Anyone know of a procedure involving a cutting balloon?

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

Anyone know of a procedure involving a cutting balloon?

Postby Donnchadh » Wed Jan 29, 2014 7:13 pm

Want to find some cases involving use of a cutting balloon in the internal jugular vein. Found several for dialysis patients but none so far for the IJV.

Want to prepare information before meeting neurosurgeon for next office visit.

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Re: Anyone know of a procedure involving a cutting balloon?

Postby CureOrBust » Thu Jan 30, 2014 1:48 am

Search through Dr Sclafani's thread. He used to use one, but now would not. The index has a few references.
chronic-cerebrospinal-venous-insufficiency-ccsvi-f40/topic11433.html
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Re: Anyone know of a procedure involving a cutting balloon?

Postby Cece » Thu Jan 30, 2014 7:28 am

http://www.ncbi.nlm.nih.gov/pubmed/24153192
J Cardiovasc Surg (Torino). 2013 Oct 24. [Epub ahead of print]

Efficacy and safety of cutting balloons for the treatment of obstructive lesions in the internal jugular veins.

Kazibudzki M, Latacz P, Ludyga T, Simka M.

Author information

Abstract

Aim: In this technical note we present the results of endovascular treatment for chronic cerebrospinal venous insufficiency with the use of cutting balloons, with focus on feasibility and safety of these endovascular devices. Methods: We used cutting balloons during 70 procedures in 65 multiple sclerosis patients presenting with strictures of the internal jugular veins, primarily at the level of jugular valves. These devices were used only in selected cases, following unsuccessful standard balloon angioplasty, and on condition that commercially available devices could be applied (currently they are maximally 8 mm in diameter). Results: In all cases the perioperative course was uneventful, with no serious adverse events. Immediate technical success rate was 94.3%. In four cases (5.7%) cutting-balloon angioplasty alone was unsuccessful and stents were implanted. Primary, assisted primary and secondary patency rates after 6 months were: 94%, 98.5%, and 98.5%, respectively. Follow-up has revealed that out of the remaining 66 angioplasties four procedures failed (failure rate: 6.1%): in two patients stents were implanted, in one patient successful redo cutting-balloon angioplasty was performed, while in another case the treated segment of jugular vein totally occluded and was not feasible to reopen endovascularly. Conclusion: Cutting balloons can be safely used for the management of stenosed internal jugular veins. These devices can replace stents in the majority of cases, especially if standard balloon angioplasty is insufficient to restore proper outflow. However, the use of cutting balloons in this particular venous territory is limited by the fact that currently only small diameter devices are available.
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Re: Anyone know of a procedure involving a cutting balloon?

Postby Donnchadh » Thu Jan 30, 2014 11:06 am

Thanks, Cece!

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Re: Anyone know of a procedure involving a cutting balloon?

Postby Cece » Thu Jan 30, 2014 11:21 am

My pleasure, Donnchadh. I knew there'd been something published recently, I just couldn't have said who from or what it was about.

One problem noted in the article is that commercially available cutting balloons are a maximum of 8 mm in diameter. The IJV is typically bigger than this. A way to get a cutting balloon effect without a cutting balloon (if the vein is too large or cutting balloons are not available) is to use a regular balloon and trap the guidewire between the balloon and the vein wall prior to inflating. "Poor man's cutting balloon," that's called. Another problem is that Ludyga's research, although consisting of 70 cutting balloon procedures in IJVs of MS patients, says specifically that the procedures were typically in the lower jugular in the area of the valves. The upper jugular is more problematic.
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Re: Anyone know of a procedure involving a cutting balloon?

Postby Donnchadh » Thu Jan 30, 2014 12:34 pm

Another way around the problem of undersized cutting balloon relative to the desired post-op size of the vein is to use a low pressure balloon afterwards. There has been good results with these technique even with tough stenosis sites. Apparently, cutting the vein wall first weakens it enough that subsequent ballooning is effective.

However these cases did not involve the IJV but with dialysis patients who frequently develop stenosis due to the high volume and pressures incurred during their weekly treatments.

Looks like I might be a pioneer again [unfortunately]. As it is right now, ballooning by itself is ineffectual and nearly all the blood from the brain is being drained by collateral veins and cerebral veins. So in that sense, things can't get worse.

I am guessing that having an anti-clotting drug regime after surgery is important.

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Re: Anyone know of a procedure involving a cutting balloon?

Postby vesta » Thu Jan 30, 2014 2:24 pm

Hello Donnchadh: I was sorry to learn your angioplasty didn't succeed and hope the next one - with the cutting balloon - does finally "liberate" you. I haven't followed your history from the outset, was it an accident that triggered off all these problems? If you've already discussed the issue, where do I turn to find it? It's frustrating to know how advanced surgery is in so many areas but somehow work on the neck veins seems in its infancy.

Cece: The Ludyga intervention was done in Torino (Turin, Italy?) Would it be fair to say that the FDA restrictions are limiting research in the US? Also, stents are apparently used in renal veins for dialysis patients. Were double blind studies performed on dialysis patients before this procedure was authorized? Sorry if these questions are off subject. Thanks, Vesta
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Re: Anyone know of a procedure involving a cutting balloon?

Postby Donnchadh » Thu Jan 30, 2014 2:50 pm

vesta wrote:Hello Donnchadh: I was sorry to learn your angioplasty didn't succeed and hope the next one - with the cutting balloon - does finally "liberate" you. I haven't followed your history from the outset, was it an accident that triggered off all these problems? If you've already discussed the issue, where do I turn to find it? It's frustrating to know how advanced surgery is in so many areas but somehow work on the neck veins seems in its infancy.

snip



Yes, I do believe that all my neck problems were due to my 1990 ladder accident-I fell over 20 feet down. Before
the accident, I was in great shape. No neurological problems of any kind.

Venoplasty [by Doctors Makris and Farrell] was completely successful in treating the bilateral stenosis in the LOWER IJV. There were immediate symptom improvements which have persisted.

The neurosurgeon successfully treated a herniated C5-C6 disc which resulted in much better sense of balance.

The remaining problems [stenosis in the UPPER IJV] and stenosis in the left sigmoid sinus have turned out to be much more difficult to deal with. Dr. Arata, after viewing my lab tests and reports, suggested that the styloid process might be compressing the veins. Turns out it was indeed a bone compression but it was from the opposite direction; I had large bone spurs growing on my C1 vertebrae. These spurs, one on the left side and one on the right side, were removed in two separate procedures.

I was hoping that with the spurs removed, a venoplasty would result in opening up the vein stenosis. What I hadn't counted on was that these stenosis were very "tough" or "fibrous" and re-collapsed post procedure like a stretched rubber band snapping back.

Using a cutting balloon is just a working guess at this point-I don't know what else can done. I am waiting for all the images from the venoplasty and 3D cat scan to arrive so I can get a better idea of what I am up against. Then I will schedule an appointment with the neurosurgeon to see what he thinks about using a cutting balloon.

Literally a two inch long section of the IJV is all that separates me from suffering with "MS" and being normal!!!
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Re: Anyone know of a procedure involving a cutting balloon?

Postby vesta » Fri Jan 31, 2014 8:04 am

Thanks Donnchadh: How frustrating to think that opening a two inch section of the IJV could change your life so dramatically. Did the fall cause the bone spurs to develop, and do you think the accident and vein compression cause the fibrous tissue to develop in the vein? I'll be following your treatment hoping for your complete recovery. Vesta
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Re: Anyone know of a procedure involving a cutting balloon?

Postby Donnchadh » Fri Jan 31, 2014 1:14 pm

vesta wrote:Thanks Donnchadh: How frustrating to think that opening a two inch section of the IJV could change your life so dramatically. Did the fall cause the bone spurs to develop, and do you think the accident and vein compression cause the fibrous tissue to develop in the vein? I'll be following your treatment hoping for your complete recovery. Vesta


These are the key questions-the doctors are very curious about my case because my "MS" symptoms are associated with a known severe neck trauma with resulting bilateral vein stenosis. The current thinking is that the bone spurs were indeed caused by the accident. The progressive nature of my symptoms is consistent with gradually enlarging C1 vertebrae bone spurs; the bone growth eventually reached the point whereby the IJV was completely compressed flat.

As far as the cause of the fibrous tissue of the venous stenosis, we simply cannot be certain yet. We are dealing in a completely new area; unlike arteries, veins have been relatively unresearched.

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Re: Anyone know of a procedure involving a cutting balloon?

Postby Donnchadh » Fri Jan 31, 2014 1:54 pm

[Received a digital copy of the cat scan report; still waiting for the disc with the actual images. Doctor and hospital names omitted by their request]



CTV NECK W/O & W CONTRAST - Details

HISTORY: Jugular vein stenosis.

COMPARISON: Venography report 12/16/2013 (right internal jugular vein
and sigmoid sinus balloon angioplasty). CTV neck 05/09/2013 and prior.

TECHNIQUE: Dynamic injection of nonionic intravenous contrast, axial
0.625 mm source images as well is 2.5 mm images obtained. Sagittal and
coronal 2-D reformatted images. Sagittal and coronal maximum intensity
projection multiplanar reformatted images. Bilateral curved planar
reformatted images. Omnipaque 350, 95 mL used.

FINDINGS:

No focal narrowing of the right transverse or sigmoid sinus. No
stenosis in the superior most aspect of the right internal jugular vein
down to the upper aspect of the styloid process. At this point, there
is a 4.2 cm length segment [THAT'S ABOUT 1 5/8'S OF AN INCH-Donnchadh]
of moderate to severe stenosis of the vein
with the upper 2 cm segment appearing severely stenotic followed by a
segment of moderate stenosis. This is seen well on sagittal reformatted
images 30-32 (series 301). Below this, no right internal jugular vein
stenosis. It is also well seen on series 2004 CPR.

No focal stenosis in the left transverse sinus or sigmoid sinus. The
jugular bulb was opacified, but below this, no definite opacification of
the left internal jugular vein is seen in the upper neck until it is
reconstituted by other veins at the upper C3 level. Below this, no
significant narrowing of the left internal jugular vein.

Also again noted are postoperative changes from ACDF at C5-C6.
[this where the neurosurgeon fused the herniated disc-Donnchadh]

IMPRESSION:

1. There is an approximately 4.2 cm length segment of moderate to severe
stenosis in the right internal jugular vein beginning superiorly at the
upper aspect of the styloid process with a 2 cm length segment of severe
stenosis followed by moderate stenosis.

2. On the left side, there is essentially nonvisualization/occlusion of
the internal jugular vein beginning just below the jugular foramen. The
vein is reconstituted by collaterals at the upper C3 level.
______________________________________________________________________________
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