CCSVI -Hector Ferral - enero2012
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Endovascular management of CCSVI: Single Center Experience
Hector Ferral, MD, George Behrens, MD, Yanki Tumer, MD, Tameem Souman, MD
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Purpose
• Present our experience in the management of CCSVI in patients with multiple sclerosis
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Materials and Methods
• Retrospective review• IRB approval: August 2011
• 95 patients (35 men/60 women) • Mean age : 48 years old (25-66) • 107 procedures: 06/2010 and
09/2011• 85 patients were self-referred• 10 patients were referred by PCP
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Materials and Methods
• All patients had a detailed clinic interview before the procedure• All patients had MS by McDonald criteria
• During the interview, a limited US was performed to assess the jugular veins
• Patients scheduled for venogram once risks & potential benefits discussed
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Materials and Methods
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Materials and Methods
• Diagnostic venogram• Performed under conscious
sedation• Femoral vein approach
• 9 French sheath
• Selective catheterization of jugular veins and azygos vein
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Diagnostic Venogram
Straight catheter with sideholes, mid-neck region50% diluted contrast-Power injector 15 cc volume at 5 cc/secHeld inspiration and expiration
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Diagnostic Venogram
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Materials and Methods
• Intravascular Ultrasound• 8 French Volcano system• Catheter advanced to mid-neck
level• Slow withdrawal looking for
stenotic areas or tight valves• Vein measurements obtained
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Left jugular vein IVUS
IVUS, left jugular vein, severe stenosis
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Materials and Methods
• Indications for Angioplasty:• Venogram + severe stenosis or severe
reflux• IVUS + for severe stenosis• IVUS showed thick, rigid valve
• Indications for Stent placement:• Stenosis not responsive to angioplasty• Recurrent stenosis after angioplasty• Occlusion after angioplasty
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Post-procedure protocol and follow-up
• Anticoagulation protocol after angioplasty• Full anticoagulation for 10 days
• Lovenox 60-80 mg sq BID for 10 days • Dabigatran etexilate (Pradaxa) 150 mg PO BID
• Plavix 75 mg PO per day for 6 weeks• Jugular vein US within 1 week • F-up visits at 1 month, 3 months, 6 months,
9 months and one year after the procedure• MSIS score started June 2011
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Results
• Diagnostic venograms in 95 patients • Positive in 90 patients (94.8%) • Negative in 5 (5.2%)
• 193 venous stenoses in 107 procedures• Left jugular vein
(n=76)• Right jugular vein (n=67) • Azygos vein (n=50)
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Results
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Angioplasty and Stents
• Angioplasty • Successful in 97.4% (188/193) lesions
• Stents• Self-expandable nitinol stents• Placed in 5 cases• Jugular vein occlusions (n=2)• Stenoses non responsive to angioplasty
(n=3)
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Angioplasty
Left jugular vein angioplasty
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Stent placement
Severe left jugular vein stenosis
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Clinical response
• A total of 50 patients (55.5%) reported a positive response with sustained benefit for more than 4 weeks in at least one of their symptoms
• Thirty-five patients (38.8%) reported no improvement at all after the procedure
• Five patients (5.5%) were lost to follow-up
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Complications
• 7/90 treated patients (7.7%)• Minor complications: 4/90 (4.4%)
• Puncture site hematoma (n=3) • Extensive bruising (n=1)
• Patient on Nattokinase supplement (Neprinol)
• Major complications: 3/90 (3.3%)• Jugular vein thrombosis after
angioplasty
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Conclusions
• Vein stenoses are common in MS patients
• Endovascular intervention is safe• 7% complication rate and most minor• No deaths related to the procedure
• Symptom relief: 55.5%
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Conclusions
• The CCSVI concept deserves further study
• Well organized, multidisciplinary prospective trials should be conducted to further understand and validate this concept