1. Endovascular management of CCSVI: Single Center Experience Hector Ferral, MD, George Behrens, MD, Yanki Tumer, MD, Tameem Souman, MD

2. Introduction Mutiple Sclerosis (MS) –Chronic Disease of unknown cause –Affects about 400,000-500,000 patients in the United States –Women are more affected than men. –It is a disease of young people –Familiar and environmental factors

3. Introduction There is no known cure for multiple sclerosis Patients have debilitating symptoms that severely affect the quality of life It is a progressive disease

4. Introduction Treatment options are limited and include: –Steroids –Disease-modifying drugs – Stem-cell transplant The goal of treatment: Modify disease, control symptoms, improve quality of life

5. CCSVI - Concept CCSVI= Chronic cerebrospinal venous insufficiency Theory proposed by Zamboni, an italian vascular surgeon Patients with multiple sclerosis have blockages in the main veins of the neck and chest (jugular veins and azygos vein) These blockages interfere with the drainage of blood from the brain back to the heart.

6. CCSVI - Concept The blockage of flow causes high pressure in the brain and deposits of iron that participate in the formation of multiple sclerosis plaques. Magnetic Resonance Imaging Scan of a patient with multiple sclerosis Notice multiple white plaques, Characteristic of the disease (red arrows)

7. CCSVI diagnosis Magnetic Resonance Venography (MRV) MRV shows large collaterals (green arrows) and severe blockage of the jugular veins (red arrows), consistent with the CCSVI concept

8. CCSVI diagnosis Catheter Venography A catheter venography is an interventional invasive procedure. It is performed through a small incision in the groin to place a catheter in the femoral vein. The catheter is advanced into the jugular veins and contrast is injected to see the inside of the veins The picture shows a venogram with A tight blockage (red arrow)

9. CCSVI Management Balloon Angioplasty According to Zamboni, patients with blockages in the veins may have improvement in their symptoms after balloon dilatation of the blockages. This balloon dilatation is called angioplasty The picture shows a balloon dilating a blockage in the jugular vein

10. Angioplasty Balloon Balloon angioplasty is a classic Interventional technique that has been used since the mid-70’s to treat vascular and non-vascular problems.

11. Our Study We used catheter venograms to evaluate 95 patients with multiple sclerosis (35 men/60 women). We performed 107 procedures: between 06/2010 and 09/2011 Patients who had venous blockages were treated with traditional balloon angioplasty

12. Our Study The venograms showed blockages in 94.8% of our patients and were negative in only 5.2% Balloon angioplasty was done in all patients with a blockage and was successful in 97.4%

13. Our Study a b Figure a shows a vein with tight blockages (arrows) Figure b shows the vein after balloon angioplasty. Notice the improvement in the blockage

14. 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

15. Complications Complications were seen in 7/90 treated patients (7.7%) and most of them were minor complications (bleeding at puncture site). Major complications were seen in three patients : 3.3% (clot formation in the treated veins). There were no deaths in our group of patients

16. Lessons learned Venous blockages are real and probably very common in patients with multiple sclerosis –Unknown cause – Is CCSVI truly an entity? Venogram and angioplasty is safe –Major complications: 3% –Excellent clinical response seen in: ≈ 55% –No deaths!!

17. Conclusion The CCSVI concept deserves further study More research in this area needs to be done –Identify those patients who will benefit from this treatment –Determine how to improve their quality of life