DrSclafani answers some questions

[drsclafani]

Hi Dr Sclafani,
sorry for the long post above; it took me a while to translate it.
I found very interesting to see what other doctors are doing specially if they have good results.
He made a point, also stressed by you, that the main cause of CCSVI is the valve at the base of the Jugular vein and that gentle dilation doesn't work.
You need to break the annulus.

i think that unnecessarily breaking of annulus can cause troubles with thrombosis. I imagine the valves floating in the vein like a sail on a mast that has broken.
So, if the valve leaflets are fused, would it not be better to perform an angioplasty that does not disrupt the annulus? I am using the IVUS and the angiography to evaluate the effectiveness of the venoplasty. If valvulostomy doesnt work, then pop away and perform an annuloplasty.
A nuance of Dr. Luppatelli is that he is using kissing balloons to increase the diameter. Using smaller balloons and doubling up, allows higher pressure (LaPlace's law, Cece) but i do not think that they can attain the pressures of the Atlas balloon, that can generate pressures of more than 40 Atm.

The other point that I have not seen mentioned before is that he performs doppler during angiography and that helps with artifact and false positive negative of both procedures.

yes i agree a useful adjunct.

The last point was that people with "normal" doppler or venography can benefit from balloon angioplasty anyway.
Your comments will be much appreciated.

it is hard to find a normal, these days

This past week a patient seemed to have a normal vein but with further analysis and gentle dilatation, it became clear that there was something amiss and both jugulars were dilated, hopefully with something good to come.

[drsclafani]

Double post from half a brain -- I'll just say good morning, everyone, and especially Dr. Sclafani and staff. Hope it's beautiful in New York this weekend.

its beautiful in Punta Cana Dominican Republic with my grands. its probably beautiful in new york for their parents

[Cece]

A nuance of Dr. Luppatelli is that he is using kissing balloons to increase the diameter. Using smaller balloons and doubling up, allows higher pressure (LaPlace's law, Cece) but i do not think that they can attain the pressures of the Atlas balloon, that can generate pressures of more than 40 Atm.

Here are some good images and description of kissing balloons, starting on page 18, and yes LaPlace's law, that's on page 16...
http://www.summitmd.com/pdf/pdf/080905_5.pdf

LaPlace's law would be why the shoulder of the balloon should be placed on the normal vein (if there is half as much tension on the shoulder than in the middle of the balloon where the wall tension is at its maximum, which should be aligned with the bad valve.) Can't say I get why doubling up allows higher pressure but I'll accept that it does.

Glad you're on vacation, especially in such a fine setting, everyone needs to take breaks!!

[drsclafani]

A nuance of Dr. Luppatelli is that he is using kissing balloons to increase the diameter. Using smaller balloons and doubling up, allows higher pressure (LaPlace's law, Cece) but i do not think that they can attain the pressures of the Atlas balloon, that can generate pressures of more than 40 Atm.

Here are some good images and description of kissing balloons, starting on page 18, and yes LaPlace's law, that's on page 16...
http://www.summitmd.com/pdf/pdf/080905_5.pdf

LaPlace's law would be why the shoulder of the balloon should be placed on the normal vein (if there is half as much tension on the shoulder than in the middle of the balloon where the wall tension is at its maximum, which should be aligned with the bad valve.) Can't say I get why doubling up allows higher pressure but I'll accept that it does.

Glad you're on vacation, especially in such a fine setting, everyone needs to take breaks!!

Burst pressure of a balloon is related to the sqaure of the radius. the larger the radius and diameter the lower the burst pressure. So an 8 mm balloon has a higher burst pressure than a 16mm ballloon. So if you put two 8mm balloons you can achieve higher pressures than if you put in a 16 mm balloon of the same material.
i am using balloons with a very strong wall that has high pressure and thus, does not require two balloons.

The downside of two balloon treatment is a larger hole in the femoral vein.

[LauraV]

Dr. Sclafani,

A friend with MS told me about this talk that Dr. Hewett (UBC MS Clinic) gave in Seattle a few weeks ago.

http://www.facebook.com/note.php?note_i ... 940&ref=mf

My understanding is that he said that there will always be re-stenosis and the only question is when it will occur, suggesting that we should expect to get repeat angioplasties. He also spoke about the importance of the azygous vein (affecting walking, bladder and bowel - things that many of us are dealing with) and it's diagnosis and treating. And I think you would agree with his take on the use of stents, as well.

Is this the kind of information that doctors are learning as more and more I'd love to get your take on all of this.

Laura

[LauraV]

Dr. Sclafani,

A friend with MS told me about this talk that Dr. Hewett (UBC MS Clinic) gave in Seattle a few weeks ago.

http://www.facebook.com/note.php?note_i ... 940&ref=mf

My understanding is that he said that there will always be re-stenosis and the only question is when it will occur, suggesting that we should expect to get repeat angioplasties. He also spoke about the importance of the azygous vein (affecting walking, bladder and bowel - things that many of us are dealing with) and it's diagnosis and treating. And I think you would agree with his take on the use of stents, as well.

Is this the kind of information that doctors are learning as more and more I'd love to get your take on all of this.

Laura

[LauraV]

Oops! I apologize for the repeat message. After sending the first time, I got a message that said that it hadn't gone through, so I pressed "submit" again.
Sorry!

[drsclafani]

Dr
for someone new to the idea of ccsvi procedure and declining quickly would you have any advice based on the recent results of your procedures?

Also have you noticed any correlation with the degree of stenosis relative to disability?

thanks

i think i missed this question.

i think that you should be non-invasively tested to see whether you have evidence of ccsvi. If you do, you should consider venography to determine the cause and if amenable consider treatment of those stenoses.
pick a doctor with experience and with compassion

this is not proven but i have noted that in general terms, patients with the most long standing symptoms tend to have the most dilatation above the stenoses. Also stenoses tend to be worse in those who have had symtoms the longest. Not always true but seems to trend that way.

[Cece]

this is not proven but i have noted that in general terms, patients with the most long standing symptoms tend to have the most dilatation above the stenoses.

Ok, that's an interesting observation. With all the imaging studies that show CCSVI is worse in patients with advanced MS (or, in the Beirut study, RR of over 10 years duration), perhaps they are seeing this increased dilatation and measuring the stenosis against the dilatation, so the stenosis gets measured as being more severe.

[bluesky63]

So Cece, what they may actually have is a degree of both stenosis and diltation? Am I misinterpreting? (Basically resulting in a larger degree of difference in size between the adjacent areas -- one narrow and considered a "stenosis," one larger and dilated -- so in general many people with CCSVI have the same degree of stenosis, but the people with worse disability get dilatation too?) Could this indicate a higher degree of "stretchiness" in the blood vessels of the people who have more disability? A collagen defect?

On a different area -- Dr. Sclafani, my apologies if this had already been asked. But I don't remember seeing this anywhere. Have any of your patients had vasospasm during a procedure? Is this a normal risk of angioplasty? Why would it happen?

[Cece]

So Cece, what they may actually have is a degree of both stenosis and diltation? Am I misinterpreting? (Basically resulting in a larger degree of difference in size between the adjacent areas -- one narrow and considered a "stenosis," one larger and dilated -- so in general many people with CCSVI have the same degree of stenosis, but the people with worse disability get dilatation too?) Could this indicate a higher degree of "stretchiness" in the blood vessels of the people who have more disability? A collagen defect?

Yes, the dilatation would result in a larger degree of difference in size, resulting in the measurements showing the stenosis as a higher percentage if it is being compared to the dilatation above it. By this theory, the same stenosis in two different patients would measure differently not because of a difference in the stenosis but because of a difference in the dilatation of the blood vessel immediately above it.

Dilatation must be a reaction of the body to the stenosis. The observation that it is most present in patients with long-standing symptoms suggests that time is a factor and so is having reached the point when the body is unable to compensate for the stenosis (thus the onset of symptoms).

I might be making much of a minor observation! And I've disregarded the second part of what Dr. Sclafani said:

Also stenoses tend to be worse in those who have had symtoms the longest. Not always true but seems to trend that way.

It does all get to the question raised by the other studies, does CCSVI worsen with time, why is CCSVI worse in patients with more advanced MS, etc.

[eric593]

It does all get to the question raised by the other studies, does CCSVI worsen with time, why is CCSVI worse in patients with more advanced MS, etc.

That's interesting. Neither I nor the two people I met also being treated,all of us each with MS for close to 20 years, had anything more than "routine" stenoses, nothing complicated or unusual, no collaterals, no severe stenoses or complicated problems, no correlation to extent of azygous stenoses and mobility, bowel, bladder, etc problems, in fact one of the people in a w/c for many years with no azygous issues found at all.

[Cece]

I do not have advanced MS on the EDSS scale by any means but I have long-standing symptoms, with my first neurological relapse and recovery being 19 years ago as a teenager. I had severe jugular stenosis (80% and 100%). I hope they stay open.

I said this:

why is CCSVI worse in patients with more advanced MS

as if it's a fact when it's only been implied by studies whose methods we have scrutinized.

That's interesting. Neither I nor the two people I met also being treated,all of us each with MS for close to 20 years, had anything more than "routine" stenoses, nothing complicated or unusual, no collaterals, no severe stenoses or complicated problems, no correlation to extent of azygous stenoses and mobility, bowel, bladder, etc problems, in fact one of the people in a w/c for many years with no azygous issues found at all.

It is so hard to draw conclusions. Can't wait for registry data.

[eric593]

It is so hard to draw conclusions. Can't wait for registry data.

I don't know if the registry data will be more detrimental than illuminating given the heterogenous skillset, techniques and treatment methods, experience and expertise among a diverse group of IR's. I fear the same or worse problems will result as Dr. Sclafani envisaged with a premature clinical trial, exacerbated by different IR's involved as well with treating patients recorded in the registry.

[AlmostClever]

Dr Sclafani,

On the report of my Doppler, it says "Collateral circulation via left lobe of the thyroid gland was noted".

Is it something that can be the cause of thyroid gland disorders? I would like to know what you think about that.

Thank you very much.

There have been some preliminary data that suggest that patients may have an inflammatory thyroiditis associated with CCSVI. Since there is venous insufficiency in the thyroid gland, it is not surprising that this might happen more work needs be done about this...like everything else!

Dr. S.,

you've talked about the bthyroid gland some and i was wondering if you've found or heard any developments?

also, i don't have my cerebral venous road map out so maybe you could learn me hjow the pituitary and hypothalumus drainand if they are affected by ccsvi? alot of symptoms from disorders there sopund like ms or ccsvi syumptoms...

i've read in the ldn section that the thyroid shrinks as ms progresses. woud low blood flow cause this also?

thx - a/c