Impact of multidisciplinary team meetings on the management of venous thromboembolism. A clinical study of 142 cases.

OBJECTIVE: Numerous guidelines have been published on the management of venous thromboembolism (VTE). However, therapeutic decision-making may prove challenging in routine clinical practice. With this in mind, multidisciplinary team (MDT) meetings have been set up in Rennes University Hospital, France. This study sought to describe the situations discussed during MDT meetings and to assess whether the meetings bring about changes in the management of these patients. MATERIALS AND METHODS: A retrospective single-center study conducted at the Rennes University Hospital included cases presented from the beginning of the MDT meetings (February 2015) up to May 2017. RESULTS: In total, 142 cases were presented in 15 MDT meetings, corresponding to a mean of 10±4 cases per meeting. Of these, 129 related to VTE patients: 33 provoked VTEs, 22 unprovoked VTEs, 49 cancer-related VTEs, and 25 unspecified VTEs. MDT meetings led to significant changes in the anticoagulation type (therapeutic, prophylactic, or discontinuation) and duration, but not in the anticoagulant choice (direct oral anticoagulants, vitamin K antagonists, heparins, etc.). CONCLUSION: Requests for MDT meetings are made for all VTE types, and these meetings have an impact on VTE management.

Update of the SFMV (French society of vascular medicine) guidelines on the conditions and safety measures necessary for thermal ablation of the saphenous veins and proposals for unresolved issues.

Venous insufficiency is a very common disease affecting about 25% of the French population (if we combine all stages of its progression). It is a complex disease and its aetiology has not yet been fully elucidated. Some of its causes are well known, such as valvular dysfunction, vein wall defect, and the suctioning effect common to all varicose veins. These factors are generally associated and together lead to dysfunction of one or more of the saphenous veins. Saphenous vein dysfunction is revealed by ultrasound scan, a reflux lasting more than 0.5 seconds indicating venous incompetence. The potential consequences of saphenous vein dysfunction over time include: symptoms (heaviness, swellings, restlessness, cramps, itching of the lower limbs), acute complications (superficial venous thrombosis, varicose bleeding), chronic complications (changes in skin texture and colour, stasis dermatitis, eczema, vein atresia, leg ulcer), and appearance of unaesthetic varicose veins. It is not possible to repair an incompetent saphenous vein. The only therapeutic options at present are ultrasound-guided foam sclerotherapy, physical removal of the vein (saphenous stripping), or its thermal ablation (by laser or radiofrequency treatment), the latter strategy having now become the gold standard as recommended by international guidelines. Recommendations concerning thermal ablation of saphenous veins were published in 2014 by the Société française de médecine vasculaire. Our society has now decided to update these recommendations, taking this opportunity to discuss unresolved issues and issues not addressed in the original guidelines. Thermal ablation of an incompetent saphenous vein consists in destroying this by means of a heating element introduced via ultrasound-guided venous puncture. The heating element comprises either a laser fibre or a radiofrequency catheter. The practitioner must provide the patient with full information about the procedure and obtain his/her consent prior to its implementation. The checklist concerning the interventional procedure issued by the HAS should be validated for each patient (see the appended document).

Neurovascular microcirculatory vasodilation mediated by C-fibers and Transient receptor potential vanilloid-type-1 channels (TRPV 1) is impaired in type 1 diabetes.

Microvascular dysfunction may have an early onset in type 1 diabetes (T1D) and can precede major complications. Our objectives were to assess the endothelial-dependent (acetylcholine, ACh; and post-occlusive hyperemia, PORH), non-endothelial-dependent (sodium nitroprusside, SNP) and neurovascular-dependent (local heating, LH and current induced vasodilation, CIV) microcirculatory vasodilation in T1D patients compared with matched control subjects using a laser speckle contrast imager. Seventeen T1D patients - matched with 17 subjects according to age, gender, Body-Mass-Index, and smoking status - underwent macro- and microvascular investigations. The LH early peak assessed the transient receptor potential vanilloid type 1 channels (TRPV1) mediated vasodilation, whereas the plateau assessed the Nitirc-Oxyde (NO) and endothelium-derived hyperpolarizing factor (EDHF) pathways. PORH explored sensory nerves and (EDHF), while CIV assessed sensory nerves (C-fibers) and prostaglandin-mediated vasodilation. Using neurological investigations, we observed that C-fiber and A-delta fiber functions in T1D patients were similar to control subjects. PORH, CIV, LH peak and plateau vasodilations were significantly decreased in T1D patients compared to controls, whereas there was no difference between the two groups for ACh and SNP vasodilations. Neurovascular microcirculatory vasodilations (C-fibers and TRPV 1-mediated vasodilations) are impaired in TD1 patients whereas no abnormalities were found using clinical neurological investigations. Clinicaltrials: No. NCT02538120.

[Peripheral artery disease in patients younger than 50 years old: Which etiology?]. / Artériopathies périphériques juvéniles.

Peripheral arterial disease (PAD) encompasses disease of all arteries of the body except the coronary arteries. The main etiology whatever the patient's age is atherosclerosis. Different etiologies can induce PAD especially when patients are younger than 50 years old and have no cardiovascular risk factors (smoking, hypertension, diabetes…). PAD that appears before 50 years old can be named juvenile PAD (JPAD) although there is no consensus about the definition. The aim of this work is to present the different etiologies of JPAD according to their hereditary, acquired or mixed origins. The following hereditary causes are addressed: Marfan syndrome, Ehlers-Danlos syndrome, homocystinuria, pseudoxanthoma elasticum, osteogenesis imperfecta "mid-aortic" syndrome. Among the acquired etiologies, inflammatory JPADs without extravascular signs such as atherosclerosis and Buerger's disease, inflammatory JPADs with extravascular signs as Takayasu's disease, Behçet's disease and Cogan's syndrome, JPADs like aortitis, embolic JPADs, iatrogenic JPADs, and mechanical or traumatic JPADs are described. Finally, mixed origins as thrombotic disease and fibromuscular dysplasia are presented. This work will assist clinicians in the diagnosis of JPAD.

Training to Perform Ankle-Brachial Index: Systematic Review and Perspectives to Improve Teaching and Learning.

OBJECTIVE: To conduct a systematic review focusing on the impact of training programs on ankle-brachial index (ABI) performance by medical students, doctors and primary care providers. Lower extremity peripheral artery disease (PAD) is a highly prevalent disease affecting ∼202 million people worldwide. ABI is an essential component of medical education because of its ability to diagnose PAD, and as it is a powerful prognostic marker for overall and cardiovascular related mortality. METHODS: A systematic search was conducted (up to May 2015) using Medline, Embase, and Web of Science databases. RESULTS: Five studies have addressed the impact of a training program on ABI performance by either medical students, doctors or primary care providers. All were assigned a low GRADE system quality. The components of the training vary greatly either in substance (what was taught) or in form (duration of the training, and type of support which was used). No consistency was found in the outcome measures. CONCLUSION: According to this systematic review, only few studies, with a low quality rating, have addressed which training program should be performed to provide the best way of teaching how to perform ABI. Future high quality researches are required to define objectively the best training program to facilitate ABI teaching and learning.

Safety and accuracy of endovascular aneurysm repair without pre-operative and intra-operative contrast agent.

BACKGROUND: Severe chronic kidney disease is a major limitation for endovascular aortic aneurysm repair (EVAR). The aim of this study is to assess the safety and accuracy of fusion imaging, when performing EVAR in the absence of pre- and intra-operative contrast agents. METHODS: From October 2013 to February 2014, every patient requiring EVAR and presenting with severe chronic renal impairment underwent a specific pre-operative imaging assessment, based on a non-enhanced CT scan. Centrelines were manually extracted and key points were placed at the landing zones. In house software makes it possible to artificially enhance the contrast between vascular structures and the surrounding tissue, by increasing the values attributed to the vascular structure voxels (500 Hounsfield units). EVAR was performed in a hybrid room (Zeego, Siemens), and the artificially enhanced CT scan was used for the construction of fusion imaging. The 3D vascular volume, together with the centrelines and key points, was overlaid onto the 2D live fluoroscopic image. RESULTS: Six patients (mean age 77.1 years) were treated by EVAR (5 abdominal aneurysms and 1 thoracic aneurysm), using fusion imaging without a contrast agent. The median pre-operative estimated glomerular filtration rate (eGFR) was 17.5 mL/min/1.73 m2. No contrast was used during the procedure. No intra-operative endoleak was observed on the duplex scan. No deterioration was observed in the eGFR at 1 week (eGFR = 21.7, p = .49), nor at 1 month follow up (eGFR = 21, p = .28). The stent graft positioning error was assessed in terms of the difference between the effective and planned landing zones, measured on pre- and post-operative CT scans. The mean error was 1.3 mm at the proximal landing zone, and 6.5 mm at the distal landing zone. CONCLUSION: EVAR without the use of pre-operative and intra-operative contrast agents appears to be safe and accurate for patients with severe chronic kidney disease.

Patency of direct revascularisation of the hypogastric arteries in patients with aortoiliac occlusive disease.

OBJECTIVES: Various indications for internal iliac artery (IIA) revascularisation have been reported. Revascularisations for gluteal ischaemia and buttock claudication remain controversial and uncommon. The objective of the study was to assess the patency of direct conventional revascularisations (CRs) of the IIA in patients with aortoiliac occlusive disease because few studies have focussed on this specific topic. MATERIALS AND METHODS: The charts of all patients who underwent CR of the IIA, between August 2000 and January 2009, were retrospectively reviewed. We recorded for each patient preoperative vascular work-up. All patients were tested for patency on January 2009. A computed tomography (CT) scan was requested if the duplex scan casts any doubt with regard to patency. If non-patent, the last date for confirmed patency was kept for the analysis. Functional outcomes at the proximal level were also collected. RESULTS: We studied 40 patients with occlusive disease. Buttock claudication was observed in 27 patients (66%), including eight (20%) in whom these symptoms were isolated. The 13 other patients had distal claudication or rest pain and documented proximal ischaemia, justifying the IIA revascularisations. We performed 44 conventional direct revascularisations of the IIA concomitant to aorto- or iliofemoral bypasses in these patients. The overall postoperative patency rate was 89%. Five early occlusions of the IIA remained asymptomatic. The median duration of follow-up was 39 months (3-86 months). The survival rate was 95% at 1 year and 86% at 5 years. The primary patency rate of the IIA was 89% at 1 year and 72.5% at 5 years. Buttock claudication disappeared in 23 of the 27 patients (85%), who were symptomatic at the proximal level prior to surgery. CONCLUSION: Direct IIA concomitant revascularisation has an acceptable patency rate in patients undergoing aorto- or iliofemoral bypasses for occlusive disease. When feasible, this technique appears to be safe for the treatment and prevention of buttock claudication.

Limitations of self-reported estimates of functional capacity using the Walking Impairment Questionnaire.

OBJECTIVE: A potential issue with the Walking Impairment Questionnaire (WIQ) is that it is relatively complex. We estimated the number of errors made by patients when self-completing the WIQ, and assessed the benefit of correcting missing, duplicate or paradoxical (i.e., reported lower difficulty for a higher-intensity task) answers. DESIGN: Prospective non-interventional study. MATERIALS: All consecutive new patients with claudication over a 3-month period. METHODS: The WIQ was self-completed before patients performed a constant-load treadmill walking test (maximised to 750 m). MAIN OUTCOME MEASURE: We analysed the coefficient of determination of the linear relationship between overall WIQ score (mean of the available subscales when at least two subscales are available) and treadmill maximal walking distance (MWD), before and after correction of errors. RESULTS: We studied 73 patients. Thirty-seven questionnaires had to be corrected for one or more errors. The coefficient of determination between the overall WIQ score and MWD was R(2) = 0.391 (n = 56) and R(2) = 0.426 (n = 73) before and after correction, respectively. CONCLUSION: Supervision of self-completed WIQs detects errors in almost half of the questionnaires, resulting in a missing overall WIQ score in 23% of cases among uncorrected questionnaires. The overall WIQ score correlates only moderately with MWD, even after correction. CLINICAL TRIAL REGISTRATION: NIH database: NCT01114178.

[Why should vascular patients have a dietary assessment?]. / Pourquoi devons-nous évaluer l'alimentation des sujets à risque vasculaire ?

Vascular diseases are a major health problem in Western countries. Coronary heart disease (CHD), stroke, and peripheral arterial disease (PAD) share many common risk factors such as age, smoking, dyslipidemia, and diabetes. Although the dietary pattern is considered as a risk factor for CHD, the impact of dietary pattern on stroke and PAD is debated. However, new studies showed that dietary pattern could also be considered as a risk factor in stroke and PAD. Dietary pattern should be evaluated in vascular patients and new tools of dietary assessment must be developed for a better prevention of vascular disease.

Functional outcome of hypogastric revascularisation for prevention of buttock claudication in patients with peripheral artery occlusive disease.

We have defined proximal lower limb ischaemia as a decrease in Exercise-transcutaneous oxygen pressure (TcPO(2)) lower than minus 15mmHg at the buttock level in patients with peripheral artery occlusive disease. The purpose of this study was to objectively evaluate the benefits of direct versus indirect revascularisation of internal iliac arteries (IIAs) for prevention of buttock claudication in this population. We retrospectively reviewed the charts of proximal ischaemia patients who underwent revascularisation and both preoperative and postoperative stress TcPO(2) testing. Revascularisation procedures were classified as either direct revascularisation, including percutaneous transluminal angioplasty and internal iliac artery bypass, resulting in a direct inflow in a patent IIA (group 1) or indirect revascularisation, including aortobifemoral bypass and recanalisation of the femoral junction on the ischaemic side, resulting in indirect inflow from collateral arteries in the hypogastric territory (group 2). Patency was checked 3 months after revascularisation in all cases. Treadmill exercise stress tests were performed before and after revascularisation using the same protocol designed to assess pain, determine maximum walking distance (MWD) and measure TcPO(2) during exercise. In addition, ankle-brachial indices (ABIs) were calculated. Between May 2001 and March 2008, a total of 93 patients with objectively documented proximal ischaemia underwent 145 proximal revascularisation procedures using conventional open techniques in 109 cases and endovascular techniques in 36. Direct revascularisation was performed on 50 limbs (35%) (group 1) and indirect revascularisation on 95 limbs (65%) (group 2). The mean interval between revascularisation and stress testing was 60+/-74 days preoperatively and 149+/-142 days postoperatively. No postoperative thrombosis was observed. Buttock claudication following revascularisation was more common in group 2 (p<0.001). No difference was observed between the two groups with regard to improvement in MWD (365 / 294 m) and ABI (0.20/0.22). Disappearance of proximal ischaemia was more common after direct revascularisation (p<0.01). The extent of lesions graded according to the TASC II classification appeared not to be predictive of improvement in assessment criteria following revascularisation. Conversely, patency of the superficial femoral artery was correlated with improvement (p<0.01). This study indicates that direct revascularisation, if feasible, provides the best functional outcome for prevention of buttock claudication.