DrSclafani answers some questions

[drsclafani]

Dear Dr. Sclafani!
It is not my case but one patient has asked me for help.
A woman got 4 stents into her jugulars. One of the stent migrated into her heart.
Either they have noticed couple of months later or it was soon after the intervention. IR tried to "pull" it out but the stent is growed to the ventricle (of her heart).
She is scared of course and does not feel very well. She gets extrasystols and feels pressure on her chest.
She does not know what to expect.
Do you have an idea?
Erika

erika
i cannot understand the use of four stents in anyone. so sad.

we need to know whether the stent is stuck to the valve area. malfunction of the valve could make her tired. The extrasystoles can be dangerous if they occur in the wrong part of the cycle. she may need medication to control her irregular heart.

poor woman. did she derive any benefit of her neuro symptoms from the stents?

[drsclafani]

A stent in her heart? That is awful, Erika.

I pushed the envelope for the son, poor guy really needed all the chance possible.Started with five millimeter angioplasty and worked up to a ten mm. Working high and low. the low was the easy stuff. But i suspect that angioplasty is not going to make that much difference.

In mom, I chose not to push the envelope because she is more function. I think that many hypoplasias end up thrombosing if you work too hard on them.

I didn't even recognise these as hypoplasias.
So if a mom and son have hypoplastic left jugulars, there would seem to be a genetic cause for the hypoplasias.

It is good that the other veins remained patent. It rather demonstrates the importance of having two fully functional jugulars, if having hypoplasia on one side meant no lasting improvements.

This case also touches on the question of patient selection, as I understand it, if you approached the mom's hypoplasia differently than the son's.

cece
medicine is really an art that uses science. judgments are really important.

in these cases it had to do with possibilities of good and harm, danger and safety, need and desire

sometimes its not easy

[drsclafani]

I pushed the envelope for the son, poor guy really needed all the chance possible.Started with five millimeter angioplasty and worked up to a ten mm. Working high and low. the low was the easy stuff. But i suspect that angioplasty is not going to make that much difference.

In mom, I chose not to push the envelope because she is more function. I think that many hypoplasias end up thrombosing if you work too hard on them.

So very sorry about the hypoplasia in both mother and son--you've given them their best opportunity for symptom relief which must be a measure of comfort for them to know they've done everything they could do for their CCSVI. Now we wait and hope their L-IJVs can stay patent like their other veins have been able to do.

Did all the blood go down the son's L-IJV after your angioplasty to 10mm, or were collaterals still being used? By what route(s) did the blood take before the angioplasty?

no, not all. the collaterals were through the spinal collaterals, as well as through the dural sinuses

[drsclafani]

Things do go in threes.....Yesterday another patient was treated. This patient with chronic severe headaches, concentration problems, and easy fatigability DID NOT HAVE MS. though by many to have an environmental toxin problem (doubt), he had an ultrasound done at BNAC which showed three of the five criteria.

After several other interventionalists turned him down, he came to me and I agreed to do a diagnostic venogram, (with little expectation of finding anything.

wrong!

Take a look at this neck venogram.....Picture on the right look familiar?



which of the three would you think would have the worst symptoms?

[Cece]

cece
medicine is really an art that uses science. judgments are really important.

in these cases it had to do with possibilities of good and harm, danger and safety, need and desire

sometimes its not easy

You could certainly fill an art gallery with some of the images we've seen here....

I would love to see a hypoplasia successfully treated. And I'm really glad I didn't have one personally.

The image you just posted is a hypoplastic jugular, in a nonMS patient. Fascinating. As for which of the three would have the worst symptoms, I wouldn't hazard a guess at that unless we had images of all their cerebrospinal drainage veins. LIJV, RIJV, verts, azygous. Total outflow mattering more than outflow through any one vein.

[Cece]

Did all the blood go down the son's L-IJV after your angioplasty to 10mm, or were collaterals still being used? By what route(s) did the blood take before the angioplasty?

no, not all. the collaterals were through the spinal collaterals, as well as through the dural sinuses

What a good question. Interesting.

[pelopidas]

Cece is right i think, it's the total outflow that matters. A patient with a hypoplastic jugular and no ms symptoms must have huge collaterals and alternative routes. ..Or a good luck and fate.

[HappyPoet]

Things do go in threes.....Yesterday another patient was treated. This patient with chronic severe headaches, concentration problems, and easy fatigability DID NOT HAVE MS. though by many to have an environmental toxin problem (doubt), he had an ultrasound done at BNAC which showed three of the five criteria.

After several other interventionalists turned him down, he came to me and I agreed to do a diagnostic venogram, (with little expectation of finding anything.

wrong!

Take a look at this neck venogram.....Picture on the right look familiar?



which of the three would you think would have the worst symptoms?

Image #1 is not a neck venogram, so I'm ruling this image out of contention.

Image #1 Second try: a short, totally blocked yet fully flowing IJV means dye can quickly reflux back into the dural sinuses, perhaps even into the deep cranial veins before the dye finds routes downward. Seems like it could be difficult to fix, depending on whether or not the IJV continues below where the dye stops and if the vein does continue, if there are anymore stenoses, such as at the valve. My guess is still #3.

Image #2 is not a familiar-looking image; could it be a side view of the neck? Looks like there is rapid flow down collaterals, so I'm ruling this image out of contention.

Image #3 looks like the mother's and son's images in the previous case -- the hypoplastic IJV has a severe stenosis, which completely blocks the flow of dye.

My guess is #3, BUT NOT because the first two images are eliminated but rather because the velocity of the blood first coming down the IJV and then having to be refluxed back up the IJV will be very slow due to the tiny diameter the entire length of the IJV. Also, there are no freely flowing collaterals present which means the route down must be through the dural sinuses, a time-consuming detour.

Refluxed blood could be forced back up into the deep cranial veins before finding a route down which would result in severe hypoxia with the patient's symptoms of severe headache, fatigue, and poor concentration accounted for.

How difficult was it for you to open the L-IJV? What size balloons did you use and how many balloonings did it take to open the entire length of the vein?


Edit #1 I incorporated DrS's post into a quote and added the last paragraph.
Edit #2 I removed my Dr. Tucker paragraph--I don't understand his idea well enough to comment; I get the gist of it, but not the specifics.
Edit #3 For image #1, I tried again because I realized I misunderstood what DrS asked (cogfog).

[msfire]

Dr. Sal.
When you did my L&R IJV the left was done at 18mm and the right was 20mm, both were done at 18ATS, are you finding this situation of larger ballooning/hi-pressure becoming more common? Is this because of the use of IVUS allowing you to see the boundaries of the veins physical properties?

[newlywed4ever]

I'm not wanting to 'interrupt' these very interesting cases. When time allows, I would love your opinion on a procedure done by Dr Stone at Mayo in Phoenix. The following is 'cut & paste':

"The surgery is simple enough: cut my neck open and take a look at the size and condition of my veins, then slice open my left leg and steal the greater saphenous vein. Then filet the vein and wrap it around a metal rod in a spiral (a bit like a paper towel tube) so as to increase the diameter, then reinsert the new, wider vein back into my neck. Simple enough for me-I just am scheduled to lay there while these guys do it all.

One last thing......if the vein below the jugular (the subclavean) isn't good enough to tie into (i.e. Not big enough, then there will be an added step of cutting my chest open to reinsert the jugular directly into the Superior Vena Cava just before the atrium. Awesome. Hope we get to do that extra step just so I can say I fully experienced this."

Mike's blog is at http://msmikejuices.blogspot.com and he is now 6 weeks post op & doing well. Your thoughts?

[Cece]

How difficult was it for you to open the L-IJV? What size balloons did you use and how many balloonings did it take to open the entire length of the vein?

Perhaps he did not treat this jugular? If the hypoplasia extends all the way up, it might not be possible to balloon that high.

[drsclafani]

Things do go in threes.....Yesterday another patient was treated. This patient with chronic severe headaches, concentration problems, and easy fatigability DID NOT HAVE MS. though by many to have an environmental toxin problem (doubt), he had an ultrasound done at BNAC which showed three of the five criteria.

After several other interventionalists turned him down, he came to me and I agreed to do a diagnostic venogram, (with little expectation of finding anything.

wrong!

Take a look at this neck venogram.....Picture on the right look familiar?



which of the three would you think would have the worst symptoms?

Image #1 is not a neck venogram, so I'm ruling this image out of contention.

Image #1 Second try: a short, totally blocked yet fully flowing IJV means dye can quickly reflux back into the dural sinuses, perhaps even into the deep cranial veins before the dye finds routes downward. Seems like it could be difficult to fix, depending on whether or not the IJV continues below where the dye stops and if the vein does continue, if there are anymore stenoses, such as at the valve. My guess is still #3.

Image #2 is not a familiar-looking image; could it be a side view of the neck? Looks like there is rapid flow down collaterals, so I'm ruling this image out of contention.

Image #3 looks like the mother's and son's images in the previous case -- the hypoplastic IJV has a severe stenosis, which completely blocks the flow of dye.

My guess is #3, BUT NOT because the first two images are eliminated but rather because the velocity of the blood first coming down the IJV and then having to be refluxed back up the IJV will be very slow due to the tiny diameter the entire length of the IJV. Also, there are no freely flowing collaterals present which means the route down must be through the dural sinuses, a time-consuming detour.

Refluxed blood could be forced back up into the deep cranial veins before finding a route down which would result in severe hypoxia with the patient's symptoms of severe headache, fatigue, and poor concentration accounted for.

How difficult was it for you to open the L-IJV? What size balloons did you use and how many balloonings did it take to open the entire length of the vein?


Edit #1 I incorporated DrS's post into a quote and added the last paragraph.
Edit #2 I removed my Dr. Tucker paragraph--I don't understand his idea well enough to comment; I get the gist of it, but not the specifics.
Edit #3 For image #1, I tried again because I realized I misunderstood what DrS asked (cogfog).

sorry hp, i misled you. All three of those images are of the same person, the nonMS patient with ccsvi manifesting with cogfog and chronic fatigue. I would not think that his disability is any less than a PwMS. he cannot function at all. He is unhappy and struggling with no one telling him how he can get well.

But the question of the three was in a comparison of the mother, son and Pw/oMS



which of these three do you think would have the worst symptoms

[HappyPoet]

DrS, I don't think you misled me anymore than I misled myself. Anyway, I'm hoping you're not asking just me this latest question because, as I was telling Cece yesterday afternoon, I won't be participating in the cases anymore due to heavy cogfog. I do hope, though, that others "Come on down!" and start to participate.

Enjoy the cases, everyone, and "Come on down!"

Edit - in red.

[drsclafani]

DrS, I don't think you misled me anymore than I misled myself. Anyway, I'm hoping you're not asking just me this latest question because, as I was telling Cece yesterday afternoon, I won't be participating in the cases anymore due to heavy cogfog. I do hope, though, that others "Come on down!" and start to participate.

Enjoy the cases, everyone, and "Come on down!"

Edit - in red.

hp
i think that your comments have shown that part of your cogfog is insecurity. I think that your comments have been pretty good. So stay with us.

and it was confusing when i sent three pictures of the NonMSer's hypoplasia and asked which of the three belonged to whom. My error in not putting the three patient images together.

[Cece]

Part of cogfog is not being able to trust yourself, because abilities are not consistent and thoughts get slippery, at least in my experience. You can trust that we want you to stay and that you add to the conversation here in a positive way.

If you need examples of insightful posts that you have made, and good questions asked, I know how to quote and link.....