DrSclafani answers some questions

[sara2407]

Dear Doctor and Cece,

the first vein dilation was in August 2010 at Tokuda Hospital, Sofia.
They performed angioplasty of both jugular veins and stenosis was 90%. On Azygos vein stenosis was 30% and they didn’t consider that the stenosis is significant, so it is not dilatated.
After controlling in January 2011 there was a restenosis. I insisted that perform angioplasty Dr. Petrov who has seen a significant stenosis in the vein azigos-80%. He explained to me that it is best to put the stent in Azigos vein to normalize blood flow and significant stenosis of both jugular veins.

I’m financially ruined ( so far spent 9450.00 euros ) and I'm not physically able to do a control.

[Cece]

Dear Doctor and Cece,

I am sorry to have inserted myself into your discussion with Dr. Sclafani. And far more sorry to hear about the financial toll this has taken on you.

You still have not said how long your doctor has prescribed the Plavix? Have you been on it been since January?

[drsclafani]

Dear Doctor,

how long should I take Plavix after stent placement in azigos vein?

i agree with cece..
Before giving my opinion, I would want to know what your doctor has recommended.

Why did you get a stent?

DrS

When you ask why a patient received a stent, which we have heard you ask before, are you looking to see if a patient received a stent unnecessarily?

cece
when i ask that question, i am trying to understand the circumstances of the stenting decision. I am trying to determine how often i agree with the indication to place the stent. Perhaps I stent too infrequently, or perhaqps I have not thought of some good reasons to stent.

also i am trying to learn how well informed patients are about the decisions that affect their lives.

[drsclafani]

Dear Doctor and Cece,

the first vein dilation was in August 2010 at Tokuda Hospital, Sofia.
They performed angioplasty of both jugular veins and stenosis was 90%. On Azygos vein stenosis was 30% and they didn’t consider that the stenosis is significant, so it is not dilatated.
After controlling in January 2011 there was a restenosis. I insisted that perform angioplasty Dr. Petrov who has seen a significant stenosis in the vein azigos-80%. He explained to me that it is best to put the stent in Azigos vein to normalize blood flow and significant stenosis of both jugular veins.

I’m financially ruined ( so far spent 9450.00 euros ) and I'm not physically able to do a control.

We we will hear Dr Petrov report his series at the NYC CCSVI symposium in a few weeks.

i want an explanation of how a vein that has a 30% stenosis (presumably for years) and has not been dilated by angioplasty can develop a 80% stenosis in six months

[Lyon]

..

[1eye]

more so perhaps in the IJVs and other cerebral outflow veins, where posture really makes a difference, than lower down in the azygos?

[Cece]

hydration status or inconsistencies in measurement....

[drsclafani]

i want an explanation of how a vein that has a 30% stenosis (presumably for years) and has not been dilated by angioplasty can develop a 80% stenosis in six months

I've read here that the parts of the venous systems being used depends on body position, so it seems that what is seen through venous imaging often might depend on body positioning and likely adds variability to what is going to be seen via imaging.do you think might be owed to image variation due to positioning of the subject?

more so perhaps in the IJVs and other cerebral outflow veins, where posture really makes a difference, than lower down in the azygos?

hydration status or inconsistencies in measurement....

My reason for asking the question is that there is some variance in reporting 30% and then 80% stenosis. When something is clearly phasic, i wonder when it is justified to treat. Clearly, it is highly unlikely that spontaneous change in the diameter of the vein would be due to increasing stenosis.
So it would depend upon where in the azygous vein this stenosis resided.

As has been stated, variations in position really make a difference. But where? In the arch? or in the ascending azygous vein?

Certainly, as Lyon states, the view performed can make a great difference. We know that angulations of the ray beam of 70-90 degrees from the vertical lays out very nicely the entire azygous arch. Less angulation of the beam could certainly change the view of a stenosis.

1eye considers this less likely than in the jugular vein where position of the neck makes a difference. Rotation of the neck can sometimes eliminate a severe narrowing in the J-2 segment of the IJV.

did you realize that different phases of breathing can really change the narrowing of the Azygous vein in the junction of the upper and middle thirds of the ascending azygous vein..

I happen to be very skeptical of the mid- ascending azygous stenosis. The diameter and the flow in this area is highly dependent upon the phase of respiration. If the images of the vein are taken during deep inspiration, there is usually less narrowing of this junction. During deep expiration it is usually narrow and there is more retrograde contrast flow into the peripheral vessels indicating reflux.

With IVUS one can see the vessel enlarge during inspiration and shrink during expiration. Because of this, I have chosen not to angioplasty this inconstant stenosis.

Can you tell us where in the azygous vein was the stent placed? Was it in the arch? or in the ascending portion?

[sara2407]

Dear Doctor,

This is from hospital - discharge letter.

V. jugularis int. dex. - 80% stenosis in the middle segment and at the confluence. Several dilatations performed with 14.0x60mm balloon at 8 atm. pressure with optimal angiographic results, without significant residual stenosis and normalized bloodflow

V. jugularis int. sin. - 80% stenosis in the middle segment and at the confluence. Several dilatations were performed with 14.0x60mm balloon at12atm. pressure with optimal angiogrphic results,without significant residual stenosis and normalized bloodflow

V.azygos - 80% stenosis in the middle segment. Several dilatations were performed with 8.0x40mm balloon 10 atm. pressure, significant residual stenosis established, which required stent implantation of Astron 10.0 x 60mm stent with optimal angiographic results, without significant residual stenosis and normalized bloodflow.

ConcluSions: CCSVI Zamboni Type B. Stenosis in both jugular veins and azygous vein. Normal venous blood flow establishe

Echo dopler examination of the jugular veins (One day post-procedurally):
v.jugularis int. sin. - min. d = 6.4 mm
V.jugularis int. dex.- min.d = 6.5 mm
Examination in the sitting position:
V. jugularis int. sin. - min.d = 0 mm;
V. jugularis int. dex. - min.d = 0 mm;
Conclusions: Normalized diameter and blood flow in both jugular veins. Normal jugular vein collapse reaction in the sitting position – indirect data of unobstructed azygos vein.

And I'm on Plavix (daily) from 25.01.2011. and Aspirin.

[drsclafani]

Dear Doctor,

This is from hospital - discharge letter.

V.azygos - 80% stenosis in the middle segment. Several dilatations were performed with 8.0x40mm balloon 10 atm. pressure, significant residual stenosis established, which required stent implantation of Astron 10.0 x 60mm stent with optimal angiographic results, without significant residual stenosis and normalized bloodflow.

Mid Azygous....hmmm

i wonder what i would have done.

[sara2407]

Dear Doctor,

what to do with Plavix?

[drsclafani]

Dear Doctor,

what to do with Plavix?

sara
it is not possible for me to give you directions for the plavix. dr petrov is my colleague. it would not be appropriate for me to advise you against him. you should email to dr petrov for advice.

DrS

[Johnson]

Dear Doctor,

This is from hospital - discharge letter.

V.azygos - 80% stenosis in the middle segment. Several dilatations were performed with 8.0x40mm balloon 10 atm. pressure, significant residual stenosis established, which required stent implantation of Astron 10.0 x 60mm stent with optimal angiographic results, without significant residual stenosis and normalized bloodflow.

Mid Azygous....hmmm

i wonder what i would have done.

My guess is that you would have investigated with IVUS, looked at diameter proximal and distal to the stenosed area upon inspiration and expiration, made a learned judgement as to what was phasic or not, and would have avoided a stent if at all possible.

Especially in the middle segment.

[Robnl]

Dear Doctor,

what to do with Plavix?

sara
it is not possible for me to give you directions for the plavix. dr petrov is my colleague. it would not be appropriate for me to advise you against him. you should email to dr petrov for advice.

DrS

Sara,

I was treated in Poland (dr Simka), a small stent is placed in the left jug. I also got Plavix for at least 3 months. My GP's advise was to use it for a year and so i did.
In March 2011 i quitted with Plavix

There is some discussion about the usek of Plavix and Ascal at the same time (Plavix less effective), but in feb 2011 my stent flowed like a charm

[sara2407]

I sent an e mail but there was a misunderstanding in communication, so I came here for advice.

In any case, thank you all,

Sara