atlas compression of IJV

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Re: atlas compression of IJV

Postby Cece » Sat Dec 14, 2013 3:46 pm

Donnchadh wrote:Going into this procedure, the exact location of the stenosis is known and now it is completely free of any impingement. So I am hopeful the right IJV can be fully opened up.

You have my greatest hopes that all your effort pays off.
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Re: atlas compression of IJV

Postby Cece » Fri Jan 17, 2014 6:15 am

Has anyone heard from Donnchadh lately? It looks like it's been a month now. I hope all is well!!
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Re: atlas compression of IJV

Postby Donnchadh » Fri Jan 17, 2014 11:35 am

UPDATE:

The venoplasty on the right IJV was completely unsuccessful. The neurosurgeon had to use 4 different size balloons in order to open up the stenosis. And the balloon was so over inflated that it was starting to leak. While resting post-op [basically to ensure no bleeding at the groin entry point], my blood pressure had dropped about 20 points but after 4 hours it returned to its high pre-op level. Bummer. Almost immediate re-stenosis to the IJV.

I was extremely depressed over this result for the next two weeks. It was as if the venoplasty didn't happen. My symptoms are as bad as before. Walking is very difficult and I have to use a walker when outside my apartment. My hopes were really "up" that this time it would be a success. I had went through two neck surgeries in preparation. The second neck surgery had two adverse complications. My younger brother and I went out to eat, and I noticed that I had a "tinny" metallic taste in my mouth. I could still taste food but the intensity of the favor was greatly diminished. It's like instead of seeing bright red, something looks like a shade of pink. This later morphed into everything having a very bitter taste-I was worried that a key nerve have been cut. The throat surgeon had warned that there are numerous fine nerves that fan out from the spinal cord at the C1 level.

Also my neck, back, and shoulder muscles were very weak and painful. I suspect that because a big chunk of the right end of the C1 atlas had to be removed the corresponding attachment points for ligaments and muscles were impaired.

Fortunately these post-op issues have been slowly improving. Taste is getting close to normal; the bitter reaction isn't anywhere near as strong [now seems to be mainly in response to sweets]. The pain is much less in my arms and neck [I wonder if the remaining muscles are becoming stronger in compensation?]. These reactions are consistent with the literature that it could take up to six months for the neck muscles and nerves to heal. Most of the time I can eat food without being aware of any bitter reactions, just like before the procedure.

At the two week post-op office visit with the neurosurgeon we went over the details of the neck procedure and the venoplasty. The bone spur on the right hand side of the atlas C1 vertebrae was in a different location as compared to the left hand side. The stenosis in the IJV is about two inches long. Below the stenosis, the IJV looks great. And unlike the left hand side, there is no stenosis inside the sigmoid sinus on the right hand side. The neurosurgeon explained how the bone spur had prevented previous venoplasty attempts to fail. He said this was the widest he has been able to open up the vein and he wanted to wait three months to see if there is any improvements. At the time, I didn't think of mentioning the very real possibility that the vein had already re-stenosed. The neurosurgeon did agree to my request for another 3D cat scan to determine the vein status.

I started researching and found out two case studies where a cutting balloon was used to treat stenosis that had resisted high pressure balloons. Tough? Scarred? vein tissues?

My plan is to obtain the procedure reports and venograms for the left and right venoplasties from the hospital records, and schedule the 3D cat scan. I can determine if the IJV has actually re-stenosed. If yes, I am going to pitch the idea of using a cutting balloon to open up the stenosis to the neurosurgeon. The case studies claim high success rates with a slightly higher rate of risk mainly to procedure complications.

I don't see any other options left at this point.

Donnchadh
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Re: atlas compression of IJV

Postby Donnchadh » Fri Jan 17, 2014 11:38 am

Should add that I had TWO problems with the right IJV. One was the bone spur impinging on the IJV, and second [unbeknownst to me prior to the venoplasty], was the very tough nature of the vein wall stenosis.

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Re: atlas compression of IJV

Postby Cece » Fri Jan 17, 2014 11:54 am

Just saw your email. Dang it.
Careful with the cutting balloons option. There are reasons to avoid them.
It sounds like it was an aggressive attempt at opening the vein; was an ultrasound done at the recent appt to check for clotting?
I am so sorry it was not a success.
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Re: atlas compression of IJV

Postby Cece » Sat Jan 18, 2014 7:12 am

Donnchadh wrote:Should add that I had TWO problems with the right IJV. One was the bone spur impinging on the IJV, and second [unbeknownst to me prior to the venoplasty], was the very tough nature of the vein wall stenosis.

Donnchadh

And this is vein wall stenosis, not the valvular stenosis that we are more often talking about.
It's hard to interpret the attempts at opening the upper jugular because we don't have the information from intravascular ultrasound. It could have been an overly aggressive attempt (the balloon leaked, the doctor kept going up in sizes). But I've never heard of an angioplasty balloon leaking. That's a part of the story that might warrant asking in Dr. S's thread. If it was not a high pressure balloon, then instead of being an overly aggressive attempt, it may have been a not aggressive enough attempt (no high pressure balloons, no exact measurement by ivus so as to use the largest possible balloon that would be unlikely to injure the vein). Underdilatation could result in near immediate restenosis.
You've interpreted the drop in blood pressure that lasted 2 hours as both signs of near-immediate restenosis and signs that there is improvement to be had if the stenosis can be opened. Otherwise one option is to accept the current outcome. You mentioned cutting balloon as an option. Stenting is an option, but again huge caution because of the risks of the stent being crushed by nearby bone and cutting off flow. Another option is to see if anything else has gone unchecked: do you have a renal vein stenosis? Another option is that pharmaceutical companies will come up with drugs that help (Diamox, perhaps) but that's a far off option because they aren't to my knowledge working on this. Another option is a procedure that combines the use of IVUS and high pressure balloons. There is a doctor in Minneapolis who uses methods nearly identical to Dr. Sclafani's. Close enough to get my approval, anyway, which is not easily gotten. I am trying to think of other options and now my kids are out here wanting breakfast. More later. Obviously I am not a doctor in any way and none of this is any more or less than knowledge gained here over the course of four years now. However my biggest concern currently is because, if the attempt at opening the upper jugular was indeed overly aggressive which it may or may not have been, then a simple ultrasound needs to be done to check if any clotting occurred as a result or loss of lumen from scarring down. You mentioned an upcoming 3D cat scan but not a 1 month ultrasound.
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Re: atlas compression of IJV

Postby Donnchadh » Sun Jan 19, 2014 2:39 pm

Cece wrote:
Donnchadh wrote:Should add that I had TWO problems with the right IJV. One was the bone spur impinging on the IJV, and second [unbeknownst to me prior to the venoplasty], was the very tough nature of the vein wall stenosis.

Donnchadh

And this is vein wall stenosis, not the valvular stenosis that we are more often talking about.
It's hard to interpret the attempts at opening the upper jugular because we don't have the information from intravascular ultrasound. It could have been an overly aggressive attempt (the balloon leaked, the doctor kept going up in sizes). But I've never heard of an angioplasty balloon leaking. That's a part of the story that might warrant asking in Dr. S's thread. If it was not a high pressure balloon, then instead of being an overly aggressive attempt, it may have been a not aggressive enough attempt (no high pressure balloons, no exact measurement by ivus so as to use the largest possible balloon that would be unlikely to injure the vein). Underdilatation could result in near immediate restenosis.
You've interpreted the drop in blood pressure that lasted 2 hours as both signs of near-immediate restenosis and signs that there is improvement to be had if the stenosis can be opened. Otherwise one option is to accept the current outcome. You mentioned cutting balloon as an option. Stenting is an option, but again huge caution because of the risks of the stent being crushed by nearby bone and cutting off flow. Another option is to see if anything else has gone unchecked: do you have a renal vein stenosis? Another option is that pharmaceutical companies will come up with drugs that help (Diamox, perhaps) but that's a far off option because they aren't to my knowledge working on this. Another option is a procedure that combines the use of IVUS and high pressure balloons. There is a doctor in Minneapolis who uses methods nearly identical to Dr. Sclafani's. Close enough to get my approval, anyway, which is not easily gotten. I am trying to think of other options and now my kids are out here wanting breakfast. More later. Obviously I am not a doctor in any way and none of this is any more or less than knowledge gained here over the course of four years now. However my biggest concern currently is because, if the attempt at opening the upper jugular was indeed overly aggressive which it may or may not have been, then a simple ultrasound needs to be done to check if any clotting occurred as a result or loss of lumen from scarring down. You mentioned an upcoming 3D cat scan but not a 1 month ultrasound.


An ultrasound is useful for getting a real time picture of blood flow, but the 3D cat scan provides a much more detailed image of the veins, bones, etc. Rivals a MRI in detail, without all the disadvantages of a MRI [cost, being stuck in a tube for a hour, etc.]. The stenosis is so high up the IJV [starts just below the skull downward for two inches] it would be difficult to get an image of it with an ultrasound.

In my case, which probably is typical only of injuries, the vein stenosis is not the result of blood clotting. It was the result of severe head trauma [like a whiplash, only very serious]; the stenosis is located at the pivot point of the head injury rotation. The "thick" tough nature of the vein walls of the stenosis was probably in response to the injury. That's why I am considering the cutting cather option; it's the only way to widen the vein back to normal dimensions. Simply ballooning doesn't result in a lasting improvement.

However, because of past partial successes in opening up these stenosis', I did experience rather dramatic nice symptom improvements. One almost immediate improvement was drop in my high blood pressure readings. My cardiologist thinks that my high blood pressure readings are due to venous insufficiency do to impaired blood flow. The way he put it to me is that "Your brain is screaming for oxygen." He had me do heart tests and they all came back normal so the problem is not because of a bad heart.

My plan is to schedule the 3D cat scan ASAP. In the meantime, I have sent off requests for reports and venogram images from the earlier right and left venoplasty attempts. When everything is assembled, I will make a decision and see if the neurosurgeon agrees. Doing nothing is not an option as my situation is worsening-I will be in a wheelchair in a year's time at the rate I am deteriorating. I have no choice but to be aggressive in treatment options.

Donnchadh
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Re: atlas compression of IJV

Postby Donnchadh » Sun Jan 19, 2014 5:14 pm

Journal of Vascular and Interventional Radiology
Volume 19, Issue 6 , Pages 877-883, June 2008

Comparison of Cutting Balloon versus High-Pressure Balloon Angioplasty for Resistant Venous Stenoses of Native Hemodialysis Fistulas

Chih-Cheng Wu, MD, Ming-Chih Lin, MD, Shih-Yun Pu, MD, Kuei-Chin Tsai, MD, Szu-Chi Wen, MD

Received 8 August 2007; received in revised form 12 February 2008; accepted 22 February 2008. published online 02 May 2008.

Abstract

Purpose

To compare the technical success, safety, and patency of cutting balloon angioplasty versus high-pressure balloon angioplasty in the treatment of resistant native hemodialysis fistula stenoses.

Materials and Methods

The authors retrospectively reviewed 1,220 percutaneous transluminal angioplasty procedures performed to treat dysfunctional native hemodialysis fistulas. Seventy patients with stenoses resistant to conventional balloon angioplasty (up to 24 atm) were included in this study: 35 patients underwent cutting balloon angioplasty from September 2003 through February 2005, and 35 patients underwent high-pressure balloon angioplasty from March 2005 through April 2006. Evaluation included technical success, complications, and post intervention patency rates up to 6 months.

Results

The technical success rates were similar between the cutting balloon (100%) and high-pressure balloon (97.1%) groups. After cutting balloon angioplasty, the primary lesion patency rates were 100% (35/35), 88.6% (31/35), and 71.4% (25/35) at 1 month, 3 months, and 6 months, respectively. After high-pressure balloon angioplasty, the primary lesion patency rates were 97.1% (34/35), 62.9% (22/35), and 42.9% (15/35) respectively. The primary lesion patency rates at 3 and 6 months were significantly better with cutting balloon angioplasty than with high-pressure balloon angioplasty (P = .018 and .009, respectively). There were no device-related complications in the cutting balloon group. Six device-related extravasations occurred in the high-pressure balloon group.

Conclusions

The results of this retrospective study suggest that, for resistant stenoses in native hemodialysis fistulas, both high-pressure balloon and cutting balloon angioplasty are effective; however, cutting balloon angioplasty seems to provide more long-standing primary patency at 6-month follow-up.
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Re: atlas compression of IJV

Postby Donnchadh » Sun Jan 19, 2014 5:26 pm

Infrainguinal vein graft stenosis: Cutting balloon angioplasty as the first-line treatment of choice

Presented at the Twenty-second Annual Meeting of the Western Vascular Society, Kohala Coast, Hawaii, Sep 8-11, 2007.

Peter A. Schneider, MD, Michael T. Caps, MD, MPH, Nicolas Nelken, MD
Division of Vascular Therapy, Hawaii Permanente Medical Group, Honolulu, Hawaii.

Received 21 September 2007; accepted 13 December 2007. published online 28 March 2008.

Objective
The optimal treatment for hemodynamically significant infrainguinal vein bypass graft stenosis is not known. This study compares three options as first choice for the revision of failing infrainguinal vein grafts: cutting balloon angioplasty (CBA), standard percutaneous transluminal balloon angioplasty (PTA), and open surgical revision (OS).

Methods
Infrainguinal vein bypass graft lesions treated in a single institution during a 12-year period were evaluated. Of these, 161 lesions in 124 infrainguinal bypasses (101 patients) were treated with OS (n = 42), PTA (n = 57), or CBA (n = 62). The initial indication for the bypass in these patients was limb salvage in 73% and claudication in 27%. The primary outcome of interest was the development of vein graft occlusion or significant stenosis (≥70%) as detected by surveillance duplex ultrasound scanning or arteriography some time after repair.

Technique of cutting balloon angioplasty
The technique of CBA of infrainguinal vein graft stenosis has been described. Clopidogrel was administered before the procedure (75 mg/d) and continued for 1 month after the procedure. In most cases, the sheath tip was placed just proximal to the origin of the vein graft. Heparin was administered (75 to 100 U/kg) before guidewire passage across the lesion.

A 0.014-inch diameter guidewire, with directional catheter support, was used to enter the graft and cross the lesion using road mapping. The balloon is inflated slowly, over approximately 60 seconds, so the atherotomes are centered by the expanding balloon, thus creating cleavage planes in the sclerotic lesion that are separated from each other along the inner circumference of the graft. The cutting balloon diameter was sized to be larger than the residual lumen within the graft at the site of the stenosis but smaller than the final intended diameter of the graft.

After CBA, a standard angioplasty balloon sized to the intended diameter of the vein graft on a 0.014-inch diameter guidewire was advanced to the site of the lesion and balloon angioplasty was performed. The angioplasty balloon was brought to the intended profile of the vein graft over 30 to 60 seconds, but was not oversized, and inflation was maintained for a minimum of a minute and often for several minutes. Patients were routinely discharged on the day of the procedure.

Results
The stenosis-free patency rates at 48 months for OS, CBA, and PTA were 74%, 62%, and 34%, respectively. PTA was associated with an increased risk of treatment failure compared with both OS (hazard ratio [HR], 3.9; P < .0001) and CBA (HR, 3.1; P < .0001). There was no significant difference between OS and CBA (HR, 1.3 for CBA vs OS, P = .6). Pseudoaneurysms developed in two CBA patients. One ruptured and required interposition graft, and one was monitored.

Conclusion
Cutting balloon angioplasty is a reasonable, initial treatment for infrainguinal vein graft stenosis in most patients. It is a safe, minimally invasive, outpatient procedure with patency rates that are comparable to OS and superior to PTA.
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Re: atlas compression of IJV

Postby Donnchadh » Sun Jan 19, 2014 5:34 pm

The Cutting balloon device is approved by the United States Food and Drug Administration for dilatation of stenoses (atherotomy) in coronary arteries in which a lesion has proven resistant to a high-pressure balloon. The manufacturer (Interventional Technologies) recommends that the coronary artery lesion be discrete (<15 mm in length) or tubular (10–20 mm in length), have a vessel diameter ranging from 2.0 to 4.0 mm, be readily accessible to the device, have a smooth angiographic contour, and lack an angiographically visible thrombus or calcification.

The Cutting balloon catheter consists of a noncompliant balloon with either three or four blades (atherotomes) arranged longitudinally about the balloon. When the balloon is inflated, it unfolds in a manner that exposes the blades to the intima of the vessel, creating controlled intimal disruption, which allows the vessel to be dilated to the desired diameter.

There have been reports in the literature on the use of the Cutting balloon for treatment of resistant stenoses of the coronary arteries [5]. Popma et al. [6] reviewed the angiographic and clinical outcomes of 160 consecutive patients with 173 lesions who underwent Cutting balloon coronary angioplasty. Angiographic success was obtained in 145 lesions (97%), and no major in-hospital complications occurred in patients after the operator used the Cutting balloon. In the coronary arteries, atherotomy poses a greater risk of perforation than that observed with conventional balloon angioplasty, and oversizing further increases the risk of perforation. To reduce the potential for vessel perforation, the operator should approximate the inflated diameter of the Cutting balloon device to the diameter of the vessel just proximal and distal to the stenosis. The procedure of ballon size selection differs from conventional angioplasty, especially in the peripheral vessels, which we often oversize by as much as 15–20%. When the catheter is introduced into the vessel, it must be observed under high-quality imaging, and care must be taken not to advance or retract the catheter unless the balloon is fully deflated under a vacuum.

The Cutting balloon has been available outside the United States for about 6 years, and, to our knowledge, few reports have appeared in the literature on the use of the Cutting balloon for indications other than coronary stenoses. Engelke et al. [7] reported excellent clinical success with Cutting balloon angioplasty for the treatment of resistant peripheral arterial bypass graft stenosis caused by neointimal hyperplasia. In this study, short-term patency with the Cutting balloon technique was superior to that of conventional angioplasty and compared well with patency after atherectomy for salvage of infrainguinal bypass grafts. Vorwerk et al. [8, 9] reported the use of the Cutting balloon in the treatment of venous stenoses in 15 Brescia-Cimino fistula lesions and four dialysis graft lesions in a single case and a small patient series. In these studies, the researchers had the benefit of having a 6-mm Cutting balloon available, which more closely approximated the actual fistula or graft size. With the use of a larger 6-mm Cutting balloon, they were able to decrease the average stenosis from a mean of 65% before the procedure to 14% after the procedure. Until recently, radiologists in the United States have not had the opportunity of using the Cutting balloon.

In our patient, the polytetrafluoroethylene graft was 6 mm in diameter. As a default, we usually use a 7-mm high-pressure balloon for angioplasty of dialysis graft stenoses, in anticipation that venous anastomotic lesions can be difficult to treat. Although the Blue Max 20 balloon is burst-rated to 20 atm of pressure, our experience is that this balloon will tolerate higher pressures because of a built-in safety margin by the manufacturer. The residual lesion was extremely tight. Although the graft was 6 mm in diameter, we believed that the 4-mm-diameter Cutting balloon, which is currently the largest diameter that is commercially available in the United States, might cause enough of a controlled incision to the intima to allow further successful angioplasty with a high-pressure balloon. This, in fact, proved to be the case, although there was still residual stenosis seen at the end of the study. We believe that the residual stenosis was a result of having to use a smaller diameter Cutting balloon than the actual vessel size, and the use of a larger balloon would have achieved a better angiographic result [8]. However, the desired clinical result was achieved in our patient in that a resumption of efficient dialysis was accomplished, and surgery or abandonment of the graft was avoided. Currently, clinical trials that are investigating the use of Cutting balloons in a dialysis population are getting under way in the United States.

Stenting of resistant venous anastomotic strictures has been shown to have patency rates similar to those of angioplasty; however, early thrombosis rates of 10% have been reported [10]. Currently, stenting is reserved for treating lesions that are resistant to angioplasty alone. It will be necessary to evaluate patency rates of a Cutting balloon versus stenting to decide how best to treat resistant venous strictures in dialysis patients in the future.

In summary, this case illustrates that the coronary-size Cutting balloon can be effective in treating resistant highly stenotic lesions in dialysis grafts. Consideration should be given to using this balloon for such lesions until the proposed larger diameter Cutting balloons become commercially available.

Address correspondence to J. M. Ryan.




Read More: http://www.ajronline.org/doi/full/10.22 ... .4.1801072
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Re: atlas compression of IJV

Postby Donnchadh » Sun Jan 19, 2014 5:48 pm

Peripheral Vascular Disease
Cutting balloon angioplasty for resistant venous stenoses of dialysis access: Immediate and patency results

Chih-Cheng Wu MD, Szu-Chi Wen MD*
Article first published online: 29 JAN 2008

DOI: 10.1002/ccd.21402

Copyright © 2008 Wiley-Liss, Inc.
Issue Catheterization and Cardiovascular Interventions
Catheterization and Cardiovascular Interventions
Volume 71, Issue 2, pages 250–254, 1 February 2008
Additional Information(Show All)

Abstract

Objectives:
To evaluate the technical success, safety and patency of cutting balloon angioplasty for the treatment of resistant dialysis access stenoses.

Background:
Cutting balloon angioplasty has been proposed to be useful in treating resistant dialysis access stenoses. However, they are based on experience with very limited cases and formal patency data is insufficient.

Methods:
The author retrospectively reviewed 896 percutaneous transluminal angioplasty (PTA) procedures for the treatment of dysfunctional or thrombotic dialysis access. Thirty-seven of 623 patients with native fistulas and 23 of 273 patients with synthetic grafts had residual stenoses of more than 30% after conventional PTA at an inflation pressure of 24 atm for 60 sec. In these 60 patients, additional cutting balloon PTA was performed.

Results:
The overall technical success rate was 96.7% and clinical success rate was 98.3%. Only one patient experienced mild local extravasation. The postintervention primary patency rates for native fistula group (N = 37) were 100%, 86.4%, and 67.5% at 1-month, 3-month, and 6-month; the postintervention primary patency rates for synthetic graft group (N = 23) were 87.0%, 60.9%, and 34.2% at 1-month, 3-month, and 6-month respectively.

Conclusions:
For resistant venous stenoses of dialysis access, cutting balloon PTA is effective, safe, and seems to provide comparative primary patency as suggested by guidelines. © 2008 Wiley-Liss, Inc.
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Re: atlas compression of IJV

Postby Donnchadh » Sun Jan 19, 2014 6:09 pm

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Re: atlas compression of IJV

Postby Donnchadh » Sun Jan 19, 2014 6:21 pm

vein stenosis before CB treatment; note distinct waist

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Re: atlas compression of IJV

Postby Donnchadh » Sun Jan 19, 2014 6:23 pm

same vein post CB treatment; results were limited by maximum size of commercially available CB. Some procedures then insert conventional balloon to stretch vein to desired width.

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Re: atlas compression of IJV

Postby Cece » Sun Jan 19, 2014 7:11 pm

Yeah the CT scan seems good especially since you have an earlier CT scan to compare. The ultrasound would be to check for compressibility to see if a clot might have formed as a result of the procedure. Ballooning of the vein wall combined with slow flow because of the stenosis that failed to be open, that can lead to new troubles.

The blood pressure drop is interesting in light of Dr. Arata's research on blood pressure after jugular venoplasty. Where is that....
http://www.ncbi.nlm.nih.gov/pubmed/24255092
Phlebology. 2013 Dec 20. [Epub ahead of print]

Blood pressure normalization post-jugular venous balloon angioplasty.

The cutting balloon research does not directly inform on if cutting balloon would be wise in a jugular vein because the jugular vein is uniquely affected by posture. When not lying down, the veins deflate. The cutting balloon used in a fistula is not a perfect analogue because the fistula is (I think) subject to very different flow that is more similar to arterial flow than to venous flow. The failure with cutting balloons is, as I understand it, an increased risk of clotting. We also need to look at what's been said about upper jugular vein stenoses. I'd have to reread this and it is two years dated but this was from Sal on the subject back then: http://www.ccsvicare.org/outreach_update01.html
Donnchadh wrote:Doing nothing is not an option as my situation is worsening-I will be in a wheelchair in a year's time at the rate I am deteriorating. I have no choice but to be aggressive in treatment options.

Your desire for action is understandable and I hope it leads to a good outcome.
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