Mannheim carotid intima-media thickness and plaque consensus (2004-2006-2011). An update on behalf of the advisory board of the 3rd, 4th and 5th watching the risk symposia, at the 13th, 15th and 20th European Stroke Conferences, Mannheim, Germany, 2004, Brussels, Belgium, 2006, and Hamburg, Germany, 2011.

Intima-media thickness (IMT) provides a surrogate end point of cardiovascular outcomes in clinical trials evaluating the efficacy of cardiovascular risk factor modification. Carotid artery plaque further adds to the cardiovascular risk assessment. It is defined as a focal structure that encroaches into the arterial lumen of at least 0.5 mm or 50% of the surrounding IMT value or demonstrates a thickness >1.5 mm as measured from the media-adventitia interface to the intima-lumen interface. The scientific basis for use of IMT in clinical trials and practice includes ultrasound physics, technical and disease-related principles as well as best practice on the performance, interpretation and documentation of study results. Comparison of IMT results obtained from epidemiological and interventional studies around the world relies on harmonization on approaches to carotid image acquisition and analysis. This updated consensus document delineates further criteria to distinguish early atherosclerotic plaque formation from thickening of IMT. Standardized methods will foster homogenous data collection and analysis, improve the power of randomized clinical trials incorporating IMT and plaque measurements and facilitate the merging of large databases for meta-analyses. IMT results are applied to individual patients as an integrated assessment of cardiovascular risk factors. However, this document recommends against serial monitoring in individual patients.

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.

Time trends in hospital admissions and mortality due to abdominal aortic aneurysms in France, 2002-2013.

BACKGROUND: Abdominal aortic aneurysms (AAA) are serious disease with a high fatality rate but recent epidemiologic data showed a decrease of AAA mortality. Our objective was to estimate, in France, the hospitalization, inhospital mortality and mortality rates due to AAA and to analyze their trends over time. METHODS: Hospitalization data were extracted from the hospital discharge summaries in the national database between 2002 and 2013. The analysis covered all patients hospitalized for AAA as a principal diagnosis. During the same period, all death certificates mentioning AAA as an initial cause of death were included in the study. Crude and standardized rates were calculated according to age and sex. Poisson regression was used to analyze the average annual percent change. RESULTS: In 2013, there were 8853 patients hospitalized for AAA in France (7986 unruptured and 867 ruptured). Between 2002 and 2013, the rate of patients hospitalized for unruptured AAA decreased slightly in men (-5.0%) but increased in women (+5.2%). By contrast, the rate of patients hospitalized for ruptured AAA has decreased by >20% in men and women. The proportion of endovascular treatment of unruptured AAA rose from <10% in 2005 to 35% in women and 40% in men in 2013. In 2013, 939 deaths from AAA were recorded. Mortality for this disease declined significantly from 2002 to 2013 in men and women. CONCLUSION: The unfavorable epidemiological trends in women and important evolution of the management of AAA call for an epidemiological surveillance of this disease.

[The best of vascular medicine in 2005]. / L'essentiel de 2005 en médecine vasculaire.

It is illusory to think that one year is long enough to establish all the truths that will guide our clinical practice in vascular medicine. On the contrary, one year was long enough to contradict what the preceding twelve months had set out to demonstrate. Consequently, promising trials in the treatment of abdominal aortic aneurysms by endoprostheses have been the object of contradictory debate with regards to the long-term benefits. In fundamental research, circulating progenitors of endothelial cells have been shown to be a marker of atherosclerosis, but is it a better marker than LDL-cholesterol values? The demonstration that these progenitors are of value in the treatment of essential ischaemia of the lower limbs is awaited. Finally, ximelagatran, a direct thrombin antagonist, seemed to have all the qualities of an ideal anticoagulant: easy to use, safe... until the report of raised hepatic enzymes, the clinical relevance of which remains to be determined. In the good news section: the Systolic Pressure Index, an unquestioned marker of arterial disease. Its reduction was known to be correlated with the prevalence of cardiovascular complications. However, it has now been shown that an increase in the index is also associated with cardiovascular complications, a real U-shaped curve. Renal arterial stenosis should be considered in patients with left ventricular failure presenting with flash pulmonary oedema. In the absence of cardiac pathology, BNP would seem to be a good biological marker of haemodynamically significant renal arterial stenosis. Finally, should superficial femoral artery stenosis be treated by an active stent. To date, there is no formal proof.

[Quantification of carotid stenosis by doppler ultrasonography: update]. / Quantification des sténoses carotidiennes par échographie doppler: mise au point.

In presence of an internal carotid artery stenosis, the evaluation of the degree of narrowing is a major issue for the achievement of most appropriate therapeutic strategy. Angiography has been for a long time considered as the gold standard, nevertheless non-invasive imaging methods are becoming of major importance. Among these techniques, duplex ultrasound is the most widely considered at the first stage. This is the single technique to provide in single stage anatomical and functional information. Criteria for carotid artery stenosis are well established. Despite this amount of data, one must notice a wide heterogeneity among different non-invasive vascular lab. Among the limits of ultrasound, discrepancy in the methodology of carotid artery stenosis evaluation is of major concern. Harmonization of reporting carotid stenosis grading should be a major issue for the optimization of the technique.

[The best of vascular medicine in 2004]. / L'essentiel de 2004 en médecine vasculaire.

The wealth of information in vascular pathology merits close examination. The French Cardiology Society vascular group turned its attention to arteries, veins, hypertension and a more fundamental investigation to analyse the results from some illuminating studies which appeared in 2004, despite some pertinent therapeutic doubts. Examination of the trials discussed here shows the importance, as much in vascular pathology as elsewhere, of founding our practice on evidence based medicine.

[Duration of action of trandolapril in mild to moderate hypertensive patients evaluated by ambulatory measurement of blood pressure]. / Durée d'action du trandolapril chez l'hypertendu léger á modéré, évaluée par mesure ambulatoire de la pression artérielle.

The duration of the antihypertensive action of transdolapril, a new angiotensin converting enzyme inhibitor, was studied in 23 patients using ambulatory blood pressure monitoring (ABPM) over 48 hours. After a 20-day placebo period (D1 to D20), mild to moderate hypertensive patients received 2 mg trandolapril once daily for 30 days (D21 to D50). The first 24-hour ABPM recording was performed on day 14, during the placebo run-in period. Two additional recordings were done successively on days 50 and 51 corresponding to a normal dosing day and a following day with a simulated missed dose, respectively. The three blood pressure recordings (placebo, treatment, missed dose) were compared. The average 24-hour systolic (SBP) and diastolic (DBP) blood pressure were significantly decreased by trandolapril. The mean +/- s.d. decrease between day 14 and day 50 were - 8.0 +/- 7.2 mmHg for the DBP and -13.3 +/- 7.8 mmHg for the SBP. Blood pressure was also consistently decreased during the daytime period (-8.7 +/- 7.9 mmHg for the DBP and - 15.6 +/- 8.5 mmHg for the SBP), nighttime period (-5.6 +/- 9.1 mmHg for the DBP and - 8.5 +/- 11.3 mmHg for the SBP) and early morning (- 12.3 +/- 9.7 mmHg for the DBP and - 15.9 +/- 15.1 mmHg for the SBP). The normal circadian pattern of blood pressure was maintained under treatment. The antihypertensive effect of trandolapril was sustained beyond 24 hours after the last intake: there were no significant difference beetween days 50 and 51 in terms of 24-hour, daytime and nighttime average blood pressure.(ABSTRACT TRUNCATED AT 250 WORDS)

[Duplex surveillance after carotid endarteriectomy: review of the literature]. / Surveillance échographique après endartériectomie carotidienne: analyse critique.

Duplex surveillance after carotid endarterectomy is a common practice but no consensus has been reached. On one hand, the low rate of restenosis, the low probability of post-operative stroke and a poor cost-effectiveness are advocating against this strategy. On the other hand, progression of controlateral atherosclerostic lesions leads to justify an ultrasound rather than a clinical follow-up. Neither literature nor recommendation allows today a validated policy. Therefore, it is possible to propose a reasonable strategy in order to balance cost and patient's benefit.

Mannheim carotid intima-media thickness consensus (2004-2006). An update on behalf of the Advisory Board of the 3rd and 4th Watching the Risk Symposium, 13th and 15th European Stroke Conferences, Mannheim, Germany, 2004, and Brussels, Belgium, 2006.

Intima-media thickness (IMT) is increasingly used as a surrogate end point of vascular outcomes in clinical trials aimed at determining the success of interventions that lower risk factors for atherosclerosis and associated diseases (stroke, myocardial infarction and peripheral artery diseases). The necessity to promote further criteria to distinguish early atherosclerotic plaque formation from thickening of IMT and to standardize IMT measurements is expressed through this updated consensus. Plaque is defined as a focal structure that encroaches into the arterial lumen of at least 0.5 mm or 50% of the surrounding IMT value or demonstrates a thickness >1.5 mm as measured from the media-adventitia interface to the intima-lumen interface. Standard use of IMT measurements is based on physics, technical and disease-related principles as well as agreements on how to perform, interpret and document study results. Harmonization of carotid image acquisition and analysis is needed for the comparison of the IMT results obtained from epidemiological and interventional studies around the world. The consensus concludes that there is no need to 'treat IMT values' nor to monitor IMT values in individual patients apart from exceptions named, which emphasize that inside randomized clinical trials should be performed. Although IMT has been suggested to represent an important risk marker, according to the current evidence it does not fulfill the characteristics of an accepted risk factor. Standardized methods recommended in this consensus statement will foster homogenous data collection and analysis. This will help to improve the power of randomized clinical trials incorporating IMT measurements and to facilitate the merging of large databases for meta-analyses.

Design, baseline characteristics and carotid intima-media thickness reproducibility in the PARC study.

BACKGROUND: Intima-media thickness (IMT) is associated with an increased risk of cardiovascular and cerebral ischemic events, but its correlation with the absolute cardiovascular risk is not known in large populations. The Paroi Arterielle et Risque Cardiovasculaire (PARC) Study is an epidemiological study designed to correlate conventional assessment of cardiovascular risk with the mean IMT of the common carotid. METHODS: In the PARC study, 6,416 subjects were enrolled, including 80.7% subjects with cardiovascular risk factors and 19.3% without. A specific methodology was designed to harmonize the acquisition and processing of data at the 283 centers. Interreader agreement on image quality and IMT measurement of the common carotid artery (CCAIMT) was assessed from a random sample of 10% of the PARC study population. RESULTS: The intraclass correlation coefficient was 0.98 (95% CI 0.966-0.985), and the accuracy was high (standard deviation of the error measurement: 0.0185 mm). CONCLUSIONS: The reproducibility of the measurements assessed by means of the intraclass correlation coefficient and the accuracy of the CCAIMT measurement obtained in the PARC Study demonstrate the feasibility of large multicenter studies of IMT measurement.

Carotid stenting with cerebral protection: first clinical experience using the PercuSurge GuardWire system.

PURPOSE: To study the feasibility and safety of carotid angioplasty and stenting using a new cerebral protection device that temporarily occludes the distal internal carotid artery (ICA). METHODS: Forty-eight high-risk patients (39 men, mean age 69.1 +/- 8 years, range 54 to 86) with 53 ICA stenoses underwent percutaneous angioplasty and stenting via the femoral approach under cerebral protection afforded by a 0.014-inch GuardWire balloon occlusion device. Mean stenosis was 82.1% +/- 9.65% (range 70 to 96) and mean lesion length was 16.0 +/- 7.5 mm (range 6 to 50). Thirty-three (62%) lesions were calcified, and 38 (72%) were ulcerated. Thirty-two (60%) of the lesions were asymptomatic. With the occlusion balloon inflated in the distal ICA, the lesion was dilated and stented. The area was cleaned by aspiration and flushed via an aspiration catheter advanced over the wire. Blood samples were collected from the external carotid artery (ECA) and analyzed to measure the size and number of particles collected. Computed tomography and neurological examinations were performed the day after the procedure. RESULTS: Immediate technical success was achieved in all patients with the implantation of 38 Palmaz stents, 8 Expander stents, and 11 Wallstents. Carotid occlusion was well tolerated in all patients but 1 who had multiple, severe carotid lesions and poor collateralization. Mean cerebral flow occlusion time was 346 +/- 153 seconds during predilation and 303 +/- 143 seconds during stent placement. Total mean flow occlusion time was 542 +/- 243 seconds. One immediate neurological complication (transient amaurosis) occurred in a patient who had an anastomosis between the external carotid (EC) and ICA territories. Debris was removed in all patients with a mean 0.8-mm diameter catheter. CONCLUSION: Cerebral protection with the GuardWire device is easy, safe, and effective in protecting the brain from cerebral embolism. Larger studies are warranted.

Mannheim intima-media thickness consensus.

Intima-media thickness (IMT) is increasingly used in clinical trials as a surrogate end point for determining the success of interventions that lower risk factors for atherosclerosis. The necessity for unified criteria to distinguish early atherosclerotic plaque formation from thickening of IMT and to standardize IMT measurements is addressed in this consensus statement. Plaque is defined as a focal structure that encroaches into the arterial lumen of at least 0.5 mm or 50% of the surrounding IMT value or demonstrates a thickness of > or =1.5 mm as measured from the media-adventitia interface to the intima-lumen interface. Standard use of IMT measurements is recommended in all epidemiological and interventional trials dealing with vascular diseases to improve characterization of the population investigated. The consensus concludes that there is no need to 'treat IMT values' nor to monitor IMT values in individual patients apart from few exceptions. Although IMT has been suggested to represent an important risk marker, it does not fulfill the characteristics of an accepted risk factor. Standardized methods recommended in this consensus statement will foster homogenous data collection and analysis. This will help to improve the power of studies incorporating IMT measurements and to facilitate the merging of large databases for meta-analyses.