Deep inside the veins of the Canadian patient lying in the modern operating room, Marcial Fallas deftly negotiates around many roadblocks on his way to unclogging blood vessels.
Watching internal pictures from X-ray and ultrasound monitors, Dr. Fallas and his five-man Costa Rican team use a thin metal wire a few feet long to guide a catheter from the entry point, a few inches inside of the patient's left hip, to the veins in her neck.
The soft-spoken Dr. Fallas explains each step of the 90-minute procedure as Jeanette Brooks, a multiple sclerosis sufferer from Rocky Mountain House, Alta., gently snores under the sedation.
Balloons follow the catheter into the veins weaving inside Ms. Brooks's thin neck. Several are inflated to smooth out jagged corners and widen narrowing straight-aways.
A few hours after the surgery ends, Ms. Brooks rests groggily in her immaculate, air-conditioned private room at Hospital Clínica Bíbilica, three storeys above a grungy section of downtown San José.
Blood from her brain now has a clearer path to flow back to her heart. Whether this helps her MS will be judged in the next few days and months, and will become another anecdotal piece in an intense conflict between elements of the medical establishment and patients desperate for help. The so-called liberation procedure pioneered by Italian doctor Paolo Zamboni has had its setbacks, including the death last month of Mohir Mostic, a 35-year-old Ontario patient, from complications while under Dr. Fallas's care. In turn, Dr. Zamboni has called for more study in Canada, which has among the highest rates of MS in the world.
Meanwhile, thousands of Canadian MS patients like Ms. Brooks are quietly taking or planning trips around the globe to seek their own answers. Across the United States, from Mexico and Costa Rica to Egypt, Jordan and India, MS patients are getting their veins widened in the belief they've finally found a treatment that helps. The bills run high. The cost in Costa Rica falls into the middle of the international range at $12,900 (U.S.), including hotel and an unusual 10 days of recovery and therapy post-op, but not all meals or air fare.
If they can afford it, money seems to be no object for patients who have lost patience with Canada's clampdown on the procedure.
"My neurologist doesn't know I'm here," said Ms. Brooks, a self-effacing mother of two, as she awaited her operation in her room. She has had difficulties grabbing small objects and walking, and loses her balance when she's tired. "It's like they've taken a stance and they all have the same talking points," she said.
Upstairs in his office, Dr. Fallas faces questions about the procedure and concerns about complications and efficacy. Thrust into the news by the death of Mr. Mostic on Oct. 19, the vascular surgeon admits he is far less at ease in the public theatre than the surgical one. He had used a stent to brace open a vein in one of the riskier versions of the procedure pioneered by Dr. Zamboni, who has said he cannot recommend his own procedure for widespread use right now.
Neither the death, nor Dr. Zamboni's call for caution, have deterred patients here. But the death does weigh on Dr. Fallas, a physician whose sensitive bedside manner is constantly praised by Canadian patients.
"Of course, you think about whether you should have done something differently. It's impossible to know now, and if I start to punish myself … I try to avoid those kind of thoughts," Dr. Fallas said.
His vascular surgery team at Hospital Clínica Bíbilica, working with a Vancouver-based medical tourism company called Passport Medical, has performed balloon angioplasty on about 300 Canadian MS patients who have come here since operations started in June.
Besides Mr. Mostic, three others have suffered complications ranging from bleeding to clotting. All three were treated successfully, according to Dr. Fallas and other physicians here.
In Mr. Mostic's case, the stent triggered a blood clot and a return to Costa Rica in October, four months after his original surgery. A procedure to remove the clot seemed successful, but he died the next day from internal bleeding.
Many Canadian patients swear by the treatment in Costa Rica, but even the staunchest proponents here say it's no miracle cure. Progress is most often measured in wiggled toes and warm extremities. Dr. Fallas says about 80 per cent of patients have reported quick improvement in a host of symptoms.
A week after news of Mr. Mostic's death broke, Canadian patients are the bulk of the off-season guests at the deluxe hotel where they await their surgery or recover from it.
About 20 patients interviewed in recent days were unanimous: They feel sorry for Mr. Mostic's family, but he knew the risks going in, as they do. Many are upset that his death has overshadowed positive results.
Nearly a dozen patients already treated at Hospital Clínica Bíbilica told The Globe and Mail they have new feeling in their feet, fewer headaches and better balance.
"We know some of the symptoms are very subjective," Dr. Fallas said. "That's the difficult part. But in some other instances, we have seen very objective findings that this really works."
In more rare and spectacular cases, patients have regained the ability to walk, feed themselves or control their bladders for the first time in years.
"It's been an amazing experience. I'm not in pain, I'm warm, I haven't been having any headaches," said Cara Boutin, a 26-year-old from Lloydminster, Sask., who has had an aggressive form of MS for five years.
Ms. Boutin had the procedure nearly two weeks ago and notes she still has some slurred speech and imperfect mobility. But on her last night in Costa Rica, she felt enough confidence on her feet to paint her toes and wear sandals. "It's the first hope I've had in years and I'm celebrating," she said.
Many neurologists, who are usually the top of the medical hierarchy in care for MS patients, maintain there is not enough scientific evidence to back it up.
Even within the team treating Canadians at Hospital Clínica Bíbilica, there are neuroscientists hungry for solid evidence. Freddy Enriquez, one of several neurologists who assess foreign MS patients, refuses to endorse the 80-per-cent success rate cited by Dr. Fallas. And he has his own ethical concerns about plunging headlong into the treatment without more study.
"Our clinical suspicion is that they are getting better but for a scientific statement, for statistics that say, 'Hey, this is working really great,' we need proper baseline evaluations and we need help from Canada for that," Dr. Enriquez said. So far only Newfoundland and Labrador has promised to contribute that kind of evaluation.
"You can do some kind of quick evaluation that they are getting better. What if this is some kind of awakening and they just go back? I am concerned about the ethics of this, but I've read all the opposing viewpoints and I'm not a judge. I can't tell anybody what to do. What I can do is start to measure."
Between desperate and hopeful patients and skeptical neurologists are vascular surgeons like Dr. Fallas, whose expertise is not MS but fixing blood vessels.
"My own first reaction was also that it was too good to be true," he said. "But if it was only a placebo, would we be seeing positive results in nearly 300 patients?"