DrSclafani answers some questions

[NZer1]

Thanks Cece for looking into this.
I have been in discussion with Marie Rhodes and this morning went and did some testing at the local Hospital with their theater equipment.
There is allot to understand about the 'stored' or overproduced oxygen in the system first and then one needs to deplete the store by exercise to get to a situation where the body is needing to produce because there is exercise absorbing the oxygen that is stored to identify the individuals base line. Then the 'true' critical points can be seen and then checked with a cerebral oximeter to test my theory. I used only finger and ear lobe systems and it will be necessary to have a treadmill (for example) to get a better understanding of the reserve amounts that we have as an average, then checking if the cerebral oximeter is detecting slow flow or reflux effects or whether there needs to other analyst equipment.

The before and after PTA is the other test that will be interesting for people that get immediate improvement versus those who don't. The reason for the change?, to identify if it is oxygen supply related is the $64 question. Why does PTA 'work' and how? Questions for Neuro's?

Regards Nigel

[NZer1]

There are a few things I would like to add about my findings. The pulse oximeters measure 75% arterial flow and the cerebral oximeter 75% Venus flow.
From that I think that these are not going to be of much use as the area of greatest interest is post capillary bed and vertebral and jugular or azygos are the regions that such a test is best targeted.
Having a simple noninvasive measurement at these places will be the most likely areas where there will be valid learning.
Does anyone know if this is available?

Regards Nigel

[astro]

Here was your original response back in May 2010. Images are in the post above. I have heard recently from astro (hi astro) and after seeing his images, I was wondering about that reflux into the subclavian. If you saw this in a patient of yours, would you investigate the subclavian for a stenosis there? I'm remembering the patient who had a port in the subclavian, I think it was.

Wow, may 2010. My current answer is consistent but clearer now. Certainly NO cutting balloons or stents are necessary for such problems, certainly without another more realistic treatment.

I am less impressed with the treatment of the right IJV than i might have been back in 2010. How is Astro? Was another treatment attempted? Shame. my guess is too small a balloon was used , but that is better, i suppose, than too large!

talking about the interpretation of the images in 2010 led me to remember that I knew i was treating valves way back in early 2010. I just recently saw my third patient from two full years ago, doing so well. in my report in January 2010 I diagnosed valvular stenosis on IVUS.So that sets the record straight, i think

Hi Dr. Sclafani! It's so good to be talking with you on this board again! I am looking forward to meeting you at my appointment in a couple weeks, but wanted to reply now with a little information given the current discussion. My venogram report acknowledges the stenosis, but I don't have a sense of how I was treated. I suspect that they gave me very conservative treatment, especially since my symptoms (and reflux) returned within 2-3 months. I can't wait to share all the details with you at my appointment, but for now here's an excerpt from my report discussing the left IJV:

...the left IJV was cannulated with some difficulty. The difficulty was secondary to severe stenosis at the proximal portion of the internal jugular vein on the left side. The catheter was negotiated into the distal external jugular vein and a venogram was performed at this location. This, once again, confirmed the high-grade stenosis at the proximal portion of the IJV with a web-like lesion and multiple collateralization around this high-grade stenosis. The wires were placed into the catheter. The intravascular ultrasound was once again used to assess the size and extent of the lesion, and based on the ultrasound measurements, a 10x40 balloon was chosen and sequential dilations were performed of the distal portion of the IJV to 8 and 10 atm pressure for 1 minute per inflation. The balloon was then removed. The catheter was replaced into the distal IJV and completion venography was performed. This showed the IJV to now be widely patent and the collaterals were no longer filling at this point as the contrast material was coming in the main channel of the vein without difficulty at this point.

Does this excerpt shed any light on my treatment, and perhaps how it relats to my current condition of worsening symptoms? Thanks!

astro

[Cece]

Astro, I was waiting for you to stop by!
Your case is making for a good discussion because your images are really clear and nice, and now you've got the specifics on your treatment too. And we also had Dr. Sclafani's response from then, compared to now.

Dr. Sclafani has indicated that higher pressures can be effective and safe if the balloon is not oversized. There's an abstract .... http://www.ccsvicare.org/outreach_update03.html

1. High pressures are required to completely dilate the lesions of CCSVI.

I would have said that if the balloon was properly sized using ivus, then going up in pressure was the way to go, but as far as I can interpret this, the ballooning was done at the distal/upper jugular where it may not have needed ballooning and it was not done at the proximal/lower jugular?

[HappyPoet]

Hi astro,

Something to consider: In the sentence you highlighted in bold, the word 'distal' might have been mistakenly used instead of 'proximal.' This possibility makes sense within the entire context of the quote, especially because the IJV, which was confirmed as having a proximal (valve area) "high grade" stenosis, was also reported as being "widely patent" after repeat venography.

...the left IJV was cannulated with some difficulty. The difficulty was secondary to severe stenosis at the proximal portion of the internal jugular vein on the left side. The catheter was negotiated into the distal external jugular vein and a venogram was performed at this location. This, once again, confirmed the high-grade stenosis at the proximal portion of the IJV with a web-like lesion and multiple collateralization around this high-grade stenosis. The wires were placed into the catheter. The intravascular ultrasound was once again used to assess the size and extent of the lesion, and based on the ultrasound measurements, a 10x40 balloon was chosen and sequential dilations were performed of the distal portion of the IJV to 8 and 10 atm pressure for 1 minute per inflation. The balloon was then removed. The catheter was replaced into the distal IJV and completion venography was performed. This showed the IJV to now be widely patent and the collaterals were no longer filling at this point as the contrast material was coming in the main channel of the vein without difficulty at this point.

This wouldn't be the first time that a reporting error has happened. I once had a new T7 lesion mistakenly reported as a T1 lesion which wasn't spotted until I insisted that my MS specialist and I actually look at the images together; an addendum to correct the error was written (so be sure to ask for one if there actually was a mix-up between 'distal' and 'proximal').

Best wishes.

[drsclafani]

Here was your original response back in May 2010. Images are in the post above. I have heard recently from astro (hi astro) and after seeing his images, I was wondering about that reflux into the subclavian. If you saw this in a patient of yours, would you investigate the subclavian for a stenosis there? I'm remembering the patient who had a port in the subclavian, I think it was.

Wow, may 2010. My current answer is consistent but clearer now. Certainly NO cutting balloons or stents are necessary for such problems, certainly without another more realistic treatment.

I am less impressed with the treatment of the right IJV than i might have been back in 2010. How is Astro? Was another treatment attempted? Shame. my guess is too small a balloon was used , but that is better, i suppose, than too large!

talking about the interpretation of the images in 2010 led me to remember that I knew i was treating valves way back in early 2010. I just recently saw my third patient from two full years ago, doing so well. in my report in January 2010 I diagnosed valvular stenosis on IVUS.So that sets the record straight, i think

Hi Dr. Sclafani! It's so good to be talking with you on this board again! I am looking forward to meeting you at my appointment in a couple weeks, but wanted to reply now with a little information given the current discussion. My venogram report acknowledges the stenosis, but I don't have a sense of how I was treated. I suspect that they gave me very conservative treatment, especially since my symptoms (and reflux) returned within 2-3 months. I can't wait to share all the details with you at my appointment, but for now here's an excerpt from my report discussing the left IJV:

...the left IJV was cannulated with some difficulty. The difficulty was secondary to severe stenosis at the proximal portion of the internal jugular vein on the left side. The catheter was negotiated into the distal external jugular vein and a venogram was performed at this location. This, once again, confirmed the high-grade stenosis at the proximal portion of the IJV with a web-like lesion and multiple collateralization around this high-grade stenosis. The wires were placed into the catheter. The intravascular ultrasound was once again used to assess the size and extent of the lesion, and based on the ultrasound measurements, a 10x40 balloon was chosen and sequential dilations were performed of the distal portion of the IJV to 8 and 10 atm pressure for 1 minute per inflation. The balloon was then removed. The catheter was replaced into the distal IJV and completion venography was performed. This showed the IJV to now be widely patent and the collaterals were no longer filling at this point as the contrast material was coming in the main channel of the vein without difficulty at this point.

Does this excerpt shed any light on my treatment, and perhaps how it relats to my current condition of worsening symptoms? Thanks!

astro

AStro, i am going to hold off on comments until i view all the information in person. Send me an email at ccsviliberation@gmail.com and let me know who ASTRO is .....its so weird to have patients i dont know talking aout their situation without information two weeks before i see them. Time enough........

[drsclafani]

interesting case. I will show the images as soon as they are ready.....

a 47 year old female college professor who was well until four years ago when she began to develop pelvic and rectal pain. After numerous and prolonged testing, she underwent gonadal venography that confirmed the presence of ovarian vein incompetence and varicosities. Pelvic congestion was manifested as well. The ovarian vein was treated by coil and Amplatzer embolization by another interventionalist. Clinical improvements in the pain were short lived. She also began to notice reduced memory, word and name recall and difficulties with multitasking and complex thinking. Balance deteriorated, severe fatigue developed and she became weak in both left upper and lower extremities. Further angiography resulted in coil embolization of the internal iliac vein. Additionally, compression of the left renal vein was identified and a diagnosis of Nutcracker syndrome was made. This was not treated.

She continued to have some relief from the pelvic pain but her new neurological symptoms worsened considerably, resulting in a subjectively diminished quality of life. She sought my consultation, having never seen a neurologist for her problems.

She gave a history of mitral prolapse with mitral regurgitation and unstable knee and poor wound healing. There was no history of multiple sclerosis, optic neuritis or vision disturbance. On physical exam she had a prominent periobital vein, hyperemia of the pharynx, drooping eyelids and double folds in her upper eyelids.She had very lax ligaments in her hands. There was slight weakness in the left hand and the left hip flexor

She had a CCSVI protocol neck ultrasound confirmed the presence of two criteria of CCSVI and revealed bilateral IJV reflux in both supine and erect positions in a small left internal jugular vein and a normal right internal jugular vein with a septum creating a infundibulum.

Venography and IVUS confirmed the right jugular vein (IJV) septum and demonstrated a 99% stenosis of the left IJV. Angioplasty of both IJV was performed with satisfactory but not complete dilatation on the left side. The azygous vein was enlarged and there was reflux in the accessory azygous vein.

Renal venography showed a classical appearance of the nutcracker. It was very difficult to advance the guidewire or catheter through the obstructed segment that was located at the position of the aorta. Venography revealed total obstruction of the vein. There were no gonadal collaterals but there was complete opacification of the entire vertebral venous system.from T3 to L5. IVUS showed complete compressive obstruction of the vein. After self-expanded stenting between the renal bifurcation and the inferior vena cava, renal blood flow was brisk and the collaterals were no longer seen.
Within 90 minutes she stated that all pelvic pain had resolved and that she felt more alert and clear.

This interesting case shows that in the presence of CCSVI, Nutcracker Syndrome is capable of exacerbating or causing neurological symptoms. With the gonadal veins occluded by coils, renal hemodynamic redirection into the hemiazygous and ascending lumbar veins augmented flow into an already compromised cerebrospinal venous system. The effects were deficits is memory and cognition, balance, strength and the development of a severe fatigue syndrome.

Upon further assessment, Ehlers Danlos syndrome also seems like a real possibility. Do you think these patients are more prone to thrombosis or delayed endothelialization? Should I continue my anticoagulation regimen for an additional few months beyond the standard one month of antithrombin a medications?

I will send on the images as soon as they are ready.

[Cece]

Oh, how interesting.

I don't know about the Ehler Danlos question, whether it makes the patient more prone to thrombosis or delayed endothelialization.

How did this patient find you, without MS to go on!

What is an 'infundibulum'? Google tells me it is a funnel-shaped structure. Ok, the septum in the RIJV created a funnel-effect? When the septum is ballooned, does it actually stick and endothelialize into the vein wall, or is it just stretched there and can spring back into place?

What's interesting too is that there was no azygous stenosis. The already compromised cerebrospinal system was the two jugulars. The redirection of flow from the renal vein did not have to hit against a stenosis in the azygous to still cause these problems.

With the iliac vein blocked after coil embolization, that would have effects on the cerebrospinal drainage comparable to May Thurner? So that was both a loss of an outflow route for the renal vein and an addition of its own flow load to the cerebrospinal drainage?

How will you ever condense this topic down to talk at ISNVD ("the consequences of venous congestion involving other vascular beds")? There is so much to talk about.

[munchkin]

Dr. S

If renal blood flow is being affected; can this also affect kidney function? Would a before and after Creatinine test possibly show an improvement to kidney function and thus provide some positive justification for treatment outside of the realm of neurologists?

[mtf]

Patient: DEIRDRE CARNEGIE

Dx: Multiple Sclerosis, Chronic Cerebrospinal Venous Insufficiency

Ms. Carnegie is a 47 years old patient with Multiple Sclerosis diagnosis since she was 35 years old. However, she presented her symptoms since the age of 17 years old. Mrs. Carnegie symptoms continued to progressed until she presented a progressive and general weakness, in particular sphincter incontinence (urinary and fecal incontinence). In the past she had two Jugular and Azigos vein angioplasty procedures, with excellent results and recovery of lost faculties, in particular the sphincter incontinence.

Months after her last Angioplasty, the symptoms came back, with par aesthesia of the limbs, motor weakness, reduction of the visual acuity, mental confusion and cognitive disorder referred as a foggy thought, but, in particular, the urinary and fecal incontinences. For this reason, the patient came back to Excel Medical Center in Tijuana, where was performed a CT angiography finding a sever occlusion on both jugular veins, particularly the left side.

As a result, she was taken to the Cardio-vascular area, and she has been prepared in order to perform a bilateral jugular angiography, and an angioplasty if it was necessary.

The angiography showed a 99% occlusion of the left jugular vein in the middle third, which could not be corrected by the angioplasty. The right jugular vein presented several severe occlusions in which were corrected by angioplasty using a 12 mm balloon which was inflated at 14 atm's with an excellent results regarding sensory-sensitive symptomatology and partially regarding with motor and cognitive symptomatology. However, the urinary incontinence persisted.

The azygos vein was patent and was not operated.

With these findings, I suggested to the patient to perform a surgical jugular angioplasty by using a vein patch to widen the vein. This treatment named “Jugular Surgical Angioplasty” also known as the “JSA Procedure”, providing a more optimum cerebral venous drainage. The patient accepted. The JSA procedure was performed two days later with excellent results and getting an excellent flow and patency of both vessels.

Remarkably, all the symptomatology that the patient had was almost entirely disappeared in the next 48 hours after the surgical Jugular angioplasty procedure. The most remarkable of these outcomes, is the disappearance of both urinary and fecal incontinences.

The patient was discharged in an excellent status and was advised to take Pradaxar® (Dibigatran) 150 mgs every 12 hrs, ASA Protect 100 mgs ones a day as well as Plavix® (Clopidogrel) tablets ones a day for a 6 weeks period.

She was advised to return to her Neurologist in 4 weeks to be re-evaluated and record the progress or regression of their symptoms.


Dr. S,
What are your comments about this case?

Ernesto L. R. Osuna, M.D., F.A.C.C.

Interventional Cardiologist

[HappyPoet]

Hi again, astro,

I forgot to mention that in the sentence highlighted in red, the word 'external' might have been mistakenly used instead of 'internal.' This possibility also makes sense within the entire context of the quote.

...the left IJV was cannulated with some difficulty. The difficulty was secondary to severe stenosis at the proximal portion of the internal jugular vein on the left side. The catheter was negotiated into the distal external jugular vein and a venogram was performed at this location. This, once again, confirmed the high-grade stenosis at the proximal portion of the IJV with a web-like lesion and multiple collateralization around this high-grade stenosis. The wires were placed into the catheter. The intravascular ultrasound was once again used to assess the size and extent of the lesion, and based on the ultrasound measurements, a 10x40 balloon was chosen and sequential dilations were performed of the distal portion of the IJV to 8 and 10 atm pressure for 1 minute per inflation. The balloon was then removed. The catheter was replaced into the distal IJV and completion venography was performed. This showed the IJV to now be widely patent and the collaterals were no longer filling at this point as the contrast material was coming in the main channel of the vein without difficulty at this point.

[1eye]

Dr. Sclafani:

Forgive me if this has already been asked and answered in your long presence on this forum. Thanks for your persistence, along with everything else. I think I have seen that you go up into the brain with the catheter. Do you ever treat up there? With balloons? I know you don't like to use stents in jugulars...

[drsclafani]

Hi again, astro,

I forgot to mention that in the sentence highlighted in red, the word 'external' might have been mistakenly used instead of 'internal.' This possibility also makes sense within the entire context of the quote.

...the left IJV was cannulated with some difficulty. The difficulty was secondary to severe stenosis at the proximal portion of the internal jugular vein on the left side. The catheter was negotiated into the distal external jugular vein and a venogram was performed at this location. This, once again, confirmed the high-grade stenosis at the proximal portion of the IJV with a web-like lesion and multiple collateralization around this high-grade stenosis. The wires were placed into the catheter. The intravascular ultrasound was once again used to assess the size and extent of the lesion, and based on the ultrasound measurements, a 10x40 balloon was chosen and sequential dilations were performed of the distal portion of the IJV to 8 and 10 atm pressure for 1 minute per inflation. The balloon was then removed. The catheter was replaced into the distal IJV and completion venography was performed. This showed the IJV to now be widely patent and the collaterals were no longer filling at this point as the contrast material was coming in the main channel of the vein without difficulty at this point.

POET
i think they had difficulty finding the internal jugular vein so they injected the external vein trying to get contrast to reflux into the internal jugular vein. Sometimes that works

S

[drsclafani]

Dr. Sclafani:

Forgive me if this has already been asked and answered in your long presence on this forum. Thanks for your persistence, along with everything else. I think I have seen that you go up into the brain with the catheter. Do you ever treat up there? With balloons? I know you don't like to use stents in jugulars...

I rarely treat up there, preferring to work with an interventional neuroradiologist in a hospital for such cases rather than in the ambulatory center.

DrSclafani

[drsclafani]

Patient: DEIRDRE CARNEGIE

Dx: Multiple Sclerosis, Chronic Cerebrospinal Venous Insufficiency

Ms. Carnegie is a 47 years old patient with Multiple Sclerosis diagnosis since she was 35 years old. However, she presented her symptoms since the age of 17 years old. Mrs. Carnegie symptoms continued to progressed until she presented a progressive and general weakness, in particular sphincter incontinence (urinary and fecal incontinence). In the past she had two Jugular and Azigos vein angioplasty procedures, with excellent results and recovery of lost faculties, in particular the sphincter incontinence.

Months after her last Angioplasty, the symptoms came back, with par aesthesia of the limbs, motor weakness, reduction of the visual acuity, mental confusion and cognitive disorder referred as a foggy thought, but, in particular, the urinary and fecal incontinences. For this reason, the patient came back to Excel Medical Center in Tijuana, where was performed a CT angiography finding a sever occlusion on both jugular veins, particularly the left side.

As a result, she was taken to the Cardio-vascular area, and she has been prepared in order to perform a bilateral jugular angiography, and an angioplasty if it was necessary.

The angiography showed a 99% occlusion of the left jugular vein in the middle third, which could not be corrected by the angioplasty. The right jugular vein presented several severe occlusions in which were corrected by angioplasty using a 12 mm balloon which was inflated at 14 atm's with an excellent results regarding sensory-sensitive symptomatology and partially regarding with motor and cognitive symptomatology. However, the urinary incontinence persisted.

The azygos vein was patent and was not operated.

With these findings, I suggested to the patient to perform a surgical jugular angioplasty by using a vein patch to widen the vein. This treatment named “Jugular Surgical Angioplasty” also known as the “JSA Procedure”, providing a more optimum cerebral venous drainage. The patient accepted. The JSA procedure was performed two days later with excellent results and getting an excellent flow and patency of both vessels.

Remarkably, all the symptomatology that the patient had was almost entirely disappeared in the next 48 hours after the surgical Jugular angioplasty procedure. The most remarkable of these outcomes, is the disappearance of both urinary and fecal incontinences.

The patient was discharged in an excellent status and was advised to take Pradaxar® (Dibigatran) 150 mgs every 12 hrs, ASA Protect 100 mgs ones a day as well as Plavix® (Clopidogrel) tablets ones a day for a 6 weeks period.

She was advised to return to her Neurologist in 4 weeks to be re-evaluated and record the progress or regression of their symptoms.


Dr. S,
What are your comments about this case?

Ernesto L. R. Osuna, M.D., F.A.C.C.

Interventional Cardiologist

Ernesto, thank you for sharing this very interesting case. It was not too easy to understand the Youtube video of the operation but I thought it was a patch angioplasty of the obstructed stenotic vein. Is that true? I am excited to have this possibility for patients whose stenoses are not amenable to angioplasty. Patch angioplasty or bypass grafting is a useful tool with little experience in the internal jugular vein. As we all know, it is a unique vein because of its periodic collapse and limited depending upon patient position, standing or supine. It will be very useful to get some followup at short intervals. I would consider a more prolonged anticoagulation. Maintaining patency of this vein is very challenging.

Please keep us informed.

If the video on YouTube has narration, i regret I did not hear it. If there is no narration, it would be a good idea to insert video explanation of the procedure for all who view it.

Good luck and hope to see you at the annual meeting of the International society for neurovascular disease (ISNVD) next week.

DrSclafani