Arata Michael, Sternberg Zohara
Synergy Health Concepts, Newport Beach, California, USA.
J Endovasc Ther. 2014 Jun;21(3):417-28. doi: 10.1583/13-4605MR.1.
To describe the use of transvascular autonomic modulation (TVAM) to improve cardiovascular autonomic nervous system (ANS) dysfunction in multiple sclerosis (MS) patients, comparing the safety and efficacy of this modified technique with traditional balloon angioplasty.
Twenty-one MS patients (11 men; mean age 48.7±13.0 years) who presented with symptoms of cardiovascular ANS dysfunction underwent TVAM. These patients were compared with age/sex-matched MS patients (10 men; 49.3±11.1 years) in the same stages of the disease who presented with chronic cerebrospinal venous insufficiency (CCSVI) and who underwent venous balloon angioplasty. TVAM involved the coupling of balloon angioplasty of the internal jugular veins with the application of external manual compression and dilation of the azygos and renal veins; unlike traditional angioplasty for CCSVI, which treats only abnormal veins (≥50% stenosis or static valve), all targeted vessels were treated with TVAM regardless of the presence of an abnormality. The effect of TVAM on ANS function was indicated by determining heart rate variability based on the electrocardiographic R-R interval lengths using vector analysis to derive the mean circular resultant (MCR) and the expiration/inspiration (E/I) ratio, the Valsalva ratio, and the 30:15 postural ratio at 24 hours after intervention.
Left renal vein compression was common among the TVAM patients and resulted in ≥50% luminal compromise in 10 of 21 patients. Azygos vein abnormalities (a static valve) were identified in 5 patients. Overall, 18 patients met the diagnostic criteria for CCSVI with at least one lesion >50%, but only 10 lesions were considered treatable by traditional balloon angioplasty. After intervention, the R-R interval values, including the 30:15 postural ratio (p=0.01), the MCR (p=0.1), and E/I ratio (p=0.1), were higher for the TVAM patients compared to the control group. The safety profile of the TVAM procedure was similar to that of traditional balloon angioplasty.
The combination of balloon angioplasty of anatomically normal veins coupled with external compression during dilation of these veins can improve indicators of ANS dysfunction. The safety and efficacy of TVAM in MS patients observed in this pilot study is encouraging, paving the way for the treatment of dysautonomia in pathological states other than MS. Further studies should investigate TVAM in a larger MS cohort.
描述经血管自主神经调节（TVAM）用于改善多发性硬化症（MS）患者心血管自主神经系统（ANS）功能障碍的情况，并将这种改良技术的安全性和有效性与传统球囊血管成形术进行比较。
21例出现心血管ANS功能障碍症状的MS患者（11例男性；平均年龄48.7±13.0岁）接受了TVAM治疗。将这些患者与年龄/性别匹配、处于疾病相同阶段且患有慢性脑脊髓静脉功能不全（CCSVI）并接受静脉球囊血管成形术的MS患者（10例男性；49.3±11.1岁）进行比较。TVAM包括颈内静脉球囊血管成形术与奇静脉和肾静脉外部手动压迫及扩张相结合；与仅治疗异常静脉（≥50%狭窄或静态瓣膜）的传统CCSVI血管成形术不同，无论是否存在异常，所有目标血管均采用TVAM治疗。通过基于心电图R-R间期长度确定心率变异性来表明TVAM对ANS功能的影响，使用矢量分析得出平均圆形结果（MCR）以及呼气/吸气（E/I）比值、瓦尔萨尔瓦比值和干预后24小时的30:15姿势比值。
TVAM患者中左肾静脉受压情况常见，21例患者中有10例管腔狭窄≥50%。5例患者发现奇静脉异常（静态瓣膜）。总体而言，18例患者符合CCSVI诊断标准，至少有一个病变>50%，但只有10个病变被认为可通过传统球囊血管成形术治疗。干预后，TVAM患者的R-R间期值，包括30:15姿势比值（p=0.01）、MCR（p=0.1）和E/I比值（p=0.1），均高于对照组。TVAM手术的安全性与传统球囊血管成形术相似。
解剖学上正常静脉的球囊血管成形术与这些静脉扩张过程中的外部压迫相结合可改善ANS功能障碍指标。在这项初步研究中观察到的TVAM对MS患者的安全性和有效性令人鼓舞，为治疗MS以外的病理状态下的自主神经功能障碍铺平了道路。进一步的研究应在更大的MS队列中研究TVAM。
