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Michael R. Jaff, DO
Conflicts of Interest
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Consultant
– Abbott Vascular (non-compensated)
– Arsenal Medical
– Becker Venture Services Group
– Boston Scientific (non-compensated)
– Covidien (non-compensated)
– Harvard Clinical Research Institute
– Medtronic (non-compensated)
– Micell, Incorporated
– Neocure
– Nexeon Medical Systems
– Primacea
Equity
– Access Closure, Inc
– Embolitech, Inc
– Hotspur, Inc
– Icon Interventional, Inc
– I.C.Sciences, Inc
– PQ Bypass, Inc
– Primacea
– Sadra Medical
– TMI
– Vascular Therapies, Inc
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Board Member
– VIVA Physicians (Not For Profit
501(c) 3 Organization)
• www.vivapvd.com
February, 2011
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CRT 2011
Washington, DC
Venous Angioplasty for Multiple Sclerosis:
Sounds Like Voodoo and Not Worth Investigating
Michael R. Jaff, DO
Associate Professor of Medicine
Harvard Medical School
Medical Director, Vascular Ultrasound Core Laboratory
Massachusetts General Hospital
Boston, Massachusetts
Voodoo—Not sure what the CRT
Organizers Meant by Voodoo…
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Multiple Sclerosis
• Chronic demyelinating central nervous system
disorder
– Four Courses
• Relapsing/Remitting
• Primary Progressive
• Secondary Progressive
• Progressive/Relapsing
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Concept of Venous Stenosis and MS
• Not a new concept
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Concept of Venous Stenosis and MS
• Not a new concept
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Tracey Putnam, Boston City Hospital,
developed an experimental dog model
of venous obstruction to study MS.
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At the end of his paper, he stated:
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“The similarity between such lesions and
many of those seen in cases of
multiple sclerosis in man is so striking
that the conclusion appears almost
inevitable that venular obstruction |is the
essential immediate antecedent to the
formation of typical sclerotic plaques.”
Putnam (1935). Studies in multiple sclerosis:
encephalitis and sclerotic plaques produced by venular obstruction.
Arch. of Neurol. and Psychiatry. 33: 929-940.
Congested Vessels Surrounded by Demyelination
Ann New York Acad Sci 1954 58:582-594
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CCSVI and MS: A New Conceptual Framework
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Anatomical anomalies in cerebrovenous
drainage (IJ, VRT and or AZG VV) alter
cerebral venous flow patterns and pressure.
These alterations cause:
• Increased expression of endothelial
adhesion molecules, chemokines,
cytokines, and prothrombotic factors.
Increased vsmc injury response and
generation of oxygen-derived free radicals
Adherence of immune cells and their
infiltration into the surrounding tissue.
Infiltrating immune cells elaborate cytokines
and oxygen-derived free radicals that further
increase vascular permeability, leading to
insudation of plasma proteins and in some
cases red blood cells.
Parenchymal injury due to inflammation and
oxidative stress with demyelination, resolving
with fibrosis and plaque formation.
J Vasc Surg 2009;50:1348-58
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Venous Obstruction: Where Does It Occur?
• High Jugular Lesions
• Mid Jugular Lesions
• Low Jugular Lesions
• Azygous
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Venous Obstruction: Where Does It Occur?
• High Jugular Lesions
• Mid Jugular Lesions
• Low Jugular Lesions
• Azygous
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Venous Obstruction: Where Does It Occur?
• High Jugular Lesions
• Mid Jugular Lesions
• Low Jugular Lesions
• Azygous
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Venous Obstruction: Where Does It Occur?
• High Jugular Lesions
• Mid Jugular Lesions
• Low Jugular Lesions
• Azygous
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Venous Obstruction: Where Does It Occur?
• High Jugular Lesions
• Mid Jugular Lesions
• Low Jugular Lesions
• Azygous
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Reduction in Venous Pressure following
Venous PTA…
J Vasc Surg 2009;50:1348-58
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…results in an improvement in function
J Vasc Surg 2009;50:1348-58
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So Far, Seems Like This is the Real Deal
• However, I have a lot of concerns…
– Does CCSVI occur more often in MS than in
normal age/sex matched controls?
– How can this be reliably diagnosed today?
– If you successfully repair the stenosis (es),
does the patient get better?
• If so, for how long?
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In the Meantime…..
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And Physicians Have Jumped on the
Bandwagon….
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Patients Can Go Anywhere for This…
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So, I Am Not Convinced That This is
Voodoo
• However, we owe it to ourselves and our patients to really
figure this out before offering this therapy outside of
clinical trials to (often) desperate patients
• We need to figure out how often CCSVI occurs in MS
patients and in the general population
• We need to standardized an effective, reliable,
reproducible diagnostic algorithm
• Then we need to study the efficacy of therapy in an
organized, safe, prospective fashion
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