DrSclafani answers some questions

[Cece]

He mentioned this here too.

Thank you for pointing that out. I thought I had given away the surprise ending.

I will admit that, after you revealed yourself, I went back to reread your earlier post to Dr. Sclafani about your wife's fatigue and balance improvements. That's the stuff we don't always hear about at the end of one of Dr. Sclafani's cases. He opens the veins as best he can but after that it's out of his hands. There has to be something that will predict improvements but they haven't found it yet that I know of.

At the least, this case gave Dr. Sclafani a workout. And we like to see him challenged.

My wife has always been an overachiever. Even with diseases.

Dr. Sclafani, would the 'puff' of contrast out to the side be the contrast refluxing into the subclavian?

I feel free to comment here, since I am in the dark on what this picture means. I think I agree with you, Cece, that this is the subclavian... it looks like the correct geography. But why would it reflux in that direction? The innominate must have an opening (even with a stenosis), or the IJV could not have been accessed. If there is an opening, there should be flow. If there is flow, the contrast should be pushed into the SVC.

My thought now is that the stenosis in the innominate is causing the flow entering from the jugular to reflux back into the subclavian. Thus the puff. The flow from the jugular is looking for another way out when it hits the innominate stenosis. It does not have to be a full occlusion, only a partial one, to cause reflux.

If the flow from the subclavian were stronger, it might prevent reflux in this direction, but the subclavian has a stenosis of its own.

[Cece]

I don't think "dismay or anger" are appropriate when the patient and her doctor chose a treatment to try to delay her MS progression that might have had side effects or risks involved. The patient is not the one expressing anger or dismay, Cece, an uninvolved observer is.

It is duly noted that eric593 experiences no anger, dismay or grieving at the further loss of patency in a fellow MS patient's already messed-up veins.

[MikeInFlorida]

My thought now is that the stenosis in the innominate is causing the flow entering from the jugular to reflux back into the subclavian. Thus the puff. The flow from the jugular is looking for another way out when it hits the innominate stenosis. It does not have to be a full occlusion, only a partial one, to cause reflux.

I concur. I think the stenosis in the innominate is further exacerbated by the catheter occupying the residual CSA of the lumen. Does anybody know the diameter of the catheter?

[MikeInFlorida]

I will admit that, after you revealed yourself, I went back to reread your earlier post to Dr. Sclafani about your wife's fatigue and balance improvements. That's the stuff we don't always hear about at the end of one of Dr. Sclafani's cases.

Excellent point - That is Exactly why I posted the update. I asked Dr.'s permission, and his response was that I can post anything as long as it is true, transparent and anonymous. If anything I have posted is untrue, it is from ignorance, and not deceit. My wife is planning on giving a more detailed status soon, but in summary, so far we have had very good results.

[Cece]

Perhaps it is more likely that the catheter occupies the entire diameter of the residual lumen of the innominate?

He's talked about this happening in a hypoplastic jugular. You can see in his images the size of the vein vs the size of the catheter. The innominate vein is typically larger than the jugular, as we've learned from all the shoulder-of-the-balloon placement discussion. If it were reduced to the size of the catheter, that would be a very high-grade stenosis.

The relevant image is the bottom one on the right:


When he was ballooning the jugular, because of how he places the balloon, the innominate vein will have already been ballooned albeit to a smaller size than its vein size. I don't see any obvious stenosis or banding in the balloon in the innominate in that middle row of images. Maybe a larger balloon placed in the innominate will tell the tale? How does a chemo scarred vein respond to ballooning? Maybe it should be left alone?

[MikeInFlorida]

I don't see any obvious stenosis or banding in the balloon in the innominate in that middle row of images.

The innominate begins at the confluence of the IJV and subclavian. So in the bottom right image, the innominate is demarcated by the "puff", right? Looking at the contrast in that last image, I would have to say that the image seems to show the contrast tapering to a point (right at the center of the chest). Do you think that is the innominate stenosis?
I do recall one particular oddity right after the port was installed. My wife (L.) told the surgeon that she could feel the tube inside of her chest. He expressed some surprise, and said that in the 100's of subclavian ports he had inserted, she was only the second person that had that particular complaint. As a precaution, he "re-X-rayed" the port (and connected tube), to make sure that it was routed correctly (and it was). But it was that X-ray that I remember... I was surprised at how long, and how deep into the chest the tube was. It was years ago, but the position of that taper looks very familiar.

[drsclafani]

The port was placedd into the subclavian vein, not the jugular vein. I suspect that the subclavian vein stenosis resulted from puncture of the subclavian vein. The catheter tip was like located at the inominate vein and the chemotherapy might have made this stenosis.

He mentioned this here too. Now I think there are more stenoses than we can count. Or, ok, three. A stenosis in the subclavian, one in the jugular valve, and maybe one in the innominate. And a fourth in the jugular on the other side.

At the least, this case gave Dr. Sclafani a workout. And we like to see him challenged.

Dr. Sclafani, would the 'puff' of contrast out to the side be the contrast refluxing into the subclavian?

BINGO!!!

[drsclafani]

Evidently many many healthy people live quite well with CCSVI and no intervention. MS, not so much according to natural history progression studies.

Because of the high correlation between MS and CCSVI, your first sentence is contradicted (or at least mitigated) by your second.

There are many studies now that do not show a high correlation between MS and CCSVI, or any correlation at all. Your first premise is not based on the bulk of research available.

Even if there were a clear association between CCSVI and MS, this in no way indicates CCSVI has a detrimental effect on health. This is supported by the Buffalo study that showed a fair number of healthy controls that had CCSVI with no apparent detrimental health effect. There are certainly no studies that show that worsening MS is due to CCSVI. Even the study that showed that some with worse MS had worse CCSVI, as we know, correlation does not mean causation. But studies are all over the map whether CCSVI and MS are even associated though with many showing no difference in CCSVI levels between MSer's and non-MSer's.

I don't see the contradiction you refer to.

(and certainly no reason to feel anger or dismay about another's choice to try to stabilize a progressive, debilitating illness with an approved treatment)

Just because a treatment is approved, does not mean that it was administered correctly. If was not, perhaps anger is justified. I believe that dismay is allowed under any circumstance if the desired outcome is not achieved.

We don't know if her treatment was administered correctly. Certainly there can be side effects even when a treatment IS administered correctly. It not only might have been administered correctly, it might have improved her MS course. I don't think "dismay or anger" are appropriate when the patient and her doctor chose a treatment to try to delay her MS progression that might have had side effects or risks involved. The patient is not the one expressing anger or dismay, Cece, an uninvolved observer is.

And if the port caused a stenosis, clearly that stenosis was not related to her already compromised health status that resulted in her undergoing chemo treatment to begin with - we have no idea if that stenosis impacted her vascular health or her MS at all.

ERIC
i am in the process of education on a case presentation, not debating the association of ms and ccsvi. To me, there is not debate. 99% of patients i have performed venography on have altered venous anatomy with stenoses, hypoplasias, septums, webs, valves etc.

But this is not the discussion at hand. Look at the images and tell me what is normal about these veins.

please ask a question and i will answer it. please do start another thread that addresses your issues. This thread is supposed to allow DrSclafani to answser some questions

thanks

[drsclafani]

Mike,

Was the unused port flushed regularly with heparin? I know doctors don't like leaving unused ports in indefinitely for no reason, but if there is an anticipated future use, it is a matter of weighing risks against benefits. Ports usually only last for up to 5 years anyway. I'm sure you must have been given information about the risks and side effects of having a port inserted.

good question.
i am unsure that five years in situ is proven safe and satisfactory. But it is a judgment. Some have been in that long but i wonder why leave it in that long.

[drsclafani]

My thought now is that the stenosis in the innominate is causing the flow entering from the jugular to reflux back into the subclavian. Thus the puff. The flow from the jugular is looking for another way out when it hits the innominate stenosis. It does not have to be a full occlusion, only a partial one, to cause reflux.

I concur. I think the stenosis in the innominate is further exacerbated by the catheter occupying the residual CSA of the lumen. Does anybody know the diameter of the catheter?

a diagnostic catheter is 4-5 French, the sheath is 10 French
French is a measure of diameters.
three french equals on mm.

So the catheters are 1.3-1.7 mm
and the sheath is 3.3 mm

And yes a 10 Fr catheter is partially obstructive

3Frenchis

[drsclafani]

Perhaps it is more likely that the catheter occupies the entire diameter of the residual lumen of the innominate?

He's talked about this happening in a hypoplastic jugular. You can see in his images the size of the vein vs the size of the catheter. The innominate vein is typically larger than the jugular, as we've learned from all the shoulder-of-the-balloon placement discussion. If it were reduced to the size of the catheter, that would be a very high-grade stenosis.

The relevant image is the bottom one on the right:


When he was ballooning the jugular, because of how he places the balloon, the innominate vein will have already been ballooned albeit to a smaller size than its vein size. I don't see any obvious stenosis or banding in the balloon in the innominate in that middle row of images. Maybe a larger balloon placed in the innominate will tell the tale? How does a chemo scarred vein respond to ballooning? Maybe it should be left alone?

cece
leaving a high grade stenosis alone is admitting defeat and preventing improvement in blood flow. So the choice is not do nothing, but how to best do this.

I treated with balloon angioplasty, as i think that a patient has the right to proper deliberation when multiple stents are considered. as narcotics were on board, i thought we would dilate and see how things go. I have great suspicion that a stent will be necessary to treat such a stenosis due to chemotherapy stenosis.

[MikeInFlorida]

I have great suspicion that a stent will be necessary to treat such a stenosis due to chemotherapy stenosis.

Dr. Sclafani, this is disconcerting.
1. How bad was the stenosis in the innominate?
2. What are the characteristics of a chemotherapy stenosis versus the typical stenoses you encounter?
3. Specifically, do chemotherapy stenoses weaken the endothelial wall? Are they more delicate? More prone to thrombosis? More prone to elastic rebound?
4. With respect to stenting, my recollection of the general tenor your historical posts is one of great reluctance to utilize stenting. Could you please elaborate on why a chemotherapy stenosis may require a stent?
5. Do you believe that both the subclavian and innominate chemotherapy stenoses may require stenting?
6. Would a stent placed in the innominate be riskier than one placed in the subclavian (specifically, more prone to travel, or more dangerous if it did travel)?
7. Do any other options exist?

[MikeInFlorida]

Dr. Sclafani,

Here is an image of the IJV - subclavian junction from Gray's anatomy:

Here is a similar X-ray image of the patient:


The junction point in the patient's X-ray looks nothing like the Gray's image. The subclavian seems to funnel down dramatically. The junction is neither the port origination point nor the termination point- it is somewhere in the middle of the port length.

1. Is this funneling actually there (or is it possibly a deceptive image?), and if so, is funneling normal (perhaps an artifact of the fact that the baloon is currently inflated)?
2. If the funnel is really there and is abnormal, would you consider this to be another stenosis?
3. If it is a stenosis, is it treatable?

[Cece]

I took the liberty of adding some arrows, to make sure we are discussing the same areas....

The blue arrow looks like a likely candidate for the subclavian stenosis, as lit by refluxing contrast. Just below the pink arrow is where you are seeing a funnel-like narrowing? The green arrow is where the contrast ends. This might be the innominate stenosis.

The jugular itself looks like a nice size.

I believe there is flow in the subclavian and innominate veins at all times, unlike the jugulars which collapse when upright, so that might be better for a stent if necessary. But let's hope the ballooning holds. What sort of follow-up imaging can be done to check on the innominate and subclavian? Is a doppler sufficient?

[MikeInFlorida]

The blue arrow looks like a likely candidate for the subclavian stenosis

Something definitely looks funny about that, and it may be the stenosis, but I was expecting the stenosis to be at the port access site. The blue arrow is much too close to the IJV to be the access site.

Just below the pink arrow is where you are seeing a funnel-like narrowing?

Yes. Doesn't look anything like the anatomy books.

The green arrow is where the contrast ends. This might be the innominate stenosis.

My thoughts too... unless the taper at the green arrow is an illusion, a combination of the sheath blocking some of the view and the diminishing contrast in the direction of flow.

One other thing for the Doctor... I know that the catheter routing shown is SVC to innominate to IJV, but the section of catheter from the green arrow to the end of the sheath (assuming the end of the sheath is the white band) looks like it is outside the innominate. Is this a distortion of the image, or the result of the sheath blocking the contrast? If the lumen includes the area occupied by the catheter in the image, then the CSA of the innominate (between the green and pink arrows) looks substantial.