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07 October 2011
The use of high-pressure balloons in the treatment of CCSVI
By Dr Jan de Letter | Vascular surgeon
Download this article in English
In a newsletter published by The Essential Health Clinic on 13-09-2011, the opinions of a cardiologist and an interventional radiologist were elicited on the use of high-pressure balloons for the treatment of CCSVI. So-called cutting balloons and guide wires were recommended over the use of high-pressure balloons. The treatment method using high-pressure balloons has been used successfully for PrivateScan several hundred times by Dr Jan de Letter in the treatment of CCSVI, and counter to the recommendations of the cardiologist and radiologist, he believes this is the best option.
There is no clear scientific evidence for successful use of cutting balloons versus high-pressure balloons in veins. Additionally, there is a higher risk of local bleeding because the blades on the cutting balloons and guide wires can cut through the thin vein wall. Another important reason why PrivateScan chooses to use high-pressure balloons is the lack of re-stenosis (renewed narrowing developing after the treatment). Finally, treatments with high-pressure balloons have proved very successful in hundreds of CCSVI patients when compared to the higher risk and more expensive cutting balloons and guide wires. In this article, vascular surgeon Dr Jan de Letter addresses the use of both types of balloons in more detail.
CCSVI and possible causes
CCSVI stands for chronic cerebrospinal venous insufficiency, and is a condition that has been linked to Multiple Sclerosis (MS). MS is a chronic neurological disease that affects the central nervous system (the brain and spinal cord). Many MS patients have a stenosis (narrowing) in the neck vein or azygos vein in the chest cavity, preventing good blood flow from the brain and upper spinal cord.
In CCSVI, the draining of blood is mostly inhibited by abnormal valves at the base of the neck veins. Not everyone has these veins. In humans, these veins have become obsolete, as unlike many animals, we walk upright. If these valves are working properly, they are supple and open and close easily. In people with CCSVI, we sometimes see that these valves are immobile, creating a kind of membrane or web in the vein, preventing good blood flow. On the other hand, we are aware of cases in which the valves are shrivelled up and create a kind of band around the vein in the vessel wall. Treatment of CCSVI addresses stuck valves, membranes and band-shaped thickening in the vessel wall.
Treatment of CCSVI
How CCSVI can best be treated is currently under investigation. There is no single clear technique for successfully treating CCSVI. In all cases, treatment focuses on improving blood flow from the brain. Currently, multiple treatment methods are used in parallel, and the chosen technique often depends on the skill and experience of the doctor. PrivateScan uses the high-pressure balloon method fine-tuned by Dr De Letter.
Sidebar: arteriosclerosis
A more common form of blood vessel narrowing is arteriosclerosis. In this condition, arteries become narrowed following deposition of calcium and cholesterol, resulting in a thickening of the inner wall of an artery. Various forms of treatment have been developed to combat this condition. A stenosis in an artery is generally fairly easy to dilate with a balloon by inflating it to 8 atmosphere. If the calcium deposits are more stubborn, the treating specialist often selects cutting balloons. These balloons cut into the calcium deposits, so inflating the balloon has the desired effect. Sometimes a specialist will implant a stent, a metal or composite tube placed in the blood vessel to keep it open.
Arteries versus veins
Techniques used for arteries cannot simply be transferred to veins. Flow rate and pressure in arteries are much higher. Furthermore, artery walls have a completely different structure than vein walls. Experiences with dialysis patients - where a vein is connected directly to an artery in a small surgical procedure - show that classic balloons used in arteries cannot apply the pressure required to open stenoses that develop in these veins (so-called dialysis fistulas). These veins are too stiff due to connective tissue bands. The use of balloons with a larger diameter than the vessel or the use of two balloons also does not offer a solution. This only results in stretching the healthy wall to either end of the stenosis, which is obviously not the objective.
To solve this conundrum, two different techniques were chosen, the previously mentioned cutting balloon being the first. By inflating this balloon multiple times, turning it a little each time, the desired effect is achieved. The disadvantage of this technique is that local bleeding may occur, as the blades can cut through the thinner vein wall. The other solution is to use high-pressure balloons. The effects are the same as for arteriosclerosis, however high-pressure balloons can be inflated to 16 bars without the risk of the balloon tearing. This allows far more force to be applied to the stenosis, and sufficiently stretches out the connective tissue that causes the narrowing. Tests have shown that the use of stents in dialysis fistulas affect the inner lining of the vein in the long term, resulting in new stenosis and even complete occlusions.
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If you select a balloon that is too large, or use two balloons, you will simply stretch out the healthy vessel. |
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Dialysis fistula versus CCSVI
The techniques used to treat dialysis fistulas can be transferred to CCSVI. For over a year now, I have been using high-pressure balloons to dilate the parts of veins where stuck valves, membranes and band-shaped thickenings are causing problems. Using high-pressure balloons, I have treated hundreds of patients with good and lasting results. It is important to note I see practically no re-stenoses (new narrowing) in patients in the long term. My conclusion is that the connective tissue strands in the band-shaped stenosis are sufficiently broken up, and no damage has been done to the wall of the treated vein.
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Normal balloon |
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Cutting balloon |
Given the thin vein wall, there is a higher risk of:
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High-pressure balloon |
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The Essential Health Clinic
The Essential Health Clinic newsletter describes the use of high-pressure balloons as aggressive, with a risk of damaging the vein wall. The newsletter recommends the use of cutting balloons and guide wires, as well as concurrent inflation of two balloons. I personally find these techniques far more aggressive and certain to lead to vein wall damage. The use of cutting balloons and guide wires and two balloons at the same time results in a less even spreading of force on the vessel wall, with a greater risk of damage and even a risk of bleeding. This is the case when these methods are used to treat dialysis fistulas. Given the experiences with dialysis fistulas, I do not recommend the use of stents for the treatment of CCVSI.
Conclusion
Given the experiences with dialysis fistulas, the use of high-pressure balloons is a logical choice for the treatment of CCSVI. The use of high-pressure balloons is safe and yields good results with few re-stenoses. The use of cutting balloons and guide wires and the use of two balloons - given the experiences with dialysis fistulas - is not recommended.
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1. Contrast injected into the vein runs off via collaterals, limited narrowing, valve system likely does not open fully
2. Balloon with a dent at the stenosis site
3. Balloon fully deployed, here at 14 atmosphere
4. Control image after use of the balloon, good contrast outflow to the heart, vein is wide open
Dr Jan de Letter, Vascular Surgeon at AZ st Jan in Bruges
For more information: CCSVI Online – Privatescan B.V.
Telephone: +31 (0)74 255 26 80
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Website: www.ccsvi-online.com
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