This Is MS Multiple Sclerosis Knowledge & Support Community

drsclafani wrote:IVUS, not shown here, revealed that there were internal echoes that represented scartissue or residual remnants of the valve or residual fixed valvular tissue.

drsclafani wrote:

Cece wrote:

drsclafani wrote:The "messy" area looks like reflux under an obstructed valve to me.

You had described this, using a wine glass in a tumbler image, at the symposium patient day. Here was me trying to describe what you had said:
http://www.thisisms.com/forum/chronic-c ... ml#p171050
I bet there's a link out there for the actual presentation now....

so lets review the right internal jugular venograms. I will review all the IVUS studies together later:



This vein was treated successfully a year ago. This image shows that there is a narrowing of the mid right IJV. Below this there is some irregularity and bulging of the contrast at the area ofof previously treated valve problems. There is reflux into the right external jugular vein (to the left of the IJV on the image).

Now a composite summary of the right side.



The first two images show the right transverse sinus emptying into the internal jugular vein. I think that this is the optimum way to fully evaluate the internal jugular vein. Opacify it by putting the constrast media upstream from the jugular vein. Sometimes, not often, you will see something wrong with the dural sinuses. You will also get a long at the condylar emissary vein which is a often seen collateral vein.Collaterals seen are minimal.

There was evidence of stenosis at the confluens where the valve was treated previously. There is refluxing contrast media in the external jugular vein and there is irregularity of the confluens. IVUS, not shown here, revealed that there were internal echoes that represented scartissue or residual remnants of the valve or residual fixed valvular tissue.

angioplasty was performed at the valvular area (balloon inflated). Then on to evaluate the mid jugular narrowing. Based upon this location, one should consider a few explanations.

1. Perhaps the first angioplasty was extended too high and the normal vein was overstretched and subsequently got scarred down. Not the case this time...

2. Consider that there was compression of the vein by the carotid artery.IVUS showed that this was not the case.

3. Final possibility was muscular compression. The final two images are with the neck rotated, first internally rotated, and the second one externally rotated. You can see that internal rotation results in a phasic complete compression of the vein with no flow at all in the IJV. All the contrast media was directed toward the external jugular vein. . When the head is turned externally, there is no stenosis and there was rapid flow.

Based upon this observation, one can say that this was a phasic narrowing caused by pressure of the muscles of the neck. I would advise no treatment beyond the angioplasty of the confluens' residual tissue narrowing the vein. Dilating muscle compression is unlikely to be helpful. Stenting is a possibility but I prefer NOT to place stents in the jugular except in a few circumstances.

NZer1 wrote:So reading between the lines there is 'chance' that residual tissue will require attention, for some?

pelopidas wrote:

drsclafani wrote:
3. Final possibility was muscular compression. The final two images are with the neck rotated, first internally rotated, and the second one externally rotated. You can see that internal rotation results in a phasic complete compression of the vein with no flow at all in the IJV. All the contrast media was directed toward the external jugular vein. . When the head is turned externally, there is no stenosis and there was rapid flow.

Based upon this observation, one can say that this was a phasic narrowing caused by pressure of the muscles of the neck. I would advise no treatment beyond the angioplasty of the confluens' residual tissue narrowing the vein. Dilating muscle compression is unlikely to be helpful. Stenting is a possibility but I prefer NOT to place stents in the jugular except in a few circumstances.

what are the treatment options?
thank you for the image uploading trick


and this is a very important lecture

drsclafani wrote:pelopidas
thanks

why should we treat something that is not constant. afterall, venous drainage from the jugular veins is absent when the patient is erect.

Cece wrote:

drsclafani wrote:IVUS, not shown here, revealed that there were internal echoes that represented scartissue or residual remnants of the valve or residual fixed valvular tissue.

Can you think of any way to differentiate between scar tissue or residual valve material? Would you expect any difference in immediate or long-term results when scar tissue is ballooned, compared to when residual valve tissue is ballooned?

Would a program of neck stretches potentially relieve some muscular compression? My son had infantile torticollis, which involves the same muscles that seem to be involved in CCSVI muscular compression cases. We did ear-to-the-shoulder stretches on him and then rotation stretches as if he was looking over his shoulder, twice a day.

PaulH wrote: Dr. Sclafani,

(not meaning to hijack the thread) But I wanted to let you know that I'm doing great since you inserted that 8cm stent into my right jugular vein two weeks ago. No fatigue. All is very well.

Thanks again for being such a pioneer in this field.

Paul.

drsclafani wrote:[
very interesting hypothesis regarding reduction of neck pain.what about this consideration: patients with MS often havfe very large condylar emissary veins that connect to the veins in the posterior neck. Could relieving the resistance in the IJV, reduce flow through the emissary vein and thus reduce venous congestion in the neck muscles?


Sal

mo_en wrote:Tempted to say the stent looks rather large compared to the phenomenal caliber of the RIJV. Seems like a candidate for the rendezvous procedure.

drsclafani wrote:absolutely, poassible that residual valvular elements can fuse to themselves with tim. I really do not think that there will be very many patients who will have only one treatment. This will be an ongoing problem. My goal is to prolong treatment intervals.

drsclafani wrote:aggressive was I in addressing this deterioration of symptoms, within two weeks venography showed occlusion and i was able to do a rendevous procedure from above, open up the vein and stent an occlusion. If i had waited a few months (which i have in a few other cases), recanalization would have been doomed to failiure

drsclafani wrote: So there just was NO downward flow in the IJV.

What is the explanation?

NZer1 wrote:So reading between the lines there is 'chance' that residual tissue will require attention, for some?