DrSclafani answers some questions

A forum to discuss Chronic Cerebrospinal Venous Insufficiency and its relationship to Multiple Sclerosis.
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Donnchadh
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Post by Donnchadh » Sat May 07, 2011 4:52 am

Perhaps we can tempt our good doctor with this:

Image

Parmigiano Reggiano could possibly be the best cheese in the world, but one thing that not many people realize is that not all Parmigiano Reggiano is created equal. This one is made by a farmhouse dairy in the remote mountains outside of Modena, and handpicked for us by Master Cheese affineur Giorgio Cravero. This high altitude means less pollution in the soil, and therefore, more flowers, herbs and fresher grasses in the cow's diet. This is reflected in the milk and ultimately, after a full 24 months of aging, in the cheese. Besides all that, what is more important is that the finished cheese has a rich, wonderfully complex flavor with a finish that will linger in your palate a long time afterward.

Donnchadh :wink:
Kitty says, "Take that, you stenosis!"

Got MS?.....Get Liberated!

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Post by Cece » Sat May 07, 2011 7:21 am

WeWillBeatMS wrote:Now no pressure Dr. Sclafani, but if my right ear should open up next week while you're roto-rooting my veins, I hope you have a box of kleenex nearby. :D
I hope it happens, WeWillBeatMS.

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drsclafani
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Re: How do you treat it?

Post by drsclafani » Sun May 08, 2011 7:59 pm

Rosegirl wrote:Assuming that IVUS finds a flap, septum or other extraneous tissue in a vein, how do you treat it? Will inflation of a balloon break or otherwise disrupt the abnormality? And if that doesn't work, is there other way to solve the problem?
rosegirl, these are attached at some point to the wall of the vein. by stretching, these abnormalities tear and allow freer flow through the vessel.

the vast majority of these are at the valve and the valve seems stuck in a partially closed position. this is restricting blood flow. Ballooning does something, stretch, tear, crack, those valves .

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drsclafani
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Post by drsclafani » Sun May 08, 2011 8:00 pm

Donnchadh wrote:Perhaps we can tempt our good doctor with this:

Image

Parmigiano Reggiano could possibly be the best cheese in the world, but one thing that not many people realize is that not all Parmigiano Reggiano is created equal. This one is made by a farmhouse dairy in the remote mountains outside of Modena, and handpicked for us by Master Cheese affineur Giorgio Cravero. This high altitude means less pollution in the soil, and therefore, more flowers, herbs and fresher grasses in the cow's diet. This is reflected in the milk and ultimately, after a full 24 months of aging, in the cheese. Besides all that, what is more important is that the finished cheese has a rich, wonderfully complex flavor with a finish that will linger in your palate a long time afterward.

Donnchadh :wink:
among the great foods

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Algis
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Post by Algis » Sun May 08, 2011 10:35 pm

Perhaps we can tempt our good doctor with this:
Even tho I'm not a Doctor; I'll have one anytime; to grate in my pastas :P

Drooling Don; you make me drooling :lol

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Donnchadh
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Post by Donnchadh » Mon May 09, 2011 3:31 am

More "motivation" for our good doctor....a sublime 100 year old Acetaia Reale Balsamic Vinegar. Truly amazing. Enjoy.


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Up in the attic of an old vinegar house in Modena referred to as Acetaia Reale, the pure grape must slowly turns into a miraculously fragrant essence that is a true balm for the palate as it is exposed to both, the sultry summer heat and icy winter cold. A century-long tradition requires Balsamic Vinegar to be produced in small wooden barrels to ensure quality and superiority.

In the attic of this 19th century farmhouse lay 1600 precious wood barrels made of oak, chestnut, ash, locust tree, mulberry and juniper. Each of them lends its very special taste and aroma to the unique and inimitable Balsamic Vinegar of Modena during aging.

This 100-year aged is the oldest and rarest Balsamic Vinegar in the world.

Donnchadh :wink:
Kitty says, "Take that, you stenosis!"

Got MS?.....Get Liberated!

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Post by Cece » Mon May 09, 2011 3:05 pm

To end this first chapter in the story, a large balloon 18mm was used to dilate the arch of the azygous. flow appeared faster and less reflux was noted.
You mention first chapter, is there a second chapter?
i hope you find this as interesting as i did. then again, i eat sleep and dream this stuff.
I do too, admittedly vicariously.... :)

A year ago I was thrilled by the front row seats you've given us all. I am just as thrilled today.

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lifeisgood
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How many times can the procedure be done?

Post by lifeisgood » Tue May 10, 2011 5:00 am

This might have been asked and and answered already. My husband has had RRMS for 20+ years and had been able to be very functional. His symptoms are numbess from the elbow to hands, knees to feet, brain fog, spasticity, horrible burning and of course the fatigue. I am afraid that he will "use up" his procedures and then he won't be able to get any relief down the road. Is that silly?

**How many times can a person have this procedure successfully? **

What are the percentages of people that have it done and then need to have it done again? It seems like it's pretty high? That's when I think we should take the wait and see attitude.

The doctor that saw him said one of his jugulars was "sluggish" not totally blocked. This is a doctor that has been in contact with you.

Saw you and the others in Chicago at the Hyatt - it was great!
Thank you !

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Post by griff » Tue May 10, 2011 7:44 am

Dr Sclafani, I would be interested in your opinion on CCSVI in general. We had some debates in a different thread where some arguments were raised by vascular specialists who are not convinced about the existence of CCSVI. I also quote here a statement from the Cardiovascular and Interventional Radiologist society of Europe. In addition to all the very interesting technical details of the angioplasty it would be good to know about the supporting and opposing views on CCSVI. I would assume that this should change by time as well as we get more info on it from the ongoing researches. So, just a idea to sometimes deal with this subject as well as you are better positioned than we are in the so many confronting views.
The core of this new theory is the CCSVI syndrome, or the abnormal venous drainage from the
brain. However, venous drainage from the head has an impressive anatomic variation, which is not
very well catalogued in most textbooks. Also valves can be present at a variety of sites in the head
and neck veins. Interventional Radiologists who practise para‐thyroid sampling are well aware of
the huge variety in venous anatomy. Besides the huge variation in normal venous anatomy the
jugular veins have some natural narrowing at two sites and the azygous vein, prominent in the
CCSVI theory, does not drain the brain at all. The azygous can clearly drain the spinal cord but not
solely, as there are many intercostal venous collaterals which fulfil the same function.
In addition, the fact that this imaging is done in the supine position will have a great influence on
blood flow and image interpretation. There have recently been randomised studies comparing
socalled venous stenoses in patients with and without MS (3‐4). Both studies show that there is no
difference in the prevalence of venous stenoses between the two groups. This seems to be a very
strong argument against the existence of CCSVI. However, physicians performing CCSVI
treatment point out that these studies were not performed according to the specific Venous
Hemodynamic Insufficiency Severity Score (VHISS) criteria. The other part of the theory is that the
venous outflow obstruction needs to be treated. However, if there is a real haemodynamic venous
outflow obstruction, there should also be a pressure gradient and this gradient should disappear
after successful balloon dilatation. It has been shown, and confirmed by those who perform
balloon dilatation for CCSVI, that over the so‐called stenosis there is never a measurable pressure
gradient. Those who perform this treatment argue that it is not the pressure gradient but the
change in outflow pattern, caused by this stenosis, that is the pathological entity.

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WeWillBeatMS
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Post by WeWillBeatMS » Tue May 10, 2011 8:08 am

griff,

You've started several threads which indicate you don't believe in CCSVI and the Liberation procedure to treat it. You said here in TIMS that you have had the procedure done. Does that mean you were diagnosed with MS and also CCSVI? Would you mind sharing where and what doctor did your procedure?

WeWillBeatMS

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HappyPoet
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Post by HappyPoet » Tue May 10, 2011 9:19 am

Dr. Sclafani, griff's post is old news, from December, 2010, which was discussed in this thread: http://www.thisisms.com/ftopicp-144998- ... tml#144998

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belsadie
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Dr. Sclafani answere some questions

Post by belsadie » Tue May 10, 2011 11:33 am

I think you mean capocollo. It's meat from the head, neck and shoulders of the pig.....Somewhat similar to priscuitto but that's from the "tush".
It is delish, though!

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pklittle
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Post by pklittle » Tue May 10, 2011 1:10 pm

To go with your cheese! :mrgreen:

Image[/img]

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drsclafani
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Post by drsclafani » Tue May 10, 2011 10:11 pm

drsclafani wrote:
WeWillBeatMS wrote:Dr. Sclafani,

Are the external jugular veins also tested for CCSVI? I know that they have not proven to be a regular problem but what about for the people like myself who have lost hearing in one ear? And at times even my good ear rings and pops and feels plugged like my bad one does all of the time.

WeWillBeatMS
The external jugular drains the face and scalp. I do not study these veins and i do not think these veins are the first line of action, perhaps they take on a greater potential when the internal jugular cannot be opened or has clotted off.

On Saturday i treated two patients with footdrop and weakness of the lower extremity. Both had exciting reduction in foot drop within the first day. I am ever cautious to have too much excitement on early findings. the proof isin the durability of these improvements.

ONe of the patients turned into a tour de force and I would like to share with you some unusual techniques that will hopefully make a difference.

Image

The right internal jugular vein was imaged first. The findings included clear valvular stenosis of the confluens of the IJV with the subclavian vein Figure 1, yellow circle. Simply treated by angioplasty (2), venography showed resolution of the stenosis (3)


Image
The left IJV was really prolematic and challenging. Ultrasound had shown that the vein had poor flow and was very small. As the patient had nver had angioplasty, the most likely diagnosis was hypoplasia. However recanaliation of a spontaneous occlusion was also a possibility.
After about thirty minutes of unsuccessfully trying to catheterize this vessel, i had reached my futility score.
Ultrasound of the neck was performed and I found a intermittently filled vein that was likely the IJV. So under ultrasound control, i placed a needle into the IJV. Through the needle a guidewire easilyi passed into the left inominate vein. (1). Even with the vein clearly demarkated by the jugular catheter, i could not advance the chest catheter into the jugular vein. You can see the stump of the IJV in (fig 2).

Just to make sure that the neck catheter was not in the external jugular vein, i placed the chest catheter into the external jugular vein, (3) i

The next step was to grab the chest guidewire with a snare placed through the neck sheath and pull it up above the obstruction (4). the Rendevous procedure. You can see from the figure 4, the catheter was in the IJV and some parts of it were open and others were stenotic.

That this was obstrucive cannot be denied. An injection at the skull base showed no flow going down the neck into the chest. on the contrary, all the contrast media refluxed into the dural sinuses and drained down the right jugular vein (figure 5). Pulling the catheter down and injecting contrast showed that the vein had areas of narrowing and areas of near normal size. (figure 6.)
The entire vein was angioplastied with 8 mm balloons. (fig 7-8)The final film shows a residual stenosis which remained after several dilatations. (figure 9).

So now I will place my first stent in one of my patients.

But that is not why i show this case. The conversation quoted by me was a question about doing angioplasty on the external jugular vein. I do not believe that there is any correlation with stenosis of the external jugular vein and hearing. However i do believe there is a place for angioplasty. When the patient has internal jugular obstruction and has stenosis of the EJV. angioplasty may improve flow through this vessel. See below

Image

Figure 1 shows stenosis of the external jugular vein (circle).
figure 2 shows balloon angioplasty
figure 3 shows no residual stenosis in the left external jugular vein

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griff
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Post by griff » Tue May 10, 2011 11:28 pm

WeWillBeatMS wrote:griff,

You've started several threads which indicate you don't believe in CCSVI and the Liberation procedure to treat it. You said here in TIMS that you have had the procedure done. Does that mean you were diagnosed with MS and also CCSVI? Would you mind sharing where and what doctor did your procedure?

WeWillBeatMS
It was done in Bulgaria, Sofia. good care, no complaints, but got restenoses and experienced no significant improvement. As i said, to me CCSVI is not a question of belief. I can only hope. I learnt a lot here in tims and I feel I still have lots of questions in me. Yes, I was diagnosed with MS based on MRIs. As with any new theory, there are lots of questions raised by doctors and the theory must be proven. Of course, I undersand that many of us are not in a postion to wait and therefore I support the treatment. It would be good to get answers to those questions that have been raised by other vascular specialists ( and now I do not mention neuros).

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