[Quality of life in patients traited for primary superficial venous insufficiency]. / Qualité de vie après traitement de l'insuffisance veineuse superficielle primaire.

Venous symptoms and quality of life (QOL) of 78 patients (54 women, mean age 49,5±13,3 years) with primary superficial venous insufficiency (PSVI) were compared at one year after treatment with crossectomy and stripping (C/S, 56 patients) or endovenous laser ablation (EVLA, 22 patients) using the VEINES-QOL questionnaire. Both treatments significantly (p<0,001) improved the scores for venous symptoms (difference 10,6±9,9 and 9,9±8,2 score points for C/S and EVLA, respectively) and QOL (difference 10,3±8,7 and 8,4±6,6 score points for C/S and EVLA, respectively). No difference was found between treatments regarding symptoms or QOL improvement (p=0,30). We conclude that C/S and EVLA are equally effective in improving symptoms and QOL in PSVI.

[Prevention of chronic venous disease: which advice for our patients?]. / Prévention de la maladie veineuse chronique: quels conseils donner à nos patients?

Chronic venous disease (CVD) is a major public health problem due to its high prevalence and socioeconomic costs. In absence of adequate care, it can lead to chronic venous insufficiency (CVI). Disturbed venous-flow patterns lead to venous hypertension. Therefore, prevention of CVD involves venous hypertension reduction. In primary prevention, it is essential to inform the patient about necessary lifestyle changes. In case of CVD, it is essential to propose treatment (compression, venoactive drugs, and interventional treatments) to avoid CVI appearance and eventually offer the best therapy solutions for CVI complications.

[Lymphatic disorders and prevention of their complications]. / Prévention des troubles lymphatiques et de leurs complications.

The prevalence of lymphedema is clearly underestimated. Too few patients receive treatment. It requires several specifically trained participants and must be conceived in the long term given the chronic nature and the incurability of this pathology. Prevention is therefore of major importance. Successfully applied to operated women for breast cancer, other models of coverage deserve to be developed to reduce the incidence of lymphedema and its complications, particularly after oncologic, orthopedic and vascular surgery and for patients affected by venous insufficiency.

[Vascular follow up in patients suffering from peripheral arterial disease and undergoing revascularization]. / Suivi angiologique des patients artériopathes après geste de revascularisation.

The rapid evolution of revascularization techniques has allowed an improvement in quality of life of patients with peripheral artery disease. The angiological follow-up aims to insure durable results of revascularization, to diminish risk of amputation and to limit progression of atheroma plaques. The patient history and physical examination are essential in evaluating impact of peripheral artery disease upon quality of life and insuring the appropriate control of cardiovascular risk factors.

[Anatomy and physiopathology of venous system]. / Anatomie et physiopathologie du réseau veineux.

The field of chronic venous disease has suffered from a lack of precision in diagnosis. This deficiency has led to conflicting reports in studies of management of specific venous problem. The establishment of an uniform language for classifying the findings of CVD was needed. In 1995, the CEAP classification was proposed for classification and grading of CVD on the basis of clinical manifestations (C), etiologic factors (E), anatomic distribution of involvement (A) and underlying pathophysiologic findings (P). The purpose was to provide a comprehensive objective classification that could be used world-wide and serve as a basis for more scientific analysis of management alternatives.

[Quality of life after superficial femoral vein harvest for infra-inguinal reconstructions]. / Evaluation de la qualité de vie après prélèvement de la veine fémorale superficielle lors de reconstructions infra-inguinales.

BACKGROUND: The superficial femoral vein (SFV) is a well-established alternative conduit for infra-inguinal reconstructivenous hypertension after SFV harvest may however result in significant morbidity. This study reports the efficiency of SFV as conduit for infra-inguinal reconstructions and characterize the anatomic and physiologic changes in harvest limbs and their relationship to the development of venous complications. METHODS: From May 1999 through November 2003, 23 SFV were harvested from 21 patients undergoing infra-inguinal reconstructions. Bypasses were controlled by regular duplex-ultrasound. The venous morbidity was assessed by measurements of leg circumferences, strain-gauge plethysmography and quality of life, investigated by the VEINES-QOL scale. RESULTS: At a mean follow-up of 10.4 months (range 1-56), primary, secondary patency and limb salvage rates of infra-inguinal bypasses using SFV are 71.4%, 76.2% and 85.7% respectively. No patient had major venous claudication. Oedema was significantly present in nine patients. Strain-gauge plethysmography showed outflow obstruction in all patients. The VEINES-QOL assessment showed no limitation in social and domestic activity, moderate complain about leg heaviness despite presence of oedema. CONCLUSION: The SFV harvest is a reliable conduit for infra-inguinal reconstructions and results in moderate venous morbidity in terms of functional consequences and quality of life.

[Early detection of atherosclerosis]. / Détection précoce de la maladie athéroscléreuse.

According to the guidelines, the global assessment of cardiovascular risk is based on traditional risk factors. The emergence of new cardiovascular risk factors may be helpful. However, at every level of risk factor exposure, there is a substantial variation of atherosclerosis. Thus, subclinical disease measurements, representing the end result of risk exposure may be useful for improving cardiovascular risk prediction. In comparison to the ankle-brachial index, the high resolution B-mode ultrasound is a more promising tool to detect early atherosclerosis both on carotid and femoral arterial wall in asymptomatic patients. It appears as a new approach to predict the risk of cardiovascular disease and to monitor the cardiovascular therapy.

Pitting edema of the four extremities of rapid appearance.

We report the case of a 70 year old white man with rapid onset edema of the four extremities without any other systemic symptoms. Cardiac failure, nephrotic syndrome and hepatic dysfunction were ruled out. Rheumatoid factor was slightly elevated at 33 UI/ml and sedimentation rate was within normal range. Ultrasound examination of the upper limb revealed increased blood flow (400 ml/min) at the level of the brachial artery and edema of the tenosynovial sheaths. A diagnosis of remitting seronegative symmetrical synovitis and pitting edema (RS3PE) was made and prednisone 15 mg/day was prescribed with rapid disappearance of the edema and reduction of the forearm blood flow.

Necrosis of the tongue and unilateral blindness in temporal arteritis.

While blindness is one of the typical clinical presentations of temporal arteritis, tongue necrosis, on the other hand, is an unusual complication of the disease. An 80 year old male patient presenting a sudden massive swelling of the tongue was admitted to the Hospital of Yverdon. The swelling rapidly progressed to a complete necrosis of the tongue within a few days. The clinical presentation, the dramatic evolution of the necrosis, and sudden unilateral blindness despite prompt treatment confirmed our diagnosis of temporal arteritis. However, all the examinations, including biopsy of the right temporal artery, remained non-specific for the disease. Our diagnosis was based on the unusual clinical presentation of the disease.

Is there a place for duplex screening of brachial artery in haemodialysis patients with vascular access?

BACKGROUND: Vascular access (VA) stenosis with subsequent thrombosis remains one of the major causes of morbidity and hospitalization in haemodialysis patients. The present cross-sectional study was planned in order to analyze the usefulness of brachial artery duplex ultrasound for detection and prediction of vascular access stenoses. METHODS: Color duplex ultrasound (Apogée Cx200, sectorial probe 7.5 MHz) was used to obtain the anatomical pattern of the VA and flow velocity waveforms of the brachial artery in 77 non-selected VA (47 Ciminio-Brescia fistulae and 30 PTFE grafts). In each VA, the resistance index (RI), the mean blood flow rate (Q) and the blood flow ratio index (QI) (QI = VA flow rate/contralateral flow rate) were calculated at the level of the brachial artery. The sensitivity and specificity of these brachial Doppler parameters were calculated for the detection of VA stenosis. In normal VA, positive (PPV) and negative predictive (NPV) values were calculated for the development of clinical stenotic complications 3 months post ultrasound examination. RESULTS: Thirteen of the 77 VA (17%) were identified as stenosed by duplex ultrasound and confirmed by fistulography and/or during surgical exploration. The best screening tests for VA stenosis detection were a QI threshold < 4.0 with a sensitivity and specificity of 69 and 69% and an RI > 0.55 with a sensitivity and specificity of 62 and 66%, respectively. In the VA considered as normal by ultrasound, the prediction of subsequent stenosis within three months post-ultrasound examination gave a PPV of only 18% and 19% for RI and QI, respectively. NPV for RI and QI were 90% and 88%. CONCLUSIONS: While Doppler ultrasound is a useful non-invasive test for the detection of prevalent VA stenosis, our results do not confirm that abnormal brachial Doppler flow parameters can predict short term development of VA stenosis.

Premature atherosclerosis in HIV-infected individuals--focus on protease inhibitor therapy.

OBJECTIVE: Lipid disorders associated with the use of protease inhibitors may contribute to the premature development of atherosclerosis. The purpose of the present study was to determine whether the administration of a protease inhibitor-containing regimen to middle-aged (30-50 years) HIV-infected individuals for 6 months or longer is associated with an increased prevalence of atherosclerosis. METHODS: High-resolution B-mode ultrasound imaging was used to visualize the femoral and carotid arteries of 68 HIV-negative and 168 HIV-infected individuals, including 136 patients who had received protease inhibitors for 26.8 +/- 8.9 months (mean +/- SD). Atherogenic plaques were defined as a thickening of the intima-media > or = 1200 mm. RESULTS: The proportion of participants with one or more plaques was higher in the HIV-infected group in comparison with the HIV-negative group (55 versus 38%; P = 0.02), and so was the prevalence of cigarette smoking (61 versus 46%; P = 0.03) and hyperlipidaemia (56 versus 24%; P < 0.001). The presence of plaque was independently associated with age, male gender, plasma low-density lipoprotein cholesterol levels and smoking. In univariate logistic regression analysis, an association was also found with HIV infection. Among HIV-infected subjects protease inhibitor therapy was not associated with the presence of plaque. CONCLUSIONS: A large proportion of the middle-aged HIV-infected individuals examined during this study had one or more atherosclerotic plaques within the femoral or carotid arteries. The presence of peripheral atherosclerosis within this population is not associated with the use of protease inhibitors, but rather with 'classic' cardiovascular risk factors such as smoking and hyperlipidaemia, which are amenable to interventions.

Effect of SR 49059, a V1a vasopressin receptor antagonist, in Raynaud's phenomenon.

OBJECTIVE: To assess whether vasopressin V1a receptor blockade reduces the abnormal vasoactive response to cold in patients suffering from Raynaud's phenomenon (RP). METHODS: SR 49059, an orally active, non-peptidic vasopressin V1a receptor antagonist, was given orally (300 mg once daily) to 20 patients with RP in a single-centre, double-blind, placebo-controlled, randomized cross-over study with two 7-day periods of treatment separated by 21 days of washout. Bilateral finger systolic blood pressure and skin temperature were assessed before and after immersion of the hand in cold water for 3 min (15 degrees C) during the screening phase and three times (before and 2 and 4 h after drug intake) on days 1 and 7 of each of the two treatment periods. Recovery of digital pressure and skin temperature was measured 0, 10, 20 and 32 min after the end of the cold immersion test. RESULTS: SR 49059 significantly attenuated the cold-induced fall in systolic pressure by 14.5% (95% confidence interval 0-29; P = 0.045) on the most affected hand on day 7 compared with placebo. Temperature recovery after the end of the cold test showed a trend to enhancement 2 and 4 h after SR 49059 on day 7 (P = 0.060 and P = 0.062 respectively). The beneficial effects on finger pressure and temperature recovery were obtained without changes in supine blood pressure or in heart rate. CONCLUSION: SR 49059 given orally once a day for 7 days to patients with RP showed favourable effects compared with placebo on finger systolic pressure and temperature recovery after cold immersion, without inducing side-effects.

[Reference values of intima-medial thickness of carotid and femoral arteries in subjects aged 20 to 60 years and without cardiovascular risk factors]. / Valeurs de référence des épaisseurs intima-média des artères carotidiennes et fémorales chez des sujets âgés de 20 à 60 ans et sans facteur de risque cardiovasculaire.

Many studies have shown a close correlation between intima-medial thickness of the carotid artery measured by high resolution ultrasonography and the presence of coronary artery disease or atherogenic risk factors. However, reference values for the value of intima-medial thickness (IMT) in healthy subjects have not yet been established. The aim of this study was, therefore, to determine the reference values of carotid (C-IMT) and femoral intima-medial thickness (F-IMT) with respect to age and gender in healthy subjects (53 women and 45 men) aged 20 to 60, with no family or personal history of cardiovascular disease or atherogenic risk factors, underwent high resolution colour echo-Doppler examination. The mean C-IMT was 556 +/- 57 microns in women and 573 +/- 70 microns in men (NS), and the femoral equivalent was 543 +/- 63 microns in women and 562 +/- 74 microns in men (NS). Between the ages of 20 and 60, the C-IMT increased by 1.8 microns per year (p < 0.03) in women and 3.4 microns (p < 0.001) in men, the variations being respectively 1.2 microns (NS) and 3.1 microns (p < 0.002) in the femoral artery. Multiple regression analysis including gender and individual values of age, body mass index and lipid profile confirmed that only age was significantly correlated to the increase in thickness. The authors conclude that the reference values of IMT do not differ with gender or site of analysis, but there is a slight influence with respect to age.

Physical activity monitoring based on accelerometry: validation and comparison with video observation.

The objective of this feasibility study is to evaluate the use of the 'Physilog' device, an ambulatory physical-activity recorder based on acceleration measurement, for the monitoring of daily physical activities. Accelerations measured at the level of the chest and the thigh are recorded by Physilog over a period of 1 h in five normal subjects. A specially designed studio-like room allowing the performance of most usual activities of everyday life is used. A video film synchronised with the Physilog is obtained for each subject to check the accuracy of the data derived from Physilog. Based on the analysis on the average and the deviation of the acceleration signal, an algorithm is developed to classify the activities in four categories, i.e. lying, sitting, standing and locomotion. Compared with the video observations, the results from the algorithm show an overall misclassification of 10.7%, which is mainly due to confusion between dynamic activities and the standing posture. In contrast, the misclassification between postures is negligible. It is concluded that Physilog can be used in the clinical setting for the reliable measurement and long-term recording of most usual physical activities.

Chronic venous disorders of the leg: epidemiology, outcomes, diagnosis and management. Summary of an evidence-based report of the VEINES task force. Venous Insufficiency Epidemiologic and Economic Studies.

BACKGROUND: To critically review the classification, epidemiology, outcomes, diagnosis and treatment of chronic venous disorders of the leg (CVDL), to issue evidence-based recommendations, and to identify areas requiring further research. METHODS: Articles identified by an extensive literature search were scored by members of an international task force. Only those articles with a moderate or strong rating for internal validity were retained. RESULTS: A scoring system weighing CVDL severity according to the probability of ulcer occurrence is proposed. Epidemiological data on the frequency of CVDL and its risk factors are reviewed. The following items are evaluated: costs associated with treatment; clinical outcomes related to CVDL and its treatment; available generic and disease-specific measures of quality of life; diagnostic procedures used to detect venous reflux; and efficacy of available treatments. CONCLUSIONS: CVDL is an important public health problem, based on its prevalence, cost and impact on quality of life. High-priority areas for research on CVDL are identified.

Vascular surveillance after peripheral artery interventions.

Prospective studies have shown that intensive vascular surveillance with echo-Doppler significantly improves arterial graft patency rate in the lower limbs although no conclusive data have demonstrated associated improvement in limb salvage. The lack of randomised controlled studies makes it difficult to advocate such intensive surveillance programmes to reduce limb loss after arterial reconstruction. Nevertheless, it appears that measures maintaining good graft patency in the lower limb have the best chance to be accompanied by improved life quality. Therefore, a fair protocol for graft surveillance should take into consideration early flow disturbances, intrinsic risks related to comorbidities and technical aspects of the graft material. Strict control of cardiovascular risk factors will greatly contribute to reducing the risk of late occlusive events by slowing or halting the evolution of the atherosclerotic process.

[Treatment of endovascular aneurysms: the indications widen]. / Le traitement endovasculaire des anévrysmes: les indications s'élargissent.

Recently, the material available for endovascular aneurysm repair (covered stents and application systems), real time medical imaging and operator experience have significantly improved. Hence, more and more complex vascular lesions, well beyond the original indications, can now be treated by endovascular surgery. Since 1996 our group has implanted 55 endovascular systems in the clinical setting: 45/55 (80%) for classical indications and 11/55 (20%) for extended indications. In the latter group four different endoprosthetic systems were used according to either their performance and availability or the type of lesion to be treated. For the 11 patients undergoing endovascular procedures with extended indications, 6/11 had thoracic aortic lesions (55%) and 5/11 (45%) had aorto-iliac lesions requiring either progressive embolisation of the internal iliac arteries or suprarenal anchorage. For these extended indications hospital mortality was 0/11 (0%). One patient died after hospital discharge. 1/11 patients (9%) had to be converted to open surgery during the interval between iliac embolisation and endovascular repair. There has been no conversion to open surgery during or after the endovascular procedures. Two major endoleaks were detected (2/11: 18%). One has been corrected by an additional covered stent and endovascular repair is planned for the other one. Spontaneously regressive functional hypoperfusion has been observed in 4/5 patients with progressive internal iliac embolisation. There was no irreversible renal insufficiency. Early results of endovascular aneurysm repair for extended indications are promising. Although the long-term outcome is unknown, it can already be said that traditional open surgery can be avoided for a considerable amount of time in an increasing number of patients.