Radiologists’ Experience With Venous Angioplasty/Stenting in MS: Is It Safe?
Angioplasty of the cerebral veins may be generally (but certainly not absolutely) safe in patients with multiple sclerosis; however, it remains unknown whether the procedure has any benefit beyond a placebo effect in the disease—which is regarded by most neurologists as autoimmune, not vascular, in nature. The safety conclusion is based on data from 3 studies presented at the 36th annual meeting of the Society of Interventional Radiology in Chicago.
The radiology data are reported at face value by MedPage Today and without important input from MS neurologists. Another screaming caveat to the coverage is the following: The radiology abstracts implicity acknowledge the existence of chronic cerebrospinal venous insufficiency (CCSVI) in multiple sclerosis—a completely unestablished concept that has been used to justify vacular intervention in the disease. It is the odd brainchild of Italy’s Paolo Zamboni, and the idea has been embraced willy-nilly by some US physicians, including Stanford’s Michael Dake. However, it is viewed with a very healthy skepticism by US neurologists who subspecialize in MS management. (For important background, go here, here, and here.)
According to MedPage, the rate of “major complications” in one retrospective series of 231 “CCSVI patients” with MS who underwent vascular intervention was 1.2% and consisted of venous thrombosis. So-called minor complications, however, weren’t inconsequential and included “thrombosis or dissection after angioplasty requiring stent placement” at a rate of 10.5%. In a much smaller study of 24 patients, 1 case of inguinal bleeding, 2 cases of inguinal hematoma, and 1 case of retroperitoneal hematoma produced a complication rate of more than 16%—suggesting limited technical skills on the part of the interventionist(s). In a third series of 18 patients, 1 patient (>5%) experienced “rupture” of the internal jugular valve, which had to be treated with “balloon tamponade and stenting.” (I don’t imagine that calm reigned in the radiology suite that day.)
All of these non-controlled studies reported clinical improvement of MS symptoms in most patients. But, it should be noted, clinical improvement (however it was measured, if at all) didn’t necessarily last, and “venous obstruction” recurred, in some cases. (And it’s completely unclear whether clinical status deteriorated in concert with the return of the presumed venous obstraction.)
Another downfall of MedPage’s coverage is the quoting of non-neurologist Michael Dake, who provided this useful [sarcasm alert] gem: “Currently there are many unknowns and lots of uncertainty.” In addition, Dake called the field “a zone of chaos”—a situation that Dake arguably help to create. MedPage failed to note that Dake’s own jugular-stent program at Stanford was shut down in December of 2009, after 1 of his MS patients died of cerebral hemorrhage and the stent of another became dislodged in his heart.
SIR Abstracts Cited by MedPage
Mandato K et al. Safety of outpatient endovascular treatment of the internal jugular and azygos veins for chronic cerebrospinal venous insufficiency (CCSVI) in multiple sclerosis: a retrospective analysis. Abstract 3.
Haskal Z et al. Feasibility evaluation of catheter-directed interventions in multiple sclerosis CCSVI patients. Abstract 82.
Pisco JM et al. Percutaneous transluminal angioplasty and stenting in patients with multiple sclerosis and venous insufficiency–preliminary results. Abstract 33.
Image of neck veins from Gray’s Anatomy (1918).