This Is MS Multiple Sclerosis Community: Knowledge & Support

http://www.ncbi.nlm.nih.gov/pubmed/23249660

some thoughts
There are some specific situations that warrant the use of stents in CCSVI, but these situations are rare. For this patient, the stents worsened the outflow.

When the doctors discovered the thrombosed stent and the migrated stent, they did nothing ("conservative care"). It may have been possible to recanalize the vein.

The authors say that continued migration of the stent is probable, which may possibly result in fatal pulmonary embolism. But my understanding is that a stent will endothelize into the vein wall within weeks of implantation. Although this stent migrated, it will not migrate further, if it is correct that it has endothelized. There are patients who live in fear of their stents migrating even a year or two after the procedure. My understanding is that this is a risk only in the first few weeks. After that the stent is a part of the vein wall itself.

The conclusion is that the authors strongly ask for restriction of PTA angioplasty in CCSVI. But what was done in this patient was not PTA. It was stenting. The outcome for this patient with stents, which is terrible, does not inform about the outcome of patients with ballooning only.

In this patient, new outflow obstructions were introduced into the veins in the form of these failed stents. When new outflow obstructions happened, the patient's EDSS deteriorated. This is only a single case study but it supports the hypothesis that extracranial outflow obstructions have negative consequences for patients with MS.

The abstract says that the full text is available but I cannot find the full text. If the right jugular stent migrated so that is blocking some of the confluence with the subclavian vein, there might be retrograde flow in the subclavian, which might then reroute up and into the jugular or the other neck veins, which would further worsen the outflow.

I do not know how such a flow situation could be helped. Vein grafting, where the entire jugular vein is subsected, has not shown a good outcome but jugular patch angioplasty may provide a better outcome. But there are no veins to patch if both are blocked with stents, nor is there a way to help the subclavian if it is partially blocked by a migrated stent, which is an assumption. Vertebral vein patch angioplasty would be the only contender and that is too risky a thought because those veins are typically smaller.

It is available, but a little convoluted to get to http://pmr.cuni.cz/file/5641/PMR2012A0030.pdf and not that detailed.

I feel sorry it had to happened to this woman, but it makes an argument to any neurologist that says vein issues cannot affect the neurological symptoms of MS. This poor woman could be an example of the Putman dog experiment performed on a human (however she did have MS to begin with, unlike Putnam's dogs).

Thanks for the link, it does have an image:


That's worse than I'd imagined from the description in the abstract. The left jugular is on the right side of the image; that's the thrombosed stent, so there's no flow through that jugular, and doesn't it look like it could be blocking the brachiocephalic vein below it partially as well?

On the left side of the image, which is the right jugular, you see the stent that was placed at the upper part of the jugular is now at the bottom, and the one that was at the bottom of the jugular is not just blocking the brachiocephalic vein but also partially blocking the superior vena cava as well. There is no way to remove these stents. It's terrible.

That stent in the right jugular vein is not in the superior vena cava. but it does look malpositioned. determining whether it migrated would require an image at implantation.
a jugular stent should extend partially into the brachiocephalic.


there were a lot of poorly done cases in 2010

As I said then, it was premature to demand randomized trials too early.
s

_________________
Salvatore JA Sclafani MD
Patient contact: ccsviliberation@gmail.com

Ok, good point about not having an image at implantation.
It was premature to do RCTs. A safety study by a Dr. Sclafani at an academic US hospital would have been in the medical literature by now, had things gone differently. We are in need of such studies. Still upsetting.

Upon reading the full article, it says that the left jugular recanalized through the stent, so I was wrong that there was no flow on that side.