DrSclafani answers some questions

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Cece
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Re: DrSclafani answers some questions

Post by Cece » 6 years ago

AZYGOUS VEIN
Image
Aneurysms? Is there an aneurysm where the swelling appears to be along the arch? There is also an odd attachment at the top of the ascending portion. Ok, I googled for vein aneurysms and didn't find any comparison images in an azygous but did find these images of an internal jugular vein aneurysm. http://img.medscape.com/article/586/585/586585-fig3.jpg

An aneurysm will have high-velocity blood flow within the central part of the aneurysm and much slower near the aneurysmal wall, with a "pseudothrombosis" effect? (http://www.medscape.com/viewarticle/586585) How does that affect drainage?

Wait, here is an aneurysm of the azygous reported in the literature, in an Ehler Danos patient: http://www.ncbi.nlm.nih.gov/pubmed/16252082
That patient was treated with a stent-graft shunt from the right hepatic vein to the azygos vein.

I don't think ballooning would do anything good for an aneurysm. Could ballooning worsen an aneurysm? Was the previous IR correct to want to stent?

Ok, now I found several more reports of azygos vein aneurysms in the medical literature: http://www.ncbi.nlm.nih.gov/pubmed?term ... 20aneurysm

Eeep! http://www.ncbi.nlm.nih.gov/pubmed/18656023 They treated the azygos aneurysm by occluding the azygos.

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drsclafani
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Re: DrSclafani answers some questions

Post by drsclafani » 6 years ago

Cece wrote:
drsclafani wrote:Ok...Here is a 30something year old female recently seen with recurrent symptoms. She was treated by another IR in december 2010. she had angioplasty of the left IJV and angioplasty of a azygous vein that had aneurysms for which the IR wanted to treat with stents that she refused.

Her symptoms of cog fog, memory problems, fatigue, numbness, temperature intolerance and imbalance all improved and remained so until fairly abrupt return of symptoms.

what follow are the venograms of the rijv, the lijv and the azygous vein from december 2010

RIGHT INTERNAL JUGULAR VEIN
Image
What a nice surprise! I wasn't expecting a case study.
It looks as if all the collateral veins are lighting up at the top of the jugular, but is that due to reflux flow from the jugular or is it due to the placement of the catheter and the force of contrast injection? There are veins opacified on the other side, which makes it look like there's a blockage in that RIJV, which was not found or treated. But I don't see a blockage if there is one (in the usual area at the level of the valves.)
only do hand injections to avoid overpowering the injection.


if you will notice, the uppermost portion of the right IJV is not opacified, probably because the catheter is in a side branch. At that level the vessel is likely to be a pharyngeal vein that will communicate with the pharyngeal veins of the other side, as well as posterior cervical branches. Those are the veins you are seeing near the midline. Since the left pharyngeal veins are going to drain into the left IJV, that is why we are seeing the Left IJV.

I agree when this much reflux is seen, one must be concerned about obstruction of the RIJV.

The obstruction is actually visible on these images. You have to discriminate the contrast in the proximal vein from the contrast media that is in the vein below the obstruction

Image
Salvatore JA Sclafani MD
Patient contact: ccsviliberation@gmail.com

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drsclafani
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Re: DrSclafani answers some questions

Post by drsclafani » 6 years ago

Cece wrote:
LEFT INTERNAL JUGULAR VEIN
Image
Is that a bad valve, where it bulges?
Those bulges are the area under the valve below the obstruction. contrast jets through the stenosis and fills the cusp retrogradely

have a look. the white arrows indicate the stenotic valve

Image
Salvatore JA Sclafani MD
Patient contact: ccsviliberation@gmail.com

Cece
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Re: DrSclafani answers some questions

Post by Cece » 6 years ago

drsclafani wrote:Those bulges are the area under the valve below the obstruction. contrast jets through the stenosis and fills the cusp retrogradely

have a look. the white arrows indicate the stenotic valve

Image
Ok, I really like this series of images. It's well captured.
You've described this retrograde filling using a wine tumbler or a wine glass in a glass.
Is this well understood, among the CCSVI IR community?

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Re: DrSclafani answers some questions

Post by Cece » 6 years ago

pssst anyone else want to join in?

Image
I added arrows to be more clear.
Blue arrow is pointing at the "odd attachment." What is that?
Yellow arrow is pointing at what looks like a narrowing before we're even into the azygous proper.
Red arrow is pointing at what seems to be a shift from darker contrast to medium contrast. Green arrow is where it shifts again from medium contrast to light contrast. Purple arrow is the light contrast. I would have guessed compression at the purple arrow if it weren't for the mention of aneurysms.
Black arrow looks like a possible aneurysm. But more than one aneurysm was mentioned...

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drsclafani
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Re: DrSclafani answers some questions

Post by drsclafani » 6 years ago

Cece wrote:pssst anyone else want to join in?

Image
I added arrows to be more clear.
Blue arrow is pointing at the "odd attachment." What is that?
Yellow arrow is pointing at what looks like a narrowing before we're even into the azygous proper.
Red arrow is pointing at what seems to be a shift from darker contrast to medium contrast. Green arrow is where it shifts again from medium contrast to light contrast. Purple arrow is the light contrast. I would have guessed compression at the purple arrow if it weren't for the mention of aneurysms.
Black arrow looks like a possible aneurysm. But more than one aneurysm was mentioned...

So the first issue is to discuss the difference between the aneurysm and a false aneurysm. These round contrast collections (blue arrow and the other collection below) were called aneurysms but they actually represent false aneurysms. They are actually leakage of the ontrast media through holes that have been created in the azygous vein by catheters or guidewires.
The black arrow is pointing to leakage of contrast outside the vein underneath the azygous vein. This probably happened when a guidewire and catheter perforated the vein and perhaps perforated back into and again out of the vein.

These are not aneurysms. Thankfully, because the venous system is a low pressure system, exsanguinating hemorrhage did not occur. If this happened
to an artery, then really bleeding would have occurred.

I performed her second procedure and all of these perforations had healed.
Salvatore JA Sclafani MD
Patient contact: ccsviliberation@gmail.com

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Robnl
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Re: DrSclafani answers some questions

Post by Robnl » 6 years ago

Very interesting!

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Re: DrSclafani answers some questions

Post by Cece » 6 years ago

Manual compression cannot be done on an azygous vein. So, had this been recognised as perforation, the next steps would have been to reinflate the balloon to see if that sealed the tears and, if not effective, to stent? The IR was 'right' in the lucky sense, because stenting was a right choice but not for the right reason?

With ivus, this would have been recognised as perforations and not aneurysms. And any clotting that occurred at the site of the tears could have been seen and addressed.

I can see why you showed us this case! Really interesting indeed. Were there any CCSVI stenoses in the azygous? If there were stenoses or compressions, that could slow the flow, which would be beneficial to the perforations healing and to not exsanguinating. I would want a closer look at the arch, especially at the green arrow for possible valve stenosis and the purple arrow in all stages of respiration for possible compression. The lightening of contrast at the red arrow is likely due to the contrast that is being lost outside of the vein.

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drsclafani
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Re: DrSclafani answers some questions

Post by drsclafani » 6 years ago

Robnl wrote:Very interesting!
The first time i put a catheter into the azygous vein, I was very nervous. When I did angioplasty, i was very worried about perforation, fearing major blood loss. I was so worried, I had a colleague who is a thoracic surgeon on call and the OR ready.And i did perforate with the guidewire but nothing happened, even with the patient on anticoagulation. The reason is that there is low pressure in this vein and enough resistance in the tissue around it. And i guess I am a lucky bugger.

I still am nervous but in a healthy way. I do not have a surgeon on call in the OR any longer. But i use softer wires, less assertive catheter movements and back off against resistance.
Salvatore JA Sclafani MD
Patient contact: ccsviliberation@gmail.com

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drsclafani
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Re: DrSclafani answers some questions

Post by drsclafani » 6 years ago

Cece wrote:
drsclafani wrote:Those bulges are the area under the valve below the obstruction. contrast jets through the stenosis and fills the cusp retrogradely

have a look. the white arrows indicate the stenotic valve

Image
Ok, I really like this series of images. It's well captured.
You've described this retrograde filling using a wine tumbler or a wine glass in a glass.
Is this well understood, among the CCSVI IR community?
For the most part among those who have expertise. There are still some docs who have just started offering the services who may not understand yet what they are doing.
Salvatore JA Sclafani MD
Patient contact: ccsviliberation@gmail.com

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drsclafani
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Re: DrSclafani answers some questions

Post by drsclafani » 6 years ago

Cece wrote:Manual compression cannot be done on an azygous vein. So, had this been recognised as perforation, the next steps would have been to reinflate the balloon to see if that sealed the tears and, if not effective, to stent? The IR was 'right' in the lucky sense, because stenting was a right choice but not for the right reason?

With ivus, this would have been recognised as perforations and not aneurysms. And any clotting that occurred at the site of the tears could have been seen and addressed.

I can see why you showed us this case! Really interesting indeed. Were there any CCSVI stenoses in the azygous? If there were stenoses or compressions, that could slow the flow, which would be beneficial to the perforations healing and to not exsanguinating. I would want a closer look at the arch, especially at the green arrow for possible valve stenosis and the purple arrow in all stages of respiration for possible compression. The lightening of contrast at the red arrow is likely due to the contrast that is being lost outside of the vein.
Actually, i think that this was pretty obvious on venography. IVUS would not show any more than this venogram. Perhaps the patient was told it was an aneurysm but the stenting was for treatment of the perforations.
Salvatore JA Sclafani MD
Patient contact: ccsviliberation@gmail.com

Cece
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Re: DrSclafani answers some questions

Post by Cece » 6 years ago

You had questionable dissections on your list for possible planned second procedures included as part of the first procedure. Is that to give the vein a chance to heal without stenting?

If you had a perforation occur, you would want the patient to trust your judgment, even if that meant stenting. Was this patient wrong to refuse stents? It worked out well, considering that the vein healed, and the patient is spared having a stent.

If the patient had bilateral jugular stenoses but a healthy azygous, it would not be good to damage a healthy azygous. From the images, the azygous looks sizeable.

And if the patient had improvements after just having one jugular treated, I'd hope for good things after this procedure with the treatment of two jugulars!

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Re: DrSclafani answers some questions

Post by drsclafani » 6 years ago

Cece wrote:You had questionable dissections on your list for possible planned second procedures included as part of the first procedure. Is that to give the vein a chance to heal without stenting?

If you had a perforation occur, you would want the patient to trust your judgment, even if that meant stenting. Was this patient wrong to refuse stents? It worked out well, considering that the vein healed, and the patient is spared having a stent.

If the patient had bilateral jugular stenoses but a healthy azygous, it would not be good to damage a healthy azygous. From the images, the azygous looks sizeable.

And if the patient had improvements after just having one jugular treated, I'd hope for good things after this procedure with the treatment of two jugulars!
i find it difficult to be absolutely sure what i would have done. If you put the catheter OUTSIDE the vein and inject contrast media, i t looks really awful. but patient might not agree. So i would have to judge based upon clinical results. If the patient developed tachcardic, i would not hesitate to put in a stent, but to put a stent in because of an awful picture...i dont think so.

i was very pleased to see that the azygous had no scars or false aneurysms when i studied it.

I cannot speak for the woman's decision. I had the sense that she was not all that comfortable with the way she was managed.

I work really hard to gain my patients' trust well in advance of the procedure. I certainly would have discuss such a scenario during my consultation. I will bet that my patient would understand the problem and trust my judgement if this came up during one of my procedures.
Salvatore JA Sclafani MD
Patient contact: ccsviliberation@gmail.com

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Robnl
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Re: DrSclafani answers some questions

Post by Robnl » 6 years ago

Dr S. wrote
I do not have a surgeon on call in the OR any longer. But i use softer wires, less assertive catheter movements and back off against resistance.
Dr S. wrote
For the most part among those who have expertise. There are still some docs who have just started offering the services who may not understand yet what they are doing.
It is all about experience doc; good tools doesnt make you a good technician (although the tools are very important)

Look at what you learned the past year, the 'suspectable' veins that you discovered . You surely added pieces of the ccsvi-picture.

BTW how do you feel, good progression with recovering?

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drsclafani
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Re: DrSclafani answers some questions

Post by drsclafani » 6 years ago

Robnl wrote:Dr S. wrote
I do not have a surgeon on call in the OR any longer. But i use softer wires, less assertive catheter movements and back off against resistance.
Dr S. wrote
For the most part among those who have expertise. There are still some docs who have just started offering the services who may not understand yet what they are doing.
It is all about experience doc; good tools doesnt make you a good technician (although the tools are very important)

Look at what you learned the past year, the 'suspectable' veins that you discovered . You surely added pieces of the ccsvi-picture.

BTW how do you feel, good progression with recovering?
thanks to you and to all my partners in crime....i am feeling better but id really did not like slowing down.
Salvatore JA Sclafani MD
Patient contact: ccsviliberation@gmail.com

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