Carotid diaphragm: Atypical fibromuscular dysplasia or atheromatous lesions?

Atypical fibromuscular dysplasia (FMD) is an underdiagnosed cause of ischemic stroke. The typical angiographic pattern of a septum on the posterolateral side of a carotid megabulb is highly suggestive of atypical FMD. We report here on two patients with this highly suggestive pattern of carotid atypical FMD, but which histological examination revealed to be atheromatous lesions. Interestingly, contrast-enhanced ultrasound of the carotid artery showed enhancement of the spur, which should never be the case with an FMD lesion, which has no vasa vasorum. Our findings suggest that the results of studies reporting stenting of atypical FMD in cervical arteries should be interpreted with caution.

[Ultrasound screening of abdominal aortic aneurysm: Lessons from Vesale 2013]. / Dépistage échographique de l'anévrisme de l'aorte abdominale - les enseignements de Vésale 2013.

Although aneurysm of the abdominal infra-renal aorta (AAA) meets criteria warranting B mode ultrasound screening, the advantages of mass screening versus selective targeted opportunistic screening remain a subject of debate. In France, the French Society of Vascular Medicine (SFMV) and the Health Authority (HAS) published recommendations for targeted opportunistic screening in 2006 and 2013 respectively. The SFMV held a mainstream communication day on November 21, 2013 in France involving participants from metropolitan France and overseas departments that led to a proposal for free AAA ultrasound screening: the Vesalius operation. Being a consumer operation, the selection criteria were limited to age (men and women between 60 and 75 years); the age limit was lowered to 50 years in case of direct family history of AAA. More than 7000 people (as many women as men) were screened in 83 centers with a 1.70% prevalence of AAA in the age-based target population (3.12% for men, 0.27% for women). The median diameter of detected AAA was 33 mm (range 20 to 74 mm). The prevalence of AAA was 1.7% in this population. Vesalius data are consistent with those of the literature both in terms of prevalence and for cardiovascular risk factors with the important role of smoking. Lessons from Vesalius to take into consideration are: screening is warranted in men 60 years and over, especially smokers, and in female smokers. Screening beyond 75 years should be discussed. Given the importance of screening, the SFMV set up a year of national screening for AAA (Vesalius operation 2014/2015) in order to increase public and physician awareness about AAA detection, therapeutic management, and monitoring. AAA is a serious, common, disease that kills 6000 people each year. The goal of screening is cost-effective reduction in the death toll.

Reproducibility in ultrasonic characterization of carotid plaques.

BACKGROUND AND PURPOSE: Echolucent carotid plaques compared with echogenic plaques could carry a significant risk of transient ischemic attacks and strokes, but the reproducibility of new ultrasonic methods has not yet been proved. The objective was to evaluate interobserver and intraobserver agreement in characterizing the carotid plaques studied by both B mode imaging and color Doppler imaging, which is the only ultrasonic method available for recognizing anechoic lesions. METHODS: Fifty-three carotid plaques greater than 40% in diameter were selected from four centers and simultaneously analyzed by 9 observers. Five types of plaques were defined by their echo structure: class I = uniformly anechogenic, class II = predominantly hypoechogenic with >50% hypoechogenic area, class III = predominantly echogenic with >50% echogenic area, class IV uniformly echogenic, class V = unclassified plaques. The luminal surface was characterized as either 1 = regular, 2 = recess of more than 2 mm in depth and width, or 3 = unclassified. Agreement of these variables was calculated by using the kappa index, agreement proportion and an intraclass correlation coefficient. RESULTS: Interobserver reproducibility was only fair for type I (kappa = 0.47) and for the luminal surface (class 1, kappa = 0.52 and class 2, kappa = 0.41). Agreement proportion was 0.51 in hypoechoic plaques and 0.64 in the determination of the regular surface. Mean intraobserver agreement was fair (kappa = 0.47 +/- 0. 1) for plaque echogenicity to good (kappa = 0.63 +/- 0.19) for surface. CONCLUSION: This study shows that the semiquantitative classification, first developed by Gray-Weale, then by Nicolaides, could be improved, thus giving rise to a new outlook in the debated field of ulcerations.

[Criteria for quantification and characterization of aneurysms of the abdominal aorta using ultrasonography. The AFFCA study. French Association of Continuous Education in Angiology]. / Critères de quantification et de caractérisation des anévrysmes de l'aorte abdominale par l'échographie. Etude AFFCA. Association Française de Formation Continue en Angiologie.

OBJECTIVE: To validate ultrasonographic quantification and characterization criteria for aneurysms of the abdominal aorta (AAA) by comparing computed tomography data and surgical findings in order to standardize diagnosis and follow-up of AAA. PATIENTS AND METHODS: A multicentric prospective study included 80 patients with AAA (January to August 1996). Standardized data on quantitative (diameter, surface area) and qualitative (topography, form, wall, thrombus) data were obtained at each ultrasound examination and at surgery. Ultrasound (US) and computed tomography (CT) explorations were performed and interpreted without prior knowledge by independent operators. US findings versus CT reference were compared in 77 cases, US findings versus surgical reference in 31, and CT findings versus surgery reference in 28. RESULTS: Compared with CT-scan, B mode ultrasound (n = 77) underestimated the anteroposterior diameter of the aneurysm (mean difference -2.16 mm; p < 0.001), the anteroposterior diameters of the flow channel lumen (-5.54 mm; p < 0.001) and upper neck of the aneurysm (-2.74 mm; p < 0.001). Surface area measurements were not significantly different both the aneurysmal sac (p = 0.3) and the flow channel lumen (p = 1). Compared with surgical findings, US (n = 30) underestimated the transverse diameter (mean difference (-4.29 mm; p = 0.0037). Compared with surgery, US findings (n = 28) were not significantly different for the anteroposterior ans transverse diameters. Analyzing the form and wall of the AAA, US/CT-scan performance was good for symmetrical fusiform aneurysms (sensitivity 77%, specificity 67%). US and CT-scan were reliable for detecting wall bugles (same sensitivity, 29%). The angle formed by the thrombus with the wall (expressed in degrees) was not significantly different (p = 0.9). When the lower pole of the aneurysm was situated above the aortic bifurcation, US (sensitivity 75%) was more reliable than the CT-scan (sensitivity 50%) compared with surgical findings. CONCLUSION: Ultrasonography should not be limited to the simple positive diagnosis of AAA. A precise analysis of the diameters and surface areas of the aneurysm should be performed.

Importance of the familial factor in varicose disease. Clinical study of 134 families.

BACKGROUND: The role of heredity in the development of varicose veins of the lower limbs has been raised many times in the literature. When evaluating this role, most authors only question the patients, without examining their relatives. As shown in other papers, the subjectivity of this type of data throws doubt on the results. OBJECTIVE: This problem was evaluated by means of a prospective study based on clinical examination of all immediate family members. METHODS: In the case-control study, the female or male patients had to satisfy the following criteria: 1. Varicose veins in their legs. 2. Age between 30 and 40 years (meaning that, in most cases, their parents were still alive). 3. No history of deep vein thrombosis. To limit the influence of certain confusing factors (diet, life-style), the control group was composed of the patients' spouses, who were not suffering from varicose veins. The parents of the cases and the parents of the controls were also examined. For each case-control couple and for the four parents, we recorded the history of venous disease, the life-style, and the results of clinical examination, including the results of palpation and percussion of the various varicose vein territories. RESULTS: One hundred and thirty-four families were examined: 67 patients and their parents and 67 controls and their parents. A total of 402 subjects were examined. The results demonstrated a prominent role of heredity in the development of varicose veins (P < .001). The risk of developing varicose veins for the children was 90% when both parents suffered from this disease, 25% for males and 62% for females when one parent was affected, and 20% when neither parent was affected.