This Is MS Multiple Sclerosis Community: Knowledge & Support

Live case from the VEF Conference which was held in Katowice March, 3-4, 2011

http://www.youtube.com/watch?v=vyqt7dzq ... re=related
In this patient, blood flow is believed to be normal in the azygous and the right jugular although the doppler indicated slow flow in the right jugular. Left jugular is stenosed as seen by doppler, MR and venogram.

procedure starts at 1:26
He shows the catheter balloon prior to inserting.
You can see him twisting a little green-and-white thing which is what controls the inflation of the balloon inside the body. He identifies it as a 12 mm balloon. You can see the waisting on the balloon in the left jugular. He chooses to wait four minutes.

This would fall into the question of how long duration of the balloon should be, either short or long, with a reason to keep them shorter being that it may reduce damage and also blood flow is not cut off for as long (since the lumen of the vein gets oxygen directly from the blood flow there could be damage to the lumen if it goes without oxygen, and also a long duration may cut off blood flow from the brain, something I distinctly remember during my first procedure, when my mostly blocked jugular was ballooned and my other side was an entirely blocked jugular!) Now in this patient, after 2 minutes, the residual waist disappeared, which is why longer durations could be attractive ….

He switches to a smaller balloon to treat a stenosis in the upper jugular.

http://www.youtube.com/watch?v=HCqgCdSt ... re=related
He sees the results. The upper part is better but the lower part, while also improved, is not enough.

It's interesting just to see the catheter inching forward on the guidewire.

He chooses to go up to a 14 mm balloon with longer inflation, with 8 atm pressure, but no waisting is seen. Four minutes duration of ballooning. It is possible that clotting could occur with a ballooning of this duration.

Earlier in the procedure you can see the flow divert to the external jugular as a collateral.

http://www.youtube.com/watch?v=hS_K2Y96 ... re=related

It sounds like he is going to look in the innominate vein for a problem? It looks like he inflates in the innominate vein with no waisting seen. And a second time. Was this an unnecessary ballooning?

Now you can see some of that 'mediastinal movement' that could obscure the images when interrogating the veins of the chest, particularly the azygous, although that is not currently being looked at.

Back up to the top of the jugular to check the flow and result of the procedure. He shows the before angioplasty, with the tight stenosis in the upper and lower portions of the jugular (j1 and j3). Then he shows the results after ballooning. Lower part is indeed wider. Patient's head is turned to the right. He says it looks like we cannot do anymore. He ballooned with a 14 mm balloon and won't go any higher. Is he accepting a treatment endpoint with the flow not as good as he'd have liked, but has to stop rather than continue and risk damaging the vein?

I wish we could have seen inside the right jugular and the azygous that were deemed normal. Normal veins, in an MS patient?

All in all it seems like he was conscientous about the procedure. I get a kick out of seeing waists disappear on balloons and flow restored. That's what it's all about. I appreciate his sharing this procedure with the conference and, through youtube, with all of us.

One thing I regret is that he never mentioned his name and I do not recognise him! Can anyone help me out? He is from Euromedic.

The doctor doing the procedure and commenting is Dr. Kazibudzki, he is actually vascular surgeon. The second doctor who is assisting him is Dr. Świerad who is an interventional cardiologist. He has experience in intravenous endovascular procedures in the area next to heart.

I am sure because both of these doctors were doing also my procedure together with Dr. Ludyga in November 2009 and prof. Simka sent me their exact names in November 2009.
I am glad they still do the job.
Erika

_________________
Aug. 7, 09 Doppler Ultras. in Poland, left Jugul. valve problem, RRMS since 1996, now SPMS,
- Nov.3,09: one stent in the left jug. vein in Katowice, Poland, LDN, never on DMDs
- Jan. 19, 11: control venography in Katowice - negative but I feel worse

Thanks, Erika. Dr. Kazibudzki and Dr. Swierad.

It's a challenge for our IRs to be doing this procedure without standardization, so that there are all these judgement calls to be made during the procedure about what tools to use, how long of duration to keep the balloon open, whether to balloon an up-high lesion, when to accept the result or when to pursue more aggressive treatment. It is good that the doctors are learning from each other and from experience.

I think anyone considering the procedure might find this video helpful, although as the patient you are not as aware of how your leg looks or the extended wire that goes in. I remember the discomfort of the very beginning when the entry vein is accessed and then felt nothing until the balloon was in place and expanded.

I ran across this while searching for something Dr. Cumming said on the definition of disrupted valves.

chronic-cerebrospinal-venous-insufficiency-ccsvi-f40/topic17810.html
That would be the concern with keeping the balloon inflated too long: disruption of oxygen supply.