To say that the relationship between CCSVI and multiple sclerosis is controversial is an understatement. This article introduces both sides of the story and summarizes the current evidence. While many physicians remain understandably skeptical, it is worth remembering that "conventional wisdom" on the pathophysiology of some diseases has turned out to be way off the mark - consider peptic ulcers. Clearly, more objective data is needed before routine interventions for CCSVI can be recommended, and hopefully, ongoing registries and trials will provide that data. In the meantime, those of us involved with the vascular laboratory should be prepared to evaluate patients for the abnormalities described in CCSVI. Detection of reflux and obstruction in the internal jugular and vertebral veins by duplex ultrasound (in both supine and seated positions) is based on the same general principles as the more familiar upper extremity venous and carotid duplex examinations. Ideally, patients should be screened and entered into a clinical study to establish an evidence base for future decision-making. Until then, we will be stuck between the "liberators" and the "nihilists", and our patients will be caught in the middle.

Robert Eugene Zierler, M.D., is professor of surgery, division of vascular surgery, department of surgery, and medical director, Vascular Diagnostic Service, University of Washington School of Medicine, Seattle, Wash. He is also an associate medical editor for Vascular Specialist.

CCSVI Controversy: A Call for New Research