DrSclafani answers some questions

[drsclafani]

Dear doctor,
could you comment on this new, fresh offensive of CCSVI?

http://bit.ly/dRqPnB

I must say that i cannot explain this discrepancy. One would wonder whether respiration is suspended in inspiration or expiration but other than that I just cannot understand how no patients with ms have reflux.I regret that the authors could not perform the gold standard to validate their observations.

In our program reflux is very common on ultrasound. and just as common on venography.

[Cece]

Till then, no baloney. i will await bologna,

Well done

[prairiegirl]

we are in this together, i suppose so we must all think about how much we are willing to sacrifice for the learning curve. if you daughter has a chance to help in this, i think she has a decision of conscience to make. No one but she can make that decision.

For sure it is her decision; (I am just a way-too-devoted, and sometimes anxious research assistant . Thanks so much for the reply-- very much appreciated.

[NZer1]

Hey Dr. S if I understand correctly you are now using shorter length wise balloons to stop damage unnecessarily when popping valve annulus's.
Very clever and good timing for Cece's office visit.
Regards Nigel

[drsclafani]

Hey Dr. S if I understand correctly you are now using shorter length wise balloons to stop damage unnecessarily when popping valve annulus's.
Very clever and good timing for Cece's office visit.
Regards Nigel

nigel, not quite correct. I think most interventionalists would desire to reduce the effect of dilatation on vein that is not stenotic. However shorter balloons are more difficult to center on the stenosis and often slip up or down, like a watermelon seed squeezed between your fingers.

we use longer balloons to trap the balloon on either side of the stenosis. We do that all the time and that is what i am and continue to do. I am now more respectful of the vein above the stenosis. By placing the upper "shoulder" of the balloon at the stenosis and by allowing much of the balloon to occupy the larger parent vessel, I am attempting to reduce the trauma on the smaller upstream vessel.

i am using IVUS to more precisely determine which size balloon to use and how to place it.

Because the vein above the stenosis does not need to be dilated. i am basing my balloon choice on accurate and precise cross sectional area of the vein. Better than estimation, ivus helps avoid over dilating the normal vein.

After venoplasty i repeat the ivus to determine whether there are still some valvular stricture or valve fusion. if still present, i will increase balloon size slightly and redilate.

So you can see as i learn and understand the IVUS, i believe i am precising the dilatation. by starting at a smaller balloon size i am avoiding injuries. by re-evaluating with ivus and determining whether increased angioplasty is necessary i am trying to finese the size of the balloon.

Now, i admit i am going to try to use shorter balloons but i am not sure that i can seat them securely before the pressure is applied.

with the aid of IVUS i am measuring the cross sectional area of the vein above the stenosis and then selecting a balloon of a cross sectional area that does not exceed the area of the vein.

but while this is exciting to the technogeeks in the group (including me) the real bottom line is: can we maximize stenosis reduction while minimizing unncessary trauma, thrombosis and intimal hyperplasia.

and further to the point, the really really bottom line is can we prolong time to disability by any of these techniques

[Wichita]

Dr. S, what would you advise for a person with MS who is taking Tysabri and contracts the brain infection PML? I have read that the best defense against PML is a strengthened immune system - something that ordinarily is not a good thing for MS. Since PML is life threatening, what do you think about dropping all immune suppressing drugs and getting immediate CCSVI treatment?

[Cece]

sorry i have been so reticent but i have been pretty busy and needed some free time...

it has actually been very slow here. I cant yet fill my calendar with patients because of obnoxious delays in getting insurance company credentialing.

what a shame i can only do a few patients a week

I hope those delays will soon be a thing of the past.
words I learned here that I dislike: IRBs, credentialing...ok, those are the only two that jump to mind....

but no specular cases to report this week. Snow and insurance are all i have to report

There is always next week!

but there hasnt been a paper yet on the appearance of the ultrasound after treatment. i dont have a clear sense of its purpose now and i have dliminated the one month followup utrasound i started doing when i returned to treatment.

What about bizzy? …it was good in her case to have that check-up.

i have started to consider whether second venograms and possible an;gioplasties should be done sooner than later as a routine

interesting as well!

but while this is exciting to the technogeeks in the group (including me) the real bottom line is: can we maximize stenosis reduction while minimizing unncessary trauma, thrombosis and intimal hyperplasia.

I didn't use to be a technogeek....

I find the amount of thought going into this to be fascinating, it gives me hope that the technique can be refined and improved.

[drsclafani]

Dr. S, what would you advise for a person with MS who is taking Tysabri and contracts the brain infection PML? I have read that the best defense against PML is a strengthened immune system - something that ordinarily is not a good thing for MS. Since PML is life threatening, what do you think about dropping all immune suppressing drugs and getting immediate CCSVI treatment?

i have been thinking about this question since I first heard about Angela. I wonder whether there is a good time to perform venoplasty in patients with this dreaded complication. Unfortunately, it is all speculation on my part but I am reluctant to add another possible problem to one that requires intense focus. So for the moment, i have decided not to perform treatment during intense management of PML

I have also been asked about patients who are going to come off Tysabri because they have developed cancers. These patients might also benefit from ccsvi treatment at that time. I do have such patient situations now. We have decided to set up for treatments as soon as the immediate concerns of the cancer have been addressed.

Similarly I have been asked about ccsvi treatment around pregnancy. While the risks of relapse are thought to be reduced during pregnancy, some women do have exacerbations after that pregnancy. So should patients undergo treatment before pregnancy? perhaps.... after pregnancy? probably not a bad idea...... During pregnancy: bad idea.

Of course, we are still in discovery. Such situations have not been discussed during physician roundtables that i have attended.

Such nuances!

my....how far we have come since I came on this site to assure patients that angioplasty was not particularly dangerous and that angioplasty was not surgery!

[HappyPoet]

I have also been asked about patients who are going to come off Tysabri because they have developed cancers. These patients might also benefit from ccsvi treatment at that time. I do have such patient situations now. We have decided to set up for treatments as soon as the immediate concerns of the cancer have been addressed.

Tysabri also can have a nasty rebound effect that results in exacerbations and lesions -- my worst exacerbation, which brought permanent symptoms, happened after Ty was temporarily pulled off the market due to PML:

"Tysabri Rebound Effect:" http://www.medpagetoday.com/Neurology/M ... rosis/6674

"The rebound effect was most pronounced among patients who had received only two monthly natalizumab infusions. They had a five-fold increase in lesion counts post-therapy, the investigators reported online in Neurology, in a study scheduled for the Dec. 11 [2007] print version."

my....how far we have come since I came on this site to assure patients that angioplasty was not particularly dangerous and that angioplasty was not surgery!

I can't imagine how far behind we'd be if you hadn't come along when you did. Thank you, Dr. Sclafani, for leading us in this great learning adventure.

[Lyon]

..

[drsclafani]

my....how far we have come since I came on this site to assure patients that angioplasty was not particularly dangerous and that angioplasty was not surgery!

The question of whether or not angioplasty is surgery has come up several times in the last year. I personally don't see why it's important to declare that it is or isn't surgery because a thing remains what it is or isn't regardless of what we call it, but it's always seemed that by definition angioplasty is surgery and my question is, as someone trained to work in the circulatory system, why don't you consider angioplasty surgery?

lyon
it is an interesting question that you ask. i have been on both sides of that debate many times. When I was young, i was proud that i was doing surgery, that is the treatment of disease by manipulation and instrumentation. I wanted to be respected like the surgeons were.

with time i have come to realize that interventional radiology is a specialty that transcends surgery, that is, it transcends the actual manipulative treatment. It encompasses imaging and intervention. My skills in imaging are not just in perception of the imaging finding but a way of thinking, of the abstract, the deductive reasoning, the inferences that the images provide. The perception is important to what i do. And i undervalued and undersold that skill when i was young.

So when surgeons and others started to do what i do because everyone has access to the fluorscope and ir was a simple alternative to standard surgery, i had my skills devalued because, after all, it was surgery, not interventional radiology that started to matter.

While there are surgeons who can become masters at IR, the full expression comes to those who embrace and live the image, not those who just push a catheter.

Thus i hold on to my sense that the imager part of me is a vital component of what makes me an interventional radiologist and not a surgeon.

As descartes, aristotle and tom edison have stated, people see what they are prepared to see. And interventional radiologists are taught to see.

[Lyon]

..

[cowboystew]

Dr. S,
Have you treated any siblings with MS, and if so, have you noted identical problems or close similarities in the areas of stenosis? I’m curious because I and my 3 siblings all have MS plus my son also. I wonder if anything could be learned from testing, treating, and comparing our cases. I am the only one who has been treated so far and I had great improvement until I restenosed after 2 weeks.

[drsclafani]

Dr. S,
Have you treated any siblings with MS, and if so, have you noted identical problems or close similarities in the areas of stenosis? I’m curious because I and my 3 siblings all have MS plus my son also. I wonder if anything could be learned from testing, treating, and comparing our cases. I am the only one who has been treated so far and I had great improvement until I restenosed after 2 weeks.

i have not treated any siblings at this point. I am working up a mother daughter pair and have treated the mother. I doubt that they will have mirror image findings because they are so different in age. Their clinical presentations are also different.

but we will see.

[newlywed4ever]

Dr. S,
Have you treated any siblings with MS, and if so, have you noted identical problems or close similarities in the areas of stenosis? I’m curious because I and my 3 siblings all have MS plus my son also. I wonder if anything could be learned from testing, treating, and comparing our cases. I am the only one who has been treated so far and I had great improvement until I restenosed after 2 weeks.

i have not treated any siblings at this point. I am working up a mother daughter pair and have treated the mother. I doubt that they will have mirror image findings because they are so different in age. Their clinical presentations are also different.

but we will see.

I, too, had wondered about this as both myself and my daughter have MS. I am PPMS (never been RRMS); she is RRMS. We were both treated in August by Dr Siskin. I had complete blockage in LIJV and azygous problem. She had 50% blockage in RIJV.