DrSclafani answers some questions

[drsclafani]

DrS, thank you for taking the time to explain to us the importance of understanding these definitions, concepts and how they apply to CCSVI and IVUS. I learned so much!

I'm saddened, though, for the many patients who might not realize they will have an incomplete procedure--a procedure without IVUS--and I'm maddened that many IRs still perform such incomplete procedures, especially when some have reaped great profits from this patient population; imo, these IRs can afford to invest in IVUS and training. The question is why aren't they??? DrS, do you know the percentage of patients you treated for CCSVI who turned down IVUS?

Edit: Cece, I didn't see your post until after I submitted mine. I agree that some IRs will cite the need for studies, but I believe, and think you'd agree, this reasoning is a weak argument, if not an outright cop-out, for IRs to spend time and money on IVUS now.

Edit: Drs, I forgot to say that you're "Leader of the pack... VROOOM, VROOOM." I see you driving the new one-thousand horsepower Shelby Cobra Mustang GT1000 which, unbelievably, is street-legal.

Edit: All readers, to clarify, my question, "The question is why aren't they???" is rhetorical and related to my prior sentence about money--I don't want anyone thinking I missed reading DrS's last post about why he thinks IVUS isn't used by more IRs.

No more edits, I promise!

IVUS was always included in my fee so who would refuse.

however i believe that there are patients who cannot afford the extra study and i have been struggling to address patient costs quite a bit.

With Fresenius' new fee schedule, many patient friendly changes have been made. Among them i have opted to unbundle IVUS and made it optional as a separate fee, although highly recommended.

So far no one has elected NOT to have IVUS.

I do not think IVUS will be necessary every time we treat a patient. Once we have done it, i think we are likely to be able to skip it on most followup procedures most of the time. We will have accurate dimension measurements, we will know where the lesions are. I would use it very selectively.

That would halve the price for repeat treatments.

[Cece]

Yes, that's what i mean; and a few problematic capillaries would cause no harm ( i think) but when a lot of them are problematic than it could slow down the bloodflow, right? And create pressure?

I think so. CCSVI slows down the bloodflow (causing stasis, mentioned below) and increases pressure ("intra-capillary oncotic pressure," below), and that can lead to the occlusion and atropy of the capillaries or small venules:

Several authors have hypothesized that reduced venous drainage outflow in MS may increase intra-capillary oncotic pressure, which would lead to decreased capillary permeability toward the extra cellular compartment and consequent intra-tissue accumulation of toxic metabolites [12,45]. In the present study, the association between presence and severity of CCSVI was particularly strong with VVV indices of small veins. We showed that there was a trend for differences between patients and controls for veins with a diameter < .6 mm. Hypoxia arising from stasis in the veins might therefore induce morphological changes which could result in occlusion and atrophy of these veins.

http://www.ncbi.nlm.nih.gov/pmc/article ... ool=pubmed

The question is, and it'd be a question for Dr. Sclafani except I don't think there's an answer yet, if these changes can be reversed.

[HappyPoet]

DrS, thank you for taking the time to explain to us the importance of understanding these definitions, concepts and how they apply to CCSVI and IVUS. I learned so much!

I'm saddened, though, for the many patients who might not realize they will have an incomplete procedure--a procedure without IVUS--and I'm maddened that many IRs still perform such incomplete procedures, especially when some have reaped great profits from this patient population; imo, these IRs can afford to invest in IVUS and training. The question is why aren't they??? DrS, do you know the percentage of patients you treated for CCSVI who turned down IVUS?

Edit: Cece, I didn't see your post until after I submitted mine. I agree that some IRs will cite the need for studies, but I believe, and think you'd agree, this reasoning is a weak argument, if not an outright cop-out, for IRs to spend time and money on IVUS now.

Edit: Drs, I forgot to say that you're "Leader of the pack... VROOOM, VROOOM." I see you driving the new one-thousand horsepower Shelby Cobra Mustang GT1000 which, unbelievably, is street-legal.

Edit: All readers, to clarify, my question, "The question is why aren't they???" is rhetorical and related to my prior sentence about money--I don't want anyone thinking I missed reading DrS's last post about why he thinks IVUS isn't used by more IRs.

No more edits, I promise!

IVUS was always included in my fee so who would refuse.

however i believe that there are patients who cannot afford the extra study and i have been struggling to address patient costs quite a bit.

With Fresenius' new fee schedule, many patient friendly changes have been made. Among them i have opted to unbundle IVUS and made it optional as a separate fee, although highly recommended.

So far no one has elected NOT to have IVUS.

I do not think IVUS will be necessary every time we treat a patient. Once we have done it, i think we are likely to be able to skip it on most followup procedures most of the time. We will have accurate dimension measurements, we will know where the lesions are. I would use it very selectively.

That would halve the price for repeat treatments.

Excellent to learn about the new fee schedule which will allow more patients to know they'll be able to afford repeat procedures--peace of mind is priceless.

[Robnl]

Dr Sclafani,

Is it possible to measure the bloodflow; like you measure electricity? F.e.: Voltmeter, wire;Point A, point B..measure 220V
It's my impression that the ccvsi treatment is now more focussing on restoring bloodflow, while in the beginning a stenosis was resolved (that also resulted in a better bloodflow ofcourse).
If you could measure the bloodflow before and after treatment, would you have more certainty about the result??

CCSVI treatment in my fantasy
- Bloodflow measurement between veins Brain-> heart ...NN ml/min
- angioplasty
- Bloodflow measurement between veins Brain-> heart ...NN ml/min

Difference in measurement after and before should be the result, right?

Hopefully i'm a bit clear....

[NHE]

Is it possible to measure the bloodflow; like you measure electricity? F.e.: Voltmeter, wire;Point A, point B..measure 220V
It's my impression that the ccvsi treatment is now more focussing on restoring bloodflow, while in the beginning a stenosis was resolved (that also resulted in a better bloodflow ofcourse).
If you could measure the bloodflow before and after treatment, would you have more certainty about the result??

SPECT scanning (single photon emission computed tomography) can measure bloodflow though it does have the drawback of exposure to radioisotopes and it's also expensive. Here are some interesting examples of SPECT scanning. http://www.amenclinics.net/brain-scienc ... e-gallery/

I believe that fMRI can also measure blood flow. The advantage is that there is no exposure to radioisotopes. It's also expensive.

The Hubbard Foundation uses a technique called BOLD to measure blood flow. http://www.hubbardfoundation.org/CCSVI_fmri.html


NHE

[Rosegirl]

Dr. Sclafani,

I have read that some doctors use a fogarty catheter as an alternative to IVUS. As I understand it, a probe (shaped like a tootsie pop!) is extended and then dragged back and forth. The purpose of this is that the probe will catch on any web, flap, etc., that may exist in the vein and help pinpoint where treatment is required. Does this allow the IR to interrogate more of the vein than a cross-section that IVUS would look at?

It sounds like this is much less expensive than IVUS and looks at a larger area, both good things. Does it mean that the treatment will be longer and thus expose the patient to more radiation?

Could you comment on the pros and cons of this strategy?

[Cece]

Feeling better?

Will you have different abstracts to submit to SIR next year? All is not lost?

I'd love to read abstracts on nutcracker and CCSVI, and on the emissary veins, and more on IVUS, and a single center experience study, and whatever I am not thinking of.

[HappyPoet]

DrS, is there a certain percentage of restenosis that is optimal for a second procedure? >50%, >75%, >90%, or some other percentage?

[drsclafani]

Dr Sclafani,

Is it possible to measure the bloodflow; like you measure electricity? F.e.: Voltmeter, wire;Point A, point B..measure 220V
It's my impression that the ccvsi treatment is now more focussing on restoring bloodflow, while in the beginning a stenosis was resolved (that also resulted in a better bloodflow ofcourse).
If you could measure the bloodflow before and after treatment, would you have more certainty about the result??

CCSVI treatment in my fantasy
- Bloodflow measurement between veins Brain-> heart ...NN ml/min
- angioplasty
- Bloodflow measurement between veins Brain-> heart ...NN ml/min

Difference in measurement after and before should be the result, right?

Hopefully i'm a bit clear....

Yes, it is possible to measure pressures either directly or via a number of surrogates, like varioius MRI, CT ultrasound imaging techniques. I am thinking that you are suggesting is a flowmeter that is real time and can be used during the intervention. Such devices do exist. There is one that combines IVUS imaging and flow and pressure measurements. I havent used it yet, nor explored its economics.

I dont think that the focus has really changed. Dilating obstructions is always about improving flow. Currently, i think lots of talk is lots of talk only. I dont see any good measures of flow being discussed. Looking at the images and the flow appearance are not particularly accurate and without focusing on detecting and correcting obstructions there will be no change in flow.

your proposal has great merit and i would not be surprised when techniques change to measure this.

[drsclafani]

Dr. Sclafani,

I have read that some doctors use a fogarty catheter as an alternative to IVUS. As I understand it, a probe (shaped like a tootsie pop!) is extended and then dragged back and forth. The purpose of this is that the probe will catch on any web, flap, etc., that may exist in the vein and help pinpoint where treatment is required. Does this allow the IR to interrogate more of the vein than a cross-section that IVUS would look at?

It sounds like this is much less expensive than IVUS and looks at a larger area, both good things. Does it mean that the treatment will be longer and thus expose the patient to more radiation?

Could you comment on the pros and cons of this strategy?

I have tried this and i must say i think it is blind faith that this has done anything. if the balloon is underinflated nothing will happen, if overinflated it will catch on the wall and just feel like an obstruction.

This technique is less expensive, but it does not look at more area because the balloon cannot extend as distal as the IVUS probe, although i doubt it makes a difference. It will increase the radiation but not much.

give me ivus in a heartbeat

[drsclafani]

Feeling better?

Will you have different abstracts to submit to SIR next year? All is not lost?

I'd love to read abstracts on nutcracker and CCSVI, and on the emissary veins, and more on IVUS, and a single center experience study, and whatever I am not thinking of.

I still think that these abstracts should be read and i will look for another venue to make my presentations and hear what audience has to say.

If i can pull it off, i would like to assess two year followups on my patients. That will require a lot of cooperation with my patients for next November will make two years of continuous treatments.

but, first i need to take care of myself a bit.

i am recovering nicely, my nail beds are slightly pink instead of white

[drsclafani]

DrS, is there a certain percentage of restenosis that is optimal for a second procedure? >50%, >75%, >90%, or some other percentage?

Well, i dont have any real knowledge about what constitutes a significant stenosis in a jugular vein. I think many of us, myself included, think that the arbitrary 50% stenosis is an artificial, and probably erroneous threshhold. I think venous pressure gradients as low as 3 mm may be significant and it could take less than 50% stenosis to cause this.

I think that the indication for a second procedure has nothing to do with %ages. it has to do with return of symptoms, new symptoms, and other signs and symptoms that we havent yet recognized. I have done second procedure after only two days based upon clinical symptom changes.

[David1949]

After venoplasty treatment how long should someone wait before driving?

[drsclafani]

After venoplasty treatment how long should someone wait before driving?

Of course it depends on your disabilities and whether you were capable of driving before treatment. I never assume miraculous improvements and i think they occur infrequently.

But if you were able to drive the day before the procedure, you should be able to drivef the day after the procedure.

The day of the procedure one should not drive because the pain killers and sedation render you at risk for inattentiveness and falling asleep after the procedure.

DrS

[David1949]

I guess I should have made that clear; I can drive fine now. I'm not expecting a miracle, just hoping to be in no worse shape when I leave than when I came in. The plan is to drive home from Chicago the day after the procedure. I guess that will work.

BTW You would be at the top of my list for IRs, but I refuse to fly anymore and New York is just too long a drive from Detroit.