DrSclafani answers some questions

[Cece]

To add to the concerns about fractured stents, there has been one anecdotal report of a stent that broke up into pieces and one of a stent that bent out of shape on one end against the vertebrae. (Both cases were in the jugulars for CCSVI.)

[pairOdime]

Dr. Sclafani,

I've heard of a couple of patients with azygos vein compression between the heart & spine. One pt. mentioned that they had 2 previous treatments (by other IRs) that utilized balloon dilation only that worked for awhile, but the vein would not remain patent. Also, the "candy wrapper" azygos malformation. What are your thoughts on these types of vein derangements?

Thanks in advance Dr. Sclafani.

[fogdweller]

yes it could be done. the problem is the durability of those stents.

I have some questions about stents in veins. Is there any history of stents collapsing/cracking/squezzing patially shut in veins? Is a series of short stents back-to-back sometimes used instead of a long stent?

Hi fogdweller,
I posted a link to a pdf a while back which discussed stent fracture in the superficial femorial artery (SFA).

http://www.thisisms.com/ftopicp-141085.html#141085

There are some photos of fractured stents that I think everyone contemplating stents should take into consideration. Essentially, the longer the stent the greater the risk of fracture and complications. However, there was still a high rate of fracture even with the shorter stents in this study. Moreover, the jugular veins being located in the neck likely experience a great deal of torsional and compression/extension movement as the head is turned side-to-side and up and down respectively. Such stress would increase the chances of fracture.

NHE

Thanks. It is probably too early to have any info on stents in jugular and azygous veins. Doesn't look good, and the superior femoral is probably less subject to twisting and compression than the jugulars.

[drsclafani]

Hi Dr.Sclafani,
I had a venogram done recently. My Azygous vein was called normal.
This is the picture.

to me there might be a possible narrowing at the beginning of the arch, to the left of the words I typed. Since I have PPMS this would be in agreement with Zamboni findings in those patients.
Please let me know what you think.
Thanks a lot.

i agree with you completely nunzio

it looks like a valvular stenosis to me, more than 50%

[Cece]

Nunzio, I can really see that one too...great teaching example but greater if you can go get that fixed.

Dr. Sclafani, exactly what are the concerns about ballooning up at the skull base, such as the J3 segment you mentioned in the case in the other thread? Dr. Cumming mentioned rupture, that must be one of the concerns, does treating these hypoplastic veins increase the risk of rupture compared to the usual CCSVI veins? Or is it the possibility of a thrombosis north of the ballooning or the balloon itself pressing against brain tissue? Which of these is the biggest concern? Have you consulted with a neurointerventional radiologist?

[NINOU]

Dr Sclafani,
i coming back with more informations.
I made in France several exams with following conclusions :
Doppler protocol Zamboni :
Diagnose CCSVI with two criterias :
Left jugular internal: no flow and refluxes in valsalva, but no stricture
Left jugular right : high flowrate
Vertebral left : high flow
Vertebral right : normal

Scanner :
The superior longitudinal veinous sinus drains almost entirely into the right lateral sinus.
The jugular foramen 73 mm2 right, left 36 mm2.
Size asymmetry of the jugular veins, the left jugular vein has an axial surface at least 15 mm2
The maximum size of the left jugular vein 95 mm2.
This asymmetry of size seems to be related to the size asymmetry of lateral venous sinus, although the recess between the C2 of the styloid process has a low antero-posterior diameter (4 mm).

MRI :
The venous vascular exploration of the neck size of the asymmetry found in appearance congenital sinus venous side with a predominance of right side.
It still looks laminate the left jugular vein high in its course without real retro-styloid extrinsic compression or intraluminal signal abnormality.


I got the following answer from a doctor (the only one making some CCSVI interventions in France) : "sorry, we can do nothing, too risky ..."

I am lost, sad and disappointed. What do you think ? is it possible to do something or to find in my brain from where is coming the problem ? With which kind of exam ?

Many thanks for your advices

[NZer1]

Dr.S is elastic recoil the same as the annulus returning to its normal size, generally speaking it would not have been popped?
Is the position in the vein of the inverted/problematic valves similar in most cases or are these valves basically any where in the jugs for instance (malformed and mal-placed)?
Is ballooning and looking for waists progressively along the vein an option, (it seems that there are going to be difficulties finding the problem areas in the veins on the more frequent treatments especially where conservative early days treatment has been performed)?
Is it true that many of the treatments done conservatively (ballooned) will likely need to be re-visited?
There are quite a few examples in Australia and New Zealand where benefit reverted quite quickly, I believe these would today be approached differently. This in my mind is going to help with understanding the stats of improvement from treatment because of the new understanding of the required sizes and pressures for ballooning. Doesn't help the financial wellbeing but increases HOPE again.

[ConstableComfortable]

Hi Dr Sclafani

I recently chased up my original MRI images from my MS diagnosis and now have them on disk. In one of the files marked 'Localizers' (which i'm guessing is a summary of all the images showing damage), I came across these 2 images:

http://constablecomfortable.blogspot.co ... nosis.html

(NB.I used the viewing software to colour them up)

They shows an area lit up at the top of the spine in the shape of a vertebral vein or artery perhaps? I have no idea if this relates to damage or is just an anomaly because of the type of scan or whatever. I'm thinking that IF it was just picking up the vein/artery by accident, then why isn't the other one there on the opposite side?
If you have a spare minute could you please tell me what I'm looking at? Many Thanks

Jon

[CindyCB]

Dear Dr Sclafani,

I was diagnosed with CCSVI this morning. Please note I do NOT have an MS diagnosis but have been assessed for it a few times nows. No leisons on my brain etc.

My report is as follows:
Right internal jugular vein is collapsed in erect position and no normal venous expansion noted in the supine position. There is venous expansion noted in the left IJV in the erect position. There is marked reduction in flow velocity and volume noted in both internal jugular veins in the supine position. On the right there is a significant mid stenotic lesion measuring 1.7mm diameter and on the left also a mid stenotic lesion measuring 3.0mm.

Evidence of bilateral valve abnormailties noted. No significant relfux.
Normal vertebral flow noted in both sides. No evidence of reflux.

Given that my valves and veins seem pretty rubbish, does this mean I am having trouble 'draining' the blood from the brain? This would make a whole heap of sense to me for my symptoms but I want to be sure.

I have numbness and altered sensations on the right side of my body, feeling like I am falling to the right a lot, crawling sensations, dizziness, a rocking sensation, feeling spaced out all the time, memory loss, fatigue and migraines. My vision in my right eye is blurred all the time and I have hearling loss on that side too.

I've had neuro symptoms for a long time but have never found the cause despite looking very hard. I want to know what I am talking about before I share with friends and family.

Many thanks in advance for taking the time to read my post.

CindyCB

[drbart]

Nunzio, I can really see that one too...great teaching example but greater if you can go get that fixed.

So... WTF!? Why are IRs making mistakes that amateur radiologists like us can see?

Not intending to troll or hijack the thread, but who out there would not agree to have their US/MR/venography posted for comment and analysis?

Medicine has a big opportunity here, with a body of patients who seem to be more interested in communication and knowledge sharing than most MDs.

Let's have a Venography Channel, either live or on YT!

[hopeful2]

Great idea drbart!

[Cece]

So... WTF!? Why are IRs making mistakes that amateur radiologists like us can see?

There is definitely a lack of consensus about what CCSVI in the azygous looks like and what to treat/when to treat.

[AlmostClever]

Dr. Sclafani,

I was wondering if you could comment on my azygous?

Doesn't the presence of all those collaterals (?) suggest a narrowing?

Thanks!

AlmostClever

[drsclafani]

Dr Sclafani,
i coming back with more informations.
I made in France several exams with following conclusions :
Doppler protocol Zamboni :
Diagnose CCSVI with two criterias :
Left jugular internal: no flow and refluxes in valsalva, but no stricture
Left jugular right : high flowrate
Vertebral left : high flow
Vertebral right : normal

Scanner :
The superior longitudinal veinous sinus drains almost entirely into the right lateral sinus.
The jugular foramen 73 mm2 right, left 36 mm2.
Size asymmetry of the jugular veins, the left jugular vein has an axial surface at least 15 mm2
The maximum size of the left jugular vein 95 mm2.
This asymmetry of size seems to be related to the size asymmetry of lateral venous sinus, although the recess between the C2 of the styloid process has a low antero-posterior diameter (4 mm).

MRI :
The venous vascular exploration of the neck size of the asymmetry found in appearance congenital sinus venous side with a predominance of right side.
It still looks laminate the left jugular vein high in its course without real retro-styloid extrinsic compression or intraluminal signal abnormality.


I got the following answer from a doctor (the only one making some CCSVI interventions in France) : "sorry, we can do nothing, too risky ..."

I am lost, sad and disappointed. What do you think ? is it possible to do something or to find in my brain from where is coming the problem ? With which kind of exam ?

Many thanks for your advices

Class, repeat after me,

the CCSVI ultrasound is consistent with CCSVI,
MRV does not have proven merit,
venography is the gold standard.

go find a doctor who will do a venogram and treat the stenoses he or she will find

[drsclafani]

Dr.S is elastic recoil the same as the annulus returning to its normal size, generally speaking it would not have been popped?

not the same but one of the reasons of elastic recoil.

Is the position in the vein of the inverted/problematic valves similar in most cases or are these valves basically any where in the jugs for instance (malformed and mal-placed)?

my experience is that most valvular stenoses are at the confluens of each of the veins with its parent

Is ballooning and looking for waists progressively along the vein an option,

yes, but finding a balloon that is good to do that has eluded me

(it seems that there are going to be difficulties finding the problem areas in the veins on the more frequent treatments especially where conservative early days treatment has been performed)?

not sure what you mean. thank god for ivus

Is it true that many of the treatments done conservatively (ballooned) will likely need to be re-visited?

it is true, but there is no data that shows that other approaches have less restenosis. These alternative approaches are as yet uproven, including my approach to larger balloons with higher pressure.

There are quite a few examples in Australia and New Zealand where benefit reverted quite quickly, I believe these would today be approached differently.

we will have to learn over the next few months whether they have more or less restenoses. remember recurrence has many causes, elastic recoil, intimal hyperplasia, thrombosis, stricture. This is why i have changed jobs rather than do a RCT.We just do not have enough info on what will work optimallyl

This in my mind is going to help with understanding the stats of improvement from treatment because of the new understanding of the required sizes and pressures for ballooning. Doesn't help the financial wellbeing but increases HOPE again.

remember we are all in this together. ideas will come and go. we will learn incrementally.