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drsclafani wrote:

Cece wrote:Any other strategies or concepts on the docket to be explored in 2012?

1. 12 month followups of patients treated in 2011
2. Development of CCSVI Centers of Excellence at American Access Care
3. Dural sinus and deep cerebral vein pressure measurements with IVUS before and after treatment
4. A Bigger and Better Symposium
5. PwMS talent show at the symposium
6. Greater networking worldwide
7. publishing, publishing, publishing

I do not know which to be more excited about. But let's see!
* 12 month follow-ups! It must be difficult with patients that are not local.
* "CCSVI Centers of Excellence"...sounds promising!
* pressure measurements, which I think is similar to what Dr. Tucker was suggesting.
* Glad to hear there are still plans for a symposium next year, and a bigger & better one to boot!
* ok, publishing, publishing, publishing is my favorite

I can't tell if it is the full catheter or just the guide wire. Up the right jugular, across the sinuses, down the left jugular. The sinuses can be sensitive, with the potential for enduring pain after the procedure if they get transversed (based on what I've heard of one other person's experience). Some reasons to do this might be if the patient had a suspected blockage in the sinuses or if the left jugular had a blockage in the area of the valves that had resisted catheterization. In the latter case, a rendez-vous procedure might be tried before trying to approach the jugular through the sinuses.

Could this be the continuation of MikeInFL's wife's case?

I doubt this is a venogram of a PTA involving the dural sinuses because the sinuses are not shown. I am not comfortable with the idea of having anything in my dural sinuses if my dural sinuses cannot be visualized the entire time. Period.

Also, wouldn't the guidewire need to be routed through the heart which this dark vertical line clearly isn't? -- I think the dark vertical line is a unique problem with this piece of equipment and is not a guidewire nor sheath nor catheter.

Do I get my usual "F" as my grade?

EDIT: Now that I've found my glasses, I can understand why the others think the 'dark vertical line' is something because I can now tell that it's not perfectly straight and its entire length is shadowed (sry, I can't find the right word). So I change my answer to that which the previous posters gave.

A small step for the guidewire, a giant step for mankind!

I change my answer to agree with HappyPoet that the straight vertical line through the chest area is peculiar! I hadn't even looked at it, I was focused on the jugular area.

Dear HappyPoet, you are more the student who gets straight A's and would lament a B as if it were an F!

Thank you, Cece.
Okay, I'll stick with my original answer (second-guessing myself is second-nature to me).

The more I think about this case and look at this image, the more questions I have about my original answer...

My original answer doesn't explain why an IR would use a machine with that exact 'dark vertical line' problem being right where the R-IJV would be? I don't think an IR would use such a defective machine for the purpose of investigating the R-IJV. So this would mean that Pam's and Cece's original answers are correct, that the catheter traversed the sinuses which would mean that the wire did go through the heart and SVC which must be lower than this image shows? So if the 'dark vertical line" really is a catheter, I'm surprised at how stiff and straight it appears in this image... "peculiar" is the right word, Cece.

My original answer also doesn't explain the absence of the guidewire below the uninflated balloon in the L-IJV which means the balloon had to have been threaded down from the sinuses, correct? Where else could the wire and balloon have come from? Unless the wire broke at the bottom of the balloon after it had been threaded up high in the L-IJV or even into the dural sinuses?

Cece, what say you?

HappyPoet wrote:Cece, what say you?

drsclafani, what say you?

HappyPoet wrote:"peculiar" is the right word, Cece.

If it is the exactly right word, ah! Happiness....

..is it inside the patient' s body?

I think the L IJV had a lower blockage, perhaps at the junction, so this was the only way to enter the L IJV was by going up the R IJV then across and down to the L IJV to clear a blockage that way. JMO

The dye was not released, so maybe IVUS was looking around the L IJV first.

What say you teacher?

pklittle wrote:

drsclafani wrote:

Comments

The catheter advanced through the sheath, up the right jugular, across the transverse sinus, and down the left jugular?

Correct. Why would i do that?

HappyPoet wrote: I am not comfortable with the idea of having anything in my dural sinuses if my dural sinuses cannot be visualized the entire time. Period.
DrS accessed my dural sinuses in June 2011. A little painful at the time but no after affects. Depends if you want a full diagnosis or not and approach to risk, personal choice.

To answer DrS's 'why would I do that ?' Do you suspect a web and this is to help diagnosis ?
Of course it could be to develop your skills/because you can/because its fun.............

MarkW

Cece wrote:I can't tell if it is the full catheter or just the guide wire. Up the right jugular, across the sinuses, down the left jugular. The sinuses can be sensitive, with the potential for enduring pain after the procedure if they get transversed (based on what I've heard of one other person's experience). Some reasons to do this might be if the patient had a suspected blockage in the sinuses or if the left jugular had a blockage in the area of the valves that had resisted catheterization. In the latter case, a rendez-vous procedure might be tried before trying to approach the jugular through the sinuses.

Could this be the continuation of MikeInFL's wife's case?

you are on the right track, Cece. Thisis a 0.014 inc floppy platinum tipped nitinol wire that I used initially to guide the IVUS probe along the veins. I found that i could use this wire during the entire catheterization after placement of the sheath in the superior vena cava. for example, i can inject contrast media through the catheter and still leave this wire in place because the end-hole of the catheter is 0.038 inches in diameter and this guidewire does not occlude the tip. This is very helpful in reducing wire exchanges. It is also a very floppy tip that reduces considerably the risk of injuries.

In this case, it was possible to advance the wire from one transverse sinus to the other. You are correct. There was an occlusion of the right left jugular vein that occured from a prior procedure by another physician. By using the wire, i was trying to create a landmark that was definitely in the internal jugular vein. If I were lucky, i might be able to advance the wire down into the left innominate vein.

When the vein is occluded (thrombosed), especially, as in this case, for a long time, the collateral veins dilate. External ultrasound can be confusing and the collaterals can mimic an internal jugular vein. Puncturing those collateral veins in the neck in a rendevous procedure will be useless.

HappyPoet wrote:I doubt this is a venogram of a PTA involving the dural sinuses because the sinuses are not shown. I am not comfortable with the idea of having anything in my dural sinuses if my dural sinuses cannot be visualized the entire time. Period.

Also, wouldn't the guidewire need to be routed through the heart which this dark vertical line clearly isn't? -- I think the dark vertical line is a unique problem with this piece of equipment and is not a guidewire nor sheath nor catheter.

Do I get my usual "F" as my grade?

EDIT: Now that I've found my glasses, I can understand why the others think the 'dark vertical line' is something because I can now tell that it's not perfectly straight and its entire length is shadowed (sry, I can't find the right word). So I change my answer to that which the previous posters gave.

F turned to a B+

Cece wrote:I change my answer to agree with HappyPoet that the straight vertical line through the chest area is peculiar! I hadn't even looked at it, I was focused on the jugular area.

Dear HappyPoet, you are more the student who gets straight A's and would lament a B as if it were an F!

The thing going from the chest to the right neck is the sheath through which the 0.014 guiewire was introduced to get over from right to left.