Saturday, June 18, 2011 2:53 AM
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Ken Torbert
Clinical questionIn patients with multiple sclerosis (MS), is angioplasty of obstructed extracranial venous lesions safe and does it improve MS symptoms? EvidenceIn a cohort study, 65 MS patients with chronic cerebrospinal venous insufficiency (CCSVI) underwent angioplasty for obstructed azygous or internal jugular venous lesions.1
Participants: mean age 41 years, 46% male, minimal to moderate disability (not in wheelchair), taking MS disease-modifying agents.
Vascular outcomes: no serious operative or immediate postoperative complications.
Neurologic outcomes at 18 months, compared with baseline (no control or placebo group):
-No benefit in primary or secondary progressive subtypes.
-Significant improvements in relapsing-remitting MS subtype: fewer patients relapsing during 1-year period (50% vs 73%, P = .0014); fewer patients with lesions seen on magnetic resonance imaging (12% vs 50%, P < .0001); and improved MS functional composite and quality-of-life scores.
All relapsing-remitting patients with patency after their procedures were relapse free.
Concerns: single study site, not randomized, no control group, and unblinded.
Context
Many patients are attempting this unproven procedure, and complications are being observed.6
Multiple subsequent studies question the relationship between CCSVI and MS.7–10
Bottom lineThe initial study seems promising, but it is critically flawed for assessing benefit, and subsequent studies are not supportive. It is premature to recommend endovascular angioplasty for MS. The fluctuating nature of relapsing-remitting MS absolutely necessitates a long-term, multicentre, blinded RCT to determine if endovascular angioplasty is beneficial. ImplementationRemind patients that all provider organizations and patient advocacy groups consider vascular surgery for MS purely experimental.11 While awaiting results of ongoing research, FPs can help manage MS symptoms, including depression.12 Decision aids can help patients weigh risks and benefits and make informed decisions.13,14 For those considering approved treatments, 2 decision aids exist.15,16 For those pursuing this experimental treatment, some information is available from the MS Society of Canada.17 Notes
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