing something other IRs are not, when my understanding is that they are all focusing on the valves.

Does anyone know of an IR who is NOT focusing on the valves?
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Postby garyak » Sun Feb 06, 2011 7:09 pm

DEL mar vein care - not
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Postby javabean » Sun Feb 06, 2011 9:49 pm

Cece,
This is my basic understanding...I had ont procedure done in Albany that was just ballooning (14mm). I had some improvements, then declined and suspected restenosis. I then went to Pacific Interventionalists where they ballooned (22mm) and cleared out the valves in my jugular veins. So if I understand your question, the procedures are different. One deals with just the vein, the other the vein and the valve in the vein. Crude understanding, but that is what I know. Sorry for the long stoty but bottom line...not all IR's deal with the valves. Albany does not, Pacific Interventionalists does, the rest, I don't know.
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Postby AlmostClever » Mon Feb 07, 2011 4:34 am

javabean wrote:Cece,
This is my basic understanding...I had ont procedure done in Albany that was just ballooning (14mm). I had some improvements, then declined and suspected restenosis. I then went to Pacific Interventionalists where they ballooned (22mm) and cleared out the valves in my jugular veins. So if I understand your question, the procedures are different. One deals with just the vein, the other the vein and the valve in the vein. Crude understanding, but that is what I know. Sorry for the long stoty but bottom line...not all IR's deal with the valves. Albany does not, Pacific Interventionalists does, the rest, I don't know.


Javabean,

Any improvements after being treated at Pacific?
If you can't explain it simply, you don't understand it well enough. - Al Einstein
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Postby CureOrBust » Mon Feb 07, 2011 4:54 am

I have had two treatments here in Australia. One in Sydney, and one in Melbourne. In Sydney they found a reflux in both jugulars, with no stenosis. They ballooned the area and said it cleared the reflux. I heard no specific talk of valves at the diagnosis ultrasound, or during or after the procedure.

The Dr that performed my procedure in Melbourne spoke of using cutting balloons on valves when I had my initial consultation (1 year ago, long story, ethics committee :evil: ). He spoke a lot about valves at this consult. He ballooned a 50% stenosis high up on my left juguar where it crossed and was indented by an artery (he said he believed it would return). There was no talk of valves; ie if mine were ok, and in my mind therefore it seems they were more focussed on stenosis and possibly reflux. At that time, he also talked about entering on the left side etc but he two weeks ago entered on the right :? so I think his opinion has moved on various issues.

During the venogram (without IVUS) can a proper evaluation of the valve be done without doing anything extra? maybe that's not clear... If a Dr was performing a normal venogram looking for a stenosis, how obvious would a valve issue present itself?
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Postby javabean » Mon Feb 07, 2011 8:26 am

Almost Clever,
No improvements as far as I can tell. I did have improvements after the first procedure though, which is weird, in my opinion.
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Postby AlmostClever » Mon Feb 07, 2011 8:29 am

Here is a valve issue from venogram (according to Dr. Sclafani - "clear cut and obvious"!!!). Treating doc said it was fine...

Make sure you get images and look at them yourself! Don't just listen to what the treating doc says! They are as new to this as you are!

Image
If you can't explain it simply, you don't understand it well enough. - Al Einstein
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Postby AlmostClever » Mon Feb 07, 2011 8:31 am

javabean wrote:Almost Clever,
No improvements as far as I can tell. I did have improvements after the first procedure though, which is weird, in my opinion.


Sorry to hear that! Hang in there!

I am now looking for someone to give me a valve job!!!
If you can't explain it simply, you don't understand it well enough. - Al Einstein
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Postby Cece » Mon Feb 07, 2011 8:52 am

This is really interesting. It makes sense to me that docs new to CCSVI might not be able to spot a valve problem or consider it as important as we are hearing from some of the more experienced docs. So maybe if we just look at the bigger names....

Dr. Siskin/Albany
Dr. Sclafani/Brooklyn
Dr. Arata/CA
Dr. Hubbard & the Del Mar IRs/CA
Dr. Arslan/FL
Dr. Haskel/RI
Dr. Sperling/NYC
Dr. Mehta/Albany
Dr. Cumming/Minneapolis
Dr. Makris/Chicago
Dr. Zamboni and Galleoti/Italy
Dr. Dake/CA
the doctor in Seattle

(I know I've missed many!)

Does the group think Dr. Siskin does not focus on valves? He's been at this openly since May 2010, he's in tight with the East Coast docs.

Dr. Sclafani focuses on valves, Dr. Arata does. The Del Mar IRs do not? This would be the group the Hubbards go through. I don't know enough about Dr. Arslan, Haskel, or Sperling. I think Dr. Haskel is planning on a trial, not straight-up treating, so it's especially important that he is doing it right, if he's putting his techniques to the test like that, and adding or detracting from the CCSVI movement based on what his results will be. Dr. Cumming has said here that most CCSVI is in the proximal end of the IJV where the valves are, does that mean he is focusing on the valves?

A doctor can treat stenosis not knowing that the stenosis is a valve.
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Valves

Postby gsiskin » Mon Feb 07, 2011 10:20 am

Interesting comments. Please know that those of us in Albany treating patients are often treating valves when we perceive valve problems are present. If one practice chooses to call this procedure valve ablation and another chooses to call it angioplasty, please know that for now, we are all talking about the same thing. More often than not, I find that we are treating the area of the valves and like Dr. Sclafani, I agree that the case imaged here is clear cut in terms of a valve abnormality. The differences between sites is more with the balloon size being used. It is our feeling that for now, we are sticking with the classic conventions associated with angioplasty in almost all areas of the body. This means that we are oversizing our balloons by 10-20% relative to the size of the vein being treated. Therefore, the thought that we are not oversizing balloons is not true...we are just not oversizing them to the extent that others may be. I am not saying the one approach is better than another. I am saying that at this early time in the evolution of CCSVI, staying close to the conventions of balloon oversizing makes sense to me and that is why I perform procedures that way. Keep in mind that balloons can injure veins. We have seen it with balloons that are oversized by 10-20% so one must assume that the risk of injury is the same or greater when even larger balloons are being used.

This is just one of those questions that remain unanswered.

Gary Siskin
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Postby Blaze » Mon Feb 07, 2011 10:31 am

Welcome Dr. Siskin! A great--and welcome--surprise to have you join us!
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Re: Valves

Postby AlmostClever » Mon Feb 07, 2011 1:46 pm

gsiskin wrote:Interesting comments. Please know that those of us in Albany treating patients are often treating valves when we perceive valve problems are present. If one practice chooses to call this procedure valve ablation and another chooses to call it angioplasty, please know that for now, we are all talking about the same thing. More often than not, I find that we are treating the area of the valves and like Dr. Sclafani, I agree that the case imaged here is clear cut in terms of a valve abnormality. The differences between sites is more with the balloon size being used. It is our feeling that for now, we are sticking with the classic conventions associated with angioplasty in almost all areas of the body. This means that we are oversizing our balloons by 10-20% relative to the size of the vein being treated. Therefore, the thought that we are not oversizing balloons is not true...we are just not oversizing them to the extent that others may be. I am not saying the one approach is better than another. I am saying that at this early time in the evolution of CCSVI, staying close to the conventions of balloon oversizing makes sense to me and that is why I perform procedures that way. Keep in mind that balloons can injure veins. We have seen it with balloons that are oversized by 10-20% so one must assume that the risk of injury is the same or greater when even larger balloons are being used.

This is just one of those questions that remain unanswered.

Gary Siskin


Welcome Dr. Siskin! TIMS stock has certainly risen today! As you have probably realized, we have a very open forum here! Your input is greatly appreciated by all!

I hope that you did not interpret my comments about CCVSI newbie docs to be referring to you! I was talking about the doc who was gracious enough to give me a venogram last week.

I have nothing but the greatest respect for you and your method, as you initially detected my valve issues back in Aug 2010 and ballooned them. Unfortunately, the problem has clearly returned! This is where you put the balloon - I believe you nailed it!

Image

I do not know what size the balloon used was but the pictre measures about 20 mm using the software's measurement tool.

I don't want to hijack Cece's thread but since you're here, would you recommend a larger balloon or something like a cutting wire or balloon?

It's good to hear from you and best wishes!

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If you can't explain it simply, you don't understand it well enough. - Al Einstein
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Postby gsiskin » Mon Feb 07, 2011 2:33 pm

I think that restenosis is an issue that almost all patients will have to address at some point. I am personally not convinced that larger balloons will make restenosis less likely so I can't really recommend that you have this repeated with a larger balloon. I know for sure that there are others out there that feel differently so you may have to wrestle with the different opinions that are out there. A repeat angioplasty may help but you should make sure that you really had a significant clinical benefit to the angioplasty before going into another procedure because there is always risk to repeat procedures. In other words, if your symptoms got a lot better after the first angioplasty then I can understand retreatment. For now, things like cutting balloons and large balloons remain outside of what Zamboni described so it would definitely be nice to see some published literature backing up that approach.
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Postby AlmostClever » Mon Feb 07, 2011 2:42 pm

gsiskin wrote:I think that restenosis is an issue that almost all patients will have to address at some point. I am personally not convinced that larger balloons will make restenosis less likely so I can't really recommend that you have this repeated with a larger balloon. I know for sure that there are others out there that feel differently so you may have to wrestle with the different opinions that are out there. A repeat angioplasty may help but you should make sure that you really had a significant clinical benefit to the angioplasty before going into another procedure because there is always risk to repeat procedures. In other words, if your symptoms got a lot better after the first angioplasty then I can understand retreatment. For now, things like cutting balloons and large balloons remain outside of what Zamboni described so it would definitely be nice to see some published literature backing up that approach.


Thanks! I have sent you an e-mail!
If you can't explain it simply, you don't understand it well enough. - Al Einstein
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Postby drsclafani » Tue Feb 08, 2011 7:53 pm

Cece wrote:This is really interesting. It makes sense to me that docs new to CCSVI might not be able to spot a valve problem or consider it as important as we are hearing from some of the more experienced docs. So maybe if we just look at the bigger names....

Dr. Siskin/Albany
Dr. Sclafani/Brooklyn
Dr. Arata/CA
Dr. Hubbard & the Del Mar IRs/CA
Dr. Arslan/FL
Dr. Haskel/RI
Dr. Sperling/NYC
Dr. Mehta/Albany
Dr. Cumming/Minneapolis
Dr. Makris/Chicago
Dr. Zamboni and Galleoti/Italy
Dr. Dake/CA
the doctor in Seattle

(I know I've missed many!)

Does the group think Dr. Siskin does not focus on valves? He's been at this openly since May 2010, he's in tight with the East Coast docs.

Dr. Sclafani focuses on valves, Dr. Arata does. The Del Mar IRs do not? This would be the group the Hubbards go through. I don't know enough about Dr. Arslan, Haskel, or Sperling. I think Dr. Haskel is planning on a trial, not straight-up treating, so it's especially important that he is doing it right, if he's putting his techniques to the test like that, and adding or detracting from the CCSVI movement based on what his results will be. Dr. Cumming has said here that most CCSVI is in the proximal end of the IJV where the valves are, does that mean he is focusing on the valves?

A doctor can treat stenosis not knowing that the stenosis is a valve.


cece
glad you listed the italian crowd

paolo zamboni, Ferrara, spoke about malformations of the valves from the beginning. This is not new. What evolved shortly thereafter were the narrowings that occured closer to the head than the valve area. Paolo told me when i met him in hamilton in januuary 2010 that they were spurious, mostly simple reflections of low flow. Some did not believe it and put in stents to keep them open because they didnt dilate after angioplasty. I decided to use IVUS to look at them and, as he predicted, they do not remain permantely fixed in a narrow position most of the time.

So the idea that the valves are the problem doesnt "belong" to any american, as much as i would like to take credit for showing it......no, the master taught than from the beginning.

The issues are several

The valves are the problem, but is that valve annulus too small? are the valve leaflets fused, or did the valves form abnormally? Hard to tell from a venogram, slightly easier with an IVUS but still the answer is elusive.

Another issue is not whether or how the valves are the problem, it is how best to treat those various problems of narrowing around the valve because there are different solutions to different valvular problems.

Finally, how does one treat those problems without damaging things that are not abnormal

so all those you mention are looking at different ways to address the valves. My dear colleagues in del mar included

s
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