[College of the French Vascular Medicine Teachers (CEMV) statement: Arterial Doppler waveforms analysis (simplified Saint-Bonnet classification)]. / Recommandations du Collège des enseignants de médecine vasculaire (CEMV) : analyse des flux artériels Doppler (classification de Saint-Bonnet simplifiée).

Lower extremity peripheral artery disease is a frequent disease. Arterial Doppler waveforms analysis is a key element in vascular medicine, especially to diagnose lower peripheral artery disease. Although Doppler waveforms are often used, descriptions are highly heterogeneous. This review presents the simplified Saint-Bonnet classification that is tought to vascular medicine residents in order to homogenize arterial flow description.

[Ankle brachial pressure index (ABPI): color-Doppler versus ultrasound Doppler correlation study in 98 patients after analysis of interobserver reproducibility]. / Étude de corrélation de mesure des index de pression systolique à la cheville (IPSc) par Doppler couleur versus Doppler continu sur une population de 98 patients après analyse de la reproductibilité interobservateur.

OBJECTIVE: Ankle Brachial Pressure Index (ABPI) by Doppler ultrasound is the gold standard non invasive method for screening of peripheral arterial disease (PAD). This reference method is little used in routine practice, particularly by vascular disease specialists since the most recent ultrasound devices no longer have continuous wave probes. The purpose of our survey was to assess interobserver reproducibility of color-Doppler measurements made in a first population, then second, to assess the correlation between ABPI measurements made with color-Doppler and with ultrasound Doppler in a second population. METHODS: One hundred twenty patients meeting screening criteria for AOMI defined by the French Health Authorities (HAS, 2006) participated in the study between October 2010 and April 2011 in the Echo Doppler and Vascular Medicine unit of the Brest University teaching hospital: 22 patients for interobserver reproducibility and 98 for color-Doppler - continuous Doppler correlation study. Two independent operators measured the ABPI index in each of the 98 patients using color-Doppler and continuous Doppler in random order, producing 353 measurements. Reliability and reproducibility were assessed using the intraclass correlation coefficient of correlation (ICC) determined with Spearman and the Bland-Altman methods. RESULTS: The ABPI was less than 0.90 in 62% of patients. The color-Doppler reproducibility study showed a mean difference of 0.02 [95% CI: -0.02 to 0.17] using the Bland Altman method with ICC equal to 0.89 (P<0.001). For the intermethod correlation study, the mean difference was 0.03 [95% CI: -0.17 to 0.23], with ICC equal to 0.84 (P<0.001). CONCLUSION: Color-Doppler could be an alternative to Doppler ultrasound for PAD screening or follow-up, depending on the results of further evaluations in larger populations.

[Validation of a clinical prediction rule for the diagnosis of deep vein thrombosis of the lower limbs in primary care]. / Validation d'un score de prédiction clinique de la thrombose veineuse profonde des membres inférieurs spécifique à la médecine générale.

PURPOSE: Patients with suspected deep vein thrombosis (DVT) are often managed on an outpatient basis. The aim of the study was to validate a clinical prediction rule specifically for use in primary care to help physicians in their decision to start anticoagulant therapy while awaiting ultrasound examination. PATIENTS AND METHODS: Between September 2007 and October 2008, 194 general practitioners prospectively included patients with clinically suspected DVT without clinically suspected pulmonary embolism. All patients underwent a standardized clinical assessment in order to collect items included in the clinical prediction rule (personal history of venous thromboembolism +1, immobilization in previous month+1, estrogen contraceptive+2, active malignancy+3, swelling of the calf+1, the presence of an alternative diagnosis more likely than that of DVT-3. DVT unlikely if score<2, likely if score≥2). RESULTS: Among the 164 included patients, 56 (34%) had DVT of them 28 (17%) had a proximal DVT. Proportions of confirmed DVT were 29% in the unlikely group and 43% in the likely group against 26% and 63% respectively in the derivation study. CONCLUSIONS: This clinical prediction rule might not fulfill the required conditions to be considered as a usable help in the ambulatory management of DVT. Variations of the cut-off value could enhance its performance.

[Validation of a deep vein thrombosis prediction rule in primary care]. / Validation d'un score de probabilité clinique de thrombose veineuse profonde des membres inférieurs spécifique à la médecine générale.

OBJECTIVE: Suspected deep vein thrombosis (DVT) of lower limbs (LL) may require different tools to rule out or confirm the diagnosis. Clinical probability provides help to select useful tests, interpret their results, and decide to treat the patient meanwhile. Clinical prediction rules that risk stratify patients with suspected DVT can be established from inpatients, but no prediction rule not requiring laboratory tests has been established from primary care patients. We previously derived and internally validated such a prediction rule. The aim of this study is to externally validate this score. PATIENTS AND METHODS: The score was applied to Optimev outpatients with suspected LL-DVT, and without suspected pulmonary embolism. Sensitivity and specificity were calculated for proximal and distal DVT, according to each score. The area under the ROC curve was calculated for each kind of DVT, in order to assess the validity of the score on predicting the presence or absence of DVT. RESULTS: Among 3523 outpatients prospectively included in the Optimev study for suspected LL DVT, overall prevalence of DVT was 29.7% (n=1046), ranging from 21.7% in the non-high score probability, to 61.4% in the high score probability. The area under the ROC curve was 0.79 [CI 95%, 0.77-0.80]. With subgroup analysis, the area under curve was 0.83 [CI 95%, 0.82-0.85] for proximal DVT, and 0.75 [CI 95%, 0.73-0.77] for distal DVT. CONCLUSION: This score reliably identifies primary care patients with LL DVT, whether proximal or distal.

[Renal and spleen infarction after massive consumption of cannabis and cocaine in a young man]. / Infarctus rénal et splénique après consommation massive de cannabis et cocaïne chez un homme jeune.

Cannabis is the most widely consumed drug in the world, particularly among young subjects. Cocaine is the third leading illicit drug. Cases of renal infarction associated with combined consumption of cannabis and cocaine have been reported in the literature. We describe the case of a 24-year-old man who presented renal and spleen infarction after massive consumption of cannabis and cocaine. Both vascular events arose on healthy arteries. Etiological tests were negative leading to the conclusion that the events resulted from a toxic cause related to cannabis and cocaine consumption. Different mechanisms, potentially including thrombosis, might explain the association of cannabis and cocaine with vascular events. We suggest that a systematic search for cannabis and cocaine consumption among young victims of vascular disease might be useful.

Overestimation of moderate carotid stenosis assessed by both Doppler US and contrast enhanced 3D-MR angiography in the CARMEDAS study.

PURPOSE: To evaluate the agreement and diagnostic accuracy of Contrast enhanced magnetic resonance angiography (CE-MRA), Doppler ultrasound (DUS) and Digital subtraction angiography (DSA) in the assessment of carotid stenosis. METHODS: DUS, CE-MRA and DSA were performed in 56 patients included in the Carotide-angiographie par résonance magnétique-échographie-doppler-angioscanner (CARMEDAS) multicenter study with a carotid stenosis ≥ 50%. Three readers evaluated stenoses on CE-MRA and DSA (NASCET criteria). Velocities criteria were used for stenosis estimation on DUS. RESULTS: CE-MRA had a sensitivity and specificity of 96-98% and 66-83% respectively for carotid stenoses ≥ 50% and a sensitivity and specificity of 94% and 76-84% respectively for carotid stenoses ≥ 70%. The interobserver agreement of CE-MRA was excellent, except for moderate stenoses (50-69%). DUS had a sensitivity and specificity of 88 and 75% respectively for carotid stenoses ≥ 50% and a sensitivity and specificity of 83 and 86% respectively for carotid stenoses ≥ 70%. Combined concordant CE-MRA and DUS had a sensitivity and specificity of 100 and 85-90% respectively for carotid stenoses ≥ 50% and a sensitivity and specificity of 96-100% and 80-87% respectively for carotid stenoses ≥ 70%. The positive predictive value of the association CE-MRA and DUS for carotid stenoses ≥ 70% is calculated between 77 and 82% while the negative predictive value is calculated between 97 and 100%. CE-MRA and DUS have concordant findings in 63-72%, and the overestimations cases were recorded only for carotid stenosis ≤ 69%. CONCLUSION: Combined DUS-CE-MRA is excellent for evaluation of severe stenosis but remains debatable in moderate stenosis (50-69%) due to the risk of overestimations.

[Incidence, risk factors and skin manifestations of post-thrombotic syndrome: a four-year follow-up of patients included in the EDITH study]. / Incidence, facteurs de risque et signes cutanés de la maladie post-thrombotique : suivi à quatre ans des patients inclus dans l'étude EDITH.

PURPOSE: Despite appropriate therapy 10 to 100% of patients with deep vein thrombosis (DVT) of the lower limbs will develop post-thrombotic syndrome (PTS). The aim of this study was to evaluate the incidence of PTS in the EDITH cohort and to estimate the association between initial patients' characteristics and the risk of development of PTS. METHODS: One hundred and eighty patients included in the EDITH study for a first event of DVT of the lower limbs without clinical signs of venous insufficiency were recalled 4 years after their initial thrombotic event. PTS was diagnosed according to the Villalta score. RESULTS: Ninety-five patients (45 men, mean age 50.7 ± 16.9 years) were evaluated for PTS. Among them, 28.4% (95% CI 19.3-37.5) developed PTS but none had severe PTS. The most frequent clinical signs of PTS were varicose veins (59%), corona phlebectatica (48%), swelling leg (30%) and pigmented dermatitis (26%). No single risk factor was associated with PTS development (age, sex, BMI thrombophilia, etiology, localization, recurrence, symptomatic DVT and familial history of DVT). CONCLUSION: PTS is a frequent disease. However, lack of uniformity of diagnosis criteria in the different studies does not make possible the estimation of PTS risk factors.

Complete venous ultrasound in outpatients with suspected pulmonary embolism.

BACKGROUND: Compression ultrasonography (US) confined to the proximal veins is usually performed to detect deep vein thrombosis (DVT) in patients with suspected pulmonary embolism (PE). Recent studies suggested a limited yield of proximal US when multislice computed tomography (MSCT) was used. OBJECTIVES: To assess whether performing an additional distal vein US would increase the diagnostic yield of the test. PATIENTS AND METHODS: Data of 855 consecutive outpatients included in a multicenter randomized controlled trial were analyzed. Patients were investigated by a sequential diagnostic strategy including clinical probability assessment, D-dimer measurement, proximal US and MSCT. Proximal US was completed by an examination of the distal veins, the result of which was not disclosed to the physician in charge of the patient. RESULTS: US was positive in 21% of patients, of whom 10% (53/541) had proximal DVT and 11% (59/541) isolated distal DVT. Of the 59 patients with distal DVT, 21 (36%) had no PE on MSCT. Twenty of those 21 patients were not given anticoagulant therapy and had an uneventful follow-up. The diagnostic performance of distal US for the diagnosis of PE was as follows: sensitivity 22% [95% confidence interval (CI) 17-29]; specificity 94% (95% CI 91-96); positive likelihood ratio 3.9 (95% CI 2.4-6.4). CONCLUSIONS: In patients with suspected PE, distal US has limited diagnostic performance, and its additional use only modestly increases the yield of US. Moreover, it carries a high false-positive rate, impeding the use of distal US as a confirmatory test for PE.

[Mondor's disease, report on three cases and literature review]. / Maladie de Mondor. A propos de trois cas et revue de la littérature.

Mondor's disease is spontaneously remitting benign superficial thrombophlebitis involving healthy veins. Fewer than 400 cases have been reported in the world literature. Typically, subcutaneous angiitis is observed on the upper anterolateral aspect of the chest wall. We report three cases in which Mondor's disease occurred after surgery for breast cancer in one patient, and had no apparent cause in two other patients. The relationship with breast cancer and risk factors suggests that routine mammography is advisable. For patients presenting idiopathic Mondor's disease, follow-up is of utmost importance.

[Foam echosclerotherapy by puncture-direct injection: technique and quantities]. / Echosclérothérapie à la mousse par ponction-injection directe à l'aiguille: technique et doses.

Foam echosclerotherapy by puncture - direct injection (EMPID) is a technique approved by the French Health Authorities for the management of varicose veins. It combines two principles: the injection of a sclerosing agent by echomonitored direct puncture and the use of this sclerosing agent as a foam. The procedure consists of four stages: targeting of the vein to sclerose and selection of the puncture site, venous puncture under echographic guiding, injection of the sclerosing product under complete echographic monitoring, and post-injection control, checking for the impact of the action and the distribution of the foam in the treated vein. First intention indications concern essentially isolated troncular reflux in lesser and great saphena veins and varicose recurrences. In second intention, EMPID is also an alternative to conventional varicose resection surgery. Emphasizing the principle of precaution, we underline the usefulness of a fine, extemporaneous, standardized and reproducible microfoam - high doses, in particular large volumes of foam, are unwarranted since it has been proven that small volumes are as effective. The recommended concentrations are directly linked to the maximal diameter of the saphena trunks targeted. The volume of foam to be injected must be determined on an individual basis and depends on the presence or not of post-injection spasm, the degree of venous filling and the endothelial impregnation of the treated varicosity (which can be easily monitored because of the spontaneous visualization of the foam producing a tracing effect on the ultrasound); it should not exceed 7.5 ml per session. Apart from the classical side effects due to the liquid form, the foam presents its own, very rare, side effects consisting of minor, constantly and spontaneously reversible, eye disorders. The foam is contraindicated for patients suffering from migraine due to higher incidence of such visual disorders. EMPID is an outpatient procedure for the treatment of varicosities which requires considerable operator skill. This technique cannot be proposed on a large scale without proper and specific training.

Prevention of venous thrombosis in patients with acute intracerebral hemorrhage.

OBJECTIVE: To assess intermittent pneumatic compression (IPC) in the prevention of venous thromboembolism (VTE). METHODS: The authors randomly allocated patients with a documented intracerebral hemorrhage (ICH) to elastic stockings (ES) alone or combined with IPC. The primary outcome was a combined criteria assessed at day 10: a symptomatic and well-documented VTE, or a death arising before day 10 and related to pulmonary embolism (PE), or an asymptomatic deep vein thrombosis (DVT) of the lower limbs detected by compression ultrasonography (CUS). Outcome assessment was blinded. RESULTS: One hundred fifty-one patients were randomized; 133 (88%) patients were evaluated at day 10. No clinical suspicion of VTE arose before day 10. Fourteen patients died before having a CUS but no death was definitely related to PE. Fourteen asymptomatic DVT were detected by CUS: three (4.7%) in the ES + IPC group (all distal) and 11 (15.9%) in the ES group (three proximal and eight distal). ES combined with IPC is associated with a reduced risk of asymptomatic DVT compared to ES alone: relative risk, 0.29 (95% CI 0.08 to 1.00). CONCLUSIONS: Asymptomatic deep vein thrombosis (DVT) was detected at day 10 in 15.9% of patients wearing elastic stockings alone. Intermittent pneumatic compression significantly decreased the occurrence of asymptomatic DVT for patients with intracerebral hemorrhage.

Volume Calculation of Venous Thrombosis Using 2D Ultrasound Images.

Venous thrombosis screening exams use 2D ultrasound images, from which medical experts obtain a rough idea of the thrombosis aspect and infer an approximate volume. Such estimation is essential to follow up the thrombosis evolution. This paper proposes a method to calculate venous thrombosis volume from non-parallel 2D ultrasound images, taking advantage of a priori knowledge about the thrombosis shape. An interactive ellipse fitting contour segmentation extracts the 2D thrombosis contours. Then, a Delaunay triangulation is applied to the set of 2D segmented contours positioned in 3D, and the area that each contour defines, to obtain a global thrombosis 3D surface reconstruction, with a dense triangulation inside the contours. Volume is calculated from the obtained surface and contours triangulation, using a maximum unit normal component approach. Preliminary results obtained on 3 plastic phantoms and 3 in vitro venous thromboses, as well as one in vivo case are presented and discussed. An error rate of volume estimation inferior to 4,5% for the plastic phantoms, and 3,5% for the in vitro venous thromboses was obtained.

[Antiretroviral therapy and cardiovascular risk]. / Traitement antirétroviral et risque cardio-vasculaire.

Current antiretroviral therapy protocols enable long-term survival of HIV-infected patients, decreasing the risk of infectious complications. Three classes of anti-HIV treatments are available. With longer survival, unusual cardiovascular complications related to iatrogenic biological anomalies (dyslipidemia and impaired glucose tolerance) have appeared among this young population which is exposed to usual risk factors of atherosclerosis. Antiretroviral therapies are suspected to cause these complications, inducing maturity-onset diabetes in 4 to 20% of patients, impaired glucose tolerance in 15 to 60%, hypertriglyceridemia in 15 to 74% depending on the survey, and hypercholesterolemia in 20 to 60%, especially in case of associated lipodystrophia. A lipid battery including total cholesterol, HDL, and triglycerides, and 12-h fasting blood glucose should be obtained before initiating antiretroviral therapy. Any anomalous finding should be followed carefully with regular surveillance every 3 to 6 months and search for other causes of secondary dyslipidemia. In the event of casual and persisting elevation of LDL-cholesterol levels, a statin treatment can be introduced. For secondary prevention, irrespective of the context, recommendations currently merge with the consensus applying to the general population. These patients require careful surveillance of cardiovascular risk factors and a specific care in addition to treatment of their immunodeficiency.

[Vascular resistances in lower limb arterial disease used to evaluate the quality of peripheral arteries. Preliminary study]. / Apport de la mesure des résistances périphériques dans l'évaluation du lit d'aval jambier chez l'artériopathe. Etude préliminaire de faisabilité.

UNLABELLED: Peripheral resistance of lower limb arteries is not a common clinical measurement despite easy-to-apply non-invasive techniques. The aim of our trial has been to test this new parameter as a marker of arterial lesions. MATERIAL AND METHODS: In this prospective study, hemodynamic data acquired non-invasively [Ankle brachial index (ABI), peak systolic velocity (PSV), end-diastole velocity (VTD) and peripheral artery quality] in patients with lower limb arterial disease were compared with the resistance index measured in the common femoral artery (Arbeille index: IR=VTD/PSV). RESULTS: Between February 1, 2003 and April 30, 2003, 150 measurements of resistance index were made in 99 individuals with ischemia following a strain (69% men, 31% women, average age 64.8+/-15.2 years). Forty-one of the resistance measurements (27%) were also made in patients with arterial disease factors (diabetics, renal replacement therapy). The resistance index was closely associated with end-diastole velocity. (r=-0.76; DDL=148; p<0.01) as well as peripheral artery quality (r=0.81; DDL=148; p<0.01); on the contrary the resistance index was not affected by the arterial disease factors (0.3+/-0.1 vs 0.33+/-0.12; p=NS). CONCLUSION: These findings suggest that the hemodynamic impact might be evaluated more precisely diabetics and renal replacement therapy patients whose hemodynamic parameters are difficult to assess due to their arterial disease factors. Prospective studies are needed to determine the role of the resistance index in the follow up of these patients, and its contribution in comparison with the measurement of end-diastole velocity.

[Drug addiction and cardiovascular pathologies]. / Toxicomanie et pathologies cardiovasculaires.

Drug addiction which entails cardiovascular risks unknown or misknown to physicians, currently involves an increasing number of miscellaneous drugs, existing in manifold forms. There appears to be no bounds on the way of intake. All territories of the body may be affected with more or less severity. In young people, the cardiac, coronary, cerebral and peripheral vascular systems are generally involved. Two illicit drugs, cannabis and cocaine, showing a permanent increase in misuse, prevail. This drug addiction comes along with intercurrent pathologies which have their own vascular toxicity, especially HIV infection. Moreover, the advent of new illicit substances emphasizes the complexity of the clinical presentations. These complex situations have a real social and medical impact. We are currently in a phase of permanently increasing risk of cardiovascular complications. The pathophysiological mechanisms involved are intertwined and complicated by the frequent association of polytoxicomania or by the effects excipients added to these drugs: direct vascular toxicity, angeitis, arterial and venous thrombosis. Arsenic, a common component of these drugs, is also found in cigarettes; arsenic toxicity mainly affects the lower limbs. Treatment of these complications is non-specific; the ideal solution being weaning which, unfortunately in this peculiar population of patients, may entail serious complications due to the misuse of substitution products.

Efficacy of pentasaccharide on a prethrombosis model based on a calibrated stasis by the increase in up-stream venous pressure.

On a previous model using Wessler's principle in the rat, we have demonstrated that a partial ligature of the inferior vena cava leading to a 40% increase in up-stream venous pressure was thrombogenic only in association with the infusion of low dose of thromboplastin (90 microg/kg). In these thrombogenic conditions, the infusion of pentasaccharide (Arixtra, fondaparinux) should lead to a strong inhibition of thrombus formation. Therefore, we performed on five groups of 10 rats: stasis alone (group S) with a 40% increase in up-stream venous pressure; stasis and thromboplastin (group ST90); and stasis, thromboplastin and pentasaccharide (groups SPT50, SPT100 and SPT250) at three different dosages (50, 100 and 250 microg/kg). The efficacy of pentasaccharide was measured according to the variations in up-stream venous pressure, thrombus weight and thrombin-antithrombin complexes levels. Only 250 microl/kg pentasaccharide significantly reduced the thrombus weight in comparison with group ST90 (5 mg versus 23.8 mg, P = 0.01) but it was not sufficient to induce a return to the basic state (5 mg versus 0.2 mg in group S, P = 0.049). Thrombin-antithrombin complex levels measured at the end of the experiment were significantly reduced in comparison with group ST90 (16.7 versus 57.8 mg, P = 0.01) and were not statistically different from group S (16.1 versus 16.6 mg, P = 0.65). In conclusion, in a very borderline model toward thrombogenesis, pentasaccharide was able to reduce thrombus weight and abolished biological hypercoagulability.

[Validation of a French translation of the Edinburgh claudication questionnaire among general practitioners' patients]. / Validation d'une traduction française du questionnaire d'édimbourg au sein d'une population de consultants en médecine générale.

OBJECTIVES: Intermittent claudication is one of the clinical symptoms of peripheral arterial disease (PAD). The presence of PAD is a high risk marker of cardiac events and stroke. The PAD screening can be enhanced by the use of questionnaires. The Edinburgh Questionnaire presents in its English version better diagnostic performances compared to the Rose (WHO) Questionnaire. The aim of this study is to precise the performances of the French version of the Edinburgh Questionnaire among a population consulting general practitioners. METHODS: Four centers instructed 10 general practitioners each to the measurement of ankle pressure with a Doppler stethoscope. The physicians administrated the Questionnaire to 10 consecutive consultants in a same day, and measured the pressure on posterior tibial, dorsalis pedis and humeral arteries. With a second questionnaire they collected data concerning age, weight, height, and the presence of major risk factors. The same protocol was repeated a second day on new patients. The diagnosis of PAD was based on an ankle-arm index lower than 0.85 for at least on limb. RESULTS: The population studied consisted of 727 subjects (351 females and 376 males). The mean age was at 58.3 +/- 16.1 years (ranging from 18 to 83.3 years). The sensitivity of the Questionnaire is at 47% (95% CI: 32.3-61.7%), the specificity at 98.8% (95% CI: 97.5-99.4%), the positive and negative predictive values are respectively at 73.3% (95% CI: 54.1-87.7%) and 94.8% (95% CI: 94.7-97.6%). Among this population of general practitioners consultants, the prevalence of a low ankle-arm index under 0.85 is at 6.7%. DISCUSSION: The French version of the Edinburgh Questionnaire maintains the very good specificity of the English version. The lower sensitivity could be explained by the choice of the gold standard, namely the ankle-arm index which includes asymptomatic patients with authentic PAD. The use of this Questionnaire can be recommended for the screening of this disease as well as in epidemiological studies.