Percutaneous angioplasty of internal jugular and azygous veins in patients with chronic cerebrospinal venous insufficiency and multiple sclerosis: early and mid-term results

Abstract

Purpose: To assess the safety of endovascular treatment of chronic cerebrospinal venous insufficiency (CCSVI) in patients with multiple sclerosis (MS).

Materials and Methods: A total of 72 patients with CCSVI and MS (44 with relapsing remitting – RR, 4 with primary progressive, 20 with secondary progressive and 4 with benign MS) underwent percutaneous angioplasty. Outcome measures were colour Doppler ultrasonography parameters, gradient pressure at the vein abnormality level, postoperative complications, re-stenosis, disease severity scored by means of Expanded Disability Status Scale (EDSS) and patients’ assumption of disease status. Controls were done after one month on 72 patients, six months on 69 patients and one year on 61 patients, respectively (the average follow-up was 11 months).

Results: There were no postoperative complications. Colour Doppler ultrasonography showed significant improvement in cross-sectional area parameters (P < 0.05) and significant decrease in confluence velocity values (P < 0.05). Postoperative gradient pressure decreased, in internal jugular vein (IJV) significantly (P < 0.05). Re-stenosis appeared in 5.3% of patients. EDSS score was significantly improved (P < 0.01) and about half of patients reported significant or mild improvement in disease status and none of them worsening of symptoms.

Conclusion: Endovascular treatment of the IJV and azygous veins in patients with CCSVI and MS is a safe procedure with no post-procedural complications followed by significant improvement of IJV flow haemodynamic parameters and decrease in the EDSS score. Whether CCSVI percutaneous treatment might affect clinical improvement in patients suffering from MS is yet to be seen after completion of major multicentric clinical trials, still it seems like that this procedure is not negligible.

Keywords

percutaneous angioplasty chronic cerebrospinal venous insufficiency multiple sclerosis internal jugular vein

Introduction

Theory of vascular pathogenesis and its impact on the clinical course and outcome in patients with multiple sclerosis (MS) has become a serious issue in vascular medicine in recent years. Namely, MS has been described as an autoimmune, inflammatory and degenerative disease of the central nervous system¹ with focal demyelination of white matter as pathognomonic lesion.²

Some postmortem^3–7 and magnetic resonance venography studies⁸ showed a significant correlation of iron deposits and fibrin cuffs, as a sign of impaired venous drainage and chronic venous insufficiency, and pathognomonic plaques in subjects with MS.

Chronic cerebrospinal venous insufficiency (CCSVI)^9,10 has been described as specific complex condition in patients with MS which is characterized by multiple areas of stenosis and various obstruction levels of internal jugular (IJV) andazygous veins resulting in a collateral venous drainage formation.^11,12 This relationship is in line with a hypothesis of blood–brain barrier disruption in the course of an autoimmune reaction.^13–15

In recent years, it has been speculated that demyelinating MS lesions might be a result of chronically impaired venous drainage from the brain.^9,10 This process could initiate inflammation and neurodegeneration, which can result in neurological deficits that characterize clinical course in patients with MS.

Various venous abnormalities can be found in patients with CCSVI and MS: stenosis, complete occlusion, distortions, intraluminal structures such as membranes, webs and inverted valves.^9–12,16 Zamboni et al.¹¹ showed that endovascular treatment (PTA) of CCSVI significantly improved MS clinical outcome measures, especially in the relapsing remitting form group (P < 0.0001) with reduction of the relapse rate by more than four times in the year subsequent to the procedure as compared with the preceding year.

The aim of the study was to assess the safety of the CCSVI endovascular treatment and its impact on the clinical outcome of the associated MS.

Matherials and methods

Our prospective single-centre study started in 2009. A total of 224 patients with clinically proven MS according to revised McDonald criteria¹⁷ were examined. Doppler ultrasonography was performed with patients in the sitting and supine position. We analysed the morphology of the IJV, azygous, vertebral (VV) and intracranial veins using high-resolution B-mode ultrasounds and computed tomography angiography (CTA) (Figures 1 and 2).

Figure 1.

Doppler ultrasonography findings of right internal jugular vein membrane with confluence stenosis.

Figure 2.

Computed tomography angiography. Left internal jugular vein (IJV) stenosis.

Out of 224 patients, 57 (25.4%) had normal ultrasonographic findings while in 167 patients (74.6%) CCSVI, which included IJV or vertebral veins morphological abnormalities, was verified.

Exclusion criteria for endovascular treatment were regular CTA findings (4 pts), Expanded Disability Status Scale (EDSS) score >9 (38 pts),¹⁸ disease durability over 20 years (9 pts) and presence of significant associated reasons (44 pts). The final study group comprised 72 patients in whom percutaneous angioplasty was performed. The majority of patients in the study group were previously treated by pulse corticosteroid therapy or interferon β-1a but, not in the last six months prior to admission. This also applies for patients with relapsing remitting (RR) form of the disease.

CCSVI assessment was performed by a single angiologist on Aloka α10 (Tokyo, Japan) Color Duplex System ultrasonic device, with a linear transducer of 5–12 MHz. We used following parameters: (1) IJV reflux – significant when >0.88 seconds; (2) reflux in the deep cerebral veins; (3) high-resolution B-mode evidence of proximal IJV stenosis – IJV confluence stenosis with prestenotic dilation (spontaneous diameter >15 mm) and decreased prestenotic flow (<20 cm/second) if increased in-site stenotic flow was >130 cm/second; (4) flow not Doppler detectable in the IJV or VV–IJV or VV occlusion or hypoplasia; (5) negative changes in cross-sectional area (CSA) of the IJV – sitting and supine position; (6) IJV stenosis (D1 – proximal IJV part, D2 – median IJV part and D3 – distal IJV part) – when IJV diameter was <2.5 mm during the Valsalva manoeuvre; (7) abnormal IJV valves; (8) reflux and flow abnormalities in the vertebral veins; (9) azygous veins flow abnormalities. In addition to previously described Zamboni’s criteria¹¹ (parameters 1–5), we have used four more parameters (parameters 6–9) that from our Institute experience,¹⁶ after examination of 64 patients with MS, on the basis of hemodynamic disorders, indicated significant morphological venous system changes. We have found them to be specific for patients with MS resulting in abnormal venous flow.

Parameters 6–9 in our study were used only to confirm morphological changes and flow abnormalities in patients with MS but not for CCSVI diagnosis, which was established only on the basis of five Zamboni’s criteria (parameters 1–5). For intracranial veins assessment, magnetic resonance imaging was done prior to admission to our institute.

We presumed that the presence of at least two or more (2/5) Zamboni’s criteria (parameters 1–5) in the same patient were suggestive for diagnosis of CCSVI and that PTA was indicated.^9–11 CTA was performed in all patients prior to PTA. CTA has been done on ‘General Electrics (GE)’ 64 slice device. During the procedure 100 mL of ‘Ultravist’ contrast media was administrated, intersections were made at 0.625 mm while three-dimensional volume render and maximum/minimum intensity projection modalities were used for the final imaging.^19–21

According to clinical course of the disease the patients were classified into four subgroups: (1) benign form; (2) RR form; (3) secondary progressive (SP) form and (4) primary progressive (PP) form.¹⁷

In all patients severity of MS was scored by means of EDSS that was assessed by an attending neurologist. The score was based on neurological testing and functional systems (FS) analysis: pyramidal (ability to walk), cerebellar (coordination), bowel and bladder functions, sensory (touch and pain), brain stem (speech and swallowing), and visual and mental.¹⁸

Patients with EDSS score 0–3 had moderate disability in one functional system or mild disability up to three or four FSs; however, these persons are still fully ambulatory. Patients with EDSS score that ranged 3–6 presented with walking disability, starting from 500 m without aid or rest (score 4) to intermittent or unilateral constant assistance to walk 100 m with or without resting (score 6). From EDSS score 6 to 9 neurological status gradually worsens, so patients are essentially restricted to a wheelchair (score 7) and later on confined to bed, but still able to communicate and eat (score 9). Data on patients’ subjective assessment of disease status were also collected.

Endovascular procedure

In all patients, percutaneous angioplasty was performed under local anesthesia with repeated insufflation of 8–10 mm ‘Optapro Johnson’ balloons (inflated to 4–6 atmospheres) or ‘Fox Abbott’ 10–12 mm balloons (length 40 mm). What type of the balloons we used depended on the type and localization of the lesions. After right femoral vein punction punctured, wire 0.035 mm was introduced. For easier manipulation and precise jugular vein cannulation JR (Judkins Right) catheters were used. This is followed by angiography of the jugular, superior vena cava (SVC) and azygous veins when possible. Following angiography, gradient pressures were measured in the IJV (both above and below the stricture) as well as in the SVC. After this, angioplasty with the balloons of above-mentioned dimensions was done. Once again following angioplasty control angiography was done and gradient pressures re-measured in the same places as before the intervention.

The patients were discharged from the hospital the next day on prophylactic dose of low-molecular heparin (0.4 mL once a day) during the next month.²²

Follow-up

Colour Doppler ultrasonography and neurological status evaluation were performed the next day after PTA (in 72 patients), and after one month (in 72 patients), six months (in 69 patients) and one year (in 61 patients). Follow-up also involved postprocedural complications observing: thrombosis, bleeding and adverse effects from contrast media. Patients with suspected re-stenosis verified by means of colour Doppler ultrasonography underwent CTA for subsequent additional PTA treatment. Data on patients’ subjective assessment of disease status were collected the next day after PTA, and one month, six months and one year after PTA. These data were collected in a form of questionnaire created by the neurologist of the Institute.

Statistical analysis

Data are expressed as mean ± standard deviation or frequencies and percentages due to type of variable in question. t-Test, chi-squared test and analysis of variance with repeated measurements were used for comparisons between the subgroups for continuous and categorical variables, respectively, as well as differences in mean values throughout the follow-up period along with subgroup differences (between type of disease and EDSS categories). A probability value of P < 0.05 was considered significant.

Institutional review board approval

The study was approved by the ethics committee of our institution, and all patients gave their consent for diagnostic and endovascular procedures.

Results

Demographic, clinical and vascular characteristics of the patients are summarized in Table 1.

Table 1

Demographic, clinical and vascular characteristic of patients with multiple sclerosis.

Variable	Mean ± SD/number of patients (%)
Demographic and clinical characteristics
Age (years)	41.84 ± 9.89
Sex
Male	40 (55.56)
Female	32 (44.44)
Multiple sclerosis duration (years)	8.82 ± 4.01
Remission (years)	1.14 ± 0.58
Baseline EDSS score	4.31 ± 1.88
Form of multiple sclerosis
Relapsing remiting (RR)	44 (61.1)
Primary progressive (PP)	7 (5.6)
Secondary progressive (SP)	20 (27.8)
Benign	4 (5.6)
IJV abnormality characteristics	Left	Right
IJV confluence stenosis	33 (45.8)	55 (77.5)
D1 IJV part stenosis	3 (4.2)	0 (0)
D2 IJV part stenosis	3 (4.2)	1 (1.4)
D3 IJV part stenosis	0 (0)	0 (0)
IJV confluence reflux	15 (21.1)	29 (40.8)
Prestenotic IJV dilation	20 (28.2)	49 (69.0)
IJV valve pathology distribution	Left	Right
Normal valves	37 (51.4)	22 (30.6)
Inverted (turned inwards) valves	10 (13.9)	6 (8.3)
Fibrosed valves	15 (20.8)	19 (26.4)
Membrane presence	8 (11.1)	23 (31.9)
Flap	2 (2.8)	2 (2.8)
Multidetector CT angiography
Stenosis of the IJV confluence	29 (40.8)
Compression of the carotid bifurcation	1 (1.4)
Compresion of transverse process of the first cervical vertebra	2 (2.8)
Intraluminal reduction	2 (2.8)
Poor distribution of contrast/obstruction of lumen	1 (1.4)
Azygous vein stenosis	1 (1.4)
More associated factors mentioned above	35 (49.3)

EDSS, Expanded Disability Statys Scale; IJV, internal jugular vein; CT, computed tomography

IJV confluence stenosis was the most common abnormality seen on both IJV (left – 45.8%, right – 77.5%) while IJV confluence reflux was seen in 40.6% of the right IJV abnormalities and in 21.1% of patients with left IJV pathological lesions (Table 1).

The most common imaging morphology were fibrosed valves and presence of membrane. Reflux in the vertebral veins (VVs) was noticed in 25.3% of the patients while VV reversed flow was verified in 24.8% of the patients. (Table 1) According to CTA, stenosis of the IJV confluence was present in 29 (40.8%) patients. Isolated external IJV compression by carotid bulb and the first cervical vertebra transverse process was observed in three patients (4.2%) (Table 1).

IJV PTA was performed bilaterally in 38.9% of patients, unilaterally in 58.4% and in 2.8% of patients azygous vein and IJV PTA was done (Table 1). All procedures were performed under local anaesthesia, and there were no postprocedural complications.

PTA of the left IJV only was done in 14 patients, and of the right IJV only in 22 patients while in 27 patients, we did bilateral IJV PTA. Left IJV PTA was done in a total of 41 patients and of the right IJV in a total of 49 patients.

Table 2.

Colour Doppler ultrasonography prior and after IJV PTA (Mean ± SD).

PRIOR PTA	AFTER PTA	P value
Left (41 patients)
CSA (cm²)	0.81 ± 0.43	0.89 ± 0.47	0.025
CSA VM (cm²)	1.002 ± 0.45	–	–
CSA 90° (cm²)	0.38 ± 0.25	–	–
PSV (cm/second)	90.5 ± 34.7	76.98 ± 24.8	0.000
Right (49 patients)
CSA (cm²)	1.32 ± 0.59	1.27 ± 0.53	0.013
CSA VM (cm²)	1.65 ± 0.84	–	–
CSA 90° (cm²)	0.41 ± 0.31	–	–
PSV (cm/second)	125.7 ± 41,5	101.4 ± 30.5	0.000

IJV, internal jugular vein; PTA, percutaneous angioplasty; CSA, cross-sectional area; CSA VM, cross-sectional area during Valsava manoeuvre; CSA 90°, cross-sectional area in sitting position; PSV, peak systolic velocity; CSA, cross-sectional area.

For differences in colour doppler ultrasonography prior and after IJV PTA.

In two patients (2.8%), we did azygous vein PTA. The next day after PTA colour Doppler ultrasonography showed significant improvement regarding CSA parameters (P < 0.05), as well as a significant decrease in confluence velocities presented as peak systolic velocities (PSV) both on the left and on the right IJV (P < 0.001). This improvement in hemodynamic parameters remained after one month, six months and one year (Table 2).

In four patients (5.3%), CTA was done for suspected IJV re-stenosis six months after PTA, but re-stenosis was not regarded as significant and did not require additional PTA procedure.

Gradient pressures were measured prior and after PTA in the IJV below and above the stenosis, as well as in the SVC (Tables 3 and 4).

Table 3.

Gradient pressures prior and after IJV PTA.

Prior PTA	After PTA	P value
IJV systolic gradient pressure (mmHg)	7.41 ± 2.65	6.14 ± 2.14	P < 0.001
IJV mean gradient pressure (mmHg)	4.75 ± 2.12	4.02 ± 1.85	P < 0.001

IJV, internal jugular vein; PTA, percutaneous angioplasty; SVC, superior vena cava.

Table 4.

Gradient pressures measured in the SVC prior and after IJV PTA.

Prior PTA	After PTA	P value
SVC systolic gradient pressure (mmHg)	6.29 ± 2.39	6.17 ± 2.41	P = 0.487
SVC mean gradient pressure (mmHg)	3.86 ± 2.07	3.66 ± 1.94	P = 0.314

IJV, internal jugular vein; PTA, percutaneous angioplasty; SVC, superior vena cava.

We were able to measure IJV gradient pressure in a total of 51 patients and SVC pressure in 35 patients. The reasons why we were not able to measure the pressure gradients in some of the patients were: very small inner IJV diameter, expressed IJV stenosis or expressed IJV spasm and collapse during the procedure. The results showed that there has been a decrease with respect to the gradient pressures with statistical significance when IJV was observed (P < 0.05) in contrast to SVC where statistical significance was not verified.

When the overall EDSS score was observed it was found that there has been a statistically significant decrease in score value in the entire cohort (n = 61, F = 22.82, P < 0.001) and also when EDSS score was compared separately prior PTA and the next day after PTA (P < 0.001) as well as one month (P < 0.001), six months (P < 0.001) and one year (P < 0.001) after PTA (Table 4). Mean values of EDSS score the next day after PTA, and at one month, six months and one year after PTA did not differ significantly (P values ranged from 0.183 to 0.581) (Table 5).

Table 5.

Changes in EDSS score before and after PTA.

Clasiffication variables/categories	EDSS scores					F value* P value
Clasiffication variables/categories	Baseline n = 72	After PTA n = 72	After 1 month n = 72	After 6 month n = 69	After 1 year n = 61	F value* P value
Total	4.31 ± 1.88	4.06 ± 1.91**	4.06 ± 1.91**	4.20 ± 1.90**	4.23 ± 1.94**	22.82 <0.001
Type of disease
Relapsing remitting n = 44 at baseline	3.72 ± 1.70	3.38 ± 1.60	3.38 ± 1.62	3.42 ± 1.63	3.44 ± 1.65	1.288 0.227
Primary progressive n = 4 at baseline	6.50 ± 0.71	6.13 ± 0.85	6.13 ± 0.85	6.38 ± 0.48	6.38 ± 0.48
Secondary progressive n = 20 at baseline	5.72 ± 1.44	5.58 ± 1.59	5.58 ± 1.59	5.58 ± 1.59	5.58 ± 1.59
Benign form n = 4 at baseline	2.83 ± 1.15	2.67 ± 1.44	2.67 ± 1.44	2.67 ± 1.44	2.67 ± 1.44
EDSS categories
<3 n = 19 at baseline	2.03 ± 0.54	1.84 ± 0.58	1.81 ± 0.58	1.84 ± 0.60	1.82 ± 0.64	0.420 0.908
3–6 n = 40 at baseline	4.54 ± 1.13	4.26 ± 1.24	4.27 ± 1.23	4.32 ± 1.27	4.33 ± 1.28
>6 n = 13 at baseline	6.96 ± 0.59	6.69 ± 0.75	6.69 ± 0.75	6.69 ± 0.75	6.75 ± 0.72

EDSS, expanded disabily status scale; PTA, percutaneous angioplasty.

According to analysis of variance with repeated measurement.

P < 0.001 for comparison with EDSS before PTA.

With respect to the disease form, the greatest decline of EDSS score was found in relapsing remitting MS group, and it maintained after one year of PTA (Table 5). In primary progressive form, there has been improvement immediately after PTA, but EDSS score gradually increased during the following months. In secondary progressive and benign MS form we verified less effective EDSS decrease that retained after one year.

When three categories of EDSS scores (<3; 3.0–6.0 and >6.0) were analysed separately, in each of them decline of scores was observed after PTA immediately, and during follow-up, and these changes had the same dynamics in all three groups of EDSS (F = 0.420, P = 0.908) (Table 5).

According to individual opinion of disease status, at the end of one year after PTA significant or mild improvement was present in 28 of 61 patients (45.9%). During follow-up, none of patients reported worsening of symptoms.

Discussion

Zamboni et al.^9–11 first showed strong correlation between MS and a condition called CCSVI which is characterized by multiple changes in extracranial venous drainage pathways. On the basis of this finding it was postulated that MS could be a haemodynamic disorder.

The association between MS and CCSVI was also reported by some other authors^16,23,27 Simka et al.²³ found that 90% of patients with MS had two or more positive criteria for CCSVI diagnosis. In a recently reported study, which included 64 patients with clinically proven MS and 37 healthy controls, we found that venous flow abnormalities were significantly more frequent in MS patients compared with their controls (P < 0.001).¹⁶ We also reported that different truncular malformations can be seen in patients with MS²⁴ and questioned the impact of external compression on the IJV to insufficient cerebral vein drainage and CCSVI occurrence in patients with MS.^25,26

Researchers at Buffalo University²⁷ examined 1600 subjects (950 with clinically proven MS, 100 with initial demyelinating events, 300 with other central nervous system diseases and 350 healthy controls) and verified CCSVI in 56% of patients with MS, in 80% of those with advanced MS and in 22% of healthy controls. They concluded that CCSVI is unequivocally associated with MS and that CCSVI must be a part of the MS disease process.

On the other hand, Doepp et al.²⁸ reported that none of 56 patients with MS examined by colour Doppler ultrasonography fulfilled more than one Zamboni criteria for CCSVI with no difference when compared with healthy controls. They challenged the hypothesis that venous congestion plays a significant role in MS pathogenesis. Similarly, Khan et al.²⁹ strongly opposed endovascular procedures that utilize stenting in patients with MS before major studies have been completed and analysed.

Zamboni and his team first published the results of endovascular treatment of chronic cerebrospinal venous insufficiency.¹¹ Percutaneous transluminal angioplasty was done in 65 consecutive MS patients with CCSVI (35 with RR form, 20 with SP form and 10 with PP MS form) and mean follow-up of 18 months.

In our study PTA was performed in 75 patients with CCSVI and clinically proven MS. CCSVI diagnosis was established according to Zamboni’s criteria (our study parameters 1–5)^9–11 while four more parameters (6–9) used in our study confirmed venous flow disorder and morphological changes but were not used for CCSVI diagnosis.

As well as in Zamboni’s study the majority of our patients had relapsing remitting form of the disease (44 pts), than secondary progressive MS form (20 pts) while four patients had primary progressive MS form and four patients had benign form.

The most common venous abnormalities seen in Zamboni’s study were annulus stenoses followed by IJV valve malformation¹¹ while the most frequent IJV abnormalities verified in our study were IJV confluence stenosis, reflux in the IJV and IJV fibrosed valves.

According to the results of the present study, endovascular treatment of CCSVI seems to be successful and safe. There were no post-procedural complications, and PTA was followed by statistically significant improvement in the IJV flow parameters and significant decrease of IJV gradient pressure values. Following angioplasty, Doppler ultrasonography showed significant improvement regarding cross CSA parameters (P < 0.05), as well as a significant decrease in confluence velocities presented as PSV (P < 0.001). These improvements in haemodynamic parameters remained after one month, six months and one year. CSA parameters improvement is extremely important to note as well as confluence PSV decrease since it is directly related to successful treatment of proximal IJV stenosis followed by reduced peak systolic velocities values. These parameters were one of the main CCSVI criteria described by Zamboni et al.^9,11 and therefore we considered that these criteria improvement following PTA significantly influenced reduced flow abnormalities in patients with CCSVI.

When gradient pressures were observed, statically significant difference was noted within the IJV after percutaneous angioplasty but not in the SVC. I gradient was measured just after the malformation, in the proximal IJV part, immediately above treated lesion. The SVC gradient was measured within the SVC, in the initial SVC part, just after innominate veins merge and form SVC and just before its confluence with the right atrium. High values of systolic pressure (6.29 ± 2.39 mmHg) measured in the SVC before PTA could be explained by significant influence of IJV proximal stenosis while mean pressure was considerably lower (3.86 ± 2.07 mmHg). The significance of gradient pressure differences is in accordance with our previous experience and recently published papers.^{16,24–26,30–33}

We believe that venous flow redistribution following PTA had a better effect within the IJV where certain lesion has been treated, and minor effect on the flow measured distally, within the SVC. Still, the difference in the gradients measured in the SVC before and after the PTA was present. In our study, statistically significant improvement in the IJV flow was noted following angioplasty as well as a significant decrease of IJV gradient pressure values while none of 75 patients had postprocedural complications.

Unlike Zamboni’s study, we verified significantly decreased number of patients with azygous vein pathological lesions. All patients underwent multidetector CT phlebography prior to PTA and conventional phlebography during the procedure, but azygous vein pathological lesion were noted in only two patients (2/72, 2.8%) and these patients were treated by percutaneous angioplasty.

Zamboni et al.¹¹ reported re-stenosis in 47% of patients following PTA at 18 months follow-up. In the present study exceptionally low rate of IJV re-stenosis (5.3%) occurred during follow-up, but they did not require additional angioplasty.

In the present study, endovascular treatment of CCSVI had favourable influence on MS severity expressed by EDSS score as well. EDSS score significantly decreased immediately after the procedure and, although score slightly increased after six and 12 months, it was during all follow-up period significantly lower in comparison with the period before intervention, P < 0.001.

The greatest decline of EDSS score was found in relapsing remitting MS, but it was present in other forms of disease as well. In Zamboni et al.¹¹ study, the strongest effect of PTA on disease severity measured by Multiple Sclerosis Functional Composite was also seen in the RR group. Zamboni et al.^9,11 suggested that uneven distribution of the four haemodynamic patterns of CCSVI could influence the distribution of lesions and the clinical course of MS and that it could also be an explanation for different postoperative outcomes in the MS patients subgroups.

The proportion of relapse-free RR patients at one year in Zamboni’s series significantly increased from 27% before PTA to 50% postoperatively while the annualized relapse rate compared with the one reported during the two years preceding PTA declined from 0.9 to 0.7, but the difference was not statistically significant.¹¹ Pre-procedural remission length of patients in our study was 1.14 ± 0.58 years, and after one year follow-up there were no deterioration of the disease. About half of patients reported significant or mild improvement in the disease status.

Another study published by Petrov et al.³³ analysed 461 patients with MS and CCSVI who underwent endovascular treatment of 1012 venous lesions. Like in our study patients included in the study had EDSS score 0–9 prior to PTA, with an average score of 5.5.

The main difference compared with our study is that we did only balloon angioplasty in all patients and avoided stenting while Petrov et al.³³ implanted 98 stents in 76 patients with a favorable outcome.

The best results were obtained in patients with EDSS score up to 5.5 with relatively low rate of postprocedural complications (groin haematoma 1%, vein rupture 0.4%, vein dissection 3.0%, in-stent/in-segment thrombosis 1.6%). Authors concluded that endovascular therapy appears to be a safe and reliable method for CCSVI treatment.

Like Zamboni et al.¹¹ and Petrov et al.³³ concluded, percutaneous angioplasty as CCSVI treatment in patients suffering from MS showed satisfactory results as safe and effective procedure in our study as well. The main drawback of the present study is that there is no control group. The observed favourable outcome in some MS patients could be the result of continuous pharmacological treatment. Zamboni et al.¹¹ already stated that carefully designed clinical trial, in which two randomly selected groups of MS patients are compared, should be undertaken. In addition, the number of patients should be greater and follow-up should be longer.

Conclusion

Endovascular treatment of IJV and azygous veins morphological abnormalities in patients with CCSVI and MS remains a controversial issue worldwide. Our study showed that percutaneous angioplasty of CCSVI performed in patients with MS is a safe procedure, with no post-procedural complications. The correlation between CCSVI and MS has been described, but whether CCSVI percutaneous treatment might affect clinical improvement in patients with MS is yet to be seen after completion of major multicentric clinical trials.

Footnotes

Funding

This manuscript was partly funded by Serbian Ministry of Science and techonological development – Project No 41002.

Conflict of interest statement

The authors have no conflicts of interest to declare.

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