Endovascular Today: the Venous Challenge

A forum to discuss Chronic Cerebrospinal Venous Insufficiency and its relationship to Multiple Sclerosis.

Endovascular Today: the Venous Challenge

Postby Cece » Wed Sep 05, 2012 9:37 am

Dr. Siskin gives the interventionalist's perspective on CCSVI:
http://bmctoday.net/evtoday/2012/07/art ... respective

and Dr. Burks and Dr. Coyle give the neurologist's perspective:
http://bmctoday.net/evtoday/2012/07/art ... erspective

The neurologist perspective is titled, "Levels of Evidence Required to Determine the Benefit of Treating CCSVI to Alleviate Symptoms of MS," and I think it is valid to look at the effect of treating CCSVI to alleviate symptoms of MS, but it is also valid to look at the effect of treating CCSVI to alleviate symptoms of CCSVI. This has to include symptoms of CCSVI that were previously misidentified as being symptoms of MS. Symptoms that improve immediately after the procedure cannot logically be symptoms of MS, a neurological disease; these symptoms can with confidence be said to be symptoms of CCSVI.

I am posting before I've read the perspectives. Over on Facebook, Joan was less than thrilled with the neurologist perspective, which makes me strongly suspect that I will be less than thrilled as well. And yet Dr. Burks has presented at various conferences, and has seemed as if he is attempting to share what the neurologists are saying among themselves (however disagreeable), and as if he is attempting to be a bridge-maker between the neurologist camp and the interventionalist camp. Let's see if I still have that opinion after I read the article....
Cece
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Re: Endovascular Today: the Venous Challenge

Postby Cece » Wed Sep 05, 2012 9:50 am

A chart from Dr. Burks and Dr. Coyle's perspective:
Considerations for the CCSVI Collaborative Group

1. What do we know already?
A. MS diagnosis, disease course, symptoms, response to, and safety issues related to immunologically based DMTs
and location of MS damage, which include perivenular lesions.
B. Treatments involving stenosis of the CNS venous system is still a “pilot phase” and will require rigorous research
before commercialization is appropriate.
C. Interdisciplinary collaboration is imperative to delineate both diagnostic and therapeutic issues.

2. What are some of the disputed findings?
A. CNS venous drainage is impaired in MS.
B. Impaired venous drainage is the cause of MS or is related to symptom severity.
C. CNS venous stenosis can be diagnosed accurately.
D. Reducing venous stenosis is beneficial to most MS patients, especially pain, mood, cognition, heat intolerance,
bowel/bladder/sexual dysfunction, and quality of life.
E. Restenosis is unlikely and is (or is not) related to increasing symptoms.
F. Iron deposits occur from venous stenosis, and this iron-induced damage causes inflammation and MS symptoms.
G. Relieving venous stenosis is a safe procedure with minimal risks.
H. The outcomes of fully established CCSVI treatments are well defined and adequate.

3. What is not known about CCSVI and its treatment?
A. The diagnostic algorithm for the definite diagnosis of CCSVI has not been fully delineated.
B. The prevalence of CCSVI in other diseases and “normals.”
C. The efficacy and safety outcomes of CCSVI-treated patients. Much data have not been collected or published.
D. Is CCSVI treatment a disease-modifying therapy, a symptom management therapy, a quality-of-life treatment,
and/or a placebo response? What type of MS would respond to CCSVI treatment?
E. Is CCSVI a hereditary condition?
F. Does MS create CCSVI or vice versa?
G. When, if ever, are stents indicated in CCSVI? Are they safe?
H. What is the risk/benefit ratio and what should MS patients be told before undergoing treatment?
I. What are the long-term benefits/risks of CCSVI treatment?
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Re: Endovascular Today: the Venous Challenge

Postby Cece » Wed Sep 05, 2012 10:06 am

If CCSVI were a causal factor for MS, then you would like to treat it very early in the disease process, before there is a lot of fixed damage. However, the initial studies do not favor this because CCSVI has been most prominent in secondary progressive MS, suggesting it is a sequelae/ secondary phenomenon of longstanding MS.

I think this is a red herring, and I am looking to the IRs to fix this red herring if they can. It has been suggested that our stenoses may become thicker and more visible over time. There is a new and improved IVUS coming out that is similar to OCT with better quality images than what we've seen to date. If new IVUS is used on patients with early MS or CIS, it may find these stenoses early in the CCSVI disease process, when they are less thick and less visible by conventional imaging methods.

CCSVI being prominent in the later phases of SP MS may mean that CCSVI is a sequelae of long-standing CCSVI. This would be because abnormal turbulent blood flow can result in further thickening of the stenoses. There is not evidence of inflammation within the veins as seen on IVUS. I think it is premature to say that the finding of more prominent CCSVI in SP MS is suggestive of CCSVI being a secondary phenomenon of MS.
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Re: Endovascular Today: the Venous Challenge

Postby Cece » Wed Sep 05, 2012 10:11 am

from Dr. Siskin's article:
Our field has thrived in a climate that enables physicians to use medical devices off-label in the best interest of their patients according to their best knowledge and judgment. Under these circumstances, the endovascular treatment of disease has grown in ways we never would have thought possible. Many of the procedures that are commonly performed today had their start when individuals used their creativity to provide elegant solutions to complex problems with devices used in an off-label manner.

Yes! Interventional radiologists are innovational radiologists. Let's let them innovate.
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