Can veins be too small for CCSVI treatment?

[Cece]

I would like to address a recent post about veins being to small for ccsvi treatment. In my experience this would be an erroneous conclusion. Several factors prognosticate the durability of treatment. Small diameter veins have a poorer prognosis for patency than large diameter veins. They do not preclude treatment.

A small (sub 8 mm) left jugular is not a rare finding. It is on the right. Bilateral sub 8 mm jugulars would be extremely rare in my experience.

At what point is a vein considered hypoplastic? I think it's under 6 mm. Has anyone here had a successfully treated hypoplastic vein? Has any IR here successfully treated one? Successful could be defined either by actually increasing the size of the vein, or by having the vein stay patent and not clot up.

There are other veins, such as vertebrals and ascending lumbars, that are in my understanding too small for treatment.

Smaller diameter veins have a poorer prognosis for patency than larger diameter veins. Size matters.... My left jugular is my small one, and it is the one that needed retreatment, although I don't know if its size had anything to do with it. Residual valve material might be more likely to stick to residual valve material in a smaller vein? In a larger one the flow could keep it more separate? With a smaller vein, it is easier to err in the ballloon size selection and go too big? Obviously clotting is a greater concern with a smaller vein. I've heard the general rule that the left vein is the vein that has complications, if complications are to be had.

[EJC]

Emma's left IJV is hypoplastic, from memory about 50% of what would expected to be normal. So normal being about 12mm that would have been 6mm.

It was treated by Donald Reid in Edinburgh. The issue in Emma's case was a malformed valve in this narrowed IJV.

When Donald talked us through the post procedure consultation it wasn't a case of if you can treat the vein but more how do you treat it.

It was ballooned, the valve was opened to a fashion but the concern is exactly how much pressure can the narrowed vein be subjected to. Obviously the only way to completely answer that question is to open it up until it fails - which wouldn't be very agreeable

Donald errs on the side of caution so he wasn't inclined to push beyond what he considered a safe limit.

As long as a ballon can physically be threaded into the vein it can be treated, the degree of inflation and size of balloon is then the critical factor.

[Nasti]

I guess mine would be extremely hypoplastic, the left one 1.3 mm, the right one .7 mm, the left one reacted positively to ballooning, the right one wouldn't even after 50 ballooning attempts. Actually, so far I haven't come across such vein sizes, are these even rarer?

[Cece]

Nasti are you sure those were the right sizes? It's not 1.3 cm and .7 cm, which would be 13 mm and 7 mm?
Had you ever had thromboses of both jugulars, that could have recanalized?
When a vein won't respond after ballooning, it could be that it's not the true stenosis but is a compression by the muscles that keep right on compressing back to small. Fifty ballooning attempts! That's a lot and would frighten me of damage being done during that many failed attempts. Was a stent eventually used?
Did your veins stay open?

EJC, thanks, that's good information. Yes, the matter of pressure....I can't remember if Dr. Reid is using high pressure balloons, although my memory says he isn't and is using cutting balloons instead in some cases. One idea is that without high pressure balloons, the valve can't be disrupted enough to stay open, so it might give a temporary effect and then goes back to how it was. The other side of that idea is if high pressure balloons are dangerous and lead to occlusion. The counter to that is to use IVUS to precisely size the balloon, the idea being that it's not the high pressure balloons leading to occlusion but the use of high pressure balloons and a too-big balloon at the same time. Then do all that in an extra small vein, which while treatable might leave less room for error.

[Nasti]

No, no cm, mm. I was amazed at first, but it is what it is. My veins were that thin at the thinnest place. That's why I has full-blown MS at 17, I guess. And I have had the symptoms since 10-13. The thinning is really high in the brain root, ear-height, so the right one had to be stented (6 cm). About the pressure, it was dr. Petrov in Bulgaria, I believe he had some kind of clue and idea what he was doing. I was like patient No 400+, so I really do not know. I had several collaterals, but they just weren't able to compensate. I mean, .7 mm? Can you imagine anything going through that?

[Nasti]

Sorry, I didn't answer all the questions. My veins in September were 7.5 mm the left one and 13 mm the right, stented one. Blood flow is great and I am feeling great. I just hope the feeling would last and that there will be no stent complications in the future, since there is no available long term study on that.

Best
nasti

[EJC]

EJC, thanks, that's good information. Yes, the matter of pressure....I can't remember if Dr. Reid is using high pressure balloons, although my memory says he isn't and is using cutting balloons instead in some cases. One idea is that without high pressure balloons, the valve can't be disrupted enough to stay open, so it might give a temporary effect and then goes back to how it was. The other side of that idea is if high pressure balloons are dangerous and lead to occlusion. The counter to that is to use IVUS to precisely size the balloon, the idea being that it's not the high pressure balloons leading to occlusion but the use of high pressure balloons and a too-big balloon at the same time. Then do all that in an extra small vein, which while treatable might leave less room for error.

Emma was procedure number 39 in Scotland and at the time they were not using IVUS. With many more patients under the bridge I think there may be more knowledge or different procedures for dealing with these veins. At the time cutting baloons were not being used, it was case of "bursting" whatever was there.