IVUS

drsclafani · Post by **drsclafani** » Wed May 11, 2011 8:22 am

Brainteaser wrote:Apart from Drs Cumming and Sclafani, who uses IVUS?

Do Vascular Surgeons use it or just IRs? Zamboni and Ludyga are VSs and I'm not sure they use it.

Does anyone have good results without using IVUS?

Does anyone using it, not have good results?

It is part of the trial in UK,
Dr Siddiqui is using it at BNAC trials
Arizona Heart is using it
Katowice states they are buying one

i have always used IVUS from Day 1 of my treatments. Having rarely used it before, and without a good teacher, it was a fumble around for a while. But as i grasped its images and learned to detect more and more, and as i began to understand what the findings represented, I believe i am doing a better job, having less complications and much much greater comfort in how i am treating these lesions.

PointsNorth · Post by **PointsNorth** » Wed May 11, 2011 8:47 am

Dr. S and Co.,

Here is an email I received this morning from EHC in the UK re: IVUS. New gold standard?

Intravascular Ultrasound
One of the most advanced pieces of imaging technology in the world is the Intravascular Ultrasound or IVUS. This involves a miniature ultrasound probe which can give imaging and feedback in real time. Developed mainly for use in arterial disease, it has increasingly been used as an aid to correct treatment options for CCSVI.

The ability to visualise the intraluminal environment, abnormal valves, membranes and other anatomical variants gives the surgeon valuable information as to where the treatable lesions are. In our experience in Edinburgh, IVUS provides excellent validation of the Doppler ultrasound findings from our clinic.

It compares well with venography which essentially only provides a 1D image of blood flow, a ribbon of dye showing areas of blockage where they exist.

There is no doubt that seeing a blocked vein released and the surge of flow on the venogram, is indeed a dramatic site. It brings home the profound changes that this relatively modest surgery can produce. There is some debate though, about whether this is the “gold standard” of diagnosing CCSVI that is often claimed.

IVUS gives a live 3D picture of what is happening in the veins and arguably provides much more immediately useful information. It also allows direct imaging of the jugular vein valves which no other technique will.

The value of both Doppler ultrasound and IVUS was brought home at a recent visit to the Edinburgh Clinic by a very eminent surgeon. He had come to see this new groundbreaking endovascular procedure and the first case that we looked at had been diagnosed by Doppler ultrasound with CCSVI. Vic Fernando had found a narrowing in the upper right internal jugular and an abnormal valve on the same side. When the dye was injected into the veins, the blood flow looked normal and there was no sign of any narrowing. My heart sunk, I could not believe that on the very occasion we had this famous surgeon visiting the clinic, the patient had no abnormality !

Mr Reid seemed undeterred and called for the IVUS. This is a very expensive piece of equipment, so is not used on every case as the probe is disposable and very expensive. It is available to be used in every case in the Edinburgh clinic but is not always required if the imaging is clear.

In this case the IVUS completely agreed with the Doppler Ultrasound findings, contradicting the findings of venography. Our esteemed visitor proclaimed that “IVUS was indeed the gold standard!” Imaging is a very important part of diagnosing and monitoring MS. It is also central to the diagnosis and management of CCSVI.

In the next few years, it is likely that IVUS will emerge as an essential part of diagnosis and treatment of MS. We are proud to be pioneering this cutting edge technology to the patients at the Essential Health Clinic and hope that this will improve outcomes over the long term for CCSVI treatment in the UK.

Cece · Post by **Cece** » Wed May 11, 2011 9:31 am

Oh, that is good. It continues to confirm my good impression of Dr. Reid and EHC too.

DrCumming · Post by **DrCumming** » Fri May 13, 2011 11:35 am

Case 2: 48 yo with RRMS

First 2 images are venograms of the azygous. First at expiration, second at inspiration.

Note the difference between the 2 images. Imaging the azygous at expiration seems to make narrowing worse or make a normal looking vein worse.

The question is ... is there a significant stenosis? Is this the so called candy wrapper or twisting of the azygous vein that is described?

I think most people would treat this lesion.

IVUS comes to the rescue.

Here we see that the vein has a very oval shape. We are imaging along the green arrow and hence the vein looks narrowed.

But is it?

The area of the vein at this level is 45 mm2

Using IVUS we can look at the vein both above and below this area. The image below shows the vein to have a less oval shape. Note the area at 47 mm2. Essentially no different.

In this case, IVUS saved the patient a venoplasty (which would not have worked). Some would have continued with a stent after the angioplasty failed.

IVUS is really the only good tool we have to validate abnormalities seen on venography. In this case, it saved a venoplasty +/- stent.

Cece · Post by **Cece** » Fri May 13, 2011 2:23 pm

great lesson, Dr. Cumming

Have you ever seen a "candy wrapper" or twist in an azygous?

Any explanation for why the vein had a more narrow shape in that section?

IVUS is really the only good tool we have to validate abnormalities seen on venography. In this case, it saved a venoplasty +/- stent.

Very good news for the patient.
I hope IVUS catches on with more doctors.

Liberation · Post by **Liberation** » Sat May 14, 2011 2:19 am

.......

1eye · Post by **1eye** » Sat May 14, 2011 5:24 am

Hi. Sorry for the hick question, but when you use the words distal and proximal like that is there some kind of synonym-like word I could just have in the back of my mind as a memory aid for the feeble of memory? Thanks. Carry on. Great stuff.

Cece · Post by **Cece** » Sat May 14, 2011 5:26 am

Distal vs Proximal:
www.thisisms.com/ftopicp-139862.html#139862

he offers central vs peripheral as alternatives

I am not sure that's any better?

edited to add: how about 'x marks the spot' with the 'x' in proximal? In the IJV, proximal is the area of the valves. 'X' marks the spot for the valves?

Johnson · Post by **Johnson** » Sat May 14, 2011 8:31 am

1eye wrote:Hi. Sorry for the hick question, but when you use the words distal and proximal like that is there some kind of synonym-like word I could just have in the back of my mind as a memory aid for the feeble of memory? Thanks. Carry on. Great stuff.

If it's a mnemonic you want, think of the heart being at the core (French=coeur). Proximal is in the proximity of (or near to) the heart, Distal is at a distance from the heart.

drsclafani · Post by **drsclafani** » Sat May 14, 2011 8:06 pm

Cece wrote:great lesson, Dr. Cumming

Have you ever seen a "candy wrapper" or twist in an azygous?

Any explanation for why the vein had a more narrow shape in that section?
IVUS is really the only good tool we have to validate abnormalities seen on venography. In this case, it saved a venoplasty +/- stent.
Very good news for the patient.
I hope IVUS catches on with more doctors.

i have rarely seen the candy wrapper that others write about. This weekend i saw one and it was quite obvious why i should see it.

i perform the aygous venograms with the patient taking a deep breath and holding it while i do the azygous venogram. I nevver see the candy wrapper but today, in a lapse of memory, instructed my patient to take a deep breath, blow it out and hold iti. Venogram shows the candy wrapper.

realizing my mistake, i repeated the venogram but this time instructed to take a deep breath and hold it and, you guessed it, the candy wrapper disappeared.

Respiratory variation clearly affects many of the findings of venography. I I often use IVUS when i see a narrowing NOT near the valve. i watch that segment in inspiration and expiration to see if it expands. if it does, it is a LMAL....leave me alone lesion..

DrCumming · Post by **DrCumming** » Tue May 17, 2011 6:26 am

Sal, I have often had problems getting the IVUS catheter to track through the sigmoid sinus. I am using a 0.014 stablizer xs wire. What are you using? It looks like you are using a Volcano machine.

DrCumming · Post by **DrCumming** » Tue May 17, 2011 7:00 am

Case 3

50 yo male with RRMS.

Images from left IJ.

First we have the venogram. Stenosis is obvious.

Next is IVUS, which shows the incompletely opening valve leaflets. We also see the EJ entering at this level (yellow text).

For balloon sizing, we cannot use the image above as the entry of the EJ makes the overall size wrong. So we look above a couple of mm.

For ballooning, we know exactly where the stenosis is and we only want to dilate at this point, minimizing any injury to the surrounding normal vein.

You can see the "knotch" in the balloon right near the end. The balloon is position as low as possible to avoid any injury to the remainder of the IJ.

We check with IVUS

and venography

Excellent results on both. Balloon was only inflated to 5 ATM.

I am hopeful that by using IVUS we are going to be able to get more durable results. Gone are the days of big balloons, cutting wires and high pressures. IVUS shows that this is not needed to treat the valves appropriately.

drsclafani · Post by **drsclafani** » Tue May 17, 2011 7:19 pm

DrCumming wrote:Case 3

50 yo male with RRMS.

Images from left IJ.

First we have the venogram. Stenosis is obvious.

Next is IVUS, which shows the incompletely opening valve leaflets. We also see the EJ entering at this level (yellow text).

For balloon sizing, we cannot use the image above as the entry of the EJ makes the overall size wrong. So we look above a couple of mm.

For ballooning, we know exactly where the stenosis is and we only want to dilate at this point, minimizing any injury to the surrounding normal vein.

You can see the "knotch" in the balloon right near the end. The balloon is position as low as possible to avoid any injury to the remainder of the IJ.

We check with IVUS

and venography

Excellent results on both. Balloon was only inflated to 5 ATM.

I am hopeful that by using IVUS we are going to be able to get more durable results. Gone are the days of big balloons, cutting wires and high pressures. IVUS shows that this is not needed to treat the valves appropriately.

mike, i would not be satisfied with those results.i think that there is incomplete opening of the valve as shows by the contrast in the cuffs.

i believe that five atmospheres will NOT be successful. Did you check for elastic recoil? did you repeat IVUs after venoplasty? I suspect that you will see that the valve leaflets are still not completely open.

i am still using high pressure. i havent yet done the calculation, but i am suspecting that pressure in range of 8-23 are necessary to eradicate elastic recoil

WeWillBeatMS · Post by **WeWillBeatMS** » Wed May 18, 2011 5:37 am

Dr. Cumming & Dr. Sclafani,

What do you guys think is the reason more IRs are not making the move to IVUS? Is the learning curve so great? or is it more of the cost of the machine? or something else?

Thanks,

WeWillBeatMS

Cece · Post by **Cece** » Wed May 18, 2011 6:47 am

DrCumming wrote:For ballooning, we know exactly where the stenosis is and we only want to dilate at this point, minimizing any injury to the surrounding normal vein.

You can see the "knotch" in the balloon right near the end. The balloon is position as low as possible to avoid any injury to the remainder of the IJ.

This is the same as when Dr. Sclafani talks about positioning the shoulder of the balloon on the healthy vein just above the valve?

I am glad for the efforts being made to minimize damage to the vein.

Thank you for sharing images. It is very encouraging that this might lead to greater durability.