Alessandro Rasman
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To the Editor Corner Paolo Zamboni, MD Sir,I read with interest the article titled Transvascular autonomic modulation: a modified balloon angioplasty technique for the treatment of autonomic dysfunction in multiple sclerosis patients of Arata and Sternberg published in the Journal of Endovascular Therapy. 1 It seems that PTA also stimulates the vagus nerve with improvement of sleep and other symptoms impacting the quality of life. Dr. Arata and his team suggests this new theory, with previous articles published in Phlebology 2 and in Acta Phlebologica. 3 What is your opinion on this topic? Alessandro Rasman (Trieste, Italy) E-mail: alessandro.rasman@libero.it References 1. Arata M, Sternberg ZJ. Transvascular autonomic modulation: a modified balloon angioplasty technique for the treatment of autonomic dysfunction in multiple sclerosis patients. Endovasc Ther 2014;21:417-28. [Crossref]2. Sternberg Z, Grewal P, Cen S, et al. Blood pressure normalization post-jugular venous balloon angioplasty. Phlebology 2013 Nov 19. [Epub ahead of print]. [Crossref] [Pubmed] 3. Arata M, Debarge P. Transvascular autonomic modulation, initial assessment of safety. Acta Phlebologica 2014;15:19-23. [Crossref] |
Reply by Paolo Zamboni
Dear Mr Rasman,
Thank you for your letter and for the interesting questions regarding the intriguing article of Arata and Sternberg.
My first consideration is that the improvement of venous outflow permits to improve CSF flow. 1 This is very important because seems to be linked with lesions formations in the white matter. It has been proven that extracranial venous outflow abnormalities determine significant reduction of cerebral spinal fluid reabsorption, and this, in turn, is proportional to the number and volume of T2 lesions either in multiple sclerosis or in Alzheimer disease. 2,3 Moreover, PTA or other surgical techniques could also improve brain perfusions, an aspect actually under investigation. 4,5 The Authors are providing very interesting data about additional effects of venous PTA linked with vagus stimulation in consequence of balloon inflation. My second consideration is that these further therapeutic effects may contribute to explain us the rapid recovery of autonomic symptoms referred by the vast majority of patients after balloon angioplasty, usually considered placebo effect. Only the double-blinded Brave Dreams trial may completely clarify the latter point. 6
References
1. Zivadinov R, Magnano C, Galeotti R, et al. Changes of cine cerebrospinal fluid dynamics in patients with multiple sclerosis treated with percutaneous transluminal angioplasty: a case-control study. J Vasc Interv Radiol 2013;24:829-38. [Crossref] [Pubmed]
2. Beggs C, Chung CP, Bergsland N, et al. Jugular venous reflux and brain parenchyma volumes in elderly patients with mild cognitive impairment and Alzheimer’s disease. BMC Neurol 2013;13:157. [Crossref] [Pubmed]
3. Magnano C, Schirda C, Weinstock-Guttman B, et al. Cine cerebrospinal fluid imaging in multiple sclerosis. J Magn Reson Imaging 2012;36:825-34. [Crossref] [Pubmed]
4. Zamboni P, Menegatti E, Weinstock-Guttman B, et al. Hypoperfusion of brain parenchyma is associated with the severity of chronic cerebrospinal venous insufficiency in patients with multiple sclerosis: a cross-sectional preliminary report. BMC Med 2011;9:22. [Crossref] [Pubmed]
5. Zamboni P, Menegatti E, Occhionorelli S, Salvi F. The controversy on chronic cerebrospinal venous insufficiency. Veins and Lymphatics 2013;2;e14. [Crossref]
6. Zamboni P, Bertolotto A, Boldrini P, et al. Efficacy and safety of venous angioplasty of the extracranial veins for multiple sclerosis. Brave dreams study (brain venous drainage exploited against multiple sclerosis): study protocol for a randomized controlled trial. Trials 2012 3;13:183.
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