Is it justified to search for cancer in patients with peripheral arterial disease?

BACKGROUND: Cancer is the leading cause of death in European countries, ahead of cardiovascular diseases. Cancer is also the most common co-morbidity among patients hospitalized for the management of cardiovascular diseases. Through an overview, we searched for the frequency and types of cancer associated with peripheral arterial disease (PAD) in order to address the relevance of cancer screening in patients with PAD. METHODS: We searched in PubMed database from 1996 to 2020 for retrospective and prospective cohort or cross-sectional or randomized studies evaluating the frequency of all types of cancer in patients with PAD excluding patients with aneurysmal disease. The keywords used were: peripheral arterial disease, arterial thrombosis, acute leg ischemia, critical leg ischemia, chronic leg ischemia, intermittent claudication, malignant tumor, cancer. RESULTS: Based on published studies, the frequency of cancer in patients with PAD varied widely from 3.8 to 30.4% depending on study design, population, method used to screen for cancer and study period. In medical records database and registers,cancer prevalence varied from 3,8% to 22,4% in 4 retrospective studies of patients with acute limb ischemia and from 10.5 to 30.4% in 3 prospective studies of patients with acute limb ischemia, critical ischemia or intermittent claudication. In 3 retrospective analyses from 2 population-based cohorts and health insurance claims data, incidence of cancer in patients with intermittent claudication, acute limb ischemia or peripheral arterial disease varied from 8% to 11.7%. The frequency of cancer in PAD patients appeared higher than in the general population. Tobacco-dependent cancers seemed to be the most common cancers in PAD. Cancers were also more frequent in case of anemia, amputation and iterative bypass thrombosis in few studies. CONCLUSION: Although there is no recommendation for cancer screening in patients with PAD, the high prevalence of cancer raises the question of screening patients at high risk such as those with acute or critical limb ischemia and especially in case of severe tobacco use, anemia, amputation and iterative bypass thrombosis. These results call for further studies with larger sample size and long term follow-up.

[Characteristics of chronic wounds in substance abuse: A retrospective study of 58 patients]. / Caractéristiques des plaies chroniques chez les toxicomanes : étude rétrospective de 58 patients.

BACKGROUND: Drug addiction causes chronic wounds (CW) responsible for severe complications. Very few studies are available on this topic. The aim of our study was to describe the demographic, clinical and etiological characteristics as well as the course of CW in drug addicts. PATIENTS AND METHODS: This was a retrospective and prospective multicenter study including all drug addicts with CW. RESULTS: We included 58 patients (17 prospectively), 84.5% of whom were male, of median age 43 years, presenting multiple CW as a result of intravenous (78.2%), inhaled (41.1%) and/or snorted (20%) drug abuse. Addiction to opioids (68.4%), cocaine (47.4%) and/or cannabis (40.4%) was ended and/or treated through substitution in 79.3% of patients. CW were fibrinous and necrotic (42.9 to 53.6%), recurrent (54.2%), and in some cases had been present for more than 1 year (61.5%). Intravenous drug addiction was associated with large, fibrinous, ulcers in a setting of venous and lymphatic insufficiency (74%). Only 23% of these wounds involved the upper limbs. Necrotic ulcers associated with clinical arteriopathy were described mainly with inhaled addiction. Abscesses (50%) and erysipelas (29.3%) were the most common cutaneous complications. After 3 months, 50% of CW were improved and 29.2% of patients were lost to follow-up. DISCUSSION: Drug abuse-related CW occurred preferentially in young men with history of intravenous abuse. For the most part, CW were seen on the legs and were associated with venous and lymphatic insufficiency, and the resulting major risk for cutaneous infection increased morbidity and mortality in this population in whom medical follow-up is inherently complicated.

[Arterial bypass iterative thrombosis and cancer: three cases]. / Thromboses itératives de pontages artériels et cancer : à propos de trois cas.

Cancer associated with venous thromboembolic disease has been recognized since Trousseau, but a link between cancer and iterative arterial thrombosis is rarely described. We report three cases of patients with iterative bypass thrombosis in whom cancer was subsequently diagnosed: lung cancer in one patient and hepatocarcinoma and bladder cancer in the others. Smoking and hypertension were risk factors in both patients. The link between arterial thrombosis and cancer is probably multifactorial. In case of iterative arterial bypass thrombosis, the search for cancer is as useful as the control of cardiovascular risk factors and the search for antiphospholipid syndrome, since patient management can be affected.

[Importance of searching for hypogonadism in patients with a longstanding history of leg ulcers?]. / Quel est l'intérêt de rechercher un hypogonadisme chez un patient présentant des ulcères de jambe récidivant depuis l'âge de 20 ans?

Androgen replacement therapy has been reported to have a beneficial effect in patients with Klinefelter's syndrome or perforating plantar ulcers. We report the case of a 55-year-old man with a 35-year history of leg ulcers and venous insufficiency. His leg ulcers healed 4 months after a management scheme including vascular rehabilitation (intermittent pressure therapy, ankle mobilization, multiple layer compression bands on the lower limbs), skin grafts and foam sclerotherapy of the great saphenous vein. The ulcers recurred 1 month later. This recurrence and the unusually young age for development of venous leg ulcers led to a search for a rare cause. The diagnosis of anterior pituitary failure was established. Sclerotherapy and androgen replacement therapy led to complete healing without recurrence at the 1-year follow-up visit. A link between androgen deficiency and fibrinolysis, protein synthesis deficiency, inflammation and trophicity is well documented in the literature. A search for hypogonadism may be useful in young patients presenting a longstanding history of leg ulcers or in patients with suspected andropause irrespective of age.

[Designing a therapeutic education program for patients with lymphedema: live with lymphedema]. / Conception d'un programme d'éducation thérapeutique pour les patients porteurs de lymphœdème: « vivre avec un lymphœdème ¼

BACKGROUND: Lymphedema is a chronic condition considered to be rare in its primary form and potentially frequent in women after breast surgery for cancer: 27,000 new cases annually. Therapeutic management is a serious challenge. In France, the health authorities (Haute Autorité de santé [HAS]) have recently proposed that appropriate management practices for lymphedema include "patient education". The HAS and the National institute for health care prevention and education also published a methodology guide devoted to structuring a therapeutic education program for patients with chronic disease. Current hospital regulations state that this education program is part of the care to be delivered to patients with chronic disease and that it must comply with the national directives. The purpose of our present work was to present the concept and the contents of a patient education program entitled "Live with lymphedema" designed for patients with lymphedema and developed within the inpatient-outpatient network GRANTED in Sud-Isère. METHODS: A standard detailed educative approach was applied. It was designed after the educational program for patients with lower limb arterial occlusive disease authorized by the Rhône-Alpes regional health agency. It was adapted to the specific problematic of patients with lymphedema, including medical management, rehabilitation, dermatology and nutritional aspects. It was developed in cooperation with patients and favors local associative actions. RESULTS: The specifically structured program included three therapeutic education consultations and five workshops. Less than one year after its institution, more than 30 patients have participated in the program. DISCUSSION: We report a structured patient education program designed for patients with lymphedema. This program was authorized by the Rhône-Alpes regional health agency in March 2011 and is in compliance with the national directives and HAS guidelines.

New rehabilitation program for intermittent claudication: Interval training with active recovery: pilot study.

BACKGROUND: Peripheral arterial disease (PAD) is one of the complications of atherosclerosis. Intermittent claudication is the second stage of PAD. In controlled studies on patients with Stage II PAD, intensive rehabilitation training has proved effective for improving the walking distance in this population. The objective of this prospective study was to determine the effects of treadmill interval training followed by active recovery (low-intensity exercise). METHODS AND RESULTS: Eleven patients with Stage II peripheral arterial disease were included in a rehabilitation program (mean age 68.3±10.3 years) for five days a week during two weeks including global exercises, exercises below and above the level of injury. The interval training program consisted of treadmill training for 30minutes twice a day (morning and evening) with a progressively increased intensity: the first week speed was increased and the second week slope was increased. Each session included five six-minute cycles. Each cycle was made of three minutes of active workout followed by three minutes of active recovery. RESULTS: All patients improved their walking distance, from a mean of 610 m (120-1930) at the beginning of the program to a mean of 1252 m (320-2870) at the end (P=0.003). All patients were very motivated by the rehabilitation training program No adverse event was reported. CONCLUSION: This study showed that an interval training program with active recovery was effective and safe for patients with Stage II peripheral arterial disease, the patients' motivation was high. This study must now be validated by a clinical trial.

[Fate of the competence of the valvular apparatus of the femoral veins after cryopreservation. Preliminary study]. / Devenir de la compétence de l'appareil valvulaire des veines fémorales après cryopréservation. Etude préliminaire.

PURPOSE: The aim of this study was to determine the impact of cryopreservation on the competency of human femoral vein valve. MATERIALS AND METHODS: Nine superficial femoral veins bearing 24 valves were harvested in brain death patients (5 men, mean age 32 years, range 16 to 63 years). Veins were divided in 24 segments bearing only one valve. Each segments was tested for reflux by using a pressure column filled with heparinized saline. After harvest, vein segments were kept in Belzer solution with antibiotics (gentamycin, colistin, lincomycin and amphotericin B). Histological study was undertaken in a fresh valve segment (n = 9). The remaining segments (n = 15) were stored in 15% dimethyl sulfoxide (DMSO) and cryopreserved in liquid nitrogen vapor for 120 days. Afterwards the 15 cryopreserved vein segments were thawed in 37 degrees C water bath and were studied for mechanical and histological changes. RESULTS: All the 24 valve segments initially tested were competent. Off the 15 cryopreserved segments only 4 (26%) were found to be non refluxive after cryopreservation. Histological study performed before cryopreservation showed a normal appearance of the vein wall (n = 9). On the contrary after cryopreservation, microscopic examination showed that in the incompetent veins, the endothelium surface was either absent or poor with a marked decrease in elastic fibres. CONCLUSION: This preliminary study indicates that DMSO cryopreservation must be improved in order to preserve vein valve competency: 26% of the cryopreserved valves remained competent. Histological findings also suggest that elastic fibres play a major role in the failure of the vein competency.

[Venous aneurysm of unusual localization revealed by a pulmonary embolism. Report of two cases]. / Anévrysme veineux de siège inhabituel révélé par une embolie pulmonaire. A propos de deux cas.

We report two uncommon cases of venous aneurysm involving the soleus vein and the saphenofemoral junction. Both cases presented with pulmonary embolism. Diagnosis of the venous aneurysm was achieved by Doppler ultrasonography during the evaluation for deep vein thrombosis. Venography showed a large fusiform aneurysm. Both aneurysms were treated by resection and ligation. At follow-up, there was no evidence of recurrent pulmonary embolism. These cases clearly illustrate the risk of pulmonary embolism associated with uncommon localizations of venous aneurysms and the potential for thrombus formation due to the venous stasis. Surgical treatment, as in the case of popliteal aneurysms, is mandatory to avoid such embolic complications.

[Deep venous thrombosis (DVT) after hip or knee prosthesis. Evaluation of practices for prevention and prevalence of DVT on doppler ultrasonography]. / Thromboses veineuses profondes (TVP) après prothèse de hanche ou de genou. Evaluation des pratiques de prévention et de la prévalence des TVP en écho-Doppler.

PURPOSE: Duplex ultrasound scanning was performed to detect deep venous thrombosis (DVT) after hip or knee arthroplasty and evaluate application of the postoperative thromboprophylaxis consensus. PATIENTS AND METHODS: A prospective multicenter study was conducted between April 1995 and April 1996 in 16 centers. Thirty angiologists included 505 patients (370 in private clinics and 135 in university hospitals). Mean patient age was 71 years. There were 288 women. Hip arthroplasty was performed in 396 patients (78%) and knee arthroplasty in 109 (22%), under general anesthesia in 323. The postoperative thromboprophylaxis consensus was recalled prior to study onset and DVT was detected 8 and 10 days after surgery by duplex ultrasonography. RESULTS: Thromboprophylaxis was prescribed by the anesthesiologist (57%), the surgeon (23%) or an angiologist (20%). Anticoagulation dosage was lower than the recommended dosage in 181 patients (36%). The prevalence of detected deep venous thrombosis was 14% (range 11-17%), including 21 cases of proximal DVT (4.2%), 33 of distal DVT (6.5%) and 17 of distal muscular DVT (3.4%). The risk of having a DVT was 1.6-fold higher in patients over 70 years of age (p = 0.04), 2.2-fold higher in case of general anesthesia (p = 0.03) and 2.1-fold higher in case of reduced mobility (p = 0.01). When heparin dosage was lower than the recommended consensus dosage, prevalence of DVT was 19% compared with 11% for patients who received the right dosage (RR = 1.7, p = 0.01). CONCLUSION: Much progress is needed in the application of the postoperative consensus on thromboprophylaxis. The high prevalence of DVT despite preventive treatment indicates that systematic detection of DVT is useful, particularly in high-risk patients or when the recommended thromboprophylaxis cannot be applied.

Leg ulcers in Klinefelter's syndrome--further evidence for an involvement of plasminogen activator inhibitor-1.

An abnormality in platelet aggregability or fibrinolysis, namely elevated activity of plasminogen activator inhibitor-1 (PAI-1), has been recently documented in patients suffering from Klinefelter's syndrome associated with leg ulceration without underlying venous insufficiency. To determine whether increased PAI-1 activity is a general feature of Klinefelter's syndrome, or more specifically associated with leg ulceration, we investigated PAI-1 influencing parameters and PAI-1 activity in two groups of patients: (i) Klinefelter patients suffering from leg ulceration (n = 7); and (ii) Klinefelter patients without leg ulceration (n = 6). On analysing PAI-1 influencing parameters such as age, body mass index, triglycerides, C-reactive protein, testosterone, smoking behaviour, the presence of diabetes mellitus, and arterial hypertension, respectively, we found no statistically significant differences between the two groups. However, PAI-1 activity in group 1 was highly significantly elevated compared with that in group two patients (P < 0.005). We conclude that (i) PAI-1 activity is not elevated in Klinefelter's syndrome in general; (ii) elevation of PAI-1 activity in patients suffering from Klinefelter's syndrome does not appear to be secondary to PAI-1 influencing parameters; and (iii) elevation of PAI-1 activity may play a crucial role in the pathogenesis of leg ulceration in Klinefelter's syndrome. Therefore, a therapy for leg ulceration in Klinefelter's syndrome that aims to return the elevated PAI-1 activity to normal should be explored.

[Chronic venous insufficiency 7 to 10 years after partial vena cava interruption with a clip]. / Insuffisance veineuse chronique 7 à 10 ans après interruption partielle de la veine cave inférieure par clip exocave.

In order to test the responsibility of inferior vena cava clips in post thrombotic venous disease, we performed a comparative retrospective study 7 to 10 years after vena cava interruption by clip. Patients were compared with patients matched for sex, age, and prior deep vein thrombosis (same period and same localisation) but without inferior vena cava partial interruption. The results show that 1) functional complaints were significantly higher in the vena cava clip group; 2) valvular incompetency, in the initially thrombosed leg, (tested by scanning duplex) was not different in the two groups: 3) inversely, on the other leg, valvular incompetency was greater in the vena cava clip group. Furthermore this valvular incompetency was principally located at a femoral level, suggesting that the vena cava clip may induce backward thrombosis; 4) complications were independent of vena cava thrombosis.

[Leg ulcer and Klinefelter syndrome]. / Ulcère de jambe et syndrome de Klinefelter.

We report a case of 47 years old patient who was admitted to hospital because of bilateral leg ulcers for 6 years. Chromosome analysis revealed XXY karyotype, confirming the clinical diagnosis of Klinefelter's syndrome. Testosterone level was low and Plasminogen Activator Inhibitor (PAI-1) was elevated. The patient was given androgen therapy which resulted in a normalization of the PAI-1 activity. The frequency of leg ulcers in patients with Klinefelter syndrome is between 6 and 12% according to studies. Different causes would explain the tendency towards leg ulcers in Klinefelter's syndrome: conjunctive tissues abnormalities were revealed in some studies. A higher frequency of venous insufficiency is reported in patients with Klinefelter's syndrome, either due to the particular morphology (obesity, taller size) or due to an androgen deficiency. A few arterial dysplasias cases of arteries's legs were described in patients with leg ulcers and Klinefelter syndrome. Haemostasis disorders presented in this case and normalized after androgen therapy will contribute to the physiopathologic discussion.