DrSclafani answers some questions

[Cece]

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.

Huh, so the port is further away. Dr. Sclafani has said that he believes the stenosis was due to the puncture, which would be at the port site. Then maybe the blue arrow is pointing to contrast leaving the subclavian and getting into little collateral veins. That has looked somewhat similar to this before.

He might have additional images, such as one of the subclavian with contrast released on the other side of the subclavian stenosis, in the normal direction!

Plus there is still a whole RIJV to look at. And maybe an azygous or two. (With CCSVI, you never know....)

No pressure, Dr. Sclafani..... ;)
Maybe a little pressure.....
This case has generated a lot of interest!

[MikeInFlorida]

Huh, so the port is further away. Dr. Sclafani has said that he believes the stenosis was due to the puncture, which would be at the port site.

I did not intend to state that with such authority. I should have said "seems much too close". I could definitely be wrong.

The port scar is definitely located below the clavicle, and comparing the scar to my anatomy book, it looks like it might be close to where the cephalic vein joins the subclavian.

[HappyPoet]

Mike, did your wife's left arm ever swell before the venoplasty? If not, maybe collateral veins weren't needed; i.e., blood flow was slow but adequate enough for the body not to create collaterals. Thx.

Cece, your puff looks like it has a right angle in it with the point of your blue arrow pointing to the vertical line of the puff. I wonder if the puff is part of the port. Thx.

Edit: An attempt to better describe the right angle I see:
The horizontal line of the right angle is at 0 degress (line of blue arrow is above and parallel to the horizontal line which starts an area of lighter gray under it).

The vertical line of the right angle is at 90 degrees (point of blue arrow is pointing to the vertical line).

[Cece]

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.

He addressed this once, a very very long time ago, when the question was raised if all CCSVI images were a hoax because the catheters were not even in the veins in some of the images!!

[Cece]

Looking at the image, do you see how the thyroid veins connect to the innominate vein? Thyroid veins may be recruited to serve as collaterals when jugulars are blocked. If the innominate is blocked too, depending on where the blockage is, it might prevent the thyroid veins from being effective collaterals.

[HappyPoet]

If the innominate is blocked too, depending on where the blockage is, it might prevent the thyroid veins from being effective collaterals.

I wonder how much of the arm's blood the thyroid veins can handle.

[MikeInFlorida]

Looking at the image, do you see how the thyroid veins connect to the innominate vein? Thyroid veins may be recruited to serve as collaterals when jugulars are blocked. If the innominate is blocked too, depending on where the blockage is, it might prevent the thyroid veins from being effective collaterals.

Your knowledge of anatomy is impressive. The thyroid collateral is a very good pickup.

I feel like I am in a game of "Clue", except I know a few of clues in advance (but for the most part, I am clueless). Since the good Doctor has already passed the ECD pre-op discussion, I guess I'll let you (and HappyPoet) in on this piece of 411: the pre-op ECD showed: either engorged thyroid collaterals (hopefully), or something else (best case, cysts, worse case, the big-C).

So here's my speculation on the good news and bad news: the good new is, you don't have thyroid cancer, and the thyroid is serving as an effective collateral. The bad new is, your innominate is pretty much blocked.

[MikeInFlorida]

Mike, did your wife's left arm ever swell before the venoplasty? If not, maybe collateral veins weren't needed; i.e., blood flow was slow but adequate enough for the body not to create collaterals. Thx.

Hi HappyPoet, we/she never noticed swelling in her arm. Apparently, that was the one negative she did not have to endure during the chemo course... everything else: hair loss, nausea, extreme fatigue, and apparently, damaged veins- occurred. After the chemo course concluded, and until Dr. Sclafani treated her, there was no perceptable swelling anywhere.

[HappyPoet]

Mike,

I'm so sorry about the roller-coaster your wife and you are on right now. She's very lucky to have your help during this emotional time.

Wishing you both the best of luck,
~Pam

[Cece]

Since the good Doctor has already passed the ECD pre-op discussion, I guess I'll let you (and HappyPoet) in on this piece of 411: the pre-op ECD showed: either engorged thyroid collaterals (hopefully), or something else (best case, cysts, worse case, the big-C).

So here's my speculation on the good news and bad news: the good new is, you don't have thyroid cancer, and the thyroid is serving as an effective collateral. The bad new is, your innominate is pretty much blocked.

Of those choices, I hope it is the engorged thyroid collaterals. It would make a lot of sense if indeed the innominate blockage is slowing the thyroid veins from draining.

Rather than an effective collateral, it had become an ineffective collateral! Prior to chemotherapy, the thyroid veins would have been one of the collaterals for the jugular blockages. But after chemotherapy, with the innominate blockage, the thyroid veins would have slow flow due to poor drainage into the innominate. Neither the before nor the after would be healthy for the thyroid. But the after is worse for the cerebrospinal drainage as a whole because one more route has been compromised.

I am glad you got your wife to a CCSVI IR, and particularly to one who knows what he's doing.

[Cece]

Cece, your puff looks like it has a right angle in it with the point of your blue arrow pointing to the vertical line of the puff. I wonder if the puff is part of the port. Thx.

Edit: An attempt to better describe the right angle I see:
The horizontal line of the right angle is at 0 degress (line of blue arrow is above and parallel to the horizontal line which starts an area of lighter gray under it).

The vertical line of the right angle is at 90 degrees (point of blue arrow is pointing to the vertical line).

I see exactly what you're describing, but I don't know what to make of it....

Good question about the arm swelling. It's a little shocking that both the innominate vein and the subclavian vein can become stenosed without symptoms to indicate it. And I don't even want to think about where the subclavian flow might be rerouting. It can't possibly be going up toward the brain?

[NHE]

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.

He addressed this once, a very very long time ago, when the question was raised if all CCSVI images were a hoax because the catheters were not even in the veins in some of the images!!

I remember this discussion as well. To the best of my recollection, the catheter tends to run along and push out to the edge of the vein while the contrast flows more toward the center. These effects give the appearance that the catheter is outside of the vein even though it is not.

NHE

[MikeInFlorida]

These effects give the appearance that the catheter is outside of the vein even though it is not.NHE

For the record, I never thought the catherter was outside. My point was that the lumen is larger than it appears. It would be great if the catheter had deployable (and retractable) "spacers" to always keep it in the center of the lumen. I should patent that idea.

[HappyPoet]

Mike, does your wife show signs of thyroid dysfunction? Hyper or Hypo? Do you know why the port has not been removed (sorry if I missed this)?

Cece, I don't think the blood necessarily refluxed into the brain itself: The left vertebral vein* could be helping in draining the left subclavian vein directly to the dural sinuses for drainage down the VVP, with the remainder of blood using the thyroid veins for getting to the IJVs for getting to the dural sinuses for getting to the VVP.

I wonder for how long the left innominate vein blockage has been stressing the thyroid veins.

Edits *:
1. Fixed a wrong word and a typo (VVs to VVP)
2. Assumes flow is strong enough to push through valve?
3. I forgot to say that maybe a collateral vein formed to connect the left innominate vein to the right innominate vein, or to the SVC, or even directly to the right atrium of the heart itself?

[MikeInFlorida]

Mike, does your wife show signs of thyroid dysfunction? Hyper or Hypo?

She does have hypothyroidism, and takes 50 mcg of generic Synthroid each day. She is scheduled to see an endocrinologist next week.

Do you know why the port has not been removed (sorry if I missed this)?

The port was removed 16 months ago. It was installed for the 18-month cytoxin series, then we left it in for an additional 20 months. It was left in place in case we decided to do another chemo series. After awhile, my wife wanted it out, so it was removed.