Short-Term Outcomes After Endovascular Treatment for Chronic Cerebrospinal Venous Insufficiency in Patients With MS
A minimally invasive endovascular treatment for chronic cerebrospinal venous insufficiency (CCSVI) is safe and may produce “significant,” short-term improvement in the physical– and mental health–related quality of life in patients with multiple sclerosis (MS), according to researchers.
“Traditional theories surrounding treatment for MS in large part focus on autoimmune causes for brain pathology and neurologic symptoms. Based on this, treatment has been predominantly medications by mouth or injection,” stated Kenneth Mandato, MD, an interventional radiologist at the Albany Medical Center in New York.
“Interventional radiologists, pioneers in the field of minimally invasive therapies, have been performing … angioplasty for years to treat blocked or narrowed arteries and veins. We have been using angioplasty to open jugular and azygos veins in the neck and chest, respectively, to improve blood flow in people with MS. On follow-up, we have seen many of these individuals report significant symptom relief.”
MS subtypes within the Albany study group included 96 individuals with relapsing-remitting MS, 66 with secondary-progressive MS, and 30 with primary-progressive MS. The study population included those who underwent angioplasty alone and three who underwent angioplasty with a stent placement.
“Results of the study were quite exciting and promising,” stated Dr. Mandato. “We can attest to significant physical improvements reported in greater than 75% of those with relapsing-remitting and primary-progressive forms of MS. Additionally, mental health scores improved in greater than 70% of individuals studied. People with secondary-progressive MS showed statistically significant improvements in both physical and mental health scores at a rate of 59% and 50%, respectively,” he added.
“During a four-month period, we treated 213 individuals; 192 of these patients (141 women; average age, 49) responded to a standard questionnaire that evaluated key quality-of-life components, including changes in physical abilities, health perception, energy/fatigue, sexual function, emotional well-being, cognition, and pain,” explained coauthor Meridith J. Englander, MD, an interventional radiologist at the Albany Medical Center. “We ultimately broke these data down into physical and mental health scores for each person and found improvement in both components of quality of life,” she added. “In addition, we found a trend that patients undergoing this treatment more than 10 years after diagnosis did not respond as well as those with a more recent diagnosis.”
“To address the needs and concerns of those with MS who feel they cannot wait until definitive studies are completed, many doctors are currently offering treatments with the hope of helping individuals with hard-to-manage symptoms of MS,” said Dr. Mandato. “Physicians who perform these treatments hope that this work will provide insights into the design of a prospective, randomized trial that is needed to rigorously evaluate the role of this treatment in MS,” he added.
“As we are still early in fully understanding the condition and its relation to treatment of CCSVI, it is our hope that future double-blinded prospective studies will be performed to further assess the durability of these results,” Dr. Mandato concluded.
Managing Chronic Cerebrospinal Venous Insufficiency in Patients With MS
Performing angioplasty on veins in the neck and chest is safe and may be an effective way to treat the venous abnormalities and provide symptom relief in patients with multiple sclerosis (MS), investigators reported in a second study.
“Our results are important, because there are an estimated 400,000 individuals affected by MS in the United States, some of whom experience symptoms that limit their quality of life in several ways. For many, it can be quite debilitating,” said lead investigator Hector Ferral, MD, an interventional radiologist at NorthShore University HealthSystem in Evanston, Illinois. “These early results show that performing angioplasty on azygos and jugular vein lesions may have a positive impact on the symptoms of those individuals with MS and also could be an effective palliative treatment geared toward improving their quality of life.
“Our experience showed that 95% of the individuals we evaluated had venous obstructions, supporting the concept that venous lesions are common in individuals with MS,” Dr. Ferral continued. “Based on follow-up that included ultrasound one week postprocedure and clinic visits every three months, our results showed that people who have this treatment are not exposed to fatal risks. Portraying venous angioplasty of the azygos and jugular veins as a high-risk procedure is a widespread misconception that needs to be addressed and corrected. In addition to these significant safety findings, we noted that angioplasty provided symptomatic benefit in 55% of the individuals we treated.”
The retrospective review examined results of 105 procedures performed in 94 patients with MS (59 women; age range, 26 to 67). About 50% of participants had relapsing-remitting MS, 39% had secondary-progressive MS, 6.4% had primary-progressive MS, and 4.2% were unknown. Jugular and azygos veins were evaluated with selective venography and intravascular ultrasound. Angioplasty was performed if the imaging confirmed reflux, allowing blood to flow backward, or a greater than 50% decrease in the vessel’s diameter. If necessary, stents were then used to treat nonresponsive lesions or blockages. These individuals were given blood-thinning medications for six weeks after the treatment.
Dr. Ferral’s team reported symptomatic improvement in 55% of the individuals treated, and 38% reported no improvement. Seven percent of patients did not comply with their follow-up visits and were considered to be lost to follow-up. Close to 60% of those with relapsing-remitting MS reported improvement in symptoms, the highest of all the subgroups in this study.
“These important results revealed that for people with MS who experience debilitating symptoms, minimally invasive interventional radiology treatments can be an effective, palliative treatment that also may improve their quality of life,” said Dr. Ferral. “As interventional radiologists, our biggest challenge is to bring to the attention of other specialists, especially those physicians specialized in MS, the evidence that venous lesions, often classified CCSVI, may be a true entity that deserves further attention and serious research,” he explained.
In 2011, members of a Society of Interventional Radiology Foundation’s Research Consensus Panel noted that evaluating patients with MS who have narrowed jugular and azygos veins—and examining the value of widening those veins with angioplasty—warranted careful, well-designed research. The multidisciplinary panel indicated that the “mandatory goal” should be conducting large-scale, pivotal, multicenter trials to explore CCSVI.