Foam sclerotherapy of the saphenous veins: randomised controlled trial with or without compression.

OBJECTIVES: This study aims to compare the efficacy and side effects of foam sclerotherapy of the saphenous veins with or without post-treatment compression using graduated elastic stockings. DESIGN: This is a prospective open randomised controlled trial conducted in two centres. PATIENTS AND METHODS: Sixty patients with incompetent great (GSV) or small saphenous veins (SSV) underwent ultrasound-guided foam sclerotherapy. Randomisation was conducted immediately after sclerotherapy to two parallel groups, one (CG) with compression stockings (15-20 mmHg worn during the day, for 3 weeks) and the other (WCG) without compression. Efficacy of sclerotherapy and all of the side effects were assessed, including side effects in the treated region. On days 14 and 28, clinical and duplex ultrasound (DUS) assessments were performed by independent experts. Patients also completed quality of life (QOL), symptom questionnaires and provided satisfaction scores. RESULTS: Five men and 55 women ranging in age from 32 to 78 (mean 57 years) years were included: 29 in the WCG and 31 in the CG group. On day 28, abolition of venous reflux and occlusion of the vein was obtained in 100% of the cases in both groups. The length of the occluded vein was the same in both groups (mean 36 cm for the GSV and 30 cm for the SSV) as was the mean diameter of the occluded vein (5 mm). Symptoms and QOL questionnaires showed equivalent improvement in both groups on day 28 compared to pre-treatment assessments. Side effects were few with no statistical difference between the two groups. Patient satisfaction scores were high in both groups for the outcome of sclerotherapy results, and good or very good for compression in 50% of the CG cases. CONCLUSION: We found no difference between compression and control groups when comparing efficacy, side effects, satisfaction scores, symptoms and QOL. Further studies are required to establish the role of compression in sclerotherapy and to evaluate other compression strategies.

[Mondor's disease, report on three cases and literature review]. / Maladie de Mondor. A propos de trois cas et revue de la littérature.

Mondor's disease is spontaneously remitting benign superficial thrombophlebitis involving healthy veins. Fewer than 400 cases have been reported in the world literature. Typically, subcutaneous angiitis is observed on the upper anterolateral aspect of the chest wall. We report three cases in which Mondor's disease occurred after surgery for breast cancer in one patient, and had no apparent cause in two other patients. The relationship with breast cancer and risk factors suggests that routine mammography is advisable. For patients presenting idiopathic Mondor's disease, follow-up is of utmost importance.

[Foam echosclerotherapy by puncture-direct injection: technique and quantities]. / Echosclérothérapie à la mousse par ponction-injection directe à l'aiguille: technique et doses.

Foam echosclerotherapy by puncture - direct injection (EMPID) is a technique approved by the French Health Authorities for the management of varicose veins. It combines two principles: the injection of a sclerosing agent by echomonitored direct puncture and the use of this sclerosing agent as a foam. The procedure consists of four stages: targeting of the vein to sclerose and selection of the puncture site, venous puncture under echographic guiding, injection of the sclerosing product under complete echographic monitoring, and post-injection control, checking for the impact of the action and the distribution of the foam in the treated vein. First intention indications concern essentially isolated troncular reflux in lesser and great saphena veins and varicose recurrences. In second intention, EMPID is also an alternative to conventional varicose resection surgery. Emphasizing the principle of precaution, we underline the usefulness of a fine, extemporaneous, standardized and reproducible microfoam - high doses, in particular large volumes of foam, are unwarranted since it has been proven that small volumes are as effective. The recommended concentrations are directly linked to the maximal diameter of the saphena trunks targeted. The volume of foam to be injected must be determined on an individual basis and depends on the presence or not of post-injection spasm, the degree of venous filling and the endothelial impregnation of the treated varicosity (which can be easily monitored because of the spontaneous visualization of the foam producing a tracing effect on the ultrasound); it should not exceed 7.5 ml per session. Apart from the classical side effects due to the liquid form, the foam presents its own, very rare, side effects consisting of minor, constantly and spontaneously reversible, eye disorders. The foam is contraindicated for patients suffering from migraine due to higher incidence of such visual disorders. EMPID is an outpatient procedure for the treatment of varicosities which requires considerable operator skill. This technique cannot be proposed on a large scale without proper and specific training.

Plaque density on CT, a potential marker of ischemic stroke.

The authors sought to determine in a retrospective analysis whether carotid plaque soft TD on CT is associated with recent ischemic neurologic events. Among 141 patients (99 asymptomatic), 106 plaques with more than 50% stenosis were selected for density measurements. They found an odds ratio for neurologic events associated with a 10-point decrease in density of 1.54 (p = 0.002), showing an association between plaque density and neurologic events.

Volume Calculation of Venous Thrombosis Using 2D Ultrasound Images.

Venous thrombosis screening exams use 2D ultrasound images, from which medical experts obtain a rough idea of the thrombosis aspect and infer an approximate volume. Such estimation is essential to follow up the thrombosis evolution. This paper proposes a method to calculate venous thrombosis volume from non-parallel 2D ultrasound images, taking advantage of a priori knowledge about the thrombosis shape. An interactive ellipse fitting contour segmentation extracts the 2D thrombosis contours. Then, a Delaunay triangulation is applied to the set of 2D segmented contours positioned in 3D, and the area that each contour defines, to obtain a global thrombosis 3D surface reconstruction, with a dense triangulation inside the contours. Volume is calculated from the obtained surface and contours triangulation, using a maximum unit normal component approach. Preliminary results obtained on 3 plastic phantoms and 3 in vitro venous thromboses, as well as one in vivo case are presented and discussed. An error rate of volume estimation inferior to 4,5% for the plastic phantoms, and 3,5% for the in vitro venous thromboses was obtained.

[Antiretroviral therapy and cardiovascular risk]. / Traitement antirétroviral et risque cardio-vasculaire.

Current antiretroviral therapy protocols enable long-term survival of HIV-infected patients, decreasing the risk of infectious complications. Three classes of anti-HIV treatments are available. With longer survival, unusual cardiovascular complications related to iatrogenic biological anomalies (dyslipidemia and impaired glucose tolerance) have appeared among this young population which is exposed to usual risk factors of atherosclerosis. Antiretroviral therapies are suspected to cause these complications, inducing maturity-onset diabetes in 4 to 20% of patients, impaired glucose tolerance in 15 to 60%, hypertriglyceridemia in 15 to 74% depending on the survey, and hypercholesterolemia in 20 to 60%, especially in case of associated lipodystrophia. A lipid battery including total cholesterol, HDL, and triglycerides, and 12-h fasting blood glucose should be obtained before initiating antiretroviral therapy. Any anomalous finding should be followed carefully with regular surveillance every 3 to 6 months and search for other causes of secondary dyslipidemia. In the event of casual and persisting elevation of LDL-cholesterol levels, a statin treatment can be introduced. For secondary prevention, irrespective of the context, recommendations currently merge with the consensus applying to the general population. These patients require careful surveillance of cardiovascular risk factors and a specific care in addition to treatment of their immunodeficiency.

[Vascular resistances in lower limb arterial disease used to evaluate the quality of peripheral arteries. Preliminary study]. / Apport de la mesure des résistances périphériques dans l'évaluation du lit d'aval jambier chez l'artériopathe. Etude préliminaire de faisabilité.

UNLABELLED: Peripheral resistance of lower limb arteries is not a common clinical measurement despite easy-to-apply non-invasive techniques. The aim of our trial has been to test this new parameter as a marker of arterial lesions. MATERIAL AND METHODS: In this prospective study, hemodynamic data acquired non-invasively [Ankle brachial index (ABI), peak systolic velocity (PSV), end-diastole velocity (VTD) and peripheral artery quality] in patients with lower limb arterial disease were compared with the resistance index measured in the common femoral artery (Arbeille index: IR=VTD/PSV). RESULTS: Between February 1, 2003 and April 30, 2003, 150 measurements of resistance index were made in 99 individuals with ischemia following a strain (69% men, 31% women, average age 64.8+/-15.2 years). Forty-one of the resistance measurements (27%) were also made in patients with arterial disease factors (diabetics, renal replacement therapy). The resistance index was closely associated with end-diastole velocity. (r=-0.76; DDL=148; p<0.01) as well as peripheral artery quality (r=0.81; DDL=148; p<0.01); on the contrary the resistance index was not affected by the arterial disease factors (0.3+/-0.1 vs 0.33+/-0.12; p=NS). CONCLUSION: These findings suggest that the hemodynamic impact might be evaluated more precisely diabetics and renal replacement therapy patients whose hemodynamic parameters are difficult to assess due to their arterial disease factors. Prospective studies are needed to determine the role of the resistance index in the follow up of these patients, and its contribution in comparison with the measurement of end-diastole velocity.

[Drug addiction and cardiovascular pathologies]. / Toxicomanie et pathologies cardiovasculaires.

Drug addiction which entails cardiovascular risks unknown or misknown to physicians, currently involves an increasing number of miscellaneous drugs, existing in manifold forms. There appears to be no bounds on the way of intake. All territories of the body may be affected with more or less severity. In young people, the cardiac, coronary, cerebral and peripheral vascular systems are generally involved. Two illicit drugs, cannabis and cocaine, showing a permanent increase in misuse, prevail. This drug addiction comes along with intercurrent pathologies which have their own vascular toxicity, especially HIV infection. Moreover, the advent of new illicit substances emphasizes the complexity of the clinical presentations. These complex situations have a real social and medical impact. We are currently in a phase of permanently increasing risk of cardiovascular complications. The pathophysiological mechanisms involved are intertwined and complicated by the frequent association of polytoxicomania or by the effects excipients added to these drugs: direct vascular toxicity, angeitis, arterial and venous thrombosis. Arsenic, a common component of these drugs, is also found in cigarettes; arsenic toxicity mainly affects the lower limbs. Treatment of these complications is non-specific; the ideal solution being weaning which, unfortunately in this peculiar population of patients, may entail serious complications due to the misuse of substitution products.

Diagnostic accuracy of compression ultrasonography for the detection of asymptomatic deep venous thrombosis in medical patients--the TADEUS project.

We assessed the accuracy of venous compression ultrasonography (CUS) for the detection of asymptomatic deep vein thrombosis in 122 consecutive patients, with a mean age of 69 years, who were hospitalised in an internal medicine unit. All included patients had CUS within 48 h of admission. Twelve out of 17 patients with a positive CUS underwent phlebography, as the others withdrew their consent, whereas the remaining 105 patients with a negative serial CUS testing were clinically followed-up at 3 months. We found that CUS had a sensitivity and a specificity of respectively 1 (95% CI, 0.73 to 1) and 1 (95% CI, 0.96 to 1) for the detection of asymptomatic deep vein thrombosis. Kappa-coefficients for intra-observer and inter-observer agreements were respectively 0.88 and 0.56. We concluded that venous compression ultrasonography, performed as described, fulfils requirements of a screening test that could be available for prophylactic clinical trials or epidemiological researches.

[Three-dimensional reconstruction calibrated with ultrasonographic images. Application to the measurement of clot volume in vitro]. / Reconstruction tridimensionnelle calibrée à partir d'images ultrasonographiques. Applications à la mesure volumique des caillots in vitro.

OBJECTIVE: We used 3D ultrasonographic reconstruction with manual acquisition to study the volume of venous clots in vitro. MATERIAL AND METHODS: Native 2D ultrasound slices were acquired free hand for 3D reconstruction. The spatial coordinates of each slice were delivered in real time with an electromagnetic captor. We applied a standard ultrasound protocol to test the calibrated 3D reconstruction quantitatively. The volume of 5 clots of increasing size was quantified in vitro using manual segmentation in a double-blind manner by two independent operators. RESULTS: The comparison tests and the interoperator regression lines evidenced good agreement between real and measured volumes, confirming the coherence of the reconstruction protocol and the feasibility of this technique in a routine medical setting. Intraoperator variability was 7 to 11% and interoperator variability 16.9%. CONCLUSION: This calibrated 3D reconstruction is compatible with in vitro measurement of venous clots. This technique could be useful to follow the evolution of the head of proximal deep vein thrombi in vivo. It will be more reliable with semi-automatic or even automatic segmentation becomes available.

Methylenetetrahydrofolate reductase C677T genotype and venous thromboembolic disease.

BACKGROUND: Many studies have suggested an increased risk of venous thromboembolism (VTE) in patients with mild hyperhomocysteinemia. The C677T mutation in the MTHFR gene has recently been described as a cause of mild hyperhomocysteinemia. OBJECTIVES: To investigate the potential of the C677T mutation in the MTHFR gene in its homozygous state as a risk factor for VTE. METHODS: Case-control study design. The presence of the mutation was determined in all consecutive patients referred from July 1994 to September 1997 and in whom the diagnosis was duly confirmed. Analysis was carried out in a subgroup of VTE patients free from both acquired and genetic risk factors (factor-V mutation and/or prothrombin gene mutation). A control group consisted of 105 volunteer blood donors. RESULTS: In the 366 patients with a confirmed VTE, 253 presented acquired risk factors and 58 were carriers of the factor-V Leiden mutation and/or G20210A mutation of the prothrombin gene. In the remaining 55 patients, VTE was considered as 'unexplained', and the frequency of the C677T mutation MTHFR was 21.8% in its homozygous state and 34.5% in its heterozygous state. In the control group, 9.5% were found homozygous and 34.3% heterozygous. The odds ratio for having VTE in the presence of the mutation in its homozygous state was 2.9 (95% CI 1. 0-8.6). CONCLUSION: This study suggests that the homozygous C677T mutation in the MTHFR gene might be a risk factor of VTE in patients with spontaneous events and without other common genetic risk factors.

[Calf muscle venous thrombosis and pulmonary embolism]. / Thrombose veineuse musculaire du mollet et embolie pulmonaire.

INTRODUCTION: The clinical significance of calf muscle venous thrombosis (CMVT) still remains a matter of debate. Detected by ultrasonography, they are overlooked by venography. This prompted us to evaluate the frequency of such localizations and their association to pulmonary embolism (PE). METHODS: Retrospective review of our database over a three-year period. All patients with an isolated CMVT were included. RESULTS: Isolated CMVT were detected in 106 patients (mean age 68.6 years; 65% women), that is 12.5% of all venous thromboses diagnosed in the vascular sonography unit over the study period Sixteen associated PE were detected (15%). CONCLUSIONS: Association of CMVT and PE is not infrequent. Whether or not such thromboses have the potential to extend into deep veins and/or to migrate into pulmonary circulation requires further studies.

[What investigations should be done following the first episode of pulmonary embolism?]. / Quel bilan réaliser au décours d'un premier épisode d'embolie pulmonaire?

Thromboembolic venous disease is both common and potentially serious, thus the first episode of pulmonary embolus calls for careful assessment. This involves two stages: a search for a venous localization of the pulmonary embolus and a search for risk factors contributing to thromboembolic venous disease. The emergence of non-invasive echographic-Doppler techniques and echocardiography make possible the localization of any residual venous thrombus. The risk of post thrombotic disease is raised in symptomatic thrombotic venous disease which requires wearing elastic stockings for a least two years. On the other hand this risk has not been assessed in asymptomatic cases of venous thrombosis. A search for risk factors requires a detailed history, a rigorous clinical examination and a routine list of laboratory investigations. Some complex investigations for detecting the early stages of a neoplasm would not appear justified unless there is objective evidence to support his. At the same time thrombophilia studies are not currently performed routinely for a first episode but may be suggested in the following cases: family history of thromboembolic venous disease, age less than 45, including those in whom the episode occurs at the same time as pregnancy, or whilst taking hormone therapy, idiopathic thromboembolism, the association of arterial and venous thrombi and finally venous thromboses occurring in an unusual anatomical site. Prospective studies have shown the value of long term anticoagulation in patients suffering from constitutional hemostatic anomalies. Finally, if there is an after thought of occult cancer or constitutional thrombocytopenia a careful follow up should be performed particularly during the first year.

[Pulmonary embolism and unusual deep venous thrombosis. Report of two cases]. / Embolies pulmonaires et thromboses veineuses profondes inhabituelles. A propos de deux observations.

Contrast venography is the gold standard for the diagnosis of deep vein thrombosis in the lower limb extremities, but it fails to visualize deep veins like deep femoral vein and internal iliac vein. The internal iliac can be examined with duplex scanning if the technique and the examination conditions are correct. As reported in these two cases, thrombosis of these deep veins may lead to pulmonary embolism. The first case is a young female with venous thromboembolic disease in whom internal iliac vein thrombosis was documented only at the second examination. In the second case, deep femoral vein thrombosis appeared early in a comatose young male. This thrombosis may be classified as proximal muscular vein thrombosis. These two cases emphasize the importance of a duplex scanning examination performed with rigorous technique, whose the main limitation being examination conditions.

Iliac aneurysm in a child complicating umbilical artery catheterization.

We report a case of an iliac artery aneurysm in a 9-year-old girl due to Staphylococcus aureus infection of an umbilical arterial catheter inserted at birth. After resection-anastomosis of the iliac artery the postoperative course was uneventful and hemodynamic data remain normal at 2 years. A review of the literature indicates that the prognosis of infective aortoiliac aneurysm is poor in children, except when the aneurysm is located solely in the iliac artery. Arterial continuity should be restored as late as possible after infection using a technique consistent with normal growth of the artery in the child.

Reliability of low-frequency auditory stimulation studies associated with technetium-99m hexamethylpropylene amine oxime single-photon emission tomography.

Development of auditory stimulation tests associated with single-photon emission tomography (SPET) shows evidence of variations in perfusion related to the stimuli. Three brain SPET examinations with technetium-99m hexamethylpropylene amine oxime were performed on eight right-handed adults with normal hearing, the first one without stimulation and the other two associated with a 500-Hz/30-dB stimulation of the right ear. Temporal regions of interest covering auditory areas, as well as parietal ones (internal control), were drawn on three successive coronal slices. A cortico-cerebellar index R was calculated, and the variation in activity was defined for each subject using the ratio R poststimulation--R prestimulation/R prestimulation. A significant increase in the temporal cortex count occurred in all subjects. This increase was bilateral, except for one subject in whom it was not significant on the right side. This result recurred during the second stimulation study. Overall the response of the left temporal cortex was stronger, although the asymmetry was not significant. The asymmetry repeated itself after each stimulation. The perfusion response is globally reliable in our study. We must ascertain how sensitive this test is with regard to deaf adults and adults with normal hearing before extending its use to children.