Volume 42 · Issue 3 · May 2013 ISSN 0301-1526 Vasa European Journal of Vascular Medicine 3/13 www.vasa-journal.eu Vasa is listed in MEDLINE, Science Citation Index Expanded (SCIE, SciSearch), Current Contents/Clinical Medicine Science Citation Index Prous Science Integrity Journal Citation Reports/Science Edition, Biological Abstracts, BIOSIS Previews, EMBASE, and Scopus The official organ of German Society of Angiology – Society of Vascular Medicine Swiss Society of Angiology Czech Society of Angiology Slovenian Society of Vascular Diseases
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Volume 42 · Issue 3 · May 2013 ISSN 0301-1526
VasaEuropean Journal of Vascular Medicine
3/13
Volu
me 42
· Issu
e 3
· May
201
3
www.vasa-journal.eu
Vasa is listed inMedline, Science Citation index
expanded (SCie, SciSearch),Current Contents/Clinical Medicine
The official organ of German Society of Angiology –Society of Vascular MedicineSwiss Society of AngiologyCzech Society of AngiologySlovenian Society of Vascular diseases
Editorials155 K. Pfister, M. Janotta, H. Apfelbeck,
P. M. KasprzakHow dangerous is a carotid plaque?
159 A. HinrichsTo screen or not to screen: That is the question!
Review161 J. Fahrni, R. P. Engelberger, N. Kucher,
T. Willenberg, I. BaumgartnerCatheter-based treatment of ilio-femoral deep vein thrombosis – an update on current evidenceDie interventionelle Behandlung der ilio-femoralen tiefen Beinvenenthrombose
Positionstatement168 M. Simka, D. Hubbard, A. H. Siddiqui,
M. D. Dake, S. J. A. Sclafani, M. Al-Omari, C. G. Eisele, Z. J. Haskal, T. Ludyga, Z. V. Miloševič, H. Sievert, M. K. Stehling, S. Zapf, M. Zorc Catheter venography for the assessment of internal jugular veins and azygous vein: Position statement by expert panel of the International Society for Neu-rovascular DiseaseKathetervenographie zur Beurteilung der Vena jugularis interna und der Vena azygos: Positionspapier von Exper-ten der International Society for Neurovascular Diseases
Originalcommunications177 Y. Wang, H. Ma, J. Yang, J. Li, X. Hao,
Q. Mou, J. Liu, X. Guo, D. Zhao, Y. XuAssociation between estimated glomerular filtration rate, ankle-brachial index, and recurrent ischemic stroke in a Chinese population of ischemic stroke patientsGlomeruläre Filtrationsrate, Knöchelarteriendruck und rezidivierender Schlaganfall bei chinesischen Schlaganfallpatienten
184 M. Vavuranakis, F. Sigala, D. A. Vrachatis, T. G. Papaioannou, K. Filis, N. Kavantzas, K. I. Kalogeras, C. Massoura, L. Toufektzian, M. G. Kariori, I. Vlasseros, I. Kallikazaros, C. StefanadisQuantitative analysis of carotid plaque vasa vaso-rum by CEUS and correlation with histology after endarterectomyQuantitative Analyse der Vasa vasorum von Carotis-plaques mit CEUS und Korrelation mit der Histologie und Immunchemie nach Endarterektomie
196 T. Ibrahim, S. Karmann, T. Schuster, M. Fusaro, I. Ott, C. Böttiger, M. Paschalidis, J. K. Hilger, H. Poppert, W. Theiss, N. von BeckerathSafety and mid-term outcome of endovascular therapy for internal carotid artery disease: a 15-year experience at a single-centre angiology institutionSicherheit und mittelfristige Ergebnisse der endovas-kulären Therapie der Karotis interna Stenose: 15-jähri-ge Erfahrung an einer angiologischen Einrichtung
208 M. Meyer, F. Dick, W. Masshardt, T. Willenberg, D.-D. Do, N. Kucher, I. Baumgartner, N. DiehmInitial results of a computerized screening alert for abdominal aortic aneurysm in patients undergoing vascular assessmentErste Ergebnisse einer coputergestützten Früherken-nung für abdominelle Aortenaneurysma bei Patien-ten, die eine vaskuläre Diagnostik durchlaufen
Casereports214 L. Calanca, A. Alatri, M.-D. Schaller,
A. Sermier, L. MazzolaiDeep vein thrombosis of the penis: an unusual but severe complication of prostatic abscessTiefe Venenthrombose des Penis: eine ungewöhnliche, aber schwere Komplikation des Prostataabszesses
218 J. Malá, R. Malý, V. Vršanská, J. Doležal, E. Popper, K. EttlerA rare clinical manifestation of lymphedema prae-cox affecting the upper extremityIsoliertes primäres, nicht kongenitales Lymphödem der oberen Extremität
223 T. Etgen, M. Hochreiter, V. KiechleSubclavian-axillary graft plus graft-carotid interpo-sition in symptomatic radiation-induced occlusion of bilateral subclavian and common carotid arteriesSubclavia-axilläres Interponat und Interponat-Karotis- Interponat bei symptomatischem strahlenbedingten Verschluss der bilateralen A. subclavia und A. carotis communis
227 T. E. Kotsis, S. N. Mylonas, L. A. Louizos, A. N. Chatziioannou, G. Kottis, E. N. BrountzosA combined approach of a complex aortoiliac aneurysm with distal landing in internal iliac artery branchKombinierte Behandlung von komplexen aortoiliaka-len Aneurysmata
231 Fromthesocieties
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Expert panel of ISNVD: Catheter venography and CCSVIDOI 10.1024/0301-1526/a000265
Catheter venography for the assessment of internal jugular veins and azygous vein: Position statement by expert panel of the International Society for Neuro vascular Disease*Marian Simka1,2, David Hubbard3,4, Adnan H. Siddiqui5, Michael D. Dake6, Salvatore J. A. Sclafani7,8, Mamoon Al-Omari9, Carlos G. Eisele10,11, Ziv J. Haskal12, Tomasz Ludyga1, Zoran V. Miloševič13, Horst Sievert14,15, Michael K. Stehling16,17, Stefan Zapf18, and Marjeta Zorc19,20
1Euromedic Medical Center, Department of Vascular Surgery, Katowice, Poland2Private Healthcare Institution SANA, Department of Angiology, Pszczyna, Poland3Applied fMRI Institute, San Diego, CA, USA4Alliant International University, San Diego, CA, USA5Departments of Neurosurgery and Radiology, University at Buffalo, State University of New York, Buffalo, NY, USA6Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA7State University of New York, Downstate Medical School, New York City, NY, USA8Fresenius Vascular Care Brooklyn, New York City, NY, USA9Jordan University of Science and Technology, Irbid, Jordan10El Hospital de Niños Ricardo Gutierrez, Buenos Aires, Argentina11Centro de Educación Médica e Investigaciones Clínicas, Buenos Aires, Argentina12Division of Interventional Radiology, University of Maryland, Baltimore, MD, USA13Clinical Radiology Institute, University Medical Centre, Ljubljana, Slovenia14CardioVasculäre Centrum Frankfurt, Frankfurt, Germany15Johann Wolfgang Goethe University, Frankfurt, Germany16Boston University School of Medicine, Boston, MA, USA17Ludwig-Maximilians-Universität München, Munich, Germany18Institut für Bildgebende Diagnostik, Offenbach am Main, Germany19International Center for Cardiovascular Diseases, Izola, Slovenia 20Institute of Histology and Embryology, University of Ljubljana, Ljubljana, Slovenia
Summary
This document by an expert panel of the International Soci-ety for Neurovascular Disease is aimed at presenting current technique and interpretation of catheter venography of the internal jugular veins, azygous vein and other veins draining the central nervous system. Although interventionalists agree on general rules, significant differences exist in terms of details of venographic technique and interpretations of angiographic pictures. It is also suggested that debatable findings should be investigated using multimodal diagnostics. Finally, the au-thors recommend that any publication on chronic cerebrospi-nal venous insufficiency should include detailed description of venographic technique used, to facilitate a comparison of published results in this area.
Kathetervenographie zur Beurteilung der Vena jugularis in-terna und der Vena azygos: Positionspapier von Experten der International Society for Neurovascular DiseasesZiel dieser Veröffentlichung eines Expertenpanels der Inter-national Society for Neurovascular Disease ist es, die der-zeitigen Techniken und Interpretationsmöglichkeiten der Katheter-Venographie der Vena jugularis interna, der Vena azygos und anderer Venen, die das Zentralnervensystem drainieren, zu präsentieren. Trotz prinzipieller Übereinstim-mung in der allgemeinen Vorgehensweise bestehen deutliche Unterschiede in der venographischen Technik und Bildin-terpretation. Es wird daher vorgeschlagen, unklare Befunde einer multimodalen Diagnostik zuzuführen. Ebenso sollte jede Publikation zum Thema chronische venöse zerebro-spinale Insuffizienz die angewendete venographische Technik detailliert auflisten, um so eine Vergleichbarkeit verschiede-ner Studien zu gewährleisten.
* This paper is the position statement of the International Society for Neurovascular Disease and has been drafted at 2nd Annual Meeting of the ISNVD in Orlando, Florida, USA, 18 – 22 February 2012.
The main goal of this document, writ-ten by the expert panel under the auspices of the International Society for Neurovascular Disease, is to pres-ent “white paper” that describes how catheter venography of the internal jugular veins, the azygous vein and other veins that may be involved in neurological pathology is currently performed and interpreted. It should be emphasized that this document is not aimed at giving recommendation how to perform catheter venography of these veins and to interpret images. Although interventionalists agree on general venographic rules, big dif-ferences exist between the centers in terms of details. Therefore, doctors should be familiar with techniques and interpretations of venographic pictures of these veins. They should also know how these different veno-graphic techniques and interpreta-tions of the images can influence final assessment, safety of endovascular procedure and clinical outcomes.
Catheter venography of the veins draining the central nervous system
Although catheter venography is widely accepted as “golden standard” for the assessment of venous patholo-gies, as far as the veins draining the central nervous system are concerned it is actually a “tarnished” standard. Contrary to some well-recognized venous territories, relatively little is known about anatomy, physiological flow and hemodynamics of the inter-nal jugular veins. Even less is known about the azygous vein [1 – 3]. Con-sequently, catheter angiography and its interpretation are currently per-formed according to the rules govern-ing examination of the other veins. Still, differences exist between the technique and interpretation amongst
centers [4 – 13] Since our knowledge about anatomy and physiology of the veins that may be involved in patho-physiology of neurological disorders (especially: multiple sclerosis) in the setting of the so-called chronic cerebrospinal venous insufficiency (CCSVI) is at its infancy, there are many problems that should be ad-dressed. For the time being, it seems that a widely accepted venographic protocol cannot be created, because scientific evidence supporting a par-ticular technique or interpretation of the images is not yet available. It is known that venography can pro-duce a number of confusing images. In general, authors of this document agree that debatable venographic findings should be thoroughly in-vestigated by means of multimodal approach, integrating classic catheter angiography with intravascular ultra-sound (IVUS) and perhaps also other novel intravascular imaging modali-ties. Still, the diagnostic value of such a multimodal approach should also be validated by well-designed studies.The authors agree that venographical-ly-defined abnormalities, which can be relevant for physiological venous outflow from the brain and spinal cord, seem to exhibit different clini-cal meaning. Consequently, they can be categorized into four main groups:1. Obvious venographic abnormali-
ties of the internal jugular veins and/or azygous vein; most of the interventionalists agree that such venographic images reflect a pa-thology.
2. Debatable venographic abnor-malities of the internal jugular veins and/or vertebral veins, and/or azygous vein; at the moment only some centers interpret these findings as abnormal.
3. Angiographic signs of impaired venous outflow in non-cerebro-spinal territories, which can be of importance for the proper venous drainage of the central nervous
system, e.g. ascending lumbar, left iliac and left renal vein; the meaning of these abnormalities in terms of neurological patho-physiology remains uncertain.
4. Angiographically-defined ab-normalities of intracranial veins and sinuses; these lesions seem to be pathological, but safety of diagnostic and therapeutic pro-cedures in this territory is not de-termined (probably they are less safe if compared with extracranial veins).
Based on previously published re-search, obvious venographic abnor-malities of the internal jugular veins and/or azygous vein include the le-sions that present with all of the below mentioned criteria:• lesion detected in any part of in-
ternal jugular vein, uni- or bilat-erally (comprising also lesions of the brachiocephalic veins) (Fig-ure 1)
or lesion of the arch of the azygous vein
and/or ascending azygous vein or
lesion of the hemiazygous or ac-cessory hemiazygous vein, if these veins constitute primary outflow route from the spinal cord;
• at least 50 % stenosis of the vein, if compared with the diameter of an adjacent segment of the vein; it also comprises: severe hypoplasia (Figure 2), complete agenesia and secondary occlusion of the vein (for example, thrombotic)
or intraluminal structures, such as:
webs, septa, membranes, etc., which are associated with at least one additional sign of impaired outflow:o no outflow of contrast medium
from the vein,o outflow of contrast medium
slowed down, i.e. its retention in the examined vein longer than one cardiac cycle,
Expert panel of ISNVD: Catheter venography and CCSVI
o backward flow of injected contrast medium (using low-pressure and low-volume in-jection),
o outflow of injected contrast medium through collaterals, instead of through the main vein.
• abnormality should be demon-strated using hand injection of the contrast or low-pressure au-tomatic injector.
Debatable venographic abnormalities include any of the below-presented findings, which seem to be a reflec-tion of pathological blood outflow from the central nervous system, but do not meet the criteria of an obvious pathology:• lesions of the arch of the azygous
vein or ascending azygous vein in the patients with dominant hemiazygous outflow route;
• lesions of the distal part of the azygous vein, hemiazygous vein, or their tributaries;
• lesions of the hemiazygous or ac-cessory hemiazygous vein, if these veins are not dominant;
• abnormalities of the vertebral veins;
• lesions revealed using high-pres-sure injector;
• stenosis less than 50 %, with no other sign of compromised out-flow;
• intraluminal structures not asso-ciated with the signs of compro-mised outflow;
• stenosis or intraluminal struc-tures associated with prestenotic dilation of the vein, but no other signs of compromised outflow;
• phasic stenosis, i.e. a narrowing, which is not visible permanently, but only during a fraction of the cardiac or respiratory cycle;
• stenosis, which is visible only using inflation of compliant an-gioplastic balloon or using IVUS, with no additional venographic signs of compromised outflow.
The authors agree that more research is needed (primarily, using multi-modal approach) to evaluate diag-nostic accuracy of these parameters and criteria. Especially, the threshold of a 50 % degree stenosis, which is ac-tually an extrapolation from arterial pathology, seems debatable. Perhaps, in a case of venous outflow abnormal-ity, even a lower degree stenosis is of clinical importance. This, however, needs further exploration.Consequently, the authors of this position document strongly suggest that any publication on CCSVI issues should include detailed description of the venographic technique used and detailed definition of the pathological result of such a venography. This will enable a comparison of future publi-cations in this field. Unfortunately, already published research often lacks such a detailed description, making analysis of presented data very dif-ficult.
Safety and ethical issues
Endovascular procedures for CCSVI become an emerging area of interven-tional radiological practice and at the moment a number of prospective ran-domized, as well as open-label clinical studies are underway. International Society for Neurovascular Disease strongly emphasizes the importance of good clinical practice in such tri-als. The research on this controversial topic should be well designed to avoid unnecessary harm for the patients. In addition to the legal and ethical issues related to endovascular diagnostic and therapeutic procedures in the set-tings of CCSVI, several technical bar-riers must also be solved before such procedures become a standard. This include: the technique of invasive and non-invasive diagnostics, interpreta-tion of the findings and qualification of the patients for endovascular in-terventions.
For the purpose of this discussion we will assume that only severe ste-noses, associated with significant and apparent flow abnormalities (as noted above, such as: reversal of the flow, collaterals, etc.) should be treated. Of course, such procedures should be performed exclusively
Figure 1: Transverse membrane (arrow) compromising outflow from the left brachiocephalic vein.
Figure 2: Complete occlusion of the left internal jugular vein (ar-rowheads). Contrast is flowing out through the external jugular vein (arrow).
within clinical trials, until results of such trials will clearly demonstrate the safety and clinical benefits of the treatment. However, how should we manage not-obviously stenosed jugu-lar valves, narrowings of the azygous vein and internal jugular veins that are not accompanied by significant hemodynamic disturbances, or he-modynamically significant lesions in the veins, which are not clearly involved in neurological pathology (iliac, renal, etc.)? Although both venography and balloon angioplasty are safe, they are not risk-free. Thus, venography should not be performed in every assessable vein, but only in the veins that are likely to be both af-fected and manageable. The more ex-tensive the examination is, the higher are: the contrast load, nephrotoxicity risk, vascular iatrogenic complica-tions and cumulative radiation dose.Similarly, angioplasty should be per-formed only to address the lesions, which have been implicated as causal for neurological pathology. Which of the above-mention measures should be applied, remains an open question. This dilemma is likely to be solved only by well-designed prospective studies, but some preliminary con-clusions can potentially be drawn from currently available literature. It should be assumed that a vein re-sponsible for neurological pathology is draining the specific part of the cen-tral nervous system containing ana-tomical structures that are respon-sible for this neurological deficit. For example: ataxia is usually caused by cerebellar plaques. Then, the symp-tom is more likely to be caused by abnormal outflow from the jugular veins which drain the cerebellum than by abnormal azygous outflow. On the contrary: plaques in the tho-racic segment of the spinal cord are more likely to be linked to pathologi-cal azygous outflow.
Technical dilemma associated with catheter venography
Uncertainties related to the tech-nique and interpretation of catheter venography in CCSVI patients can be grouped into several domains:
1. Vascular access Most venographies are currently per-formed through femoral access. Ac-cess through an upper extremity vein is a theoretical option in the case of agenesis of the inferior vena cava. A direct puncture of the internal jugu-lar vein can also be used, but can be technically challenging if such a vein is hypoplastic or collapsed. Alterna-tively, an access through the great saphenous vein under sonographic control can be used [14]. Still, the femoral access is the preferred route. However, there are some issues, which need to be considered when using femoral access. Firstly, if venography is accompanied by pressure gradient measurements, the pressure measurement in the in-ternal jugular vein may not be reliable (jugular valve is potentially kept open by the diagnostic catheter – possibly reducing or eliminating any cross-valve pressure differential). Options may include using a smaller caliber device such as a pressure-sensing wire, which is less disruptive to the valves. Alternatively, for accurate pressure measurement a direct jugu-lar access may be considered. Secondly, there is a discussion about which femoral vein (right or left), should be punctured. Insertion of the catheter through the left femoral vein allows a much easier assessment of the left iliac vein (May-Thurner syn-drome), the ascending lumbar veins and the left renal vein (nutcracker syn-drome). On the other hand, an access through the right femoral vein makes the angiography and angioplasty of the left internal jugular and azygous
veins much easier, particularly in a case of tortuous iliac and left brachio-cephalic veins. In addition, there is currently no evidence to support an angioplasty of asymptomatic steno-sis of the left iliac or left renal vein, thus a potential benefit from the left femoral access is not clear. We there-fore recommend the right femoral (or saphenous) vein access for routine as-sessment and possible consideration of an angioplasty of the internal jugu-lar and azygous veins. Left femoral vein access may be an option if the screening of additional veins, such as the left iliac vein is planned.
2. Angiographic contrastAngiographic contrast may be used diluted (1:1) or non-diluted. Diluted contrast allows a better visualization of endoluminal structures (valve leaf-lets, webs, etc.). However, non-diluted contrast allows a better opacification of epidural and other collaterals, as well as a better estimation of overall features of the veins. There is no clear consensus on wheth-er the contrast should be hand- or pressure-injected. Hand injections are performed using smaller vol-umes of contrast under lower pres-sure. Pressure injectors involve higher volume and higher pressure. There are proponents for both approach-es. While hand injection mimics physiological venous flow, pressure injectors are more accurate, repro-ducible and make some flow-related analyses quantifiable. Either or both approaches may be utilized, depend-ing on the objectives desired. There are some modern injectors that allow a low-pressure administration of the contrast and perhaps such equipment should be preferentially used.
3. Interpretation of venographic pictures: Left versus right jugular veinIt may seem obvious that venography of both internal jugular veins should
Expert panel of ISNVD: Catheter venography and CCSVI
be interpreted in the same way. But there are some arguments favoring a different approach to the right vs. left (or: dominant vs. non-dominant) jugular vein. Right internal jugular vein is usually larger, its valve has lon-ger leaflets; the left internal jugular vein is smaller and has more transver-sally oriented valve leaflets. Perhaps these parameters should be taken into account while deciding if the vein assessed should be interpreted as normal (Figure 3) or pathological [4]. These dilemmas will be of spe-cial importance if the definition of pathology is based on quantitative as-sessment of the flow, which in most normal individuals is asymmetric. It should also be emphasized that asym-metry between the jugular veins is not pathological. However, other attributes, such as stenoses, need to be considered in the context of each individual jugular vein. In terms of what should be regarded as a stenosis, little consensus has been reached. The authors of already published research have utilized an arbitrary definition of 50 % luminal restriction when com-pared to nominal diameter of the proximal vein. However, jugular vein stenosis is more difficult to evaluate because it usually dilates cranially to the valve (Figure 4). Therefore, per-haps a nominal diameter of the vein proximal to the bulb, or the most di-lated part of the distal jugular vein should be utilized. Besides, unless the diagnostic catheter is placed at the level of the skull base, it is likely to miss a number of ana-tomical and flow-related anomalies in the upper jugular vein (Figure 5). Also, if an angled catheter is used and is positioned medially, the injected contrast preferentially opacifies the vertebral and cervical epidural plex-uses through the mastoid and con-dylar emissary veins, suggesting an underlying hemodynamic anomaly, when none actually exists. Therefore, it is important that an angled cath-
eter is directed laterally at the level of the jugular foramen. Frequently the transverse process of the C1 vertebra visibly indents the jugular vein (since the vein lies on this bony structure). However, in such a case a compliant balloon inflated under low pressure and a Valsalva maneuver usually confirm that no pathology actually exists. Venography with neck rotation to the opposite direction can reveal whether such a compression is tran-sient (position-dependent) or fixed. It is also known that aberrant neck muscles, especially omohyoid muscle, can significantly squeeze IJV and that such a compression may be poorly visible on standard venography [15].
4. Interpretation of venographic pictures: Jugular valveWhat should be regarded as a patho-logic valve? Currently there are two ways of thinking. Firstly, some au-thors interpret jugular valve as ab-normal if a narrowing at its level is detected: using venography, by in-flating a compliant angioplastic bal-
loon, or by intravascular ultrasound (IVUS). Secondly, some suggest that the valve should be interpreted as ab-normal if flow disturbances are found (no outflow through the vein, venous outflow slowed down, reversed flow
Figure 3: Normally-appearing left internal jugular vein. Valve leaf-lets are visible (arrow), but no stenosis is detected and contrast is freely flowing to the brachioce-phalic vein.
Figure 4: Typical stenosis of the left internal jugular vein at the level of malformed jugular valve (arrow) with dilatation of middle part of the vein.
Figure 5: Tandem stenosis of the right internal jugular vein: There is a minor stenosis at the level of jugular valve (arrow) and a tight stenosis below the skull (arrow-head).
direction, outflow through collater-als, etc.) in addition to anatomical stricture. Probably more research in healthy individuals is needed to solve this problem [16 – 19]. Such a research – however – will not be easy to perform taking into account the invasive nature of venography.
5. Interpretation of venographic pictures: Azygous veinThere is a huge discordance between performance and interpretation of azygous venograms. Firstly, there are no standards as to where exactly along the course of the azygous vein a contrast injection should be made. Any injection made in the arch is like-ly to miss a pathology in more distal portions of the vein, while abdominal injections in a much smaller caliber vessel may artificially induce reverse flow and evidence of collaterals, in-cluding epidural venous channels. A standard position of diagnostic catheter may be at the level of the di-aphragm (T12), since this allows esti-mation of essentially the entire spinal cord venous outflow, since the spinal cord conus (terminal segment of the spinal cord) is typically located at L1. Secondly, interpretation of venogra-phy varies as well, with some authors suggesting that any narrowing more than 50 % is pathological, while oth-ers interpret a narrowing as patho-logical only if it is accompanied by reversed flow or outflow through collateral network (Figure 6). Con-sequently, azygous vein pathology in multiple sclerosis patients is diag-nosed in some centers in 80 – 90 % of the cases [7, 12], while others find pathology less frequently [13,20] or even in 5 – 10 % only [4, 5, 9, 21].The valve of the azygous vein is typi-cally seen at its junction with the su-perior vena cava. Sometimes it is very difficult to negotiate with diagnostic wires and catheters across this valve [22]. For the time being it remains unclear if such a difficult passing
through represents a pathology, or whether it is the sign of a perfectly competent valve. It should also be remembered that the azygous vein is typically narrowed where it arches over the right main bronchus and a “stenosis” in this area is not neces-sarily pathological. In addition, some azygous lesions are simply reflective of intra-thoracic pressures. There-fore, they are likely to be a product of respiratory cycles (phasic stenosis) and not true anatomical lesions. Thus, if a lesion is identified, it should be investigated during an inspiratory arrest to induce maximal thoracic venous return. Also, IVUS that will show variations in luminal dimen-sions during the various respiratory phases can be applied.
6. Classification of outflow abnormalitiesAccording to the published classifica-tion [4], abnormal venographic flow patterns can be categorized into four grades:• grade 1: venous outflow slowed
down, no reflux detected;• grade 2: venous outflow slowed
down, mild reflux and/or pre-stenotic dilation of the vein;
• grade 3: venous outflow slowed down, with reflux and outflow through collaterals;
• grade 4: no outflow through the vein, huge outflow through col-laterals.
As of yet, an alternative classification has not been suggested (which does not mean that the above-presented scale is perfect).
7. The role of IVUS in the assessment of CCSVIShould IVUS be an integral part of venography? What are the advan-tages and disadvantages of such an approach? Doctors who are using IVUS routine-ly have found this diagnostic tool to be incredibly helpful as an adjunctive
to catheter venography [5, 14, 23]. It is well known that venography is less sensitive than IVUS in detecting en-doluminal anomalies (septae, chronic organized/recanalized thrombi, valve leaflet anomalies, phasic variability, etc.). IVUS can be performed safely, with minimal change of guidewires and catheters utilized, fluoroscopy time and contrast volume. While many multiple sclerosis patients demonstrate venographic anoma-lies, IVUS reveals even more lesions, since CCSVI appears to be principally an endoluminal disease (Figure 7). Thus, a combination of venography and IVUS provides a comprehensive assessment of venous anatomy, en-doluminal structures and the flow. Although at the moment the use of IVUS could be recommended for di-agnosing CCSVI, an actual value of this test should be evaluated by future research. Of special importance will be the problem: whether the treat-ment of lesions that can be detected by IVUS only, and not by catheter venography alone, will give an addi-tional clinical benefit to the patients.
Figure 6: Severe stenosis of the azygous vein distally from the arch (arrows) with outflow of in-jected contrast through collateral network (arrowheads).
Expert panel of ISNVD: Catheter venography and CCSVI
How to evaluate and to manage stenoses in the upper part of the internal jugular vein, especially at the level of jugular foramen?In some patients the upper (cranially to the facial vein) internal jugular vein is narrowed, hypoplastic, sometimes with associated outflow impairment. The questions regarding this particu-lar problem are:• should we interpret such a vein
as pathological according to the diameter measurements (if yes, which cutoff should be applied);
• alternatively, should we rather look at flow disturbances, espe-cially at backflow of the injected contrast;
• what is the best mode of manage-ment of such stenosed venous segment: standard balloon an-gioplasty (pro – a relatively safe procedure; contra – high rate of restenosis), stenting (pro – more efficient than PTA; contra – risk of stent migration, risk of throm-bosis or occlusion due to intimal
hyperplasia), cutting balloon (pro − more efficient than PTA, more safe than stenting; contra – thrombotic or bleeding complica-tions possible).
Should we assess stenoses of intracranial sinuses?
Catheterization, mechanical and chemical thrombolysis, angioplasty and stenting of intracranial venous sinuses are performed by neurointer-ventionalists for venous thrombosis, pseudotumor cerebri associated with venous stenosis and a few other un-common disorders. However, the magnitude of possible complica-tions is significantly higher than in the case of similar interventions in the extracranial veins. The most dramatic potential complication is a perforation of the jugular bulb or sinus, or perforation with a wire of cortical or cerebellar vein, with devas-tating and usually fatal intracerebral hemorrhage. In addition, intracranial veins are not very plastic and compli-ant, since these venous channels are encased partly in bone and partly in rigid leafs of the dura permeated by delicate and rather “unpredictable” draining veins. The questions regard-ing the management of intracranial sinuses are:• should we perform venography
of these veins routinely, or only in very selected cases, since most physicians will not manage a le-sion in this location even if de-tected, while the risk of diagnostic venography in this particular area cannot be neglected;
• should we perform therapeutic procedures in this territory, or rather should we wait until an evidence of clinical benefit from the treatments performed in other venous territories (like the inter-nal jugular veins) will be more obvious;
• pre-procedural evaluation of intra-cranial vein routinely consists of MR venography; it is well-known that there are a lot of artifacts as-sociated with this imaging test, for example very often the left trans-verse sinus does not show at MRV, while in fact it is perfectly patent;
• which is the best way to evaluate intracranial sinuses before and after endovascular treatment?
Phasic stenosis
Should a narrowing of the vein, which is not visible permanently, but only during a fraction of the cardiac or re-spiratory cycle, be regarded as patho-logic? And does such a lesion require treatment? Balloon angioplasty is not likely to be successful in such a case. Stenting of the “phasic” stenosis may be associated with a high risk of stent migration. Moreover, intimal hyper-plasia inside the stent in these cases seems to be a big problem. Perhaps such lesions should be left untouched until other therapeutic strategies are developed.
Conclusions
More studies are needed to under-stand how to perform catheter venog-raphy of the veins draining the central nervous system properly and safely, and how to interpret these veno-graphic images. Perhaps,multimodal diagnostics should be preferred in this particular vascular territory. In-ternational Society for Neurovascular Disease encourages such a research, which should strictly follow good clinical practice principles.
Conflicts of interest
Marian Simka: travel expenses, con-sulting fees: Servier International,
Figure 7: Stenosis of the left in-ternal jugular vein at the level of jugular valve. A: venographic pic-ture of malformed valve (arrows); B: IVUS reveals an immobile thick-ened valve; C: longitudinal IVUS reformation shows an echogenic material (circled areas) illustrat-ing intraluminal nature of the stenosis.
BIBA Medical, American Access Care, Esaote International;Salvatore J. A. Sclafani: consulting fees: Fresenius Vascular Access Cen-ters;Tomasz Ludyga: co-owner of Euro-medic Medical Center;Horst Sievert: study honoraries, travel expenses, consulting fees: Abbott, Access Closure, AGA, Angiomed, Arstasis, Atritech, Atrium, Avinger, Bard, Boston Scientific, Bridgepoint, Cardiac Dimensions, CardioKinetix, CardioMEMS, Coherex, Contego, CSI, EndoCross, EndoTex, Epi-tek, Evalve, ev3, FlowCardia, Gore, Guidant, Guided Delivery Systems, Inc., InSeal Medical, Lumen Bio-medical, HL T, Kensey Nash, Kyoto Medical, Lifetech, Lutonix, Medinol, Medtronic, NDC, NMT, OAS, Oc-clutech, Osprey, Ovalis, Pathway, PendraCare, Percardia, pfm Medi-cal, Rox Medical, Sadra, Sorin, Spec-tranetics, SquareOne, Trireme, Tri-vascular, Velocimed, Veryan.All other authors declare that there exist no conflicts of interest.
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Correspondence address
Marian SimkaDepartment of Vascular SurgeryEuromedic Medical Centerul. Kościuszki 9240 – 519 [email protected]
Submitted: 22.11.2012Accepted after revision: 11.01.2013
