Jugular Angioplasty for MS May Improve Perceived Quality of Life

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Two new studies appear to support the controversial hypothesis that angioplasty can improve perceived quality of life (QOL), and possibly symptoms as well, in patients with multiple sclerosis (MS). The studies, presented January 16, 2011, at the International Symposium on Endovascular Therapy (ISET) in Miami Beach, FL, involve a large series of patients treated at a single institution in Italy within the last year.

The theory that endovascular treatment of 1 or both of the internal jugular veins and sometimes the azygos veins, located in the thoracic vertebral column, may help alleviate MS arose from studies suggesting that perivenous inflammation, a histopathological signature of MS, may be initiated by cerebral venous hypertension or chronic cerebrospinal venous insufficiency (CCSVI). However, the theory is highly controversial, with some clinicians believing it gives false hope to patients desperate for newer, better treatments.

Improvements in Walking, Talking and Bladder Control

Marco Magnano, MD, of the University of Catania (Sicily, Italy), presented the 2 new studies, which examined both QOL and safety in patients who have undergone jugular angioplasty for MS since November 2010 at his institution.

For the QOL study, 170 patients (median age, 39 years) were evaluated using the expanded disability status scale (EDSS), a standard method used to quantify the level of disability in MS patients. Using the EDSS, patients rank their symptoms from 0 to 9, with higher numbers indicating more severe disability. Prior to treatment, the patients in the study averaged 4.5, meaning they had some limitation of activity and were able to walk without resting for slightly more than 300 yards. Three months after treatment, they improved to an average of 4.0, meaning they were up and about 12 hours a day and able to walk more than 500 yards without resting. Patients who initially scored higher on the disability scale were less likely to improve than those with lower scores.

In a telephone interview with TCTMD, Dr. Magnano said the improvements typically reported by patients in addition to a better ability to walk include improved speech and bladder control.

“They tell us a lot of the time that they also feel more safe and much more resistant to fatigue when walking,” he said. “This is true in about 50% or more of my patients.”

To date, follow-up is only 6 months, but Dr. Magnano said he plans to follow patients for as long as possible.

In the other study, Dr. Magnano and colleagues reported on 380 patients who underwent jugular angioplasty via the femoral route. Of these, 25% also underwent azygos angioplasty. All patients were diagnosed with CCSVI via color Doppler ultrasound. Patients received heparin during the procedure and for 3 weeks afterward as well as aspirin for 3 months. Ultrasound was repeated at 1 and 3 months.

According to Dr. Magnano, there were no vessel ruptures and no major complications. One symptomatic pulmonary embolism occurred, which was caused by deep vein thrombosis in the access site.

Interest Growing, Skepticism Remains

Interest in the CCSVI theory of MS arose in 2006 when the first of several studies were published by Paolo Zamboni, MD, of Azienda Ospedaliero-Universitaria di Ferrara (Ferrara, Italy). Dr. Zamboni reported evidence of the presence of CCSVI in patients with MS but not in control subjects. Since then, a number of researchers have tried and failed to verify Dr. Zamboni’s results. Most recently, researchers led by Olaf Stüve, MD, PhD, of the VA North Texas Health Care System (Dallas, TX), used the identical methods but concluded that there was no significant difference in the number of ultrasound abnormalities between patients with MS and controls (Marder E, et al. Arch Neurol. 2011;68:1521-1525).

In the United States a small number of researchers have been experimenting with angioplasty for MS, but for the most part it is not considered an acceptable treatment and is not endorsed by any major medical society. One exception is the Society of Interventional Radiology, which said in a position statement in 2010 that it supports CCSVI research and safety studies on endovascular MS treatments. Most of this research, however, is being conducted in Europe and Canada.

According to Dr. Magnano, over 450 CCSVI-related angioplasties in MS patients have been performed at his institution in the last 13 months. While he believes these patients when they report that they are feeling better after the procedure, he remains highly skeptical himself.

“I see that the patients do better, but I want to understand if it is a placebo effect or if it really works,” he said. “So far, we have no data to answer this question. I myself believe that the placebo effect may be the reason why patients feel better. There may be some [physiological] component, but we just do not really know.”

Dr. Magnano said he would like to see more trials conducted to try to answer these questions and understands why so many do not support such a treatment.

“We have a long way to go and it is not easy to do,” he said. “I believe CCSVI exists, but I wonder if it’s really connected to MS. This is a big question right now.”

 

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Sources:
1. Magnano M. QoLS and EDDSS variations after PTA in 170 MS-CCSVI patients. Presented at: International Symposium on Endovascular Therapy; January 16, 2012; Miami Beach, FL.

2. Magnano M. Complications and safety of jugular and azygos angioplasty in CCSVI patients with MS. Presented at: International Symposium on Endovascular Therapy; January 16, 2012; Miami Beach, FL.

3. Vedantham S, Benenati JF, Kundu S, et al. Interventional endovascular management of chronic cerebrospinal venous insufficiency in patients with multiple sclerosis: A position statement by the Society of Interventional Radiology, endorsed by the Canadian Interventional Radiology Association. J Vasc Interv Radiol. 2010; 21:1335-1337.

 

 

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