Revision of NICE submission begins here.........................MarkW
I love the work and activism you've put into this.
A – Entry is best made through the saphenous vein rather than the femoral vein. This reduces the patient’s risk of a thrombosis in the femoral vein. Local anaesthesia is used. The puncture site is compressed manually at the end of the procedure, which is generally more successful than if the femoral vein was used.
This one is Dr. Sclafani's technique. I have not heard any of the other IRs pick up on it. It seems logical because we are likely to repeat procedures over a lifespan of managing our venous malformations and this protects the femoral vein from injury. If the saphenous vein is injured, it is of less consequence. Using the saphenous instead of the femoral might be minor in comparison to some of the more major differences in technique, such as doctors not checking the left renal vein.
D – Treatment is largely confined to venoplasty of vein valves in leading practice, which follows Prof Zamboni’s recent paper. This reduces, probably eliminating, vein dissection and vein rupture. This area requires future research before any CCSVI syndrome treatment procedure is finalized.
Septums too. Dr. Fox's autopsy study found more septal abnormalities than valvular abnormalities. I am curious about this because we don't hear much talk about septums or about how the treatment of a septum differs than a valve. Septums may be more resistant to treatment. 'Intraluminal abnormalities' would be a more encompassing term than vein valves for this point. And vein dissection and rupture can be due to overaggressive ballooning such as oversizing or excessively long or repeated balloonings. I believe this can happen as easily at the area of the valves as anywhere else in the vein. They have always been treating the area of the valves, even if they did not know it was the valves that they were treating.
D - Correct sizing of the balloon in relation to the vein value being treated is best evaluated using IVUS. Pressure in the balloon of up to 20 atmospheres may be required, although lower pressure of up to 5 atmospheres is often sufficient.
In Dr. Sclafani's abstract on high pressure balloons, the range went as low as 4 atms, which surprised me. I do not think 5 atms is sufficient for most of us.http://www.ccsvicare.org/outreach_update03.html
His conclusions were that high pressures are required to completely dilate the lesions of CCSVI and that IVUS reduces the risk of vein injury.
And who wants incomplete dilation of the lesions of CCSVI or vein injury.[/quote]