DrSclafani answers some questions

[Cece]

do not understand why it should be funny, think Professor Sclafani takes no stents in these patients because of the risk for complications when you could not immediately be reached because of the distance, or have I misunderstood something ??, mhhhhhh sorry but it is difficult with the language

No, I would not call it funny, but witty is different than funny? Witty is when something is well-phrased or cleverly said or unexpected and intelligent in that way.

If what has been called restenosis is often a result of underdilatation, then a patient who is treated with adequate dilatation may have more durable results, which would mean that this can be achieved without stents and the issues that go with stents, regardless of how far a patient travels? Dr. Zamboni had about 50% restenosis in his patients at 18 months in his published study but he also used a 10 mm balloon and low pressures, so even among Dr. Zamboni's patients what was called restenosis might have been underdilatation.

[Cece]

Did the flouroscopy images look similar to the same images in MS, with impaired flow? I am assuming that the images with the red background were taken at the site of the valve. It almost looks like a physiological stenosis, as is sometimes seen in the upper portion of the vein but that expands under valsalva and does not warrant treating. Did you balloon this stenosis? Did it improve flow?

Was the big problem the valve stenosis, or was the big problem the vein wall itself being thickened? It appears that the thickening in the vein wall reduces the lumen of the vein. Was the thickening present throughout the vein or only at the area of the valve? Are there treatments for venous edema, if that is what this is?

Lyme's patient:

MS patient:

The differences in the appearance of the vein wall is striking. (The vein wall, meaning the white circle of the vein itself: in the top image, it is lumpy; in the bottom images, it is smooth.)

I hope the procedure was a success and that the patient had some relief from the headaches. Is it plausible that treatment of CCSVI would help improve delivery of antibiotic to the brain? I would think the opposite, that the slowed perfusion of CCSVI weakens the blood-brain barrier, and that there is greater access when CCSVI is present. I would think treatment of CCSVI was warranted but possibly not for that reason.

[drsclafani]

I seem to be getting distracted by many conjectures, lyme, parkinson, other infectious agents, car accidents, stem cell augmentation, etc. in an ambush

I don't think it is intended as an ambush. But I think we are bringing you our answers instead of our questions.

Long distance travel is not one of my indications for stenting.

Wit should be acknowledged, and this was witty...

do not understand why it should be funny, think Professor Sclafani takes no stents in these patients because of the risk for complications when you could not immediately be reached because of the distance, or have I misunderstood something ??, mhhhhhh sorry but it is difficult with the language

Lety
i do not think that stenting is contraindicated in patients at great distance from my center.

i have distinct indications for stenting. I have maintained them for quite some time

1. bale out of injury during angioplasty
2. two restenoses within one year
3. during revascularization of thrombosis
4. inability to keep the vein open despite an excellent angioplasty
5. nutcracker syndrome

Of course long distance management includes partnership with a local physician who can manage the anticoagulation necessary to manage stents.

[drsclafani]

Did the flouroscopy images look similar to the same images in MS, with impaired flow? I am assuming that the images with the red background were taken at the site of the valve. It almost looks like a physiological stenosis, as is sometimes seen in the upper portion of the vein but that expands under valsalva and does not warrant treating. Did you balloon this stenosis? Did it improve flow?

Was the big problem the valve stenosis, or was the big problem the vein wall itself being thickened? It appears that the thickening in the vein wall reduces the lumen of the vein. Was the thickening present throughout the vein or only at the area of the valve? Are there treatments for venous edema, if that is what this is?

Lyme's patient:

MS patient:

The differences in the appearance of the vein wall is striking. (The vein wall, meaning the white circle of the vein itself: in the top image, it is lumpy; in the bottom images, it is smooth.)

I hope the procedure was a success and that the patient had some relief from the headaches. Is it plausible that treatment of CCSVI would help improve delivery of antibiotic to the brain? I would think the opposite, that the slowed perfusion of CCSVI weakens the blood-brain barrier, and that there is greater access when CCSVI is present. I would think treatment of CCSVI was warranted but possibly not for that reason.

i do not think that the angioplasty had any substantial effect. I am waiting for followup.

[Lety]

Lety
i do not think that stenting is contraindicated in patients at great distance from my center.

i have distinct indications for stenting. I have maintained them for quite some time

1. bale out of injury during angioplasty
2. two restenoses within one year
3. during revascularization of thrombosis
4. inability to keep the vein open despite an excellent angioplasty
5. nutcracker syndrome

Of course long distance management includes partnership with a local physician who can manage the anticoagulation necessary to manage stents.

Thank you for the explanaition Prof. Sclafani

Sorry, unfortunaly I missunderstood the meaning because of translation difficulties ( google translator + school english ) of course it would make no sense to fly to you and not to be treated when a stent is needed.

[mtf]

Hi Dr.,

Thanks alot for your help last week. I'm happy that my left lgv isn't trombosed but now I have other to think about (occlusion/trombos) near my brain. Can you please, now, tell me what do you think about my veins?
Thank you very much (it was very good to talk to you) .

[drsclafani]

Hi Dr.,

Thanks alot for your help last week. I'm happy that my left lgv isn't trombosed but now I have other to think about (occlusion/trombos) near my brain. Can you please, now, tell me what do you think about my veins?
Thank you very much (it was very good to talk to you) .

Dear MTF,
it was a pleasure to meet you in Lisboa.
for the group's curiosity, I was visiting MTF's doctor to learn from him a new treatment for enlarged prostate glands that result in difficulties with urination. In that treatment a very tiny catheter is placed into the arteries that supply oxygenated blood to the prostate gland. Fine particles are injected to block these arteries and this results in the ability to urinate without drugs that may make men impotent. It is a challenging procedure and I admire MTF's doctor for the skill and dedication he shared with me.

As it turned out, MTF and another patient with MS came to visit him that day, perhaps because i was visiting and I watched advised her doctors as they repeated the procedure.

I gave them some critical pointers that led to the change of diagnoses from occlusion of the J1 segment of the left IJV to in-stent stenosis of both internal jugular veins. These were treated with angioplasty. I also advised that they look at the upper part jugular veins that had not been looked at before. Regretably, this showed that there seemed to be obstructions higher up in the jugular veins that had not been previously recognized. I say "seemed to be" because they were unable to advance the guidewire or the catheter into the dural sinuses and thus could not confirm continuity between the dural sinus and the jugular vein. so it was not definite but highly probable. It is possible for improvement of flow by opening the lower stenoses even with an upper obstruction.

Perhaps, mtf, it would be useful to have an MRV to look for continuity or lack of continuity. However MRV can sometimes be misleading in this regard.

If there is no continuity between the jugular and the dural sinus, there is nothing I can think of to relieve that situation. It is too high for bypass.

Most importantly, how are you feeling? I admire your bravery and leadership. Dr P seems to feel the same way.

Best

DrS

[drsclafani]

Hi Dr.,

Thanks alot for your help last week. I'm happy that my left lgv isn't trombosed but now I have other to think about (occlusion/trombos) near my brain. Can you please, now, tell me what do you think about my veins?
Thank you very much (it was very good to talk to you) .

Dear MTF,
it was a pleasure to meet you in Lisboa.
for the group's curiosity, I was visiting MTF's doctor to learn from him a new treatment for enlarged prostate glands that result in difficulties with urination. In that treatment a very tiny catheter is placed into the arteries that supply oxygenated blood to the prostate gland. Fine particles are injected to block these arteries and this results in the ability to urinate without drugs that may make men impotent. It is a challenging procedure and I admire MTF's doctor for the skill and dedication he shared with me.

As it turned out, MTF and another patient with MS came to visit him that day, perhaps because i was visiting and I watched advised her doctors as they repeated the procedure.

I gave them some critical pointers that led to the change of diagnoses from occlusion of the J1 segment of the left IJV to in-stent stenosis of both internal jugular veins. These were treated with angioplasty. I also advised that they look at the upper part jugular veins that had not been looked at before. Regretably, this showed that there seemed to be obstructions higher up in the jugular veins that had not been previously recognized. I say "seemed to be" because they were unable to advance the guidewire or the catheter into the dural sinuses and thus could not confirm continuity between the dural sinus and the jugular vein. so it was not definite but highly probable. It is possible for improvement of flow by opening the lower stenoses even with an upper obstruction.

Perhaps, mtf, it would be useful to have an MRV to look for continuity or lack of continuity. However MRV can sometimes be misleading in this regard.

If there is no continuity between the jugular and the dural sinus, there is nothing I can think of to relieve that situation. It is too high for bypass.

Most importantly, how are you feeling? I admire your bravery and leadership. Dr P seems to feel the same way.

Best

DrS

by the way, i am seeing more stented veins that are doing pretty well. There was only mild in-stent stenosis. this is certainly better than persistent recurrent restenosis of immobile valves. The more experience I get, the more I see that stenting can be beneficial in keeping these veins open. I still believe that angioplasty is sufficient for most patients, but feel more comfortable, in the right circumstances, with stenting for the indications i have listed previously.

[mtf]

I know, I felt very happy when my doc said you were coming to Lisboa and I should be there.

Well, to know that mine left ljv isn´t total lost was very good.
Soon I will have another MRI done (requested by my neuro doc., she doesn't believe in CCSVU btw). What could be that occlusion?

I feel some improvements, but not very much. Less fatigue, warm feet and the best one is: lack of "arrithyms" (better word?) that I was felling since 1 year at least. It seemed I was going to have, everyday, a "heart attack", but for now it's ok - if you understand what I'm trying to say.

I'm only trying to find a way to beat MS, that's all.

[mtf]

Btw, I'm now taking 1 per day Pradaxa 75mg and aspirin for 3 months.
Do you think it's enough?

[drsclafani]

Btw, I'm now taking 1 per day Pradaxa 75mg and aspirin for 3 months.
Do you think it's enough?

The recommended dose of pradaxa is 150 mg every twelve hours or twice per day.


i am guessing that you are on plavix, not pradaxa. The dose would be 75 mg per day

it would be unfair of me to question dr p's medication choices

[dlynn]

Dr. Sclafani,
I saw a video, "Dr. Bill Code Part 2" on youtube. At 6min.30sec. mark, Dr. Code mentions Plavix and its'
ineffectiveness for veins. What are your thoughts. (sorry I don't know how to provide the link)
Thank you

[PointsNorth]

Hi dlynn/Dr. S

I did a search and this is what I found:



Dr. Code is an anesthesiologist by trade (with MS).

PN

[drsclafani]

Dr. Sclafani,
I saw a video, "Dr. Bill Code Part 2" on youtube. At 6min.30sec. mark, Dr. Code mentions Plavix and its'
ineffectiveness for veins. What are your thoughts. (sorry I don't know how to provide the link)
Thank you

dlynn
plavix is an platelet function inhibitor. It is being used by many physicians to reduce the aggregation of platelets on stent material. Others use it in lieu of an anticoagulant drug.

I use aspirin for platelet inhibition. the combination of plavix and aspirin may be more effective but it is associated with an increase in hemorrhages.

I use pradaxa for inhibition of blood clot formation

[gibbledygook]

Dear Professor Sclafani,

It's now been 2 months since my operation which involved stenting the left renal vein and ballooning both jugular valves and the azygous vein. I deteriorated immediately after the operation and have remained worse than I was before the operation in terms of walking ability, bladder control, eyesight and twitchiness. Both the left renal vein and the jugular veins were scanned for thrombosis and were found to be free of clots. What probability do you assign to a restenosis of the azygous vein?

Best regards,

Alex