OPINIONS DR ARATA & DR HEWITT

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

IVUS

Postby Endovasc » Wed Jul 06, 2011 10:00 pm

IVUS is a useful toll for evaluation of vascular abnormalities. When I first started I used it on almost all cases. It is however an anatomic imaging modality. Specifically it doesn't assess flow

What has become clear is that CCSVI is a disorder of flow. Diagnosis and treatment rest on venographic evaluation of flow. Anatomic data plays a role but what matters is the flow. I will not speak in terms of stenosis when discussing CCSVI and I urge others to follow suite. At least i/3 of patients in our practice with CCSVI, have NO stenosis. FLOW IS THE ISSUE.

IVUS can help find lesions that are impeding flow in challenging cases. I rely on it for them. If IVUS interrogation is a focus of routine CCSVI evaluation then the focus is deviating towards anatomy and away from flow.
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Mr success

Postby pollyanna » Wed Jul 06, 2011 10:03 pm

Nice try
If that is all it took to get Arata on Tims....
He is not interested enough in his clients,
To come and be real.
He doesn't have the integrity of a Sclafani.
Narcissists only come out to brag
Egotists come out to say they are the best in the world.
Words are easy.
Actions not so much.
He will never come out on Tims
He couldn't compete.
He will only be busy looking in the mirror.
Paul Amos
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"blood thinners"

Postby Endovasc » Wed Jul 06, 2011 10:22 pm

Our initial experience with CCSVI did not entail usage of blood thinners. Venous thrombosis, while uncommon, results in symtom relapse in most cases if it occurs. To minimize this we began recommending anticoagulation. We did so recognizing the unlikely but real possibility of bleeding complications. We recommend full dose anticoagulation with agents such as heparin, LMWH, coumadin or Pradaxa.

Anti-platelet agents such as aspirin or Plavix do not have a role in our CCSVI practice and we discontinue usage unless an alternative indication is present. These agent diminish platelet activation. Platelets become activated at site of increased sheer stress. This is most commonly seen near atherosclerotic plaques in arteries. Venous flow is slower and mostly laminar. Platelet activation is a minor player in the venous thrombosis cascade. To our knowledge there no published data has shown a benefit to usage of anti-platelet agents in CCSVI, venous stents or reduction of venous clotting. At least one published study suggested increased bleeding risk with use of aspirin in venous thrombosis prevention.

Aspirin and Plavix cannot be recommended for CCSVI patients based on mechanism of action, physiology of venous thrombosis and available published data.
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Postby Endovasc » Wed Jul 06, 2011 10:28 pm

Thanks for the invite. Hope sharing our experience helps. Please feel free to contact me if any questions arise.
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Postby Thekla » Thu Jul 07, 2011 3:56 am

Are you diagnosing the need for treatment on the patient's description of symptoms or a Haacke mri or Zamboni Dopplar ultrasound? Can you identify flow on an mri? What about the impact a potential asymptomatic illiac blockage has on the flow in an impaired azygous? I thought that was the reason behind Dr Zamboni always checking the illiac with a left entry.
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Postby Cece » Thu Jul 07, 2011 7:29 am

For those who are unsure of Endovasc's identity, he previously posted here in January with the signature as Michael Arata MD:
www.thisisms.com/ftopicp-151156.html#151156

I have no reason to doubt that he is Dr. Arata.

Full dose anticoagulation has my support over antiplatelets or nothing at all. I also look for doctors that do not keep doing the same thing but adjust their protocols as they learn. It is good to hear that Synergy is doing this.

When you say a third of patients have no stenosis, does this include valvular stenosis?

One of the suggested uses of IVUS is to accurately measure the size of the vein in order to select an appropriately sized balloon. It is also said to be of use in finding valvular stenosis in the azygous that cannot be seen on flouroscopy alone. I must disagree that the use of IVUS deviates the focus away from flow and toward anatomy. It is a tool that gives more information on what is going on in the veins, including what is causing the flow abnormalities; with more information, better decisions can be made.

Your position on the iliac and renal veins is very different from what we have more commonly heard. Thank you for sharing it, it is good to know both sides of these debates. I would argue that, if CCSVI is about flow, then the impact of stenoses in the iliac and renal vein on the flow in the azygous cannot be denied.

Thank you for all your reponses, they are indeed helpful.
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Postby jamit » Thu Jul 07, 2011 8:16 am

I am sure doctor Arata is a very good doctor and a smart guy, but as with everything buyer beware and make sure you get what you think you are paying for.

Some responses are a little too convenient to me. Not bothering with US insurance does not help my suspicion. Doctor Hewitt's road trip to "enlighten" the Canadians about the merits of ccsvi could be just self advertising, not that I have anything against, but I just like to know what is what.

The response "Additional veins such as the vertebrals, lumbars, renals etc do NOT cause CCSVI. They do serve as collateral veins. Proper treatment dictates correction of the jugular or azygous problem. NOT Venous angioplasty of Collaterals."

Could be interpreted as not possible to finish with a patient quickly enough if you had to check more than the usual 3 veins let alone use IVUS.

Here is his response on the Newport etc facebook "Use IVUS for problem solving. When I started I used it every case. Once you do a few hundred cases it adds nothing to straightforward cases. April 22"

Their clinic does not have IVUS they say, but he used it in the beginning. I guess in hospitals since they all have it. It seems to me from what I hear from doctors C and S here that many patients if not most have at least one odd vein that warrants a look with IVUS to determine proper treatment, but I suppose most cases look "straight-forward" if one does not use IVUS. I wonder how long they used it for ccsvi as they started treating in various clinics almost right away until they got their new clinic set up. Some members here got treated in clinics and reported it here almost a year ago.

Ballooning the azygos without knowing whether it needs it seems a little rushed to me and could perhaps lead to treatment where non is needed, seems like IVUS is a wonderful solution to that problem but alas takes more time. I guess doctor Sinan started using the "always balloon the azygos approach". I have had trouble finding data on his patients, he should have a lot of data by now one should think.

Ballon size, pressure used, cutting balloon use etc differ from doctor to doctor. We still don't know what works best, but we can still form an opinion and select doctors accordingly.
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Postby Cece » Thu Jul 07, 2011 9:10 am

Here are some patients' posts from last september about Dr. Arata and IVUS:
val57gal wrote:Hello! Katie41 and I have both posted several times about having surgery with Dr. Arata. He has been expensive--not so much him, but the hospitals he works at. One reason is the use of IVUS, which is cutting edge but costly.
val57gal wrote:Their center won’t have IVUS to start with, but they’re looking into it. Unfortunately, it’s very expensive.

www.thisisms.com/ftopicp-132203.html#132203
As I understand it, he used IVUS at the hospital but then when he moved to the clinic, he chose to forego IVUS because of the expense.
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Re: Renals and iliacs

Postby AlmostClever » Thu Jul 07, 2011 11:07 am

Endovasc wrote:I challenge any physician in the world to show me a single case of CCSVI caused by iliac or renal veins.

As physicians we need to educate each other and clean our own house. Renal and iliac venograms and especially angioplasty on CCSVI patients needs to stop and stop now. Our collective credibility is at stake.


I believe this is Dr. Arata.


Sorry for sucking you into our little world, Doc!


One point - could an obstructed iliac lead to increased flow into the lumbar and ultimately the azygous, thus clogging the network?

Doc A.- you looked at my existing iliac stent to make sure it looked OK and noticed a backflow in the IVC. I had an echocardiogram done (upon your suggestion) and everything looked fine. What else might account for the backflow you saw?

Might a vein that is compressed in the manner of the diagram provided by Cece exhibit lower blood flow which might cause a turbulent (back)flow such as mine?

http://www.thisisms.com/ftopic-13911-15.html

Could one determine if a vein were compressed like this other than by using IVUS?

I certainly don't mean to hog up your time - we all know what a busy person you are! Thanks for any info or insight you can contribute and thanks for performing the treatments you have done!

Regards,

A/C
If you can't explain it simply, you don't understand it well enough. - Al Einstein
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Postby Jugular » Thu Jul 07, 2011 8:26 pm

I was treated by Dr. Arata last December. Our pre and post-op consults were among the best conversations that I've had with a doctor. He knowledgeably, thoroughly, and respectfully answered all my questions. Based on the improvements I've experienced going on seven months now, I'd have to say that the man knows what he is talking about.
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Postby esta » Fri Jul 08, 2011 9:33 am

Phew!!!!!!!!!!!!!!!
After a consult with Dr. Hewett, I am planning to go in Feb (just because of money). It was also very informative and i love the valve concept, it just makes sense. when i saw my CD's and he showed my valves and how the blood was obviously not flowing through as it should.

this will be my 3rd time, i'd kind of like to hope i'll see improvements, doing something different.
PPMS. Liberated Katowice, Poland
06/05/10 angioplasty RJV-re-stenodsed
26/08/10 stent RJV
28/12/10 follow-up ultrasound intimal hyperplasia
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Re: "published data"

Postby eric593 » Fri Jul 08, 2011 10:26 am

Endovasc wrote: To our knowledge there no published data has shown a benefit to usage of anti-platelet agents in CCSVI, venous stents or reduction of venous clotting. At least one published study suggested increased bleeding risk with use of aspirin in venous thrombosis prevention.



Could you please point me to the published data that demonstrates that destroying valves is 1) safe, and 2) efficacious and has some sustained, demonstrable, tangible and measurable health benefit beyond improved blood flow to your patients? Can you direct me to the published data that shows that improved blood flow in patients translates into neurological benefit and that your methods of achieving it are safe? Thank you.
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Postby MrSuccess » Fri Jul 08, 2011 11:20 am

Eric - you need to do some homework on your own . We don't need to wear our eyes out reading research ..... over and over .... again.

The procedure of entering - and no doubt destroying valves [ your description ] is old hat. This is what IR's do.

I will remind you of the published results of Dr.Hubbard's fMRI study ........ that showed an improvement in cognitive capability's in pwMS that had venoplasty. Post procedure these people matched the ability's of healthy controls . Pre Procedure ...... well below.

If that doesn't knock your socks off ........ there's no hope for you.

Do your homework. The information is readily available . :idea:



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Re: "published data"

Postby Jugular » Fri Jul 08, 2011 12:04 pm

eric593 wrote:Could you please point me to the published data that demonstrates that destroying valves is 1) safe, and 2) efficacious and has some sustained, demonstrable, tangible and measurable health benefit beyond improved blood flow to your patients? Can you direct me to the published data that shows that improved blood flow in patients translates into neurological benefit and that your methods of achieving it are safe? Thank you.


Do you have any studies to show that impaired blood flow is good for the brain or at least produces no ill-effect? Thank-you.
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Postby David1949 » Fri Jul 08, 2011 1:25 pm

It's amazing how the understanding of CCSVI is growing. Now we have primary CCSVI and secondary CCSVI. It would be nice if we had time to wait for all the studies to be done. Unfortunately many of us don't have time.
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