Carotid and Neurovascular Disease and Intervention
Published online October 23, 2012
TCT-196 Chronic Cerebrospinal Venous Insufficiency: The Association Between the Extent Of Extracranial Venous Anomalies and Clinical Severity and Duration of Multiple Sclerosis
Juraj Madaric; Andrej Klepanec; Rastislav Bazik; Marek Toth; Terezia Urlandova; Jana Margitfalviova; Juraj Mikulas; Erika Drangova; Daniela Hladikova; Tibor Balazs; Vladimir Neuschl; Ivan Vulev
J Am Coll Cardiol. October 23, 2012,60(17_S): doi:10.1016/j.jacc.2012.08.217
Chronic cerebrospinal venous insufficiency (CCSVI) characterized by stenoses or obstructions of the internal jugular veins (IJV) and/or azygos vein (AZY), has been reported to be associated with multiple sclerosis (MS). However, such association is a matter of debate. The aim of our retrospective analysis was to determine the relationship between the extent of extracranial venous pathology and clinical severity of MS.
We analyzed 50 consecutive patients (pts) with relapsing-remitting (32 pts) and secondary progressive (18 pts) clinical course of MS (age 38±10 years, M:F=15:35) scheduled for duplex ultrasound (DUS), invasive phlebography, and eventual endovascular procedure of IJV and/or AZY. The extent of stenotic/obstructive process of IJV, and AZY, or IJV reflux, were graded by combination of invasive phlebography and duplex ultrasound as negative (group A), unilateral/focal stenosis/regurgitation (group B), or bilateral/multifocal stenoses/regurgitation (group C). The clinical severity of MS was evaluated by expanded disability disease scoring (EDSS). The study was approved by the local scientific and ethical committee.
Out of 50 analyzed pts (mean EDSS 3.7±2.4) there were 10 pts with negative DUS and venous phlebography pathology (20%), 16 pts with unilateral/focal venous pathology (32%), and 24 pts with bilateral/multifocal pathology (48%). The 20 cases were treated by balloon angioplasty alone, whereas the stenting of at least one vein was required in 14 pts. Importantly, there was significant difference in MS clinical severity of group A versus group B (EDSS 1.8±1.3 vs 3.0±2.2, p<0.05), as well as compare to group C (EDSS group B vs group C 3.0±2.2 vs 5.0±2.2, p<0.005). Similarly, there was significant difference in MS duration in group A versus group C (4±3 years versus 9±5 years, p<0.005).
The clinical severity of multiple sclerosis as well as duration of disease seems to be associated with the extent of pathological venous drainage of the central nervous system. To answer the question if CCSVI is only the accompanying secondary process, or the underlying condition of MS, the blinded randomized studies are needed.
Of concern is the 14 out of 34 patients who received stents, when some other clinics are stenting in approximately 2% of patients. 14 out of 34 is approximately 40%. Also of concern is that 10 out of 50 patients were found to have no pathology.
Without having confidence in the doctors' ability to diagnose all stenoses, I cannot have confidence in the conclusion that the more severe or greater duration of MS was associated with more severe CCSVI. But this has been suggested before, in the Beirut study. More research will shed more light on this. I am appreciative that the authors of this study collected their data and published. We benefit if all doctors are doing likewise.