Cece wrote:The patient would also have an accurate diagnosis now, of both the innominate stenosis and the renal stenosis. That is a very important something gained.
edited to add: With the first image of the jugular that you showed us, with the contrast going upward instead of downward, were there any clues there that we could have picked up? What were you expecting when you then released contrast within the stent?
that was a clue. Once I saw contrast flow upward, the next issue was to define the abnormality in the stent. One could expect intimal hyperplasia to be the culprit, or perhaps thrombosis. So the next step would be to pull back the catheter and inject the contrast in the stent. I admit i expected the stenoses to be in the stent, but once i saw the size of the lumen filled with contrast media, i knew it had to be more proximal toward the chest. My first thought was that there was a membrane at the bottom of the stent. The next step was to pull back a bit more and see where the contrast media went. It obviously wasnt going back toward the heart!.
Was the flow stronger than it should have been for reflux flow?
absolutely! one never sees reflux above an obstruction, something was wrong.
By the time you released contrast in the subclavian, did you have the mystery solved and what you saw confirmed what you expected, or was it still coming together?
The subclavian venogram was icing on the cake.
You have now seen two patients with stenosis in the innominate or subclavian vein, that we know of. Are these veins that CCSVI IRs need to be aware may be involved and, while maybe not necessitating routine checking of these veins, are there any obvious indicators when the IR should check these veins? When the catheter is going through the innominate, and there is a compression, does that affect the catheter's progression through the vein so you can detect the compression stenosis at that time?
I think anytime i see slow flow AFTEr performing venoplasty, i must check the more central veins. Some IRs study these veins all the time. I am not sure they are wrong.
Lots of questions because I'm finding it hard to express the main point, which is: how hard is it to make this diagnosis? What could the first IR have done differently to have caught this one, or to catch the next such one? If a patient has had chemotherapy or dialysis, should that be an automatic indicator to check the subclavian and innominate veins? I know this patient hadn't had chemo, but the prior patient with the subclavian stenosis had.
i think we learn from these cases. but i think the diagnosis should have been made before reaching me..