Endovascular management of CCSVI:
Single Center Experience
Hector Ferral, MD, George Behrens, MD, Yanki
Tumer, MD, Tameem Souman, MD
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
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
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
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.
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)
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
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)
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
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.
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
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%
Our Study
Figure a shows a vein
with tight blockages
(arrows)
Figure b shows the vein
after balloon angioplasty.
Notice the improvement
in the blockage
a
b
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
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
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!!
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