DrSclafani answers some questions

[SammyJo]

Sometimes CCSVI promlems turn out to be something that is an already recognized condition tha they've been treating for awhile. That's the advantage of having experienced doctors like Sclafani. Thorasic Outlet Syndrome TOS has come similarities, especially with muscle compression of veins. Botox is one treatment option that they try before surgery. Here's more info on TOS:

http://www.atosa.org/treatment
Botox (Botulinum) Injections
Botox injections are used to treat upper extremity pain by targeting certain muscles. Most often, Botox is injected into the scalenes with varied reports of success. Some patients state relief of pain and continue ongoing Botox injections while other report no or non-sustained relief after first or multiple injections. Botox injections do have serious risks and you should always discuss these risks with your physician. It is generally recommended that physicians performing BOTOX injections use additional visual guidance.

[Cece]

Botox of the neck muscles also seems to be a well-researched treatment for cervical dystonia. Efficacy for physiological stenoses in CCSVI is unknown, but safety studies in the cervical dystonia population seem to indicate it's safe.

http://onlinelibrary.wiley.com/doi/10.1 ... 20403/full (dysport, not botox)
http://www.springerlink.com/content/bfnp55ddqn7064yr/ (long-term study)
http://www.springerlink.com/content/tkmbkhjdbkpp7mu9/
http://www.springerlink.com/content/xtmejk86km1myxnw/ (cervical dystonia in an MS patient)
http://www.springerlink.com/content/j13v43w481203145/ (Botulinum toxin in multiple sclerosis)
http://www.springerlink.com/content/ujj287125268106g/ (cervical dystonia in an MS patient, treated with botox)

This was a thought. Let's not all go out and get botox of the neck strap muscles until some discussions and evaluations are done..

So I should cancel my internet order of do-it-yourself botox???

Why would it require a venogram to check? If someone were to undertake this research, couldn't it be checked by doppler ultrasound? What percentage of patients might have a physiological stenosis due to neck muscles, even after treatment of other stenoses? I know it was just a thought, but it's a new thought, and an interesting one.

[CD]

Special care would have to be avoiding the Voice box, Esophagus and/ or Thyroid gland. Another powerful thought.
CD

[Cece]

http://www.phlebolymphology.org/2009/07 ... -syndrome/

Whatever the technique used, it should be remembered that LRV compression is increased by the standing position because of the weight of the bowel and thus may be underestimated in imaging examinations performed in decubitus (CT scan, magnetic resonance angiography, and phlebography).

Fitoz10 showed that upright position imaging revealed comparatively narrower SMA angles and more pronounced entrapment values in patients with nutcracker syndrome. The SMA angle measurement had sensitivity and specificity of 69.6% and 61.5%, respectively, in the supine position, and 87.0% and 76.9% in the upright position when the cutoff values were set to less than 41° and 21°, respectively.

Rather than looking for nutcracker during the procedure, which exposes the area to radiation, would it be effective to look for it using doppler ultrasound during the pre-procedure doppler? This would allow for a standing exam, and here it is saying that the left renal vein compression is increased by the standing position and may be underestimated in imaging exams performed in "decubitus."

edited: fixed the link

[pelopidas]

Why would it require a venogram to check? If someone were to undertake this research, couldn't it be checked by doppler ultrasound? What percentage of patients might have a physiological stenosis due to neck muscles, even after treatment of other stenoses? I know it was just a thought, but it's a new thought, and an interesting one.

..or even an ivus alone procedure just to measure the cross-sectional area of IJV before and after (after =one month later) of botoulinum injections?
I edit this quote, to make it clearer. The case here is a hypothetical patient who first underwent successful venoplasty procedure but still has a physiological stenosis due to neck muscles contraction. It was just another thought, to measure / prove / document toxin's efficacy in case that doppler ultrasound, as Cece put it, is not adequate. Of course it's not technically easy, but the results would be certain and important.
Dr S, we all know you are the only one who has performed ivus alone venoplasty!

[drsclafani]

If i am not mistaken, vein abnormalities that lead to CCSVI are mostly congenital. However CCSVI seems to be an evolving, not a static condition. That means there is a transition between a non-problematic to a problematic CNS drainage at some point in a patients life. Is that point at birth, or rather puberty?

it can be difficult because of the inter-relationship between ccsvi and ms symptoms

i think that symptoms of ccsvi, like those of ms, can occur early but that things become manifest after 20.

need more information

[drsclafani]

Botox of the neck muscles also seems to be a well-researched treatment for cervical dystonia. Efficacy for physiological stenoses in CCSVI is unknown, but safety studies in the cervical dystonia population seem to indicate it's safe.

http://onlinelibrary.wiley.com/doi/10.1 ... 20403/full (dysport, not botox)
http://www.springerlink.com/content/bfnp55ddqn7064yr/ (long-term study)
http://www.springerlink.com/content/tkmbkhjdbkpp7mu9/
http://www.springerlink.com/content/xtmejk86km1myxnw/ (cervical dystonia in an MS patient)
http://www.springerlink.com/content/j13v43w481203145/ (Botulinum toxin in multiple sclerosis)
http://www.springerlink.com/content/ujj287125268106g/ (cervical dystonia in an MS patient, treated with botox)

This was a thought. Let's not all go out and get botox of the neck strap muscles until some discussions and evaluations are done..

So I should cancel my internet order of do-it-yourself botox???

Why would it require a venogram to check? If someone were to undertake this research, couldn't it be checked by doppler ultrasound? What percentage of patients might have a physiological stenosis due to neck muscles, even after treatment of other stenoses? I know it was just a thought, but it's a new thought, and an interesting one.

i would like to assure myself that this technique was actually relieving muscular compression of the IJV. I would not want to continue treatments that had no effect. I am not sure that the IJV strap muscle compression of the IJV is symptomatic.

[drsclafani]

http://www.phlebolymphology.org/2009/07 ... -syndrome/

Whatever the technique used, it should be remembered that LRV compression is increased by the standing position because of the weight of the bowel and thus may be underestimated in imaging examinations performed in decubitus (CT scan, magnetic resonance angiography, and phlebography).

Fitoz10 showed that upright position imaging revealed comparatively narrower SMA angles and more pronounced entrapment values in patients with nutcracker syndrome. The SMA angle measurement had sensitivity and specificity of 69.6% and 61.5%, respectively, in the supine position, and 87.0% and 76.9% in the upright position when the cutoff values were set to less than 41° and 21°, respectively.

Rather than looking for nutcracker during the procedure, which exposes the area to radiation, would it be effective to look for it using doppler ultrasound during the pre-procedure doppler? This would allow for a standing exam, and here it is saying that the left renal vein compression is increased by the standing position and may be underestimated in imaging exams performed in "decubitus."

edited: fixed the link

Because there is a nutcracker phenomenon and a nutcracker syndrome, we have to have more to go on than a comprssion. Symptoms, of course, but also pressure gradients and images of collaterals.
i think it will be difficult to diagnose this on an upright ultrasound. I also want to measure pressure gradients so i have to catheterize the vein and i need to see the collaterals.

i think venography remains the gold standard.

[drsclafani]

Why would it require a venogram to check? If someone were to undertake this research, couldn't it be checked by doppler ultrasound? What percentage of patients might have a physiological stenosis due to neck muscles, even after treatment of other stenoses? I know it was just a thought, but it's a new thought, and an interesting one.

..or even an ivus alone procedure to measure the cross-sectional area of IJV before and after?

I do IVUS too; the vein looks like a pancake. but the picture of the renal vein will not differentiate the syndrome and the phenomenon.

Pressure gradient of more than 3-4 mm, visualization of hemiazygous and gonadal collaterals, and symptoms such as hematuria, proteinuria, pelvic congestion, varicoele and CCSVI meet that requirement

[Cece]

..or even an ivus alone procedure to measure the cross-sectional area of IJV before and after?

Here is what an ivus-only procedure looks like:
http://www.thisisms.com/forum/chronic-c ... ml#p167439
Patient was allergic to the contrast dye. There were still flouroscopy images of the bones and general structure, but nothing to outline the veins, and then the images from ivus from within the veins.

[ttucker3]

Suggesting Botox injections in muscles near the IJV worry me a bit because I think treatment wants to increase the compliance of the veins and surrounding tissue, increase their ability to expand and thereby absorb some of the over-pressure associated with reflux. This increased expansion down lower in the veins should reduce the pressure forced higher into the venule region.

Trev. Tucker

[pklittle]

DrS,
A post you made on your facebook page (11/2) indicated you were about finished with a paper about nutcracker syndrome. Is it completed and if so can you point me to it?
thanks

[drsclafani]

Suggesting Botox injections in muscles near the IJV worry me a bit because I think treatment wants to increase the compliance of the veins and surrounding tissue, increase their ability to expand and thereby absorb some of the over-pressure associated with reflux. This increased expansion down lower in the veins should reduce the pressure forced higher into the venule region.

Trev. Tucker

trev
please clarify. I dont understand what you mean. if the muscles are relaxed, that should increase the compliance. also if, (i am not asserting that this is the case) the spastic muscles are causing compression and obstruction of the J2 segment, then relaxation of those muscles should increase luminal diameter and antegrade flow.

So speak to me more about your idea

S

[drsclafani]

DrS,
A post you made on your facebook page (11/2) indicated you were about finished with a paper about nutcracker syndrome. Is it completed and if so can you point me to it?
thanks

When I finish a paper I put it in a drawer for a couple of weeks and then look at it again. It allows me to have a less biased opinion when i give it a second read. This second version will be closer to submission to a medical journal. The process of approval can take at least twelve weeks, so i cannot share the paper publication.

I will post a summary on my facebook as soon as i can

S

[munchkin]

Dr S

In a situation where you are required to use a stent, how do you determine the size and type of stent?


thanks.