Percutaneous venoplasty for chronic cerebrospinal venous insufficiency in multiple sclerosis

The condition

2.1 Multiple sclerosis is a disease of the central nervous system, which usually starts in early adult life. It is characterised by neurological symptoms caused by episodes of inflammation and scarring in the white matter of the brain or spinal cord. It causes a range of symptoms including problems with vision, arm or leg movement, sensation or balance. Muscle spasms, pain, fatigue, and emotional problems or depression may also occur. Symptoms may vary over time and some people become profoundly disabled. The 3 most common types of multiple sclerosis are: relapsing–remitting, in which periods of good health or remission are followed by sudden onset of symptoms or relapses; secondary progressive, in which symptoms gradually worsen with fewer remissions; and primary progressive, which involves a gradual, continuous worsening of symptoms.

Current treatments

2.2 Current treatment for multiple sclerosis includes specialist neurological rehabilitation, and medication aimed at symptom control and preventing disease progression (see NICE's guideline on multiple sclerosis in adults).

The procedure

2.3 The aim of percutaneous venoplasty for chronic cerebrospinal venous insufficiency is to relieve multiple sclerosis symptoms by improving cerebrospinal venous drainage. However, the full mechanism of action is not currently understood.

2.4 Percutaneous needle puncture of the femoral vein is done under local anaesthesia and a vascular sheath inserted using a standard needle, guidewire and catheter technique. The guidewire is advanced into the superior vena cava under fluoroscopic control. Selective venography of veins, including but not limited to the internal jugular and azygos, is used to identify any abnormal luminal narrowing and collateral circuits. Intravascular ultrasound may also be used. Abnormally narrowed segments are dilated with a standard angioplasty balloon. Sometimes a stent is left in place after the angioplasty. Further venography or ultrasound, or both, are used to assess the outcome of the intervention before the guidewire and sheath are removed.