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The optimal strength of compression needed to prevent post-thrombotic syndrome (PTS) after a proximal deep vein thrombosis (DVT) is debated. We aimed to assess whether 25 mm Hg elastic compression stockings (ECS) are non-inferior to 35 mm Hg ECS in preventing PTS after a DVT.In this multicentre, double-blind, non-inferiority, randomised controlled trial, we enrolled adults (≥18 years) with a first ipsilateral proximal DVT attending 46 French vascular medicine hospital departments or private practices. Participants were randomly allocated (1:1, stratified by centre, age, and sex; with varying block sizes of two and four) to wear 25 mm Hg or 35 mm Hg ECS for 2 years. The primary outcome was the cumulative rate of PTS 2 years after inclusion, defined by a Villalta scale (≥5). Efficacy was assessed by intention-to-treat and in eligible participants who had complete primary outcome data. A per-protocol analysis was also conducted among compliant patients as a secondary outcome measure. Safety was assessed in all participants who used ECS at least once, and for which we have at least some tolerance information during follow-up. The margin for non-inferiority was 12·5%. This study is registered with ClinicalTrials.gov, NCT01578122, and has been completed.Between June 28, 2012, and July 21, 2017, we enrolled 341 eligible participants who consented to randomisation. 233 (68%) were men and median age was 59 years (IQR 45-70). Collection of ethnicity and race as a routine research variable is not authorised in France. Median follow-up was 735 days (IQR 721-760). 249 (73%) had complete data at 2 years. For the primary analysis, 40 (31%) of 129 participants with complete data in the 25 mm Hg ECS group and 40 (33%) of 120 in the 35 mm Hg group had PTS (absolute difference -2·3% [90% CI -12·1 to 7·4], pAlthough we did not reach the prespecified sample size, our results suggest that 25 mm Hg ECS are non-inferior to 35 mm Hg ECS in preventing PTS. Larger more powerful studies are needed.Laboratoires Innothera, France.

International audience; BACKGROUND: Cardiovascular risk is increased in giant cell arteritis (GCA). We aimed to characterize myocardial infarction (MI) in a GCA cohort, and to compare the GCA and non-GCA population affected by MI. METHODS: In patients with a biopsy-proven diagnosis of GCA between 1 January 2001 and 31 December 2016 in Côte D'Or (France), we identified patients with MI by crossing data from the territorial myocardial infarction registry (Observatoire des Infarctus de Côte d'Or) database. Five controls (non-GCA + MI) were paired with one case (GCA + MI) after matching for age, sex, cardiovascular risk factors and prior cardiovascular disease. MI were characterized as type 1 MI (T1MI), resulting from thrombus formation due to atherothrombotic disease, or type 2 MI (T2MI), due to a myocardial supply/demand mismatch. GCA-related MI was defined as MI occurring within 3 months of a GCA flare (before or after). RESULTS: Among 251 biopsy-proven GCA patients, 13 MI cases were identified and paired with 65 controls. MI was GCA-related in 6/13 cases, accounting for 2.4% (6/251) of our cohort. T2MI was more frequently GCA-related than GCA-unrelated (80% vs. 16.7%, p = 0.080), and GCA diagnosis was the only identified triggering factor in 75% of GCA-related T2MI. GCA-unrelated MI were more frequently T1MI and occurred in patients who had received a higher cumulative dose of prednisone (p = 0.032). GCA was not associated with poorer one-year survival. CONCLUSIONS: GCA-related MI are mainly T2MI probably caused by systemic inflammation rather than coronaritis. GCA-unrelated MI are predominantly T1MI associated with atherothrombotic coronary artery disease.

The impact of cholesteryl ester transfer protein (CETP) on atherosclerotic development in humans remains unclear. Plasma cholesteryl ester transfer was shown to be associated with carotid intima-media thickness in type 2 diabetic (T2D) patients with adequate metabolic control. Since glycation of CETP may influence cholesteryl ester transfer processes, it is important to determine if plasma cholesteryl ester transfer is still a determinant of carotid intima-media thickness (IMT) in patients with poorly controlled diabetes. The aim of the present study was to determine whether CETP activity influences carotid IMT in T2D patients with poor metabolic control. In 110 individuals with T2D, we measured CETP mass concentration with ELISA, CETP activity with a radioactivity method and carotid intima-media thickness with high-resolution real-time B-mode ultrasonography. The mean HbA1C was 8.8 ± 1.7%. Carotid IMT did not correlate with CETP activity in the total population. In T2D patients with HbA1C

Background Color-duplex ultrasonography (DUS) could be an alternative to computed tomography-aortography (CTA) in the lifelong surveillance of patients after endovascular aneurysm repair (EVAR), but there is currently no level 1 evidence. The aim of this study was to assess the diagnostic accuracy of DUS as an alternative to CTA for the follow-up of post-EVAR patients. Methods Between December 16, 2010, and June 12, 2015, we conducted a prospective, blinded, diagnostic-accuracy study, in 15 French university hospitals where EVAR was commonly performed. Participants were followed up using both DUS and CTA in a mutually blinded setup until the end of the study or until any major aneurysm-related morphological abnormality requiring reintervention or an amendment to the follow-up policy was revealed by CTA. Database was locked on October 2, 2017. Our main outcome measures were sensitivity, specificity, positive predictive value, negative predictive value, positive and negative likelihood ratios of DUS against reference standard CTA. CIs are binomial 95% CI. Results This study recruited prospectively 659 post-EVAR patients of whom 539 (82%) were eligible for further analysis. Following the baseline inclusion visit, 940 additional follow-up visits were performed in the 539 patients. Major aneurysm-related morphological abnormalities were revealed by CTA in 103 patients (17.2/100 person-years [95% CI, 13.9–20.5]). DUS accurately identified 40 patients where a major aneurysm-related morphological abnormality was present (sensitivity, 39% [95% CI, 29–48]) and 403 of 436 patients with negative CTA (specificity, 92% [95% CI, 90–95]). The negative predictive value and positive predictive value of DUS were 92% (95% CI, 90–95) and 39% (95% CI, 27–50), respectively. The positive likelihood ratio was 4.87 (95% CI, 2.9–9.6). DUS sensitivity reached 73% (95% CI, 51–96) in patients requiring an effective reintervention. Conclusions DUS had an overall low sensitivity in the follow-up of patients after EVAR, but its performance improved meaningfully when the subset of patients requiring effective reinterventions was considered. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01230203.

Background Ultrasound-guided percutaneous angioplasty of arteriovenous fistulas (AVFs) makes it possible to avoid contrast agents and X-rays, to optimize the puncture site and to locate some stenoses on the fistulography, but is it really useful? Our objective is to report the results of our experience. Methods Between November 2012 and November 2017, all the patients treated according to this method in our center were collected retrospectively. The surgical indications were an insufficient maturation of the AVF, an increase in the venous pressure, an inadequate outflow, difficulties in puncture, a prolonged bleeding time, a flow drop, or an aneurysmal evolution. Results During this period, 50 patients had 72 ultrasound-guided angioplasties, 64 on native AVFs (88.9%) and 8 on prosthetic AVFs (11.1%). The technical success rate was 100%. The average preoperative flow of AVFs was 506.8 ± 302.2 vs. 955.9 ± 371.4 mL/min after angioplasty. The mean duration of follow-up was 13.4 ± 12.9 months. The cumulative rates of primary, assisted primary, and secondary patency were 43.5%, 68.8%, 81.5% at 1 year and 31.7%, 63.9%, 76.8% at 2 years, respectively. Conclusions AVF angioplasty under ultrasound guidance only is feasible, effective, and represents an interesting alternative. A controlled study comparing ultrasound guidance with angioplasties performed under conventional angiographic guidance as the reference technique would better clarify the value of this technique.

International audience

International audience; Background: Post-thrombotic syndrome (PTS) is a frequent complication of deep vein thrombosis (DVT) despite adequate treatment. Venous angioplasty and stent placement has been progressively used to restore and maintain venous patency in PTS patients. This study reports our single-center experience with the use of endovascular treatment for chronic post-thrombotic symptomatic ilio-femoral venous obstructive lesions. Methods: A prospective mono-centric observational cohort study of PTS patients with chronic symptomatic ilio-femoral venous obstructive lesions referred for endovascular treatment was conducted from March 2012 to April 2016. Procedure consisted in recanalization, pre-dilation and self-expandable stenting of stenotic or occluded iliac and/or femoral veins. Severity of PTS, quality-of-life and treatment outcomes were assessed using Villalta scale and Chronic Venous Insufficiency Questionnaire (CIVIQ-20) at baseline and 3 months after the procedure. Imaging follow-up was based on duplex ultrasound (US) and computed tomography (CT). Results: Twenty-one patients (11 females, 10 males; median age, 41 years; range, 32-60) were included. Recanalization and stenting was successfully accomplished in all prime procedures, 4 patients benefitted from an additional procedure. Immediate technical success rate was 96% considering 25 procedures, performed without any complications. Median follow-up was 18 months (range, 6-30 months) with a 90.5% stent patency rate. Villalta score significantly decreased from baseline compared with 3 months after the procedure [14 (range, 11-22) and 5 (range, 1-10), respectively, P

Resume Objectif L’index de pression systolique mesure a la cheville (IPSCh) permet de diagnostiquer l’arteriopathie obliterante des membres inferieurs (AOMI) et de definir les patients a risque vasculaire. La Haute Autorite de sante (HAS) a edite des recommandations applicables a une population asymptomatique de medecine generale. Nous avons voulu connaitre, par rapport a un depistage systematique, l’interet et l’impact de ces recommandations si elles etaient appliquees a des patients hospitalises en medecine interne. Methodes Nous avons realise une mesure systematique des IPSCh dans deux services de medecine interne. Nous avons ensuite confronte les resultats obtenus aux criteres de depistage et de bonnes pratiques recommandes par la HAS. Resultats Les criteres de depistage recommandes par la HAS etaient remplis par 91 % de nos 97 patients. Une AOMI a ete observee chez 37,1 % des patients. Dans 83 % des cas, le diagnostic etait meconnu ( p = 0,02). L’AOMI etait symptomatique dans 83 % des cas si l’AOMI etait connue avant le depistage et dans 3,3 % si elle etait nouvellement diagnostiquee ( p 0,001). La sensibilite des criteres de depistage de la HAS appliques a notre population etait de 100 %. La mesure des IPSCh etait justifiee chez la plupart des patients. La specificite etait de 11,5 %, la valeur predictive positive de 40 % et la valeur predictive negative de 100 %. Le traitement optimal recommande etait present chez 50 % des patients connus comme arteriopathes et chez 10 % des patients atteints d’AOMI nouvellement diagnostiquees ( p = 0,04). Conclusion La prevalence de l’AOMI est elevee en medecine interne et la mesure systematique des IPSCh justifiee. Selectionner les patients a depister selon les criteres de la HAS est d’un faible interet dans notre population. Le traitement optimal est insuffisamment prescrit meme chez les arteriopathes connus.

Recently, it has been shown in the general population that an allele in the adiponutrin (PNPLA3) gene was strongly associated with increased liver fat content (LFC), independently of visceral adiposity and insulin resistance.In this study, we set out to determine whether LFC, evaluated using (1)H-MR spectroscopy, was associated with PNPLA3 rs738409 polymorphism in people with type 2 diabetes. We also evaluated the influence of this polymorphism on the relationship between LFC and either visceral adiposity or carotid intima media thickness (CIMT).A total of 218 type 2 diabetic patients were included in this study.LFC, area of visceral fat, and CIMT were measured.A total of 139 (63.7%) patients had steatosis. The rs738409 minor G allele was associated with LFC. The number of patients with steatosis was significantly higher among minor G allele carriers in comparison to C allele homozygote carriers (70.3 vs. 57.2%; P=0.04) In the subgroup of C allele homozygote carriers, LFC correlated with body mass index (r=0.27; P=0.003) and visceral fat area (r=0.30; P=0.002), but not with CIMT. In the subgroup of minor G allele carriers, LFC correlated inversely with CIMT (r=-0.23; P=0.03), but not with body mass index or with visceral fat area. In multivariate logistic regression, the relationship between the highest quartile of CIMT and steatosis was different according to adiponutrin polymorphism.This study confirms that in people with type 2 diabetes, LFC is related to rs738409 polymorphism. The lack of a relationship with visceral obesity and the inverse correlation with CIMT suggest that fatty liver associated with the minor G allele of the PNPLA3 rs738409 polymorphism may not be linked to metabolic disorders.

Nonalcoholic fatty liver disease (NAFLD) is commonly associated with obesity, metabolic syndrome, and type 2 diabetes. Several studies suggest that NAFLD is independently associated with an increased risk of cardiovascular disease in nondiabetic subjects. In type 2 diabetic subjects, the link between fatty liver and atherosclerosis is less clear. In this study, we set out to determine, whether fatty liver content, evaluated using 1H-magnetic resonance spectroscopy, a very precise imaging technique, was associated with atherosclerosis in people with type 2 diabetes.A total of 101 patients with type 2 diabetes mellitus were included in this study. Liver fat (1H-magnetic resonance spectroscopy) and carotid intima media thickness (IMT) were measured.Sixty-one (60.3%) patients had steatosis (hepatic triglyceride content greater than 5.5%). Liver fat content was correlated with fasting serum triglycerides (r = 0.22; P = 0.02) and alanine aminotransferase (r = 0.42; P = 0.0001). Sixty-eight percent of subjects with severe steatosis (hepatic triglyceride content greater than 15%) had aspartate aminotransferase in the normal range. Age was strongly correlated with IMT (r = 0.37; P = 0.0002). Steatosis did not correlate with IMT (r = -0.03; P = 0.75). There was no significant difference between the two groups (with and without hepatic steatosis) for IMT values.this study suggests that in people with type 2 diabetes, fatty liver is not associated with cardiovascular disease. In a diabetic population, it seems that fatty liver is not a determinant factor associated with carotid IMT.

To prevent ischemia during carotid endarterectomy, a routine or selective shunt can be set up in cases of insufficient cerebral perfusion during the carotid clamping. The aim of this study was to analyze predictive factors for shunting under locoregional anesthesia and to validate a risk index to predict shunt.Using a prospective database, we studied carotid endarterectomy performed under locoregional anesthesia between January 1, 2003, and December 31, 2010 (n=1,223). A shunt was used because of clinical intolerance of clamping in 88 cases (group S, 7.2%). Clinical, comorbidities, demographics, and duplex scan data were used to compare group S to a control group (group C, n=1,135, 92.8%). A multivariable logistic regression was performed to identify predictors of shunt. Coefficients were assigned to each predictor to propose a predictive score.Patients in group S were significantly older than those in group C (75.6±7.8 years vs. 72.6±9.4 years, P0.001). Other factors associated with a carotid shunt were female sex (odds ratio [OR]=2.41, 95% confidence interval [CI]: 1.54-3.78, P0.001), systemic arterial hypertension (OR=2.478, 95% CI: 1.16-4.46, P=0.016), occlusion of the contralateral carotid artery (OR=6.03, 95% CI: 2.91-12.48, P0.001), and 1 factor against the likelihood of a carotid shunt, a history of contralateral carotid surgery (OR=0.34, 95% CI: 0.12-0.93, P=0.037). The mean flow in the contralateral common carotid artery was 696.5±298.0 mL/sec in group S and 814.7±285.5 mL/sec in group C (P0.001). Using those 6 items, we propose a prognostic score validated in our series and allowing to divided risk of intolerance of clamping into low-risk (≤6%), intermediate-risk (6.1%-15%), and high-risk (15%) groups.We have established the first version of a score that predicts the need for a shunt by studying factors associated with intolerance to clamping. The relevance of this score, validated in our series, must be confirmed and adjusted by studies based on a larger sample size.

Background and Purpose— Carotid angioplasty and stenting (CAS) may be more often associated with residual or recurrent stenosis than carotid endarterectomy (CEA). We compared the rates of restenosis in patients treated with CAS or CEA in the EVA-3S trial. Methods— Five hundred seven patients (242 treated by CAS and 265 by CEA) had carotid ultrasound follow-up (mean carotid ultrasound follow-up, 2.1 years) according to a predefined protocol. Carotid restenosis of 50% to 69% was diagnosed on planimetry, whereas carotid restenosis of ≥70% or occlusion was diagnosed using either planimetry or velocity criteria. Results— The rate of carotid restenosis of ≥50% or occlusion was significantly higher after CAS (12.5%) than after CEA (5.0%; time ratio, 0.16; 95% CI, 0.03–0.76; P =0.02). The rates of severe restenosis of ≥70% or occlusion were low and did not differ significantly between the 2 groups (3-year rates are 3.3% in the CAS group and 2.8% in the CEA group). Age at baseline was the only vascular risk factor significantly associated with carotid restenosis. Our study could not detect any effect of carotid restenosis on ipsilateral stroke. Conclusions— The short-term rate of carotid restenosis of ≥50% or occlusion is ≈2.5-times more common after CAS than after CEA, a difference accounted for by an excess risk in moderate restenosis. More data with longer follow-up are needed to assess the rates of late severe restenosis and to determine the relation between restenosis and recurrent stroke over time.

The ankle brachial pressure index (ABPI) makes it possible to diagnose peripheral artery disease (PAD) and identify patients with a vascular risk. Recently, the Haute Autorité de santé (HAS) issued guidelines. We wanted to determine the interest and impact of these guidelines when applied to patients hospitalised in an internal medicine department.We systematically measured the ABPI in two internal medicine departments. We compared the results obtained with the screening criteria and the good practices recommended by the HAS.The screening criteria recommended by the HAS were already applied in 91% of our 97 patients. PAD was found in 37.1% of patients. In 83% of cases, the diagnosis was unknown (p = 0.02). The PAD was symptomatic in 83% of the known PAD cases, and 3.3% in newly-diagnosed cases (p0.001)). The sensitivity of the HAS screening criteria applied to our population was 100% but almost patients justifies ABPI screening. The specificity was 11.5%, the positive predictive value 40% and the negative predictive value 100%. The optimal treatment recommended was implemented in only 50% of patients with known arteriopathy and in 10% of newly-diagnose PAD (p = 0.04).PAD prevalence is high in internal medicine department and systematic measurement of ABPI is effective. Determining patients to screen with the HAS criteria has a poor impact in our patients. The optimal treatment is still extremely under-prescribed even in patients with known PAD.

Stroke in the elderly differs from stroke in younger adults in several points. It represents the most frequent consequence of atherothrombotic disease associated with hypertension, diabetes and hypercholesterolemia. It is also the main complication of cardiac arrhythmia. From a clinical point of view, epileptic seizure is frequently observed at the onset, and prognosis is darkened by a high risk of dementia occurrence (20%). Management of stroke in acute phase requires intensive care, which has been shown to decrease mortality and handicap by 20% in Stroke Units. Fibrinolysis with rt-PA can be carried out till 80 years. Primary and secondary prevention are still very efficacious in old patients and decrease not only the risk of stroke, but also the risk of dementia. Moreover, influenzae vaccination has been shown to decrease the risk of stroke in the following year in subjects over 65 years.

Because a popliteal artery aneurysm (PAA) generates emboli that progressively deteriorate the distal arterial network, they can constitute limb-threatening lesions. In 20 to 40% of cases, discovery of PAA coincides with sudden occlusion and resulting acute ischemia. In 40 to 60% of these patients, surgical revascularization fails and amputation is required. The objective of this prospective study was to assess the value of intraarterial thrombolysis to restore distal runoff before surgical revascularization. Between January 1, 1992 and December 31, 1996, we treated 15 PAA causing acute ischemia in 15 male patients with a mean age of 66.7 years (range, 44 to 87 years). Diagnosis was documented by clinical examination and ultrasound imaging. Intraarterial thrombolysis was performed under arteriographic control through a multiperforated catheter inserted by the anterograde femoral route to the thrombus. After an initial bolus of 100,000 U of urokinase, 600,000 to 1,600,000 U was continuously infused over a period of 6 to 18 hr. Heparin sodium was administered throughout thrombolysis. Surgical revascularization was performed within 1 to 4 days (mean, 2 days) after thrombolysis by exclusion and bypass in 14 cases and percutaneous transluminal angioplasty with stenting in 1 case. The ensuing results showed that, if performed carefully, intraarterial thrombolysis can safely prepare patients presenting with occluded PAA with acute ischemia for surgical revascularization to restore distal runoff. We use this combined technique routinely in our department. Morbidity is low in comparison with the risks of amputation.

Introduction La steatose hepatique est frequemment associee au syndrome metabolique et au diabete de type 2. Son association au risque coronarien semble bien demontree dans la population generale. Par contre, dans la population des sujets diabetiques de type 2 (DT2) nous ne disposons pas d’etude confirmant cette relation. De plus la mesure de la steatose est souvent realisee avec des moyens non specifiques comme la biologie (augmentation des transaminases), ou l’echographie. Notre objectif est d’evaluer la steatose des patients diabetiques de type 2 par la technique non invasive de reference, la spectrometrie IRM, et de rechercher une association au risque coronarien evalue par la mesure de l’epaisseur de l’intima media carotidienne (EIM). Materiels et methodes Quatre-vingt dix-neuf sujets diabetiques de type 2 ont ete inclus dans l’etude. Tous ont beneficie d’un examen par spectrometrie IRM hepatique avec mesure de la steatose de facon quantitative. La quantite de graisse viscerale a ete mesuree par IRM. La mesure de l’EIM est la moyenne des mesures pour les 2 carotides. Resultats Soixante et un (61,6 %) patients presentent une steatose avec un pourcentage de graisse > 5 % a la spectrometrie IRM. La quantite de steatose est correlee au taux des transaminases (ASAT r = 0,27, p = 0,009 ; ALAT r = 0,28, p = 0,007), des triglycerides (r = 0,27, p = 0,01), des gamma-GT (r = 0,20, p = 0,05), mais pas au taux de HDL-cholesterol, de LDL-cholesterol ou a la quantite de graisse viscerale mesuree par IRM. Soixante-treize pourcent des patients avec une steatose > 5 % et 57.8 % de ceux avec une steatose severe > a 15 % ont des taux de transaminases dans les normes. Concernant le risque vasculaire, l’EIM carotidienne n’est pas correlee a la quantite de steatose (r = 0,05 ; p = 0,68). Conclusion Ce travail montre que chez les sujets diabetiques de type 2, la steatose ne semble pas etre associee a une augmentation du risque vasculaire evalue par la mesure de l’EIM carotidienne. La prevalence de la steatose chez les sujets diabetiques est tres elevee avec environ 2/3 de patients atteints de surcharge hepatique en graisse. Par contre, la mesure des transaminases ne semble pas etre un bon outil pour le depistage de la steatose du patient diabetique.

Objective The incidence of venous thromboembolism (VT) after aortic abdominal aneurysm (AAA) surgery is imprecisely reported. On one hand, thromboprophylaxis has improved, on the other hand, AAA patients have become older and/or present worse comorbidities. Herein, we prospectively analyzed the incidence of VT in a continuous series of patients operated on for AAA repair and looked for predictive factors. Materials and Methods Between January 1, 2005, and December, 31, 2006, 193 consecutive patients (177 men and 16 women), mean age 73 (range, 47-93) underwent elective AAA repair, 137 open (71%) and 56 endovascular (29%), in our institution. Thromboprophylaxis consisted of thigh-length compression bandages or stockings, early mobilization, and a daily subcutaneous injection of low-molecular-weight heparin (enoxaparin 40 mg per day). Patients with renal insufficiency or aged over 80 were given unfractionated heparin (5000 IU twice a day). Heparin was started between day 1 and day 5 (median = day 1) after surgery, according to the prescription of the surgeon. A bilateral lower limb duplex venous compression ultrasonography scan using 3 to 7.5 MHz transducers was systematically done before and after surgery in each patient. Two groups were considered: group 1 with postoperative VT (n = 17) and group 2 without (n = 176). The 17 patients with VT were compared with 51 patients randomly chosen among the 176 patients without VT. Different characteristics such as venous risk factors, preoperative antithrombotic treatment, anatomical features of the AAA, and perioperative data were studied. Results Seventeen patients (8.1%) were diagnosed with postoperative VT (15 asymptomatic deep vein thrombosis [DVT] and 2 symptomatic pulmonary embolisms [PE]). VTE tended to be more frequent in open (10.2%) than endovascular (5.3%) repair ( P = .28). Among perioperative data, delay to thromboprophylaxis was related to bleeding complication ( P = .05) and blood transfusion ( P = .02), and tended to be longer in VT patients (1.7 +/− 1.4 vs 0.9 +/− 0.9 day; P = .09). Conclusion Despite systematic prevention with heparin, surgery for AAA repair induces a high incidence of postoperative VT. This series mandates for vigilance about VT, with particular attention to the patients who received transfusion with fresh frozen plasma. Even though this series is one of the largest ever published on this topic, the rarity of the events calls for confirmation with a larger prospective study.