At the present time, we are offering both diagnostic and endovascular treatment for CCSVI (Liberation Treatment) in patients with an established diagnosis of symptomatic multiple sclerosis who reside both within and outside of the Albany, New York area. Doppler ultrasound testing and MR venography are available to diagnose disease in the dominant veins providing outflow from the central nervous system. Based on the findings from these examinations, we can consider patients on an individual basis for endovascular treatment.
Endovascular treatment for CCSVI consists of both angioplasty and stent placement. These procedures are most typically performed from common femoral vein access. First a venogram is performed. This involves placement of a small catheter (approximately the size of a piece of spaghetti) into the vein. This catheter is then advanced into the right and left internal jugular veins as well as the azygous vein. The catheter is advanced using fluoroscopy so that we can watch it as we move it through the venous system into the correct position. While the catheter is in each of those veins, contrast or dye is injected so that images can be obtained. These images will enable us to determine if the veins are patent (open) or if they have a stenosis, which means that a blockage exists within the vein that is potentially compromising the blood flow as it leaves the central nervous system.
If a stenosis is present, we can then move forward with angioplasty for treatment. This involves exchanging the catheter that was used for the venogram for a catheter that has a balloon built into it. Once that balloon is positioned across the narrowed area that was identified on the venogram, the balloon is inflated. This helps to treat the narrowing. The size of the balloon is selected based on the size of the normal vein above or below the narrowed area. Once the angioplasty is performed, another venogram is performed to confirm that the treatment was successful at addressing the stenosis. At this time, stents are being considered when angioplasty results in no change or a worsening of the stenosis that was targeted for treatment. In that case, a stent, which is a “tube” made of metal wires that goes into the vein and holds the vein open, is placed across the stenosis. It is placed in the vein in a manner that is similar to an angioplasty balloon and once the stent is positioned appropriately across the stenosis, it is released into the vein. Patients who receive a stent will typically need to be on anticoagulation medication for at least 3 months.
Like most invasive procedures, there are some risks associated with this procedure. These procedures do use fluoroscopy for guidance, which is a form of low-level diagnostic radiation. The average fluoroscopy time for a venogram is typically <10-15 minutes. Angioplasty may add 5-10 minutes to that total. Based on these fluoroscopy times and based on the fact that different areas of the body are being imaged within that time, the risk of radiation-induced injury as a result to this procedure is almost nonexistent. Any risk, however, will be minimized with careful use of fluoroscopy and with other procedural maneuvers designed to limit exposure. These procedures also require the use of intravenous contrast for visualization of the veins before and after treatment. The contrast used is an iodine-based dye and its use has been associated with both allergic reactions and impaired kidney function after administration. The risk of allergy can be minimized by pre-medicating patients with a history of allergic reactions to contrast, which is why it is important for us to know in advance if this is the case. Evaluating kidney function prior to the procedure, which will be done at our facility, can minimize the risk of impaired kidney function. In addition, only the minimum amount of contrast necessary for performance of the procedure will be used during the procedure.
Venography and venous angioplasty do carry some additional risk. In order to place a catheter into the internal jugular and azygous veins, it has to pass from the inferior vena cava, which is the main vein below the heart, into the superior vena cava, which is the main vein above the heart. As the catheter passes through the heart, it can cause changes in the heart rhythm. That is why patients are monitored during the procedure. This risk can be minimized by carefully observing the catheter as it passes through the heart. Once the catheter is within the internal jugular or azygous vein, it is possible that blood clots can form, which is unusual in this situation. During angioplasty, venous rupture is possible, but that risk should be minimized with careful sizing of the balloon that is used for angioplasty. In Zamboni’s study (59), some patients reported a headache after angioplasty, but this went away spontaneously in all patients. Finally, migration of a stent placed in a patient with CCSVI has been reported. This migrated into the heart and did require an additional procedure to remove the stent. This is felt to be an extremely rare risk of this procedure.
All of these procedures require an observation period of 3 hours before patients are discharged from our facility. If you are traveling to us for these services, we ask that you remain in the area for at least 24 hours if you have been treated with angioplasty or stent placement. Patients who undergo a venogram that reveals no evidence for CCSVI can leave once the 3-hour recovery has been completed.