M. Englander

Safety of Endovascular Treatment of Chronic Cerebrospinal Venous Insufficiency: A Report of 240 Patients with Multiple Sclerosis

PURPOSE To evaluate the safety of outpatient endovascular treatment in patients with multiple sclerosis (MS) and chronic cerebrospinal venous insufficiency (CCSVI). MATERIALS AND METHODS A retrospective analysis was performed to assess complications occurring within 30 days of endovascular treatment of CCSVI. The study population comprised 240 patients; 257 procedures were performed over 8 months. The indication for treatment in all patients was symptomatic MS. Of the procedures, 49.0% (126 of 257) were performed in a hospital, and 51.0% (131 of 257) were performed in the office. Primary procedures accounted for 93.0% (239 of 257) of procedures, and repeat interventions accounted for 7% (18 of 257). For patients treated primarily, 87% (208 of 239) had angioplasty, and 11% (26 of 239) had stent placement; 5 patients were not treated. Of patients with restenosis, 50% (9 of 18) had angioplasty, and 50% (9 of 18) had stent placement. RESULTS After the procedure, all but three patients were discharged within 3 hours. Headache after the procedure was reported in 8.2% (21 of 257) of patients; headache persisted > 30 days in 1 patient. Neck pain was reported in 15.6% (40 of 257); 52.5% (21 of 40) of these patients underwent stent placement. Three patients experienced venous thrombosis requiring retreatment within 30 days. Sustained intraprocedural arrhythmias were observed in three patients, and two required hospital admission. One of these patients, who was being retreated for stent thrombosis, was hospitalized because of a stress-induced cardiomyopathy. CONCLUSIONS Endovascular treatment of CCSVI is a safe procedure; there is a 1.6% risk of major complications. Cardiac monitoring is essential to detect intraprocedural arrhythmias. Ultrasonography after the procedure is recommended to confirm venous patency and to identify patients experiencing acute venous thrombosis.

Results of Iliac Artery Stent Placement in Patients Younger than 50 Years of Age

PURPOSE To determine long-term outcome in patients 50 years of age or younger treated with iliac artery stent placement. MATERIALS AND METHODS The records of 412 patients who underwent iliac artery stent placement during a 62-month study period were reviewed retrospectively. Forty-two patients younger than age 50 (mean age = 45 y) at the time of stent placement were included in the study population. Presenting symptoms included claudication (47%), rest pain (17%), ulceration/tissue loss (31%), and blue toe syndrome (5%). Anatomic, hemodynamic, and clinical success rates of the stent placement procedure were assessed. Stent patency rates were calculated by life-table methods. RESULTS Fifty-nine iliac lesions were treated with stents; 62% of patients underwent treatment of a single lesion whereas 38% had multiple lesions treated. Thirty-one percent were treated after a failed angioplasty procedure and 69% were treated with stent placement primarily. After stent placement, 34 patients (82%) experienced symptomatic relief, although eight of these patients (19%) underwent a planned ipsilateral infrainguinal bypass procedure during the same hospitalization. During follow-up, five patients (12%) required a bypass procedure as a result of stent failure and two patients (5%) required below-knee amputation. Seven patients (17%) required endovascular stent revision, with none requiring additional surgery. At 1, 2, and 3 years, the primary patency rates were 86%, 72%, and 65%, and the secondary patency rates were 90%, 88%, and 88%, respectively. CONCLUSIONS Iliac stent placement successfully addresses the presenting symptoms of young patients with peripheral vascular disease and results in patency rates that are similar to those reported in a more general population. With appropriate postprocedural surveillance, restenosis can be addressed in many patients with use of endovascular techniques, limiting the need for surgical revision.

Review of Venous Anatomy for Venographic Interpretation in Chronic Cerebrospinal Venous Insufficiency

Chronic cerebrospinal venous insufficiency (CCSVI) represents a recently described condition that may potentially contribute to the symptoms experienced by patients with multiple sclerosis. The evaluation of a prospective patient for CCSVI often involves an invasive evaluation with venography of the internal jugular and azygos veins. The purpose of this article is to review the normal anatomy of the internal jugular, vertebral, and azygos veins, as an understanding of these veins is necessary for appropriate interpretation of the venograms obtained to evaluate patients for CCSVI.

Internet-Based Social Networking and Its Role in the Evolution of Chronic Cerebrospinal Venous Insufficiency

The Internet is being seen as a growing resource for health-related information for a large number of patients. It is undeniable that its widespread presence has led to the growth of awareness that chronic cerebrospinal venous insufficiency (CCSVI) as an entity that may contribute to the symptoms experienced by patients with multiple sclerosis (MS). Social networking and file-sharing Web sites have brought patients with MS together from all over the world and have facilitated the distribution of personal experiences and information derived from medical research as it relates to CCSVI. As a result, there has been an accelerated growth in the number of patients seeking treatment for this syndrome in light of the possibility that it may improve their present condition. This article will review this phenomenon, the Internet-based resources available to MS patients seeking information about CCSVI, and the responsibilities of physicians as they participate in these online discussions.

Catheter Venography and Endovascular Treatment of Chronic Cerebrospinal Venous Insufficiency

Multiple sclerosis (MS) is a disorder characterized by damage to the myelin sheath insulation of nerve cells of the brain and spinal cord affecting nerve impulses which can lead to numerous physical and cognitive disabilities. The disease, which affects over 500,000 people in the United States alone, is widely believed to be an autoimmune condition potentially triggered by an antecedant event such as a viral infection, environmental factors, a genetic defect or a combination of each. Chronic cerebrospinal venous insufficiency (CCSVI) is a condition characterized by abnormal venous drainage from the central nervous system that has been theorized to have a possible role in the pathogenesis and symptomatology of MS (1). A significant amount of attention has been given to this theory as a possible explanation for the etiology of symptoms related to MS patients suffering from this disease. The work of Dr. Zamboni, et al, who reported that treating the venous stenoses causing CCSVI with angioplasty resulting in significant improvement in the symptoms and quality of life of patients with MS (2) has led to further interest in this theory and potential treatment. The article presented describes endovascular techniques employed to diagnose and treat patients with MS and CCSVI.

The ABCs of the FDA: A Primer on the Role of the United States Food and Drug Administration in Medical Device Approvals and IR Research

The role of the US Food and Drug Administration (FDA) in medical device regulation is important to device-driven specialties such as interventional radiology. Whether it is through industry-sponsored trials during the approval process for new devices or investigator-initiated research prospectively evaluating the role of existing devices for new or established procedures, interaction with the FDA is an integral part of performing significant research in interventional radiology. This article reviews the potential areas of interface between the FDA and interventional radiology, as understanding these areas is necessary to continue the innovation that is the hallmark of this specialty.

Uterine Fibroid Embolization without the Use of Iodinated Contrast Material

Editor: Uterine fibroid embolization (UFE) is a safe and effective therapy for women with symptomatic uterine fibroids (1). At the present time, contraindications specific to UFE are still being established. However, the relative contraindications to angiography apply to this procedure, including a history of a severe allergic reaction to iodinated contrast material. Because hysterectomy is a proven alternative to UFE, patients with a history of anaphylaxis may choose to undergo surgery rather than risk a potentially lethal reaction during UFE. We have recently performed UFE in a patient with a history of anaphylaxis to iodinated contrast material with use of CO2 and gadolinium as the angiographic con-

The Female Threat

It has only been 100 years or less since women earned the right to vote throughout Europe and in the USA. Since that time, women have entered the workforce and joined the professions. Whereas once they were barred from professional medical practice, the percentage of medical school graduates that were women rose from approximately 10% in the 1960s to over 50% in the early part of this century. The number of women physicians is also increasing. This past year, for the first time ever, the province of Quebec [1] reported more female physicians in practice than male. This changing demographic has implications for medical practice as women are needed in all the specialties to ensure equitable availability of services for patients. According to the 2016 UK Radiology workforce census, 35% of consultant radiologists and 39% of trainees are female, but only 10% of the current consultant IR body is female. At both CIRSE and SIR, only 12% of full members are women. Although precise figures vary between countries and continents, this phenomenon is repeated globally. Interventional Radiology (IR) is under threat, not just by competing specialties, but by its apparent lack of attraction to women. Unless IR is able to reverse this and attract more women, it will be missing out on some of the most talented medical graduates and may have trouble filling all the jobs. In the UK, there is already a crisis of not enough interventional radiologists to meet the need. In 2009, the Royal College of Physicians of the UK published research into the implications of the rapidly increasing share of female doctors on the medical profession [2]. The two major findings from this report were that women doctors had a far greater preference for flexible working arrangements with scheduled work hours and they preferred specialties offering greater patient interaction. There are many aspects of IR which should appeal to women. It offers patient interaction and longitudinal care and the opportunity to make a real difference to patients’ lives using innovative, minimally invasive procedures. It is constantly progressing and evolving and consequently, never boring. IR is inclusive of almost every body system, and there is the opportunity to develop a subspecialty interest in areas including interventional oncology, vascular disease, women’s health, neurovascular and paediatrics, to name but a few. So why aren’t women flocking to IR? Assuming they learn about IR in medical school (and that is an issue in itself; Lee and Lee [3]), the fact that radiation is involved is a big deterrent. This is despite the fact that nowadays occupational radiation exposure to IRs is similar to the natural background dose and most female IRs who continue to work through their pregnancy have foetal radiation doses

JOURNAL CLUB: Women in Interventional Radiology: How Are We Doing?

OBJECTIVE This article describes survey findings as well as provides a narrative description of the issues facing women in interventional radiology (IR) today. MATERIALS AND METHODS In an attempt to reflect the experiences of as many women interventional radiologists as possible, a survey was conducted via a post on the Women in Interventional Radiology page of SIR Connect, the online members-only forum of the Society of Interventional Radiology (SIR). The survey consisted of 62 items, including demographics, marital and parental status, experiences in training, relationships with coworkers and patients, and details about career achievements and goals. Respondents were encouraged to write comments. We analyzed responses for trends and reviewed comments. RESULTS Ninety-nine surveys were completed. Women at all phases of training and practice and in a broad range of practice settings were represented. Many women responding to the survey reported experiences with gender bias, discrimination, and sexual harassment. CONCLUSION Further research is needed to better understand gender bias in IR and how it affects women throughout their training and careers. From this research, evidence-based interventions can be implemented to help level the playing field for all. Women are committed to and passionate about IR, and IR needs women to succeed so that the field can continue to thrive.

Society of Interventional Radiology Position Statement on Parental Leave

The SIR recognizes that the choice to become a parent should not prevent a physician from having a successful career in Interventional Radiology (IR), and that a successful career in Interventional Radiology should not preclude parenthood. The choice to become a parent does not diminish one’s commitment to the profession. Interventional radiologists who choose to have children, whether by pregnancy or adoption, should not face discrimination or punitive consequences of any kind. The SIR joins other medical specialty organizations that also have policy statements supporting members who choose to become parents (1,2,3).