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International audience; After a proximal lower limb deep vein thrombosis (DVT; involving popliteal veins or above), up to 40% of patients develop postthrombotic syndrome (PTS) as assessed by the Villalta scale (VS). Poor initial anticoagulant treatment is a known risk factor for PTS. The risk of developing PTS after isolated distal DVT (infra-popliteal DVT without pulmonary embolism), and the impact of anticoagulant treatment on this risk, are uncertain.Methods: Long-term follow-up of CACTUS double-blind trial comparing 6 weeks of s.c. nadroparin (171 IU/kg/d) versus s.c. placebo for a first symptomatic isolated distal DVT. At least 1 year after randomization, patients had a PTS assessment in clinic or by phone using the VS.Results: After a median follow-up of 6 years, PTS was present in 30% (n = 54) of the 178 patients who had a PTS assessment. PTS was moderate or severe in 24% (n = 13) of cases. There was no statistically significant difference in prevalence of PTS in the nadroparin versus placebo groups (29% versus 32%, P = .6), except in patients without evidence of primary chronic venous insufficiency (9% versus 24%, P = .04). Rates of venous thromboembolism recurrence during follow-up in the nadroparin and placebo groups were, respectively, 8% (n = 7) and 14% (n = 13; P = .2).Conclusion: After a first isolated distal DVT, the risk of PTS is substantial but much lower than that reported after proximal DVT. Anticoagulation with nadroparin doesn't provide any clear benefit to prevent PTS, except in patients without preexisting chronic venous insufficiency. Anticoagulation might be associated with a lower risk of venous thromboembolism recurrence.

Recurrent deep vein thrombosis (DVT) is often suspected in patients after anticoagulant drug withdrawal. The clinical signs can be confused with the onset of post-thrombotic syndrome. For these reasons, diagnosis of DVT recurrence must rely on an accurate method.In order to assess this challenging clinical issue, we performed an overview of the literature regarding ultrasound criteria for the diagnosis of recurrent DVT through a Medline search, which included articles published from January 1, 1980 to February 20, 2017.Eighty-eight publications were found based on the defined keywords, of which nine articles with a relevant abstract were selected. By searching the reference lists of these nine articles, we obtained another 27 relevant articles. A new non-compressible vein or an increase in the diameter of a previously thrombosed vein segment by4mm are sufficient to confirm the diagnosis of DVT recurrence. In contrast, an increase in diameter of2mm enables recurrence to be ruled out. An increase between 2 and 4mm is deemed equivocal. Criteria based on echogenicity and Doppler venous blood flow are not reproducible. Other diagnostic imaging methods, mainly direct thrombus magnetic resonance imaging, are currently under evaluation.Ultrasound remains the most useful test for the diagnosis of recurrent DVT. Further imaging tests need to be validated.

Objectifs Apres une thrombose veineuse profonde (TVP), des bas de compression elastique (CE) sont frequemment prescrits pour prevenir la survenue d’un syndrome post-thrombotique (SPT). Une observance therapeutique defaillante constitue un frein important a l’efficacite de la CE pour prevenir le SPT. L’utilisation d’une CE moins forte que celle utilisee dans les essais cliniques ( Methodologie Essai therapeutique de non-inferiorite randomise en double insu comparant la CE 25 mmHg vs. 35 mmHg pour prevenir le SPT chez les patients presentant un premier episode de TVP aigue proximale des membres inferieurs sans insuffisance veinolymphatique significative preexistante et traites au moins 3 mois par anticoagulant (clinicalTrial.gov : NCT01578122 ). Le critere principal de jugement est l’incidence cumulee de SPT a 2 ans evaluee par le score de Villalta a 1 ou 2 ans. La marge de non-inferiorite pour la difference de taux de SPT entre les groupes a ete fixee a 12,5 %. Une observance optimale etait definie comme un port de la CE 80 % du temps. Cette etude a ete approuvee par les autorites de sante et un comite d’ethique et tous les patients ont signe un formulaire de consentement eclaire (clinicaltrial.gov : NCT01578122 ). Resultats De 2012 a 2017, 350 patients ont ete randomises. L’incidence cumulee de SPT etait de 31 % dans le groupe 25 mmHg et 33,3 % dans le groupe 35 mmHg (difference absolue −2,3 %, (IC 90 % : −12,1 ; 7,4), p = 0,006 pour la non-inferiorite). L’incidence cumulee de SPT moderes a severes etait de 4 % dans le groupe 25 mmHg et de 9,4 % dans le groupe 35 mmHg, p = 0,09. L’observance dans les groupes 25 mmHg et 35 mmHg etait optimale dans 51,4 % et 41,8 % des cas respectivement, p = 0,1. Chez les patients observants optimaux, l’incidence cumulee du SPT dans les groupes 25 mmHg et 35 mmHg etait de 29,4 % et 21,6 % respectivement, p = 0,3. Conclusions La CE 25 mmHg est non-inferieure a la CE 35 mmHg pour prevenir le SPT a 2 ans et l’observance therapeutique est meilleure numeriquement. Il semble exister une relation dose/reponse chez les patients observants optimaux avec une tendance pour une meilleure observance dans le groupe 25 mmHg.

To describe characteristics and long-term outcomes of the rare symptomatic lower-limb giant-cell arteritis (LL-GCA).Retrospective analysis of 8 patients (6 women; mean±SD age, 63.6±10.9 years; follow-up, 137.3±57.3 months).Four patients satisfied≥3 American College of Rheumatology (ACR) GCA-classification criteria; 4 had3 criteria and histological LL-GCA proof or associated typical upper-limb involvement. Patients had 2.1±1.1 vascular risk factors. Bilateral and rapidly progressive arterial claudication was the first LL sign; 2 had rest ischemia. Imaging-visualized most-to-least frequent inflammatory lesion localizations were: superficial femoral, popliteal, tibiofibular trunk, posterior tibial arteries. All received corticosteroids for 132±76.2 months; 2 required immunosuppressive agent adjunction. Only 3 required 1-6 revascularizations: twice during the first month post-diagnosis and twice later. Thromboendarterectomy and endovascular procedures did not work while bypasses were successful. LL-claudication regressed for 7 (10.5±12.1 months) and disappeared for 5 (16.8±9.8 months). Three patients stopped corticosteroids (26-90 months), 1 restarted 45 months later. Every patient relapsed once (23.9±26.7 months, mean corticosteroid dose: 0.28±0.30mg/kg/day). LL-GCA caused only 1 of the 4 deaths.Symptomatic LL-GCA attributable long-term mortality seems to be low despite frequent relapses and corticosteroid-dependence.

Resume L’objectif de l’etude etait d’evaluer l’incidence, les caracteristiques et la distribution des thromboses veineuses des membres inferieurs diagnostiquees par echo-Doppler chez des patients atteints de cancer, a la recherche de criteres supplementaires utilisables pour mieux cibler, en cas de thromboses inexpliquees, celles pouvant etre liees a un cancer occulte. Patients et methodes Entre janvier 2001 et mai 2012, 38 424 comptes rendus standardises d’echo-Doppler ont ete incrementes dans une base de donnees informatisee. Ont ete selectionnes 3263 comptes rendus d’echo-Doppler effectues chez des patients ayant un cancer actif ou datant de moins de cinq ans, parmi lesquels 1026 avaient une thrombose veineuse. Les caracteristiques de la population d’origine, l’incidence et la distribution anatomique des thromboses veineuses ont ete analysees. Resultats Parmi les 3263 patients avec cancer, les incidences de thrombose veineuse etaient : totales 31,4 % (n = 1026), proximales 14,5 % (n = 472), bilaterales 8,5 % (n = 278), localisations multiples (au moins trois sites non contigus) 4,6 % (n = 149). Le taux de suspicion clinique d’embolie pulmonaire (EP) etait de 49,9 % (n = 1628). Parmi les patients avec thrombose (n = 1026), une localisation proximale etait presque aussi frequente qu’une localisation distale, avec 17,6 % (n = 181) de thrombose ilio-cave. Les axes gastrocnemiens, poplites et femoraux etaient concernes avec des frequences presque identiques, respectivement de 28,7 % (n = 278), 27,1 % (n = 294) et 25,6 % (n = 263). Les veines superficielles etaient concernees dans 23,5 % (n = 241) des cas. Des thromboses partielles ou mobiles etaient frequentes dans quatre localisations : femorale commune, iliaque externe, femorale superficielle et poplitee. Conclusion Des localisations proximales, multiples, partielles ou mobiles, ainsi qu’inhabituelles (gastrocnemiennes ou superficielles) pourraient etre caracteristiques des thromboses liees a un cancer.

Resume L’objectif a ete d’evaluer, a partir de donnees de la litterature, le risque d’hemorragies fatales qu’ajouterait un eventuel traitement anticoagulant curatif des thromboses veineuses asymptomatiques depistees par un echo-doppler systematique apres protheses totales de hanche/genou, et de fractures de hanche. Materiel et methodes L’incidence des evenements thromboemboliques et hemorragiques avec la prophylaxie recommandee et celle des hemorragies majeures iatrogenes liees au traitement anticoagulant curatif, ont ete extraites d’essais cliniques randomises, d’analyses des codages de pathologies en sortie d’hospitalisation, de registres et enquetes observationnelles. L’incidence des evenements mortels a ete calculee pour l’embolie pulmonaire, les hemorragies sous prophylaxie, et les hemorragies iatrogenes sous anticoagulation curative, en multipliant le taux moyen de l’evenement symptomatique par son coefficient de mortalite. Les taux d’evenements mortels ont ete evalues pour un ensemble theorique de 10 000 protheses totales de hanche/genou, et de 10 000 fractures de hanche. Resultats Sur 10 000 patients apres protheses de hanche/genou, cinq embolies pulmonaires fatales et deux hemorragies fatales sont attendues malgre la prophylaxie recommandee. L’anticoagulation curative des thromboses asymptomatiques sous-jacentes ajouterait neuf hemorragies fatales dont huit liees au traitement des seules thromboses distales. Sur 10 000 fractures de hanche soumises a une prophylaxie prolongee, six embolies pulmonaires fatales et 23 hemorragies fatales sont attendues. L’anticoagulation curative des thromboses asymptomatiques ajouterait 16 hemorragies fatales dont 14 liees au traitement des seules thromboses distales. Conclusion L’anticoagulation curative des thromboses veineuses asymptomatiques, en particulier distales, conduirait a davantage de deces par hemorragie qu’elle ne pourrait en eviter par embolie pulmonaire, ce qui renforce la recommandation de ne pas les depister.

International audience; BACKGROUND:The efficacy and safety of anticoagulant treatment is not established for patients with acute symptomatic deep vein thrombosis (DVT) of the calf. We aimed to assess whether therapeutic anticoagulation is superior to placebo in patients with symptomatic calf DVT.METHODS:In this randomised, double-blind, placebo-controlled trial, we enrolled low-risk outpatients (without active cancer or previous venous thromboembolic disease) with a first acute symptomatic DVT in the calf from 23 university medical centres or community medical clinics in Canada, France, and Switzerland. We randomly assigned (1:1) patients to receive either the low-molecular-weight heparin nadroparin (171 UI/kg, subcutaneously, once a day) or placebo (saline 0·9%, subcutaneously, once a day) for 6 weeks (42 days). Central randomisation was done using a computer-generated randomisation list, stratified by study centre. Random allocation sequences of variable block size were centrally determined by an independent research clinical centre. Study staff, patients, and outcome assessors (central adjudication committee) were masked to group assignment. Numbered boxes of active drug or placebo were provided to pharmacies in identical packaging. All patients were prescribed compression stockings and followed up for 90 days. The primary efficacy outcome was a composite measure of extension of calf DVT to proximal veins, contralateral proximal DVT, and symptomatic pulmonary embolism at day 42 in the modified intention-to-treat population. The primary safety outcome was major or clinically relevant non-major bleeding at day 42. The trial was registered with ClinicalTrials.gov, number NCT00421538.FINDINGS:Between Feb 1, 2008, and Nov 30, 2014, we screened 746 patients, enrolling 259 patients (50% of the prespecified sample size), before the trial steering committee terminated the trial because of expiry of study drug and slow recruitment. The intention-to-treat analysis population comprised 122 patients in the nadroparin group and 130 in the placebo group. There was no significant difference between the groups in the composite primary outcome, which occurred in four patients (3%) in the nadroparin group and in seven (5%) in the placebo group (risk difference -2·1%, 95% CI -7·8 to 3·5; p=0·54). Bleeding occurred in five patients (4%) in the nadroparin group and no patients in the placebo group (risk difference 4·1, 95% CI 0·4 to 9·2; p=0·0255). In the nadroparin group one patient died from metastatic pancreatic cancer and one patient was diagnosed with heparin-induced thrombocytopenia type 2.INTERPRETATION:Nadroparin was not superior to placebo in reducing the risk of proximal extension or venous thromboembolic events in low-risk outpatients with symptomatic calf DVT, but did increase the risk of bleeding. Avoidance of systematic anticoagulation for calf DVT could have a substantial impact on individual patients and from a public health perspective.FUNDING:Swiss National Science Foundation, the Programme Hospitalier de Recherche Clinique in France, and the Canadian Institutes of Health Research.

Resume Introduction Un traitement thrombo-prophylactique est recommande pendant 35 a 40 jours apres la pose d’une prothese totale de hanche (PTH). Les injections d’heparine de bas poids moleculaire (HBPM), faites par des tiers, assurent une bonne observance du traitement. Des nouveaux anticoagulants oraux sont apparus recemment, mais leur observance n’est pas connue avec precision. La prise orale, sans tests de controle d’efficacite, peut inquieter pour le traitement d’une affection potentielle dont l’absence de symptome premonitoire ne vient pas rappeler au patient la necessite de le prendre regulierement jusqu’a la fin de la prescription. Hypothese L’hypothese du travail etait que l’observance de ces nouveaux anticoagulants oraux etait bonne tout au long de la duree de traitement preconise. Materiel et methode Cette etude de cohorte a evalue prospectivement l’observance d’un traitement per os apres PTH (deux gelules de dabigatran etexilate [Pradaxa®] par jour en une prise, a heure determinee). Un dispositif electronique enregistrait en continu le jour et l’heure de chaque « sortie » de gelule. Tous les patients inclus ont eu une evaluation clinique et echo-doppler au 30e jour ± 5 apres le debut de l’etude. Resultat Cinquante-six patients ont ete inclus lors de leur retour a domicile. L’observance globale etait de 98,1 % (3188 gelules « correctes » sur 3246) avec une legere baisse avec le temps, sans descendre sous 97,1 %. Un patient a fait une thrombophlebite symptomatique, diagnostiquee 34 jours apres l’intervention, associee a un ecart d’observance a j11. Quatre thromboses veineuses distales asymptomatiques ont ete notees a l’echo-Doppler final. Il n’y a pas eu de complication hemorragique. Discussion Le risque de complication thromboembolique decroit avec le temps et les anticoagulants oraux ont une large fenetre therapeutique et une demi-vie relativement longue (15 a 17 h). Leur efficacite a ete demontree, et ils apportent un confort au patient et une economie. Notre etude montre que l’observance est satisfaisante. Cela ne dispense pas, comme dans notre etude, de donner au patient une information adaptee afin de favoriser son adhesion au traitement. Niveau de preuve III prospective diagnostique.

Summary Introduction Thirty-five to 40 days’ thromboprophylaxis is recommended following total hip replacement (THR). Low molecular weight heparin (LMWH) injected by a health professional ensures good compliance. Compliance with recent oral anticoagulants has not been precisely assessed. Oral self-administration, without coagulation monitoring tests, may be a worrying issue in the management of what is a potentially catastrophic adverse event, without prodromal symptoms alerting the patient to the need for regular intake throughout the prescription period. Hypothesis It was hypothesized that compliance with these new oral anticoagulants is good over the entire treatment period. Patients and method The present cohort study prospectively assessed compliance with oral medication (two capsules of dabigatran etexilate [Pradaxa ® ] per day in a single dose at a set time) following THR. An electronic device continuously monitored the day and time of extraction of capsules from the package. All included patients underwent clinical and echo-Doppler examination at day 30 ± 5 after the start of the study. Results Fifty-six patients were included at their discharge home. Overall compliance was 98.1% (3,188/3246 capsules correctly taken), falling off slightly over time but never below 97.1%. One patient was diagnosed with symptomatic thrombophlebitis 34 days postoperatively, associated with non-compliance at day 11. End of follow-up echo-Doppler found four cases of asymptomatic distal venous thrombosis. There were no hemorrhagic complications. Discussion The risk of thromboembolic complications diminishes over time, while oral anticoagulants have a wide therapeutic window and relatively long half-life (15–17 hrs). Efficacy was demonstrated, with improved patient comfort and cost-saving. Compliance in the present series was satisfactory. This, however, should not mean that patients not be appropriately informed, as in the present study, so as to improve compliance. Level of evidence Level III, prospective diagnostic.

Resume Objectifs Determiner l’incidence et la distribution des localisations de thromboses veineuses diagnostiquees par echo-doppler incluant l’exploration des mollets, au decours de trois chirurgies orthopediques majeures en vue de les comparer aux resultats phlebographiques rapportes dans la litterature. Patients et methodes Entre janvier 2001 et decembre 2009, a partir de 30 510 comptes rendus echo-doppler standardises dans une base de donnees informatisee, ont ete selectionnes ceux effectues pour diagnostic de thrombose au decours de prothese totale de hanche (PTH, n = 1652), de genou (PTG, n = 1440) et de fracture de hanche (FH, n = 2889). Les caracteristiques des trois populations, les incidences de thrombose et leur distribution anatomique ont ete analysees. Resultats Le motif d’examen etait un depistage systematique dans 95,1 % des cas ( n = 5689). L’incidence des thromboses totales et proximales etait respectivement de 27,8 % ( n = 460) et 2,8 % ( n = 46) dans la PTH, de 32,5 % ( n = 939) et 4,4 % ( n = 126) dans la FH, et 50,3 % ( n = 724) et 3,8 % ( n = 55) dans la PTG. Les thromboses distales representaient 89,3 % ( n = 1896) des thromboses. Plus de la moitie d’entre elles ( n = 1014) etaient limitees aux seules veines soleaires. L’incidence des thromboses iliocaves etait de 0,18 % ( n = 11), et celle des localisations superficielles de 1,5 % ( n = 89). Conclusion Cette etude montre que les taux de thromboses veineuses diagnostiquees par un echo-doppler complet et standardise sont proches des taux phlebographiques publies.

Resume Cette mise au point cherche a apporter une aide aux praticiens en charge de la gestion de la maladie thromboembolique veineuse (MTEV), en insistant sur les specificites propres a la thrombose veineuse en medecine. Elle concerne l’etat actuel des connaissances : epidemiologie, facteurs de risque, prophylaxie, prise en charge diagnostique, therapeutique et perspectives et s’appuie sur la recente parution de la huitieme edition des recommandations du groupe d’experts de l’American College of the Chest Physicians (ACCP). Les scores de probabilite clinique, le dosage des D-dimeres, l’imagerie en particulier par echographie et echographie-doppler sont reunis dans des algorithmes decisionnels qui permettent de securiser et d’uniformiser les prises en charge diagnostiques. Les principales indications des traitements preventifs et les principales recommandations de l’ACCP concernant les traitements curatifs sont abordees. Sont evoquees les perspectives concernant les nouveaux antithrombotiques et les etudes en cours, avec leurs objectifs : amelioration de la prophylaxie en medecine, traitement des thromboses distales et des thromboses superficielles, validation d’une formation acceleree a une echographie limitee a deux points, en vue de proposer de nouveaux algorithmes diagnostiques.

La trombosis venosa profunda es el resultado de un fenomeno fisiologico que se desarrolla en un lugar no deseado de la red venosa. Se produce por razones que pocas veces estan relacionadas con trastornos de la coagulacion (trombofilia), sino sobre todo con la estasis venosa y con lesiones endoteliales. Estos tres elementos constituyen la clasica triada de Virchow. Es probable que el factor tisular sea un mediador determinante de la enfermedad tromboembolica, cuyas consecuencias locales pueden producir molestias funcionales en la pierna y ser potencialmente catastroficas si da lugar a una embolia pulmonar. La cirugia ortopedica y traumatologica es causa destacada de enfermedad venosa tromboembolica, sobre todo las protesis totales de cadera y de rodilla, asi como las fracturas del extremo superior del femur, que aparecen en una poblacion a menudo envejecida, con una movilidad reducida, con sobrepeso y con factores frecuentes de comorbilidad. La profilaxis farmacologica ha experimentado progresos considerables en las ultimas decadas, hasta el punto de que la embolia pulmonar mortal se ha convertido en excepcional, por fortuna. En cambio, no esta desprovista de riesgos y, en la actualidad, el carne de identidad de un antitrombotico debe incluir un estudio preciso de dos aspectos: el beneficio profilactico y el riesgo hemorragico. Los estudios se realizan en poblaciones escogidas y se basan en las pruebas complementarias, que son mas sensibles que los fenomenos clinicos gracias a la frecuente positividad. Deben completarse mediante cohortes de pacientes de la «vida real». La flebografia ya no se emplea mas que en los estudios. La eco-Doppler es la exploracion de rutina en la practica clinica. La farmacopea aumenta con regularidad gracias a nuevas moleculas, procedentes en la mayoria de los casos de la fragmentacion de la heparina, que bloquean la formacion de trombina mediante el factor X activado o directamente la propia trombina. La eficacia de los medicamentos ha creado un autentico apasionamiento por su utilizacion, y la tendencia actual deberia ser mas selectiva para adaptar a cada paciente concreto la molecula, su posologia, la hora de la primera inyeccion, asi como su ritmo de prescripcion, pasando de la epoca del tratamiento «listo para administrar» a la del tratamiento «sobre medida».

Background: Despite use of the anti-thrombotic prophylaxis, clinical thrombo-embolic events and fatal pulmonary embolism are still observed after total hip replacement. To reduce these complications, two strategies have been adopted: to prolong the use of low-molecular-weight heparins (LMWH) to 35 days or to screen patients systematically before discharge, using duplex ultrasonography, following the short-course prophylactic treatment. Objective: To assess, based on published literature, the relative costs and benefits of these two strategies for prophylaxis following total hip arthroplasty. Method: The author identified relevant papers in this field from his own resources and from medical literature databases. Synthesis: Prolonging LMWH treatment to a total of 35 days represents a direct cost in France of approximately £340 per patient, or for 100000 total hip replacements per year, an annual budget of £34 000000. If this strategy attained maximum efficacy, it would avoid 150 fatal pulmonary embolisms. The direct cost would therefore be at least £227000 per life saved. A systematic single duplex ultrasound examination before discharge from hospital would cost £76 per patient, or for 100 000 arthroplasties a total annual budget in France of £7 600000. If this approach achieved maximum efficacy, preventing the 150 fatal pulmonary embolisms corresponding to 100000 total hip replacements, the minimum direct cost would be £50 300 per life saved. Conclusion: Duplex screening may be more effective and lest costly than prolongation of prophylactic treatment using LMWH. This deduction needs to be confirmed by complex cost-benefit studies using clinical end-points.

See also Tan M, Velthuis SI, Westerbeek RE, van Rooden CJ, van der Meer FJ, Huisman MV. High percentage of non-diagnostic compression ultrasonography results and the diagnosis of ipsilateral recurrent proximal deep vein thrombosis. J Thromb Haemost 2010; 8: 848–50; Tan M, Huisman MV. High percentage of non-diagnostic compression ultrasonography results and the diagnosis of ipsilateral recurrent proximal deep vein thrombosis: reply to a rebuttal. This issue, pp 417–8.

To analyze localizations of duplex ultrasonography-diagnosed lower-limb venous thrombosis in young women in hormonal periods in order to optimize the ultrasound exploration.From 42,018 standardized ultrasonography report forms, incremented in a database (January 2001 - July 2013), those performed for a first diagnosis of venous thrombosis in women ≤ 45 years were selected (n = 996). Among those, diagnosed venous thrombosis (n = 172) were classified into three groups: oral contraception (n = 74), pregnancy (n = 39) and post-partum period (n = 59). Clinical symptoms and thrombosis distribution were analyzed.In the contraception group, pulmonary symptoms at presentation were much more frequent than in the obstetrical group: 69% vs 20% (P0.001). The thrombosis was limited to the iliac veins in 31% (23/74) and to the left internal iliac vein in six patients. During pregnancy, the thrombosis was limited to the iliac veins in 28% (11/39), and to the left internal iliac vein in two patients. In the post-partum period, superficial venous thromboses were found more frequently (37/59). Among the 22 deep venous thromboses, nine were limited to the proximal segment, including four in the vena cava coming from a right ovarian vein thrombosis.Duplex ultrasonography in young women taking oral contraception, as during pregnancy, must target iliac venous segments, especially on the left side, otherwise one thrombosis out of three may be missed; in the post-partum period, the inferior vena cava and superficial veins are to be explored too.

Contexte Les anticoagulants reduisent le risque de complications thromboemboliques veineuses apres traumatisme isole du membre inferieur.

Resume Theme Mettre en œuvre une formation courte des urgentistes au flash-echo-deux-points (FEDP) [pli inguinal et pli poplite], qui pourrait dans l'avenir s'integrer dans une strategie d'attente pour securiser une prise en charge au domicile des suspicions de thrombose veineuse en attendant leur documentation par un echo-doppler veineux complet. Objectifs Valider la formation proposee par une etude de concordance entre operateurs (urgentiste en formation et medecin vasculaire), en multicentrique, sur 60 urgentistes, et etablir la courbe d'apprentissage. Methodologie Formation theorique : deux pages de schemas et consultation d'une banque d'images sur le Web. Formation pratique : 25 patients en tout dont les 15 derniers comme operateur independant, avec redaction d'un compte rendu standardise. Concordance interoperateurs : (a) centralisation, saisie, et analyse independante des comptes rendus standardises de l'urgentiste et du medecin vasculaire, accouples par patient, du 11e au 25e ; (b) calcul des coefficients de concordance, kappa, et construction de la courbe d'apprentissage (900 points de concordance pour 60 urgentistes). Criteres d'inclusion (a) thrombose traitee, distale ou proximale (conserve l'aveugle sur le resultat du FEDP) recrutee par le medecin vasculaire ; (b) accord oral du patient. Resultats attendus Inflechissement de la courbe d'apprentissage autour du 20e patient avec un kappa superieur a 0,61 voire a 0,80. Apport original du projet (a) Etude prospective, multicentrique, en aveugle : (i) confirmant la faisabilite de l'echographie veineuse deux points, par les urgentistes ; (ii) validant le contenu et la duree d'une formation courte et simplifiee ; (b) Validation d'un critere de retour au domicile ; (b) si validee, formation-type applicable a d'autres disciplines (reanimation, geriatrie).

Le syndrome post-thrombotique (SPT) est presume lie a l’obstruction residuelle et/ou aux reflux veineux secondaires aux lesions anatomiques parietales et valvulaires observees au decours d’une thrombose veineuse profonde (TVP). Son diagnostic et sa quantification sont difficiles du fait du caractere non specifique des signes cliniques, des delais variables de son installation, ainsi que des interferences avec les signes cliniques initiaux et/ou avec des pathologies associees confondantes. Par defaut, il est fait appel a un score (Villalta) associant signes subjectifs et objectifs. La compression elastique (CE) en est le traitement curatif, mais son efficacite en preventif du SPT est actuellement discutee. Objectif Rassembler des arguments confortant l’usage de la CE (classe 3) pour prevenir le SPT. Methodes Selectionner dans la litterature les etudes apportant des resultats probants. Resultats Six etudes comparatives contre placebo/groupe controle ont ete recensees, utilisant (pour 4 sur 6) le score de Villalta a + 2 ans (critere intermediaire) comme critere de jugement. Quatre etudes sont positives mais souffrent d’effectifs reduits et de biais, en particulier du fait de l’absence d’aveugle. Deux etudes sont negatives dont la recente etude SOX, de methodologie rigoureuse (multicentrique, double aveugle, > 800 patients). Elle n’est cependant pas plus probante du fait de la tres mauvaise compliance des patients : environ la moitie des patients ont porte la compression la moitie du temps. Les preuves d’inefficacite sont donc insuffisantes pour abandonner la CE au decours d’une TVP. En effet, l’efficacite de la CE est demontree pour : reduire les œdemes meme lymphatiques, obtenir la cicatrisation des ulceres veineux, soulager les plaintes des patients au decours de TVP, c’est-a-dire pour prendre en charge le SPT constitue ! Conclusion Si la CE ne peut evidemment pas reparer les lesions anatomiques irreversibles de la TVP, elle rend leurs consequences moins deleteres. Son efficacite preventive sur les troubles trophiques cutanes pourrait etre mieux demontree, en utilisant un critere de jugement plus robuste comme l’ulcere veineux et en testant une CE de pression a la cheville plus faible afin d’ameliorer l’observance, seul gage d’efficacite, comme pour un medicament. C’est le rationnel de l’etude CELEST (Pr J.L. Bosson, Grenoble et Innothera). Il est indispensable d’y participer pour temperer les resultats de SOX.

The study objective was to evaluate the incidence, characteristics and distribution of lower limb deep venous thrombi diagnosed by ultrasound among known cancer patients, in order to determine additional criteria that could be used to help select patients with unprovoked deep venous thrombosis caused by occult cancer.From January 2001 to May 2012, standardized report forms (n=38,424) were entered into a database. A total of 3263 report forms corresponding to cancer patients with suspected venous thrombo-embolic disease were selected from which 1026 cases of deep venous thrombosis were diagnosed by ultrasonography. Baseline characteristics, incidence, and anatomic distribution of venous thrombi were analyzed.For 3263 patients with cancer, the venous thrombosis incidence was: total 31.4% (n=1026), proximal 14.5% (n=472), bilateral 8.5% (n=278) and multiple venous sites 4.6% (n=149). The rate of clinical suspicion of pulmonary embolism was 49.9% (n=1628). For 1026 patients with thrombosis, proximal thrombi were nearly as frequent as distal thrombi, with 17.6% (n=181) iliocaval thrombi. Gastrocnemial, popliteal and femoral veins were almost equally concerned by thrombosis with respective rates of 28.7% (n=278), 27.1% (n=294) and 25.6% (n=263). Superficial veins were concerned in 23.5% (n=241). Partial or floating clots occurred frequently in 4 localizations: common femoral, external iliac, femoral and popliteal veins.Proximal, multiple, partial, mobile thrombi, and such unusual locations as gastrocnemial or superficial thromboses, are potentially indicators for selecting patients that may benefit from a cancer check-up because their venous thrombosis could be due to cancer.

The study objective was to evaluate the potential increase in fatal bleeding risk related to curative anticoagulation of asymptomatic deep venous thromboses diagnosed by routine ultrasound screening after total hip/knee replacement or hip fracture using data from a comprehensive literature review.Rates of venous thromboembolic and bleeding events occurring with recommended prophylaxis, and rates of iatrogenic bleeding risk induced by curative anticoagulation were extracted from randomized clinical trials, diagnosis codes at discharge, electronic databases, and observational studies. The fatal events rate was calculated for pulmonary embolism, major bleeding with prophylaxis, and iatrogenic bleeding from curative anticoagulation by multiplying the mean rate by its case-fatality rate. Fatal event rates were evaluated for 10,000 total hip or knee replacements and for 10,000 hip fractures.For 10,000 patients undergoing total hip or knee replacement, five fatal pulmonary embolisms and two fatal bleedings are expected, despite recommended extension of thromboprophylaxis. Curative anticoagulation of asymptomatic venous thrombosis would add nine fatal bleedings, 8/9 related to distal thrombosis care. For 10,000 patients undergoing hip fracture surgery, six fatal pulmonary embolisms and 23 fatal bleedings are expected. Curative anticoagulation of asymptomatic venous thrombosis would add 16 fatal bleedings, 14/16 related to distal thrombosis care.Curative anticoagulation of asymptomatic distal deep vein thromboses, leads to more fatal bleeding compared to avoidable fatal pulmonary embolism. These findings strengthen recommendations against routine ultrasound screening for asymptomatic distal deep vein thrombosis.

Background: The postthrombotic syndrome account for approximately one half of advanced chronic insufficiency, and its incidence is related to the severity of the thrombotic event and the quality of the treatment in the acute phase, but also influenced by the behavior and lifestyle of the patient (physical activity, weight control and compliance to elastic stockings1⁄4). The aim of therapeutic education is to help the patient to achieve the required changes in lifestyle and health related behaviors by improving his knowledge, skills and motivation, which seem appropriate in patients with high risk of postthrombotic syndrome. We developed and performed a preliminary evaluation of a structured therapeutic education program dedicated to the patients with a recent episode of proximal deep vein thrombosis. Methods: The education program is organized as a six days course for small groups of 6 to 10 patients who benefit from, one individual educative consultation, four group education workshops and six sessions of active balneotherapy, also aiming at educational objectives. Three training courses were organized in three different spa resorts specifically dedicated to the care of patients with venous diseases (La Lechere, Rochefort et Bagnoles de l’Orne). Main inclusion criteria were a recent ( 2 years) proximal DVT of the lower limbs remaining symptomatic but with no skin changes (C0s-C3), availability for the course and written consent. An evaluation of CIVIQ2 quality of life scale (autoevaluation), and VCSS and Villalta score (by an independent observer) was performed at inclusion, and at 2 and 6 months follow-up. Results: Twelve women and nine (median age 58 years; 20-89) were enrolled. No dropout was observed during follow-up. Every participant declared a high level of satisfaction level. Two and six months follow-up showed a significant improvement of the CIVIQ2 quality of life scale (P .01), the VCSS (P .05) and the Villalta score (P .01). Conclusion: This promising results have to be confirmed in a larger scale randomized controlled study with longer follow-up, which has just started. Work supported by a grant of the Association Francaise pour la Recherche Thermale (#2009-02).

To evaluate the efficacy and safety of gelified ethanol, a newly developed sclerosing agent for slow-flow vascular malformations.Seventy-nine sclerotherapy procedures were performed on 44 patients with 37 venous malformations, 2 glomuvenous malformations, 2 lymphatic malformations, 2 lymphatico-venous malformations, and 1 Klippel-Trenaunay syndrome. The median injected volume was 1.00 mL/site of injection. Effects of sclerotherapy on pain, functional and cosmetic disturbance were statistically evaluated with a final result score. Local and systemic complications were recorded.The mean Visual Analogue Scores were 5.20 ± 2.81 before and 1.52 ± 1.25 after treatment (p 0.001). Functional and aesthetic improvement was achieved in 31/35 patients (89%) and in 33/41 (80%), respectively. Minor local side effects included necrosis with or without issue of ethylcellulose, palpable residue, and hematoma. No systemic side-effects occurred.Per mL used, radio-opaque gelified ethanol is at least as effective as absolute ethanol. No systemic complication was observed, as only a low dose of ethanol was injected. Indications for sclerotherapy can be widened to areas with higher risk for local side effects (hands and periocular region), as ethanol is trapped in the lesion. Careful injection procedure is though necessary, because only a limited amount of ethylcellulose can be used per puncture. Key Points • Development of a new sclerosing agent for venous malformations. • Interesting novel way to deliver alcohol to slow-flow vascular malformations. • Alcohol-based with less local and systemic side-effects.

To determine the incidence and distribution of lower limb venous thrombosis diagnosed by duplex ultrasonography, including calf exploration, after total hip or knee replacement or hip fracture, and to compare them with the venographic results reported by recent randomized control trials testing new antithrombotic drugs.From January 2001 to December 2009, 30,510 standardized report forms incremented a database from which files corresponding to major orthopaedic surgery were selected: 1652 after total hip replacement (THR), 1440 after total knee replacement (TKR) and 2889 after hip fracture (HF). Base-line characteristics, incidence and anatomic distribution of venous thrombosis were analysed in the three populations.Systematic screening was applied for 95.1% of the exams (n=5689). Incidence of total and proximal venous thrombosis was, respectively, 27.8% (n=460) and 2.8% (n=46) for THR, 32.5% (n=939) and 4.4% (n=126) for HF, and 50.3% (n=724) and 3.8% (n=55) for TKR. Venous thrombosis was distal in 89.3% (n=1896). More than half (n=1014) of distal venous thromboses were strictly muscular soleal locations. Ilio-caval thrombosis incidence was 0.18% (n=11), and superficial venous thrombosis incidence was 1.5% (n=89).This study shows that incidence and distribution of venous thromboses diagnosed with a complete and standardized duplex ultrasonographic screening are very close to the rates published with venographic screening in recent trials.

Objectif Analyser la distribution anatomique des thromboses veineuses (TV) des membres inferieurs (MI) diagnostiquees par echo-Doppler veineux (EDV) chez des femmes en contexte hormonal : contraception œstro-progestative (COP), grossesse (G) et post-partum (PP), en vue d’optimiser dans ce contexte, l’exploration EDV. Methodes : – analyse retrospective de donnees recueillies en prospectif dans une base de donnees rassemblant depuis 12 ans les comptes rendus EDV standardises ; – selection des comptes rendus EDV effectues chez des femmes ≤ 45 ans pour suspicion de TV ou d’embolie pulmonaire ayant pour seul facteur de risque un contexte hormonal ; – repartition des TV en 3 groupes selon le contexte hormonal (COP, G et PP) ; – les TV limitees a 1 seul segment veineux ont ete qualifiees d’isolees ; – description de la distribution des TV. Resultats Parmi 42 018 comptes rendus, 996 concernaient un contexte hormonal (326 COP, 670 G ou PP). Une TV etait presente chez 172 femmes (17,3 %) dont 74 COP, 39 G et 59 PP, d’âge moyen (± ecart type) de 29,4 ± 7,1 ans. La repartition des TV figure au Tableau 1 . Les TV profondes proximales isolees, en particulier iliaques gauches, etaient plus frequentes pendant la grossesse et sous COP qu’en PP ( Tableau 2 ). En revanche en PP, les TV superficielles etaient plus frequentes que les TV profondes ( Tableau 1 ). Conclusion L’exploration EDV doit absolument cibler, en sus du reseau superficiel, l’etage iliaque en particulier gauche, chez la jeune femme sous COP comme pendant la grossesse, et l’etage cave inferieure en PP.

Objective: To evaluate if elevated D-dimer level is specific for venous malformations (VMs) and thus useful for differential diagnosis, which can be problematic even in specialized interdisciplinary centers. Localized intravascular coagulopathy, characterized by elevated D-dimer levels, has been observed in approximately 40% of patients with VMs. Design: Prospective convenience sample accrued from 2 interdisciplinary sites. Setting: Two interdisciplinary centers for vascular anomalies in Brussels, Belgium, and Caen, France Participants: The study population comprised 280 patients with clinical data, Doppler ultrasonograms (for 251 patients), and coagulation parameter measurements. Main Outcome Measure: Measurement of D-dimer levels. Results: A VM was diagnosed in 195 of 280 patients (69.6%), and 83 of them had elevated D-dimer levels; the sensitivity of D-dimer dosage was 42.6% (95% confidence interval, 35.6%-49.5%). Among the 85 patients without VM, D-dimer levels were elevated only in 3 patients; the specificity of the dosage was 96.5% (95% confidence interval, 92.5%-100%). Conclusions: Elevated D-dimer level is highly specific for VMs (pure, combined, or syndromic), and therefore this easy and inexpensive biomarker test should become part of the clinical evaluation of vascular anomalies. It can detect hidden VMs and help differentiate glomuvenous malformation (normal D-dimer levels) from other multifocal venous lesions. Elevated D-dimer level also differentiates a VM from a lymphatic malformation. Moreover, slow-flow Klippel-Trenaunay syndrome (capillaro-lymphatico-venous malformation with limb hypertrophy) can be distinguished from fast-flow Parkes Weber syndrome (capillary malformation with underlying multiple microfistulas and limb hypertrophy). For these reasons, D-dimer level measurement is a useful complementary tool for diagnosing vascular anomalies in everyday practice.

Background: Although older patients with restricted mobility are at increased risk for venous thromboembolism, they are under-represented in clinical trials evaluating prophylactic treatments against deep vein thrombosis (DVT). Objective: To determine whether prolonged prophylaxis with low-molecular-weight heparin (LMWH) is associated with a lower rate of DVT in older patients with restricted mobility. Methods: Two cross-sectional studies were conducted in 50 hospital-based, post-acute care facilities in France in 2001 and 2003. The studies included 1603 evaluable patients aged ≥65 years, including 866 LMWH users (median treatment duration 23 days; interquartile range 13–42) and 737 LMWH non-users. All patients underwent complete compression ultrasonography performed by board-certified vascular medicine physicians. The primary study outcome was proximal DVT. Propensity analyses were used to control for bias in LMWH treatment assignment. Results: The rate of proximal DVT was 4% (35/866) and 5.7% (42/737) for LMWH users and non-users, respectively (p = 0.16). Prophylaxis with LMWH was associated with decreased odds of proximal DVT after adjusting for baseline characteristics (odds ratio [OR] 0.56; 95% CI 0.33, 0.95; p = 0.03) or quintile of propensity score (OR 0.58; 95% CI 0.35, 0.99; p = 0.04). In propensity matched analysis, 342 LMWH users were at decreased odds of proximal DVT compared with 342 non-users (OR 0.50; 95% CI 0.24, 1.00; p = 0.04). The decrease in proximal DVT was paralleled by a similar decrease in distal DVT. Compared with non-users, only high-risk dose users had decreased odds of DVT. Conclusions: In this observational study, prophylaxis with a high-risk dose of LMWH was associated with decreased odds of proximal DVT in older patients with restricted mobility. Further study is needed before recommending routine prophylaxis with LMWH in these patients.

OBJECTIVE: To determine which venous malformations (VMs) are at risk for coagulopathy. Venous malformations are slow-flow vascular malformations present at birth, and localized intravascular coagulopathy (LIC) causes pain and thrombosis within a lesion and severe bleeding during surgical procedures. DESIGN: Prospective convenience sample accrued from 2 multidisciplinary sites in Brussels, Belgium, and Caen, France. PARTICIPANTS: The study population comprised 140 patients with clinical data and coagulation parameters. Magnetic resonance imaging was performed for 110 patients. MAIN OUTCOME MEASURE: Measurement of D-dimer levels. RESULTS: Of the 140 participants, 59 (42%) showed high D-dimer levels, 36 (61%) of whom had levels higher than 1.0 microg/mL. Six of the participants had low fibrinogen levels. In univariate analysis, large surface, presence of palpable phleboliths, and truncal localization were associated with high D-dimer levels. In the multivariate analysis, only large surface area and presence of phleboliths remained independently associated with high D-dimer levels. Severe LIC, characterized by concomitant low fibrinogen level, was associated with extensive venous malformations of the extremities. CONCLUSIONS: Localized intravascular coagulopathy is statistically significantly associated with large and/or deep venous malformations that affect any location, which can have a palpable phlebolith. These patients are at risk of local pain due to thrombosis. Lesions with elevated D-dimer levels associated with low fibrinogen levels (severe LIC) commonly affect an extremity and have a high risk of hemorrhage. Low-molecular-weight heparin can be used both to treat the pain caused by LIC and to prevent decompensation of severe LIC to disseminated intravascular coagulopathy.

BACKGROUND: The development of a short training program for emergency care physicians for rapid ultrasound assessment of two points (the groin and popliteal areas) could be useful for later implementation of a safe home care strategy for patients with suspected deep vein thrombosis before the results of a complete duplex-Doppler exploration are available. PURPOSE: Validation of the proposed training program by studying inter-operator agreement (trainee versus vascular physician) in a multicentric assessment of 60 emergency care physicians. Establish the learning curve. METHODOLOGY: Theoretical training: two-page document with schematic drawings and consultation of image bank on the Web. Practical training: 25 patients in all, the last 15 as an independent operator, writing a standardized report. Interoperator agreement: (a) centralized data collection and independent analysis of the report written by the trainee and a vascular physician for the same patients (n(o) 11 to 25); (b) determination of the coefficient of variance, kappa, and construction of the learning curve (900 agreement points for 60 trainees). INCLUSION CRITERIA: (a) Treated distal or proximal thrombosis recruited by the vascular physician (blinded to the result of the flash US); patient's oral consent. EXPECTED RESULTS: Learning curve leveling off at about the 20th patient with a kappa>0.61 or even 0.80. ORIGINAL CONTRIBUTION OF THE PROJECT: (a) Prospective, multicentric, blinded study: (i) confirming the feasibility of a two-point venous ultrasound performed by emergency care physicians; (ii) validation of the contents and duration of a short simplified training program; (b) Validation of a decision criterion for home care; If validated, this type of training program might be applied in other disciplines (intensive care, geriatrics).

Isolated iliac venous thrombosis (IIVT) is uncommon. Duplex ultrasonography of the iliac vessels is not recommended and not generally performed.The purpose of this study was to determine the frequency of IIVT in a hospital recruitment population and to identify characteristic features of onset which might be associated with this localization in order to better target explorations.The study included 18,297 patients referred for Duplex-ultrasonographic exploration of possible deep vein thrombosis of the lower limbs between January 1st 1994 and December 31st 2000. Selection of isolated iliac thrombosis, defined as the absence of retrograde extension to the common femoral vein, was made from the digitalized data recorded daily. The following factors were tested: sex, age, absence of clinical signs in the lower limb, presence of pulmonary signs. The raw odds ratios were calculated followed by construction of a multivariate logistic regression model. The circumstances of onset were retrieved from the patient's medical files.Isolated iliac venous thrombosis was discovered in 48 patients, i.e. 0.26% (95% CI 0.19%-0.35%) in the recruitment population and 0.82% (95% CI 0.61%-1.09%) among the 5827 patients with thrombosis. The common iliac was involved predominantly (35 out of 48). The left side predominated in women compared with men (24/36 versus 4/12) (p = 0.04). Specifically female circumstances (oral contraceptives, peri-obstetrical period) always led to a left localization. For the other identified circumstances (cancer, inflammatory bowel disease, orthopedic surgery, pelvic trauma), there was no predominant side. Variables explaining the multivariate model were sex, age (less than or more than 35 years), suspected pulmonary embolism, and age interaction with suspected pulmonary embolism. For women, the risk of IIVT was twice as high as for men (OR = 1.97, 95% CI 1.02-3.81). Young age was also a risk factor for IIVT and increased with suspected pulmonary embolism. The odds ratio for subjects under 35 varied from 4.20 (95% CI 1.79-9.84) without suspected pulmonary embolism to 35.01 (95% CI 14.78-82.89) with suspected pulmonary embolism.The incidence of isolated iliac venous thrombosis is very low (0.26) in this hospital recruitment population but reached 9.40% in young women under 35 with suspected pulmonary embolism. These age and sex characteristics are also the principal circumstances for the development of these thrombotic events (pregnancy, post partum period, oral contraception). Under these circumstances, it is necessary to carefully explore the iliac vessels with duplex ultrasonography.

Duplex ultrasonography performance in detecting embolic foci has not been proven satisfactory compared with phlebography or autopsic findings. In case of suspected pulmonary embolism, the embolic focus is only discovered in 11 to 18% of the cases compared with more than 30% with phlebography. For overt acute pulmonary embolism, the discovery rate is in the 30 to 45% range versus 70 to 80% with phlebography or autopsy findings. This discrepancy might result from the fact that duplex ultrasonographic explorations are generally limited to the deep collectors at the cruropopliteal level. The purpose of this study was to assess the prevalence of duplex ultrasonography detected venous thrombosis in patients with suspected or acute pulmonary embolism when the exploration includes the entire venous system from the inferior vena cava to the ankles and examines not only the deep collectors but also the muscle and superficial networks.This study included all patients with suspected pulmonary embolism referred to the emergency unit from January 1, 1995 through December 31, 1998. The patients' hospital files were used to determine the suspected pulmonary embolism population. The acute pulmonary embolism population was defined as the patients whose files contained documented proof of pulmonary embolism (highly probable ventilation/perfusion pulmonary scintigraphy, positive pulmonary angiography, positive proximal angioscan). Thrombosis of the deep venous collectors with or without associated superficial or muscular localization was classed as "deep venous thrombi" and superficial or muscular thrombosis without involvement of the deep collectors was classed as "other venous thrombi". Subpopliteal thrombosis was classed as distal and popliteal or suprapopliteal thrombosis as proximal.The suspected pulmonary embolism group included 352 patients, 118 men and 234 women aged 67.6 +/- 15.4 and 70.8 +/- 20.0 years respectively (m +/- SD). The acute pulmonary embolism group included 60 patients, 17 men and 43 women aged 66.2 +/- 12.5 and 69.7 +/- 16.6 years respectively. Overall prevalence of duplex-ultrasound detected venous thrombosis was 30.4% (107/352) (95%CI: 25.6-35.2) in the suspected pulmonary embolism group and 80% (48/60) (95%CI: 69.9-90.1) in the acute pulmonary embolism group. Deep venous thrombi reaching the collectors and proximal thrombi predominated. Prevalence of "other venous thrombi" and distal venous thrombi were 6.5% (23/352) and 11.4% (40/352) respectively in the suspected pulmonary embolism group and 15.0% (9/60) and 26.7% (16/60) in the acute pulmonary embolism group. The frequency of asymptomatic venous thrombosis of the lower limbs, irrespective of the localization, was 42.1% (45/107) in the suspected pulmonary embolism group and 52.1% (25/48) in the acute pulmonary embolism group.The prevalence of duplex-ultrasonography detected venous thrombosis in patients with suspected or proven pulmonary embolism found in this series was equivalent to the rates reported in phlebography and autopsy series. The prevalence was higher than usually reported for duplex-ultrasonography studies limited to the cruro-popliteal level. The difference came from the "other venous thrombi" and "distal deep venous thrombi" discovered by exploring the superficial and muscular networks and the calves. This study demonstrates the contribution of duplex-ultrasonography to the diagnostic strategy for pulmonary embolism.

Absolute alcohol is the most effective treatment of venous malformations. We created an alcoholic sclerosing solution less diffusible and we report a preliminary study on 6 patients. The viscosity of the alcohol was enhanced with ethylcellulose and we treated 7 patients with VM. Two benign skin ulcerations were observed and one patient with a large VM of the face could be treated around the eyes in a dangerous area. The results are encouraging and a larger study is being performed.

Assess the diagnostic performance of phlebography and discrepancies with duplex ultrasonography in screening for asymptomatic deep vein thrombosis after total hip arthroplasty. Search for arguments which would favor contributing false-negatives or false-positives to one of the two exploration methods.The study included 24 patients who underwent the 2 explorations independently between day 7 and day 14 in a multicentric therapeutic trial of a new heparin. Discrepancies between the two techniques were recorded. Diagnostic performance of phlebography was calculated from contingency tables. The phlebograms were then reviewed with knowledge of the duplex ultrasonographic findings. The course of the venous thrombus after treatment was monitored with duplex ultrasonography.Phlebography allowed the diagnosis of thrombus formation in 9 patients. Ultrasonography provided the diagnosis in 14 cases out of 24. Sensitivity of phlebography compared with duplex ultrasonography was 64% (95% CI = 35.1-87.2) (9/14) and specificity was 100% (95% CI = 69.1-100) (10/10). Several localizations were not visualized with phlebography: 3 partially obstructive thrombi near the femoral junction, and 38 distal thrombi including 31 soleus thrombi (fig. 5). When the phlebograms were reviewed again, defects compatible with a partial thrombus were found for the 3 proximal localizations and for 2 of the distal localizations (fig. 1, 2, 4). None of the soleus localizations were visualized. Duplex ultrasonographic follow-up concerned 12 of the 14 patients with a thrombus identified by duplex ultrasonography involving 44 localizations. In five case, the operator was different from the operator for the initial duplex ultrasonography. Follow-up revealed: 1 new localization, 37 narrowings and 6 repermeabilizations.The coherence of the duplex ultrasonographic follow-up and the presence of images compatible with partial thrombus on the revised phlebograms which had been initially interpreted as wash out flow constitute a group of arguments suggesting that the discrepancies observed should be considered as phlebography false-negatives. This defect in the sensitivity of phlebography has been reported by others in the literature both for distal and proximal localizations.

A patent lumen after deep vein thrombosis can be achieved but at the cost of valve destruction which occurs in 50 to 75% of the cases within 6 to 12 months after the thrombotic event. The diagnosis of post-thrombotic valve destruction is made on the basis of direct consequences of venous back flow. Photoplethysmographic measurement of venous filling pressure while walking or after a Valsava manoeuvre lacks specificity and is insufficiently sensitive, especially in case of minimal back flow. Retrograde femoral phlebography can miss distal back flow if the femoral valves functions correctly. Dynamic popliteal phlebography in the upright position could be the reference examination. Ultrasonography-Doppler is however widely used as the first intention investigation providing a positive diagnosis, recognizing the localization and quantifying the back flow. The patient is placed in the upright position and reflux is checked after standardized distal compression. The ultrasonographic aspect (fibrosis, thick wall, tributary vessels) gives further arguments for differential diagnosis. The consequences of valve destruction on skin trophicity appear to be worse than non-repermeation after a thrombotic event. Surgical repair (transposition, transplantation, valvuloplasty) should be proposed for young patients with severe trophicity disorders which resist well-conducted medical treatment. The rate of failure is approximately 50% i.e. higher than for primary valve destruction.

1580 Background: Long-term treatment with low-molecular-weight heparin (LMWH) is recommended for treatment of venous thromboembolism (VTE) in cancer patients. Few data are available on compliance in this population. Our study measured whether the management of VTE in patients with cancer was consistent with French recommendations. Methods: Compliance with recommendations (CR+) was analysed according to malignancy and VTE from a 500-patient cross-sectional observational study run between May and October 2010. CR+ was defined as the compliance to initial 10-day treatment followed by long-term LMWH for at least 3 months, avoiding LMWH in patients with renal insufficiency (SRI). All inpatients with a diagnosis of cancer and VTE of less than 6 months were included in the study. Results: Of 500 patients included in 47 centers, 242 (49%) were male, 81 (18%) had local (T+), 83 (18%) had loco-regional (N+) and 287 (64%) had metastatic malignancies. Malignancies were gastro-intestinal (25%), gynaecologic (23%), pulmonary (21%), haematological (14%), urologic (10%) or other (8%). Twelve patients had SRI. Overall, treatment was CR+ in 289/500 patients (58% [95% CI 53%-62%]). Out of 12 patients with SRI only 3 (25%) were treated long-term with vitamin K antagonists (VKA), as usually recommended. Tumour site influenced CR+ (p=0.02). Treatment for haematological malignancy was poorly compliant with recommendations (32%) while patients with lung malignancy had the best compliance (68%). TNM stage and VTE location had no influence on treatment compliance. Conclusions: In French practice, treatment of cancer-related VTE is CR+ in 58% of cases. TNM stage and VTE location do not influence compliance which remains insufficient, especially in patients with haematological malignancy. [Table: see text]

This study was undertaken to estimate the efficiency of duplex ultrasound scanning and its utility to detect deep vein thrombosis in orthopedic patients and to describe their features.A total of 1647 in-patients, all receiving low-molecular-weight heparin, were investigated from 1989 to 1993, either for screening because of a high risk of thrombosis (asymptomatic group: 930 patients, mean age + SD: 63 + 17 years) or for clinical suspicion of deep vein thrombosis (symptomatic group: 717 patients, mean age + SD: 57 + 21 years). Difference between the two groups mean ages was significant (p10(-8)). An Hitachi EUB 450 duplex and an Acuson colour duplex 128 XP, with 3.5 MHz and 7.5 MHz linear probes were used. Veins were tested for compressibility in the transverse view from caval site to both ankles. Retrospective analysis of patients' database results was done.There was no significant difference in deep vein thrombosis rate between screening asymptomatic group (356/930: 38 per cent) and symptomatic group (2531717: 35 per cent). There was a linear relation, in the 2 groups, between age and deep vein thrombosis rate, from 10 per cent before twenty to 45 per cent after eighty years old. For a relative risk to have thrombosis detected before twenty definite at 1, it was 2.1 for 20-29, 4.9 for 40-49, 6.2 for 60-69 and 8.6 later than 80 years old. Proximal deep vein thrombosis was detected in only 5 per cent (87/1647) of patients. Distal muscular soleal veins were the most usual involved sites of thrombosis. Isolated soleal thrombosis were detected in 16 per cent (270/1647) of patients. There was no significant difference between the deep vein thrombosis rate after total knee or hip arthroplasty among selected patients for duplex scanning from 1989, and the true prevalence assessed among all the patients who have undergone total hip or knee arthroplasty during the last 6 months.Pessimistic results previously reported for duplex screening among asymptomatic patients are not confirmed. Calf vein thrombosis rate assessed with duplex exceeds by 15 to 20 per cent the rates assessed by contrast venography, among patients receiving low molecular weight heparins. That difference could be attributed to the isolated muscular soleal thrombosis usually missed at contrast venography.Deep vein thrombosis rate among orthopedic surgical patients, is much higher when detected with Duplex ultrasound scanning than detected with contrast venography, and is related to patient age. Soleal vein thrombosis is the most prevalent. Duplex ultrasound scanning is an efficient and useful screening method for deep vein thrombosis in orthopedic surgery. Mechanical calf venous pump stimulation in association with low molecular weight heparin, has to be evaluated in attempting to reduce those muscular soleal veins thrombosis.