DrSclafani answers some questions

[drsclafani]

Dr S

If the jugular has scar tissue and a stent is required will the risk of intimal hyperplasis be higher due to the damage to the lumin or will the damage to the vein inhibit endothelial growth over part of the stent causing more concern with clot formation? Sorry if I am using the wrong terms.

Thanks

wow!
it is nice to get such good questions. the volume of questions has certainly dropped off. but this reminds me of the good old days.

If the vein is occluded, the intima should die because it is not getting venous blood to provide oxygen to the intimal layer. Intima should redeposit if a flowing channel forms as some of the clot is dissolved. But slow flow is still present and thus thrombosis remains a concern. The stent is trying to get more flow through this vein but the foreign body is another reason for clotting. So we have many concerns for re-thrombosis. Slow flow, foreign body, absent intima and a small lumen. Anticoagulation and antiplatelet therapy is really important in this situation.

[pelopidas]

the great "eyes wide open/eyes wide shut" video

http://youtu.be/cRq7L1HQsbs

[munchkin]

Hi Dr.S

My GP had a question. He was wondering why shunts aren't being used if stents have so many issues.

I hope you and everyone here at ThisIsMS have a wonderful holiday season.

Thanks

[Cece]

The patient would also have an accurate diagnosis now, of both the innominate stenosis and the renal stenosis. That is a very important something gained.
edited to add: With the first image of the jugular that you showed us, with the contrast going upward instead of downward, were there any clues there that we could have picked up? What were you expecting when you then released contrast within the stent?

that was a clue. Once I saw contrast flow upward, the next issue was to define the abnormality in the stent. One could expect intimal hyperplasia to be the culprit, or perhaps thrombosis. So the next step would be to pull back the catheter and inject the contrast in the stent. I admit i expected the stenoses to be in the stent, but once i saw the size of the lumen filled with contrast media, i knew it had to be more proximal toward the chest. My first thought was that there was a membrane at the bottom of the stent. The next step was to pull back a bit more and see where the contrast media went. It obviously wasnt going back toward the heart!.

Was the flow stronger than it should have been for reflux flow?

absolutely! one never sees reflux above an obstruction, something was wrong.

By the time you released contrast in the subclavian, did you have the mystery solved and what you saw confirmed what you expected, or was it still coming together?

The subclavian venogram was icing on the cake.

Fantastic Voyage was sci-fi, but perhaps you were influenced by Sherlock Holmes as well?

[blossom]

hi dr. sclafani, i saw your last post you were happy to be getting questions "like the good old days". now this may have been asked or brought up before and i missed it. don't know if you recall my case or if you still have the cd copy of my procedure done at dr. sisken's "not by him". you did mention keeping it for research. i was not a happy camper not just because i had no improvement but the fact that my left leg was novacain numb immediatly noticed big time when i woke up. i never had numbness before. my symptoms were progressed but never before numbness. and that remains -only worse well here goes- i had talked with you through a few pm's about reviewing my procedure and maybe getting your opinion and when ready get treated.

one of your comments was "that you had not before seen such "tortious veins".

this as i said may have been discussed on your thread or else where on tims, not sure. but i just came across AVM of the spinal cord information. in one part they referred to them as "tortious veins and arteries. twisted balled up that can cause many neurological problems amongst other things. sometimes caused by "trauma" amongst other causes.

you knowing what you know and good at what you do and your interest and input always very much appreciated-can you tell me if AVM can be seen when ccsvi treatment is done? is there a separate way of testing for it? being it can be in different locations in the spine and as of yet ccsvi treatment does not treat or look at the total spine yet. right?

also, would you be able to treat it or have you or who would?

to think that the neurologist dealing with ms have checked this out in cases i doubt it. in my case anyway as much as i've yapped to them about spinal involvement and blood flow for the last 20 yrs.i would have remembered if they would have been looking in that realm of thinking.

these questions i hope are not taken as trying to side track ccsvi because that's not the intention in any way. some people are getting good results and some not so good. dr.'s like you are trying hard to figure this out. could AVM be a part of this puzzle? and somehow not being looked into in this realm of new thinking? dr. sclafani, we mser's are all individul individuals thrown not by choice into being branded by symptoms someone decided to name ms.

this is part of your reply to me wth a pm after looking at my film: "Those are some wild jugulars you have, that amount of tortuosity i havent seen before."

that stuck in my head that's why i'm asking you. and if AVM would happen to play apart in my case the answers to my questions above will be greatly appreciated. of coure treating this when possible doesn't seem to be a cake walk. sounds freaky scarey.

today being a holiday i hope you are relaxing and enjoying lt all. seems you are burning the candle at both ends sometimes. thank you, blossom

[Cece]

blossom, was this back before he started treating at AAC, or was it more recently? I am wondering if yours were the most tortuous veins he had seen back when he'd treated only a small number of patients, or if it includes the patients he's treated at AAC.

[blossom]

cece,

he replied to me mar. 7, 2011.

[drsclafani]

Fantastic Voyage was sci-fi, but perhaps you were influenced by Sherlock Holmes as well?

it was elementary, watson

Actually, i am a Holmes fanatic, i have read all the stories twice and watched movies from basil to downey. Even saw the musical twice in 1960s.

At University, I had a Hans tooth coat and a double brimmed hat to go along with my pipe. Never did get into the cocaine tho.

[drsclafani]

hi dr. sclafani, i saw your last post you were happy to be getting questions "like the good old days". now this may have been asked or brought up before and i missed it. don't know if you recall my case or if you still have the cd copy of my procedure done at dr. sisken's "not by him". you did mention keeping it for research. i was not a happy camper not just because i had no improvement but the fact that my left leg was novacain numb immediatly noticed big time when i woke up. i never had numbness before. my symptoms were progressed but never before numbness. and that remains -only worse well here goes- i had talked with you through a few pm's about reviewing my procedure and maybe getting your opinion and when ready get treated.

Your numbness was likely to be neuropraxia, a lower motor neuron injury cause by a needle going through or near the femoral nerve, which is lateral to the artery. Sometimes it can be very close or lie on top of the artery. Neuropraxia bruises the nerve and causes either numbness or neurological pain or both. It usually goes away in a few months. Did your numbness resolve??

one of your comments was "that you had not before seen such "tortious veins".

this as i said may have been discussed on your thread or else where on tims, not sure. but i just came across AVM of the spinal cord information. in one part they referred to them as "tortious veins and arteries. twisted balled up that can cause many neurological problems amongst other things. sometimes caused by "trauma" amongst other causes.

Tortuosity can come from too much flow, as in shunting from artery to vein or as in collaterals because of obstruction. The artery does not get tortuous in venous obstruction, but it certainly does when there is a direct connection between and artery and a vein that bypasses the capillary.

you knowing what you know and good at what you do and your interest and input always very much appreciated-can you tell me if AVM can be seen when ccsvi treatment is done? is there a separate way of testing for it? being it can be in different locations in the spine and as of yet ccsvi treatment does not treat or look at the total spine yet. right?

I have not heard of AVM being associated with MS, although some of the symptoms are similar in these two entities. Afterall, high flow INTO the vein because of the AV shunt should have the same effect as OUTflow obstruction of the azygous vein. Venography will not show this directly, it is suggested by xrays of the spine, better screened by MRI,/MRA or CTA and properly looked at by spinal arteriography for full diagnosis.

also, would you be able to treat it or have you or who would?

I can treat them but these are very difficult to treat.

today being a holiday i hope you are relaxing and enjoying lt all. seems you are burning the candle at both ends sometimes. thank you, blossom

help people is sometimes relaxing, often not so , but it is always enjoyable.

[blossom]

hi dr. sclafani,

i just got a doppler fri. dec. 30. they say i have flow. i had my procedure aug. 2, 2010.

i declined faster after the procedure than before. anyone i've read about that had a faster decline afterwards either had clots or intimal hyperplasia. i was asking the doppler tech. questions. i know the entry is the femoral vein to get to the jugulars. i'm not good at naming the whole route but it's not a real straight shot anyway. i know that anywhere the angioplasty goes though the veins there could be a chance the vein could be scraped or injured. thus possible clotting or intimal hyperplasia. the tech. said that the middle veins would have to be checked by a ct scan something besides a doppler. and that i could still have jugular flow even if there was a problem in between. i always got the point of entry checked too. are you or anyone else checking this possibility out? the ones that had improvement and lost it i'd say were more likely to get the procedure again if they could and that's when clots or scarring was usually found. now, in my case getting worse faster but still have flow in the jugulars, people like me aren't as likely to want to hurry back. we're kinda sitting back and waiting.

the numb leg is another issue. i agree with your explanation. kinda strange that when i came out of recovery and asked the dr. what happened to my leg it was so numb and i never had numbness anywhere before. she gave me no explanation. my brother and my friend were standing right there and heard me and her so it wasn't the drugs making me goofy. in fact i mentioned it to dr. sisken when he checked the flow afterwards and i got a answer something like oh that will probably clear up. that was at the time they were real busy and at least with me very little time was spent.

you asked me if the numbness had improved. the answer is no. it has gotten worse.

i'm anxious to hear your input to my questions.
as always thank you for your interest and work you are doing.

[jean-la-grenouille]

Dear Dr Sclafani,

I wish you an exciting new year and thank you for your commitment to MS sufferer.

I have 2 simple questions (sorry if this as already been discussed) :

1)are there valves in the internal jugular veins ?
I have been told by a french vascular surgeron, that blood flow doesn't need valves because it's not opposed to gravity.

2)I don't know much about the technique (IVUS) you use to diagnose CCSVI. Does an echo-doppler, performed by a competent doctor, provide enough information to check for CCSVI ?

[Cece]

Two good questions from over at Dr. Sclafani's Facebook site:
https://www.facebook.com/Sal.Sclafani.M ... l&filter=1

Dr. Sclafani, back in 2010 Dr. Tariq Sinan presented at your symposium. I believe he was also the lead investigator for the Kuwait CCSVI study. We have not heard much about him or the Kuwait study for the last year. Do you have any information if this doctor is still involved in CCSVI treatments or if the study is still in progress?

I don't have contact with my surgeons in Poland but I was wondering if anyone out there who IS in contact with their surgeon can ask a question for me. Please ask if veso dialators would help prevent re-stenosis POST PROCEDURE. I have very limited knowledge of their intended use but maybe they would help prevent future narrowings? ....Can you answer this question Dr S?

[Cece]

Have you had a chance to read what's been discussed in the migraine thread? The research from Dr. Chung et al shows that patients with migraines tend to have jugulars lacking in distensibility.

http://www.thisisms.com/forum/chronic-c ... ml#p184174

I am wondering about a specific case. This is a patient who upon first procedure had MS improvements but the improvements faded. Upon second procedure, the patient had a hypoplastic IJV valve treated. After the procedure a terrible migraine developed. It persisted for at least two months. New white matter lesions appeared. The procedure was a technical success, because doppler showed veins to still be open. But it was a failure in terms of any improvements being seen and, indeed, it seemed to be a cause of the migraine and worsening.

Thoughts on the worsening were:
1 – could the jugulars have become occluded or damaged (no, doppler shows them to be open)
2 – did the ballooning cut off flow to the brain during the procedure, badly enough to cause all this damage (no, patient does not remember such an event)
3 – could it be a random MS relapse, perhaps brought on by the strain of travel etc? (possible)
4 – new theory – what if the patient's jugular was as described in Dr. Chung's paper? The jugular is abnormally lacking in distensibility. In this situation, the malformed valve was preventing outflow but also preventing reflux back from the heart. When the valve is successfully treated, any valsalva strain would result in flow traveling up the jugular. If the jugular cannot distend under valsalva, the flow would continue upward, striking the dural sinus, with an increase in cerebral venous hypertension, triggering migraine.

Lack of jugular distensibility can be detected by doppler ultrasound, and this is what was used in Dr. Chung and Dr. Hu's research. Might it be useful information if this patient were to get another doppler ultrasound, this time specifically to look at jugular distensibility?

Can lack of overall jugular distensibility be improved by ballooning? In treating CCSVI, placing the balloon so that the shoulder of the balloon is on the stenosis minimizes the ballooning of healthy vein. But in patients who lack jugular distensibility, could this be the wrong method? Centering the balloon in such a patient would result in some stretching of the vein itself, which might improve the lack of distensibility, even if that lack of distensibility of the presumed healthy vein wall had never been diagnosed.

I know you check for distensibility when you find a narrowing, to see if it is stenotic or physiological. But if the jugulars are not narrowed, a jugular would not be checked for distensibility?

This is something that could be routinely assessed during the pre-imaging, if jugular distensibility is a factor that could affect treatment choices or outcome.

Here is more of the relevant research from the migraine thread:
Women with a migraine diagnosis at the beginning of an epidemiology study were 47% more likely to develop MS:
http://www.thisisms.com/forum/chronic-c ... ml#p184216

Venous outflow as meaured by MRI shows a pattern of secondary collateral flow and not primary jugular flow in both migraine patients and in CCSVI patients but not in healthy controls:
http://www.thisisms.com/forum/chronic-c ... ml#p184129

Compressing jugulars during a migraine makes migraine pain worsen, especially when supine:
http://www.thisisms.com/forum/chronic-c ... ml#p184166

[jean-la-grenouille]

I found the answer to my first question :

"The valves in the jugular veins are not essential with over 20% of the population having no valves in these veins. It is thought that permanent disruption of the valves using balloons alone is not possible at present and that over aggressive high pressure ballooning may risk venous damage.(Dr Sclafani, ccsvi-locator)

[1eye]

I found the answer to my first question :

"The valves in the jugular veins are not essential with over 20% of the population having no valves in these veins. It is thought that permanent disruption of the valves using balloons alone is not possible at present and that over aggressive high pressure ballooning may risk venous damage.(Dr Sclafani, ccsvi-locator)

I bet the 1/5 of humanity who don't, are not in the Cirque du Soleil, or the space program either. I don''t think being upside-down a lot is essential for most people. If you have jugular reflux problems, wouldn't it help to have those valves?