[News in the work-up of deep vein thrombosis (DVT)]. / Actualités dans la prise en charge de la thrombose veineuse profonde (TVP).

Deep vein thrombosis (DVT) is a component of venous thromboembolism (VTE), the other being pulmonary embolism (PE). Its incidence is 1 to 2/1.000/year and nearly 1/100/year after 80 years. The major complication of DVT is PE which occurs in about 1/3 of cases, is often asymptomatic but can be fatal. Another common complication, occurring in 20-50 % of cases is the post-thrombotic syndrome (PTS) which is likely to alter the quality of life. Several issues remain unanswered when considering DVT. The optimal management of distal DVT versus proximal DVT is not well codified. The diagnostic approach to DVT is essential : it is based on the estimation of clinical probability, the possible use of D-dimer test and compression ultrasonography. The new direct oral anticoagulants (NOACs) have been proven effective in the phase 3 studies but when to use them and which to choose in the real life ? Wearing compression stockings to prevent the SPT is recommended: what is the definition of compression stockings and is there some evidence of their efficacy ? The purpose of this article is to provide some useful information to primary care physicians to address a DVT.

[New developments in antithrombotic care]. / Nouvelles approches des traitements anticoagulants.

For more than 50 years vitamin K antagonists (VKA) have been the gold standard for long-term oral anticoagulant treatment. New anticoagulants are now in extensive clinical development what will probably have a significant impact on daily practice in the near future. Compounds that specifically block activated factor X (FXa) or activated factor II (thrombin) have entered impressive phase III trials. Idraparinux is a long-active derivative from fondaparinux (synthetic pentasaccharide) and is administered subcutaneously. It inhibits indirectly FXa. Apixaban and rivaroxaban are small molecules that directly block FXa following oral administration. Dabigatran is another substance that is administered orally and directly inhibit thrombin. This article will review the potential interest of these new drugs in the modern antithrombotic care. In the meantime, we will briefly discuss two new tools that have been developed to optimalizing the classical VKA anticoagulation: anticoagulation clinics and point-of-care testing of INR that allows self-monitoring.

Screening Program of Abdominal Aortic Aneurysm.

In Europe, the prevalence of abdominal aortic aneurysms (AAAs) in the elderly population (≥65 year old) has declined in the past decades to <4%. Aneurysmal degeneration of the aorta is a serious and potentially life-threatening vascular disease. Abdominal aortic aneurysms typically develop subclinically and often only become symptomatic when complicated by impending rupture. Most AAAs are discovered incidentally while investigating for an unrelated pathology. Ruptured AAA is the tenth leading cause of death in Belgium (0.32% of all deaths in 2014). Health-care providers have emphasized the importance of early detection of AAA and elective repair when the rupture risk outweighs operative risk (usual diameter threshold of 55 mm). Routine AAA screening programs, consisting of a single abdominal ultrasonography at the age of 65 years, aim to reduce the number of AAA-related deaths. Does population-based ultrasound screening for AAA achieve its objective and is it cost-effective? This literature review tries to answer these challenging questions.

Ankle brachial index combined with Framingham Risk Score to predict cardiovascular events and mortality: a meta-analysis.

CONTEXT: Prediction models to identify healthy individuals at high risk of cardiovascular disease have limited accuracy. A low ankle brachial index (ABI) is an indicator of atherosclerosis and has the potential to improve prediction. OBJECTIVE: To determine if the ABI provides information on the risk of cardiovascular events and mortality independently of the Framingham risk score (FRS) and can improve risk prediction. DATA SOURCES: Relevant studies were identified. A search of MEDLINE (1950 to February 2008) and EMBASE (1980 to February 2008) was conducted using common text words for the term ankle brachial index combined with text words and Medical Subject Headings to capture prospective cohort designs. Review of reference lists and conference proceedings, and correspondence with experts was conducted to identify additional published and unpublished studies. STUDY SELECTION: Studies were included if participants were derived from a general population, ABI was measured at baseline, and individuals were followed up to detect total and cardiovascular mortality. DATA EXTRACTION: Prespecified data on individuals in each selected study were extracted into a combined data set and an individual participant data meta-analysis was conducted on individuals who had no previous history of coronary heart disease. RESULTS: Sixteen population cohort studies fulfilling the inclusion criteria were included. During 480,325 person-years of follow-up of 24,955 men and 23,339 women, the risk of death by ABI had a reverse J-shaped distribution with a normal (low risk) ABI of 1.11 to 1.40. The 10-year cardiovascular mortality in men with a low ABI (< or = 0.90) was 18.7% (95% confidence interval [CI], 13.3%-24.1%) and with normal ABI (1.11-1.40) was 4.4% (95% CI, 3.2%-5.7%) (hazard ratio [HR], 4.2; 95% CI, 3.3-5.4). Corresponding mortalities in women were 12.6% (95% CI, 6.2%-19.0%) and 4.1% (95% CI, 2.2%-6.1%) (HR, 3.5; 95% CI, 2.4-5.1). The HRs remained elevated after adjusting for FRS (2.9 [95% CI, 2.3-3.7] for men vs 3.0 [95% CI, 2.0-4.4] for women). A low ABI (< or = 0.90) was associated with approximately twice the 10-year total mortality, cardiovascular mortality, and major coronary event rate compared with the overall rate in each FRS category. Inclusion of the ABI in cardiovascular risk stratification using the FRS would result in reclassification of the risk category and modification of treatment recommendations in approximately 19% of men and 36% of women. CONCLUSION: Measurement of the ABI may improve the accuracy of cardiovascular risk prediction beyond the FRS.

Spontaneous renal artery dissection in an otherwise healthy male.

Dissection of a renal artery is rare and, in most cases, associated with underlying arterial diseases. Spontaneous renal artery dissection (RAD) is exceptional. We report the case of a young and otherwise healthy man with an isolated dissection of the right renal artery without any obvious origin. Diagnosis was made by angiography. He received medical treatment and rapidly recovered. Renal artery dissection can be misdiagnosed because its clinical presentation may be confusing. Selective renal angiography is essential to evaluate the extent of the dissection and the suitability for repair. Control of the hypertension and renal function preservation are the two main goals of the treatment. The place of surgical repair remains unclear because of the poor results on hypertension improvement and high complication rate.

[Venous thromboembolic disease: which coagulation screening, for whom, when?]. / La maladie veineuse thrombo-embolique: quel bilan de coagulation, pour qui, quand?

Testing for laboratory evidence of thrombophilia is now common but it has limited predictive value for the majority of unselected symptomatic patients. So when is testing indicated ? And which one? The term "thrombophilia" describes disorders of the haemostatic mechanisms which are likely to predispose to thrombosis. Thrombophilia may be heritable, acquired or mixed, resulting of the environment interacting with genetic background. To date, a limited number of genetic variants and other defects are proven to be independent risk factors for venous thromboembolism. These include antithrombin deficiency, protein C deficiency, protein S deficiency, factor V Leiden, the prothrombin gene mutation, hyperhomocysteinemia and antiphospholipid antibodies. There is no good evidence currently available to support the hypothesis that heritable thrombophilias increase the risk of arterial disease. But acquired or mixed thrombophilias such as hyperhomocysteinemia and antiphospholipid antibodies have been found in association with both venous and arterial thrombotic disorders. When testing for thrombophilia is indicated, especially in case of venous thromboembolism, it should include assays for heritable, mixed or acquired defects: deficiency of antithrombin, protein C or protein S, factor V Leiden and prothrombin G20210A mutations, elevated factor VIII, hyperhomocysteinemia and for antiphospholipid antibodies. Depending on the site of venous thrombosis, laboratory testing to exclude myeloproliferative disorders should be performed.

Plasma homocysteine concentration in a Belgian school-age population.

BACKGROUND: Total plasma homocysteine (tHcy) is an independent risk factor for cardiovascular disease in adults. Data for children and adolescents are lacking. OBJECTIVE: The aim of this study was to provide a reference range for tHcy and to explore the relation between tHcy and nutritional indexes in a Belgian pediatric population. DESIGN: tHcy, folate, and vitamin B-12 were measured in 647 healthy children (353 girls and 294 boys) aged 5-19 y. RESULTS: The tHcy distribution was, as in adults, skewed to the right [geometric mean (-1 SD, +1 SD): 7.41 micromol/L (5.51, 9.96)]. Concentrations were lowest in younger children and increased with age. After the tHcy distribution was examined according to age, 3 age ranges were distinguished: 5-9 y [6.21 micromol/L (5.14, 7.50)], 10-14 y [7.09 micromol/L (5.69, 8.84)], and 15-19 y [8.84 micromol/L (6.36, 12.29)]. We observed no significant differences in tHcy values between girls and boys in children aged < 15 y; in postpubertal children, however, concentrations were higher in boys than in girls. In the 3 age groups, folate was inversely correlated with tHcy; the negative relation between tHcy and vitamin B-12 was less strong. Familial cardiovascular disease was more frequent in children who had hyperhomocysteinemia. CONCLUSIONS: These observations suggest that in children, as in adults, genetic, nutritional, and endocrine factors are determinants of the metabolism of homocysteine. The significance of tHcy values in childhood and young adulthood in terms of predicting cardiovascular risk in adulthood should be investigated.

Infected false aneurysm following carotid endarterectomy with vein patch angioplasty.

The authors report a case of infected false aneurysm that developed after carotid endarterectomy with vein patch angioplasty. This complication is extremely rare and occurs most commonly when a Dacron patch graft has been employed. Various clinical presentations are described and the etiology of infection is discussed. Surgical management consisted of the resection of the pseudoaneurysm and segmental replacement with vein. Parenteral antibiotic therapy was given for three weeks and topical irrigation with an antiseptic solution performed for two weeks.

Salmonella endarteritis, about two cases and their management.

Mycotic aneurysms due to Salmonella are a classical but uncommon complication of Salmonella infections. We report two cases of such aneurysms, the first one having developed two successive aneurysms of the iliac arteries due to Salmonella typhimurium. The literature on Salmonella endarteritis is briefly reviewed. The importance of an aggressive surgical approach of the mycotic aneurysm, with removal of all infected material and extra-anatomic bypass through contaminated tissue is emphasized. The role of antibiotic treatment is also discussed.

The antiphospholipid syndrome.

The antiphospholipid syndrome (APS) defines the clinical association between antiphospholipid antibodies and a syndrome of hypercoagulability or thrombophilia (the term of "sticky blood" is sometimes used in APS). Antiphospholipid antibodies comprise a broad family of antibodies including both lupus anticoagulants and anticardiolipin antibodies. The pathogenesis of APS remains unclear. Nevertheless, an understanding of the biology, clinical and laboratory diagnosis, and clinical manifestations of APS are important to the neurologist because the brain is commonly affected by the disease. These points are addressed herein focusing on neurological manifestations of APS. Treatment of APS of which anticoagulation is the cornerstone is also discussed.

Venous thromboangiitis associated with regional enteritis.

Thromboembolic complications occurring in patients with Crohn's disease are increasingly reported and are associated with a high mortality. The mechanism by which the thrombogenic process occurs is unclear. As recent findings suggest that Crohn's disease is a chronic vasculitis with multifocal gastrointestinal infarctions secondary to an imbalance of the cellular hemostatic pathway, extradigestive thrombotic complications might be mediated by the same vascular immune reaction. We report an unusual case of recurrent venous thrombosis associated with regional enteritis, the main point of interest being two-fold: first, this case provides a morphological evidence for an angiitic process as the cause of extradigestive thrombosis; second, the gastrointestinal disease remained subclinical for more than four years although the patient developed major venous thrombotic complications.

Vertebral arteriovenous fistula following central venous cannulation: a case report.

The authors report a case of vertebral arteriovenous fistula that has been disclosed three years after central venous cannulation (CVC). The real incidence of this complication is discussed and various clinical presentations are enumerated. From a review of the literature, some recommendations are made to prevent the diagnosis from being missed and chiefly to reduce the risk of arterial puncture that results in fistula formation.

Role of the captopril test in renovascular hypertension: a case report.

This article reports the case of a rapidly severe stenosis of the right renal artery, causing uncontrolled hypertension. After failure of a percutaneous transluminal renal angioplasty, which provoked the thrombosis of the vessel, a surgical revascularization was performed after +/- eighteen hours of renal ischemia. Blood pressure, blood urea nitrogen and serum creatinine returned to normal values. A dramatic improvement of the right renal function was attested at the hippuran scintigraphy after a dose test of captopril. The results of renographic studies obtained in this clinical case underline the role of the captopril radionuclide test in detection and follow-up after treatment of renovascular hypertension.

Cerebral venous thrombosis and procoagulant factors--a case study.

Cerebral venous thrombosis is a polymorphic clinical entity for which diagnosis has become more frequent with the advent of neuroradiology. The superior sagittal and transverse sinuses are frequently involved, whereas cavernous sinus thrombosis is much less frequent. Inherited resistance to the anticoagulant action of activated protein C (APC resistance), antithrombin deficiency, protein C and S deficiencies, and hyperhomocysteinemia seem to represent major causes of thrombophilia when unusual thromboembolic events (ie, before the age of 45 years) are observed. The authors present the combined occurrence of protein C and protein S deficiencies in a 32-year-old woman, manifested by extensive cerebral venous thrombosis.

[Venous thromboembolic disease and Klinefelter's syndrome]. / Maladie veineuse thromboembolique et syndrome de Klinefelter.

Venous thromboembolic disease was rarely described in association with Klinefelter's syndrome. It is nevertheless more frequent than in a genetically normal male population (5-20 times). This abnormality is not clearly explained. We report a classical case of Klinefelter's syndrome detected by the help of a venous thromboembolic disease. The patient was of blood-group A (the relative incidence of thrombosis is raised among group-A persons as compared with group-O persons). The evaluation disclosed a high rate of beta-thromboglobulin suggesting an underlying hypercoagulability. The abnormal incidence of venous thromboembolic disease among Klinefelter patients may find a partial explanation in this way.

[Livedo vasculitis: report of a case]. / Vascularite livédoïde: a propos d'un cas.

Livedo vasculitis is an occlusive thrombotic hyalinizing vessel disease characterized by parietal hyalinization, endothelial proliferation, fibrin deposits and formation of thrombi within the superficial and deep dermal vessels. Diagnosis, essentially clinical, emphasizes the clinical and histopathological features of livedo vasculitis. We conducted an etiological investigation in our case, as required to diagnose idiopathic livedo vasculitis. Several therapies have been suggested with inconstant results and recurrence after withdrawal. In our case, treatment with recombinant tissue plasminogen activator was successful but was unable to prevent recurrence.

[Pulmonary embolism and pregnancy: report of a case; review of the literature]. / Embolie pulmonaire et grossesse: à propos d'une observation; revue de la littérature.

Pulmonary embolism occurring during pregnancy is a rare accident but that still brings about a high mother mortality; it seems to be five to six times more frequent during the pregnancy and the post-partum than for non-parturient women who don't take any estro-progestogens, pulmonary embolism would involve complications for 0.5/1000 pregnancies before delivery. As it presents a lot of diagnostic problems, it is under-estimated. The vascular radiological examinations expose the foetus or embryo to considerable radiation and to a risk of foetal hypothyroidism leading to backwardness. The lung perfusion scanning has the advantage of not injecting iodine but is not specific. Fortunately, some medical examinations such as plethysmography or Doppler echography are safe and can also guide the clinician. As far as therapy is concerned, intravenous heparin is the first intention treatment, it can be replaced subsequently by subcutaneous heparin (low molecular weight heparin). In case of heavy pulmonary embolism endangering the vital prognosis of the patient, in case of clinical or biological resistance to the medical treatment, it could be necessary to perform a pulmonary embolectomy with, if necessary, vena cava interruption with insertion of a mechanical filter.

[The role of season in the incidence of deep venous thrombosis]. / Rôle de la saison dans l'incidence de la thrombose veineuse profonde.

INTRODUCTION: The question of the role of season as a predisposing factor for development of venous thromboembolic disease still remains a matter of debate. Actually, most reports described a higher incidence of thrombotic disorders in winter, while a recent study showed no seasonal variation in the incidence of deep vein thrombosis (DVT). These data led us to study the seasonal distribution of all outpatients with DVT admitted to our Department over a period of 14 years. METHODS: Retrospective review of the files of all outpatients with confirmed (venography or ultrasound) DVT of the legs admitted from Jan. 1st 1982 to Dec. 31st 1995 (n = 512; mean age 59.4 years; 49.4% women). RESULTS: DVT occurred in spring in 135 (26.4%), in summer in 104 (20.3%), in autumn in 142 (27.7%) and in winter in 131 (25.6%) patients. This distribution appears to be similar to an expected uniform distribution [chi 2(3) df = 6.48; p = 0.090 (NS)]. CONCLUSIONS: In our study, by investigating retrospectively 512 outpatients with confirmed DVT, no correlation was found between season and development of thrombosis, suggesting that cold seasons do not represent a predisposing factor for DVT. Further large prospective studies are needed in order to validate our data and to investigate the clinical implications and the precise role of the season in the risk of occurrence of venous thrombosis.

[Transluminal percutaneous angioplasty by thermal lasers. 20 cases of peripheral artery occlusion]. / Angioplastie transluminale percutanée assistée au laser thermique. Expérience de 20 cas d'oblitérations artérielles périphériques.

The authors report their experience of laser thermal angioplasty in a series of 20 patients. An argon laser with a 1.5 or 2.0 millimeter diameter metalcapped optical fiber (Hot Tip Trimedyne Inc.) was used; the laser probe was pushed to the occlusion point; after a channel was produced through the obliteration, a conventional percutaneous balloon angioplasty was performed. The indications were: 4 primitive iliac occlusions, 15 femoral/popliteal occlusions and 1 subclavian obliteration. The immediate results were as follows (table I): 75% overall recanalization (50% at the iliac level, 87% at the femoral/popliteal level and failure at the subclavian level); 5 notable complications were observed (2 limb ischaemia, 2 voluminous inguinal haematoma and 1 aortic cross perforation) without clinical sequelae. The short term follow-up (1 to 8 months) of the successfully treated patients (table II) shows 100% permeability at the iliac level and 77% at the femoral/popliteal level. We conclude that laser thermal angioplasty is a very attractive method in the treatment of primitive iliac and femoral/popliteal occlusions. The well-defined indications must form the subject of a closely discussion between the angiologist, the vascular surgeon and the interventional radiologist.

[Autologous venous graft disease. Incidence, physiopathologic aspects and therapeutic means of graft salvage]. / La maladie du greffon veineux autologue. Incidence, aspects physiopathologiques et moyens thérapeutiques de sauvetage du greffon.

From 1980 to 1985, 134 patients with severe ischemia of lower limbs benefited from surgical recovery by inversed autologous venous graft in subarticular femoropopliteal and distal femoral position. During the 5 year follow-up period, 14 grafts (9%) developed hemodynamic degradation requiring angiographic surveillance followed by surgical repair or percutaneous dilatation. A retrospective study of evolution of venous grafts implanted in the contralateral supra-articular femoropopliteal and femoro (ilio) femoral position demonstrated a lower incidence of hemodynamic degradation (5.3%). Localizations (proximal and distal anastomotic stenosis, valvular stenosis, stenotic degradation of the donor or receiving arterial segment) and physiopathologic mechanisms (progressive atheromatosis, anastomotic or valvular fibrosis, premature atheromatosis of graft) are systematically reviewed together with results of pathology. Etiopathogenic factors invoked for this affection are discussed as a function of findings, together with choice of therapy used, including surgical repair, fibrinolysis and percutaneous dilatation.