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Re:

Posted: Tue Nov 01, 2011 3:49 pm
by Cece
drsclafani wrote:
Cece wrote:If it were a healthy valve, how would it look different, would there still be bright signals showing the valve edge?
cece,
my analogy for this problem is that there is a door with a mail slot. If the postal worker tries to put an envelope through it, there is no problem, but if that person tries to put a big box, it just isnt going to happen if the door is locked.

I see these fused valves in much the same way. The IJ vein is the door, but these fused valves are the mail slot. They just cannot open.

There is motion in these valves....they get smaller. but the valves just do not open all the way to the outer reaches of the vessel wall.

The signal on the edges of the valve are thicker in these valves than in normal valves.
*bump*
A nice analogy I ran across while linking info on jugular duplications in another thread.
Instead of a door we get a mail slot! No wonder we have problems. And the IRs can stretch out the mail slot so that it is the size of the door. It might not open and close nicely like those of other people, but at least it lets the flow through.

Re: DrSclafani answers some questions

Posted: Tue Nov 01, 2011 7:20 pm
by drsclafani
aliki wrote: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?
aliki

First it would be good to understand the anatomy and the oxygen supply of the vein

The vein does not have a good blood vessel supplying oxygen to the inner lining of the vein. Therefore the inner part of the vein gets its oxyten from the blood itself. When a clot forms and no blood is flowing, then the inner lining is devoid of oxygen and blood clotting ensues. without that oxygen the cells lining the vein interior (ENDOTHELIUM) will die. The absence of endothelium results in thrombosis and fibrosis.

When the lumen is restored (for example, like in rendevous), we are left with a troubled vein that will likely clot again and may scar down. So we put a stent in as a heroic effort to maintain the vein. Remember, that there is little to loses. It might require prolonged anticoagulation but our goal is to keep that vein open.

And you, my Dear Aliki, know, more than most, what it means to have a vein with no flow

DrS

Re: DrSclafani answers some questions

Posted: Tue Nov 01, 2011 7:26 pm
by drsclafani
Cece wrote: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.
cece
tamponade is a clinical condition where blood leaks into the pericardium, the sac that encloses the heart.The sac is not particularly stretchable , so limited amounts of blood within it, can lead to progressive cardiac failure and shock. Treatment is urgen removal of the blood from the pericardium.

Metal in the wall can lead to erosion into the pericardium but this is rare

The greater problems with migrated stent are that the metal gets trapped in the wall near the valves and this leads to heart failure.

i have taken such objects out of the heart, mostly bullets, but if they are in a safe location and they are not causing problems such as arrhythmias, i say leave them alone.

Re: DrSclafani answers some questions

Posted: Wed Nov 02, 2011 1:03 am
by ErikaSlovakia
Thank you all for the information about migrating stent.
I think the patient will inform me in case of some changes.
Erika

Re: DrSclafani answers some questions

Posted: Wed Nov 02, 2011 6:35 am
by aliki
Dear doctor,
as my thrombus was three months old when discovered and totally occlusive in J1 area, is it possible to expect that it may partially dissolve in time, if I remain on strong anticoagulation? Or is the rendezvous procedure the only solution for the vein to stay open?

Re: DrSclafani answers some questions

Posted: Wed Nov 02, 2011 12:45 pm
by MarkW
Dr S,
Thanks for the info below. I have dural sinuses on my list. I checked where these
veins are and see that 'dural sinuses' are many veins, which are close to the brain.
Should I keep them on my list of veins which should be investigated for a full
diagnosis ??? These veins do not have valves according to the textbook, are you
checking that septa/webs are present ??? Is is possible to investigate any of the
dural sinuses using IVUS ???
Kind regards,
MarkW
PS I agree that investigating 3 veins 'does not cut it'. I am less polite and say
that doctors who check only 3 veins are cheating pwMS by offering just this.
--------------------------------------
Dr S posted:
There is no correlation between location of stenoses and symptoms that i can detect.
There are about 20 veins that can be involved in ccsvi
right and left transverse sinuses
right and left IJV
right and left vertebral veins
right and left innominate veins
Azygous vein
Hemiazygous vein
left renal vein
left iliac vein
ascending lumbar vein
and eight lumbar veins
Each is either an inflow vein or an outflow vein depending on circumstances.
A three vein interrogation just does not cut it.
--------------------------------------------

Re: DrSclafani answers some questions

Posted: Thu Nov 03, 2011 9:00 pm
by Cece
http://www.facebook.com/Sal.Sclafani.MD ... l&filter=1

Dr. Sclafani is working on a paper on nutcracker syndrome, that might be finished within a week.
Nutcracker syndrome is commonly seen in chronic fatigue syndrome....!
So how does a renal vein stenosis cause fatigue? Through slowed perfusion in the left kidney? Or because it diverts the heavy renal flow to the azygous, which slows the cerebrospinal drainage, causing neurological fatigue?

I think we've been fortunate to be privy to Dr. Sclafani's thoughts and research on CCSVI here, which is why we know the value of what he contributes, which is why I think it is very good for it to be getting down on paper, backed up by the data, and into the medical literature.

Maybe a dural sinus paper, once the nutcracker syndrome paper is done?

Re: DrSclafani answers some questions

Posted: Thu Nov 03, 2011 9:09 pm
by Cece
With the discussion of rendez-vous procedures, I looked for this link from when he demonstrated a rendez-vous.
http://www.thisisms.com/forum/chronic-c ... ml#p147738

Re: DrSclafani answers some questions

Posted: Thu Nov 03, 2011 10:30 pm
by drsclafani
aliki wrote:Dear doctor,
as my thrombus was three months old when discovered and totally occlusive in J1 area, is it possible to expect that it may partially dissolve in time, if I remain on strong anticoagulation? Or is the rendezvous procedure the only solution for the vein to stay open?
aliki
there may be no solution. It is likely that it will not dissolve. I think the best to hope for is a small length of clotted vein that can have a rendevous

Re: DrSclafani answers some questions

Posted: Thu Nov 03, 2011 10:34 pm
by drsclafani
MarkW wrote:Dr S,
Thanks for the info below. I have dural sinuses on my list. I checked where these
veins are and see that 'dural sinuses' are many veins, which are close to the brain.
Should I keep them on my list of veins which should be investigated for a full
diagnosis ??? These veins do not have valves according to the textbook, are you
checking that septa/webs are present ??? Is is possible to investigate any of the
dural sinuses using IVUS ???
Kind regards,
MarkW
PS I agree that investigating 3 veins 'does not cut it'. I am less polite and say
that doctors who check only 3 veins are cheating pwMS by offering just this.
--------------------------------------
Dr S posted:
There is no correlation between location of stenoses and symptoms that i can detect.
There are about 20 veins that can be involved in ccsvi
right and left transverse sinuses
right and left IJV
right and left vertebral veins
right and left innominate veins
Azygous vein
Hemiazygous vein
left renal vein
left iliac vein
ascending lumbar vein
and eight lumbar veins
Each is either an inflow vein or an outflow vein depending on circumstances.
A three vein interrogation just does not cut it.
--------------------------------------------
Dear Mark
there are better ways to visualize the dural sinuses and the likelihood of CCSVI is low. My number one reason for putting the catheter or wire up there is to make sure that i am truly in the IJV. it is possible to be in a parallel vein rather than the IJV if you do not put the catheter through the foramen. so that is #1 reason for me to catheterize the dural sinues. I havent found many problems, just a few, so i will make a decision if i need to actually do a dural venogram on January 1 when I make my next iteration of my diagnosis and treatment protocol. I do so every couple of months. As I promised cece (and you) there are other fish to fry and VV comes to the front of the list.

Re: DrSclafani answers some questions

Posted: Fri Nov 04, 2011 2:57 am
by pelopidas
Cece wrote:http://www.facebook.com/Sal.Sclafani.MD ... l&filter=1

Dr. Sclafani is working on a paper on nutcracker syndrome, that might be finished within a week.
Nutcracker syndrome is commonly seen in chronic fatigue syndrome....!
So how does a renal vein stenosis cause fatigue? Through slowed perfusion in the left kidney? Or because it diverts the heavy renal flow to the azygous, which slows the cerebrospinal drainage, causing neurological fatigue?
Cece, if this is a referendum, i positively vote for resolution number 2: renal flow diverts into the azygous.
A few more days and another mystery is solved!

Re: DrSclafani answers some questions

Posted: Sat Nov 05, 2011 5:57 pm
by Cece
drsclafani wrote:As I promised cece (and you) there are other fish to fry and VV comes to the front of the list.
Oh, how exciting. Vertebral veins to the front of the list? Will you try ballooning the vertebral veins, despite their small size? Will we get IVUS images of the vertebral veins? As far as I know the vertebral veins don't have valves, so I wonder what types of CCSVI issues exist in the verts. Very early on, you had a patient who had blocked verts, and I remember the discussion from then.

a reference thread from a year ago: http://www.thisisms.com/forum/chronic-c ... =vertebral

I wonder if you think it would be worthwhile to look at verts in all patients or only in patients who have an occluded main vessel? Have you talked to Dr. Zamboni about ballooning the verts? I believe he has treated some but I don't know with what results.

Re: DrSclafani answers some questions

Posted: Sun Nov 06, 2011 10:37 am
by Hooch
The patient that Dr Sclafani treated for only Nutcracker Syndrome this time (jugulars and azygous were running freely from a previous procedure) was thought to have Chronic Fatigue before she received her MS diagnosis. This is all getting even more interesting!

Re: DrSclafani answers some questions

Posted: Sun Nov 06, 2011 1:40 pm
by NZer1
This was posted on Dr. Flanagan's thread and I think it of interest for us all;

http://www.rush.edu/webapps/MEDREL/serv ... se?id=1527

September 01, 2011
Signs of Aging May be Linked to Undetected Blocked Brain Blood Vessels

Many common signs of aging, such as shaking hands, stooped posture and walking slower, may be due to tiny blocked vessels in the brain that can’t be detected by current technology.

In a study reported in Stroke: Journal of the American Heart Association, researchers from Rush University Medical Center, Chicago, examined brain autopsies of older people and found:

Microscopic lesions or infarcts — too small to be detected using brain imaging — were in 30 percent of the brains of people who had no diagnosed brain disease or stroke.

Those who had the most trouble walking had multiple brain lesions. Two-thirds of the people had at least one blood vessel abnormality, suggesting a possible link between the blocked vessels and the familiar signs of aging.

“This is very surprising,” said Dr. Aron S. Buchman, lead author of the study and associate professor of neurological sciences at Rush. “The public health implications are significant because we are not identifying the 30 percent who have undiagnosed small vessel disease that is not picked up by current technology. We need additional tools in order to identify this population.”

In 1994, the researchers began conducting annual exams of 1,100 older nuns and priests for signs of aging. The participants also donated their brains for examination after death. This study provides results on the first 418 brain autopsies (61 percent women, average 88 years old at death).

Although Parkinson’s disease occurs in only 5 percent of older people, at least half of people 85 and older have mild symptoms associated with the disease.

Before the study, researchers believed that something more common, such as microscopic blocked vessels, might be causing the physical decline. The study’s autopsies found the small lesions could only be seen under a microscope after participants died. The lesions couldn’t be detected by current scans.

During the annual exams of the nuns and priests, researchers used the motor skills portion of a Parkinson’s disease survey to assess their physical abilities. Researchers observed and rated the participants’:

Balance
Ability to maintain posture
Walking speed
Ability to get in and out of chairs
Ability to make turns when walking
Sense of dizziness
“Often the mild motor symptoms are considered an expected part of aging,” said Buchman, who is also a member of the Rush Alzheimer’s Disease Center. “We should not accept this as normal aging. We should try to fix it and understand it. If there is an underlying cause, we can intervene and perhaps lessen the impact.”

Co-authors from Rush are Sue E. Leurgans, PhD; Dr. Sukriti Nag, PhD; Dr. David A. Bennett, and Dr. Julie A. Schneider, MS. The National Institutes of Health and the Illinois Department of Public Health funded the study.

Re: DrSclafani answers some questions

Posted: Sun Nov 06, 2011 3:48 pm
by drsclafani
Cece wrote:
pelopidas wrote:Cece, if this is a referendum, i positively vote for resolution number 2: renal flow diverts into the azygous.
A few more days and another mystery is solved!
It's an interesting connection between nutcracker syndrome and chronic fatigue.
drsclafani wrote:As I promised cece (and you) there are other fish to fry and VV comes to the front of the list.
Oh, how exciting. Vertebral veins to the front of the list? Will you try ballooning the vertebral veins, despite their small size? Will we get IVUS images of the vertebral veins? As far as I know the vertebral veins don't have valves, so I wonder what types of CCSVI issues exist in the verts. Very early on, you had a patient who had blocked verts, and I remember the discussion from then.

a reference thread from a year ago: http://www.thisisms.com/forum/chronic-c ... =vertebral

I wonder if you think it would be worthwhile to look at verts in all patients or only in patients who have an occluded main vessel? Have you talked to Dr. Zamboni about ballooning the verts? I believe he has treated some but I don't know with what results.
i dont think this is going to be very fruitful but it has to be assessed at some point. I dont thing it is that simple. sometimes it is difficult to determine whether the vein that looks like the vert is actually the vert