Digital ischemia associated with cancer: results from a cohort study.

Digital ischemia associated with cancer (DIAC) is increasing in frequency and recent reports have suggested the concept of paraneoplastic manifestation. The aims of this study were to characterize the clinical presentation of DIAC and identify clinical features that could lead physicians to diagnose underlying cancer.From January 2004 to December 2011, 100 patients were hospitalized in the Department of Internal Medicine at Rouen University Hospital, France for a first episode of DI. Fifteen (15%) exhibited symptomatic or asymptomatic cancer during the year preceding or following vascular episode and constituted the DIAC group. Other patients without cancer made up the digital ischemia (DI) group.Median time between diagnosis of cancer and episode of digital necrosis was 2 months [0.25-9]. Diagnosis of DI and concomitant cancer was made in 7 of the 15 patients, while DI preceded the malignant disorder in 2 cases and followed it in 6 cases. Histological types were adenocarcinoma for 7 (46.7%), squamous cell carcinoma for 4 (26.7%), and lymphoid neoplasia for 3 patients (20%). Six patients (40%) had extensive cancer. Three patients were lost to follow-up and 5 patients died <1 year after diagnosis of cancer. Cancer treatment improved vascular symptoms in 6 patients (40%). Patients with DIAC, compared to patients with DI, were significantly older (56 years [33-79] vs 46 [17-83] P =0.005), and had significantly lower hemoglobin and hematocrit levels (12.7 g/dl vs 13.9 g/dl; P =0.003 and 38% vs 42%; P =0.003, respectively). Patients with DIAC had a higher platelet rate (420 vs 300 G/L P =0.01), and 6 patients with DIAC (40%) had thrombocytosis. There was no difference between groups either in C-reactive protein level (12 mg/L vs 5 mg/L; P =0.08) or regarding cardiovascular risk factors, presence of autoimmunity, or monoclonal protein.This retrospective study suggests that DIAC may be more prevalent than previously reported. Outcomes of the 2 diseases were not strictly chronologically parallel. However, in the majority of cases, treatment of the tumor resolved vascular involvement. Our findings suggest that age >50 years and thrombocytosis should alert physicians to consider a possible occult malignancy when digital necrosis occurs.

Detection of microcirculatory impairment by transcutaneous oxymetry monitoring during hemodialysis: an observational study.

BACKGROUND: Little is known about the effects of intermittent hemodialysis on microcirculatory perfusion. The aim of this study is to assess the effects of hemodialysis on microvascular perfusion using transcutaneous oxymetry (TCPO2). METHODS: In this observational study, hourly TCPO2 measurements were performed during hemodialysis sessions. Ankle brachial index (ABI) was carried out to classify patients according their vascular condition. RESULTS: 50 patients (mean age 70 ± 8 years old) were enrolled. Mean TCPO2 decreased significantly on average 23.9% between start and finish of hemodialysis. Severe ischemia (TCPO2 < 30 mmHg) and critical ischemia (TCPO2 < 10 mmHg) occurred during dialysis in 47.1% and 15.5% respectively. Critical ischemia occurred only in limbs with ABI < 0.9 (8.3%) or > 1.3 (28%). Patients with critical ischemia experienced a significantly larger decline in mean blood pressure (32.4 ± 26.1 mmHg vs 12.7 ± 10.7 mmHg; P = 0.007) and a more pronounced ultrafiltration (45.55 ± 16.9 ml/kg vs 35.17 ± 18.2 ml/kg; P = 0.04) compared to patients without ischemia. Clinical outcomes (death or vascular procedures) were five times more frequent in patients who had developed critical ischemia (55.7% vs 10.1% P = 0.01). The elevated age of patients, the low basal value of TCPO2, and the occurrence of critical ischemia were more frequently associated with clinical outcome (P = 0.03, P = 0.048, P = 0.01 respectively). CONCLUSIONS: This study demonstrates that hemodialysis induces microcirculatory injury, dependent on blood pressure reduction, peripheral vascular state and ultrafiltration. The occurrence of critical ischemia is associated to pejorative patient outcome and therefore, TCPO2 seems to be useful to avoid potential distal tissue damage during hemodialysis.

Transcutaneous oxymetry as predictive test of peripheral vascular revascularization in haemodialysis population.

BACKGROUND: Peripheral arterial disease (PAD) occurs frequently among haemodialysis patients but it is underestimated. Vascular treatment and amputations are more frequent in end stage renal disease (ESRD) population compared to the general population possibly because of a diagnosis of PAD delayed. Transcutaneous oxymetry (TcPO2) is commonly used in vascular medicine to reflect local arterial blood flow and skin oxygenation.The aim of this study was to assess the accuracy of the TcPO2 measurements to screen PAD and to predict vascular outcomes in haemodialysis population. METHODS: In a 1-year prospective study, the value of TcPO2 was assessed in a cohort of 48 patients when starting haemodialysis. RESULTS: Twenty one patients had at least one vascular stenosis (42%) on Doppler examination and were considered as affected by PAD. At inclusion a pathologic resting TcPO2 (<40mmHg) was found in 13 patients (29%). A severe ischemia (TcPO2 <30mmHg) was noted in 8 patients (16.7%) and a critical limb ischemia (TcPO2 <10mmHg) in 3 patients.(6%). Eleven (25.5%) and 6 patients (15%) had a TcPO2 <40mmHg at 6 and 12 months respectively. During the follow-up, death was seven times more frequent in patients with abnormal TcPO2 at T0 compared to patients with normal TcPO2 (38% vs 5.7%; p = 0.04). Revascularization (n = 6) or amputation (n = 5) were required for 5 patients. TcPO2 was pathologic in all patients and legs requiring a vascular treatment. The sensitivity, specificity, positive predictive value and negative predictive value were 100%, 85.2%, 38% and 100% respectively. CONCLUSIONS: This study confirms the underestimated PAD diagnosis and the severity of PAD in haemodialysis population. A TcPO2 less than 40mmHg at the onset of the haemodialysis could identify patients at high risk of death and patients requiring vascular treatment. Moreover, since haemodialysis seems to be an accelerating factor of atherosclerosis, TcPO2 might be perform as a complement to traditional vascular explorations to assess the distal vascular conditions of limbs of haemodialysis patients.

Early atheroma in primary and secondary antiphospholipid syndrome: an intrinsic finding.

OBJECTIVES: The relationship between atherosclerosis and the antiphospholipid syndrome (APS) is unclear. This study compared intima-media thickness (IMT), arterial stiffness, and presence of plaques in APS patients and controls to evaluate the risk of atherosclerosis in this patient population. The study also explored the relationship between these parameters and cardiovascular risk factors. METHODS: Carotid and femoral IMT and stiffness were measured in 58 APS patients and 58 controls. In addition, antiphospholipid antibodies and cardiovascular risk factors were investigated and other systemic lupus erythematosus (SLE)-related serologic parameters were measured. Details of the patients' previous medical history and information regarding disease treatment were analyzed. RESULTS: A significant difference was found between IMT, arterial stiffness, and the presence of plaques in patients and controls (P<0.05). All of these parameters were independent of cardiovascular risk factors. No differences in these parameters were found between patients with primary APS and those with secondary APS, or between patients with thrombosis and those with obstetric manifestations. There was no correlation between SLE disease activity and atheroma. Patients with plaques had taken a lower total dose of corticosteroids and/or hydroxychloroquine. CONCLUSIONS: Some markers of early atherosclerosis could be detected in both primary and secondary APS, irrespective of clinical manifestations. These data suggest that atherosclerosis might be an intrinsic finding in APS patients, independent of cardiovascular risk factors, and that immunosuppressive treatment may prevent atherosclerosis.

Long-term follow-up of hypothenar hammer syndrome: a series of 47 patients.

Hypothenar hammer syndrome (HHS) is an uncommon form of secondary Raynaud phenomenon, occurring mainly in subjects who use the hypothenar part of the hand as a hammer; the hook of the hamate strikes the superficial palmar branch of the ulnar artery in the Guyon space, leading to occlusion and/or aneurysm of the ulnar artery. In patients with HHS, such injuries of the palmar ulnar artery may lead to severe vascular insufficiency in the hand with occlusion of digital artery. To date, only a few series have analyzed the long-term outcome of patients with HHS. This prompted us to conduct the current retrospective study to 1) evaluate the prevalence of HHS in patients with Raynaud phenomenon and 2) assess the short-term and long-term outcome in patients with HHS. From 1990 to 2006, 4148 consecutive patients were referred to the Department of Internal Medicine at the University of Rouen medical center for evaluation of Raynaud phenomenon using nailfold capillaroscopy. HHS was diagnosed in 47 of these 4148 patients (1.13% of cases).Forty-three patients (91.5%) had occupational exposure to repetitive palmar trauma. The more common occupations were factory worker (21.3%), mason (12.8%), carpenter (10.6%), and metal worker (10.6%); the mean duration of occupational exposure to repetitive palmar trauma at HHS diagnosis was 21 years. One patient (2.1%) had recreational exposure (aikido training) to repetitive trauma of the palmar ulnar artery, and 3 other patients (6.4%) developed HHS related to a single direct injury to the hypothenar area. Clinical manifestations were more often unilateral (87.2%) involving the dominant hand (93%). HHS complications included digital ischemic symptoms (ischemia: n = 21, necrosis: n = 20) and irritation of the sensory branch of the ulnar nerve (n = 11). In HHS patients, angiography demonstrated occlusion of the ulnar artery in the area of the Guyon space (59.6%), aneurysm of the ulnar artery in the area of the Guyon space (40.4%), and embolic multiple occlusions of the digital arteries (57.4%). All patients were advised to change their occupational exposure. They were given vasodilators, including calcium channel blocker (n = 37) and buflomedil (n = 12); 36 patients (76.6%) also received oral platelet aggregation inhibitors. Twenty-one patients with digital ischemia/necrosis were further given hemodilution therapy to reduce the hematocrit level to 35%. In 3 patients with HHS-related digital necrosis who exhibited partial improvement with vasodilators, prostacyclin analog therapy (a 5-day regimen of intravenous prostacyclin analog) was instituted, resulting in complete healing of digital ulcer in these 3 patients. Other conservative treatment options included controlling risk factors (smoking cessation, low-lipid diet, therapy for arterial hypertension) and careful local wound care of fingers in the 20 patients with digital necrosis. Only 2 patients, exhibiting digital necrosis and multiple digital artery occlusions, with nonthrombotic ulnar artery aneurysm underwent reconstructive surgery, that is, resection of the aneurysm with end-to-end anastomosis of the ulnar artery. The median length of follow-up in patients with HHS was 15.9 months. Thirteen patients (27.7%) exhibited clinical recurrences of HHS; the median time of HHS recurrence onset was 11 months. Outcome of HHS relapse was favorable with conservative measures in all cases. Awareness of HHS is required to increase suspicion of the disorder so that further exposure to risk factors like repetitive hypothenar trauma can be avoided for these patients; this is of great importance for their overall prognosis. We found favorable outcomes in most patients after conservative measures were initiated; therefore we suggest that surgery may be undertaken in the subgroup of patients who exhibit partial improvement while receiving conservative therapy. Finally, because we observed recurrence of HHS in 27.7% of patients, we note that HHS patients require close follow-up, including both regular and systematic physical vascular examination.