PRE DIAGNOSIS: Central venous occlusive disease
POST DIAGNOSIS: Same
DETAILS OF PROCEDURE:
EKG was interpreted throughout the procedure. The left groin was prepped and draped. An 8F sheath was placed and a catheter was used to select the right IJ. A venogram was performed which showed a diffuse narrowing within the mid portion of the vein and a 50% stenosis at the level of the valve inferiorly. An 8mm balloon was initially used to treat both portions of the IJ with no improvement.
We do not commonly hear reports of the mid portion of the IJV being narrowed. This may have been ballooned unnecessarily. IVUS would have been useful to determine if it was a true stenosis or if it was physiological.
8 mm balloon is an extremely small balloon although without knowing the exact measurement of the vein, it is difficult to know if it was appropriately sized. My guess would be that this is an undersized balloon.
Thus a 10mm balloon was also used with a waist that resolved upon full inflation of the balloon at the level of the valve.
A waist that resolved sounds good!
However, the mid portion of the jugular was still had a 90% stenosis.
The mid portion of the vein still had a 90% stenosis? And it was left this way. Not good. I do not think this vein was investigated or treated thoroughly enough. An exact measurement of the vein would've allowed for a larger balloon to most likely be used in the area of the valves (presuming that a remaining stenosis there is causing the low flow higher up that would allow a physiological stenosis to compress the vein to 90%). There can be more than one waists. It could be that the IR was tricked into complacency upon seeing one waist resolve in the area of the valves, when another waist would have been seen on the next balloon size up.
The left internal jugular vein was then selectively catheterized. A venogram was performed which showed findings similar to the MRV performed yesterday.
It is good to know that the MRV was predictive of what was found in the venogram. Dr. Dake's recent published research on his original patients showed an 80% concordance between what was seen on the MRV and what was seen on the catheter venogram, with the venogram as gold standard.
The IJ from the skull base to the lower neck was very small in caliber with an equally sized collateral running parallel to it into the skull base. Both were approximately 5-6mm in diameter.
This is very small. And the collateral running into the skull base? Does that mean, if it runs into the skull base, that it is an emissary vein going through a skull canal? Not sure. Interesting that the collateral measured the same size as the IJV.
In the lower neck, the IJ and it’s collateral joined and the IJ was approximately 10mm with a 50% stenosis at the level of the inlet to the subclavian vein. The flow through the IJ system was very minimal and slow due to the small caliber throughout. To treat the valve region a 10mm balloon was used with a residual waist so a 12mm balloon was used.
How do you calculate the CSA of a 5-6 mm diameter vein?
CSA is n*r*r but what is n?
ok this only took me ten minutes but n is not n. It is pi. Lol.
pi * (5.5/2) * (5.5/2) = 23 mm2 for the CSA
This could've been done more precisely with ivus. Just sayin'.
Using Dr. Sclafani's chart from here ( www.thisisms.com/ftopicp-172379.html#172379
), a vein with a CSA of 23 would get a size 6 balloon with a willingness to go up to size 7. I think.
Instead this procedure started with a 10 mm balloon, then a 12 mm balloon. A residual waist was seen. The next step in the following paragraph as a high pressure balloon, but still with the same 12 mm size.
I believe that this vein has been overtreated. Using this big of a balloon on this small of a vein could result in more damage, including scarring.
A residual waste was seen so a high pressure Conquest balloon was used to treat the valve with resolution of the waist. Repeat venogram showed residual slow flow through the IJ system. A small amount of intimal disruption but no extravastation was seen within the venoplasty region so 5000U of heparin were given.
And see? There was intimal disruption but no extravasation. I think this means the vein tore.
Again, with IVUS, the doctor could have looked at the tear. It may have already been forming a thrombus right there on the table. This could be seen with IVUS and then suctioned out, if it were happening.
I have no way to interpret the administration of heparin at this time, presumably in response to the intimal disruption. Wouldn't the patient already have been heparinized?
A Cobra catheter was used to catheterize the Azygus vein and venogram was performed. No evidence of disease was seen with rapid antegrade flow throughout the vein. Thus the catheter was removed.
The flow in the azygous was rapid. I think that's good? If there was a renal stenosis causing a rerouting of flow to the azygous, that too could result in rapid flow.
The azygous is difficult to diagnose but stenoses in the azygous are present only in a subset of patients (perhaps 25%).
The RIJ was re-examined and venogram showed residual 90% mid stenosis with significant collateral flow. Thus despite aggressive angioplasty, recoil was present. A 14mm x 6cm Zilver uncovered stent was deployed across the lesion and completion venogram showed rapid antegrade flow with no collaterals.
So the doctor did return to the RIJ! But what is this? The patient received a stent in the mid-portion of the IJV. This is not a common place for CCSVI stenoses. Could this be overtreatment? What else could cause a mid-jugular narrowing? IVUS might have informed whether it was a physiological stenosis or not (such as if it could've expanded if the patient holds her breath; this could be caused by compression from the carotid or a muscle).
If the vein ultimately required a 14 mm stent, does that mean it was a 12 mm vein? If so, wouldn't the initial ballooning with an 8 mm balloon, then a 10 mm balloon, be undersized?
Please know, I don't know if this was the right choice or not. I am cautious about stents.
The LIJ was selected and venogram showed stagnant flow due to residual stenosis at the inferior portion. A small amount of thrombus could not be ruled out so 2mg of tPA was given in that region.
tPA is tissue plasminogen activator, a powerful clot-busting drug that also raises the risk of hemorrhage. It may have been the drug that led to the unfortunate passing of the patient in Costa Rica. But I have no idea of the quantities or how much 2mg of tPA is, in context.
Further angioplasty with the 12mm balloon was also performed. Completion venogram showed a small amount of mobile filling defects but with antegrade flow.
Ballooned again on the LIJV, with a much too big balloon. Not sure what the mobile filling defects represent. Could it be clots?
IMPRESSION: Central venous occlusive disease. RIJ mid stenosis treated with 10mm PTA and ultimately a 14mm x 6cm stent. Left IJ small in caliber as described above. Inferior portion treated with 10 and 12mm balloon. Intimal disruption and subsequent filling defects. Ultimately resultant antegrade flow with small intra luminal filling defects. Normal Azygus vein.
PLAN: Pt will be given a prescription for lovenox to take for the next several days to allow the intimal tear to heal within the left IJ. Pt will see me in the office tomorrow for ultrasound to ensure no evidence of DVT.
I am glad to see that there were plans for follow-up with ultrasound to check for deep vein thrombosis.
I think this patient was undertreated (RIJV in the area of the valves), overtreated (LIJV) and then overtreated (RIJV in the mid jugular region). The patient left with a tear in the left jugular and a stent in the midportion of the right. Perhaps this could have been avoided.
I take away from this that, with the steep learning curve for the IRs, it might be best to go expert or not to go at all, at this time. Being undertreated is unfortunate but being overtreated can be tragic if it results in the loss of a jugular.
Any thoughts on this case?