Better late then never... sorry for the delay uploading these!
Images from both IJ's
Very classic findings. Bilateral IJ stenosis secondary to poorly opening valve leaflets. Excellent examples of using IVUS for pre and post ballooning.
This side is dominant.
Venogram prior to ballooning showing the stenosis at the level of the expected location of the valve plane.
and IVUS better showing the valves and the size of the normal vein at the level of the valves. Knowing this allows better selection of balloon size.
Area at valves is 96 mm sq
Vein at this level is 160 mm sq
Initial ballooning was 16 mm. This was suboptimal on IVUS. Next ballooning was 18mm. Repeat IVUS shows improvement to 142 mm sq. Up for debate is should I have gone larger. Note in the top right corner, the valve leaflet is still not completely open. I do not have a good answer. The enemy of good is perfect so I elected to leave this alone. Its a substantial improvement from the original area of 96mm sq
Post 18mm venogram looks good. You can see the one leaflet that is still not 100% open.
This side is smaller then the right but not hypoplastic.
Venography shows no real narrowing. Yes, the vein does narrow as it enters the low neck. Trying to make this segment of vein look like the mid portion of the IJ will often result in occlusion or severe restenosis. See discussion below.
But IVUS at the valve plane shows the incompletely opening valve leaflets with an area of 49 mm sq.
The area of the jugular vein at this level is 96 mm sq.
The area of the jugular vein just above the valve plane is 62 mm sq (Not shown).
So, this raises some interested questions about how to treat the left side.
1. Do we make the opening of the valves equal to the area of the jugular vein immediately distal?
2. Make the valves open to the size of the vein at the level of the valves? Can we do this without causing significant injury to the "normal" smaller jugular vein just distal to the valves?
3. Make the entire proximal segment of the jugular vein as big as the mid portion of the jugular vein?
Number 3 in my experience often results in occlusion or severe restenosis. I do not do this anymore.
So, we are left with 1 and 2. 1 is definitely going to be the less traumatic option (in terms of intimal injury). But may not result in optimal treatment benefit. Option 2 may work, but also may cause too much intimal injuryto the vein just distal. I don't have a good answer but I was requested to do the procedure to minimize risk. So I chose option 1.
Initial dilation to 10 mm did not improve the area. Dilation to 12 mm improved the area to 62 mm sq.
And post venogram is not all that different (as expected).
So, some very good images and examples of the complexity of the decision making behind these procedures and the many things we do not know. Yet.