[Ambulatory heparin-antivitamin K relay]. / Le relais héparine antivitamine K en ambulatoire.

In order to reach the active threshold as quickly as possible, heparin is usually given at the onset of anticoagulant therapy. The risk of thrombopenia is reduced by early initiation of antivitamin K drugs which also simplifies the treatment regimen and reduces costs. During this transition period, the desired level of hypocoagulation is attain by two mechanisms. Treatment effectiveness, side effects and interactions must be monitored regularly with the active participation of the patient after discharge. Laboratory tests for monitoring heparin therapy, including activated cephalin time for non-fractionated heparin and anti-Xa activity for low molecular weight heparin and biweekly platelet counts are maintained. Antivitamin K therapy is initiated without a loading dose and followed with coagulation time expressed in INR (isocoagulability = 1) at regular intervals, depending on the half-life of the chosen drug, for adapting dosage. Heparin can be withdrawn when the INR has reached equilibrium between 2 and 3. For ambulatory patients, the protocol must be rigorously applied and requires at least four laboratory tests over a period of six days. Except in cases of emergency, the two treatments are given simultaneously for a period of about one week which means that the antivitamin K must be given within 72 hours in order not to override the generally accepted duration of heparin therapy of ten days.

[Treatment of superficial varicose phlebitis]. / Traitement de la phlébite superficielle variqueuse.

The usual physical activity of the patient must be preserved when treating phlebitis of superficial varicosities, maintenance of the ability to walk about being an essential factor for a favorable outcome. Local and general anti-inflammatory treatment of the initial acute phase of inflammation for less than one week improves the comfort of the patient and facilitates the application of the indispensable compression. Ambulatory thrombectomy can rapidly relieve pain, decompress the varicosities, accelerate revascularization and reduce the risk of residual pigmentation. To be simple and useful this procedure must be carried out before the fibrous organization of the clot. Stasis is controlled by an elastic stocking or bandage, the latter being often more effective and better tolerated initially. Compression must be maintained until elimination of the responsible varicose vein. Surgery and anticoagulants of all types are not indicated for treatment of uncomplicated superficial thrombosis, being indicated only in case of an authentic extension to the deep venous network. Surgery should then be limited to a safety crossectomy, heparins being reserved strictly for often prolonged preventive therapy or for treatment of a deep phlebitis.

Complications of anomalous origin of the right subclavian artery: case report and review of the literature.

A 35-year-old black woman presented with thrombosis of an anomalous right subclavian artery and distal arterial embolization. Initially, her right subclavian artery was reimplanted onto the common carotid artery, and a brachial artery embolectomy plus intraoperative thrombolytic therapy were used to reopen her distal arterial circulation. When her brachial artery repair thrombosed the following day, a distal ulnar artery bypass and repeat thrombolytic therapy were required to restore arterial patency. Six months later, she returned with severe, progressive, neointimal hyperplasia of her brachial artery and a second attempt at arterial reconstruction was unsuccessful. She eventually required a right below-elbow amputation. This patient demonstrated an anomalous right subclavian artery that presented with distal embolization without an antecedent history of severe atherosclerotic disease or the development of a right subclavian artery aneurysm. A review of the medical literature relating to complications of this anomaly is provided.

[Practical use of low molecular weight heparins in angiology]. / Utilisation pratique des héparines de bas poids moléculaire par l'angiologue.

The recent development of low molecular weight heparins (LMWH), obtained by the depolymerization of standard non-fractioned heparin (NFH), considerably simplifies the course of anticoagulant treatments. They now allow effectively and safely dealing with the risks of thrombosis, both in hospital and at the patient's home. Their effectiveness for both the prevention and the treatment of thromboembolic accidents has been proved by many clinical trials. In comparison to standard heparin, the LMWHs still have a high anti-Xa activity, but their anti-IIa action is much reduced, thus preserving their antithrombotic power while reducing the hemorrhagic risks. Owing to their better bioavailability and longer half-life, they allow using in priority the subcutaneous route, reducing the frequency of the injections and simplifying surveillance, without impairing the effectiveness of the treatment. The prevention of thrombosis with LMWHs requires one daily subcutaneous dose. The control of the anti-Xa activity is not necessary for the doses used. Prior to initiating a curative treatment, it is essential to confirm the existence of thrombosis. When the diagnosis is definitive, the three LMWHs currently known are used after reconversion, at a dosage of 100 IU/kg/12 hrs. The anti-Xa activity, in samples taken 3 to 4 hours after the injection, must be maintained between 0.5 and 1 IU anti-Xa/ml. It is prudent to control the platelet level at D5 and D10, although thrombocytopenia is exceptional. The changeover treatment with antivitamins K (AVK), which is essential to prevent the recurrence of venous thrombosis, is initiated very early (2nd or 3rd day).(ABSTRACT TRUNCATED AT 250 WORDS)

Development of a safe and effective one-minute preoperative skin preparation.

Three consecutive controlled randomized clinical trials utilizing 1,324 patients were conducted to study the efficacy of incise drapes to prevent wound infections. When a polyester antimicrobial incise drape (loban 2 Antimicrobial Film) was applied to an operative area after a one-minute skin preparation using either 70% alcohol or 2% iodine in 90% alcohol, the clean wound infection rate (1.3%) and overall wound infection rate (2.5%) were comparable to those following a standard ten-minute skin preparation with Betadine (1.3% and 2.3%, respectively). During preliminary studies, it was demonstrated that separation of polyethylene antimicrobial incise drapes from the skin during operation was associated with a sixfold increase in infection rate when compared with operations in which the incise drape did not lift. Design of the drape and technique of application are important considerations in preventing lift from the skin.

[The diagnosis and treatment of recent deep venous phlebitis outside hospital (author's transl)]. / Diagnostic et traitement des phlébites profondes récentes en milieu extra-hospitalier.

Three angeiologists from different regions and in different ways suggest, on the basis of their experience, a method for the management of the non-hospitalised patient suspected of suffering from a deep venous thrombosis of the lower limbs. They consider the early clinical diagnosis, clinical forms, differential diagnosis and the special investigations which must be prescribed, remembering a therapeutic trial with heparin. First they deal on the one hand with systemic treatment, i.e. anticoagulants and their contraindications, anti-inflammatory agents, vasodilators and procaine, and secondly local treatment. The authors conclude in the need for a rapid and precise diagnosis and treatment adapted to each individual case, closely observed and continued until a return to normal.

[Various cases of calcinosis]. / Sur quelques cas de calcose

The authors report seven cases of calcinosis, two of which were intravenous (phlebolithiasis) and five subcutaneous. Radiography of the soft tissues revealed in some cases a truly calcareous shealth, the size of which would not have been suspected from a clinical examination. Extensive calcification may be surprisingly well tolerated and results only in torpid ulceration that heals with simple conservative methods. On the other hand, pain and secondary infections may necessitate surgical resection of the calcareous plaques after arteriography.