**Indications:**  
  
 **Multiple Sclerosis (MS)**  
MS is an autoimmune disease of the central nervous system. In MS, inflammation
of nervous tissue causes the loss of myelin, a fatty material that acts as a
protective insulation for the nerve fibers in the brain and spinal cord. This
demyelination leaves multiple areas of hard scarred tissue (plaques) along the
covering of the nerve cells. Another characteristic of MS is the destruction
of axons, which are the long filaments that carry electric impulses away from
a nerve cell. The demyelination and axon destruction disrupts the ability of
the nerves to conduct electrical impulses to and from the brain, and produces
the various symptoms.  
  
**Chronic cerebrospinal venous insufficiency (CCSVI)**  
Recent information suggests that obstruction to venous flow or inadequate
venous valves in the great veins in the neck, thorax and abdomen may cause
insufficient drainage and damaging backflow into the cerebral and spinal cord
circulations.  
  
Chronic cerebrospinal venous insufficiency (CCSVI) has been described as
follows in multiple sclerosis (MS) patients. CCSVI is characterized by
impaired brain venous drainage due to outflow obstruction in the extracranial
venous system, mostly related to anomalies in the internal jugular and azygos
veins. The current CCSVI diagnosis is based on Doppler sonography of
extracranial and transcranial venous hemodynamics where there has been
documentation of stenotic and occlusive lesions in the azygos and internal
jugular veins in patients with MS. The literature is inconclusive on whether
CCSVI is a clinically important factor in the development and/or progression
of MS.  
  
 **Treatment of CCSVI with balloon angioplasty and or stent placement**  
Venous angioplasty (with or without stent placement) is currently under
investigation as a method to improve blood flow in chronic cerebrospinal
venous insufficiency (CCSVI). The hypothesis is that symptoms of MS might
improve with this treatment. Unfortunately, MS is associated with frequent
spontaneous exacerbations of signs and symptoms. Thus it is very difficult to
determine whether any change in medical condition is due to a treatment, or
merely represents a normal fluctuation of the disease process. The literature
currently is inconclusive on whether balloon angioplasty and/or stent
placement are clinically effective in treating patients with MS.  
  
Endovascular treatment for CCSVI is typically performed from common femoral
vein access. Initially a venogram is performed so that images can be obtained.
A small catheter is inserted and advanced into the right and left internal
jugular veins as well as the azygos vein. If the venogram indicates a vein is
stenosed then angioplasty is performed. Another venogram is done post
angioplasty to confirm that the stenosis was successfully corrected. If the
venous angioplasty results in no change or worsening of the stenosis, then
stent placement is considered. Individuals who receive a stent typically are
placed on anticoagulants for at least three months.  
  
 **Limitations:**  
  
The evidence is inconclusive as to whether CCSVI impacts multiple sclerosis
and therefore if treatment with angioplasty would impact the disease.
Therefore, venous angioplasty (with or without stent placement) for any of the
jugular veins, azygos veins, or other thoracic veins is considered
investigational and not medically necessary for the treatment of multiple
sclerosis and not covered by Medicare.