Provided by Danielle Rhéaume and posted on FaceBook
Note: Dr. McGuckin was one of the presenters at the “Big Event” in Seattle where our Eric Feigenbutz also presented:
These questions were asked on the CCSVI in Seattle group page and answered by Dr McGuckin of Vascular Access Centers in February:
1) How aggressively do you treat stenosis? Are the veins/valves simply stretched, or are they ‘disrupted?’ Angioplasty causes a controlled tear in the lining and the wall of the blood vessel, leading to plastic deformation and therefore disruption of the stricture/web/stenosis/valvular irregularity, resulting in an increase in diameter of the vein. Increased diameter leads to increased flow, which leads to decreased venous pressure. We disrupt all narrowings via angioplasty.
2) How do you choose balloon size/pressure? Balloon size is chosen to match the patient’s anatomy. You would be surprised how different people are on the inside. Some big men have very small vessels, and some tiny women have the opposite. So, the venogram gives the correlative picture upon which the balloon size is chosen. It’s very important to treat these narrowings with high pressure angioplasty because some of these lesions are extremely resistant. Our goal is to use the largest balloons that the anatomy will tolerate at the highest rated burst pressure of the balloon, with prolonged inflation.
3) What is the prevalence of problems with valves in the patients that you treat? Do you routinely do valvuloplasties? Most patients have valvular disorders causing stenoses. All these stenoses get valvuloplasty.
4) What is your philosophy/experience with stents? At what point would you insert a stent? Stents are an incredibly important tool in minimally invasive medicine because they enable holding open a vessel that re-narrows after a successful angioplasty. I recommend stents, however, only at times of failed angioplasty, dissection/rupture of the vessel, when recanalizing an occluded vessel, or intra-stent stenosis which also has failed angioplasty. I think it has received a lot of bad press because of mishaps, but I can assure you that it is generally very safe, and when appropriately sized and delivered, an invaluable tool. It would be a mistake to restrict its usage in the proper setting.
5) Will you treat a patient for whom there is little apparent stenosis? Yes. I have seen amazingly thin webs and synechiae in the azygous, iliac, and jugular systems that would be easily missed by a non-invasive study.
6) If a clot forms, is this usually an emergency situation? Is there a doctor at the VAC Center in Tukwila at all times who can deal with it? Or can this be treated by most vascular/coronary doctors. How much time would a patient have to get treatment? Is it like a blood clot leading to the brain (not away from it)? All VAC physicians are prepared to perform CCSVI procedures and its potential complications, including the potential need for stenting or thrombolysis. Clots rarely form in endovascular procedures, but when they do, the clot can be removed, broken up, or dissolved in rapid fashion. If a clot were to occur, it would be in a vein leading away from the brain and the other veins draining the brain would compensate. While this is an important condition to resolve, it is not typically life-threatening.
7) How often does severe restenosis occur? Could this be an emergency situations in some cases? Is there at doctor at the VAC Center at any time to deal with this? My analogy for stenosis is as if a bridge on your commuter path were being narrowed inch by inch, day by day.
Commuters would learn of the impending slow-down and would learn to take alternate routes as the commute worsened. The body does the same thing when stenoses occur and these alternate routes are called collaterals. When we treat the underlying stenoses successfully, typically these collaterals will regress. Restenosis in venous therapy is common, but fortunately treatable & most often does not pose an emergent threat.
8) What kind of follow-up do you have? Do you check for restenosis? How often? I think the best indicator of the patients’ vascular health is the monitoring of their own symptoms. If the symptoms present at the time of Liberation recur over a prolonged period, it is likely that restenosis has occurred. We are aiming to adhere to the Hubbard Registry protocol and also request that our patients fill out a MS QOL form at 1, 3, 6, and 12 months post-procedure.
9) What kind of blood thinner do you use? Is any kind of follow-up needed for this? Would it be a good idea to get a blood test to see the ability of the blood to coagulate (can’t remember the right term here)? I don’t use any anti-coagulant during the procedure and I only use Plavix post-procedure for patients that receive stents, as stents are foreign bodies and require a few weeks to get covered by a fresh lining, called endothelialization. Typically, I’ll have them stay on the medicine for a month, but I would prefer it indefinitely.
10) Generally, what have the results been for VAC? What is the rate of restenosis?Our positive results are approaching 80%, but we inform the patients about the “rule of thirds” – 1/3 of patients see dramatic improvement, 1/3 of patients see some transient improvement, and 1/3 of patients see little to no improvement at all. Restenosis is a process that typically occurs at 6 months to 12 months post-procedure, so I do not have an accurate assessment thus far. I can say, in patients that I have treated that have been seen elsewhere, that restenosis is typically w/in existing stents or stenoses are being discovered that were never treated.
11) In the case of restenosis, is there a reduced charge for treatment? Charges vary based on treatment
12) Who are the other IR’s who perform angioplasties in Dr. McGuckin’s absence? Would he be available in an emergency situation? How quickly? Other IR physicians at VAC include Dr. Robert Worthington-Kirsch, Dr. Mario Moya, Dr. Jorge Salazar, Dr. David Singh, Dr. John Rundback, and Dr. Daniel Simon. Treatment of CCSVI is an elective procedure and scheduled at a time that works mutually for the physician and patient. This is an outpatient procedure and patients typically travel the following day. To date, we have not seen any complications post-procedure
13) How many patients has VAC treated to date? Over 75
14) What other techniques are you using – i.e. cutting balloons, using blood flow in the azygos to diagnose stenosis, etc? When high-pressure angioplasty fails (which is very uncommon), we use a cutting balloon technique to achieve maximum dilation and resolve the underlying pathology.
15) Is VAC part of Dr. Hubbards registry? If not – why not? Our patients are bringing the data to the registry presently, as we actively pursue membership to the registry. We are also in the process of pursing our own IRB-sanctioned prospective CCSVI study.
16) Have you seen any MS patients who DIDN’T have CCSVI? No
17) What veins are you actually testing/treating Iliac, IVC, Renals, SVC, Brachiocephalic, Azygous, Jugulars
18) I’d like to hear an overview of your impressions of CCSVI, how he relates it to MS, & what is your impression of this discovery? Budd-Chiari is a similar disease process effecting the liver and causing fibrosis from iron deposition. The treatment here is promoting venous drainage from the liver. The treatment of opening the venous drainage of the brain in CCSVI patients makes sense from this perspective. While I think MS has multiple etiologies, the vascular component can be treated successfully.
19) Anything else you think is important? I think that patients need to understand that the procedural risk is very low and treatment typically takes less than an hour, however, the benefits can be amazing. If I had MS, I would seek out the Liberation procedure.
More about Dr. McGuckin:
Dr. McGuckin is Director of the Philadelphia Vascular Institute located in Philadelphia, Pennsylvania. Dr. McGuckin’s research interest include: Cardiovascular Systems, Endoscopy and Endosurgery, Peripheral Arterial Disease, Limb Salvage, Percutaneous Oncologic Therapy and therapy related to the End Stage Renal Disease population. He is currently researching recanalization of Central Venous Occlusion using RF ablation. He holds 39 patents and has over 170 pending patents. Dr. McGuckin double majored in Mechanical Engineering and Pre-Medical from the University of Notre Dame in 1983, and received his M.D. from Hahnemann University in 1987, General Surgery in 1988, Masters Degree in Bioengineering at the University of Pennsylvania in 1990, Diagnostic Imaging in 1995, and completed his Fellowship in Interventional Radiology at the Hospital of the University of Pennsylvania in 1996. [Note: Dr. McGuckin lives in PA, but does CCSVI treatments from Vascular Access Center’s Seattle location.]