Clinical question

In patients with multiple sclerosis (MS), is angioplasty of obstructed extracranial venous lesions safe and does it improve MS symptoms?

Evidence

In 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.

  
  
  
  

  • -Restenosis at 1 year was about 50% for internal jugular.

    
    
  
  
  
  



• Neurologic outcomes at 18 months, compared with baseline (no control or placebo group):

  
  

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  • -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.

  
  
  
  

  • -Remission is a hallmark of relapsing-remitting MS: untreated patients can have reductions (even prolonged) in clinical symptoms^2,3 or lesions.⁴ A control group and long-term follow-up are essential.

    
    
  
  
  
  

Context

• Hypothesis of CCSVI and MS: chronic insufficient cerebral venous drainage ? cerebral iron deposits ? engender the immune response underlying MS. Angioplasty improves cerebral blood outflow ? decreases iron deposits ? improves MS symptoms.⁵

  
  

• 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

  
  

Notes

• http://171.66.125.180/content/57/6/676.full