CCSVI: can we justify the procedure at this time?

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Presentation transcript:

CCSVI: can we justify the procedure at this time? Richard F. Neville, MD Professor, Department of Surgery Chief, Division of Vascular Surgery George Washington University MFA

I have no real or apparent conflicts of interest to report. Richard F. Neville, MD I have no real or apparent conflicts of interest to report.

Chronic Cerebrospinal Venous Insufficiency (CCSVI) Theory Insufficient drainage of the cerebral circulation Reduced cerebral blood flow Increased mean transit time (MRI perfusion studies) Truncal venous malformations Annulus Malformed valves/Congenital septae or webs Hypoplasia Twisting/kinking

Chronic Cerebrospinal Venous Insufficiency (CCSVI) Syndrome characterized by truncal stenoses of (internal jugular, azygous veins) with collateral formation (SC)

Truncal venous malformations in CCSVI Embryologic parallel between truncular venous malformation in the jugular veins and in other venous segments. (a) Membranous obstruction of the SVC in Budd-Chiari syndrome (b) Membranous obsturction observed in the IJV c) Truncular stenosis of the IJV d) Truncular stenosis of the external iliac vein Lee BB, Neville RF. Intl Angio 2010;29(2):95-107

CCSVI and Multiple Sclerosis High rate of cerebral venous reflux in MS Extracranial reflux transmitted to the deep cerebral system Histology in MS Iron stores encircling the vein wall Hemosiderin deposits in macrophages (CVI) Pericapillary fibrin cuffs (CVI) CCSVI prevalance in MS Reported to be 56 – 100% Not contradictory with the autoimmune theory

CCSVI Theory Patterns Prof Paolo Zamboni 2009 Multiple sclerosis Type A (30%) Proximal Azygous One IJV Type B (38%) Both IJVs Type C (14%) Normal azygous Type D (18%) Proximal azygous Lumbar azygous Prof Paolo Zamboni 2009 Multiple sclerosis Duplex US MRI – insufficient drainage - increased mean transit time Venograpy – truncular venous malformations Zamboni P, J Vasc Surg

Duplex Ultrasound criteria Reflux in cervical veins Flow direction in intracranial veins B mode images IJ area < 0.4cm2 Asymmetry of IJVs Blocked outflow in cervical veins in all postural positions Cross sectional area does not widen in supine position

Dynamic US IJV cross-sectional area Increased cross-sectional area (CSA) in the IJVs of controls from the sitting to the supine posture. Flat or negative CSA variation in the majority of CCSVI-MS patients. Zamboni P, Galeotti R. Phlebology 2010;25:269-279

Venography Left: annulus of the IJV between the venous valve (VV) and the brachio cephalic trunk (BCT) Right: twisting of the AZY with dilation and reflux toward the spine.

Treatment (a) Stenosis of the right IJV (b) Balloon inflated during PTV (c) Postoperative result IJV

Others don’t agree 21 MS patients (relapsing-remitting) 20 controls MRI (phase-contrast) 3/21 IJV stenosis No difference in IJV outflow No difference in IJV reflux Sundstrom P, et al. Ann Neurol 2010;68:255-259

Our Study Multiple sclerosis and Chronic Cerebrospinal Venous Insufficiency, IRB# 2010-186, August 2010

Methods Duplex US screening of MS patients n=100 61 relapsing remitting MS 36 secondary progressive MS 3 primary progressive MS Multiple Sclerosis Quality of Life (MSQOL)-54 Instrument Positive Zamboni criteria n= 57 Venograms (> 2 US criteria) n= 48 IVUS on all studies Positive findings – treated n= 32 Angioplasty only Large, low pressure balloons Prolonged inflation times

Imaging Data Duplex ultrasound Stenosis (IJ area) R IJV 19% L IJV 23% Reflux (0.55-2.25 secs) R IJV 57% L IJV 62% Unilateral reflux 52% Bilateral reflux 43% Stenosis (IJ area) R IJV 19% L IJV 23% 1 IJ thrombosis Venography Any abnormality 73% R IJV stenosis 29% L IJV stenosis 33% Azygous stenosis 10%

IJV stenosis? IVUS may help

R IJV valve, Left IJV stenosis

R IJV, L IJ with valve

Treatment Data Angioplasty 32 R IJV angioplasty 9 L IJV angioplasty 13 Azygous angioplasty 4 Combination 6

Right IJV angioplasty

Left IJV angioplasty

Azygous angioplasty

Summary (no Conclusions) Initial observations of central venous system in MS No controls Seemingly, a large number of venous abnormalities IVUS important Identify valves Discern pathology Questionable results without adjunct techniques beyond angioplasty alone Questionable outcomes

Thank you