From: Willis, Chris [mailto:firstname.lastname@example.org]
Sent: February 23, 2011 10:43 AM
Subject: CCVI testing
Good morning Mr. Robak. I just listened to your message that was left on my voice mail. I would like to thank you for inquiring about our services here at Eastern Maine Medical Center. The vascular laboratory has started testing patients who have undergone jugular vein angioplasty through the Rhode Island Vascular Institute. Our protocol is to look for continued patency of these jugular veins. Our protocol was designed to meet the needs of Rhode Island Vascular Institute. We also follow the Zamboni protocol as well. I would like to emphasize that we are not (currently) performing this exam to screen for CCVI. We are however, scanning patients who have documented CCVI and who have under gone jugular vein angioplasty.
Just to give you a brief history: I am currently the only tech that is performing this procedure in this department. I am a registered vascular technologist who has been in this field for approximately 19 years. I have literally scanned thousands of jugular veins in my career.
The protocol that we are performing for CCVI patients who have undergone jugular vein angioplasty is quite extensive. We scan the patient's jugular vein with the patient in the supine position. We evaluate the jugular vein via gray scale imaging in transverse and sagittal views looking for areas of narrowing and/or abnormalities. We measure the diameter of the jugular vein in 3 different locations. We identify the jugular valve and check for reflux. We evaluate the flow in the jugular vein with color duplex as well as spectral waveform analysis. We assess phasicity and direction of blood flow. We also evaluate the vertebral veins and their blood flow in the supine position. We always look at both jugular veins and both vertebral veins. We repeat the entire process stated above with the patient sitting in an upright position. Our exams are read by only one dedicated vascular physician who has researched normal and abnormal findings.
The protocol and what to take for pictures is a new process for us however the normal and abnormal anatomy and hemodynamics of blood flow of the jugular/vertebral veins is not. I have researched several articles and have had several conversations with Rhode Island Vascular Institute on what to look for. I feel very confident on my skill level to perform an accurate exam. I am very excited about this new service we are offering!
I hope this e-mail answers your questions. Please feel free to e-mail me with any other questions.Thanks
Chris Willis RVTCoordinatorVascular LaboratoryEastern Maine Medical CenterBangor, Maine 04401Phone: (207) 973-7471Fax: (207) 973-7450
Then I asked him: "One question I thought of (and my readers probably will be thinking the same): when you talk of the vertebral veins, you presumably aren't talking about the azygous vein so, without taking too much of your time, could you explain which vertebral veins and whether there is any checking of the azygous. Or do the vertebrals lead to the azygous and are, therefore, a proxy for finding problems in the azygous? Thanks in advance for your explanation."
And here was Chris' reply:
When a patient is supine, the jugular vein performs the majority of the cerebral venous drainage. When a patient is sitting upright the vertebral veins performs the majority of the cerebral venous draining. Each vein has certain size characteristics and flow characteristics when supine and sitting upright. If there is an occlusion or tight stenosis of a jugular vein the characteristics change and the vertebral vein can compensate for the lack of venous drainage from the jugular vein and vice versa. In other words we evaluate the cervical vertebral veins more so as a proxy for jugular vein issues. The Azygous vein I believe is not easily identified via duplex ultrasound but is best evaluated by venogram. Not sure if this answered your questions.Therefore, this test doesn't really check for restenosis of the azygous, but then the azygous is not as likely to have restenosis, from what I have heard.
I'm looking forward to getting feedback from people who use this service.
In a later response, Amy from Ontario told me:
Chris has done a good job of answering your questions, Ted. It sounds to me like the azygos isn’t being addressed by the Doppler, and I don’t think it is being addressed by any of the Dopplers. When I went to Albany, I asked Dr. Mandato if my azygos vein had been addressed. He said there was no indication of a flow problem there. I’m now hearing from Dr. Tariq Sinan, Dr. Arata and Dr. Hewett, that it’s not good enough to just do a venogram of the azygos, but the azygos must be ballooned in order to see problems properly. Dr. Hewett says if you have mobility, bowel and bladder issues, your azygos must be ballooned. It looks like this was missed in my case. Thanks for your recount of the conversation, Ted. Great details…and good news for Atlantic Canadians.
Now that makes me wonder whether I may still have some problems with the azygous (or azygos) since in Poland I'm pretty sure they only did a venogram, no ballooning. I sure hope we start to get some expertise in Canada soon!