critiquing random CCSVI procedure found in billing forum....

[Cece]

www.aapc.com/memberarea/forums/showthread.php?t=42564

PRE DIAGNOSIS: Central venous occlusive disease
POST DIAGNOSIS: Same

DETAILS OF PROCEDURE:
EKG was interpreted throughout the procedure. The left groin was prepped and draped. An 8F sheath was placed and a catheter was used to select the right IJ. A venogram was performed which showed a diffuse narrowing within the mid portion of the vein and a 50% stenosis at the level of the valve inferiorly. An 8mm balloon was initially used to treat both portions of the IJ with no improvement. Thus a 10mm balloon was also used with a waist that resolved upon full inflation of the balloon at the level of the valve. However, the mid portion of the jugular was still had a 90% stenosis.

The left internal jugular vein was then selectively catheterized. A venogram was performed which showed findings similar to the MRV performed yesterday. The IJ from the skull base to the lower neck was very small in caliber with an equally sized collateral running parallel to it into the skull base. Both were approximately 5-6mm in diameter. In the lower neck, the IJ and it’s collateral joined and the IJ was approximately 10mm with a 50% stenosis at the level of the inlet to the subclavian vein. The flow through the IJ system was very minimal and slow due to the small caliber throughout. To treat the valve region a 10mm balloon was used with a residual waist so a 12mm balloon was used. A residual waste was seen so a high pressure Conquest balloon was used to treat the valve with resolution of the waist. Repeat venogram showed residual slow flow through the IJ system. A small amount of intimal disruption but no extravastation was seen within the venoplasty region so 5000U of heparin were given.

A Cobra catheter was used to catheterize the Azygus vein and venogram was performed. No evidence of disease was seen with rapid antegrade flow throughout the vein. Thus the catheter was removed.

The RIJ was re-examined and venogram showed residual 90% mid stenosis with significant collateral flow. Thus despite aggressive angioplasty, recoil was present. A 14mm x 6cm Zilver uncovered stent was deployed across the lesion and completion venogram showed rapid antegrade flow with no collaterals.

The LIJ was selected and venogram showed stagnant flow due to residual stenosis at the inferior portion. A small amount of thrombus could not be ruled out so 2mg of tPA was given in that region. Further angioplasty with the 12mm balloon was also performed. Completion venogram showed a small amount of mobile filling defects but with antegrade flow.


IMPRESSION: Central venous occlusive disease. RIJ mid stenosis treated with 10mm PTA and ultimately a 14mm x 6cm stent. Left IJ small in caliber as described above. Inferior portion treated with 10 and 12mm balloon. Intimal disruption and subsequent filling defects. Ultimately resultant antegrade flow with small intra luminal filling defects. Normal Azygus vein.

PLAN: Pt will be given a prescription for lovenox to take for the next several days to allow the intimal tear to heal within the left IJ. Pt will see me in the office tomorrow for ultrasound to ensure no evidence of DVT.

[Cece]

www.aapc.com/memberarea/forums/showthread.php?t=42564

PRE DIAGNOSIS: Central venous occlusive disease
POST DIAGNOSIS: Same

DETAILS OF PROCEDURE:
EKG was interpreted throughout the procedure. The left groin was prepped and draped. An 8F sheath was placed and a catheter was used to select the right IJ. A venogram was performed which showed a diffuse narrowing within the mid portion of the vein and a 50% stenosis at the level of the valve inferiorly. An 8mm balloon was initially used to treat both portions of the IJ with no improvement.

We do not commonly hear reports of the mid portion of the IJV being narrowed. This may have been ballooned unnecessarily. IVUS would have been useful to determine if it was a true stenosis or if it was physiological.

8 mm balloon is an extremely small balloon although without knowing the exact measurement of the vein, it is difficult to know if it was appropriately sized. My guess would be that this is an undersized balloon.

Thus a 10mm balloon was also used with a waist that resolved upon full inflation of the balloon at the level of the valve.

A waist that resolved sounds good!

However, the mid portion of the jugular was still had a 90% stenosis.

The mid portion of the vein still had a 90% stenosis? And it was left this way. Not good. I do not think this vein was investigated or treated thoroughly enough. An exact measurement of the vein would've allowed for a larger balloon to most likely be used in the area of the valves (presuming that a remaining stenosis there is causing the low flow higher up that would allow a physiological stenosis to compress the vein to 90%). There can be more than one waists. It could be that the IR was tricked into complacency upon seeing one waist resolve in the area of the valves, when another waist would have been seen on the next balloon size up.

The left internal jugular vein was then selectively catheterized. A venogram was performed which showed findings similar to the MRV performed yesterday.

It is good to know that the MRV was predictive of what was found in the venogram. Dr. Dake's recent published research on his original patients showed an 80% concordance between what was seen on the MRV and what was seen on the catheter venogram, with the venogram as gold standard.

The IJ from the skull base to the lower neck was very small in caliber with an equally sized collateral running parallel to it into the skull base. Both were approximately 5-6mm in diameter.

This is very small. And the collateral running into the skull base? Does that mean, if it runs into the skull base, that it is an emissary vein going through a skull canal? Not sure. Interesting that the collateral measured the same size as the IJV.

In the lower neck, the IJ and it’s collateral joined and the IJ was approximately 10mm with a 50% stenosis at the level of the inlet to the subclavian vein. The flow through the IJ system was very minimal and slow due to the small caliber throughout. To treat the valve region a 10mm balloon was used with a residual waist so a 12mm balloon was used.

oh dear.
How do you calculate the CSA of a 5-6 mm diameter vein?
CSA is n*r*r but what is n?
ok this only took me ten minutes but n is not n. It is pi. Lol.
pi * (5.5/2) * (5.5/2) = 23 mm2 for the CSA
This could've been done more precisely with ivus. Just sayin'.

Using Dr. Sclafani's chart from here ( www.thisisms.com/ftopicp-172379.html#172379 ), a vein with a CSA of 23 would get a size 6 balloon with a willingness to go up to size 7. I think.

Instead this procedure started with a 10 mm balloon, then a 12 mm balloon. A residual waist was seen. The next step in the following paragraph as a high pressure balloon, but still with the same 12 mm size.

I believe that this vein has been overtreated. Using this big of a balloon on this small of a vein could result in more damage, including scarring.

A residual waste was seen so a high pressure Conquest balloon was used to treat the valve with resolution of the waist. Repeat venogram showed residual slow flow through the IJ system. A small amount of intimal disruption but no extravastation was seen within the venoplasty region so 5000U of heparin were given.

And see? There was intimal disruption but no extravasation. I think this means the vein tore.

Again, with IVUS, the doctor could have looked at the tear. It may have already been forming a thrombus right there on the table. This could be seen with IVUS and then suctioned out, if it were happening.

I have no way to interpret the administration of heparin at this time, presumably in response to the intimal disruption. Wouldn't the patient already have been heparinized?

A Cobra catheter was used to catheterize the Azygus vein and venogram was performed. No evidence of disease was seen with rapid antegrade flow throughout the vein. Thus the catheter was removed.

The flow in the azygous was rapid. I think that's good? If there was a renal stenosis causing a rerouting of flow to the azygous, that too could result in rapid flow.

The azygous is difficult to diagnose but stenoses in the azygous are present only in a subset of patients (perhaps 25%).

The RIJ was re-examined and venogram showed residual 90% mid stenosis with significant collateral flow. Thus despite aggressive angioplasty, recoil was present. A 14mm x 6cm Zilver uncovered stent was deployed across the lesion and completion venogram showed rapid antegrade flow with no collaterals.

So the doctor did return to the RIJ! But what is this? The patient received a stent in the mid-portion of the IJV. This is not a common place for CCSVI stenoses. Could this be overtreatment? What else could cause a mid-jugular narrowing? IVUS might have informed whether it was a physiological stenosis or not (such as if it could've expanded if the patient holds her breath; this could be caused by compression from the carotid or a muscle).

If the vein ultimately required a 14 mm stent, does that mean it was a 12 mm vein? If so, wouldn't the initial ballooning with an 8 mm balloon, then a 10 mm balloon, be undersized?

Please know, I don't know if this was the right choice or not. I am cautious about stents.

The LIJ was selected and venogram showed stagnant flow due to residual stenosis at the inferior portion. A small amount of thrombus could not be ruled out so 2mg of tPA was given in that region.

tPA is tissue plasminogen activator, a powerful clot-busting drug that also raises the risk of hemorrhage. It may have been the drug that led to the unfortunate passing of the patient in Costa Rica. But I have no idea of the quantities or how much 2mg of tPA is, in context.

Further angioplasty with the 12mm balloon was also performed. Completion venogram showed a small amount of mobile filling defects but with antegrade flow.

Ballooned again on the LIJV, with a much too big balloon. Not sure what the mobile filling defects represent. Could it be clots?

IMPRESSION: Central venous occlusive disease. RIJ mid stenosis treated with 10mm PTA and ultimately a 14mm x 6cm stent. Left IJ small in caliber as described above. Inferior portion treated with 10 and 12mm balloon. Intimal disruption and subsequent filling defects. Ultimately resultant antegrade flow with small intra luminal filling defects. Normal Azygus vein.

PLAN: Pt will be given a prescription for lovenox to take for the next several days to allow the intimal tear to heal within the left IJ. Pt will see me in the office tomorrow for ultrasound to ensure no evidence of DVT.

I am glad to see that there were plans for follow-up with ultrasound to check for deep vein thrombosis.

I think this patient was undertreated (RIJV in the area of the valves), overtreated (LIJV) and then overtreated (RIJV in the mid jugular region). The patient left with a tear in the left jugular and a stent in the midportion of the right. Perhaps this could have been avoided.

I take away from this that, with the steep learning curve for the IRs, it might be best to go expert or not to go at all, at this time. Being undertreated is unfortunate but being overtreated can be tragic if it results in the loss of a jugular.

Any thoughts on this case?

[HappyPoet]

Wow, Cece! DrS has got to see your terrific analysis of this case!

Initial thoughts:

Right-IJV
Too bad we don't know the atmospheres of pressure used for each balloon inflation, nor for how many minutes each inflation lasted, nor the number of times each balloon was inflated. This info might answer why some stenoses were or appeared persistent, such as the middle section of the R-IJV which was stented.

This is not a common place for CCSVI stenoses. Could this be overtreatment? What else could cause a mid-jugular narrowing? IVUS might have informed whether it was a physiological stenosis or not (such as if it could've expanded if the patient holds her breath; this could be caused by compression from the carotid or a muscle).

This patient's R-IJV is very small (5-6 mm); perhaps there was catheter-induced vasospasm that caused the uncommon mid-IJV stenoses which the IR was "fooled" into stenting?

Left IJV Later. I'm out of time for now.

[Cece]

Wow, Cece! DrS has got to see your terrific analysis of this case!

I am curious what I may have gotten wrong or what his thoughts would be.
This ain't easy!

Initial thoughts:

Right-IJV
Too bad we don't know the atmospheres of pressure used for each balloon inflation, nor for how many minutes each inflation lasted, nor the number of times each balloon was inflated. This info might answer why some stenoses were or appeared persistent, such as the middle section of the R-IJV which was stented.

As far as I can tell, high pressure balloons were only used on the left IJV. So the right IJV was at ordinary pressure. I don't know what the upper limit of a normal pressure balloon is. I couldn't find it just now looking up.

On the left side, a Conquest balloon was used, and that's quite a balloon. It has a rated burst pressure of 30 atm but according to a chart in this great presentation: http://vascularaccessdoc.com/PPT/Art%20 ... plasty.pdf they couldn't get the Conquest balloon to burst, although the lesser ones did.

In this case, the right jugular was stented despite only being treated with a 10 mm balloon that was not high pressure.

I agree with everything you've listed, it would be helpful to have more information.

This is not a common place for CCSVI stenoses. Could this be overtreatment? What else could cause a mid-jugular narrowing? IVUS might have informed whether it was a physiological stenosis or not (such as if it could've expanded if the patient holds her breath; this could be caused by compression from the carotid or a muscle).

This patient's R-IJV is very small (5-6 mm); perhaps there was catheter-induced vasospasm that caused the uncommon mid-IJV stenoses which the IR was "fooled" into stenting?

It was the left IJV that was 5-6 mm. We don't have the measurements for the right IJV. Since a 14 mm stent was eventually used and stents are typically oversized so that they wedge into place a bit, my guess is that the right IJV was around 12 mm. Only a guess though.

Interesting thought about the vasospasm. I don't know how common such a spasm is.

Left IJV Later. I'm out of time for now.

Come back when you can, I am having fun.

[David1949]

Cece I think you're about ready to perform your first venoplasty procedure.

[HappyPoet]

Cece, regarding this case, I misread this sentence (which is a nice way of saying I have poor reading comprehension skills): "Both were approximately 5-6mm in diameter." I thought the author was referring to both jugulars, but the author was really talking about the L-IJV and its "equally sized" collateral.

Here's another case, which is too extensive to post here, but I think you'll like some of the complexities for when you have more time. For a quick overview now, there's a neat little scrolling sidebar with interesting venograms (with explanations) of the case. I'm having fun exploring such cases.

http://www.mirs.org/Interventional%20Ra ... svcfrm.htm

[Cece]

Cece I think you're about ready to perform your first venoplasty procedure.

As long as I had IVUS....

But there is something even better than IVUS! It's OCT for inside the veins.

Here's an article on it:
www.invasivecardiology.com/article/4338

It allows for even more precise imaging.

Optical coherence tomography (OCT) represents a promising new technology for imaging the vascular microstructure at a level of 10–20 mm, which has not yet been achieved with the use of other imaging modalities.

According to the OCT images, the lumen surface was not smooth, but rather very irregular with fine floating flaps, despite the fact that the IVUS images showed acceptable results in this case.

[Cece]

Cece, regarding this case, I misread this sentence (which is a nice way of saying I have poor reading comprehension skills): "Both were approximately 5-6mm in diameter." I thought the author was referring to both jugulars, but the author was really talking about the L-IJV and its "equally sized" collateral.

It's strange, isn't it, for the collateral to be the size of the jugular!

Here's another case, which is too extensive to post here, but I think you'll like some of the complexities for when you have more time.

Thanks!
I stumbled on this procedure report accidentally. If anyone wants me to take a crack at their procedure report, minus any identifying information, you could pm it to me. Caveats would be that I am not a doctor and that I've been heavily influenced by Dr. Sclafani's methods.

[Cece]

I think this patient was undertreated (RIJV in the area of the valves), overtreated (LIJV) and then overtreated (RIJV in the mid jugular region). The patient left with a tear in the left jugular and a stent in the midportion of the right. Perhaps this could have been avoided.

I am curious if people agreed, disgreed, or did not think there was enough information for these conclusions?

[Cece]

We are discussing, in the IVUS thread, a case involving residual narrowing that prompted an increase in pressure and in balloon size, which unfortunately led to an occluded vein six weeks later. It's an informative case on endpoints and it reminded me of this one. Where should the endpoint have been in this case? Sometime before the intimal disruption....

The IJ from the skull base to the lower neck was very small in caliber with an equally sized collateral running parallel to it into the skull base. Both were approximately 5-6mm in diameter.

In the lower neck, the IJ and it’s collateral joined and the IJ was approximately 10mm with a 50% stenosis at the level of the inlet to the subclavian vein. The flow through the IJ system was very minimal and slow due to the small caliber throughout. To treat the valve region a 10mm balloon was used with a residual waist so a 12mm balloon was used.

oh dear.
How do you calculate the CSA of a 5-6 mm diameter vein?
CSA is n*r*r but what is n?
ok this only took me ten minutes but n is not n. It is pi. Lol.
pi * (5.5/2) * (5.5/2) = 23 mm2 for the CSA
This could've been done more precisely with ivus. Just sayin'.

Using Dr. Sclafani's chart from here ( http://www.thisisms.com/ftopicp-172379.html#172379 ), a vein with a CSA of 23 would get a size 6 balloon with a willingness to go up to size 7. I think.

Instead this procedure started with a 10 mm balloon, then a 12 mm balloon. A residual waist was seen. The next step in the following paragraph as a high pressure balloon, but still with the same 12 mm size.

I believe that this vein has been overtreated. Using this big of a balloon on this small of a vein could result in more damage, including scarring.

A residual waste was seen so a high pressure Conquest balloon was used to treat the valve with resolution of the waist. Repeat venogram showed residual slow flow through the IJ system. A small amount of intimal disruption but no extravastation was seen within the venoplasty region so 5000U of heparin were given.

And see? There was intimal disruption but no extravasation. I think this means the vein tore.

[drsclafani]

Any thoughts on this case?

ughh

not necessarily better to go closer to home


i agree with cece

[drsclafani]

Cece I think you're about ready to perform your first venoplasty procedure.

As long as I had IVUS....

But there is something even better than IVUS! It's OCT for inside the veins.

Here's an article on it:
http://www.invasivecardiology.com/article/4338

It allows for even more precise imaging.

Optical coherence tomography (OCT) represents a promising new technology for imaging the vascular microstructure at a level of 10–20 mm, which has not yet been achieved with the use of other imaging modalities.

According to the OCT images, the lumen surface was not smooth, but rather very irregular with fine floating flaps, despite the fact that the IVUS images showed acceptable results in this case.

I wish.

i explored the possibility about three months ago. The device is not suitable for the jugular veins. The field of view is too small. when i discussed this with the rep, as soon as we clarified the size of the vein, he basically hung up on me.

too bad, it does seem like it might be of value

[Cece]

So an OCT could potentially be used on hypoplastic jugulars, or vertebrals, or ascending lumbars...not sure what use that would be. That is disappointing. I liked the thought of it.