Venous stent or not...

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

Venous stent or not...

Postby mrhodes40 » Sat Jun 20, 2009 11:32 am

Does the presence of stenosis all by itself indicate that repair SHOULD be done?

In legs the answer is yes............. and that is just in a leg! yeah, you need your leg but the BRAIN, I would argue, is even more important...

FOUND HERE

Venous outflow obstruction: An underestimated contributor to chronic venous disease.Neglén P, Thrasher TL, Raju S.
River Oaks Hospital, Flowood, MS 39232, USA. neglenmd@earthlink.net

OBJECTIVE: To assess the importance of iliac venous outflow obstruction in limbs with and without concomitant deep or superficial reflux, we performed a retrospective analysis of data contemporaneously entered into a set time-stamped electronic medical records program. MATERIAL AND METHOD: Four hundred forty-seven limbs underwent iliac vein stenting of chronic, nonmalignant obstruction when greater than 50% morphologic stenosis was found at transfemoral venography or intravascular ultrasonography. Group 1 (female-male ratio, 3.4:1; left limb-right limb, 2.7:1; nonthrombotic-thrombotic, 1.8:1) included 187 stented limbs in 176 patients with absence of deep and superficial reflux as identified at erect duplex Doppler scanning. Group 2 (female-male, 1.7:1; left-right, 1.9:1, nonthrombotic-thrombotic limb, 1:2.1) included 260 limbs in 253 patients with combination obstruction and reflux. Reflux was left untreated during the observation period. Clinical outcome (ulcer healing and recurrence rate, degree of pain per visual analog scale, swelling grade) and hemodynamic effects (ambulatory venous pressure, venous refilling time, venous filling index at 90 seconds) of iliac venous stenting were assessed. RESULT: Patients with reflux and obstruction had more severe disease (clinical class 4-6, 53% in group 2 vs 24% in group 1; P <.001). Similarly, rate of active ulcer was low in limbs with obstruction only (3% vs 24%, groups 1 and 2, respectively). Mean clinical follow-up was 13 +/- 12 months (SD) in 86% of limbs. Because of the presence of reflux in group 2, venous pressure was higher, venous filling time was shorter, and venous filling index at 90 seconds increased, compared with group 1. Multisegment scores were 2.6 +/- 1.6 and 0, respectively. Of greater interest, there was no deterioration in venous hemodynamics in group 2 after stenting. There was substantial clinical improvement in both groups after stenting. Approximately half of patients were completely relieved of pain after stenting, and a third were completely relieved of swelling. In addition, 55% of ulcerated limbs healed. CONCLUSION: Iliac venous outflow obstruction appears to have an important role in clinical expression of chronic venous insufficiency, particularly in producing pain, and is easily overlooked, mainly because of diagnostic difficulty. The combination of reflux and obstruction is seen more frequently with severe clinical disease than is obstruction alone. Ulcer prevalence is clearly associated with reflux, with a low incidence in patients with obstruction alone. Removal of iliac vein outflow obstruction does not result in increased axial reflux, with clinical deterioration in limbs with combined reflux and obstruction.

PMID: 14603188 [PubMed - indexed for MEDLINE


I'll pick it apart

OBJECTIVE: To assess the importance of iliac venous outflow obstruction in limbs with and without concomitant deep or superficial reflux, we performed a retrospective analysis of data contemporaneously entered into a set time-stamped electronic medical records program.
This study is to see if it helps to repair a blockage (a stenosis) in the veins of the legs when the blockage does not show reflux -reflux meaning that the blood hit the obstruction and then swirled around in there chaotically, usually detected on doppler. They will compare people with blockage and reflux to people with JUST blockage. This study looked at data from people who had already had surgery to see what the results were after the fact. FYI it is generally considered to be more important to treat where reflux is seen, so this study is trying to answer whether treating in absence of that reflux is useful.



MATERIAL AND METHOD: Four hundred forty-seven limbs underwent iliac vein stenting of chronic, nonmalignant obstruction when greater than 50% morphologic stenosis was found at transfemoral venography or intravascular ultrasonography. Group 1 (female-male ratio, 3.4:1; left limb-right limb, 2.7:1; nonthrombotic-thrombotic, 1.8:1) included 187 stented limbs in 176 patients with absence of deep and superficial reflux as identified at erect duplex Doppler scanning. Group 2 (female-male, 1.7:1; left-right, 1.9:1, nonthrombotic-thrombotic limb, 1:2.1) included 260 limbs in 253 patients with combination obstruction and reflux. Reflux was left untreated during the observation period. Clinical outcome (ulcer healing and recurrence rate, degree of pain per visual analog scale, swelling grade) and hemodynamic effects (ambulatory venous pressure, venous refilling time, venous filling index at 90 seconds) of iliac venous stenting were assessed.


This just says that many people with blockage of greater than 50% were treated. Group one had no reflux, Group 2 did have reflux as well as the stenosis. To assess how well people did they noticed how well healing of the venous stasis ulcers occurred (ulcer=an open wound in the foot/ankle area that is caused by blocked blood flow) , how often the ulcers returned, the degree of pain they had and how swollen the leg was. They also did some technical evaluations such as checking pressure, how fast the veins refilled and how well the stents worked.

RESULT: Patients with reflux and obstruction had more severe disease (clinical class 4-6, 53% in group 2 vs 24% in group 1; P <.001). Similarly, rate of active ulcer was low in limbs with obstruction only (3% vs 24%, groups 1 and 2, respectively). Mean clinical follow-up was 13 +/- 12 months (SD) in 86% of limbs. Because of the presence of reflux in group 2, venous pressure was higher, venous filling time was shorter, and venous filling index at 90 seconds increased, compared with group 1. Multisegment scores were 2.6 +/- 1.6 and 0, respectively. Of greater interest, there was no deterioration in venous hemodynamics in group 2 after stenting.


This chunk just says that people with both reflux and stenosis had worse disease and had more ulcer issues. It also says that of special interest is the fact that these people with both obstruction and reflux actually did well after stenting and their blood flow was good.

There was substantial clinical improvement in both groups after stenting. Approximately half of patients were completely relieved of pain after stenting, and a third were completely relieved of swelling. In addition, 55% of ulcerated limbs healed. CONCLUSION: Iliac venous outflow obstruction appears to have an important role in clinical expression of chronic venous insufficiency, particularly in producing pain, and is easily overlooked, mainly because of diagnostic difficulty. The combination of reflux and obstruction is seen more frequently with severe clinical disease than is obstruction alone. Ulcer prevalence is clearly associated with reflux, with a low incidence in patients with obstruction alone. Removal of iliac vein outflow obstruction does not result in increased axial reflux, with clinical deterioration in limbs with combined reflux and obstruction.

This says it worked well and it did not cause any other kinds of problems to treat this with stents (that last sentence about axial reflux treatment; it did not cause axial reflux).

It also says that reflux AND obstruction together had a lot of stasis ulcers.

If you have not kept up with this information on CCSVI , just a reminder that a venous stasis ulcer has the same cytokines as an MS lesion, MMP9 upregluation TIMP1 iron deposits etc. This is why an obstruction with reflux in the neck is a big deal and a possible cause for the MS lesion.

Ok now tell me again why it is good to ignore this same type of obstruction and reflux in the head?

It is illogical to accept that a leg stenosis should be opened up with a stent based on good medical literature but it is OK to ignore a neck one with the brain being the impacted tissue because we "don't know" if it caused the brain lesions.

please add anything to this thread that supports the position that stenoses (that's plural for stenosis) should be treated for their own sake...

This ammo may help make the case to insurance companies as we go forward in absence of complete studies.
marie
Last edited by mrhodes40 on Sat Jun 20, 2009 1:13 pm, edited 1 time in total.
I'm not offering medical advice, I am just a patient too! Talk to your doctor about what is best for you...
http://www.thisisms.com/ftopic-7318-0.html This is my regimen thread
http://www.ccsvibook.com Read my book published by McFarland Health topics
User avatar
mrhodes40
Family Elder
 
Posts: 2066
Joined: Thu Sep 23, 2004 3:00 pm
Location: USA

Postby peekaboo » Sat Jun 20, 2009 11:48 am

Good post marie

holly
User avatar
peekaboo
Family Elder
 
Posts: 623
Joined: Sun Feb 08, 2009 4:00 pm
Location: Arizona

Postby mrhodes40 » Sat Jun 20, 2009 1:12 pm

Thanks Holly!
another one
FOUND HERE
BACKGROUND: Stenting of chronic nonmalignant obstruction in the venous outflow tract started in earnest in 1997. Data sets are now available to perform long-term analysis of stent-related outcome and clinical and hemodynamic results of this intervention. MATERIALS: From 1997 to 2005, 982 chronic nonmalignant obstructive lesions of the femoroiliocaval vein were stented under intravascular ultrasound guidance. Median patient age was 54 years (range, 14 to 90 years), the female/male was 2.6:1, and left/right limb symptoms, 2.4:1. Clinical score of CEAP was 2 in 7%, 3 in 47%, 4 in 24%, 5 in 5%, and 6 in 17%; primary/secondary etiology was 518:464. Stent-related outcome (morbidity, thrombotic events, patency, in-stent recurrent stenosis), clinical outcome, quality of life (QOL) as assessed by the Chronic Venous Insufficiency Quality of Life Questionnaire (CIVIQ), and hemodynamics were evaluated before and after intervention. RESULT: Monitoring for 94% of patients lasted a mean 22 months (range, 1 to 107 months). Stenting was performed with no mortality (<30 days) and low morbidity. Thrombotic events were rare (1.5%) during the postoperative period (<30 days) and during later follow-up (3%). At 72 months, primary, assisted-primary, and secondary cumulative patency rates were 79%, 100%, and 100% in nonthrombotic disease and 57%, 80%, and 86% in thrombotic disease, respectively. Cumulative rate of severe in-stent restenosis (>50%) occurred in 5% of limbs at 72 months (10% in thrombotic limbs, 1% in nonthrombotic limbs). The main risk factors associated with stent occlusion were the presence and severity of thrombotic disease; thrombophilia by itself was not a risk factor. The median pain score and degree of swelling decreased significantly poststent. Severe leg pain (visual analogue scale >5) and leg swelling (grade 3) decreased from 54% and 44% prestent to 11% and 18% poststent, respectively. At 5 years, cumulative rates of complete relief of pain and swelling were 62% and 32%, respectively, and ulcer healing was 58%. The mean CIVIQ scores of QOL improved significantly in all categories. Mean hand-foot pressure differential decreased and mean ambulatory venous pressure improved in stented limbs with no concomitant reflux. The hemodynamic response was modified, depending on the presence of deep and superficial reflux in subsets of patients with adjunct saphenous procedures. No increase in venous reflux was observed. CONCLUSIONS: Venous stenting can be performed with low morbidity and mortality, long-term high patency rate, and a low rate of in-stent restenosis. It resulted in major symptom relief in patients with chronic venous disease, which was not consistently reflected in any substantial hemodynamic improvement by conventional measurements. The beneficial clinical outcome occurred regardless of presence of remaining reflux, adjunct saphenous procedures, or etiology of obstruction.

PMID: 17980284 [PubMed - indexed for MEDLINE]


This one says that venous stenting worked really well without causing many problems and it did not matter if other procedures were also needed and it did not matter what caused the obstruction.

Importantly for us, these venous stents did not plug up and stayed useful for long term drainage, so if anyone tells you they don't do stents for veins they are wrong, this review was on nearly 1000 patients who were treated with venous stents.
marie
I'm not offering medical advice, I am just a patient too! Talk to your doctor about what is best for you...
http://www.thisisms.com/ftopic-7318-0.html This is my regimen thread
http://www.ccsvibook.com Read my book published by McFarland Health topics
User avatar
mrhodes40
Family Elder
 
Posts: 2066
Joined: Thu Sep 23, 2004 3:00 pm
Location: USA

Postby cheerleader » Sat Jun 20, 2009 3:17 pm

Great job, Marie...
This is an excellent point, and the research shows that venous stenting is safe and effective.
The reason leg veins have been stented more frequently is that we can see venous ulcers on the leg, and this indicates venous insufficiency. In CCSVI, venous insufficiency appears on MRI as demyelinated lesions. There is no need for any autoimmune activity. And stenting works!

One important difference...legs need to combat gravity in order to get blood back to the heart, and there is a squeezing on the veins that could potentially hinder stent efficacy. In the jugulars or azygos, there is not the need to fight gravity, no venous pressure, and blood flow should be smooth sailing back to the heart.
cheer
Husband dx RRMS 3/07
dx dual jugular vein stenosis (CCSVI) 4/09
http://ccsviinms.blogspot.com
User avatar
cheerleader
Family Elder
 
Posts: 5021
Joined: Mon Sep 10, 2007 3:00 pm
Location: southern California

Postby Lyon » Sat Jun 20, 2009 3:45 pm

.
Last edited by Lyon on Sat Nov 26, 2011 12:52 pm, edited 1 time in total.
Lyon
Family Elder
 
Posts: 6063
Joined: Wed May 03, 2006 3:00 pm

Postby cheerleader » Sat Jun 20, 2009 5:40 pm

Hi Bob-
Hope you had a terrific vacation! We're looking forward to getting out of town over the 4th.
Absolutely right- CCSVI is still theoretical- although we do have scientifically proven disease mechanisms where venous insufficiency creates lesions... unlike the autoimmune theory which instead claims the body attacks itself (although there is no scientific proof in a found antigen.) We'll get to that concordance someday. In the meantime, Jeff's doing great.
cheer
Husband dx RRMS 3/07
dx dual jugular vein stenosis (CCSVI) 4/09
http://ccsviinms.blogspot.com
User avatar
cheerleader
Family Elder
 
Posts: 5021
Joined: Mon Sep 10, 2007 3:00 pm
Location: southern California

Postby Lyon » Sat Jun 20, 2009 7:53 pm

.
Last edited by Lyon on Sat Nov 26, 2011 12:52 pm, edited 1 time in total.
Lyon
Family Elder
 
Posts: 6063
Joined: Wed May 03, 2006 3:00 pm

Postby chrishasms » Sun Jun 21, 2009 11:28 am

1123
Last edited by chrishasms on Sun Dec 06, 2009 12:47 pm, edited 1 time in total.
chrishasms
Family Elder
 
Posts: 1161
Joined: Thu Sep 14, 2006 3:00 pm

Postby mrhodes40 » Tue Jun 23, 2009 2:11 pm

FOUND HERE there is a great little abstract on the role of venous outflow obstruction in patients with venous dysfunction.

Of particular note is the following comment
CONCLUSIONS: The anatomical extent of venous obstruction and the development of collateral circulation determine the hemodynamic severity of the chronic venous obstruction. The deep collaterals seem to be more important than the superficial venous system in bypassing the obstruction. The VOR and the A-F PD tests can be used to identify those patients who have venous obstruction, whereas the use of the VOF test may reduce the need for performing the above tests in 50% of the patients


The key to identifying severe obstruction in legs is in fact the collateral circulation as we have discussed before. Seeing collateral circulation means that the obstruction is significant to the body physiologically and it has made the physical changes necessary to try to go arund the obstruction. This paper was trying to find a way to identify severity of obstruction ahead of venogram. They were focusing in various types of venous outflow tests to see if they could find one that consistently identified the issue before having to do a venogram...

But I post it here because it confirms the notion that collateral circulation indicates a severe obstruction.

Those of us how have been to Stanford so far all have had collateral circulation. Our stent procedures have all resulted in the collaterals suddenly being invisible to the venogram (because the minute the stent goes in, the path of least resistence for the blood is the regular vein, not the collaterals so they collapse and do not have blood in them, and therefore are suddenly not visible. Dr Dake's resident assured me this was how they determined the surgery was a success).

HERE is a paper on stenting

There was a significant symptomatic improvement in the stented group, with minimal morbidity.23 In another review, the same group25 reported excellent results with iliac vein interventions, including stents placed in 455 limbs with chronic, nonmalignant obstruction (stenosis or occlusion). At 3 years, primary patency was 75%, primary-assisted patency was 92%, and secondary patency was 93%. Nonthrombotic limbs had better primary patency than thrombotic limbs (89% vs 65%, respectively).
These studies illustrate that, although surgical strategies exist, iliocaval occlusion can more often than not be successfully recanalized by angioplasty and stenting. Patients who experience venous claudication due to chronic isolated iliac vein occlusion often experience immediate relief after such recanalization.


This again is on legs and they found good results from treatment with stents.
glossary:
angioplasty-surgery on a blood vessel
patency--the vein was open as it should be not plugged back up
thrombotic- a vein with a clot pluggin it
canalization-opening the vein with a procedure
stents- little mesh tubes that hold a vein open after placing it in one
morbidity-illness or disease or in this case problems caused by surgery
I'm not offering medical advice, I am just a patient too! Talk to your doctor about what is best for you...
http://www.thisisms.com/ftopic-7318-0.html This is my regimen thread
http://www.ccsvibook.com Read my book published by McFarland Health topics
User avatar
mrhodes40
Family Elder
 
Posts: 2066
Joined: Thu Sep 23, 2004 3:00 pm
Location: USA


Return to Chronic Cerebrospinal Venous Insufficiency (CCSVI)

 


  • Related topics
    Replies
    Views
    Last post

Who is online

Users browsing this forum: No registered users


Contact us | Terms of Service