[A post-thrombotic pelvic congestion syndrome]. / Un syndrome de congestion pelvienne post-thrombotique.

INTRODUCTION: Pelvic congestion syndrome is a chronic pelvic pain syndrome related to pelvic varices developed in the setting of primary venous insufficiency or secondary to venous obstruction. OBSERVATION: We report the case of a 35-year-old patient undergoing anticoagulant therapy for an extensive unprovoked left iliac vein thrombosis, who developed a disabling pelvic congestion syndrome secondary to chronic obstruction of the left iliac vein. Recanalization with stenting of the left iliac vein, combined with antithrombotic treatment with antiplatelet therapy (aspirin 100mg) and anticoagulation (rivaroxaban 20mg) for three months, followed by antiplatelet therapy alone, led to a complete and lasting regression of symptoms. DISCUSSION: Management of pelvic congestion syndrome secondary to post-thrombotic lesions must take into account its pathophysiology. It involves iliac venous angioplasty with stent placement in combination with antithrombotic therapy, which modalities remain to be specified in long-term follow-up.

Supervised short-stretch compression therapy in mixed leg ulcers.

OBJECTIVES: This study was conducted to determine hemodynamic and clinical tolerance under short-stretch compression therapy in elderly patients suffering from mixed-etiology leg ulcers. DESIGN: Transversal observational study conducted in 25 hospitalized patients with a moderate peripheral arterial occlusive disease defined as an ankle-brachial pressure index>0.5, an ankle pressure of>70mmHg and a toe cuff pressure (TP)>50mmHg. MATERIAL AND METHODS: Short-stretch bandages were applied daily with pressures from 20 to 30mmHg. Ankle-brachial pressure, great toe laser Doppler flowmetry (LDF) and transcutaneous oxygen pressure (TcPO2) on dorsum of the foot were measured at baseline and after its removal at 24hours. Great toe LDF was also measured at 10minutes after bandage application. Compression pressure (CP) was measured with a sub-bandage device at baseline, at 10minutes and before bandage removal at 24hours. Clinical tolerance was evaluated taking into account the patient's pain and skin tolerance. RESULTS: Mean age of patients was 80±15 years. Median duration of ulcers was 18 months. Hypertension was highly prevalent. One third of patients had diabetes. Toe pressure index and TcPO2 values did not significantly change under compression therapy (P=0.51 and P=0.09, respectively) whereas CP decreased significantly during 24hours. The loss of CP was significant 10minutes after bandage application (P<0.001). Nearly all ulcers were painful prior to placement of compression therapy and required level 1 analgesics. One patient required level 2 analgesic for pain relief. No increase in pain and no ischemic skin damage occurred under compression therapy. CONCLUSIONS: In elderly patients with mixed leg ulcers and with an absolute TP>50mmHg, short-stretch compression of up to 30mmHg does not adversely affect arterial flow and appears clinically well tolerated. Such bandages with appropriate levels of compression may aid ulcer healing by treating the venous part of the disease.

[Identifying barriers to screening for abdominal aortic aneurysm in general practice: Qualitative study of 14 general practitioners in Paris]. / Identification des freins au dépistage de l'anévrisme de l'aorte abdominale en médecine générale : étude qualitative auprès de 14 médecins généralistes exerçant à Paris.

INTRODUCTION: Abdominal aortic aneurysm (AAA) is a silent pathology with often fatal consequences in case of rupture. AAA screening, recommended in France and many other countries, has shown its effectiveness in reducing specific mortality. However, AAA screening rate remains insufficient. OBJECTIVE: To identify barriers to AAA screening in general practice. MATERIAL AND METHOD: Qualitative study carried out during 2016 among general practitioners based in Paris. RESULTS: Fourteen physicians were included. Most of the barriers were related to the physician: unawareness about AAA and screening recommendations, considering AAA as a secondary question not discussed with the patient, abdominal aorta not included in cardiovascular assessment, no search for a familial history of AAA, AAA considered a question for the specialist, lack of time, lack of training, numerous screenings to propose, oversight. Some barriers are related to the patient: unawareness of the pathology and family history of AAA, refusal, questioning the pertinence of the doctor's comments, failure to respect the care pathway. Others are related to AAA: source of anxiety, low prevalence, rarity of complications. The remaining barriers are related to screening: cost-benefit and risk-benefit ratios, sonographer unavailability, constraint for the patient, overmedicalization. CONCLUSION: Information and training of general practitioners about AAA must be strengthened in order to optimize AAA screening and reduce specific mortality.

[When to ask for a skin biopsy in a patient with leg ulcer? Retrospective study of 143 consecutive biopsies]. / Quand poser l'indication d'une biopsie cutanée chez un patient porteur d'ulcère de jambe ? Étude rétrospective sur 143 biopsies consécutives.

OBJECTIVE: A vascular cause is found in around 85% of leg ulcer patients, but non-vascular causes are also observed. Their diagnosis is based on a set of clinical arguments and skin biopsy with histological analysis. The aim of this study was to analyze the results of these biopsies and to find common criteria for ulcers whose skin biopsies had led to the diagnosis of a non-vascular ulcer. MATERIAL AND METHOD: A retrospective study was carried out on the analysis of 143 skin biopsies of leg ulcers. The reasons for the biopsy were mainly atypical clinical signs and/or the lack of improvement in care after 6 months, as advocated by the French health authorities. RESULTS: The skin biopsies led to a diagnosis of non-vascular ulcer in 4.9% of cases (7/143), including skin cancer (n=5, 3.5%), cutaneous leishmaniasis (n=1, 0.7%) and Pyoderma gangrenosum (n=1, 0.7%). The univariate statistical analysis revealed that an elevated rim and abnormal excessive granulation tissue were significantly more frequently found in these ulcers. All patients with a positive skin biopsy had associated vascular involvement. CONCLUSION: This study found a 5% rate of non-vascular causes of ulcers, mainly skin cancer. Elevated rims and abnormal excessive granulation tissue were the unusual features most commonly found in these ulcers. All patients whose skin biopsy revealed a non-vascular cause had associated vascular involvement. This information confirms the need to perform a skin biopsy, even in the presence of a vascular disease.

[Deep venous thrombosis of the upper limb in a violin player: The "bow syndrome"]. / Thrombose veineuse profonde du membre supérieur chez une violoniste : « le syndrome de l'archet ¼.

BACKGROUND: Exercise-induced thrombosis is a rare cause of deep venous thrombosis (DVT) of the upper limb and usually affects young subjects without comorbid conditions. The diagnosis may be challenging. CASE REPORT: A 23-year-old female right-handed French teacher and amateur violin player presented with edema of the root of the right arm associated with erythrocyanosis of the extremity and collateral circulation of the shoulder. History taking revealed oral contraception and recent change in violin playing habits. D-dimers were negative. A second duplex-Doppler was required before visualization of a DVT in the right subclavian vein. The patient was given low-molecular-weight heparin alone, followed by rivaroxaban. The outcome was very favorable at 48h. The patient was seen at 4 months and had not had a recurrent episode. DISCUSSION: The diagnosis of DVT of the upper limb is basically clinical. There is a clinical probability score for the introduction of anticoagulation even if the duplex-Doppler fails to visualize DVT, a situation that can occur due to the clavicular superposition in this region. Exercise-induced DVT should be suspected in patients with minimally intense but repeated exercise (hyper-abduction), e.g. as here playing the violin. Anticoagulation is the treatment of choice. The role for surgery and pharmacomechanical strategies remains to be defined. CONCLUSION: Exercise-induced thrombosis (Paget-Schroetter syndrome) should be suspected in young patients free of any comorbidity who develop a thrombosis of the upper limb. Studies comparing different therapeutic options would be useful to achieve more homogeneous management practices despite the heterogeneous clinical presentations.

[How can leg ulcer pain be reduced?]. / Comment réduire la douleur liée à un ulcère de jambe ?

Chronic vascular wounds are often painful. Pain can develop whatever the cause of the ulceration. It is well known during wound care but can occur at any time. The pain is often a complex phenomenon involving nociceptive pain, neuropathic pain, anxiety and emotional suffering, all directly related to the chronic disease. Care for the patient suffering from pain must take into consideration all of these aspects of the disease. The therapeutic strategy should rely on the use of different pharmacological agents, well-adapted local care using the different available analgesic tools and include psycho-affective care.

[Skillful care for chronic vascular wounds]. / Quels « petits ¼ gestes infirmiers rendent de grands services en cas de plaies chroniques d'origine vasculaire ?

In vascular medicine, wound care requires pluridisciplinary expertise and nursing skill. Care must be perfectly adapted to each individual patient, the specificities of each particular wound, and the underlying vascular disease. The goal is to achieve wound healing. Inappropriate care can retard healing or even aggravate the wound. The skin should be cleaned with water a non-allergic detergent and should concern the entire limb in addition to the wound itself. Fibrin or necrosis detersion is an important step that can be painful. Different tools are available. The skin around the wound should be hydrated and protected, focusing on fragile areas, such as the tibial crest and heals, in order to prevent the development of new wounds. Other more complex interventions include tenosynovectomy, bone gouging and reduction of the necrotic toe that when properly performed can prevent a new passage in the operating room. If the ischemia becomes critical, the foot should be held warm with a carded cotton, taking care to separate the toes with dry dressings in order to preserve the healthy tissue and avoid induced wounds. Finally, compression bands are indispensable in cases with edema or venous hyperpressure. A skillful banding technique is essential, especially for legs with complex morphology.

[Leg ulcers: Should general practitioners hospitalize their patients?]. / Ulcères de jambe: une expertise hospitalière est-elle souhaitable?

OBJECTIVES: Determine whether general practitioners have sufficient expertise in the field of leg ulcers. METHOD: A cross-sectional survey was conducted among 179 general practitioners working in the region Île-de-France to evaluate the implementation of leg ulcer guidelines issued by the Superior Health Authority (HAS) in 2006. Participating physicians were either internship supervisors or practitioners in Paris' 14th district. RESULTS: The first hundred usable answers (response rate 65%) came from 71 internship supervisors and 29 practitioners of Paris' 14th district. Only 40% of the physicians were aware of the guidelines, with no significant difference noted between the two groups. 9/10 practitioners examined less than 10 patients with leg ulcers per year. Physical examinations were done according to the guidelines and a venous Doppler was prescribed in two thirds of the cases. The ankle-brachial pressure index (ABPI) essential to diagnose lower limb arteriopathy was measured for only 10% of the patients. In accordance with the guidelines, compression was by far (73%) considered as the main treatment as compared to dressing (37%), but compression therapy was well prescribed in only one-third of the cases. Despite poor prognosis criteria (characteristic and time course), referral for a specialized opinion was rare. CONCLUSION: Even if they were not always aware of the detailed guidelines, the practitioners applied the main recommendations. Nevertheless, practices could be improved by measuring the ABPI, searching for a diagnosis of arteriopathy, and better prescription of compression therapy. General practitioners should refer patients with leg ulcers to a specialized hospital unit.

[Venous thromboembolic risk during repatriation for medical reasons]. / Risque veineux thromboembolique et sa prévention lors d'un rapatriement sanitaire.

In France, approximately 3000 people are repatriated every year, either in a civil situation by insurers. Repatriation also concerns French army soldiers. The literature is scarce on the topic of venous thromboembolic risk and its prevention during repatriation for medical reasons, a common situation. Most studies have focused on the association between venous thrombosis and travel, a relationship recognized more than 60 years ago but still subject to debate. Examining the degree of venous thromboembolic risk during repatriation for medical reasons must take into account several parameters, related to the patient, to comorbid conditions and to repatriation modalities. Appropriate prevention must be determined on an individual basis.

[Ankle and foot ulcerations in a diabetic patient revealing cutaneous leishmaniasis]. / Des ulcérations de cheville et du pied chez un diabétique révélant une leishmaniose cutanée.

INTRODUCTION: Cutaneous leishmaniasis is a parasitic disease that typically manifests as a typical crusted ulcer called the oriental sore. Its localization on the lower limbs can be mistaken for a leg ulcer. CASE REPORT: An 81-year-old male, native of Algeria, with type 2 diabetes, arterial hypertension and arteriopathy developed a chronic ulceration of the right ankle and foot compatible with the diagnosis of infectious diabetic foot. Non-improvement with antibiotics, local treatment and rest, and the absence of any hemodynamic arteriopathy led to skin biopsies. Polymerase chain reaction performed on biopsy samples for parasitological investigations yielded the diagnosis of cutaneous leishmaniasis due to Leishmania major. Complete healing was obtained with topical care alone, the patient having declined an etiological treatment. DISCUSSION: Cutaneous leishmaniasis is one of the rare infectious etiologies of chronic leg ulcers. Several therapeutic options, including abstention, can be proposed.

Compression therapy in 100 consecutive patients with venous leg ulcers.

OBJECTIVE: To evaluate compression therapy for venous leg ulcers in terms of adherence, acceptability, quality, and effectiveness. DESIGN OF STUDY: Prospective observational cohort study. SETTING: Vascular diseases outpatient clinic in Paris, France. SUBJECTS: One hundred consecutive patients with active or healed leg ulcers and chronic lower limb venous insufficiency stage C5 or C6 in the CEAP classification scheme. INTERVENTIONS: Compression systems applied in a community-based practice. MAIN OUTCOME MEASURES: A standardized form was used to collect: (1) data on patient adherence; (2) objective criteria evaluating the quality, effectiveness, and correct application of compression systems and; (3) patient education and perceptions about their compression therapy. RESULTS: Patient adherence with compression therapy was high (89%), even though it was often a source of discomfort. Only 10% of patients signaled no discomfort. Drawbacks reported by patients were excessive warmth (29%), pruritus (33%), unacceptably high cost (48%), and moderate to considerable difficulty putting on footwear (64%). In the 11% of patients who did not wear their compression system, reasons for nonadherence were inadequate comprehension of expected benefits (45.5%), pain related to compression (36.4%), difficulty applying the compression system (27.3%), and difficulty putting on footwear (27.3%). Application was correct in 51.7% of adherent patients; errors in the remaining patients included slippage, failure of the bandage to extend to just under the knee (55.8%), a tourniquet effect (21%), failure of bandaging starting at the base of the toes (37.2%), and failure to cover the heel (53.5%). Full edema control was achieved in 51.7% of adherent patients. Compression was adequate overall (worn, correctly applied, and effective) in 49% of adherent patients. The most common reasons for lack of effectiveness were inadequate pressure and errors in application. Lack of awareness of potential benefits and wearing modalities of compression therapy was noted in 56% of patients. CONCLUSION: Patients, nurses, and physicians have inadequate knowledge of the modalities of compression therapy and as a result they are not well respected. Educational programs are needed.

Endovascular treatment for post-thrombotic syndrome. Two case studies and a literature review.

The recent application of endovascular treatment techniques to venous pathologies has meant that new therapeutic solutions can be offered to patients suffering from post-thrombotic syndrome. This often-underestimated condition frequently complicates cases of deep vein thrombosis, whether treated or not, leading to a chronic and disabling set of clinical symptoms (oedema, claudication, pain, venous ulcers, etc.) due to the combination of the pathophysiological phenomena of obstructions and reflux. These clinical signs see only minimal improvement when managed with the classic medical treatment, venotonic agents, and venous compression. We report the cases of two patients suffering with chronic post-thrombotic venous obstruction of the lower limbs in whom endovascular treatment brought clear and long-lasting clinical improvement.