Use of high-pressure balloons in CCSVI by Dr. Jan de Letter

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Use of high-pressure balloons in CCSVI by Dr. Jan de Letter

Postby Cece » Thu Oct 20, 2011 4:43 pm

http://www.ccsvi-online.com/news/studie ... ment-ccsvi

Dr. Jan de Letter of Bruges compares and contrasts the use of normal balloons, cutting balloons, and high pressure balloons in CCSVI. He also provides images of a ballooning done at 14 atm. (In the wall tension thread, I was discussing placement of the balloon, and in Dr. de Letter's images, you can see what it looks like when the balloon is centered on the stenosis instead of lower down.)

Techniques used for arteries cannot simply be transferred to veins. Flow rate and pressure in arteries are much higher. Furthermore, artery walls have a completely different structure than vein walls. Experiences with dialysis patients - where a vein is connected directly to an artery in a small surgical procedure - show that classic balloons used in arteries cannot apply the pressure required to open stenoses that develop in these veins (so-called dialysis fistulas). These veins are too stiff due to connective tissue bands. The use of balloons with a larger diameter than the vessel or the use of two balloons also does not offer a solution. This only results in stretching the healthy wall to either end of the stenosis, which is obviously not the objective.

To solve this conundrum, two different techniques were chosen, the previously mentioned cutting balloon being the first. By inflating this balloon multiple times, turning it a little each time, the desired effect is achieved. The disadvantage of this technique is that local bleeding may occur, as the blades can cut through the thinner vein wall. The other solution is to use high-pressure balloons. The effects are the same as for arteriosclerosis, however high-pressure balloons can be inflated to 16 bars without the risk of the balloon tearing. This allows far more force to be applied to the stenosis, and sufficiently stretches out the connective tissue that causes the narrowing. Tests have shown that the use of stents in dialysis fistulas affect the inner lining of the vein in the long term, resulting in new stenosis and even complete occlusions.

Does the use of the "kissing balloons" methods with two balloons used to increase pressure result in stretching of the healthy vein wall when compared to high pressure balloons? I thought it only resulted in a larger insertion scar down at the groin. But here is the image:
Image
I like the one on the top right, where the stenosis gives way. The lower two images should both result in a higher dilating force on the stenosis, so the stenosis may yet give way, but at least in the one with the larger balloon, the wall definitely gets more dilating force against it too.

This next part is good:
For over a year now, I have been using high-pressure balloons to dilate the parts of veins where stuck valves, membranes and band-shaped thickenings are causing problems. Using high-pressure balloons, I have treated hundreds of patients with good and lasting results. It is important to note I see practically no re-stenoses (new narrowing) in patients in the long term. My conclusion is that the connective tissue strands in the band-shaped stenosis are sufficiently broken up, and no damage has been done to the wall of the treated vein.

He goes on to take aim at other doctors' methods, which are cutting balloons and the use of two balloons at once to increase pressure, as being more aggressive and certain to lead to vein damage. He also does not recommend the use of stents in CCSVI given the experience with dialysis fistulas.
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Re: Use of high-pressure balloons in CCSVI by Dr. Jan de Let

Postby 1eye » Sat Oct 22, 2011 10:46 am

He sounds like he knows of what he speaks. Does he use IVUS?
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Re: Use of high-pressure balloons in CCSVI by Dr. Jan de Let

Postby 1eye » Sat Oct 22, 2011 11:06 am

From Wikipedia:

The bar is a unit of pressure equal to 100 kilopascals, and roughly equal to the atmospheric pressure on Earth at sea level. Other units derived from the bar are the megabar (symbol: Mbar), kilobar (symbol: kbar), decibar (symbol: dbar), centibar (symbol: cbar), and millibar (symbol: mbar or mb). They are not SI units, nor are they cgs units, but they are accepted for use with the SI.[1] The bar is widely used in descriptions of pressure because it is only about 1% smaller than the atmosphere (symbol: atm), which now is defined to be 1.01325 bar exactly. The bar is legally recognized in countries of the European Union.[2]
Couldn't you use a balloon that had a bump, a wider (diameter-wise) channel in the middle, sized for the valve, with thicker rubber? The smaller outside part of the balloon might damage the healthy endothelium less, with a weaker wall strength?
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Re: Use of high-pressure balloons in CCSVI by Dr. Jan de Let

Postby drsclafani » Sat Oct 22, 2011 12:05 pm

1eye wrote:From Wikipedia:

The bar is a unit of pressure equal to 100 kilopascals, and roughly equal to the atmospheric pressure on Earth at sea level. Other units derived from the bar are the megabar (symbol: Mbar), kilobar (symbol: kbar), decibar (symbol: dbar), centibar (symbol: cbar), and millibar (symbol: mbar or mb). They are not SI units, nor are they cgs units, but they are accepted for use with the SI.[1] The bar is widely used in descriptions of pressure because it is only about 1% smaller than the atmosphere (symbol: atm), which now is defined to be 1.01325 bar exactly. The bar is legally recognized in countries of the European Union.[2]
Couldn't you use a balloon that had a bump, a wider (diameter-wise) channel in the middle, sized for the valve, with thicker rubber? The smaller outside part of the balloon might damage the healthy endothelium less, with a weaker wall strength?

that is sort of like a cutting balloon.

Remember that veins are highly compliant, they are made that way to accommodate significant increases and decreases in flow volume during different activities. Thus there is some safety in increasing size of balloon over the visualized diameter. The trick is to not increase the balloon too much to exceed the capacity of the vein wall tissue to stretch. Stretching to the size of the vein wall does not seem to always be sufficient to open the valvular obstructions. Sometimes you have to stretch the attachments of the valve to stretch the valve open.
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Re: Use of high-pressure balloons in CCSVI by Dr. Jan de Let

Postby CureOrBust » Sat Oct 22, 2011 5:11 pm

Having a balloon with a larger diameter in the middle, I think would probably be a good but an expensive option, as there would be many variations in diameter differences and gradients between the two sizes etc etc A cutting balloon is also very different from my understanding. If I have it right, it actually "cuts" into the vein with longitudinal cutting "ridges", where I think he was suggesting an in-plane "bump" (ie radially, in line with the narrowing)

From my understanding, the common case where a stenosis occurs, and does not fully respond to being ballooned, is at a valve. The vein may be "compliant" but at the point of the valve, it is less compliant, and thereby the surrounding veins expand more (as in the diagram above, if you assume the black bits are the valve) I think this is what happened in my last procedure at one or more sites.
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