Feasibility and safety of endovascular treatment for chronic cerebrospinal venous insufficiency in patients with multiple sclerosis Tommaso Lupattelli,

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Presentation transcript:

Feasibility and safety of endovascular treatment for chronic cerebrospinal venous insufficiency in patients with multiple sclerosis Tommaso Lupattelli, MD, Giovanni Bellagamba, MD, Elena Righi, MD, Vincenzo Di Donna, MD, Isac Flaishman, MD, Rita Fazioli, MD, Francesco Garaci, MD, Paolo Onorati, MD Journal of Vascular Surgery Volume 58, Issue 6, Pages 1609-1618 (December 2013) DOI: 10.1016/j.jvs.2013.05.108 Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 1 Right internal jugular vein (IJV) balloon angioplasty at the vein outlet (a). No evidence of collateral vessels after complete reopening of the vein (b). Narrowing of the left IJV at the level of the ostium (c). Angioplasty with a standard balloon proved ineffective due to the presence of a highly resistant stenosis (d). The standard balloon was changed for a high-pressure one that allowed full dilation of the vein lesion (e and f). Right IJV stenosis/occlusion; balloon dilatation (g) with subsequent significant improvement of the vein outflow (h). Journal of Vascular Surgery 2013 58, 1609-1618DOI: (10.1016/j.jvs.2013.05.108) Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 2 Left internal jugular vein (IJV) narrowing at the vein outlet. A large collateral vessel draining at the junction between the subclavian and the anonymous veins is also seen (a). Balloon angioplasty with the kissing-balloon technique. Following dilatation of both balloons (b), complete reopening of the vein as well as disappearance of the large collateral vein is seen (c). Journal of Vascular Surgery 2013 58, 1609-1618DOI: (10.1016/j.jvs.2013.05.108) Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 3 Azygos vein (AZ) rupture following balloon angioplasty at the vein outlet. Subtraction angiography shows massive extravasation of contrast medium (arrows) within the mediastinum (a). A standard balloon is placed close to the vein outlet and inflated at two atmospheres for 20 minutes in an effort to stop the vessel from bleeding (b). After balloon removal, complete cessation of bleeding is noted. However, a 3- × 3-cm pseudoaneurysm of the AZ (arrow) located at 2 cm from the junction with the superior vena cava is also seen (c). Bare stent placement of the AZ (d) followed by coil embolization of the pseudoaneurysm. Coil embolization was performed using a 4F Cobra catheter with its tip advanced through the meshes of the stent (e). Confirmation angiography shows good coil packaging of the sac with a preserved flow throughout the AZ. A vein spasm of the descending portion of the AZ is noted at the end of the procedure (arrows) (f). SVC, Superior vena cava. Journal of Vascular Surgery 2013 58, 1609-1618DOI: (10.1016/j.jvs.2013.05.108) Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 4 The proximal segment of the azygos vein (AZ), which is the portion between the vena cava and the azygous arch (within the circle), may lead to a massive bleeding into the mediastinum if it breaks during balloon dilatation (a and b). SVC, Superior vena cava. Journal of Vascular Surgery 2013 58, 1609-1618DOI: (10.1016/j.jvs.2013.05.108) Copyright © 2013 Society for Vascular Surgery Terms and Conditions