Over the past five years, an idea that gained some currency was that multiple sclerosis is caused by poor blood flow from the brain. The theory was called chronic cerebrospinal venous insufficiency (CCSVI), and it led to some centres offering surgery to dilate the veins (with venous angioplasty) to relieve the problem. CCSVI captured a great deal of attention – in part because it defied conventional notions about MS – but there was little scientific evidence for or against the approach of opening up the veins as an MS therapy. (For more on this topic, see our four-part series beginning with MSology, August 16, 2012.)
The first well-controlled study of CCSVI has now investigated whether venous angioplasty is effective in MS (Siddiqui and colleagues. Neurology 2014; epublished June 27, 2014). The phase II study enrolled 19 people with MS who met the criteria for CCSVI. Subjects were randomized to angioplasty or a sham procedure. The “sham” involved surgically operating on some people but not actually dilating their veins, so it served as a fairly intrusive “placebo”.
Surgery was generally safe, which is consistent with what is seen with angioplasty procedures for other medical conditions. There were no surgical complications, although one person with a history of fainting did develop an abnormally slow heart rate that required a pacemaker.
Angioplasty did result in improved blood flow one month after the procedure, but not after six months. A greater concern was that after the procedure, there was a trend for people to do worse. People experienced more relapses and had more new inflammatory lesions on their MRI after angioplasty compared to after the sham surgery. Greater success in relieving blood flow problems was associated with an increasing number of new lesions. This may be because the blood stream is how inflammatory cells enter the brain, so improving blood flow may make inflammation worse in the central nervous system. The long-term consequences of this worsening picture were not investigated.
The study was only six months in duration, so it was too short a time to determine if there were any longer term benefits on quality of life or other measures. However, in the short term, it appears that angioplasty has at best no effect on MS and may actually worsen the underlying disease process.
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