DrSclafani answers some questions

[NZer1]

Hi Dr., I have been going through the videos you have posted and I have the nagging thought about veins that are thought to be stenotic that turn out to open when different breathing is called for on the testing.
I have how lost good posture, I have also noticed that I rearly take deep breathes and also are not as active in ways that would regularly, during the day, mean that I am increasing breathing depth.
In my mind as the disease progresses this will be, for all of us, common.
Is the the breathing that is asked for on testing vein compression that different to normal daily breathing of a PwMS?
Regards Nigel

[Cece]

I am terribly behind on the videos. So far I have watched the opening remarks by Dr. Sclafani. Does everyone know where to find the videos on the Sal Sclafani facebook page, as well as the playlist?

I have been worrying about lumen loss since Dr. Cumming brought it up over on the IVUS thread. When you are back, Dr. Sclafani, do you have any thoughts on lumen loss due to ballooning, not due to intimal hyperplasia or clotting? Could this explain the phenomenon in some patients where improvements that are lost after the first procedure are not regained after the second procedure? Since you are convinced that high pressure balloons are necessary to open valves, is this a trade-off and accepting a greater potential of lumen loss from the high pressure or is this not the case, in your opinion?

And here is the schedule from today's IVEC:
http://www.unimib.org/ivec/Scientific_P ... C_2011.pdf

IVEC/ISNVD Joint Session on CCSVI

President: Paolo Zamboni - President ISNVD: International Society for
Neurovascular Diseases

Chairperson: Carlo Setacci - President SICVE: Italian Society for Vascular &
Endovascular Surgery

93. 11.43-11.50 Rationale of CCSVI Treatment
Paolo Zamboni (Ferrara, Italy)

94. 11.51-11.58 Doppler Ultrasonographic Screening for CCSVI
Stefano Bastianello (Pavia, Italy)

95. 11.59-12.06 Jugular Venous Wall During CCSVI and Therapeutic Implications
Matteo Coen (Geneva, Switzerland)

96. 12.07-12.14 Intravascular Ultrasound for Diagnosis and Treatment Planning in
CCSVI Salvatore ja Sclafani (New York, NY, USA)

97. 12.15-12.22 PTA of CCSVI: Hardware, Results and Problems
Donald B. Reid (Glasgow, Scotland)

98. 12.23-12.30 Neurological Evaluation of PTA Outcome
Giovanni Meola (Milan, Italy)

12.30-12.40 Discussion, opened by: Mohan Adiseshiah (London, UK)

Did any of the other presenters influence your thinking? Is the candy store of ideas still well-stocked?

[Cece]

I can now answer 5 and 7
5. The ultrasound shows an occlusive clot on J1 segment of the LJV, with a lot of collaterals.
J2 and J3 are free of thrombus. No hypoplasia.
RJV and vertebrals show brisk flow. There is reflux in the deep cerebral veins.
7. There is no coagulopathy in the medical history
My friend is on Pradaxa 110 mg twice a day now.

Dr S, what do you suggest?
Is a second intervention possible? If yes, when?

From what he said before

That clot is getting organized and hard. the chances to dissolve it are quickly disappearing. The harder the clot, the more difficult it will be to get a catheter to traverse the clot.

I want to diagnose a thrombosis as soon as possible because time is vein. The longer the duration of the thrombosis, the more damage to the vein, the more organized therombus, the less likely that it can be dissolved, catheterized, lumen restored.

I know of a patient who had a 9-month-old clot that Dr. Sclafani was able to successfully recanalize. Hope is not lost. But if we have learned one thing about clots, it is that they are a serious threat to our veins that gets worse if they are allowed to sit.

[ada]

[quote="Cece"]I am terribly behind on the videos. So far I have watched the opening remarks by Dr. Sclafani. Does everyone know where to find the videos on the Sal Sclafani facebook page, as well as the playlist?

i think this is what you are looking for or not

[pelopidas]

and this one is very important, too
http://youtu.be/JEr--Twpp0w

[Cece]

thanks

[drsclafani]

again, no medical training here , but veins are flexible from my understanding. So, if after being expanded, the blood flow (and/or pressure) is insufficient at times to hold the vein open in the new larger diameter, could the vein possibly just take up the smaller diameter, and the extra vein diameter/stretched material be forced to "gather" and appear as scar material? If not, what would happen to a vein that was ballooned, but then did not have sufficient flow and pressure to hold it open? worst case, if a new blockage occurred upstream in the flow?

----- edit ----
Just found cece's post in another thread, regarding "vascular remodelling" which I think places the above a LOT more eloquently, and uses that medical/science stuff ... wait a sec... that was after my post. Do you think the researchers read mine? huh?

I think that dilated vein tissue will be more compliant than stenosed veins but i try not to dilate vein, only dilate the fused valve

Dr. Matteo Coen presented another autopsy paper. They noted preponderance of Type 3 collagen in the wall of the vein. This reduces elasticity and therefore compliance. It may explain some of the restenosis after angioplasty

[drsclafani]

the treatment starategy of thrombosis depends upon
1. clinical effects
2. location of the thrombus
3. whether thrombus is occlusive or not
4. how old the thrombus is
5.how long the thrombosis is
6. whether there is room to manipulate catheters above and below the thrombus
7. whether there is an inherent coagulopathy
8. what caused the thrombus
9. what was the prognosis for the vein before the thrombosis
10. what are the risks of the intervention

as you can see this is going to be a long discussion.

Lets see if anyone is reading.

I can now answer 5 and 7
5. The ultrasound shows an occlusive clot on J1 segment of the LJV, with a lot of collaterals.
J2 and J3 are free of thrombus. No hypoplasia.
RJV and vertebrals show brisk flow. There is reflux in the deep cerebral veins.
7. There is no coagulopathy in the medical history
My friend is on Pradaxa 110 mg twice a day now.

Dr S, what do you suggest?
Is a second intervention possible? If yes, when?

that makes it possible at least. Rendevous is at least possible. The longer the interval of thrombosis, the more difficult it becomes to re-establish flow

so i would think the sooner its tried, the better the chance. But it is getting quite late already. Re-establishing continuity will already be a challenge, but in light of your friend's clinical deterioration, it seems worth the chance.

[drsclafani]

Hi Dr., I have been going through the videos you have posted and I have the nagging thought about veins that are thought to be stenotic that turn out to open when different breathing is called for on the testing.
I have how lost good posture, I have also noticed that I rearly take deep breathes and also are not as active in ways that would regularly, during the day, mean that I am increasing breathing depth.
In my mind as the disease progresses this will be, for all of us, common.
Is the the breathing that is asked for on testing vein compression that different to normal daily breathing of a PwMS?
Regards Nigel

i say, take a deep breath and hold it. some patients breath like they are about to dive into the ocean, others just take a breath before a sigh

[drsclafani]

I am terribly behind on the videos. So far I have watched the opening remarks by Dr. Sclafani. Does everyone know where to find the videos on the Sal Sclafani facebook page, as well as the playlist?

I have been worrying about lumen loss since Dr. Cumming brought it up over on the IVUS thread. When you are back, Dr. Sclafani, do you have any thoughts on lumen loss due to ballooning, not due to intimal hyperplasia or clotting? Could this explain the phenomenon in some patients where improvements that are lost after the first procedure are not regained after the second procedure? Since you are convinced that high pressure balloons are necessary to open valves, is this a trade-off and accepting a greater potential of lumen loss from the high pressure or is this not the case, in your opinion?

And here is the schedule from today's IVEC:
http://www.unimib.org/ivec/Scientific_P ... C_2011.pdf

IVEC/ISNVD Joint Session on CCSVI

President: Paolo Zamboni - President ISNVD: International Society for
Neurovascular Diseases

Chairperson: Carlo Setacci - President SICVE: Italian Society for Vascular &
Endovascular Surgery

93. 11.43-11.50 Rationale of CCSVI Treatment
Paolo Zamboni (Ferrara, Italy)

94. 11.51-11.58 Doppler Ultrasonographic Screening for CCSVI
Stefano Bastianello (Pavia, Italy)

95. 11.59-12.06 Jugular Venous Wall During CCSVI and Therapeutic Implications
Matteo Coen (Geneva, Switzerland)

96. 12.07-12.14 Intravascular Ultrasound for Diagnosis and Treatment Planning in
CCSVI Salvatore ja Sclafani (New York, NY, USA)

97. 12.15-12.22 PTA of CCSVI: Hardware, Results and Problems
Donald B. Reid (Glasgow, Scotland)

98. 12.23-12.30 Neurological Evaluation of PTA Outcome
Giovanni Meola (Milan, Italy)

12.30-12.40 Discussion, opened by: Mohan Adiseshiah (London, UK)

Did any of the other presenters influence your thinking? Is the candy store of ideas still well-stocked?

i didnt think there was much new for me. Hopefully it opened some eyes.
The politics around brave dreams is amazing, not that i have any details.
perhaps the trial will begin in december.

[drsclafani]

I am terribly behind on the videos. So far I have watched the opening remarks by Dr. Sclafani. Does everyone know where to find the videos on the Sal Sclafani facebook page, as well as the playlist?

I have been worrying about lumen loss since Dr. Cumming brought it up over on the IVUS thread. When you are back, Dr. Sclafani, do you have any thoughts on lumen loss due to ballooning, not due to intimal hyperplasia or clotting? Could this explain the phenomenon in some patients where improvements that are lost after the first procedure are not regained after the second procedure? Since you are convinced that high pressure balloons are necessary to open valves, is this a trade-off and accepting a greater potential of lumen loss from the high pressure or is this not the case, in your opinion?

And here is the schedule from today's IVEC:
http://www.unimib.org/ivec/Scientific_P ... C_2011.pdf

IVEC/ISNVD Joint Session on CCSVI

President: Paolo Zamboni - President ISNVD: International Society for
Neurovascular Diseases

Chairperson: Carlo Setacci - President SICVE: Italian Society for Vascular &
Endovascular Surgery

93. 11.43-11.50 Rationale of CCSVI Treatment
Paolo Zamboni (Ferrara, Italy)

94. 11.51-11.58 Doppler Ultrasonographic Screening for CCSVI
Stefano Bastianello (Pavia, Italy)

95. 11.59-12.06 Jugular Venous Wall During CCSVI and Therapeutic Implications
Matteo Coen (Geneva, Switzerland)

96. 12.07-12.14 Intravascular Ultrasound for Diagnosis and Treatment Planning in
CCSVI Salvatore ja Sclafani (New York, NY, USA)

97. 12.15-12.22 PTA of CCSVI: Hardware, Results and Problems
Donald B. Reid (Glasgow, Scotland)

98. 12.23-12.30 Neurological Evaluation of PTA Outcome
Giovanni Meola (Milan, Italy)

12.30-12.40 Discussion, opened by: Mohan Adiseshiah (London, UK)

Did any of the other presenters influence your thinking? Is the candy store of ideas still well-stocked?

Cece, i do not buy into the diameter loss at all. it is not my experience except in a few cases. Most of the time, restenosis looks just like before angioplasty. the rest of the vein looks the same or dilated.

actually, i have noted that dilation with smaller balloons or at lower pressures looks a lot of the time like the stenosis was just not opened completely

i am uncommitted on redo being less than initial results.

Look forward to some papers on that in the future.

[Cece]

Thanks for the answer.

i am uncommitted on redo being less than initial results.

In fact, my personal experience was that the redo was better than the initial results.

[aliki]

Dr Sclafani I am pelopida's friend , i would like to ask you if in rendevous procedure do you ude a stent because i am afraid of that .
Also i would like to ask what are the possibilities of this , i mean if we put a stend after can we hope that we saved the vein?

[ErikaSlovakia]

Just a little update about the patient with a stent in the heart.
Well, the stent looks patent to me even it looks like a hockeystick.
The patient feels better than I do and can do much more than I can. I do not want to say that I want to live with "a hockeystick" in my heart.
Her MS is not as far as mine. The stent is in her right ventricle grown to the right side.
She goes for Holter test soon. She feels no neurological changes after the procedure.
I wish she could simply live with that.
Erika

[Cece]

I googled stent migration to right ventricle. A lot of articles come up, and either quick removal before it has endothelized or open surgery seem to be the trend. Here is one where they initially tried a conservative approach, but then grew concerned that the stent would erode through the ventricular wall, causing tamponade and death. (Tamponade? Not sure what that means.) It does say that 'watch-and-wait' has been a successful way to manage migrated stents in the past.
http://www.acponline.org/about_acp/chap ... egde10.pdf
What a frightening outcome. I hope she will be ok.

Aliki, welcome to Dr. Sclafani's thread.