DrSclafani answers some questions

[pklittle]

I am online reading here as you post. It is late.

WAVING HI TO YOU DR.SCLAFANI !!!

I have no questions, I am still on hold.

[NotFound]

Dear Dr. Sclafani,

After having had the stent placed in my Azygous (at Pacific Interventionalists)
I have been having intermittent (not very frequent either) dull pains where I think my azygous is.

Somewhat below / at the level of the heart?

Pain is not debilitating or anything, however it has me concerned.

I had the procedure done on December 14 2010 (3+ months ago). I have been diligently on blood thinners (Warfarin, after getting my INR stabilized between 2 and 3 by injections).

I was not given nor told to take any blood thinners prior to the procedure (not even aspirin). It took more than 10 days for the INR to get to the "therapeutic" level post procedure.

According to the operating Doctor, even if my azygous were to completely clog up, I would not be any worse off (his words, not mine), because my occlusion (which was due to azygous twisted about itself) was greater than 90%.

Can I please hear your take on this?
What can the pains be due to?

In my understanding to check the status of the stent will involve going in through the veins again and Doppler is no help here.

Thank you in advance.

i would think that the pain is likely caused by the stretching of the azygous as well as by the continued radial force of the stent

i have skepticism about these azygous stenoses.I think lots of them are phasic changes in th positionof the azygous. for example I have never seen a candhy wrapper.At this point you would think i would be seeing them too. Perhaps the difference is in the phase of respiration i image the azygous? Ivus also shows that many narrowings are phasic in the azygous

you are correct that the azygous is not measured by noninvasive imaging very well

Thank you.

Although I feel rather bad realizing that I might have a 6cm stent now that was absolutely not necessary One would think IR doctors would know about dynamic positioning of the veins.

[drsclafani]

Dear Dr. Sclafani,

After having had the stent placed in my Azygous (at Pacific Interventionalists)
I have been having intermittent (not very frequent either) dull pains where I think my azygous is.

Somewhat below / at the level of the heart?

Pain is not debilitating or anything, however it has me concerned.

I had the procedure done on December 14 2010 (3+ months ago). I have been diligently on blood thinners (Warfarin, after getting my INR stabilized between 2 and 3 by injections).

I was not given nor told to take any blood thinners prior to the procedure (not even aspirin). It took more than 10 days for the INR to get to the "therapeutic" level post procedure.

According to the operating Doctor, even if my azygous were to completely clog up, I would not be any worse off (his words, not mine), because my occlusion (which was due to azygous twisted about itself) was greater than 90%.

Can I please hear your take on this?
What can the pains be due to?

In my understanding to check the status of the stent will involve going in through the veins again and Doppler is no help here.

Thank you in advance.

i would think that the pain is likely caused by the stretching of the azygous as well as by the continued radial force of the stent

i have skepticism about these azygous stenoses.I think lots of them are phasic changes in th positionof the azygous. for example I have never seen a candhy wrapper.At this point you would think i would be seeing them too. Perhaps the difference is in the phase of respiration i image the azygous? Ivus also shows that many narrowings are phasic in the azygous

you are correct that the azygous is not measured by noninvasive imaging very well

Thank you.

Although I feel rather bad realizing that I might have a 6cm stent now that was absolutely not necessary One would think IR doctors would know about dynamic positioning of the veins.

its an ivus thing

not many are using it yet.

[drsclafani]

I am online reading here as you post. It is late.

WAVING HI TO YOU DR.SCLAFANI !!!

I have no questions, I am still on hold.

it is late. i promised my self that i wouldnt do this any more. it really is exhausting.

so off to bed i go

[jak7ham9]

Dear Dr. S
Hi I had the procedure done by you last march patient 10 barbara with cutting balloon. I am quite sure I restenosed but after viewing so much questions and changes in the operation and how it is done I am wondering should I get it done again or should I wait. I feel my mobilility is somewhat less than before I had operation (deffinately less than week after). I want to improve but I don't want to do any harm. So confusing. It just seems that there are not a lot of improvements for many people . Then of course I read of patients with scarring or clots..... I keep using my hbot in hopes the o2 will at least slow progression in the mean while.) Drugs have never been helppful. I really would love some kind of direction. b

[bestadmom]

Dr. S,

I heard someone's CCSVI was treated this week by cryoplasty vs a stent. It wasn't her first treatment. Was there talk of this method at ISNVD or SIR? What does the "freezing" do to the vein wall?

i am perplexed by this treatment. for a valvular stenosis. makes no sense to me.
any idea who is doing this?

Dr. Montague in Tampa used this last week on someone I know. It wasn't her first procedure.

[Cece]

now back to treatments full time yeah!

double yeah

If you think that the narrowing is due to scar tissue you will try to overdilate intentionally about20% to maximize the stretch of the scar.

Didn't know you could stretch scar tissue in these veins. That is encouraging as well.

[pklittle]

I am online reading here as you post. It is late.

WAVING HI TO YOU DR.SCLAFANI !!!

I have no questions, I am still on hold.

it is late. i promised my self that i wouldnt do this any more. it really is exhausting.

so off to bed i go

Perhaps we should look into having this forum shut down after midnight.

Dr. Sclafani, in all honestly, you need to take care of yourself first. We know you care for all of us and want to help us so badly, but remember we all care about you too! Do not exhaust yourself.

ok, off my soapbox now....

[Liberation]

..

[drsclafani]

now back to treatments full time yeah!

double yeah

If you think that the narrowing is due to scar tissue you will try to overdilate intentionally about20% to maximize the stretch of the scar.

Didn't know you could stretch scar tissue in these veins. That is encouraging as well.

cece
just because you think that the narrowing is scar tissue, doesnt mean it is. In fact, i do not think it is when the narrowing is in the vicinity of the valves.
i was just making the statement that most IRs believe it is scar until proven otherwise and thus are over dilating.

I think it is not and have backed off on sizeing balloons to conform to the diameter of the vein to start.

[drsclafani]

First I thought that the RIJV has a narrow annulus where the vein gets real thin in a very small segment and that is why the long part above is stenosed, but then souldn't there be a bulge above the narrow annulus? As far as I know they dilated the valve and the vein with a small balloon (6x20mm) but they did not break the annulus. So a few weeks later the lower part got restenosed (1cm) then a week ago I got another Doppler and the IR saw the whole full section got back where it was. I guess this would be an elastic recoil. However, the second time the IR told me that he sees some drifting piece there. If there is a narrow annulus, souldn't be enough to break that and then the vein sould get normal? Of course, if there is no thickening of the wall.

i am sorry, Liberation, in truth, the images that you show are so bad that one cannot really make accurate comments about them. There do appear to be segmental narrowings (?hypoplasia) but the area of the valve is not visible at all. Also you state that a 6x20 balloon was used. seems rather short, possibly rather thin. Might i guess that your IR was a cardiologist? just a guess and with no bias intended.

you cannot tell wall thickness from a venogram. A venogram only shows the inner part of the vein, a "lumenogram"

As for the two other veins I do not see major obstacles.

Liberation, i dont see any "major" obstacle either....the problem is I don't think that i see anything there. You have to accept that what you are showing us does not meet standards. One cannot make ANY comments at all. And what is "MAJOR"? That is still under debate.

Dr Sinan told me he would dilate the valves there. I am not sure if saw specific problem there or he always do that. As far as I know he always enters the veins with a balloon to see whether he encounters any problem there. Would ivus be a better way exploring these problems? Would a problem be better identified with ivus or entering by balloon would have some merits?

i prefer NOT to inflate a balloon until I have found some reason to inflate it. Inflating balloons to find lesions is something many physicians do. It can damage intima. That is one of the reasons that I use IVUS which is less traumatic and more accurate in so many ways than inflating a balloon.

That is true that the upper parts are not indicated in the images. Could it be that they did not see those parts?

I think we should always try to see the ENTIRE vein, and, ideally, see the connection between the dural sinuses in the head and the jugular veins in the neck. Just last week i had a case of segmental hypoplasia which did not show reflux into the head. I sent the patient for a BRAIN MRV (not MRV of neck) and it showed clearly a number of dural sinus stenoses.

On the other hand if my recollection is right, Dr Cumming just said a day before that using an extra large balloons in the upper part of the IJVs can cause big problems as it did a full occlusion with Winni's IJV. Could it be? What should be done if those parts are stenosed? Are there valves in those segments that can cause the problems or there is a vein problem?

perhaps you are misunderstanding dr cumming
I agree that one should not use extra large balloons in the upper IJV because it will be a mis-sizing and ballooning may cause more harm that good WITH A BALLOON THAT IS TOO LARGE. Doesnt mean that using a properly sized balloon cannot improve flow in the vein.

If I understand correctly mostly valves are the cause of stenosis.
I try to get the MRV images that were prepared half a year before my operation those should be much better quaility.

ok. but perhaps your scan of your venogram is the problem. do you have the images? or do you have paper prints?
MRV just isnt as good as venography, but perhaps that will help us all understand what you are trying to show us.

Based upon what you have said and shown us here, my opinion is that we cannot provide you with any clarity, sorry.

[Cece]

cece
just because you think that the narrowing is scar tissue, doesnt mean it is. In fact, i do not think it is when the narrowing is in the vicinity of the valves.
i was just making the statement that most IRs believe it is scar until proven otherwise and thus are over dilating.

I think it is not and have backed off on sizeing balloons to conform to the diameter of the vein to start.

I see what you were saying, you were talking about the original stenoses.

In a different scenario, we are hearing reports of patients who have scarring as a result of the procedure. Depending on what is exactly going on with those patients, as long as the vein does not close completely, it can still be ballooned again? I had thought scarring sounded so severe, this would not be possible.

sent the patient for a BRAIN MRV (not MRV of neck) and it showed clearly a number of dural sinus stenoses.

What next, for such a patient? Will the dural sinus stenoses be treated and by whom?

[HappyPoet]

Hi Dr. Sclafani,

A very happy update for you!

My follow-up US showed strong flow throughout my left femoral vein which had been occluded by clot [from 1st procedure, different doctor].

Your post-procedure protocol of using Arixtra dissolved the very scary clot (DVT) and saved my leg and my life for which my family and I can never thank you enough. You will be forever in our hearts.

Thank you for everything, Superstar.

[Liberation]

........

[Cece]

Your post-procedure protocol of using Arixtra dissolved the very scary clot (DVT) and saved my leg and my life for which my family and I can never thank you enough. You will be forever in our hearts.

Thank you for everything, Superstar.

Hooray, HappyPoet!! What a relief.