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Cece...the beauty of the online forum is that this info has just been published and will make it's way to IR's across the globe via their patients

Go Dr. S.
It has been said "it's what we don't know thats important".
The study of the veins is going to unearth so much.
The technology of imaging is going to be vital.
Thank you for having the interest in questioning everything you find. The information you are gathering is so vital to this vascular issue.
There appears to be need for internal and external understanding of the veins you are working on. As much as is being found in the internals there is likely to be external aspects that will need investigating, such as Marc's situation as an example.
Thanks for the dedication Dr., and for sharing this with us!
Compliments, Nigel.

Dear Dr S,
Really, really nice images of the azygous (as far as I can say).
1st question - what is your take on an alternative imaging technique of the azygous I've heard of recently - the so called "occlusion phlebography" with following setup:
Catheter is fed into the upper part of the azygous and then the vein is closed near its confluence with SVC by means of a compliant baloon inflation, so that blood flow towards heart is temporarily disabled. Then with only a single dye injection, the whole azygous system becomes visible at once (assuming the dye can flow backwards into all veins - would this apply only for a healthy azygous system?). The idea here is to possibly replace multiple step-wise dye injections typically done while moving the catheter tip upwards from the very bottom. Would you find such type of images interesting, at least to get a first global picture of the system? (Unfortunatelly, I do not have any images to show here)
2nd question: I know cases where for IJV valve annulus dilatation 14mm baloons inflated to 35(!) atm pressure for 4(!) minutes were succesfully used. These are pretty high numbers - where is the pressure and time limit?
All the best for 2011!

Hi Dr. Sclafani,

I don't have a question, but if I may...

Cece, congratulations on your first anniversary at TIMS: 1-5-11

HappyPoet wrote:Hi Dr. Sclafani,

I don't have a question, but if I may...

Cece, congratulations on your first anniversary at TIMS: 1-5-11

Thanks HappyPoet!

How did you know you could find me in this thread, I could've missed this.

drsclafani wrote:ok class....

Today we review an azygos vein. This vein, which drains the spinal cord via intercostal veins and lumbar veins, enters the superior vena cava at the top, the renal vein in the middle and the ascending lumbar veins at the bottom.

The findings of malformations are
1. valvular problems of fixation, stiffness and fusion
2. Webs & septations running through the ascending component of the vein
3. twists and kinks

Let's have a look at this:


1. on the left contrast media is injected at the tip of the catheter (red arrow). One notes that there is no dye flowing up toward the superior vena cava.
2. on the second image one sees that there is dye above the area of blockage (red arrows). This is flowing past the obstruction through a large feeding branch. (orange curved arrow)
3. On the third image the narrowed segment is quite obvious. For those readers who are not obvious and have real moral character, the red arrow points to the pointed narrowing.
4. Finally, the last image on the right SHOWS NO NARROWING. What could be the explanation?

Tomorrow we will continue this harrowing adventure.

This is Dr Whiplash, i am out to lunch.

So, to get back to this. (and to allow me to play curious med-school wanna-be who couldn't stand blood so had to choose another career path doctor, for a little bit)

The images below show:

1. shows the ascending lumbar veins (bottom) and the mystery "stenosis" of the azygos vein (red arrow) a few vertebrae up?what vertebrae level would this be at? Also in image 1, there appears to be some dark outline shadowy parts on the image that appear to be the hip bones ... is that correct?

2. shows the "stenosis" of the azygos vein again, what vertebrae level would this be at? and is that the hemi-azygos feeding the dye above the stenosis? or is it a "bypass" vein - a colleteral? I'm not sure if we've moved up the azygos or if it's at the same arrow level as the first picture (the wire seems to be shorter in the 2nd image than the 1st) ... that's why I ask.

3. again, a more in tight view of the "stenosis" of the azygos ... what vertebrae level would this be at? (I realize the answer to all the vertebrae levels are going to be the same)

4. This image is the most interesting to me - for the many questions I have. I've had a hard time finding real pictures of what the azygos looks like online, so here go my questions ...

So the picture starts with the ascending lumbar veins (correct)?

Then the left vertical vein is the azygos (correct)?

And the right vertical vein (along which the yellow arrow runs) is the hemi-azygos (correct)?

In addition to that, there is a little knob (you can see it in image 1 and image 4) on the azygos above which the "stenosis" is in image one. WHAT IS THAT?

I notice there is a (what seems to be) connection of the hemi-azygos (the right vein) and the azygos (the left vein if I'm correct) about 1/2 way up the yellow arrow line. Is that common? Because that seems to be just above where the "stenosis" is in the azygos.

Lastly, the hemi-azygos ends in the azygos (typically) at about T9 vertebrae ... is that where the arrow head of the yellow line is in this case? (so I can assume that's at or near T9?)

end of image related questions, now some commentary and thought provoking questions


Just trying to figure out the anatomy in this case ... and what veins this picture is actually showing us.

Then maybe after that we can figure out what around there might be causing this "stenosis" of the azygos vein.


And ... final question ... wouldn't constant proper flow through the azygos vein be important or necessary for the health of the spinal area? Isn't the backwash caused by an issue (valvular or ortherwise) in the jugulars what (theoretically) causes damage in the CCSVI model?

So if there is that backwash of sometimes working sometimes not blood in the azygos ... isn't that the same thing?

The veins in image 4 look healthy when working properly (inspiration I guess) ... but in image 1 they show CCSVI characteristics.

.................

(maybe we'll discuss via PM instead?) but I think showing the anatomy to people is indeed important.

JohnJoseph wrote:2nd question: I know cases where for IJV valve annulus dilatation 14mm baloons inflated to 35(!) atm pressure for 4(!) minutes were succesfully used. These are pretty high numbers - where is the pressure and time limit?

Wow, which doctor was that? It's ok if you don't want to say.

Were the patients anticoagulated before the procedure?

Dear Dr Sclafai,
I do have a question. I have had RRMS since 1997, and in 2009 it went to SPMS.
I found out about CCSVI in spring 2010 and had balloon angioplasty in India (I was #12 at my hospital). Then I restenosed, and went to Mexico because the trip to India was just too hard. There I was #50 or so. I had good results, but my right leg has been cold and never warmed up.
Now most of my symptoms are back, though I have not had any new attacks since it was done the first time. It's been 6 months since the second procedure.
I live in Denver, and I can get it done in Tucson. Lots of other places now, too.
If I have it done again, I am thinking I should be checked for May-Thurner.
Do you think it's safe to balloon again? Do you have any idea why I keep restenosing? Any other advice or words of wisdom?

And congratulations on working out a way for CCSVI to be treated at the chain of clinics you partnered with.

Laura

another day of treating CCSVI patients, another set of images/patient case studies for us?

Hope all went beautifully today!

Cece wrote:another day of treating CCSVI patients, another set of images/patient case studies for us?

Hope all went beautifully today!

to tell you the truth, i dont know how anyone can do this procedure in an hour as i have heard related. Today, i am breezing along at 1.5 hrs with only an azygos to do, when challenges came up that result in a 3 hour procedure.

Second case of the day also took three hours, but well worth it. incredible, amazing. i will share as soon as i can, hopefully while watching the jets disassemble the colts of indianapolis tomorrow night.

If anyone can see the finding on the venogram that i will post, they would go right up to the front of the line for a procedure. And I was not the first who could not see the problem, the patient had been treated previously in Europe by a well known group, only to restenose within two months after a good response.

I am still blown away by it.

But as i haveto awaken early to treat, i am going to say good night

s

...

drsclafani wrote:Second case of the day also took three hours, but well worth it. incredible, amazing. i will share as soon as i can, hopefully while watching the jets disassemble the colts of indianapolis tomorrow night.

Can't wait.

Dr Sclafani,

I'm amazed and happy about your experience! I truly think that current treatments are not 100%. Not because of 'bad' docters, but just because some problem can only be seen with a microscope, so to speak

Chapeau doc, keep sharing!

Robert

drsclafani wrote: to tell you the truth, i dont know how anyone can do this procedure in an hour as i have heard related. Today, i am breezing along at 1.5 hrs with only an azygos to do, when challenges came up that result in a 3 hour procedure.

My partners actual procedure took around 90 minutes, however there was 30-40 minutes of preparation followed by a 90 minute procedure then 60 minutes of recovery.

She had both jugulars balooned (malformed valves opened) and the azygos (at the junction of the superior vena cava) and so far so good. you can see here results int he following thread if it's of interest to you:-

http://www.thisisms.com/ftopict-15074.html

This took place at the Edinburgh Clinic in sunny Scotland.

Dr Reid who is performing the procedure is a cardio specialist.

They have decided on each procedure now to have a CT scan to pin point any problems with the azygos before the procedure ont he gorunds they then know what they are looking for rather than having a look around once they're in. They have now also decided to add an MRI before and after procedure to monitor lesions.

Anyhow, in Edinburgh they seem to be finding a very high level of (what they consider congenital) valve malformation, so my (non medical) mind has come up with the following thought:-

Many people seem to be putting CCSVI down to stenosis as the problem - but what if stenosis is actually another symptom and the problem is valve malformation or other physical obstructions which then lead to stenosis?

Could it be that some of the centres are currently treating a symptom (stenosis) rather than the casue (valve problems or obstructions) which then leads to re stenosis?

Or have I put two and two together and got twenty two?

In my case, I'm sure it's a valve problem.

Walking is my only problem, thank God, but for the last six years, it's been almost impossible. Except for the periods when I can walk perfectly. These "remissions" last from 30 seconds to a few minutes, so it really isn't a case of "relapsing/remitting" when it changes that quickly. There's no pattern to when it starts and stops.

I had a venogram last July that opened my mostly closed azygous, but the IR couldn't do anything about all the collaterals in my LIJV.

I'll be "auditioning" doctors to make sure the next one is up on the latest valve technology.