Second Annual CCSVI update Symposium

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

Second Annual CCSVI update Symposium

Postby DrSnyder » Sat Jul 16, 2011 5:49 am

OK in keeping my promise with one of my patients I will post some of the highlights from the meeting this morning.
1. Dr. Zamboni was unable to attend the meeting due to a broken leg. Here wishing him a Speedy recovery.
2. Dr. Sclafani started with the morning welcome and turned things over to Dr. Zivadinov. He covered some of his previous introductory material and reiterated the various associations with other entities like Epstein Barr virus and history of infectious mononucleosis. Good talk

3. Dr. Clive Beggs through volume, humor and animation at the podium presented a fascinating talk about fluid mechanics. Outstanding job!!!
He mentioned the paper by Moyer et al (1954) Journal of Applied Physiology 7 p245-247. He reviewed this paper and spent a good bit of time elucidating the findings. Man, he did such a great job he made a simple minded Interventional Radiologist like myself actually UNDERSTAND the physics.
Could have used him in undergrad.

That's it for now. So far excellent meeting. I am looking forward to the rest of the weekend.
Gregory B. Snyder, MD DABR Vascular and Interventional Radiology University of Minnesota Hospital & Clinics Mayo B-228C Mayo Memorial Building 420 Delaware Street SE Minneapolis, MN 55455 <br /><br />
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More Sat morning.

Postby DrSnyder » Sat Jul 16, 2011 7:45 am

Dr. Haacke presented very compelling MRI work. I got lost a little bit in the numbers towards the end. Spent time reinterpreting Doepps data. Neuroradiology 20O4. Very interesting. Check out www.ms-MRI.com

After break: Dr. Beggs was back with another outstanding eval of pressures with csf and addressing volume in = volume out issues and any changes in outflow MUST equal increased intravenous pressure.
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Continuing the day -after lunch

Postby DrSnyder » Sat Jul 16, 2011 11:02 am

Dr. Salvi began with presentation on diagnosis of CCSVI.
Presented some anecdotal data linking a decrease of pedal edema and improvement in impotence following treatments. Somewhat rejected MRI for use as followup. Unclear if this included MRV as well. Dr. zivadanocv made a compelling argument to followcwith MRI and sue other well established standards so the data would be meaningful. This part generated a lot of questions and discussion. Discussion was cut short so day would continue on schedule.

Karen Marr, RVT
Presented thoughts on how to do a proper ultrasound. Showed some pictures. No questions yet. Most interesting to me was the need for WARM gel. I don't think we did that at my facility. We will now....

Apologize for adding my picture. It scares me each time I see it...
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Evening question and answer session

Postby DrSnyder » Sat Jul 16, 2011 12:25 pm

Dr. Simka, Dr. mcDonald and Karen Marr presented after. Much needed coffee for a question and answer session.

several questions were posed to McDonald and Simka about appropriate follow up after the procedure. There was no consensus but it seems like the most prevalent from those who provided data was ultrasound of the jugulars plus/minus immediately after the case then at 1 or 3 months, 6, 9 and 12 months. Others favored just doing a followup once symptoms recurred. Clearly no consensus here.

I asked Ms. Marr a question about dopplar angle in the jugular vein. I don't think she understood it since she provided a non- answer. Too bad.

Now excellent talk about how to maintain a Ccsvi practice within a current practice by Dr. Kevin Sullivan.
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Postby Cece » Sat Jul 16, 2011 2:47 pm

Keep the reports coming, this is great.

Dr. Beggs spoke twice then? Lots to be learned from him.

When you asked about doppler angle, do you mean what angle it is held at? Are you doing Zamboni protocol dopplers? And are you doing them yourself or do you have a tech doing them?

I like the picture! Do you know how to scale it down a bit?

Maybe I will put my picture up too.
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Postby newlywed4ever » Sat Jul 16, 2011 6:58 pm

Thank you Dr Snyder - for the updates & keep 'em coming.

Your picture is one of those that portray character - I like that. But, you're right...it's kind of startling since it's so much bigger than most. I had to laugh when you said it scared yourself!

Cece, you're right...you're due for a real pic :)
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Postby marcstck » Sat Jul 16, 2011 10:34 pm

Thanks Dr. Snyder for providing the accounts of the presentations. I can't wait to review the videos once they are posted on YouTube.

Please, no worries about your picture. I don't know anybody who enjoys seeing themselves in photographs.

Cece, you should definitely post a picture of yourself. Having seen you in person, I can tell you in all honesty that you are very lovely. I hope that's not taken any kind of wrong way, I'm an old happily married cripple, and I hope that gives me some license to tell a pretty woman that she is pretty without eliciting any suspicions of ulterior motives…
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Postby Cece » Sun Jul 17, 2011 6:15 am

You are easy on the eyes yourself, dear Marc.
And I mean that in the most happily married way. :wink:
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CCSVI symposium day 2

Postby DrSnyder » Sun Jul 17, 2011 7:17 am

Good morning!
Many of us showed up slightly bleary eyed.
I have no further comments about that.

Dr. Ponec moderated the morning sessions
Dr. Sullivan began with a basic lecture on the "how too" about doing the angiograms and some results.

Dr. Sclafani gave an interesting lecture on the use of intra-vascular ultrasound. This does seem to show quite a bit of information about the valves that may be difficult to get in another fashion. Some discussion about cross sectional areas and ultrasound viewed pathology was also included.
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Re: CCSVI symposium day 2

Postby Cece » Sun Jul 17, 2011 8:07 am

Good morning! I had hoped you would continue these reports.
DrSnyder wrote:Dr. Sclafani gave an interesting lecture on the use of intra-vascular ultrasound. This does seem to show quite a bit of information about the valves that may be difficult to get in another fashion. Some discussion about cross sectional areas and ultrasound viewed pathology was also included.

Did the other IRs in the audience seem to share this view?
We have discussed IVUS a great deal here on this forum and I was able to see the patient day version of his IVUS talk on Friday. With the cross sectional areas, he showed the difficulties when trying to measure the vein by flouroscopy, since veins are oval shaped, and you will get a different measurement if you are looking at them straight-on or from a different angle. So some precision is lost if measuring through flouroscopy as compared to IVUS and one question is how important is that precision? How vulnerable are these veins to damage, if the balloon is oversized? Or to undertreatment, if undersized.

He was also going to share what he has been seeing of webs on IVUS, which he has treated in some patients, and you really don't hear much talk about webs but they were discussed in Zamboni's original work as among the intraluminal abnormalities that make up CCSVI.
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Day 2 after the break

Postby DrSnyder » Sun Jul 17, 2011 10:52 am

Ok - actually two of the lectures happened before the break.

Dr. Ponec showed some Intersting cases on venous stenosis and the use of stenting. Jumping ahead it seems like stenting is only done in less than 5 % of patients which is about what Dr. Petrov is finding as well. Dr. Simka's group has been more prone to stenting with around 44% stenting.

Dr. Siskin spoke on defining and treating upper jugular lesions using the standard cervical zone anatomy. He had some very interesting cases and results. There was some discussion about intrinsic and extrinsic lesions and the role of stenting.

Dr. Sullivan presented a talk on the management of immature venous fistulas for dialysis work. He demonstrated how they were treated at his clinic to promote maturity, but ultimately concluded that the differences between arterialized flow in a vein and regular venous flow may make it difficult to extrapolate techniques from this model into CCSVI treatments.

Question and answer session with the panel.
Discussion of difficult hypothetical cases.
Discussion of anticoagulation strategy. In summary, all would anticoagulate longer and do more follow up if a stent is involved. There appeared to be a consensus that anticoagulation was moving towards dabigatran.

A second presentation from Dr. Sclafani about the use of IVUS and cross sectional anatomy and how he uses IVUS to make real time treatment decisions.

Dr. Petrov discussed the data from their large population of patients. If I understood another publication is forthcoming. Agreement was that at worse the procedure is safe with very limited major complication outcomes.

A second presentation from Dr. Siskin about what he has learned, some interesting cases and a discussion about addressing restenosis.

Chavdar Botev presented some very interesting data about combining autologous bone marrow transplant with the liberation procedure. A I understood it, the stem cells are injected arterially immediately after the venous side is treated. Some preliminary data showed some promise.

Lunch $19 hamburger (sore feet from a lot of walking last night kept me in the hotel).
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Postby Cece » Sun Jul 17, 2011 10:58 am

http://en.wikipedia.org/wiki/Dabigatran

Dabigatran is marketed as Pradaxa. It's a pill instead of an injectable. It does not require INR testing.
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Pradaxa

Postby DrSnyder » Sun Jul 17, 2011 11:02 am

Thanks Cece. correct.

I will answer the questions that you folks have asked (and seriously reduce the size of my picture) right after the meeting.


there is about another 2 hours to go. If anyone has any questions that I can ask now, please let me know. I will ask. And post responses.
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Postby Cece » Sun Jul 17, 2011 11:21 am

I don't have any questions that would need asking (but thank you for the offer). I am interested in your impression of the mood at the symposium. Is there the same excitement for CCSVI that we have here? Is there a sense of how soon this may move into the mainstream as a standard care treatment?
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Following lunch

Postby DrSnyder » Sun Jul 17, 2011 11:41 am

Dr. Simka presented all of their data from Poland.
Dr. Petrov presented their data from Bulgaria.

Again consensus is that the procedure is safe and that over time as experience has developed, the use of stenting has reduced.

Dr. Ponec presented some data that will be published about the current state of the Hubbard registry. This was very informative.
His point is that we still don't have enough idea about how we treat this process to make a solid randomized study reasonable. With such variables in treatment we cannot even enter into a randomized study as we don't have consensus on how to treat. The results from the study are from outcomes on the MISI-29 which show positive outcomes at 1 and 6 months. This data looks comprehensive and as Dr. ponec points out, this is The first data to report a benefit from the procedure since Zamboni's original publication.
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