How does one determine that treating a J3 stenosis is absolutely necessary?James McGuckin
Recanalization of the jugular vein and CCSVI
How often does it occur
Was the pt on anti coagulation
Primary or secondary case
Had the pt been stented
Social network patient driven disease
Pts travel all over the world
He sees pts where lesions are missed
Dilate without rupture or dissection
Primary cases should not be stented in general
We should not dilate J3 stenoses unless absolutely necessary and only after J1 and J2 lesions are completely treated
Stenting in J3 can lead to CN XI pain and palsy and have a high risk of thrombosis
Ptss are released without adequate f/u care
We need to descern the best after care meds ASA, Plavix, Coumadin, pradaxa
We need to determine best f/u imaging tool and frequency
Pts who have benefited from the procedure know their body dopplor MRI
Occluded stents use regular wire Cold technique
Hot technique may be used if the Cold doesn’t work for recanaliziation..uses baylis radiofrequency powerwire
J3 is much more difficult to deal with and only uses cold technique because it’s so high.
Success at J3 is only 25% can’t go near skull base with hot technique too dangerous
J1 J2 occlusions
Dx before we treat
Mjst carful dilat
Primarycases shouldn’t be stented
Don’t dilate J3 stenoses unless absolutely necessary and only after J1 and 2 have been treated
*Anticoagulation does not seem to be enough to keep the flow going which is what maintains patency. Do we need to add more?
Is he asking if the anticoagulation needs to be higher? Is there any way to increase flow (exercise, lying down to keep the jugulars open, diamox or other drug that increases perfusion)?
This is a very interested talk on the details of techniques. Dealing with occlusions is something some IRs won't take on. It's good to know more about the boundaries Dr. McGuckin has set up for the use of RF ablation. He will not use it in the upper jugular because it is too dangerous. Dr. Sclafani has indicated that RF ablation may be a possibility if the clotted jugular originally had a stent, but Dr. McGuckin does not mention if it is easier or safer when the occluded vein has a stent. My understanding is that the stent helps show where the vein is, so that there is less risk of the laser being misdirected and doing damage.
He mentions a 25% success rate at clearing occlusions in the upper jugular but does not mention what the success rate is in the lower jugular, except that it is higher. What I would love to know is if those cleared occlusions remain open at follow-up.
Social network driven disease! It is a way to get the information out, and this is information that people with MS should have, regardless of whether they act on it or not.
He says that primary cases shouldn't be stented, meaning that if it is your first angioplasty, you should not leave with stents. I am not a fan of stents but if there is a situation where a stent is necessary, it's likely to reveal itself during the first procedure, by not responding to angioplasty, or in the case of a renal stenosis, by being caused by a compression. I have to disagree with him. But I remember the 'stent-happy' days of 2009 and early 2010, and I am glad those are behind us, because more has been learned and most if not all IRs are more cautious about stenting in the jugular now.
He mentions recanalization of the jugular vein. I've heard of exactly one report here at TiMS from a patient who knew they had a thrombosis soon after the procedure and that it had cleared up on its own a month after procedure. If that is the timing, most patients would not know they ever had a thrombosis or that it recanalized, because most do not get such an early post-treatment doppler.
We are starting to get some information on how often thrombus occurs, although this may vary depending on the doctor's techniques and on the anticoagulation regimen. There were studies from a couple of clinics including EHC sharing their outcome data with crucial follow-up.
I agree about patients being released without adequate follow-up care.