Isolated distal deep vein thrombosis: What have we learnt from the OPTIMEV study?

The OPTIMEV (OPTimisation de l'Interrogatoire dans l'évaluation du risque throMbo-Embolique Veineux) study has provided some important and innovative information for the management of lower extremity isolated distal deep vein thrombosis (distal DVT). Indeed, if distal deep-vein thrombosis (DVT) therapeutic management is nowadays still debated, before the OPTIMEV study, the clinical relevance of these DVT itself was questioned. Via the publication of 6 articles, between 2009 and 2022, assessing risk factors, therapeutic management, and outcomes of 933 patients with distal DVT we were able to demonstrate that: - When distal deep veins are systematically screened for suspicion of DVT, distal DVT are the most frequent clinical presentation of the venous thromboembolic disease (VTE). This is also true in case of combined oral contraceptive related VTE. - Distal DVT share the same risk factors as proximal DVT and constitute two different clinical expressions of the same disease: the VTE disease. However, the weight of these risk factors differs: distal DVT are more often associated with transient risk factors whereas proximal DVT are more associated with permanent risk factors. - Deep calf vein and muscular DVT share the same risk factors, short and long-term prognoses. - In patients without history of cancer, risk of unknown cancer is similar in patients with a first distal or proximal DVT. - After 3years and once anticoagulation has been stopped, distal DVT recur twice less as proximal DVT and mainly as distal DVT; However, in cancer patients, prognosis of distal and proximal DVT appear similar in terms of death and VTE recurrence.

Milk production and efficiency of utilization of nitrogen, metabolizable protein, and amino acids are affected by protein and energy supplies in dairy cows fed alfalfa-based diets.

Alfalfa has a lower fiber digestibility and a greater concentration of degradable protein than grasses. Dairy cows could benefit from an increased digestibility of alfalfa fibers, or from a better match between nitrogen and energy supplies in the rumen. Alfalfa cultivars with improved fiber digestibility represent an opportunity to increase milk production, but no independent studies have tested these cultivars under the agroclimatic conditions of Canada. Moreover, decreasing metabolizable protein (MP) supply could increase N use efficiency while decreasing environmental impact, but it is often associated with a decrease in milk protein yield, possibly caused by a reduced supply of essential AA. This study evaluated the performance of dairy cows fed diets based on a regular or a reduced-lignin alfalfa cultivar and measured the effect of energy levels at low MP supply when digestible His (dHis), Lys (dLys), and Met (dMet) requirements were met. Eight Holstein cows were used in a double 4 × 4 Latin square design, each square representing an alfalfa cultivar. Within each square, 4 diets were tested: the control diet was formulated for an adequate supply of MP and energy (AMP_AE), whereas the 3 other diets were formulated to be deficient in MP (DMP; formulated to meet 90% of the MP requirement) with deficient (94% of requirement: DMP_DE), adequate (99% of requirement: DMP_AE), or excess energy supply (104% of requirement; DMP_EE). Alfalfa cultivars had no significant effect on all measured parameters. As compared with cows receiving AMP_AE, the dry matter intake of cows fed DMP_AE and DMP_EE was not significantly different but decreased for cows fed DMP_DE. The AMP_AE diet provided 103% of MP and 108% of NEL requirements whereas DMP_DE, DMP_AE, and DMP_EE diets provided 84, 87, and 87% of MP and 94, 101, and 107% of NEL requirements, respectively. In contrast to design, feeding DMP_EE resulted in a similar energy supply compared with AMP_AE, although MP supply has been effectively reduced. This resulted in a maintained milk and milk component yields and improved the efficiency of utilization of N, MP, and essential AA. The DMP diets decreased total N excretion, whereas DMP_AE and DMP_EE diets also decreased milk urea-N concentration. Reducing MP supply without negative effects on dairy cow performance is possible when energy, dHis, dLys, and dMet requirements are met. This could reduce N excretion and decrease the environmental impact of milk production.

Assessment of primary lymphedema and post-thrombotic lower limb edema patient's pathway.

OBJECTIVES: To assess: (1) lower limb primary lymphedema or post-thrombotic syndrome patient's pathway in terms of health care professional use and (2) if aetiology of edema has an impact on this pathway. METHODS: Ancillary survey of the transversal prospective CHROEDEM pilot study. Forty patients with either lower limb primary lymphedema or post-thrombotic syndrome were invited to participate. RESULTS: Seventy-five percent of primary lymphedema patients and 50% of post-thrombotic patients benefited from a multidisciplinary management (P=0.10) including the general practitioner, the vascular medicine physician and either a physiotherapist (particularly in case of primary lymphedema), a registered nurse (particularly in case of post-thrombotic syndrome). Main ambulatory health care professionals' correspondent of hospital-based vascular medicine physicians were general practitioners (80%) in post-thrombotic patients, and general practitioners (60%) and physiotherapists (45%) in primary lymphedema patients. Pharmacists were also involved in patient education. CONCLUSION: Management of primary lymphedema and post-thrombotic related chronic edema is usually multidisciplinary. General practitioners and vascular medicine physicians are the cornerstones of this management, that also involves the physiotherapist in case of primary lymphedema and in a lesser extent the registered nurse and the pharmacist. This suggests that these five healthcare professional should play a key role in case of development of standardized patient pathways for primary lymphedema and post-thrombotic syndrome.

[Takayasu's arteritis and atherosclerosis]. / Artérite de Takayasu et athérosclérose.

INTRODUCTION: Chronic inflammatory diseases such as systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA), are accompanied by high cardiovascular morbidity and mortality secondary to accelerated and premature atherosclerosis. Atherosclerosis is correlated with chronic systemic inflammation independently of the factors for cardiovascular risk. Vasculitis of large arteries such as Takayasu's disease, are characterized both by chronic systemic inflammation and local parietal vascular inflammation. METHODS: We prospectively analyzed in a case-control study, a group of 64 carriers of Takayasu's arteritis patients with a mean age of 41 years [±11.94], a group of 50 RA female patients aged 45 years [±10.27], and a control group with an average age of 44 years [±12.63]. We recorded classic cardiovascular risk factors and used the Framingham equation to calculate the risk. We measured the intima-media thickness (IMT) in the carotids and noted the presence of carotid, aortic and femoral atheroma. RESULTS: The mean calculated cardiovascular risk was 3.5 % in the Takayasu's group. It was 4.4 % in the RA group, and 4.5 % in controls with no significant difference between the three groups (P=0.153). Subclinical atherosclerosis defined by IMT> 0.70mm and/or the presence of atheroma plaque was found in 87 % of Takayasu's patients versus 76 % of RA patients, (P=0.088) and 48 % of controls (P<0.001). Most atherosclerotic plaques were found in the Takayasu group. Compared to the control group the carotid intima-media thickness was significantly higher in the Takayasu group. The average IMT in the Takayasu group was 0.91mm [±0.368], 0.76mm [±0.151] for the PR group, and 0.71mm [±0.141] for controls. DISCUSSION: Atherosclerosis observed in Takayasu's disease was accelerated and premature, occurring in young patients with a low overall cardiovascular risk. Recent data support the central role of inflammation in all stages of atherogenesis from endothelial dysfunction to plaque rupture. Systemic inflammation associated with local parietal inflammation observed in Takayasu's arteritis, appears to be responsible for accelerated and premature atherosclerosis. The results of our study and the literature review favor an active strategy for cardiovascular prevention in Takayasu's disease.

[Prevalence and risk factors of sub-renal abdominal aortic aneurysm in an Algerian population aged over 60]. / Prévalence et facteurs de risque de l'anévrysme de l'aorte abdominale sous-rénale dans une population algérienne âgée de plus de 60 ans.

INTRODUCTION: The prevalence of abdominal aortic aneurysm (AAA) in the general population in our country is not known, our aim was to evaluate it in patients over 60 years of age, to specify the risk factors and to evaluate the extension of aneurysmal disease and multisite subclinical atherosclerosis. METHODS: Descriptive, transversal, study collecting the data of a systematic ultrasound screening of sub-renal AAA in subjects receiving care in two Algerian hospital structures. Epidemiological data, AAA risk factors, cardiovascular disease risk factors (CVD RF) and the personal history (cardiovascular diseases, chronic obstructive pulmonary disease) and family history of AAA were collected during the screening. An abdominal echography was performed in all patients. A biological and morphological assessment was carried out for AAA cases detected. Multivariate logistic regression analysis was used to study the factors associated with AAA. RESULTS: Systematic screening for 600 patients revealed an overall AAA prevalence of 2.2% (n=13). In multivariate analysis a positive association with AAA was observed with active smoking, its duration in years and its intensity in year-packages; with hypertension, dyslipidemia and a history of cardiovascular events. While a negative association was observed with a smoking cessation of more than 20 years, type 2 diabetes and android obesity. The study of detected AAA cases found five cases of aneurysm isolated from the primary iliac artery but no popliteal and/or femoral aneurysm. The carotids were atheromatous in more than 80% of cases and the arteries of the lower limbs in more than one-third of cases. CONCLUSION: The prevalence of AAA in our population (2.2%) corresponds to the prevalence reported recently in Europe, but it would have been higher if the screening had targeted males and smokers. The factors associated with AAA in our patients are similar to those described in the literature.

[Time in therapeutic range (TTR) and follow-up of patients on vitamin K antagonist: A cohort analysis]. / Utilité du TTR (temps passé dans la cible thérapeutique) dans le suivi des patients sous antivitamine K : analyse d'une cohorte de patients.

INTRODUCTION: Despite the increasing utilization of direct oral anticoagulant (DOAC) prescriptions, vitamin K antagonists (VKAs) remain the treatment of choice for treating and preventing thromboembolic events. The morbidity and mortality of VKAs are partly due to the difficulty of keeping the patient within the therapeutic range. For patients treated by VKA, time in therapeutic range (TTR) is a quality parameter of treatment, widely used in clinical trials but rarely by prescribers. It is well established that its use correlates with the risk of hemorrhage, thrombosis or mortality. We studied this parameter in a cohort of patients to evaluate the quality of their therapeutic follow-up and tried to identify risk factors for low TTR. METHODS: The study was made in collaboration with LaboSud Oc Biologie for a duration of 4 months. It included 3387 patients representing 2,4029 INR. We calculated the patients' TTR. The laboratory transmitted to us the sex and age of each patient and the VKA molecule used, the therapeutic range and the specialty of the prescriber. We then analyzed the odds ratio associated with these different factors. RESULTS: The mean TTR was 68%, close to the TTR recommended by scientific societies. Patient's sex was the only statistically correlated factor, with a worse equilibrium in females taking VKAs (OR=1.22, 95% CI: 1.06-1.39, P=0.00552). Many factors usually correlated with poor equilibrium under VKA have not been studied due to lack of information. CONCLUSION: Given the context of economic restriction and the TTR of our cohort close to the recommended 70%, there would be no benefit in terms of safety to prefer DOAC for the patients involved in this study. Regular monitoring of the individual patient's as well as the cohort's TTR should optimize the management of patients receiving VKAs.

[Direct oral anticoagulants (DOACS): A necessary focus]. / Anticoagulants oraux directs (AOD) : une mise au point nécessaire.

In 2008, we decided to enter the era of direct oral anticoagulants (DOACS). Was that the right decision to make? The answer will depend on how well we meet the conditions of proper use. This means avoiding underdosing and overdosing as well as understanding how DOACS were validated so that our prescriptions fulfill their role in the management of thrombotic disease.

[Quality standards for ultrasonographic assessment of peripheral vascular malformations and vascular tumors. Report of the french society for vascular medicine. 2018 Update]. / Standards de qualité pour la pratique de l'examen écho-Doppler dans l'étude des malformations et tumeurs vasculaires. Rapport de la Société française de médecine vasculaire (SFMV) : actualisation 2018.

The quality standards of the French Society of Vascular Medicine for the ultrasonographic assessment of vascular malformations are based on the two following requirements: (1) technical know-how: mastering the use of ultrasound devices and the method of examination; (2) medical know-how: ability to adapt the methods and scope of the examination to its clinical indication and purpose, and to rationally analyze and interpret its results. AIMS OF THE QUALITY STANDARDS: To describe an optimal method of examination in relation to the clinical question and hypothesis. To homogenize practice, methods, glossary, and reporting. To provide good practice reference points, and promote a quality process. ITEMS OF THE QUALITY STANDARDS: The 3 levels of examination; their clinical indications and goals. The reference standard examination (level 2), its variants according to clinical needs. The minimal content of the examination report; the letter to the referring physician (synthesis, conclusion and proposal for further investigation and/or therapeutic management). Commented glossary (anatomy, hemodynamics, semiology). Technical bases. Setting and use of ultrasound devices. Here, we discuss ultrasonography methods of using of ultrasonography for the assessment of peripheral vascular malformations and tumors (limbs, face, trunk).

[Treatment of post-catheterization pseudoaneurysms by ultrasound-guided thrombin injection: A single-center experience and practical guideline]. / Le traitement des faux anévrismes postcathétérisme par injection échoguidée de thrombine : expérience monocentrique et guide pratique.

Ultrasound-guided thrombin injection has been shown to be a safe and effective treatment for iatrogenic post-catheterization pseudoaneurysms, but still is underused in France. We report our single-center experience and propose a technical guideline for ultrasound-guided thrombin injection. Ultrasound-guided thrombin injection should be considered to be the first-line treatment of iatrogenic pseudoaneurysms.

Renal function and venous thromboembolic diseases.

Anticoagulant agents have been approved by international regulatory agencies to prevent and treat venous thromboembolism (VTE). However, chronic kidney disease (CKD) is: (1) highly frequent in VTE patients; (2) strongly linked to VTE; and (3) a risk factor for cardiovascular morbidity/mortality and fatal pulmonary embolism. Therefore, an increasing number of patients are presented with CKD and VTE and more and more physicians must face the questions of the management of these patients and that of the handling of anticoagulant agents in CKD patients because of the pharmacokinetic modifications of these drugs in this population. These modifications may lead to overdosage and dose-related side effects, such as bleeding. It is therefore necessary to screen VTE patients for CKD and to modify the doses of anticoagulants, if necessary.

[Vitamin K antagonist, direct oral anticoagulants: Where is the truth?] / Antivitaminiques K, anticoagulants oraux directs : où est la vérité ?

Vitamin K antagonists (VKA) and direct oral anticoagulants (DOACs) are now in competition. The companies are trying to replace VKA by DOACs, totally or at least greatly VKA should VKA disappear in favor of DOACs? There are still many questions about DOACs. The purpose of this article is to make a well-considered decision in this area. The aim is not to denigrate one or the other but to share things between these two families of anticoagulants. Physicians using these drugs must have a full knowledge about compared efficacy and safety. We feel necessary to increase distance between effective results of the clinical trials and industrial communication around DOACs.

[Venous thrombo-embolic disease in cancer. Low molecular weight heparin indications]. / Maladie thrombo-embolique veineuse au cours du cancer. Indication des héparines de bas poids moléculaires.

Cancer and venous thrombo-embolic disease (VTE) are closely related. Indeed, cancer can reveal VTE and VTE can be the first sign of cancer. Low molecular weight heparin (LWMH) is now the first line treatment in cancer patients. Compliance with marketing authorizations and guidelines are crucial for patient-centered decision-making. This work deals with the prescription of LWMH in patients who develop VTE during cancer in order to better recognize what should or should not be done. The patient's wishes must be taken into consideration when making the final therapeutic decision. The other treatments are discussed: vitamin K antagonists and direct oral anticoagulants (DOACs) may be useful.

[A new specialty is born: Vascular medicine]. / Naissance d'une nouvelle spécialité : la médecine vasculaire.

On the 4th of December 2015, the French authorities officially recognized the birth of a specialty in vascular medicine entitled CO-DES cardiology-vascular/vascular Medicine. France is the 7th country to obtain this specialty after Switzerland, Germany, Austria, Czech Republic, Slovakia and Slovenia, six countries in the EEC. It has taken years to achieve a long but exciting experience: we went from hopes to disappointments, sometimes with the blues, but lobbying helping… with sustained confidence. This article tells the story of 30 years of struggle to achieve this vascular medicine specialty. Gaston Bachelard wrote: "Nothing is obvious, nothing is given, all is built." For the construction of vascular medicine, we had to overcome many obstacles, nothing was given to us, everything was conquered. Beware "The specialist is one who knows more and more things about an increasingly restricted field, up to 'knowing everything about nothing"' recalled Ralph Barton Ferry, philosopher; so there is room for modesty and humility but also convictions. The physical examination will remain the basis of our exercise. But let us recall the contributions of all those vascular physicians who practiced in the past, together with those currently active, who built day after day, year after year, a vascular medicine of quality. It is because of the trust of our colleagues and our patients that we can occupy the place that is ours today.

[Ultrasound screening of abdominal aortic aneurysm: Lessons from Vesale 2013]. / Dépistage échographique de l'anévrisme de l'aorte abdominale - les enseignements de Vésale 2013.

Although aneurysm of the abdominal infra-renal aorta (AAA) meets criteria warranting B mode ultrasound screening, the advantages of mass screening versus selective targeted opportunistic screening remain a subject of debate. In France, the French Society of Vascular Medicine (SFMV) and the Health Authority (HAS) published recommendations for targeted opportunistic screening in 2006 and 2013 respectively. The SFMV held a mainstream communication day on November 21, 2013 in France involving participants from metropolitan France and overseas departments that led to a proposal for free AAA ultrasound screening: the Vesalius operation. Being a consumer operation, the selection criteria were limited to age (men and women between 60 and 75 years); the age limit was lowered to 50 years in case of direct family history of AAA. More than 7000 people (as many women as men) were screened in 83 centers with a 1.70% prevalence of AAA in the age-based target population (3.12% for men, 0.27% for women). The median diameter of detected AAA was 33 mm (range 20 to 74 mm). The prevalence of AAA was 1.7% in this population. Vesalius data are consistent with those of the literature both in terms of prevalence and for cardiovascular risk factors with the important role of smoking. Lessons from Vesalius to take into consideration are: screening is warranted in men 60 years and over, especially smokers, and in female smokers. Screening beyond 75 years should be discussed. Given the importance of screening, the SFMV set up a year of national screening for AAA (Vesalius operation 2014/2015) in order to increase public and physician awareness about AAA detection, therapeutic management, and monitoring. AAA is a serious, common, disease that kills 6000 people each year. The goal of screening is cost-effective reduction in the death toll.

Comparative evolution of carotidynia on ultrasound and magnetic resonance imaging.

Carotidynia is rare and associates neck pain with tenderness to palpation usually over the carotid bifurcation, the diagnosis of which is based on magnetic resonance imaging (MRI). Ultrasounds (US) are also frequently used but their accuracy in predicting the course of the disease is unknown. We are reporting the case of a 52-year-old man who presented a typical carotidynia. Clinical symptoms, ultrasound and MRI imaging evolution were closely correlated. Our case suggest that after a first MRI to set a positive diagnosis of carotidynia and exclude differential diagnoses, US which is more widely available and less expensive could constitute the imaging of reference for the follow-up.