Endovascular management of CCSVI: Single Center Experience Hector Ferral, MD, George Behrens, MD,...

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Endovascular management of CCSVI: Endovascular management of CCSVI: Single Center Experience Single Center Experience Hector Ferral, MD, George Behrens, MD, Yanki Tumer, MD, Tameem Souman, MD

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Page 1: Endovascular management of CCSVI: Single Center Experience Hector Ferral, MD, George Behrens, MD, Yanki Tumer, MD, Tameem Souman, MD.

Endovascular management of Endovascular management of CCSVI: Single Center ExperienceCCSVI: Single Center Experience

Hector Ferral, MD, George Behrens, MD, Yanki Tumer, MD, Tameem Souman, MD

Page 2: Endovascular management of CCSVI: Single Center Experience Hector Ferral, MD, George Behrens, MD, Yanki Tumer, MD, Tameem Souman, MD.

IntroductionIntroduction

• Mutiple Sclerosis (MS)– Chronic Disease of unknown cause– Affects about 400,000-500,000

patients in the United States– Women are more affected than men. – It is a disease of young people– Familiar and environmental factors

Page 3: Endovascular management of CCSVI: Single Center Experience Hector Ferral, MD, George Behrens, MD, Yanki Tumer, MD, Tameem Souman, MD.

IntroductionIntroduction

• There is no known cure for multiple sclerosis

• Patients have debilitating symptoms that severely affect the quality of life

• It is a progressive disease

Page 4: Endovascular management of CCSVI: Single Center Experience Hector Ferral, MD, George Behrens, MD, Yanki Tumer, MD, Tameem Souman, MD.

IntroductionIntroduction

• Treatment options are limited and include:– Steroids– Disease-modifying drugs– Stem-cell transplant

• The goal of treatment: Modify disease, control symptoms, improve quality of life

Page 5: Endovascular management of CCSVI: Single Center Experience Hector Ferral, MD, George Behrens, MD, Yanki Tumer, MD, Tameem Souman, MD.

CCSVI - ConceptCCSVI - Concept

• CCSVI= Chronic cerebrospinal venous insufficiency

• Theory proposed by Zamboni, an italian vascular surgeon

• Patients with multiple sclerosis have blockages in the main veins of the neck and chest (jugular veins and azygos vein)

• These blockages interfere with the drainage of blood from the brain back to the heart.

Page 6: Endovascular management of CCSVI: Single Center Experience Hector Ferral, MD, George Behrens, MD, Yanki Tumer, MD, Tameem Souman, MD.

CCSVI - ConceptCCSVI - Concept

• The blockage of flow causes high pressure in the brain and deposits of iron that participate in the formation of multiple sclerosis plaques.

Magnetic Resonance Imaging Scan of a patient with multiple sclerosisNotice multiple white plaques,Characteristic of the disease (red arrows)

Page 7: Endovascular management of CCSVI: Single Center Experience Hector Ferral, MD, George Behrens, MD, Yanki Tumer, MD, Tameem Souman, MD.

CCSVI diagnosisCCSVI diagnosisMagnetic Resonance Venography Magnetic Resonance Venography

(MRV)(MRV)

MRV shows large collaterals(green arrows) and severe blockageof the jugular veins (red arrows),consistent with the CCSVI concept

Page 8: Endovascular management of CCSVI: Single Center Experience Hector Ferral, MD, George Behrens, MD, Yanki Tumer, MD, Tameem Souman, MD.

CCSVI diagnosisCCSVI diagnosisCatheter VenographyCatheter Venography

A catheter venography is an interventional invasive procedure.It is performed through a small incisionin the groin to place a catheter in the femoral vein. The catheter is advanced into the jugular veins and contrast is injected to see the inside of the veinsThe picture shows a venogram with A tight blockage (red arrow)

Page 9: Endovascular management of CCSVI: Single Center Experience Hector Ferral, MD, George Behrens, MD, Yanki Tumer, MD, Tameem Souman, MD.

CCSVI ManagementCCSVI ManagementBalloon AngioplastyBalloon Angioplasty

According to Zamboni, patients with blockages in the veins may have improvement in their symptoms after balloon dilatation of the blockages. This balloon dilatation is called angioplastyThe picture shows a balloon dilating ablockage in the jugular vein

Page 10: Endovascular management of CCSVI: Single Center Experience Hector Ferral, MD, George Behrens, MD, Yanki Tumer, MD, Tameem Souman, MD.

Angioplasty BalloonAngioplasty Balloon

Balloon angioplasty is a classicInterventional technique thathas been used since the mid-70’sto treat vascular and non-vascularproblems.

Page 11: Endovascular management of CCSVI: Single Center Experience Hector Ferral, MD, George Behrens, MD, Yanki Tumer, MD, Tameem Souman, MD.

Our StudyOur Study

• We used catheter venograms to evaluate 95 patients with multiple sclerosis (35 men/60 women).

• We performed 107 procedures: between 06/2010 and 09/2011

• Patients who had venous blockages were treated with traditional balloon angioplasty

Page 12: Endovascular management of CCSVI: Single Center Experience Hector Ferral, MD, George Behrens, MD, Yanki Tumer, MD, Tameem Souman, MD.

Our StudyOur Study

• The venograms showed blockages in 94.8% of our patients and were negative in only 5.2%

• Balloon angioplasty was done in all patients with a blockage and was successful in 97.4%

Page 13: Endovascular management of CCSVI: Single Center Experience Hector Ferral, MD, George Behrens, MD, Yanki Tumer, MD, Tameem Souman, MD.

Our StudyOur Study

a b

Figure a shows a vein with tight blockages (arrows)Figure b shows the vein after balloon angioplasty. Notice the improvement in the blockage

Page 14: Endovascular management of CCSVI: Single Center Experience Hector Ferral, MD, George Behrens, MD, Yanki Tumer, MD, Tameem Souman, MD.

Clinical ResponseClinical 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

Page 15: Endovascular management of CCSVI: Single Center Experience Hector Ferral, MD, George Behrens, MD, Yanki Tumer, MD, Tameem Souman, MD.

ComplicationsComplications

• Complications were seen in 7/90 treated patients (7.7%) and most of them were minor complications (bleeding at puncture site).

• Major complications were seen in three patients : 3.3% (clot formation in the treated veins).

• There were no deaths in our group of patients

Page 16: Endovascular management of CCSVI: Single Center Experience Hector Ferral, MD, George Behrens, MD, Yanki Tumer, MD, Tameem Souman, MD.

Lessons learnedLessons learned

• Venous blockages are real and probably very common in patients with multiple sclerosis– Unknown cause– Is CCSVI truly an entity?

• Venogram and angioplasty is safe– Major complications: 3% – Excellent clinical response seen in: ≈ 55%– No deaths!!

Page 17: Endovascular management of CCSVI: Single Center Experience Hector Ferral, MD, George Behrens, MD, Yanki Tumer, MD, Tameem Souman, MD.

ConclusionConclusion

• The CCSVI concept deserves further study• More research in this area needs to be done

– Identify those patients who will benefit from this treatment

– Determine how to improve their quality of life


kclpure.kcl.ac.uk · arXiv:1806.04345v1 [math.AG] 12 Jun 2018 HOMOLOGICAL MIRROR SYMMETRY FOR K3 SURFACES VIA MODULI OF A∞-STRUCTURES YANKI LEKILI AND KAZUSHI UEDA Abstract. We

kclpure.kcl.ac.uk · arXiv:1806.04345v1 [math.AG] 12 Jun 2018 HOMOLOGICAL MIRROR SYMMETRY FOR K3 SURFACES VIA MODULI OF A∞-STRUCTURES YANKI LEKILI AND KAZUSHI UEDA Abstract. We

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