CCSVI or TOS or both? (new research)

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

CCSVI or TOS or both? (new research)

Postby pairOdime » Wed Aug 28, 2013 5:05 am

We were looking at this abstract and thought it would be a good idea if these researchers attend the ISNVD Meeting in SF in February. They may not even be aware of the ISNVD.

We have dedicated a number of recent posts to the discussion of thoracic outlets syndrome (TOS), a condition which causes compression of the blood vessels and nerves at the top of the chest. Dr. Sam Ahn of University Vascular Associates, along with other colleagues, study this condition and recently found that compression (stenosis) of the internal jugular vein is found in patients with TOS.

This finding represents a new concept in the diagnosis of this often debilitating condition. Furthermore, the authors reported that using a balloon on the tip of a catheter to expand the compression or blockage in the jugular and/or subclavian veins can relieve symptoms of TOS. This new concept will be presented to other surgeons at the Fall semi-annual meeting of The Texas Surgical Society to be held this September in Houston (http://txsurgicalsociety.com/UpcomingMeeting.aspx).

Below is the abstract of the scientific paper to be presented at the meeting.

TITLE: Percutaneous Transluminal Angioplasty as Therapy for Thoracic Outlet Symptoms

AUTHORS: Ahn, Samuel S; Chen, Julia F; Miller, Travis J.; Chen, Sheena W.; Feldtman, Robert; Hwang, William

OBJECTIVES: Traditionally, thoracic outlet syndrome (TOS) has been associated with axillo-subclavian vein stenosis without any mention of the internal jugular (IJ) vein. However, we recently reported a high prevalence of IJ stenosis in 109 patients with TOS in a limited study. To further understand the clinical significance of this finding, we analyzed a larger cohort of patients and their subsequent follow-up.

METHODS: We retrospectively analyzed 237 consecutive unique patients referred to our practice with thoracic outlet syndrome. From April ’08 to Dec ’12, all patients underwent diagnostic brachiocephalic venograms. Average age was 49.9 years (r:17 to 81), with 71.8% females and 28.2% male. We looked at the right and left internal jugular veins and the right and left subclavian veins. Stenoses were classified into high (>66%), medium (33%-66%),and low (<33%). We also looked for presence of collaterals around the obstructions. Venogram findings were independently confirmed by four investigators. For the purposes of this analysis, high stenosis was considered significant. Medium and low stenoses were considered significant only if there were visible collaterals. Of this group, we then looked at all patients who received intervention via PTA at the stenosed IJ sites. Patients were categorized into Groups I or II. Group I: patients who received no immediate relief of symptoms after PTA; Group II: patients who did receive immediate relief of symptoms after PTA. Group II was further broken down into subgroups IIA, IIB, and IIC. Group IIA: those who required additional surgical intervention due to symptom recurrence; Group IIB: those who report sustained relief; Group IIC: those who were lost to follow-up.

RESULTS: Left internal jugular vein stenosis, left subclavian vein stenosis, right internal jugular vein stenosis, and right subclavian vein stenosis was seen in 67.5%, 57.6%, 62.7%, and 61.6% of patients, respectively. Internal jugular vein stenosis was not present in 18.1% of patients, present unilaterally in 33.3% of patients, and present bilaterally in 48.5% of patients. Subclavian vein stenosis was not present in 24.1% of patients, present unilaterally in 32.5% of patients, and present bilaterally in 43.5% of patients. Significant collaterals were present in 26.80% of high stenosis, 21.5% of medium and 12.8% of low. Of 237 patients, 67.7% (n=147) received PTA intervention. Of those who received intervention, 28.6% (n=42) were in Group I, 67.4% (n=99) were in Group II, and 4% (n=6) did not have available data. Of those in Group II, the breakdown was as follows: IIA (35%, n=34) with a median of less than 7 days (r: 2-210) of relief; IIB (31%, n=31) with 120 days (r: 5 to 406) of follow-up; IIIC (31%, n=31) with 93.5% (n=29) reporting sustained relief at 7-day follow-up and median follow-up of 7 days (avg: 25, r: 6-182).

CONCLUSIONS: Internal jugular vein stenosis is common in patients with thoracic outlet symptoms and percutaneous treatment provides benefit to some patients. These findings could fundamentally change the diagnosis and treatment of thoracic outlet syndrome. Further studies are warranted.
It's a paradigm shift
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Re: CCSVI or TOS or both? (new research)

Postby pairOdime » Wed Aug 28, 2013 7:10 am

Here is a bio-sketch for Dr. Ahn.
With more than 30 years of medical experience, board-certified vascular surgeon Samuel S. Ahn, MD, has taught at the David Geffen School of Medicine at the University of California, Los Angeles (UCLA) from 1986 to 2006, holding the positions of Lecturer and Examiner, as well as a Mentor for the UCLA Short Term Training Program. In the past, Dr. Ahn has taken on the roles of Preceptor for UCLA medical students, Associate Clinical Professor of Surgery, Course Chairman for Principles of Laser Surgery, and Professor of Surgery.

Besides UCLA, Samuel Ahn, MD, has imparted his knowledge to students around the world, having acted as Visiting Professor at Yonsei University College of Medicine in South Korea, University Medical Center Utrecht in the Netherlands, and Toronto General and Wellesley Central Hospitals in Canada, among others. Samuel Ahn, MD, also has received invitations to lecture at the Great Lakes Endovascular Symposium and VEITHsymposium.

Aside from teaching, Dr. Ahn addresses the vascular needs of patients at University Vascular Associates, an outpatient surgery center he founded in 2006. There, he provides treatment for various conditions, including abdominal aortic aneurysms, thoracic outlet syndrome, peripheral vascular diseases, and varicose veins. Additionally, Samuel Ahn, MD, serves as Attending Surgeon at St. John’s Health Center in Santa Monica, Cedar-Sinai Medical Center in Beverly Hills, CA, Methodist Dallas Medical Center, and UCLA Medical Center.
It's a paradigm shift
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Re: CCSVI or TOS or both? (new research)

Postby Cece » Wed Aug 28, 2013 1:05 pm

lol I was just looking up his bio and his university too before I saw your second post
http://universityvascular.com/doctor/sam-ahn/

This is retrospective research, so it's not as strong as prospective research, but I am really happy to see that they're investigating this. The subgroup dividing is smart too.

Group 1: no relief of symptoms after angioplasty
Group 2: immediate relief of symptoms after jugular angioplasty

Group 2 subgroup 2A: immediate relief of symptoms but required repeat angioplasty after a week
Group 2 subgroup 2B: immediate relief of symptoms that was sustained and did not require further intervention at 120 days follow-up
Group 2 subgroup 2C: immediate relief of symptoms that was sustained at 7 days post-procedure but no further follow-up
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Re: CCSVI or TOS or both? (new research)

Postby 1eye » Wed Aug 28, 2013 1:18 pm

Have you told them about ISNVD? This is the area Dr. Zamboni complained about the McMaster study missing out.

There may be overlap between TOS, CCSVI, and MS, IIH, and Lyme's in causation as well as symptoms. At the very least, if the TOS research is successful it may provide codes to charge the PTA to. Call it by any of its maybe names, jugular venous insufficiency must be treated, or most sufferers will have deficits.

Doctors, scientists, insurance, drug companies, politicians, rely too heavily on the human capacity for vein angiogenesis. We now know that in "MS", or TOS, or IIH,or Lyme's, or CCSVI, a jugular stenosis results in large numbers of additional collateral veins. We know that in supine position, when jugulars would otherwise be used, the collaterals become the alternate pathway. They have no valves, and may not be sufficient. We also know that in the case of "MS", there is reduced perfusion, reduced flow, and loss of capillaries, where vessels are smallest, increasing their individual resistance to flow, and thus their vulnerability to hypoxia and hypoglycemia. We think there is venous hypertension when these stenoses occur.

The azygus is part of the thoracic outlet system. It must be treated too. I do not advocate the use of stents, but I know they can sometimes be necessary and effective. Sometimes other surgical interventions must be used, such as muscle resection, rib removal, etc. Maybe even a shunt-type device is required. In the next few years I expect the world to wake up to a lot of these syndromes, diseases, conditions, and/or medical problems, and insurance companies to bite the bullet, and start recognizing them. When they won't, people who have medical insurance start paying with or without the ability to claim. If they get better, something is very wrong. Individuals and their prospective employers may benefit, but the claims are being avoided without any legitimate justification.

Insurance companies have their cake and eat it too, when people go back to work without their claims being honoured.
"Try - Just A Little Bit Harder" - Janis Joplin
CCSVI procedure Albany Aug 2010
'MS' is over - if you want it
Patients sans/without patience
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Re: CCSVI or TOS or both? (new research)

Postby pairOdime » Mon Sep 02, 2013 8:08 am

I will contact Dr. Ahn's office (mail & email), mention our interest in his study and note the ISNVD Meeting in San Francisco, Feb 7-9, 2014. It may be of some benefit for the ISNVD communiations staff to send Dr. Ahn an information packet, if possible.

It seems that joint TOS/CCSVI or CCSVI/TOS studies could potentially further the exploration and advancement of CCSVI diagnosis and treatment.
It's a paradigm shift
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Re: CCSVI or TOS or both? (new research)

Postby pairOdime » Tue Oct 22, 2013 6:51 am

Spoke with Dr. Ahn on Sunday...he is very aware of CCSVI and the TOS overlap. Due to his schedule he is unable to attend the ISNVD Conference in Feb, but he is very interested in sending one of his team members to the meeting. I passed along Kelly Denz's (ISNVD) contact info to him. Dr. Ahn is a really nice and very personable doc & researcher.
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