In August, I received a message asking me what I thought about CCSVI in multiple
sclerosis. I had the same reaction most of you did when you read the title of this
article – “What the hell is CCSVI?” A Google search told me it stood for “chronic
cerebrospinal venous insufficiency” and a PubMed search led me to a handful of papers
on CCSVI, all authored by an Italian vascular researcher/surgeon named Paolo Zamboni.
The papers provided solid and mind-expanding evidence that an entirely new disease
process was part of MS. It soon became clear that the concept of CCVSI had the potential
to completely change how we saw MS and how to treat it.
The Italian researchers discovered that, in persons with multiple sclerosis, the
veins which acted as the main drainage pathways for blood flowing from the brain
back to the heart were substantially narrowed and even blocked. These included the
jugular veins, veins along the spinal column, and other veins I had not heard of
before such as the azygous vein. The researchers had never seen these problems in
anyone before. Their equipment allowed them to study the blood flow in the veins
and to also take pictures of the veins. They found that all the persons with MS they
examined had impaired venous drainage from the brain and that such a problem caused
the phenomenon of “reflux”. This means the venous blood would flow back toward the
brain as it established new pathways around the blocked and narrowed veins. They
labelled this compromised venous drainage as CCSVI.
Improper venous drainage is well known in the lower torso of many people (e.g. varicose
veins, etc). In some cases, it has been demonstrated that poor venous flow in the
lower body can result in iron deposition and associated inflammation. Furthermore,
sclerosis and degenerative lesions can occur with the inflammation. Knowing the problems
that poor venous drainage can cause in the lower torso, Zamboni and his co-authors
offered the reasonable interpretation that the reflux action of the blood flow into
the veins of the brain resulted in iron deposition and inflammation of the blood-brain
barrier (BBB). Notably iron deposits have long been documented in MS lesions and
it is well known that every MS lesion forms symmetrically around a vein. Such characteristics
of MS lesions have never been satisfactorily explained before the Zamboni discoveries.
In the MS literature, there are two opposing hypotheses for how MS autoimmunity begins.
The most popular one is that myelin-sensitive T cells are activated through molecular
mimicry by a childhood virus such as EBV. The myelin-sensitive T cells then cross
the BBB and lead an autoimmune attack on myelin. The other hypothesis is that the
initial event in the MS disease process is a breech of the BBB and the consequent
exposure of the central nervous system to the immune system. This uncovering of previously
hidden antigens not seen before by the immune system leads to an autoimmune attack
With the work of Dr Zamboni, it now appears that the second hypothesis, the breech
of the BBB due to impaired venous drainage, is the best explanation for the initiation
of MS autoimmunity. In support of this, the researchers found that, of the 109 persons
with MS studied, every last one of them had impaired venous drainage. Furthermore,
of the 177 control subjects, a group that included persons with other neurological
diseases and healthy people of various ages, not a single one had impaired venous
drainage from the brain.Such a 100% separation of persons with MS from controls on
the basis of impaired venous drainage leaves little doubt that such a phenomenon
is very important in the MS disease process.
Another important observation made by Zamboni’s team is that the pattern of reflux,
that is, the specific pathway the blood uses to flow back to the brain, showed a
strong correlation to the type of MS. Persons with PPMS had a different reflux pattern
that those with RRMS and SPMS. Furthermore, the PPMS reflux pattern provided a good
explanation why this form of MS is more aggressive and problematic.
The other convincing data that demonstrates that CCSVI is a key part of MS are the
results from the use of a treatment which relieves the venous drainage problems.
This treatment is called ‘the liberation procedure”. The problematic veins are first
identified by venography. Then, balloon angioplasty is used to open up the problematic
veins and, in some cases, stents are inserted in non responding sections. The procedure
is relatively non-invasive and is done in day hospital under local anaesthesia. Access
to the veins is through the left femoral vein in the thigh. Total time in the hospital
is usually less than 6 hours and the subject has a compression dressing on for 24
Dr Zamboni has described the results of the use of the liberation procedure on 51
patients with relapsing-remitting MS. Eighteen of the subjects were treated in emergency
with an acute attack and all of them had their symptoms completely resolved within
a few hours to a few days. The other subjects had a greatly reduced yearly attack
rate and, notably, the only ones experiencing an attack following the procedure were
those who had a recurrence of the impaired venous drainage problems. The subjects
also reported a dramatic improvement in chronic fatigue.
In summary, it would appear that the relief of venous drainage problems results in
major improvements of MS symptoms. This is further evidence of the major role that
CCSVI plays in MS.
Finally the researchers noted that there was no difference in the severity of venous
drainage problems between those using an MS drug and those not on a drug.
Given that CCSVI explains why PPMS differs from RRMS, as well as the occurrence of
previously inexplicable features of MS lesions (e.g. venocentricity, iron deposits),
CCSVI becomes a very compelling explanation for the initiation of CNS autoimmunity
which drives MS. Further research is needed to confirm this.
Perhaps the most important question that remains is “what is the ultimate cause of
the venous drainage problems?” Zamboni and colleagues did not offer any explanations/speculations
on this. Hopefully, this question will be the subject of an intensive research effort.
It is worth noting that, given adequate vitamin D in childhood prevents MS in most
cases, vitamin D supply must have a substantial effect on the venous drainage system.
This new understanding of the MS disease process makes the use of the recommended
nutritional strategies even more imperative. These strategies enhance blood flow,
strengthen the BBB, counteract autoimmune reactions and quite possibly improve venous
drainage from the brain. Overall, the Zamboni work provides further insight into
why nutritional strategies work so well for many people.
In answer to the question in the title of this article, I am convinced that CCSVI
is a huge breakthrough for MS. Correction of this problem with a relatively simple
procedure may well turn out to be a very effective, long lasting, drug free treatment
for MS at the time of diagnosis. However, a great deal of research and clinical testing
will have to happen before CCSVI is widely accepted as a key part of MS and the liberation
procedure becomes standard procedure. In the past, non-drug treatments for MS have
been marginalized, mainly for financial reasons. I predict it will be a long, hard
fight to get the treatment of CCSVI from the laboratory to the clinic.