1. CCSVI: can we justify the procedure at this time?
Richard F. Neville, MD
Professor, Department of Surgery
Chief, Division of Vascular Surgery
George Washington University MFA

2. I have no real or apparent conflicts of interest to report.
Richard F. Neville, MD
I have no real or apparent conflicts of interest to report.

3. Chronic Cerebrospinal Venous Insufficiency (CCSVI)
Theory
Insufficient drainage of the cerebral circulation
Reduced cerebral blood flow
Increased mean transit time (MRI perfusion studies)
Truncal venous malformations
Annulus
Malformed valves/Congenital septae or webs
Hypoplasia
Twisting/kinking

4. Chronic Cerebrospinal Venous Insufficiency (CCSVI)
Syndrome characterized by truncal stenoses of (internal jugular, azygous veins) with collateral formation (SC)

5. Truncal venous malformations in CCSVI
Embryologic parallel between truncular venous malformation in the jugular veins and in other venous segments.
(a) Membranous obstruction of the SVC in Budd-Chiari syndrome
(b) Membranous obsturction observed in the IJV
c) Truncular stenosis of the IJV
d) Truncular stenosis of the external iliac vein
Lee BB, Neville RF. Intl Angio 2010;29(2):95-107

6. CCSVI and Multiple Sclerosis
High rate of cerebral venous reflux in MS
Extracranial reflux transmitted to the deep cerebral system
Histology in MS
Iron stores encircling the vein wall
Hemosiderin deposits in macrophages (CVI)
Pericapillary fibrin cuffs (CVI)
CCSVI prevalance in MS
Reported to be 56 – 100%
Not contradictory with the autoimmune theory

7. CCSVI Theory Patterns Prof Paolo Zamboni 2009 Multiple sclerosis
Type A (30%)
Proximal Azygous
One IJV
Type B (38%)
Both IJVs
Type C (14%)
Normal azygous
Type D (18%)
Proximal azygous
Lumbar azygous
Prof Paolo Zamboni
2009
Multiple sclerosis
Duplex US
MRI – insufficient drainage - increased mean transit time
Venograpy – truncular venous malformations
Zamboni P, J Vasc Surg

8. Duplex Ultrasound criteria
Reflux in cervical veins
Flow direction in intracranial veins
B mode images
IJ area < 0.4cm2
Asymmetry of IJVs
Blocked outflow in cervical veins in all postural positions
Cross sectional area does not widen in supine position

9. Dynamic US IJV cross-sectional area
Increased cross-sectional area (CSA) in the IJVs of controls from the sitting to the supine posture.
Flat or negative CSA variation in the majority of CCSVI-MS patients.
Zamboni P, Galeotti R. Phlebology 2010;25:

10. Venography
Left: annulus of the IJV between the venous valve (VV) and the brachio cephalic trunk (BCT)
Right: twisting of the AZY with dilation and reflux toward the spine.

11. Treatment (a) Stenosis of the right IJV
(b) Balloon inflated during PTV
(c) Postoperative result IJV

12. Others don’t agree 21 MS patients (relapsing-remitting) 20 controls
MRI (phase-contrast)
3/21 IJV stenosis
No difference in IJV outflow
No difference in IJV reflux
Sundstrom P, et al. Ann Neurol 2010;68:

13. Our Study
Multiple sclerosis and Chronic Cerebrospinal Venous Insufficiency, IRB# , August 2010

14. Methods Duplex US screening of MS patients n=100
61 relapsing remitting MS
36 secondary progressive MS
3 primary progressive MS
Multiple Sclerosis Quality of Life (MSQOL)-54 Instrument
Positive Zamboni criteria n= 57
Venograms (> 2 US criteria) n= 48
IVUS on all studies
Positive findings – treated n= 32
Angioplasty only
Large, low pressure balloons
Prolonged inflation times

15. Imaging Data Duplex ultrasound Stenosis (IJ area) R IJV 19% L IJV 23%
Reflux ( secs)
R IJV %
L IJV %
Unilateral reflux 52%
Bilateral reflux 43%
Stenosis (IJ area)
R IJV 19%
L IJV %
1 IJ thrombosis
Venography
Any abnormality 73%
R IJV stenosis 29%
L IJV stenosis 33%
Azygous stenosis 10%

16. IJV stenosis? IVUS may help

17. R IJV valve, Left IJV stenosis

18. R IJV, L IJ with valve

19. Treatment Data Angioplasty 32 R IJV angioplasty 9 L IJV angioplasty 13
Azygous angioplasty 4
Combination 6

20. Right IJV angioplasty

21. Left IJV angioplasty

22. Azygous angioplasty

23. Summary (no Conclusions)
Initial observations of central venous system in MS
No controls
Seemingly, a large number of venous abnormalities
IVUS important
Identify valves
Discern pathology
Questionable results without adjunct techniques beyond angioplasty alone
Questionable outcomes

24. Thank you