Feasibility and reliability of ankle/arm blood pressure index in preventive medicine.

Despite its potential usefulness for assessing preclinical atherosclerosis and cardiovascular risk, the ankle/arm blood pressure index (AAI) has not yet been the matter of study evaluating its feasibility and reliability by nonspecialist doctors in a general population. This study was planned for two steps. In step 1, the measurement of AAI, (ratio between Doppler systolic pressure at the ankle for each lower limb and the highest value of Doppler systolic pressure of the two upper limbs), should be performed by 50 general practitioners (GPs), 50 social security center physicians, and 50 occupational health physicians in 3,000 male smokers, 40 to 59 years, without clinical cardiovascular disease. In step 2, AAI measurement, coupled with echography-Doppler of iliofemoral arteries, should be repeated by a specialist in all subjects with decreased AAI (<0.90) and the first two subjects with normal AAI recruited in step 1 by each nonspecialist. The number of physicians and subjects participating in step 1 was lower than planned (80 physicians and 962 subjects) with the greatest defect for GPs (six physicians and 35 subjects) and the prevalence of decreased AAI was low (28 subjects). AAI measurement was repeated in step 2 in only 12 subjects with decreased AAI in step 1 and in 124 subjects with normal AAI in step 1. Five of the six subjects with decreased AAI in step 2 also had decreased AAI in step 1 and 123 of the 130 subjects with normal AAI in step 2 also had normal AAI in step 1. As regards echographic stenosis, decreased AAI had a sensitivity of 44% and a specificity of 98%. AAI seems more feasible for occupational health physicians and social security center physicians and AAI is also reliable for nonspecialists previously trained, but its predictive value as regards echographic stenosis is poor in asymptomatic subjects, which may limit its usefulness for detecting preclinical atherosclerosis.

[Quantitative assessment of carotid stenosis: comparison between Doppler ultrasound, spiral computed tomography angiography, magnetic resonance angiography and digital angiography]. / Quantification du degré de sténose carotidienne. Comparaison entre l'échographie Doppler, le scanner hélicoïdal, l'imagerie par résonance magnétique et l'angiographie numérise.

BACKGROUND: The North American Symptomatic Carotid Endarterectomy Trial has confirmed the benefit of carotid endarterectomy in comparison to medical treatment in stroke prevention in symptomatic patients having a carotid stenosis of 70% or more. The Asymptomatic Carotid Atherosclerosis Study has concluded that the benefit of surgical treatment remains significant in asymptomatic patients with 60% (or more) stenosis of the ipsilateral internal carotid artery, when mortality rate remains inferior to 3%. In these two trials, angiography has been used to quantify the stenosis. Though this test is carrying some neurological and renal risks, replacing the angiography stenosis grading for a non or less invasive test, seems to be permissible. METHODS: In our retroprospective study, the assessments of the carotid stenosis by several non-invasive tests findings were compared to the angiography results. Nineteen carotid arteries of fifteen patients, both symptomatic and asymptomatic, having a carotid stenosis at least 60% or more and being detected by the Doppler ultrasound were explored either by magnetic resonance angiography (MRA), spiral computed tomography angiography (SCTA) and angiography. RESULTS: The ultrasonography and angiography findings were well correlated (r=0,88; p<0.002) according to the Spearman test. The assessments of the MRA were better correlated to the angiography than to the SCTA (respectively r=0.91, p<0.0001 and r=0,68, p<0.001). Using both ultrasonography and MRA as a confirmatory test, the rate of injustified carotid endarterectomy was 25%. And this rate rose up to 33% when the ultrasonography was used with the SCTA. It is noteworthy that negative predictive value of ARM was 100%. To reduce the mortality rate, several surgical teams managed the carotid stenosis without angiography. CONCLUSION: MRA could replace angiography, on condition that the rate of unjustified carotid endarterectomy lowers and becomes acceptable. Far reaching complementary studies are necessary to confirm the fiability of those non-invasive tests. In order to raise the benefit to carotid endarterectomy, the research studies should turn to the predictive score determination of a surgical international risk and towards the "High benefit" patients groups after endarterectomy.

Reproducibility in ultrasonic characterization of carotid plaques.

BACKGROUND AND PURPOSE: Echolucent carotid plaques compared with echogenic plaques could carry a significant risk of transient ischemic attacks and strokes, but the reproducibility of new ultrasonic methods has not yet been proved. The objective was to evaluate interobserver and intraobserver agreement in characterizing the carotid plaques studied by both B mode imaging and color Doppler imaging, which is the only ultrasonic method available for recognizing anechoic lesions. METHODS: Fifty-three carotid plaques greater than 40% in diameter were selected from four centers and simultaneously analyzed by 9 observers. Five types of plaques were defined by their echo structure: class I = uniformly anechogenic, class II = predominantly hypoechogenic with >50% hypoechogenic area, class III = predominantly echogenic with >50% echogenic area, class IV uniformly echogenic, class V = unclassified plaques. The luminal surface was characterized as either 1 = regular, 2 = recess of more than 2 mm in depth and width, or 3 = unclassified. Agreement of these variables was calculated by using the kappa index, agreement proportion and an intraclass correlation coefficient. RESULTS: Interobserver reproducibility was only fair for type I (kappa = 0.47) and for the luminal surface (class 1, kappa = 0.52 and class 2, kappa = 0.41). Agreement proportion was 0.51 in hypoechoic plaques and 0.64 in the determination of the regular surface. Mean intraobserver agreement was fair (kappa = 0.47 +/- 0. 1) for plaque echogenicity to good (kappa = 0.63 +/- 0.19) for surface. CONCLUSION: This study shows that the semiquantitative classification, first developed by Gray-Weale, then by Nicolaides, could be improved, thus giving rise to a new outlook in the debated field of ulcerations.

[Renal stenosis in hypertensive children. Doppler/arteriographic correlation]. / Sténoses rénales chez les enfants hypertendus. Corrélation Doppler/arteriographie.

To evaluate the reliability of Doppler-ultrasonography in identifying children with renal artery stenosis among those with hypertension, we compared Doppler ultrasonography results in 29 hypertensive children (mean age: 8.3 +/- 4.7 years) with angiography. Doppler-ultrasonography and arteriography were performed within a period less than two months. First, we established normal values in 40 normotensive children (mean age: 8.4 +/- 4.5 years). The diagnosis of renal artery stenosis was settled when maximal systolic velocities where > or = to 1.70 m.s-1. Peak systolic velocities values of Doppler-ultrasonography were significantly higher in patients with proven angiographic renal artery stenosis (3.56 +/- 0.70 m.s-1) than in hypertensive patients with normal renal arteries at angiography (1.02 +/- 0.29 m.s-1, p < 0.0001), and than in normotensive healthy children (1.05 +/- 0.33 m.s-1, p < 0.0001). We observed 3 false negative and 2 false positive diagnoses with Doppler-ultrasonography. Of the 3 false negatives, one had a stenosis on a right and posterior segmental artery and the other had bilateral and multiply intra-renal artery stenosis with few hemodynamic significance. The 2 false positives were due to a sinuous main renal artery and to a technical mistake, respectively. In another patient, Doppler-ultrasonography revealed a tight main renal artery stenosis, not detected by arteriography. Renal artery stenosis was subsequently confirmed by a second arteriography. Our results showed a sensitivity of 88%, a specificity of 93%, a positive predictive value of 92% and a negative predictive value of 89%, demonstrating the reliability of Doppler-ultrasonography for the diagnosis of renal artery stenosis in hypertensive children. With the use of a rigorous methodology and the increasing experience of the operators, diagnostic errors of renal artery stenosis are currently avoidable. Nevertheless, it is not excluded that intra-renal artery stenosis with few hemodynamic significance might be missed by Doppler-ultrasonography.

[Does the inferior vena cava have 2 surfaces and 2 borders also?]. / La veine cave inférieure a-t-elle aussi deux faces et deux bords?

The vena cava that has a preferential flattening axis, has also 2 wall sides and 2 borders. The back wall fits closely round on the back vertebral plane and the main colaterals terminate on the borders of the vein. TM echography perfectly analyses the movements of the walls of the vein, as well as the respiratory and auricular movements. In a lying patient, echo-doppler colour shows the expiratory acceleration of the vena cava flow in subrenal area associated with an inspiratory slowing down (as well as for the femoral veins) and the inspiratory acceleration of the flow in suprarenal area associated with an expiratory slowing down. In a standing patient, the vena is cylindrical. When he/she walks on a treadmill, the diameter of the cava seems to be constant, i.e. quasi identical to the aorta's, as fluxes vary in the aorta according to the ventricular contractions and in the LVC according to the patient's gait.

[Evaluation of the results of the curative treatment of varices using 3 scoring systems: clinical, Doppler and echographic]. / Evaluation des résultats des thérapeutiques curatives des varices par trois scores: clinique, Döppler et échographique.

There have been many studies reporting results of curative treatment of varicose veins. Four methodological errors are nevertheless often committed: groups of varicose vein patients not comparable with regard to the degree of venous dilatation; insufficient objective parameters; population inadequately followed up; retrospective studies. It was felt necessary to develop systems for the quantification of varicose disease. These systems provide three grades: a clinical grade, a Doppler grade and an ultrasonographic grade. Clinical grade essentially involves the maximum diameter of varicose veins found by palpation and expressed in millimetres. The Doppler grade takes into account the maximum duration of the reflux wave in compression-decompression manoeuvres. The ultrasonographic grade also involves the maximum diameter of the varicose system. These grades enable the numerical assessment of the results of curative treatment of varicose veins, as well as forming the basis for statistically satisfactory epidemiological surveys.

[Tissue identification of carotid lesions using ultrasound]. / Caractérisation tissulaire des lésions carotidiennes par échotomographie.

Technical progress in echotomography has made it possible to identify a number of structures within the atheromatous lesion itself. Such echotomographic data were compared with peroperative findings and histology of the endarterectomy specimen in the context of carotid pathology. Appearances were differentiated in terms of the density and homogeneity of the echos obtained. Heterogeneous and relatively undense lesion corresponded in the majority of cases with moveable intraluminal matter or intraplaque hematomas. False negatives were due in one case to technical impossibility (calcifications) and in one case to multiple ulcerations. Regular and homogeneous appearances corresponded to fibrous plaques, rich in collagen and free of potential emboligenic material. Preoperatively, echotomography may be used to assess the histological characteristics of a plaque with a high degree of sensitivity and good specificity. This new approach may help in the choice of treatment and will improve knowledge of the natural history of carotid lesions necessary for the study of preventive treatment, in particular in asymptomatic patients.

[Value of plethysmographic methods as a means of monitoring arteriopathies]. / Valeur des méthodes pléthysmographiques comme moyen de surveillance à terme d'une artériopathie.

Plethysmography provides an original solution to the study of arteriopathy, complementing other non-invasive investigational methods. The different fields of application are discussed, and the diagnostic and prognostic value of each of them outlined. Methods used include: pulsed plethysmography, measurement of segmental pressures, hyperemia test, irrigraphy and measurement of segmental blood flow. Principal advantages of the technique are undoubtedly the evaluation of global function, monitoring of therapy and, to some degree, prediction of course.

[Can lasers have a place in the treatment of pigmentation?]. / Le laser peut-il avoir une place dans le traitement des pigmentations?

After reviewing the physical principles of laser radiation, the author briefly describes the various tissue effects depending on the wavelength and the power used. This discussion reveals the various applications of laser in the field of phlebology, some of which are currently in use, others remain to be developed. A review of the literature only reveals a few studies limited in particular to varicose veins, with fairly disappointing results. The papers concerning pigmentations are even fewer. Pulsed emissions would appear to be a useful method for the future. The theoretical principles of this treatment and the studies which have been conducted in other specialties justify further research into the application of this technique in phlebology, in combination with the other forms of available treatment and in the context of the range of phlebological pathophysiology.

[Contribution of the Doppler examination to the venous pathology of the lower extremities]. / Apport de l'examen Doppler en pathologie veineuse des membres inférieurs.

The fluxometer "Doppler" is widely used in venous pathology but is usually limited to a mere "sounding" of the femoral and popliteal segments. The author recommends a full methodology based on venous physiopathology. Some very simple modifications of the apparatus mean that it is possible to get graphic outlines; this makes analysis easier and means that results can be reproduced. At the acute thrombosis stage diagnosis and localization are remarkably reliable. At the chronic stage the anatomic aspect is of less interest than the functional aspects, as the Doppler is of much greater use than phlebography. The advantages of this atraumatic method are obvious if results of the Doppler examination are accurate; its only conditions are a thorough knowledge of the physiopathology and great precision in the analysis.