CCSVI -Hector Ferral - enero2012


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Abstract del Dr. Hector Ferral acerca del manejo endovascular de la CCSVI en pacientes portadores de Esclerosis Múltiple.

El Dr. Ferral se licenció en Medicina en la ciudad de Mexico, Universidad Anahuac (1979-1985)
Residencia en Medicina Interna: Instituto nacional de Nutricion 1986-1988
Residencia en Radiologia: Instituto nacional de Nutrición: 1988-1991
Fellowship en Intervencionismo: Universidad de Minnesota, Minneapolis : 1991-1993

Attending, Profesor asociado: Lousiana State University, New Orleans: 1995-2000
Attending: Profesor Asociado: University of Texas, San Antonio: 2000-2003
Attending: Profesor de Radiologia: Jefe del Servicio de Intervencionismo, Rush University, Chicago: 2004-2011
Attending: North Shore University: Evanston, Chicago Dic. 2011 a la fecha

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CCSVI -Hector Ferral - enero2012

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