Post-liberation CCSVI testing in Bangor, Maine

[fiddler]

Here's an opportunity for people (perhaps especially for Atlantic Canadians) who have been liberated and need follow-up testing of their veins:

From: Willis, Chris [mailto:cwillis@emh.org]
Sent: February 23, 2011 10:43 AM
Subject: CCVI testing

Good morning Mr. Robak. I just listened to your message that was left on my voice mail. I would like to thank you for inquiring about our services here at Eastern Maine Medical Center. The vascular laboratory has started testing patients who have undergone jugular vein angioplasty through the Rhode Island Vascular Institute. Our protocol is to look for continued patency of these jugular veins. Our protocol was designed to meet the needs of Rhode Island Vascular Institute. We also follow the Zamboni protocol as well. I would like to emphasize that we are not (currently) performing this exam to screen for CCVI. We are however, scanning patients who have documented CCVI and who have under gone jugular vein angioplasty.

Just to give you a brief history: I am currently the only tech that is performing this procedure in this department. I am a registered vascular technologist who has been in this field for approximately 19 years. I have literally scanned thousands of jugular veins in my career.

The protocol that we are performing for CCVI patients who have undergone jugular vein angioplasty is quite extensive. We scan the patient's jugular vein with the patient in the supine position. We evaluate the jugular vein via gray scale imaging in transverse and sagittal views looking for areas of narrowing and/or abnormalities. We measure the diameter of the jugular vein in 3 different locations. We identify the jugular valve and check for reflux. We evaluate the flow in the jugular vein with color duplex as well as spectral waveform analysis. We assess phasicity and direction of blood flow. We also evaluate the vertebral veins and their blood flow in the supine position. We always look at both jugular veins and both vertebral veins. We repeat the entire process stated above with the patient sitting in an upright position. Our exams are read by only one dedicated vascular physician who has researched normal and abnormal findings.

The protocol and what to take for pictures is a new process for us however the normal and abnormal anatomy and hemodynamics of blood flow of the jugular/vertebral veins is not. I have researched several articles and have had several conversations with Rhode Island Vascular Institute on what to look for. I feel very confident on my skill level to perform an accurate exam. I am very excited about this new service we are offering!

I hope this e-mail answers your questions. Please feel free to e-mail me with any other questions.
Thanks

Chris Willis RVT
Coordinator
Vascular Laboratory
Eastern Maine Medical Center
Bangor, Maine 04401
Phone: (207) 973-7471
Fax: (207) 973-7450

Then I asked him: "One question I thought of (and my readers probably will be thinking the same): when you talk of the vertebral veins, you presumably aren't talking about the azygous vein so, without taking too much of your time, could you explain which vertebral veins and whether there is any checking of the azygous. Or do the vertebrals lead to the azygous and are, therefore, a proxy for finding problems in the azygous? Thanks in advance for your explanation."

And here was Chris' reply:

When a patient is supine, the jugular vein performs the majority of the cerebral venous drainage. When a patient is sitting upright the vertebral veins performs the majority of the cerebral venous draining. Each vein has certain size characteristics and flow characteristics when supine and sitting upright. If there is an occlusion or tight stenosis of a jugular vein the characteristics change and the vertebral vein can compensate for the lack of venous drainage from the jugular vein and vice versa. In other words we evaluate the cervical vertebral veins more so as a proxy for jugular vein issues. The Azygous vein I believe is not easily identified via duplex ultrasound but is best evaluated by venogram. Not sure if this answered your questions.

Therefore, this test doesn't really check for restenosis of the azygous, but then the azygous is not as likely to have restenosis, from what I have heard.

I'm looking forward to getting feedback from people who use this service.

[Rokkit]

So we can add this place to the growing list of facilities that seem to have no problem telling the difference between normal and abnormal veins. Yet there continue to be researchers around the world who cannot tell the difference. The only thing these researchers seem to be good at is getting their papers published in neurological journals. Baffling.

[Cece]

This is good!! Best is for the technician to have gone for training in the Zamboni protocol, but this is very good as well.

Rhode Island Vascular Institute must be treating more patients now, if they needed to arrange for follow-up ultrasounds? That is Dr. Haskal, isn't it.

[msgator]

Dr. Haskal is in Maryland. They had 5 docs doing the procedure in RI when I went in for me 3 mos follow up US. They were very open about having follow up US done elsewhere even during my initial consult.

I forget how many procedure they were doing a week at this point.

Ann

[drsclafani]

Here's an opportunity for people (perhaps especially for Atlantic Canadians) who have been liberated and need follow-up testing of their veins:

From: Willis, Chris [mailto:cwillis@emh.org]
Sent: February 23, 2011 10:43 AM
Subject: CCVI testing

Good morning Mr. Robak. I just listened to your message that was left on my voice mail. I would like to thank you for inquiring about our services here at Eastern Maine Medical Center. The vascular laboratory has started testing patients who have undergone jugular vein angioplasty through the Rhode Island Vascular Institute. Our protocol is to look for continued patency of these jugular veins. Our protocol was designed to meet the needs of Rhode Island Vascular Institute. We also follow the Zamboni protocol as well. I would like to emphasize that we are not (currently) performing this exam to screen for CCVI. We are however, scanning patients who have documented CCVI and who have under gone jugular vein angioplasty.

Just to give you a brief history: I am currently the only tech that is performing this procedure in this department. I am a registered vascular technologist who has been in this field for approximately 19 years. I have literally scanned thousands of jugular veins in my career.

The protocol that we are performing for CCVI patients who have undergone jugular vein angioplasty is quite extensive. We scan the patient's jugular vein with the patient in the supine position. We evaluate the jugular vein via gray scale imaging in transverse and sagittal views looking for areas of narrowing and/or abnormalities. We measure the diameter of the jugular vein in 3 different locations. We identify the jugular valve and check for reflux. We evaluate the flow in the jugular vein with color duplex as well as spectral waveform analysis. We assess phasicity and direction of blood flow. We also evaluate the vertebral veins and their blood flow in the supine position. We always look at both jugular veins and both vertebral veins. We repeat the entire process stated above with the patient sitting in an upright position. Our exams are read by only one dedicated vascular physician who has researched normal and abnormal findings.

The protocol and what to take for pictures is a new process for us however the normal and abnormal anatomy and hemodynamics of blood flow of the jugular/vertebral veins is not. I have researched several articles and have had several conversations with Rhode Island Vascular Institute on what to look for. I feel very confident on my skill level to perform an accurate exam. I am very excited about this new service we are offering!

I hope this e-mail answers your questions. Please feel free to e-mail me with any other questions.
Thanks

Chris Willis RVT
Coordinator
Vascular Laboratory
Eastern Maine Medical Center
Bangor, Maine 04401
Phone: (207) 973-7471
Fax: (207) 973-7450

Then I asked him: "One question I thought of (and my readers probably will be thinking the same): when you talk of the vertebral veins, you presumably aren't talking about the azygous vein so, without taking too much of your time, could you explain which vertebral veins and whether there is any checking of the azygous. Or do the vertebrals lead to the azygous and are, therefore, a proxy for finding problems in the azygous? Thanks in advance for your explanation."

And here was Chris' reply:

When a patient is supine, the jugular vein performs the majority of the cerebral venous drainage. When a patient is sitting upright the vertebral veins performs the majority of the cerebral venous draining. Each vein has certain size characteristics and flow characteristics when supine and sitting upright. If there is an occlusion or tight stenosis of a jugular vein the characteristics change and the vertebral vein can compensate for the lack of venous drainage from the jugular vein and vice versa. In other words we evaluate the cervical vertebral veins more so as a proxy for jugular vein issues. The Azygous vein I believe is not easily identified via duplex ultrasound but is best evaluated by venogram. Not sure if this answered your questions.

Therefore, this test doesn't really check for restenosis of the azygous, but then the azygous is not as likely to have restenosis, from what I have heard.

I'm looking forward to getting feedback from people who use this service.

Fiddler, there is no reliable imaging test to evaluate the azygous vein. The ultrasound test studies global cerebrospinal venous hemodynamics. As such there might be reflections seen upon problems with the azygous but no one can demonstrate the azygous vein adequately short of a catheter venogram.

[fiddler]

Thanks, Dr. Sclafani. I did get some more information from someone else that suggests that even a venogram may not be adequate, that if there are "indicators" of azygous problems, then it should be ballooned:

Chris has done a good job of answering your questions, Ted. It sounds to me like the azygos isn’t being addressed by the Doppler, and I don’t think it is being addressed by any of the Dopplers. When I went to Albany, I asked Dr. Mandato if my azygos vein had been addressed. He said there was no indication of a flow problem there. I’m now hearing from Dr. Tariq Sinan, Dr. Arata and Dr. Hewett, that it’s not good enough to just do a venogram of the azygos, but the azygos must be ballooned in order to see problems properly. Dr. Hewett says if you have mobility, bowel and bladder issues, your azygos must be ballooned. It looks like this was missed in my case. Thanks for your recount of the conversation, Ted. Great details…and good news for Atlantic Canadians.

Would you agree, Dr. Sclafani?
...Ted