[Necrotic leg ulcers after topical application of chlormethine]. / Ulcères de jambe nécrotiques après application locale de chlorméthine.

BACKGROUND: Topical chlormethine has been widely used in the early stages of mycosis fungoides for many years. Cutaneous reactions (skin irritation and itch) are the most frequent adverse effects. Herein we report a rare side effect: severe necrotic leg ulcers. PATIENTS AND METHODS: An 82-year-old woman with a history of high blood pressure developed hyperalgesic necrotic ulcers on the lower limbs following local trauma one month after initiation of topical chlormethine (Valchlor®) to treat mycosis fungoides. Aetiological examination showed moderate peripheral arterial disease which, while constituting an aggravating factor, did not account fully for these skin ulcers. Moreover, drug-induced ulcer was suspected on account of the chronology. Dermal corticoids and topical treatment were prescribed in place of chlormethine and led to a favourable outcome. CONCLUSION: Incrimination of chlormethine was based on the chronological and semiological criteria. This is the first published case of leg ulceration induced by Valchlor®.

Evaluation of the ankle brachial index and toe brachial index for peripheral arterial disease diagnosis in patients over 70 years with lower limb ulcers.

OBJECTIVE: The aim of our study was to evaluate the diagnostic performance of the ankle brachial index using pulsed Doppler, and the toe brachial index using laser Doppler, in comparison with the arterial Doppler ultrasound of the lower limbs as a reference test, in a population of non-diabetic subjects over 70 years old with lower limb ulcers and without chronic renal failure. METHODS: We included 50 patients, 100 lower limbs from the vascular medicine department of the Paris Saint-Joseph hospital from December 2019 to May 2021. RESULTS: We found a sensitivity of 54.5% for the ankle brachial index and a specificity of 67.6%. Regarding the toe brachial index, the sensitivity was 80.3% and the specificity 44.1%. We could explain the low sensitivity of the ankle brachial index in our population by the mediacalcosis of elderly subjects, avoidable with the measurement of the toe blood pressure index, which had a better sensitivity. CONCLUSION: In a population of subjects over 70 years of age with a lower limb ulcer, without diabetes and without chronic renal failure, it would seem judicious to use the ankle brachial index in association with the toe brachial index for the diagnosis of peripheral arterial disease, followed by an arterial Doppler ultrasound of the lower limbs in order to evaluate the lesion profile of patients with a result of less than 0.7 of toe brachial index.

Amputation-free survival in the long-term follow-up and gender-related characteristics in patients revascularized for critical limb ischemia.

OBJECTIVE: Patients with Critical Limb Ischemia (CLI) present a high risk of cardiovascular events and death. Revascularization is the cornerstone of therapy to relieve ischemic pain and prevent limb loss. Literature data suggest that women tend to present with worse outcomes after revascularization. The aim of the present study is to determine amputation-free survival in a long-term follow-up in women and men following endovascular revascularization procedure for CLI. METHODS: From November 2013 to December 2020, 357 consecutive patients were retrospectively included. Clinical and biological parameters were recorded at baseline before endovascular revascularization. During follow-up until February 2023, overall survival and amputation-free survival (freedom from major amputation) were analysed using the Kaplan-Meier method. Univariate and multivariate analyses were performed to study the parameters associated with amputation-free survival. A P<0.05 was considered as statistically significant. RESULTS: A total of 357 consecutive patients were included, 189 men and 168 women with CLI, with a mean age of 78.6±12 years. Treated hypertension (79%), diabetes mellitus (48%), coronary artery disease (39%) and protein malnutrition (61%) were the most prevalent comorbidities. Women were older than men with a mean age of 82.4±11.4 years (versus 75.4±11 years in men) and presented more frequently with protein malnutrition (70% of women). Prevalence of diabetes, tobacco use and history of coronary heart disease were significantly higher in men. During the 10-year follow-up period, 241 patients had died (68%) and 38 (11%) underwent major amputation, of whom 22 patients were still alive on February 2023. Median survival was 35.5 months [IQR: 29.5; 43] in the overall population, 38.5 [32; 50.4] months in women and 33.5 months [24.7; 43.5] in men. No gender-related differences were noted according to peri-procedural complications, survival probability and amputation-free survival. In multivariate analysis for amputation-free survival, age, previous coronary heart disease, C-reactive protein level, left ventricular ejection fraction (LVEF)<60% and albumin level<35g/L were correlated with poor outcome. In particular, protein malnutrition, as a treatable risk factor, appears significantly correlated with poor outcome in both men and women (HR=2.50 [1.16;5.38], P=0.0196 in men; HR=1.77 [1.00;3.13], P=0.049 in women). CONCLUSION: The present results highlight that mortality in patients after endovascular revascularization remains high with a mortality rate of 28% at 1 year, 40% at 2 years and 51% at 3 years. Women represented a distinct population, almost 10-year older than their male counterparts, with more prevalent protein malnutrition. However, no gender-related difference was noted according to amputation-free survival on the long-term follow-up. Associated risk factors are mainly age, a history of coronary heart disease, pre-procedural inflammatory syndrome and protein malnutrition. Correction of malnutrition could have the potential to improve functional and general long-term prognosis in patients with CLI together with optimal medical and interventional management.

Specific management of lipodermatosclerosis (sclerotic hypodermitis) in acute and chronic phase.

Lipodermatosclerosis or sclerotic hypodermitis is presented as a complication of venous insufficiency and in particular of post-thrombotic syndrome with a high risk of progression to leg ulcers. However, it has also been described in obese patients without venous insufficiency, and even in the course of various systemic diseases including scleroderma. It most often affects middle-aged women and is usually bilateral, with a typically "inverted champagne bottle" leg appearance. The pathogenic role of venous hypertension explains why compression with bands or stockings is the basis of treatment. In acute phase, which may precede or complicate chronic forms, the pain is so severe that compression is not tolerated. In acute phase, non-steroidal anti-inflammatory drugs, intra-lesional use of triamcinolone, and capsaicin transdermal patches indicated for neuropathic pain have been proposed. In chronic forms, the treatment of superficial venous insufficiency and/or incontinent perforating veins, documented during a Duplex ultrasound scan, is usually proposed, whenever possible. In association with elastic compression, pentoxifylline and colchicine have been used without clear evidence of clinical efficacy. Finally, in the most advanced clinical presentation with the appearance of a sclerotic gaiter associated with ulcerations, surgical treatment with excision-cutaneous grafting associated or not with perforating veins ligation and a fasciotomy may be discussed as a last resort for treatment.

Incident cardiovascular events and early mortality in patients with revascularized critical limb ischemia.

OBJECTIVES: Patients with critical limb ischemia (CLI) present a high risk of cardiovascular events and death. This study aimed to investigate the incidence of major adverse cardiovascular events (MACE) and one-year mortality in patients undergoing percutaneous revascularization procedure for CLI. METHODS: This investigation is a retrospective analysis of an ongoing cohort study in patients with CLI undergoing endovascular revascularization, hospitalized in the vascular medicine department from November 2013 to December 2018. Major cardiovascular events were collected during the first year after revascularization procedure and were defined as heart failure, acute coronary syndrome, ischemic stroke and sudden death. Mortality and major limb amputations, defined as above-the-ankle amputation, were determined during the one-year follow-up period. Multivariate logistic regression analyses were performed to identify factors independently associated with the occurrence of MACE and one-year mortality after revascularization procedure. A P≤0.05 was considered as statistically significant. RESULTS: The study included 285 consecutive patients, 157 men (55%) and 128 women (45%), with a mean age of 77.8±12 years. Treated hypertension was present in 222 (78%) patients; diabetes was present in 137 (48%) patients; 112 (39%) patients had known coronary heart disease and 20 (7%) patients were dialysis dependent. During the one-year follow-up after revascularization procedure, 75 (26.3%) patients presented an incident cardiovascular event, of whom 19 (6.7%) patients in the perioperative period. Cumulative mortality rate was 26.7% (76 patients) mostly from cardiovascular causes. Twenty-five patients (8.8%) experienced major amputation. In multivariate analysis, the occurrence of MACE was associated with an increased mortality risk (HR 6.96 (2.99-16.94), P<0.001). Other variables associated with an increased mortality were living in a nursing home and malnutrition. Decompensated heart failure and coronary heart disease were both associated with incident MACE in multivariate analysis, independently of confounders. CONCLUSION: In the present study population, incident MACE were prevalent in the year following endovascular revascularization procedure in patients with CLI and were associated with an increased risk of mortality. Coronary heart disease and decompensated heart failure are important contributors for the occurrence of MACE. In this elderly patient population with CLI, these results should be taken into account during the multidisciplinary team meeting before consideration of revascularization procedure.

Hormone-dependent gynaecological disorders and contraceptive modalities in women with a history of venous thromboembolic event: The THROMBOGYN study.

CONTEXT: Hormone-dependent gynaecological disorders, such as polycystic ovary syndrome (PCOS) or endometriosis, have been recently discussed as potential risk factors for venous thromboembolism (VTE). Combined hormonal contraceptive (CHC) therapy, which is a well-known risk factor for VTE, is usually used to alleviate symptoms related to these gynaecological disorders. Nevertheless, prevalence of hormone-dependent gynaecological disorders at the time of VTE event and the management of hormonal contraceptives are not well known. OBJECTIVE: To assess retrospectively the prevalence of hormone-dependent gynaecological disorders in patients with VTE event and the hormonal therapy at the time of VTE event and at the time of inclusion in the present study. METHODS: Women aged between 18 to 50-year-old who were hospitalized at Saint-Joseph Hospital (Paris) for a VTE event from January 1st, 2016 to December 31st, 2020 were included in this retrospective observational study. RESULTS: In total, 125 women were included. At the time of VTE event, mean age was 39-years-old (±8) and mean body mass index (BMI) 26kg/m2 (±8). Pulmonary embolism represented more than two third (68%) of VTE events. Fourteen women (11%) had PCOS and among them, 6 (43%) were using CHC. Eleven women (9%) had endometriosis and among them, 1 (9%) was using CHC. Women with PCOS appeared to be younger at the time of VTE compared to non-PCOS women (mean age 32 years (±6.0) vs. 40 years (±8.0), respectively, P<0.001), whereas women with endometriosis were older with a mean age of 43-year-old (±7.8), which did not differ significantly from women without endometriosis. Among PCOS women, 1 (7%) VTE event was idiopathic, whereas among those with endometriosis, 5 (46%) VTE events were idiopathic. Regarding contraceptive use at the time of inclusion, with a mean delay between VTE event and inclusion of 3 years (±1), 1 woman pursued CHC, 35 (28%) used non-hormonal contraceptive. Seventy-three women (58%) were aware of hormonal contraindications due to VTE event. CONCLUSION: The present study, including 125 young women with a mean age of 39 years, allowed a description of gynecological pathologies and history of contraceptive use potentially involved in VTE events.

Peri-procedural complications following endovascular revascularization for critical limb ischemia.

OBJECTIVE: Revascularization procedures are considered the cornerstone of therapy in patients with critical limb ischemia (CLI) and multiple procedures are often required to attain limb salvage. The aim of the present study is to determine the prevalence of peri-procedural complications after endovascular procedure, and to determine the clinical and biological characteristics of patients associated to the risk of peri-procedural complications. METHODS: From November 2013 to May 2021, 324 consecutive patients were retrospectively included, of whom 99 underwent more than one revascularization procedure for contralateral CLI or clinical recurrence of CLI. A total of 532 revascularizations were performed. Clinical and biological parameters were recorded at baseline before endovascular revascularization. The occurrence of a peri-procedural complication (local complications, fatal and non-fatal major bleeding or cardiovascular events) was recorded up to 30days after revascularization. Univariate and multivariate analyses were performed to study the parameters associated with per-procedural complications. A P<0.05 was considered as statistically significant. RESULTS: A total of 324 consecutive patients were included, 177 men and 147 women with CLI, with a mean age of 77.6±11.9years. Most of these patients had cardiovascular comorbidities (41% with a history of coronary heart disease, 78% treated hypertensive patients, 49% diabetic patients). Peri-procedural mortality occurred in 13 patients (4%) and 9 patients (2.8%) experienced major amputation at one-month following revascularization. Among the 532 revascularization procedures, 99 major bleeding events (22.8% of the cohort population) and 31 cardiovascular events (8.6% of the cohort population), were recorded in the peri-procedural period. Cardiovascular events were associated with peri-procedural mortality. Complications at the puncture site occurred during 38 of the 532 procedures (10.2% of the cohort population). Compared with patients undergoing a single revascularization procedure, patients with multiple procedures presented a higher risk of major bleeding events (48.5% vs. 11.6%, P<0.0001) and access site complications (20.2% vs. 5.78%, P<0.0001). In multivariate analysis, pulse pressure <60mmHg and hemoglobin level <10g/dl were correlated with the occurrence of major bleeding events; left ventricular ejection fraction<60% and the absence of statin treatment were correlated with the occurrence of cardiovascular complications; a high chronological rank of revascularization was correlated with the occurrence of local complication. Finally, age and gender were not associated with the occurrence of peri-procedural complication. CONCLUSION: The present results highlight that multiple revascularization procedures for limb salvage are required in almost one third of the population with critical limb ischemia and were associated with the risk of major bleeding events and access site complications. The most frequent complications of peripheral vascular interventions were major bleeding events. Adverse cardiovascular events were related with peri-procedural mortality. Anemia, blood pressure, left ventricular ejection fraction and statin treatment are important parameters to consider for peri-procedural outcomes, independently of age, gender and the chronological rank of revascularization procedure.

Prevalence and management of antivitamin K overdose in a hospital setting.

INTRODUCTION: Vitamin K antagonist (VKA) related adverse events are the first cause for iatrogenic events in France, particularly due to the narrow therapeutic margin. The risk of bleeding increases significantly when the INR level is ≥5. The main objective of this study was to assess the prevalence of VKA overdose in a hospital setting (at D2 of hospital entry) and to evaluate physicians' adherence to clinical practice guidelines for the management of VKA overdose according to French National Authority for Health recommendations. METHODS: This single-center retrospective observational study consisted in querying the computerized database of a Parisian hospital on 21275INR determinations (3995 patients, 6813 hospital stays) performed between 2013 and 2018. RESULTS: An INR level ≥5 was noted during 350 (6%) of the hospital stays, in 331 patients (of whom 57% were women). The mean age of the patient population with an INR≥5 was 81.1 years. Infection, heart failure and renal failure were the most frequent acute medical conditions for hospital admission. Twenty-three patients (7%) had a bleeding complication, 11 of which were major bleeding complications. Older age was associated with the severity of bleeding complications. Fifteen in-hospital deaths (4%) were reported, not related to bleeding events. The management of VKA overdose did not comply with the recommendations in 43% of cases, in particular for the highest INRs (50% of noncompliance for an INR>6.4). Non-compliance with recommendations for VKA overdose was related to: the delay until the INR was checked (44% of cases); the indication for prescribing vitamin K (34% of cases); the dose or route of administration of vitamin K therapy (19% of cases); and the interruption or not of VKA therapy (12% of cases). CONCLUSION: The management of VKA overdose in a hospital setting remains non-compliant with the recommendations in almost half of the cases, mainly due to the delayed INR control and inappropriate management of vitamin K therapy. Computerized alert system would be helpful for personalized patient management and improved pharmacovigilance to prevent iatrogenic VKA events.

Characteristics and outcomes of octogenarians with revascularized critical limb ischemia: Impact of altered cardiac function for early mortality.

OBJECTIVE: Patients with critical limb ischemia (CLI) present with advanced age and end-stage organ damage, in particular heart failure. The aim of the present study is to describe clinical and biological characteristics in octogenarian patients with CLI compared to their younger counterparts and to determine the peri-procedural risk and early mortality after endovascular procedure. METHODS: From November 2013 to May 2019, 315 consecutive patients were retrospectively included. Clinical and biological parameters were recorded at baseline before endovascular revascularization. The main outcome was total 1-year mortality. RESULTS: The study included 170 octogenarians and 145 non-octogenarians. The mean age of octogenarian patients was 86.9±4.8 years, almost 20 years higher than that registered in non-octagenarians patients (67.4±8.6 years). Octogenarian patients were mostly women (59.4%), presented with lower body mass index (23.8±4.4kg/m2), lower serum albumin level (31.5±5.4g/L) and lower creatinine clearance (66.1±24.5mL/mn) than younger counterparts. They were more likely to be institutionalized in a nursing home (27.1%). In the peri-procedural period, major bleeding occurred in 40 patients (12.7%), without statistical significance between the two age groups. Peri-procedural mortality occurred in 12 patients (3.8%), of whom 10 patients (83%) were octogenarians. Cumulative mortality rate was 25.4% (80 patients) during the one-year follow-up period: 58 octogenarians died (34.1%) compared to 22 non-octogenarian patients (15.2%), P<0.001. Cardiovascular events were highly prevalent, accounting for 40% of overall mortality. Twenty-five patients (8%) experienced major amputation, without significant difference between the two age groups. In octogenarian population, institutionalized status (P=0.004) and BNP level (P=0.001) were positively correlated with mortality whereas systolic blood pressure (P<0.001), left ventricular ejection fraction (P=0.003), serum albumin (P=0.020), C-Reactive protein (P=0.020) and renin-angiotensin system inhibitors at hospital discharge were negatively correlated with mortality. In multivariate analysis for mortality, only BNP level≥500pg/mL (HR 3.27; 95% CI 1.04-10.97; P=0.04), was correlated with mortality, independently of other confounders. CONCLUSION: In the present study population, octogenarians represent a rather distinct CLI population, 20 years of age older as compared to non-octogenarians, with prevalent malnutrition and institutionalized status. The present results underline a substantial one-year mortality rate of 34.1% in this elderly population following revascularization procedure with a 6% peri-procedural mortality. Decompensated heart failure is an important contributor for mortality.

Foot ischemia related to essential thrombocytemia and atherosclerosis.

We report two cases of foot ischemia combining microvascular thrombosis related to essential thrombocytemia (ET) and a proximal ulcerating atherosclerotic plaque. This suggests that myeloproliferative neoplasms could also trigger distal embolism from an unstable atherosclerotic plaque by creating a prothrombotic status. These distal ischemic events were the first ET manifestation and therefore lead to myeloproliferative neoplasm diagnosis. In ET, thrombosis event can occur with a normal platelet count. Furthermore, hemogram should be regularly controlled among JAK2 muted patients considering the frequent evolution from isolated JAK2 mutation to ET.

Patients with atherosclerotic peripheral arterial disease have a high risk of lung cancer: Systematic review and meta-analysis of literature.

PURPOSE: Lung cancer and atherosclerosis share common risk factors. Literature data suggest that the prevalence of lung malignancy in patients with peripheral arterial disease (PAD) is higher than in the general population. Our goal was to determine, through a systematic literature review, the prevalence of lung cancer in patients with PAD. METHODS: We consulted available publications in the Cochrane library, MEDLINE, PUBMED, EMBASE, and ClinicalTrials.gov. We included all articles, written in English or French, published between 1990 and 2020 reporting the prevalence of lung cancer in patients with PAD (atherosclerotic aortic aneurysm or peripheral occlusive diseases). Patients with coronary artery disease, cardiac valvulopathy or carotid stenosis were not included. We did not include case reports. We performed a critical analysis of each article. Data were collected from two independent readers. A fixed effect model meta-analysis allowed to estimate a summary prevalence rate. RESULTS: We identified 303 articles, and selected 19 articles according to selection criteria. A total of 16849 patients were included (mean age 68.3 years, 75.1% of males). Aortic aneurysms were found in 29% of patients and atherosclerotic occlusive disease in 66% of patients. Lung cancer was identified in 538 patients, representing a prevalence of 3%. DISCUSSION: Lung cancer is found in 3% of patients with atherosclerotic PAD. This prevalence is higher than that found in lung cancer screening programs performed in the general population of smokers and former smokers. These patients should be screened for lung cancer. Their selection may dramatically increase the benefit of lung cancer screening.

Innovative endovascular approach for limb salvage in critical limb ischemia.

In the absence of feasible revascularization, nearly one third of patients with critical limb ischemia experienced major amputation at 6 months. In patients with an independent living status, this decision is difficult to support without exhausting all chances to attain limb salvage and preserve functional autonomy. The present report describes a new procedure of revascularization by performing a full endovascular extra-anatomic femoropopliteal bypass for the treatment of limb-threatening ischemia. The patient presented with extensive tissue loss and a short-term risk of major amputation. She had experienced previous failure of conventional surgical and endovascular revascularization procedures and ligation of proximal femoral artery precluded any further revascularization attempt. Limb salvage was achieved with this endovascular revascularization procedure with complete wound closure. The patient still presents an independent living status and preserved functional autonomy without wound recurrence after a follow-up of more than 5 years.

Peripheral arterial disease and isolated systolic hypertension: the ATTEST study.

Hypertension is a risk factor for cardiovascular (CV) diseases, either coronary artery disease (CAD), peripheral artery disease (PAD) or cerebrovascular disease (CVD). The relationships between those different localizations of CV disease and the haemodynamic features of hypertension have been poorly evaluated in the past. In the ATTEST study, a geographically representative panel of 3020 general practitioners recruited 8316 consecutive patients with CV diseases (PAD, CAD or CVD, alone or in association). Blood pressure, which was not an inclusion criterion, was then measured and related to the different forms of CV diseases. Blood pressure classification involved 20% normotensive subjects, 24% subjects with controlled hypertension, 42% subjects with isolated systolic hypertension and 14% subjects with systolic-diastolic hypertension, all hypertensives with or without antihypertensive therapy. From multiple regression analysis, it appeared that subjects with systolic hypertension were characterized by the presence of PAD, with little or no presence of CAD and/or CVD. Subjects with systolic-diastolic hypertension were characterized by the presence of CAD and/or CVD, but without PAD. Although the former was only influenced by age, dyslipidaemia and diabetes mellitus influenced the latter. This study confirms the high prevalence of hypertension (80%) in a large population of patients with CV diseases selected in primary care. Analysis of different features of hypertension revealed that isolated systolic hypertension was the most prevalent form of hypertension in this treated population. Finally, one of the predominant goals of secondary prevention in subjects with PAD should be the treatment of isolated systolic hypertension.

Prevalence of peripheral arterial disease in high-risk patients using ankle-brachial index in general practice: a cross-sectional study.

AIMS: The deleterious nature of peripheral arterial disease (PAD) is compounded by a status of underdiagnosed and undertreated disease. We evaluated the prevalence and predictive factors of PAD in high-risk patients using the ankle-brachial index (ABI). METHODS: The ABI was measured by general practitioners in France (May 2005-February 2006) in 5679 adults aged 55 years or older and considered at high risk. The primary outcome was prevalence of PAD (ABI strictly below 0.90). RESULTS: In all, 21.3% patients had signs or symptoms suggestive of PAD, 42.1% had previous history of atherothrombotic disease and 36.6% had two or more cardiovascular risk factors. Prevalence of PAD was 27.8% overall, ranging from 10.4% in patients with cardiovascular risk factors only to approximately 38% in each other subgroup. Prevalence differed depending on the localization of atherothrombotic events: it was 57.1-75.0% in patients with past history of symptomatic PAD; 24.6-31.1% in those who had experienced cerebrovascular and/or coronary events. Regarding the classical cardiovascular risk factors, PAD was more frequent when smoking and hypercholesterolemia history were reported. PAD prevalence was also higher in patients with history of abdominal aortic aneurysm, renal hypertension or atherothrombotic event. Intermittent claudication, lack of one pulse in the lower limbs, smoking, diabetes and renovascular hypertension were the main factors predictive of low ABI. CONCLUSIONS: Given the elevated prevalence of PAD in high-risk patients and easiness of diagnosis using ABI in primary care, undoubtedly better awareness would help preserve individual cardiovascular health and achieve public health goals.

[Ease of use, feasibility and performance of ankle arm index measurement in patients with chronic leg ulcers. Study of 100 consecutive patients]. / Mesure de l'index de pression artérielle systolique à la cheville chez un patient porteur d'un ulcère de jambe. Faisabilité et performance chez 100 patients consécutifs hospitalisés dans un service spécialisé

International guidelines on leg ulcers recommend measuring the ankle arm index (AAI) to diagnose and assess peripheral arterial occlusive disease (PAOD) of the lower limbs. These guidelines do not, however, describe the method which should be used to make the measurement: which artery should be measured -in the event of an open leg ulcer, what are the practical difficulties for positioning the cuff- how well do patients tolerate the procedure? We conducted a prospective study focusing on ease of use, tolerance and performance of AAI measurements in patients with leg ulcers. In compliance with recent French guidelines, we measured the AAI for both distal leg arteries and retained the lowest value for analysis. Within a six-month study period, 100 consecutive inpatients with leg ulcers of various etiologies were studied. Mean age was 75, female predominance 60%, body mass index 27. Etiologies of leg ulcers were pure venous (29%), mixed venous predominant (17%), pure arterial (9%), mixed arterial predominant (8%), mixed (6%), hypertensive ulcers (11%), rare cause (8%), multifactorial (12%). Pain was present in 92%, with a VAS above 3 for 73%. Measurement of AAI was possible in 98% of patients. It was too painful and thus considered unethical for two patients with hypertensive ulcers. For the 98 patients measured, the ulcer had to be protected during the measurement in 76%. The measurement procedure only took five minutes for one leg, and was judged easy to perform by 93% of the operators. For the majority (76%) of patients, the measurement was not painful. We determined the diagnostic performance of AAI by comparing the results with those of arterial ultrasound in 90 patients who had a complete arterial ultrasound exploration of the legs. Compared with arterial ultrasound, the sensitivity of AAI<0.9 for detecting the presence of PAOD was 84.7%, with 97% specificity. PAOD was not diagnosed in any patient who had two palpable distal pulses and a normal AAI. Measurement of AAI in patients with leg ulcers is an easy to use, well-tolerated, high-performance tool for the assessment of PAOD.

[Advance directives in hospital practice: A matter of concern for every healthcare professional and consumer]. / Les directives anticipées à l'hôpital : l'affaire de tous ?

INTRODUCTION: In France, Leonetti and Claeys-Leonetti laws relating to patients' rights and end-of-life practice have introduced the advance healthcare directives (ADs). Although family doctor's role is important in initiating discussions regarding AD, hospital healthcare professionals should also be concerned by the health care planning laws. METHODS: A descriptive, quantitative and qualitative study was conducted in Paris Saint-Joseph hospital to evaluate the knowledge of nursing personnel regarding ADs. Among healthcare professionals present on 02/06/2016 and agreeing to participate, 50 non-medical caregivers and 50 doctors were randomly selected and took part in this survey. Three trainee lawyers conducted interviews, recorded and anonymized them. The Nvivo software analyzed the qualitative part of the results. RESULTS: Only 10% of healthcare professionals knew these legal and ethical issues in health care. Most caregivers were not in favor of informing all patients admitted to a hospital (hospitalized patients or patients received consultations). For 44%, only hospitalized end-of-life patients should be informed about ADs. For 76% of the people questioned, family doctor has a unique position to guide the patient on the preparation and registration of living wills. In hospital stay, the nurse was proposed by 52% of the staff as the preferred caregiver for AD communication, as part of an interdisciplinary healthcare team approach. Finally, the clear majority of caregivers (85%), called for discussions and documentation about ADs, and end-of-life training. CONCLUSION: Advance directives remain poorly known in the hospital, 12 years after the first Leonetti law. The attitude of professionals about ADs is not homogenous but interest for the subject is obvious in the vast majority of caregivers. The results of this survey highlighted that discussions and documentation about ADs as well as training on end-of-life patient care are essential.

Endovascular Extra-Anatomic Femoro-Popliteal Bypass for Limb Salvage in Chronic Critical Limb Ischemia.

PURPOSE: To report the initial clinical experience with fully endovascular extra-anatomic femoro-popliteal bypass (FPB) for limb salvage in patients with critical limb ischemia (CLI) and no traditional endovascular or surgical revascularization options. METHODS: Between June 2013 and May 2018, endovascular procedure was proposed for limb salvage during multidisciplinary team meeting in fifteen hospitalized patients (median age 67 years; 73% men) with CLI and a high risk of major amputation. Primary outcome was amputation-free survival at 1 year. Secondary outcomes included mortality, cardiovascular (CV) events and major limb amputation at 1 year, primary/secondary bypass patency and wound healing at the last follow-up visit. Procedure-related complications (deaths, CV events, hemorrhages) were recorded through 30 days. RESULTS: Technical procedure success rate was 100%. Major peri-procedural outcomes occurred in two patients (13%): One patient died secondary to cardiogenic shock; one patient suffered acute coronary syndrome associated with iliopsoas bleeding. No major amputation occurred through 30 days. Median follow-up period was 21.5 (18.25-45.5) months (last follow-up visits on April 2019). Amputation-free survival at 1-year and at the last follow-up visit was 80% and 53%, respectively. Cumulative mortality at 1-year and at the last follow-up visit was 13% and 33%, respectively. Primary and secondary bypass patency was 27% and 60%, respectively. Complete wound healing was achieved in 11 patients (73%). CONCLUSION: Endovascular extra-anatomic FPB represents an innovative approach for limb salvage in CLI with no traditional endovascular or surgical revascularization options. Our clinical experience highlights that this technique remains challenging because of frequent comorbidities and fragility of this patient population. LEVEL OF EVIDENCE: Level 4, Case series.

Ranibizumab and digital ischemia.

Case report of a patient with age-related macular degeneration whose digital ischemia can most plausibly be attributed to ranibizumab. PURPOSE: To report ranibizumab as the probable cause of digital ischemia in a patient treated for age-related macular degeneration. METHODS: Single-patient case report. RESULTS: An 83-year-old woman with an unremarkable medical history suffered acute ischemia in her left hand with necrosis of the distal phalange of the fifth finger after six intravitreal injections of ranibizumab. Her etiological work-up was negative. Her condition improved after endovascular revascularization and remained good at six months' follow-up after three months of dual antithrombotic therapy (low molecular weight heparin then rivaroxaban, both with aspirin) followed by rivaroxaban alone and four courses of intravenous iloprost. CONCLUSION: The increased incidence of peripheral arterial thromboembolic events in patients under ranibizumab treatment is slight but significant, with 0.8-5% of patients affected, most of which suffer strokes. These events seem to occur at a random time after ranibizumab treatment is initiated and no reliable marker has yet been identified. The most probable cause of digital ischemia in our patient was ranibizumab.

[Identifying barriers to screening for abdominal aortic aneurysm in general practice: Qualitative study of 14 general practitioners in Paris]. / Identification des freins au dépistage de l'anévrisme de l'aorte abdominale en médecine générale : étude qualitative auprès de 14 médecins généralistes exerçant à Paris.

INTRODUCTION: Abdominal aortic aneurysm (AAA) is a silent pathology with often fatal consequences in case of rupture. AAA screening, recommended in France and many other countries, has shown its effectiveness in reducing specific mortality. However, AAA screening rate remains insufficient. OBJECTIVE: To identify barriers to AAA screening in general practice. MATERIAL AND METHOD: Qualitative study carried out during 2016 among general practitioners based in Paris. RESULTS: Fourteen physicians were included. Most of the barriers were related to the physician: unawareness about AAA and screening recommendations, considering AAA as a secondary question not discussed with the patient, abdominal aorta not included in cardiovascular assessment, no search for a familial history of AAA, AAA considered a question for the specialist, lack of time, lack of training, numerous screenings to propose, oversight. Some barriers are related to the patient: unawareness of the pathology and family history of AAA, refusal, questioning the pertinence of the doctor's comments, failure to respect the care pathway. Others are related to AAA: source of anxiety, low prevalence, rarity of complications. The remaining barriers are related to screening: cost-benefit and risk-benefit ratios, sonographer unavailability, constraint for the patient, overmedicalization. CONCLUSION: Information and training of general practitioners about AAA must be strengthened in order to optimize AAA screening and reduce specific mortality.

[A post-thrombotic pelvic congestion syndrome]. / Un syndrome de congestion pelvienne post-thrombotique.

INTRODUCTION: Pelvic congestion syndrome is a chronic pelvic pain syndrome related to pelvic varices developed in the setting of primary venous insufficiency or secondary to venous obstruction. OBSERVATION: We report the case of a 35-year-old patient undergoing anticoagulant therapy for an extensive unprovoked left iliac vein thrombosis, who developed a disabling pelvic congestion syndrome secondary to chronic obstruction of the left iliac vein. Recanalization with stenting of the left iliac vein, combined with antithrombotic treatment with antiplatelet therapy (aspirin 100mg) and anticoagulation (rivaroxaban 20mg) for three months, followed by antiplatelet therapy alone, led to a complete and lasting regression of symptoms. DISCUSSION: Management of pelvic congestion syndrome secondary to post-thrombotic lesions must take into account its pathophysiology. It involves iliac venous angioplasty with stent placement in combination with antithrombotic therapy, which modalities remain to be specified in long-term follow-up.