CCSVI -Hector Ferral - enero2012

Endovascular management of CCSVI: Single Center Experience

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

Purpose

• Present our experience in the management of CCSVI in patients with multiple sclerosis

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

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

Materials and Methods

Materials and Methods

• Diagnostic venogram• Performed under conscious

sedation• Femoral vein approach

• 9 French sheath

• Selective catheterization of jugular veins and azygos vein

Diagnostic Venogram

Straight catheter with sideholes, mid-neck region50% diluted contrast-Power injector 15 cc volume at 5 cc/secHeld inspiration and expiration

Diagnostic Venogram

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

Left jugular vein IVUS

IVUS, left jugular vein, severe stenosis

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

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

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)

Results

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)

Angioplasty

Left jugular vein angioplasty

Stent placement

Severe left jugular vein stenosis

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

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

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%

Conclusions

• The CCSVI concept deserves further study

• Well organized, multidisciplinary prospective trials should be conducted to further understand and validate this concept