DrSclafani answers some questions

[drsclafani]

It looks like theres an obstruction at the arc of the azygous, just to the right of where it bulges.

Let me place the image here for ease of discussion


That is a good thought. A bulge like that is not uncommon. Bulging in obstructions is often due to an obstruction as the flow is forced through a narrowed area and velocity rises; it could also occur if there were increased flow through an area.. Also one could get a bulge after an angioplasty, but the first IR did not treat anything in the azygous vein. Personally, I thought that the bulging was within the range of normal.

But perhaps you are correct. But where is the stenosis adjacent to the bulge? or where would the increased flow come from?

[drsclafani]

The right internal jugular has a messy valvular area and a curious stenosis above it. Is it the external jugular receiving some dye?

The left internal must have severe intimal hyperplasia because of the stent around its upper side, leaving only a small channel for the catheter. The dye goes all around the other side to the right internal jugular which means that the confluence of sinuses is clear inside the head.

In the azygous view, is there a dye congestion/reverse flow in the lower branches or just an early picture?

curious stenosis above. good thought. what could that be? My initial thought was that the first angioplasty overdilated a normal area but in fact the angioplasty of the RIJV was actually below at the confluens. The "messy" area looks like reflux under an obstructed valve to me.

Good call on the reflux in the LIJV. But differential of thrombus and intimal hyperplasia should be considered. Its not surprising that there is reflux into the contralateral IJV. There seems to be NO flow through that LIJV. I was anticipating complete obstruction of that vein. its not, but who thought it was?

also good thoughts on the azygous. I am not sure of the answer. this was a very gentle hand injection so i would not expect such opacification if there were no obstruction. But those vessels are large, arent they?

[Cece]

It looks like theres an obstruction at the arc of the azygous, just to the right of where it bulges.

Let me place the image here for ease of discussion

Just a comment that this is a longer view of the azygous than is normally shown. We are seeing past the candy cane (or walking stick, as Dr. Zamboni described it in the interview that Cheer transcribed recently) to a few veins at its root.

[Cece]

LEFT INTERNAL JUGULAR VENOGRAM:

That just hurts to see. But you were able to get the catheter through it.

what do you think that i got through? What do you see in the jugular view?

I see the mesh stent with no flow going through it. About an inch above the mesh stent is where the jugular flow ends. This would appear to be an occluded stent with the occlusion extending beyond the stent for that inch. I cannot tell the cause of the occlusion but would guess clotting or intimal hyperplasia.

The catheter shows us the path where the vein is, but there is no vein flow to see for much of it.

Since the catheter got through, I would expect that you were able to open the vein. An occluded jugular is indication for another stent to be placed. I wish that this patient lived closer to Brooklyn, or anywhere where quality follow-up CCSVI care would be available. This jugular should be monitored because of the risk of it closing up again.

edited to add: you can also see the jugular on the other side lighting up, taking the flow that cannot go down this jugular, as mo_en has said.

[drsclafani]

LEFT INTERNAL JUGULAR VENOGRAM:

That just hurts to see. But you were able to get the catheter through it.

what do you think that i got through? What do you see in the jugular view?

I see the mesh stent with no flow going through it. About an inch above the mesh stent is where the jugular flow ends. This would appear to be an occluded stent with the occlusion extending beyond the stent for that inch. I cannot tell the cause of the occlusion but would guess clotting or intimal hyperplasia.

The catheter shows us the path where the vein is, but there is no vein flow to see for much of it.

Since the catheter got through, I would expect that you were able to open the vein. An occluded jugular is indication for another stent to be placed. I wish that this patient lived closer to Brooklyn, or anywhere where quality follow-up CCSVI care would be available. This jugular should be monitored because of the risk of it closing up again.

edited to add: you can also see the jugular on the other side lighting up, taking the flow that cannot go down this jugular, as mo_en has said.

what if i told you that ultrasound showed that there was flow in the left jugular . what would you think then?

[Cece]

LEFT RENAL VENOGRAPHY:

I have not seen many renal venograms yet, so cannot say for sure, but is that nutcracker syndrome?

the nutcracker syndrome requires venographic or CT evidence of obstruction, typically where the renal vein enters the inferior vena cava, collateral flow, symptoms. What do you see? Does the history have any symptoms of nutcracker?

If you follow the catheter from the right side of the image, once you approach the middle of the image you see a dark area, then a light area, then a more smooth mid-dark large vein that is taking the flow upwards. The light area would be the compression, as I am interpreting it.... There is an offshoot going upwards, just before the compression, that could be collateral flow. If indeed the azygous had increased flow and larger vessels, that would be as a result of the renal vein obstruction.

Yes the history shows symptoms of nutcracker, if fatigue and CCSVI are to be counted as symptoms of nutcracker.

[Cece]

what if i told you that ultrasound showed that there was flow in the left jugular . what would you think then?

muscular compression ?
have the patient turn her head

[drsclafani]

LEFT RENAL VENOGRAPHY:

I have not seen many renal venograms yet, so cannot say for sure, but is that nutcracker syndrome?

the nutcracker syndrome requires venographic or CT evidence of obstruction, typically where the renal vein enters the inferior vena cava, collateral flow, symptoms. What do you see? Does the history have any symptoms of nutcracker?

If you follow the catheter from the right side of the image, once you approach the middle of the image you see a dark area, then a light area, then a more smooth mid-dark large vein that is taking the flow upwards. The light area would be the compression, as I am interpreting it.... There is an offshoot going upwards, just before the compression, that could be collateral flow. If indeed the azygous had increased flow and larger vessels, that would be as a result of the renal vein obstruction.

Yes the history shows symptoms of nutcracker, if fatigue and CCSVI are to be counted as symptoms of nutcracker.

oops!

i neglected to mention her hypertension, treated by medication. We do not know yet whether she has hematuria, or proteinuria. She does not have pelvic pain or varicose veins of the labia

[Cece]

oops!

i neglected to mention her hypertension, treated by medication. We do not know yet whether she has hematuria, or proteinuria. She does not have pelvic pain or varicose veins of the labia

Is she going to be tested for hematuria or proteinuria? Would those conditions persist after treatment, for a short time, presuming this is indeed nutcracker syndrome and was stented?
Hypertension is indeed a symptom of nutcracker syndrome, although I had to double-check: http://www.thisisms.com/forum/chronic-c ... ml#p181719

The "messy" area looks like reflux under an obstructed valve to me.

You had described this, using a wine glass in a tumbler image, at the symposium patient day. Here was me trying to describe what you had said:
http://www.thisisms.com/forum/chronic-c ... ml#p171050
I bet there's a link out there for the actual presentation now....

[Cece]

Dr Sclafani, you worked on both my jugular veins back in March and I have recently developed laryngospasm. Could it be related? I've learned that it is usually due to an injured nerve. Do you come in contact with the larnyx during ballooning the jugulars? Thanks, Dori

*bumping this up*

[ozwannabe]

Thanks Dr S Love reading your posts and on facebook too. I'm wondering if the stent on the left is in another vessel other than LIJ. I say this because in my own case I have a massive collateral vessel that initially was catheterised as it was obstructing the view of my poor hypoplastic vein. It may have been stented in error?

Cheers,
Vicki

[drsclafani]

Dr Sclafani, you worked on both my jugular veins back in March and I have recently developed laryngospasm. Could it be related? I've learned that it is usually due to an injured nerve. Do you come in contact with the larnyx during ballooning the jugulars? Thanks, Dori

*bumping this up*

cece, take a look. I think i answered this question.
bottom line, i do not think that laryngospasm would occur six months after angioplasty
the vagus nerve does run close to the jugular vein so it is possible that angioplasty could affect this nerve. But it should not take that long for it to become a problem. I am more concerned about a relapse or some non-ms related problem.

[drsclafani]

The "messy" area looks like reflux under an obstructed valve to me.

You had described this, using a wine glass in a tumbler image, at the symposium patient day. Here was me trying to describe what you had said:
http://www.thisisms.com/forum/chronic-c ... ml#p171050
I bet there's a link out there for the actual presentation now....

so lets review the right internal jugular venograms. I will review all the IVUS studies together later:



This vein was treated successfully a year ago. This image shows that there is a narrowing of the mid right IJV. Below this there is some irregularity and bulging of the contrast at the area ofof previously treated valve problems. There is reflux into the right external jugular vein (to the left of the IJV on the image).

Now a composite summary of the right side.



The first two images show the right transverse sinus emptying into the internal jugular vein. I think that this is the optimum way to fully evaluate the internal jugular vein. Opacify it by putting the constrast media upstream from the jugular vein. Sometimes, not often, you will see something wrong with the dural sinuses. You will also get a long at the condylar emissary vein which is a often seen collateral vein.Collaterals seen are minimal.

There was evidence of stenosis at the confluens where the valve was treated previously. There is refluxing contrast media in the external jugular vein and there is irregularity of the confluens. IVUS, not shown here, revealed that there were internal echoes that represented scartissue or residual remnants of the valve or residual fixed valvular tissue.

angioplasty was performed at the valvular area (balloon inflated). Then on to evaluate the mid jugular narrowing. Based upon this location, one should consider a few explanations.

1. Perhaps the first angioplasty was extended too high and the normal vein was overstretched and subsequently got scarred down. Not the case this time...

2. Consider that there was compression of the vein by the carotid artery.IVUS showed that this was not the case.

3. Final possibility was muscular compression. The final two images are with the neck rotated, first internally rotated, and the second one externally rotated. You can see that internal rotation results in a phasic complete compression of the vein with no flow at all in the IJV. All the contrast media was directed toward the external jugular vein. . When the head is turned externally, there is no stenosis and there was rapid flow.

Based upon this observation, one can say that this was a phasic narrowing caused by pressure of the muscles of the neck. I would advise no treatment beyond the angioplasty of the confluens' residual tissue narrowing the vein. Dilating muscle compression is unlikely to be helpful. Stenting is a possibility but I prefer NOT to place stents in the jugular except in a few circumstances.

[NZer1]

So reading between the lines there is 'chance' that residual tissue will require attention, for some?

[pelopidas]

3. Final possibility was muscular compression. The final two images are with the neck rotated, first internally rotated, and the second one externally rotated. You can see that internal rotation results in a phasic complete compression of the vein with no flow at all in the IJV. All the contrast media was directed toward the external jugular vein. . When the head is turned externally, there is no stenosis and there was rapid flow.

Based upon this observation, one can say that this was a phasic narrowing caused by pressure of the muscles of the neck. I would advise no treatment beyond the angioplasty of the confluens' residual tissue narrowing the vein. Dilating muscle compression is unlikely to be helpful. Stenting is a possibility but I prefer NOT to place stents in the jugular except in a few circumstances.

what are the treatment options?
thank you for the image uploading trick


and this is a very important lecture