Accuracy of maximal acceleration time of pedal arteries to diagnose critical limb-threatening ischemia.

INTRODUCTION: Maximal acceleration time of distal arteries of the foot (ATmax) is correlated to ankle-brachial index (ABI) and toe-brachial index (TBI), and seems very promising in diagnosing severe peripheral artery disease (PAD) and especially critical limb-threatening ischemia (CLTI). Our goal was to confirm the cut-off value of 215 ms to predict a toe pressure (TP) ⩽ 30 mmHg. METHODS: A 4-month retrospective study was conducted on patients addressed for suspicion of PAD. Demographic data, ABI, TBI, and Doppler ultrasound scanning parameters of the dorsal pedis and lateral plantar arteries (DPA and LPA) were recorded. RESULTS: A total of 137 patients with 258 lower limbs were included. ATmax was highly correlated to TBI (r = -0.89, p < 0.001). With the cut-off value of 215 ms, ATmax was effective to diagnose TP ⩽ 30 mmHg with a sensitivity of 93% [95% CI 77-99], a specificity of 96% [95% CI 92-98], a positive predictive value of 73% [95% CI 56-86], a negative predictive value of 99% [95% CI 97-100], and an area under the receiver operating characteristics curve of 0.99 [95% CI 0.98-1.00]. ATmax also showed promising results to rule out PAD in healthy patients. CONCLUSION: ATmax is a reliable diagnostic tool to diagnose low TP and could be a new easily performed hemodynamic criterion for diagnosis of CLTI.

Selective elevation in external carotid artery flow during acute gravitational transition to microgravity during parabolic flight.

This study sought to determine to what extent acute exposure to microgravity (0 G) and related increases in central blood volume (CBV) during parabolic flight influence the regional redistribution of intra and extra cranial cerebral blood flow (CBF). Eleven healthy participants performed during two parabolic flights campaigns aboard the Airbus A310-ZERO G aircraft. The response of select variables for each of the 15 parabolas involving exposure to both 0 G and hypergravity (1.8 G) were assessed in the seated position. Mean arterial blood pressure (MAP) and heart rate (HR) were continuously monitored and used to calculate stroke volume (SV), cardiac output ([Formula: see text]), and systemic vascular resistance (SVR). Changes in CBV were measured using an impedance monitor. Extracranial flow through the internal carotid, external carotid, and vertebral artery ([Formula: see text]ICA, [Formula: see text]ECA, and [Formula: see text]VA), and intracranial blood velocity was measured by duplex ultrasound. When compared with 1-G baseline condition, 0 G increased CBV (+375 ± 98 mL, P = 0.004) and [Formula: see text] (+16 ± 14%, P = 0.024) and decreased SVR (-7.3 ± 5 mmHg·min·L-1, P = 0.002) and MAP (-13 ± 4 mmHg, P = 0.001). [Formula: see text]ECA increased by 43 ± 46% in 0 G (P = 0.030), whereas no change was observed for CBF, [Formula: see text]ICA, or [Formula: see text]VA (P = 0.102, P = 0.637, and P = 0.095, respectively).NEW & NOTEWORTHY Our findings demonstrate that in microgravity there is a selective increase in external carotid artery blood flow whereas global and regional cerebral blood flow remained preserved. To what extent this reflects an adaptive, neuroprotective response to counter overperfusion remains to be established.

Arterial Blood-Flow Acceleration Time on Doppler Ultrasound Waveforms: What Are We Talking About?

In recent years, the assessment of systolic acceleration in lower-extremity peripheral artery disease (PAD) has been brought back into the spotlight, whatever measure is used: time (in s) or acceleration (in cm.s-2). Acceleration time (also called systolic rise time) and maximal acceleration are two different but very useful measurements of growing interest in PAD. A background of the historical development, physics rationale, semantics, and methods of measurement, as well as their strengths and weaknesses, are discussed herein. Acceleration time is a powerful tool for predicting significant arterial stenosis or for estimating the overall impact of PAD as it is highly correlated to the ankle or toe pressure indexes. It could even become a new diagnostic criterion for critical limb ischemia. Similarly, maximal systolic acceleration ratios are highly predictive of carotid or renal stenosis. However, the literature lacks reference standards or guidelines for the assessment of such variables, and their measurement techniques seem to differ between authors. We propose herein a semantic and measurement statement order to clarify and help standardize future research.

Diagnostic Performance of Pulsed Doppler Ultrasound of the Common Femoral Vein to Detect Elevated Right Atrial Pressure in Pulmonary Hypertension.

Right atrial pressure (RAP) is an important prognostic criterion in pulmonary hypertension (PH). The main goals were to evaluate the following: (i) the accuracy of Doppler assessment of common femoral vein flow waveform to detect elevated RAP and (ii) the diagnostic accuracy of RAP assessed by echocardiography (eRAP). Fifty-seven patients, addressed for right heart catheterization, were included in a retrospective cross-sectional study during a 6-month period. Forty-five patients (78.9%) had PH confirmed by RHC. Elevated RAP was defined by RAP ≥ 10 mmHg. Femoral venous stasis index (FVSI) was highly correlated to RAP on both univariate (p < 0.001) and multivariate analysis (p = 0.003), and showed good diagnostic performances to detect elevated RAP (specificity: 92.3% [80.0-99.3], diagnosis accuracy: 90.4 [77.4-97.3], positive likelihood ratio: 12.5 [3.01-51.97]). Diagnosis accuracy of eRAP was only 51.2% (36.2-66.1). FVSI is independently correlated to RAP and a useful tool to predict elevated RAP in PH patients.

Gender Differences in the Medical Treatment of Peripheral Artery Disease.

BACKGROUND/OBJECTIVES: Peripheral arterial disease is a frequent and severe disease with high cardiovascular morbidity and mortality. However, female patients appear to be undertreated. OBJECTIVES: The primary goal was to compare the prescription of optimal medical treatment (OMT) of peripheral arterial disease between women and men in primary health care. MATERIAL AND METHODS: An observational retrospective study was based on the data collected from general practitioners (GP) office in Brittany. RESULTS: The study included 100 patients, aged 71 ± 10 years old, with 24% of women. Compared to men, women received the OMT less frequently (29.2% vs. 53.9%, p = 0.038), especially after 75 years old. Antiplatelet therapy was largely prescribed (100%), statins less frequently (70.8% women vs. 85.5% men), and prescription of renin-angiotensin-aldosterone system inhibitors was still not optimal in the two genders (41.7% women vs. 61.9% men). Active smoking is important for both women and men (33% and 30% respectively). CONCLUSION: Optimal medical treatment of peripheral artery disease is insufficiently prescribed, especially in women in this region of France.

Inter-rater Reliability of a 13-Category Arterial Doppler Waveform Classification and Practice of French Vascular Physicians.

Background: Arterial Doppler Ultrasound waveform (DW) analysis allows the detection and evaluation of lower extremity peripheral artery disease. The high heterogeneity of the reported description of DW is reduced by the use of classification. However, the reliability of these classifications is either unknown or low to moderate and practices of vascular caregivers regarding the use of these classifications remain unknown. Aims: This study aims to assess the inter-observer reliability of the Saint-Bonnet classification, a 13-category DW classification. The secondary objective was to determine the utilization rate of the most common classifications and the ability of these classifications to describe DW. Methods: A national survey was conducted among all vascular physicians of French society of vascular medicine. They were invited by email to describe on a website 20 DW without and with the display of the Saint-Bonnet classification. The reliability of this classification was estimated by Fleiss' Kappa expressed with [95% confidence interval]. A semantic analysis allowed us to classify the physicians' responses according to the terms used. Finally we have evaluated for each classification the rate of misuse, i.e., the addition of a complementary term to the defined categories. Results: One hundred and ten physicians participated and only 5% of these were familiar with Saint-Bonnet classification. Fifty-four percent of vascular physicians used no classification at all. Vascular physicians used the Spronk (four-category), Descotes (five-category) and Saint-Bonnet (13-category) classifications for respectively, 31, 10, and 5%. Kappa coefficient of Fleiss (κ) was 0.546 [0.544-0.547] (p < 0.001). Reliability by category ranges from κ of 0.075 to 0.864. In multivariate analysis, the use of a classification was associated with fewer years of experience and was dependent on geographic location. Misuse rate by classification was 88, 82, and 5% using Spronk, Descotes and Saint-Bonnet classifications respectively. Conclusion: The reliability of Saint-Bonnet classification is weak to moderate by vascular physicians who are not familiar with its use. However, unlike the other classifications, it seems to be sufficiently precise so that the user does not need to complete its description. There is a significant heterogeneity in the use of arterial Doppler classifications in France.

Performance of the Wells score in predicting deep vein thrombosis in medical and surgical hospitalized patients with or without thromboprophylaxis: The R-WITT study.

The Wells score had shown weak performance to determine pre-test probability of deep vein thrombosis (DVT) for inpatients. So, we evaluated the impact of thromboprophylaxis on the utility of the Wells score for risk stratification of inpatients with suspected DVT. This bicentric cross-sectional study from February 1, 2018 to January 31, 2019 included consecutive medical and surgical inpatients who underwent lower limb ultrasound study for suspected DVT. Wells score clinical predictors were assessed by both ordering and vascular physicians within 24 h after clinical suspicion of DVT. Primary outcome was the Wells score's accuracy for pre-test risk stratification of suspected DVT, accounting for anticoagulation (AC) treatment (thromboprophylaxis for ⩾ 72 hours or long-term anticoagulation). We compared prevalence of proximal DVT among the low, moderate and high pre-test probability groups. The discrimination accuracy was defined as area under the receiver operating characteristics (ROC) curve. Of the 415 included patients, 30 (7.2%) had proximal DVT. Prevalence of proximal DVT was lower than expected in all pre-test probability groups. The prevalence in low, moderate and high pre-test probability groups was 0.0%, 3.1% and 8.2% (p = 0.22) and 1.7%, 4.2% and 25.8% (p < 0.001) for inpatients with or without AC, respectively. Area under ROC curves for discriminatory accuracy of the Wells score, for risk of proximal DVT with or without AC, was 0.72 and 0.88, respectively. The Wells score performed poorly for discrimination of risk for proximal DVT in hospitalized patients with AC but performed reasonably well among patients without AC; and showed low inter-rater reliability between physicians. ClinicalTrials.gov Identifier: NCT03784937.

Accuracy of Acceleration Time of Distal Arteries to Diagnose Severe Peripheral Arterial Disease.

CONTEXT: Ankle-brachial index (ABI) and toe-brachial index (TBI) are the recommended tests for the diagnosis of lower extremity peripheral artery disease (PAD) and the assessment of its severity, whereas Doppler ultrasound (DUS) is usually used to localize vascular lesions. However, the performance of DUS as an alternative to TBI and ABI measurement is unknown. OBJECTIVE: The goals were (i) to evaluate the correlation between DUS parameters of distal arteries of the lower extremities with TBI in patients with PAD; (ii) to evaluate the correlation between DUS parameters of distal arteries with ABI; and (iii) to assess the diagnostic accuracy of maximal acceleration time of pedal arteries to detect toe pressure ≤30 mmHg. METHODS: An observational retrospective study was conducted for 1 year on patients with the diagnosis of PAD on DUS. Demographic data, ABI, TBI, and DUS parameters of the dorsal pedis and lateral plantar arteries (DPA and LPA) were recorded. RESULTS: Seventy-seven patients with 88 limbs were included, aged 69 [interquartile range: 11 years] with 28.6% of diabetic patients. The highest acceleration time of either DPA or LPA (ATmax) was the most correlated to TBI on both univariate (r = -0.78, p < 0.0001) and multivariate analysis (p < 0.0001). DUS parameters had a weaker correlation with ABI. ATmax > 215 ms showed high diagnosis accuracy to a toe pressure of 30 mmHg or less [sensitivity of 86% [0.57-0.98] and negative predictive value of 97% [0.89-1.00]]. CONCLUSION: ATmax demonstrates a high correlation with TBI in patients with PAD, and high diagnostic accuracy for detection of critical limb ischemia. Based on these results, ATmax can represent the next step in evaluating PAD severity with DUS, in patients with advanced lower extremity PAD.

Gravitational Transitions Increase Posterior Cerebral Perfusion and Systemic Oxidative-nitrosative Stress: Implications for Neurovascular Unit Integrity.

The present study examined if repeated bouts of micro- and hypergravity during parabolic flight (PF) alter structural integrity of the neurovascular unit (NVU) subsequent to free radical-mediated changes in regional cerebral perfusion. Six participants (5♂, 1♀) aged 29 ±â€¯11 years were examined before, during and after a 3 h PF and compared to six sex and age-matched (27 ±â€¯6 years) normogravity controls. Blood flow was measured in the anterior (middle cerebral artery, MCA; internal carotid artery, ICA) and posterior (vertebral artery, VA) circulation (duplex ultrasound) in-flight over the course of 15 parabolas. Venous blood was assayed for free radicals (electron paramagnetic resonance spectroscopy), nitric oxide (NO, ozone-based chemiluminescence) and NVU integrity (chemiluminescence/ELISA) in normogravity before and after exposure to 31 parabolas. While MCA velocity did not change (P > 0.05), a selective increase in VA flow was observed during the most marked gravitational transition from micro- to hypergravity (P < 0.05). Increased oxidative-nitrosative stress defined by a free radical-mediated reduction in NO and elevations in glio-vascular GFAP and S100ß were observed after PF (P < 0.05), the latter proportional to the increase in VA flow (r = 0.908, P < 0.05). In contrast, biomarkers of neuronal-axonal damage (neuron-specific enolase, neurofilament light-chain, ubiquitin carboxy-terminal hydrolase L1 and tau) did not change (P > 0.05). Collectively, these findings suggest that the cumulative effects of repeated gravitational transitions may promote minor blood-brain barrier disruption, potentially related to the combined effects of haemodynamic (posterior cerebral hyperperfusion) and molecular (systemic oxidative-nitrosative) stress.

Delayed severe median nerve palsy due to undiagnosed brachial pseudoaneurysm.

Post-catheterization pseudoaneurysms are a well-known complication of many endovascular procedures at the site of arterial puncture. However, long-term neurological complications due to undiagnosed compression are rare. A 60-year-old man presented to our unit for round, non-pulsatile, painless swelling in the inner side of his upper arm. Clinical examination showed finger paralysis, associated with amyotrophy of the forearm. Large brachial pseudoaneurysm with median nerve compression was diagnosed. The patient underwent autologous vein bypass, with poor 6-month neurological recovery. Early diagnosis of pseudoaneurysms is paramount because, when associated with nerve compression, the longer the diagnostic delay, the poorer the neurological prognosis.

Normative and pathological values of hemodynamic and Doppler ultrasound arterial findings in children.

Doppler ultrasound is an effective, useful and remarkably powerful tool in pediatric imaging. If possible, its use is always favored to avoid exposure to radiation or sedatives. By waveform spectrum analysis, Doppler ultrasound reveals information on blood flow and details on normal physiology and pathological processes undiscernible from gray-scale imaging alone. However, Doppler ultrasound remains underused, largely due to the difficult interpretation of changes in Doppler waveforms during childhood. This article provides a narrative review of the literature regarding the normative values and the physiological arterial changes through childhood according to age, weight or height, as well as frequent pathological arterial findings in children, classified by arterial territory.

Diabetes-associated dermatological manifestations in primary care and their association with vascular complications.

INTRODUCTION: Although type 2 diabetes mellitus (DM) is a global public health problem, the diabetes-associated dermatological (non-infectious) manifestations (DADM) remain poorly understood and under-diagnosed. We aimed to evaluate the prevalence of 7 known DADM in a primary care setting, and their association macro/microvascular complications. METHODS: Cross-sectionnal study included patients consulting in general practice for DM-follow up, from November 2016 to January 2017. Patients aged <18 years old or consulting for other reason than DM follow up were excluded. Each patient were screened for diabetic dermopathy (DD), Huntley's papules (HP), necrobiosis lipoidica diabeticorum (NL), acanthosis nigricans (AN), cheiroarthropathy (CA, or stiff hand syndrom), scleredema adultorum of Buschke (SB) and bullosis diabeticorum (BD). RESULTS: 213 diabetic patients were included over a period of 3 months. We found a prevalence of 17.8% (38 patients) for DD, 8.5% (18) for HP, 2.8% (6) for NL, 2.3% (5) for AN, 1.9% (4) for CA, 1.4% (3) for SB and 1.4% (3) for BD. DADM seems to be a risk factor for vascular complications (OR 1.97, p ≤ 0.001). Association with vascular involvement was stronger with DD and macroangiopathy (OR 1.86, p ≤ 0.001), and with NL and microangiopathy (OR 9.7, p ≤ 0.001). CONCLUSION: In primary care, DM-associated dermatological manifestations present similar prevalence rates to a tertiary care setting, based on litterature. Complete dermatological examination of diabetic patients is essential and could lead to a better overall management of the pathology, as diabetic cutaneous manifestations appear as a sign of vascular involvement.