Diagnostic criteria for Buerger's disease: International Consensus of VAS - European Independent Foundation in Angiology/Vascular Medicine

Buerger's disease (BD) remains a debilitating condition and early diagnosis is paramount for its effective management. Despite many published diagnostic criteria for BD, selective criteria have been utilized in different vascular centers to manage patients with BD worldwide. A recent international Delphi Consensus Study on the diagnostic criteria of BD showed that none of these published diagnostic criteria have been universally accepted as a gold standard. Apart from the presence of smoking, these published diagnostic criteria have distinct differences between them, rendering the direct comparison of patient outcomes difficult. Hence, the expert committees from the Working Group of the VAS-European Independent Foundation in Angiology/Vascular Medicine critically reviewed the findings from the Delphi study and provided practical recommendations on the diagnostic criteria for BD, facilitating its universal use. We recommend that the 'definitive' diagnosis of BD must require the presence of three features (history of smoking, typical angiographic features and typical histopathological features) and the use of a combination of major and minor criteria for the 'suspected' diagnosis of BD. The major criterion is the history of active tobacco smoking. The five minor criteria are disease onset at age less than 45 years, ischemic involvement of the lower limbs, ischemic involvement of one or both of the upper limbs, thrombophlebitis migrans and red-blue shade of purple discoloration on edematous toes or fingers. We recommend that a 'suspected' diagnosis of BD is confirmed in the presence of a major criterion plus four or more minor criteria. In the absence of the major criterion or in cases of fewer than four minor criteria, imaging and laboratory data could facilitate the diagnosis. Validation studies on the use of these major and minor criteria are underway.

Laser Doppler imaging evaluation of nitroglycerin patch application in systemic sclerosis patients

Recent studies suggest the use of topical nitroglycerin (NTG) application in systemic sclerosis (SSc)-associated Raynaud phenomenon (RP). With the current study, we aimed to characterize for the first time the microvascular response to a NTG patch (Trinipatch^® 5 mg/24 h) applied to the hand dorsum in patients with SSc using Laser Doppler imaging (LDI) at baseline and following a cold challenge. The study included 21 patients with SSc and 13 controls. Blood flow was evaluated by LDI at the level of the fingertips and metacarpus. Microvascular morphology was evaluated by nailfold capillaroscopy (NC). LDI revealed decreased fingertip baseline perfusion and a stronger vasoconstrictor response to a cold challenge in patients with SSc versus control. Metacarpal application of a NTG patch led to an increase in blood flow and hand temperature in patients with SSc. Furthermore, NTG administration led to a faster reperfusion after cold challenge. Correlation analyses revealed that the magnitude of the vasodilatory response was inversely related to baseline fingertip perfusion and hand temperature, but unrelated to the number of capillaries/mm assessed using NC. In conclusion, we provide evidence of a vasodilatory reaction following NTG patch application in patients with SSc using LDI and a protective effect against cold challenge. The magnitude of the response to NTG was related to functional, but not structural features. Our results support a further evaluation of the NTG patch as a possible therapeutic agent in SSc-associated RP.

The European/International Fibromuscular Dysplasia Registry and Initiative (FEIRI)-clinical phenotypes and their predictors based on a cohort of 1000 patients

AIMS

Since December 2015, the European/International Fibromuscular Dysplasia (FMD) Registry enrolled 1022 patients from 22 countries. We present their characteristics according to disease subtype, age and gender, as well as predictors of widespread disease, aneurysms and dissections.

METHODS AND RESULTS

All patients diagnosed with FMD (string-of-beads or focal stenosis in at least one vascular bed) based on computed tomography angiography, magnetic resonance angiography, and/or catheter-based angiography were eligible. Patients were predominantly women (82%) and Caucasians (88%). Age at diagnosis was 46 ± 16 years (12% ≥65 years old), 86% were hypertensive, 72% had multifocal, and 57% multivessel FMD. Compared to patients with multifocal FMD, patients with focal FMD were younger, more often men, had less often multivessel FMD but more revascularizations. Compared to women with FMD, men were younger, had more often focal FMD and arterial dissections. Compared to younger patients with FMD, patients ≥65 years old had more often multifocal FMD, lower estimated glomerular filtration rate and more atherosclerotic lesions. Independent predictors of multivessel FMD were age at FMD diagnosis, stroke, multifocal subtype, presence of aneurysm or dissection, and family history of FMD. Predictors of aneurysms were multivessel and multifocal FMD. Predictors of dissections were age at FMD diagnosis, male gender, stroke, and multivessel FMD.

CONCLUSIONS

The European/International FMD Registry allowed large-scale characterization of distinct profiles of patients with FMD and, more importantly, identification of a unique set of independent predictors of widespread disease, aneurysms and dissections, paving the way for targeted screening, management, and follow-up of FMD.

Chilblains

Idiopathic chilblain is a relatively common yet poorly recognized acrosyndrome. This literature review aims to better understand and draw attention to this disorder. Chilblain is a localized inflammation of the skin that occurs on exposure to cold but non-freezing wet weather. It usually resolves spontaneously. The etiology is uncertain, but vasospasm seems to play a role in this abnormal reaction to cold. Diagnosis is most often based on clinical presentation, but a skin biopsy can be useful in dubious cases. In histology, dermal edema and an inflammatory infiltrate are usually present. A distribution of the infiltrate particularly around the eccrine gland is typical. Systemic symptoms and underlying autoimmune disease should be screened. Avoiding cold and keeping extremities warm is the first recommendation for management, as well as smoking cessation. Calcium channel blockers (in particular nifedipine) seems to be the treatment that has been most evaluated in chilblains. However, their effectiveness is not confirmed by all studies. Topical betamethasone is often used but its effect has not been confirmed by randomized clinical trials. Other treatments, such as pentoxifylline, hydrochloroquine and topical nitroglycerin have shown positive effects only in a reduced number of patients. Acupuncture seems to bring a benefit.

Focus on echovascular imaging assessment of arterial disease: complement to the ESC guidelines (PARTIM 1) in collaboration with the Working Group on Aorta and Peripheral Vascular Diseases

The main goal of the present document is to provide a set of practical recommendations for ultrasound imagers who are interested in artery diseases or for physicians who intend to undertake vascular procedures. This is the first part of the work. It is dedicated to general principles of ultrasonography, cervicoencephalic, subclavian, aortoiliac and lower extremity arteries, abdominal aorta, and popliteal aneurysms. It also discusses miscellaneous items such as medial arterial calcinosis, arterial embolism, arteritis, arterial stents and bypasses, false aneurysms, aortic dissection, popliteal entrapment syndrome, and iliac endofibrosis.

ESVM guidelines – the diagnosis and management of Raynaud’s phenomenon

Abstract. Regarding the clinical diagnosis of Raynaud’s phenomenon and its associated conditions, investigations and treatment are substantial, and yet no international consensus has been published regarding the medical management of patients presenting with this condition. Most knowledge on this topic derives from epidemiological surveys and observational studies; few randomized studies are available, almost all relating to drug treatment, and thus these guidelines were developed as an expert consensus document to aid in the diagnosis and management of Raynaud’s phenomenon. This consensus document starts with a clarification about the definition and terminology of Raynaud’s phenomenon and covers the differential and aetiological diagnoses as well as the symptomatic treatment.

The PANDORA study: peripheral arterial disease in patients with non-high cardiovascular risk

Few studies are available with sufficient sample size to accurately describe the prevalence of low ankle-brachial index (ABI) in patients at 'non-high' cardiovascular (CV) risk. The aim of this study was to evaluate the prevalence of asymptomatic peripheral arterial disease (PAD), as determined by using ABI, in this patient population. A non-interventional, cross-sectional, pan-European study was conducted in patients with ≥1 CV risk factor in addition to age, evaluating the prevalence of asymptomatic PAD (ABI ≤ 0.90). Secondary objectives included assessing the prevalence and treatment of CV risk factors. Patients were consecutively recruited during scheduled visits to the physician's office, or were randomly selected by the physician from a list of eligible patients. Patients with diabetes were excluded as this condition was deemed to be a secondary prevention risk. 10,287 patients were enrolled (9,816 evaluable: mean age 64.3 years; 53.5% male). Prevalence of asymptomatic PAD was 17.8% (99% CI 16.84-18.83). Factors significantly associated with asymptomatic PAD included hypertension, age, alcohol intake, family history of coronary heart disease, low levels of high-density lipoprotein-cholesterol, and smoking (p < 0.0001). Patients treated with statins were significantly less likely to have asymptomatic PAD than those who were not (odds ratio 0.62; 95% CI 0.50-0.76; p < 0.0001). Asymptomatic PAD was highly prevalent in patients with non-high CV risk, the majority of whom would not typically be candidates for ABI assessment. These patients should be carefully screened, and ABI measured, so that therapeutic interventions known to diminish their increased CV risk may be offered.

[New developments in antithrombotic care]

For more than 50 years vitamin K antagonists (VKA) have been the gold standard for long-term oral anticoagulant treatment. New anticoagulants are now in extensive clinical development what will probably have a significant impact on daily practice in the near future. Compounds that specifically block activated factor X (FXa) or activated factor II (thrombin) have entered impressive phase III trials. Idraparinux is a long-active derivative from fondaparinux (synthetic pentasaccharide) and is administered subcutaneously. It inhibits indirectly FXa. Apixaban and rivaroxaban are small molecules that directly block FXa following oral administration. Dabigatran is another substance that is administered orally and directly inhibit thrombin. This article will review the potential interest of these new drugs in the modern antithrombotic care. In the meantime, we will briefly discuss two new tools that have been developed to optimalizing the classical VKA anticoagulation: anticoagulation clinics and point-of-care testing of INR that allows self-monitoring.

Assessment of pretest probability of pulmonary embolism in the emergency department by physicians in training using the Wells model

INTRODUCTION

Assessment of pretest probability should be the initial step in investigation of patients with suspected pulmonary embolism (PE). In teaching hospitals physicians in training are often the first physicians to evaluate patients.

OBJECTIVE

To evaluate the accuracy of pretest probability assessment of PE by physicians in training using the Wells clinical model and to assess the safety of a diagnostic strategy including pretest probability assessment.

PATIENTS AND METHODS

291 consecutive outpatients with clinical suspicion of PE were categorized as having a low, moderate or high pretest probability of PE by physicians in training who could take supervising physicians' advice when they deemed necessary. Then, patients were managed according to a sequential diagnostic algorithm including D-dimer testing, lung scan, leg compression ultrasonography and helical computed tomography. Patients in whom PE was deemed absent were followed up for 3 months.

RESULTS

34 patients (18%) had PE. Prevalence of PE in the low, moderate and high pretest probability groups categorized by physicians in training alone was 3% (95% confidence interval (CI): 1% to 9%), 31% (95% CI: 22% to 42%) and 100% (95% CI: 61% to 100%) respectively. One of the 152 untreated patients (0.7%, 95% CI: 0.1% to 3.6%) developed a thromboembolic event during the 3-month follow-up period.

CONCLUSION

Physicians in training can use the Wells clinical model to determine pretest probability of PE. A diagnostic strategy including the use of this model by physicians in training with access to supervising physicians' advice appears to be safe.

Spontaneous renal artery dissection in an otherwise healthy male

Dissection of a renal artery is rare and, in most cases, associated with underlying arterial diseases. Spontaneous renal artery dissection (RAD) is exceptional. We report the case of a young and otherwise healthy man with an isolated dissection of the right renal artery without any obvious origin. Diagnosis was made by angiography. He received medical treatment and rapidly recovered. Renal artery dissection can be misdiagnosed because its clinical presentation may be confusing. Selective renal angiography is essential to evaluate the extent of the dissection and the suitability for repair. Control of the hypertension and renal function preservation are the two main goals of the treatment. The place of surgical repair remains unclear because of the poor results on hypertension improvement and high complication rate.

[Venous thromboembolic disease: which coagulation screening, for whom, when?]

Testing for laboratory evidence of thrombophilia is now common but it has limited predictive value for the majority of unselected symptomatic patients. So when is testing indicated ? And which one? The term "thrombophilia" describes disorders of the haemostatic mechanisms which are likely to predispose to thrombosis. Thrombophilia may be heritable, acquired or mixed, resulting of the environment interacting with genetic background. To date, a limited number of genetic variants and other defects are proven to be independent risk factors for venous thromboembolism. These include antithrombin deficiency, protein C deficiency, protein S deficiency, factor V Leiden, the prothrombin gene mutation, hyperhomocysteinemia and antiphospholipid antibodies. There is no good evidence currently available to support the hypothesis that heritable thrombophilias increase the risk of arterial disease. But acquired or mixed thrombophilias such as hyperhomocysteinemia and antiphospholipid antibodies have been found in association with both venous and arterial thrombotic disorders. When testing for thrombophilia is indicated, especially in case of venous thromboembolism, it should include assays for heritable, mixed or acquired defects: deficiency of antithrombin, protein C or protein S, factor V Leiden and prothrombin G20210A mutations, elevated factor VIII, hyperhomocysteinemia and for antiphospholipid antibodies. Depending on the site of venous thrombosis, laboratory testing to exclude myeloproliferative disorders should be performed.

[Antiplatelet therapy in 2005]

Atherothrombosis is a common physiopathologic process resulting in morbid or fatal ischemic events affecting the cerebral, coronary, or peripheral arterial circulation. Antiplatelet agents are effective in preventing recurrence of vascular events among patients with established vascular disease or with multiple risk factors. Aspirin was the most widely studied antiplatelet drug but the optimal dose remains difficult to define. This article summarizes new data on antiplatelet agents including aspirin, clopidogrel, dipyridamole and glycoprotein IIb/IIIa antagonists with the aim of giving practical recommendations in this very moving field of therapy.

[The medico-surgical department of vascular disease]

The Department of Vascular Diseases can be defined as a multidisciplinary integrated clinical entity involving internists and surgeons interested in patient care, education and research in the field of arterial, venous and lymphatic diseases. Because of the increasing medical complexity with the proliferation of treatment options available, the combined expertise of specialists from different training background is required to provide the optimal patient management. The truly integrated entity with interactions on daily basis between internists and surgeons also provides opportunities for improvement in the training of fellows in vascular medicine. Basic and clinical research is focused on thrombosis and atherosclerosis. The main topics that have been developed include: the pathophysiology of thrombosis, atherogenesis and the diagnosis and treatment of venous thromboembolic disease. The successful development of our Department demonstrates that the combined expertise of internists and surgeons has resulted in marked improvement in the efficiency of patient management.

Lumbar paraspinal rhabdomyolysis and compartment syndrome after abdominal aortic aneurysm repair

Lumbar paraspinal compartment syndrome is an extremely uncommon condition that is known to occur after strainful exercise or trauma. We report on the original case of a 55-year-old man in whom lumbar paraspinal rhabdomyolysis and compartment syndrome developed after open abdominal aortic aneurysm repair, documented with technetium Tc(99m) bone scan and computed tomographic imaging, and in whom successful complete recovery was achieved with conservative management. Clinical features, pathophysiology, and diagnostic and therapeutic strategies of this unusual adverse event are discussed.

The antiphospholipid syndrome

The antiphospholipid syndrome (APS) defines the clinical association between antiphospholipid antibodies and a syndrome of hypercoagulability or thrombophilia (the term of "sticky blood" is sometimes used in APS). Antiphospholipid antibodies comprise a broad family of antibodies including both lupus anticoagulants and anticardiolipin antibodies. The pathogenesis of APS remains unclear. Nevertheless, an understanding of the biology, clinical and laboratory diagnosis, and clinical manifestations of APS are important to the neurologist because the brain is commonly affected by the disease. These points are addressed herein focusing on neurological manifestations of APS. Treatment of APS of which anticoagulation is the cornerstone is also discussed.

[Which anticoagulants?]

Anticoagulants used in daily practice include low molecular weight heparins (LMWHs) and vitamin K antagonists. LMWHs are easy to use by means of adjusted subcutaneous injection, weight-adjusted in case of therapeutic indications. LMWHs are cleared principally by the renal route and are contra-indicated in case of renal insufficiency. The LMWHs are indicated in the prevention and treatment of venous thromboembolism. They can be safely administered in pregnancy and during breast-feeding. Oral anticoagulant therapy is the treatment of choice for long term management. Vitamin K antagonists are contra-indicated in pregnancy, especially between the 6th and the 12th week of gestation (risk of embryopathy); they can be given during breast-feeding subject to some precaution. Main indications for vitamin K antagonists are long term treatment of venous thromboembolism, prevention of both arterial and venous thrombo-embolic events associated with the antiphospholipid--antibody syndrome, prevention of systemic embolism associated with heart valves and, rheumatic mitral valve disease and, atrial fibrillation and, acute myocardial infarction.

Early inflammatory response after elective abdominal aortic aneurysm repair: a comparison between endovascular procedure and conventional surgery

OBJECTIVE

To determine the nature of and to compare the inflammatory responses induced by (1) endovascular and (2) conventional abdominal aortic aneurysm (AAA) repair.

MATERIAL AND METHODS

Twelve consecutive patients undergoing elective infrarenal AAA repair were prospectively studied. Seven patients were selected for endovascular procedures (the EAAA group); five patients underwent open surgery (the OAAA group). Three control patients undergoing carotid thromboendarterectomy were also included. Serial peripheral venous blood samples were collected preoperatively, immediately after declamping or placement of the endograft, and at hours 1, 3, 6, 12, 24, 48, and 72. Acute phase response expression of peripheral T lymphocyte and monocyte activation markers and adhesion molecules (flow cytometry), soluble levels of cell adhesion molecules (enzyme-linked immunosorbent assay), cytokine (tumor necrosis factor alpha, interleukin-6, and interleukin-8) release (enzyme-linked immunosorbent assay), and liberation of complement products (nephelometry) were measured.

RESULTS

Regarding acute phase response, the EAAA and OAAA groups showed significant increases in C-reactive protein (P <.001 and P =.001), body temperature (P =.035 and P =.048), and leukocyte count (P <.001 and P <.001). Similar time course patterns were observed with respect to body temperature (P =.372). Statistically significant different patterns were demonstrated for C-reactive protein (P =.032) and leukocyte count (P =.002). Regarding leukocyte activation, a significant upregulation of peripheral T lymphocyte CD38 expression was observed in the OAAA group only (P =.001). Analysis of markers such as CD69, CD40L, CD25, and CD54 revealed no perioperative fluctuations in any group. Regarding circulating cell adhesion molecules, the EAAA and OAAA groups displayed significant increases in soluble intercellular adhesion molecule-1 (P =.003 and P =.001); there was no intergroup difference (P =.193). All groups demonstrated high soluble von Willebrand factor levels (P =.018, P =. 007, and P =.027), there being no differences in the patterns (P =. 772). Otherwise, soluble vascular cell adhesion molecule-1, soluble E-selectin, and soluble P-selectin did not appear to vary in any group. Regarding cytokine release, although a tendency toward high tumor necrosis factor alpha and interleukin-8 levels was noticed in the EAAA group, global time course effects failed to reach statistical significance (P =.543 and P =.080). In contrast, interleukin-6 showed elevations in all groups (P =.058, P <.001, and P =.004). Time course patterns did not differ between the EAAA and OAAA groups (P =.840). Regarding complement activation, the C3d/C3 ratio disclosed significant postoperative elevations in the EAAA and OAAA groups (P =.013 and P =.009). This complement product release was reduced in the EAAA group (P <.001).

CONCLUSIONS

The current study indicated that both endovascular and coventional AAA repair induced significant inflammatory responses. Our findings showed that there were no large differences between the procedures with respect to circulating cell adhesion molecule and cytokine release. Moreover, the endoluminal approach produced a limited response in terms of acute phase reaction, T lymphocyte activation, and complement product liberation. This might support the concept that endovascular AAA repair represents an attractive alternative to open surgery. Given the relatively small sample size, further larger studies are required for confirmation of our observations.

Plasma homocysteine concentration in a Belgian school-age population

BACKGROUND

Total plasma homocysteine (tHcy) is an independent risk factor for cardiovascular disease in adults. Data for children and adolescents are lacking.

OBJECTIVE

The aim of this study was to provide a reference range for tHcy and to explore the relation between tHcy and nutritional indexes in a Belgian pediatric population.

DESIGN

tHcy, folate, and vitamin B-12 were measured in 647 healthy children (353 girls and 294 boys) aged 5-19 y.

RESULTS

The tHcy distribution was, as in adults, skewed to the right [geometric mean (-1 SD, +1 SD): 7.41 micromol/L (5.51, 9.96)]. Concentrations were lowest in younger children and increased with age. After the tHcy distribution was examined according to age, 3 age ranges were distinguished: 5-9 y [6.21 micromol/L (5.14, 7.50)], 10-14 y [7.09 micromol/L (5.69, 8.84)], and 15-19 y [8.84 micromol/L (6.36, 12.29)]. We observed no significant differences in tHcy values between girls and boys in children aged < 15 y; in postpubertal children, however, concentrations were higher in boys than in girls. In the 3 age groups, folate was inversely correlated with tHcy; the negative relation between tHcy and vitamin B-12 was less strong. Familial cardiovascular disease was more frequent in children who had hyperhomocysteinemia.

CONCLUSIONS

These observations suggest that in children, as in adults, genetic, nutritional, and endocrine factors are determinants of the metabolism of homocysteine. The significance of tHcy values in childhood and young adulthood in terms of predicting cardiovascular risk in adulthood should be investigated.

[Intermittent claudication in a young patient. A case of isolated fibromuscular dysplasia of the external iliac artery]

Effort-linked intermittent claudication of arterial origin in sportsmen is often attributed to endofibrosis of the external iliac artery. Some knowledge of possible differential diagnoses, in particular the fibrodysplasia, is of importance regarding the therapy involved. Angioplasty treatment of external iliac endofibrosis may be controversial. However, the same does not apply to fibrodysplasia angioplasty, particularly if the latter is accomplished by inserting an endoprothesis. A case of fibromuscular dysplasia of external iliac artery in a 37 year old woman, treated with endoluminal angioplasty and stent, is reported.

Adventitial cystic disease of the popliteal artery communicating with the knee joint. A case report

We describe the case of a patient with adventitial cystic disease of the popliteal artery in which a direct anatomic communication between the cysts and the nearby knee joint was demonstrated by magnetic resonance imaging and confirmed by surgery. This unusual observation could shed some light on the much debated question of the cause, the pathogenesis, and the management of the affection. Moreover, it emphasizes the importance and the role of magnetic resonance imaging in the diagnosis of adventitial cystic disease of the popliteal artery.

Occluding aortic endoluminal stent graft combined with extra-anatomic axillofemoral bypass as alternative management of abdominal aortic aneurysms for patients at high risk with complex anatomic features: a preliminary report

PURPOSE

To describe an exclusion endoluminal technique for management of abdominal aortic aneurysms among high-risk patients with complex anatomic features.

METHODS

From January 1995 to December 1996, among 143 patients with infrarenal abdominal aortic aneurysm treated by means of endograft placement, 9 (6.3%) had complex aortic or aortoiliac morphologic features. For these patients, the endograft was delivered through a femoral cutdown in an occluding aortoiliac configuration. The contralateral iliac artery was occluded with an iliac endograft. Axillofemoral bypass grafting was performed. Computed tomographic scans were obtained regularly.

RESULTS

There was 1 postoperative death of severe arrhythmia. All aneurysms were found to be affected by thrombosis on immediately postoperative computed tomographic scans, except in 1 patient with a proximal leak, which was managed successfully with angiographic embolization. The mean follow-up time was 12 months. Aortic aneurysm diameter decreased from 2 mm at 6 months (2 patients) to 6 mm at 12 months (6 patients). All axillofemoral bypass grafts are patent.

CONCLUSIONS

Placement of an occluding endograft associated with axillofemoral bypass grafting is a good alternative for patients at high risk with complex anatomic features. Longer-term follow-up study is needed to evaluate this endoluminal technique.

Modifications of arterial blood flow to the hand after carpal tunnel release

Any surgical procedure is followed by an inflammatory reaction, associated with arteriolar dilatation and increased capillary permeability. The normal evolution is in most cases a progressive decrease of the inflammatory signs. Some patients however, particularly after orthopedic trauma affecting the extremities, develop algodystrophy, initially characterized by arterial vasodilatation and low capillary flow. In an effort to better understand the normal phenomena seen after uncomplicated hand surgery, the authors have evaluated the postoperative arterial blood flow using the Duplex flowmetry ultrasound technique in 13 patients operated for carpal tunnel syndrome, who did not subsequently develop algodystrophy. After measurement of the transverse section of the ulnar and radial arteries, and longitudinal measurement of the mean velocimetry, the arterial blood flow was calculated. The measurements were done 1, 2 and 4 weeks after the operative procedure. The study demonstrated a moderate (15%-30%) but significant increase in the arterial blood flow to the hand, related to arterial dilatation of the vessels and to an increase in blood velocimetry.

Evaluation of two D-Dimer assays in the diagnosis of venous thromboembolism

A qualitative (Instantia) and a quantitative (VIDAS D-Dimer) D-Dimer test have been evaluated and compared with an ELISA method (Asserachrom D-D) in a population of 74 patients suspected of presenting a deep vein thrombosis. Among the thirty-two patients presenting a deep vein thrombosis on phlebography, there were 16 (50%) proximal vein thrombosis and 16 (50%) distal vein thrombosis. Sensitivity and negative predictive value for proximal thrombosis were 100% in all three tests. For distal vein thrombosis, sensitivity and negative predictive value were respectively 81% and 81% for Asserachrom D-DI 75% and 76% for VIDAS D-Dimer and 63% and 82% for Instantia. In conclusion, this study shows that these D-Di assays are a useful tool to exclude proximal vein thrombosis, at least for patients who are not under anticoagulant therapy.

Cerebral venous thrombosis and procoagulant factors--a case study

Cerebral venous thrombosis is a polymorphic clinical entity for which diagnosis has become more frequent with the advent of neuroradiology. The superior sagittal and transverse sinuses are frequently involved, whereas cavernous sinus thrombosis is much less frequent. Inherited resistance to the anticoagulant action of activated protein C (APC resistance), antithrombin deficiency, protein C and S deficiencies, and hyperhomocysteinemia seem to represent major causes of thrombophilia when unusual thromboembolic events (ie, before the age of 45 years) are observed. The authors present the combined occurrence of protein C and protein S deficiencies in a 32-year-old woman, manifested by extensive cerebral venous thrombosis.

[The role of season in the incidence of deep venous thrombosis]

INTRODUCTION

The question of the role of season as a predisposing factor for development of venous thromboembolic disease still remains a matter of debate. Actually, most reports described a higher incidence of thrombotic disorders in winter, while a recent study showed no seasonal variation in the incidence of deep vein thrombosis (DVT). These data led us to study the seasonal distribution of all outpatients with DVT admitted to our Department over a period of 14 years.

METHODS

Retrospective review of the files of all outpatients with confirmed (venography or ultrasound) DVT of the legs admitted from Jan. 1st 1982 to Dec. 31st 1995 (n = 512; mean age 59.4 years; 49.4% women).

RESULTS

DVT occurred in spring in 135 (26.4%), in summer in 104 (20.3%), in autumn in 142 (27.7%) and in winter in 131 (25.6%) patients. This distribution appears to be similar to an expected uniform distribution [chi 2(3) df = 6.48; p = 0.090 (NS)].

CONCLUSIONS

In our study, by investigating retrospectively 512 outpatients with confirmed DVT, no correlation was found between season and development of thrombosis, suggesting that cold seasons do not represent a predisposing factor for DVT. Further large prospective studies are needed in order to validate our data and to investigate the clinical implications and the precise role of the season in the risk of occurrence of venous thrombosis.

[Diagnosis and general treatment of leg ulcers]

A comprehensive history and the physical examination are the mainstays of the diagnosis of leg ulcers. Some diagnostic procedures will allow to establish a proper diagnosis in most cases. The precipitating cause of ulcer has to be taken in charge if possible. Most leg ulcers are secondary to chronic venous insufficiency: the principal treatment modalities are compression and increasing venous return by adapted exercises. The evidence for the efficacy of medications is still limited.

Plasma homocysteine as a risk factor for vascular disease. The European Concerted Action Project

CONTEXT

Elevated plasma homocysteine is a known risk factor for atherosclerotic vascular disease, but the strength of the relationship and the interaction of plasma homocysteine with other risk factors are unclear.

OBJECTIVE

To establish the magnitude of the vascular disease risk associated with an increased plasma homocysteine level and to examine interaction effects between elevated plasma homocysteine level and conventional risk factors.

DESIGN

Case-control study.

SETTING

Nineteen centers in 9 European countries.

PATIENTS

A total of 750 cases of atherosclerotic vascular disease (cardiac, cerebral, and peripheral) and 800 controls of both sexes younger than 60 years.

MEASUREMENTS

Plasma total homocysteine was measured while subjects were fasting and after a standardized methionine-loading test, which involves the administration of 100 mg of methionine per kilogram and stresses the metabolic pathway responsible for the irreversible degradation of homocysteine. Plasma cobalamin, pyridoxal 5'-phosphate, red blood cell folate, serum cholesterol, smoking, and blood pressure were also measured.

RESULTS

The relative risk for vascular disease in the top fifth compared with the bottom four fifths of the control fasting total homocysteine distribution was 2.2 (95% confidence interval, 1.6-2.9). Methionine loading identified an additional 27% of at-risk cases. A dose-response effect was noted between total homocysteine level and risk. The risk was similar to and independent of that of other risk factors, but interaction effects were noted between homocysteine and these risk factors; for both sexes combined, an increased fasting homocysteine level showed a more than multiplicative effect on risk in smokers and in hypertensive subjects. Red blood cell folate, cobalamin, and pyridoxal phosphate, all of which modulate homocysteine metabolism, were inversely related to total homocysteine levels. Compared with nonusers of vitamin supplements, the small number of subjects taking such vitamins appeared to have a substantially lower risk of vascular disease, a proportion of which was attributable to lower plasma homocysteine levels.

CONCLUSIONS

An increased plasma total homocysteine level confers an independent risk of vascular disease similar to that of smoking or hyperlipidemia. It powerfully increases the risk associated with smoking and hypertension. It is time to undertake randomized controlled trials of the effect of vitamins that reduce plasma homocysteine levels on vascular disease risk.

[Hyperhomocysteinemia: risk factor for premature atheromatosis]

Hyperhomocysteinemia is an independent risk factor for atherosclerosis and cardiovascular disease. The cause of hyperhomocysteinemia is either an inborn metabolic defect or acquired. Main causes are either a defective homocysteine remethylation (thermolability of the enzyme 5,10-methylenetetrahydrofolate reductase) or nutritional deficiencies of B vitamins especially folic acid. The relative risk for myocardial infarction has been found of 3,1 in case of hyperhomocysteinemia. It is considered that a 5 microM/l homocysteine increment elevates vascular risk by as much as cholesterol increases of 20 mg/dl. B vitamins supplements are potentially useful.

A case of pyoderma gangrenosum stabilized with lymecycline, topical benzoyl peroxide and treated by autograft

Pyoderma gangrenosum is a chronic inflammatory ulcerative skin disease of unknown etiology, often associated with various systemic disorders such as inflammatory bowel disease, rheumatoid arthritis, chronic active hepatitis, diabetes mellitus and hematologic malignancies. The ulcers are characterized by their undermined violaceous borders. The disease remains a therapeutic challenge. Corticosteroids are the mainstay of therapy; however, side effects from this treatment and recalcitrant pyoderma gangrenosum require therapeutic alternatives. We report the case of a large subacute pyoderma gangrenosum stabilized with lymecycline, topical benzoyl peroxide and successfully treated by an autograft. This observation supports the opinion that the risk of pathergy of a graft can be avoided by the stabilization of the disease.

[Spontaneous dissection of the internal carotid artery: apropos of a case]

Dissections of the extracranial internal carotid artery are probably underestimated in the general population. They are often unrecognized and asymptomatic as shown in this case report and are only the cause of 1 to 4% of cerebral ischaemic accidents. However, they are responsible for 5 to 20% of such accidents in adults younger than 30 years of age. The nontraumatic nature of the carotid artery dissection in our case has been suggested by the medical history although minor trauma could have been missed. A skin biopsy has enabled us to eliminate elastopathies such as Marfan's or Ehlers-Danlos' syndrome. The diagnosis of dissection has been suggested by a Doppler colour echography ; it was confirmed by the arteriography which revealed a long dissection looking like "string sign" at the level of the internal carotid artery just over the carotid bulb. As far as the evolution is concerned, a medical treatment made it quickly favourable.

[Cardiovascular diseases: toward an optimal use of clinical biological laboratories]

Cardiovascular diseases are a frequent cause of morbidity and mortality in our country. The early detection of risk factors by laboratory tests and the subsequent preventive treatment may have a substantial beneficial effect on public health. However, since these tests are performed on large populations, they must be chosen with caution, in order to optimise their cost/ effectiveness ratio. Savings obtained by the judicious use of the clinical lab could allow, already in 1996, the reimbursement of some new informative tests, like the plasma homocysteine and the LDL-cholesterol, and later, of the lipoprotein (a), all tests which are presently at the charge of the patient.

[Vascular complications of diabetes]

Vascular complications are common in diabetics. Patients with type I diabetes mellitus may be more likely to suffer microvascular complications (retinopathy, nephropathy, neuropathy), whereas patients with type II diabetes may be more likely to have macrovascular complications (similar to atherosclerotic disease). Amputation rates are 10 to 15 times more common in the diabetic than in the non diabetic. A meticulous examination (historical and physical) combined with doppler ultrasonography will indicate the presence of peripheral vascular disease in the diabetic. Such an evaluation enables correct management of the risk factors and ensures an appropriate follow-up and treatment of the diabetes related lesions as soon as they occur.

Cardiovascular effects of moderate normovolaemic haemodilution during enflurane-nitrous oxide anaesthesia in man

The cardiovascular effects of mild normovolaemic haemodilution during enflurane-nitrous oxide anaesthesia were studied in 20 patients with normal cardiac function before, during and after total hip replacement. After induction of anaesthesia, patients were randomly allocated to one control group (C), or one haemodiluted group (H) where Hct was decreased to 30% by replacement of blood volume by an identical volume of hydroxyethyl starch 200/05. Each patient was monitored with a pulmonary artery catheter allowing the measurement of right ventricular ejection fraction. During haemodilution, stroke index and right ventricular end-diastolic volume index increased from 33.1 +/- 7.9 to 39.3 +/- 7.1 ml.M-2 and from 73.8 +/- 20.3 to 94.9 +/- 18.5 ml.M-2 respectively (mean +/- s.d., both P < 0.05). However, heart rate decreased so that cardiac index did not change. O2 delivery decreased significantly (from 389 +/- 70 to 311 +/- 63 ml.min-1.m-2; P < 0.05), but was not different to the control group. O2 consumption was maintained by an increase in O2 extraction. During the surgical procedure, cardiac index was higher in the haemodiluted group than in the control group, so that O2 delivery was similar in the two groups. O2 consumption tended to be greater in the haemodiluted group. In patients with normal cardiac function, enflurane-nitrous oxide anesthesia could alter the normal physiologic response to mild normovolaemic haemodilution.