Fluorescence angiography compared to toe blood pressure in the evaluation of severe limb ischemia.

Background: Severity of limb ischemia in peripheral arterial disease (PAD) patients is usually evaluated by clinical assessment and toe blood pressure (TBP) or transcutaneous oxygen pressures (TcPO 2). Indocyanin green angiography (IGA) is a promising tool generating a foot cartography of skin microvascular perfusion. However, there is no consensus about the fluorescence parameters that should be used to evaluate ischemia. The purpose of this cross-sectional evaluation and 3-month clinical follow-up was to determine the best fluorescence parameter for the evaluation of severe PAD, using TBP as reference. Patients and methods: IGA was realized in patients with clinical suspicion of CLI in addition to TBP and TcPO 2. Parameters from the time intensity fluorescence curve measured on the foot were compared with TBP (primary reference), and with TcPO2. Clinical outcomes (amputation, revascularization, death) were recorded at 3 months follow-up. Results: Thirty-four patients were included and IGA could be analysed in 29 of them. When all limbs were studied, no significant correlation was found between any of the measured fluorescence parameters (saturation time, ingress slope, amplitude, delay) and TBP pressure neither TCPO2. In the limbs with CLI, a significant correlation between the TBP and amplitude on the forefoot was found. According to the outcome, none of the fluorescence parameters showed a significant prognostic value in contrast to the significant results for TBP and TcPO2. Conclusions: In this study, quantitative analysis of IGA parameters did not show any prognostic value, nor was there any significant statistical association with well-established prognostic parameters such as TBP and TcPO 2 in patients with suspected CLI. A correlation was found between amplitude and TBP in patients with CLI. Topographical information such as perfusion heterogeneity was not evaluated and remains a valuable target to be investigated.

Anaemia as an independent key risk factor for major haemorrhage in patients treated with vitamin K antagonists: Results of the SCORE prospective cohort.

INTRODUCTION: Risk scores for the prediction of haemorrhage are poorly predictive of major bleeding. The aim of this study was to refine the estimation of bleeding risk by identifying one or several parameters of prognostic significance among these algorithms. MATERIALS AND METHODS: The SCORE study was a prospective, multicentre cohort study conducted in France in 2009-2010. Patients were eligible if they had received vitamin K antagonist (VKA) for any therapeutic indication for at least 3months. The primary outcome was the occurrence of major bleeding at 1-year follow-up. RESULTS: In total, 962 patients were included in this study and evaluated at 1year. The incidence of major bleeding at 1-year follow-up (Kaplan-Meier method) was 2.9% [95% confidence interval (CI) 1.9-4.2]. The rate of major bleeding was 8.2% (95 CI 3.4-16.2) per year in patients classified as high risk by at least four scores. In a multivariate Cox analysis, of the risk factors for the different scores, only anaemia <100g/l at inclusion was strongly associated with risk of major bleeding (hazard ratio 6.1, 95% CI 2.7-13.8, P<0.0001). Through an induction tree analysis performed to identify a common parameter in the majority of scores, anaemia was found to be the main predictor of correct classification as high risk by at least four scores (55% of patients classified as high risk by at least four scores vs 3.3% in the absence of anaemia). CONCLUSION: Anaemia with haemoglobin <100g/l is the most important predictor of high risk of bleeding in patients treated with VKA.