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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.

Objective: Venous leg ulcers (VLUs) are considered the most frequent category of hard-to-heal limb ulcers. Although evidence-based care of VLUs suggests that compression therapy plays a pivotal role in the standard of care, patient adherence is considered low, with at least 33% non-compliance, either due to perceived problems from clinicians regarding their own competency in applying the bandages, or from the patient finding the wrapping bothersome. For many years, four-layer bandaging has been considered the ‘gold standard’, but application can be difficult and may also prove uncomfortable for patients. Accurate application may be facilitated by a stretch indicator which has been engineered to act as a surrogate for appropriate pressure application that can address the skill concern, while fewer layers can save clinicians' time and improve the quality of life of patients. Here, we review the literature supporting a two-layer system which combines elastic (long stretch) and inelastic (short stretch) components as well as both layers having graphic markers to define that the dressing has been applied at the proper tension. Method: An initial search was conducted on PubMed and then followed up by a manual search of Google Scholar to retrieve evidence of different levels, in order to evaluate the outcomes of use of the specific two-layer compression system with pressure indicators in the management of patients presenting with VLUs. Results: A total of four papers discussing the specific compression system in question were identified from 32 publications retrieved from PubMed, while a further six were retrieved from Google Scholar. These 10 publications were considered relevant to the two-layer system and were analysed for the outcomes of care, including wound healing, appropriate application, time-saving and better patient acceptance and adherence. Conclusion: Previous authors have demonstrated that two-layer systems are equivalent to four-layer systems. However, the ability to reproducibly apply appropriate compression has remained a question. The papers reviewed demonstrate that evidence suggests that the two-layer compression bandage system with indicators provides continuous, consistent and comfortable treatment that may be easier to apply with accurate pressure levels due to their indicator systems, and therefore, is a procedure that may increase patient adherence and acceptability to the wound therapy.

Objective To assess the contribution of large and small nerve fiber alteration in erythromelalgia (EM). Methods Thirty-three EM patients were included and underwent clinical evaluation based on EM severity score, DN4, and Utah Early Neuropathy Scale (UENS) score. Neurophysiological evaluation consisted in nerve conduction studies (NCS) for large nerve fibers and specific tests for small nerve fibers: electrochemical skin conductance, cold and warm detection thresholds, and laser evoked potentials. Finally, the evaluation of vascular changes was based on the presence of clinical feature of microvascular disorders and the measurement of the Toe Pressure Index (TPI). Results While 28 patients (85%) had vascular alteration on TPI or clinical features, 23 patients (70%) had small-fiber neuropathy on neurophysiological tests, and only 10 patients (30%) had large fiber neuropathy on NCS. Regarding clinical scores, there was no difference between groups (presence or absence of large- or small-fiber neuropathy or microvascular disorder) except for a higher UENS score in patients with large fiber neuropathy. Conclusion Peripheral neuropathy, mostly involving small nerve fibers, is almost as common as microvascular changes in EM, but remains inconstant and not related to a specific neuropathic pattern or higher clinical severity. Significance The association of neuropathic and vascular factors is not systematic in EM, this syndrome being characterized by different pathophysiological mechanisms leading to a common clinical phenotype.

Resume Introduction Le syndrome de congestion pelvienne est un syndrome douloureux chronique du petit bassin en rapport avec des varices pelviennes developpees dans le cadre d’une insuffisance veineuse primitive ou secondairement a une obstruction veineuse. Observation Nous rapportons l’observation d’une patiente de 35 ans, sous traitement anticoagulant pour une thrombose veineuse profonde iliofemorale gauche idiopathique, ayant developpe un syndrome de congestion pelvienne invalidant secondaire a des sequelles obstructives iliaques. La recanalisation veineuse avec stenting de l’axe iliaque gauche, associee a une bitherapie antithrombotique par antiagregant plaquettaire (acide acetylsalicylique 100 mg) et anticoagulant (rivaroxaban 20 mg) pendant trois mois puis antiagregant plaquettaire seul, a permis une regression complete et durable des symptomes. Discussion La prise en charge du syndrome de congestion pelvienne secondaire a des lesions iliaques post-thrombotiques doit tenir compte de sa physiopathologie. Elle fait intervenir l’angioplastie veineuse iliaque avec mise en place de stent en association a un traitement antithrombotique dont les modalites restent a preciser avec le suivi au long cours de ces patients.

INTRODUCTION Abdominal aortic aneurysm (AAA) is a silent pathology with often fatal consequences in case of rupture. AAA screening, recommended in France and many other countries, has shown its effectiveness in reducing specific mortality. However, AAA screening rate remains insufficient. OBJECTIVE To identify barriers to AAA screening in general practice. MATERIAL AND METHOD Qualitative study carried out during 2016 among general practitioners based in Paris. RESULTS Fourteen physicians were included. Most of the barriers were related to the physician: unawareness about AAA and screening recommendations, considering AAA as a secondary question not discussed with the patient, abdominal aorta not included in cardiovascular assessment, no search for a familial history of AAA, AAA considered a question for the specialist, lack of time, lack of training, numerous screenings to propose, oversight. Some barriers are related to the patient: unawareness of the pathology and family history of AAA, refusal, questioning the pertinence of the doctor's comments, failure to respect the care pathway. Others are related to AAA: source of anxiety, low prevalence, rarity of complications. The remaining barriers are related to screening: cost-benefit and risk-benefit ratios, sonographer unavailability, constraint for the patient, overmedicalization. CONCLUSION Information and training of general practitioners about AAA must be strengthened in order to optimize AAA screening and reduce specific mortality.

Resume Objectif Les ulceres de jambes sont dans pres de 85 % des cas de causes vasculaires. Il existe aussi des ulceres de causes non vasculaires. Leur diagnostic repose sur un faisceau d’arguments cliniques et la biopsie cutanee avec analyse anatomopathologique. Materiel et methode Etude retrospective ayant porte sur l’analyse de 143 biopsies cutanees d’ulceres de jambe. Les raisons ayant motive la biopsie etaient principalement des signes cliniques atypiques et/ou l’absence d’amelioration sous soins bien conduits au-dela de 6 mois, comme le preconise la Haute Autorite de sante. Le but de cette etude etait d’analyser les resultats de ces biopsies et de rechercher des criteres communs aux ulceres, dont la biopsie cutanee avait permis d’etablir le diagnostic d’ulcere non vasculaire. Resultats Au total, 4,9 % des biopsies cutanees permettaient d’etablir un diagnostic d’ulcere de cause non vasculaire (7/143) : 5 carcinomes cutanes (3,5 %), 1 leishmaniose cutanee (0,7 %) et 1 pyoderma gangrenosum (0,7 %). L’analyse statistique univariee revelait que les berges surelevees et le caractere hyperbourgeonnant etaient significativement plus frequemment retrouves dans ces ulceres. Tous les patients, dont la biopsie cutanee permettait un diagnostic d’ulcere non vasculaire, avaient une atteinte vasculaire associee. Conclusion Cette etude a retrouve un taux de 5 % d’ulceres de causes non vasculaires, principalement des carcinomes cutanes. Les berges surelevees et l’hyperbourgeonnement etaient les caracteres inhabituels plus frequemment retrouves dans ces ulceres. Tous les patients, dont la biopsie cutanee revelait une cause non vasculaire, avaient une atteinte vasculaire associee. Cette information confirme la necessite de realiser une biopsie cutanee y compris en presence d’une atteinte vasculaire qui n’explique pas a elle seule l’evolution de l’ulcere.

Resume Introduction La thrombose veineuse d’effort est une cause rare de thrombose veineuse profonde du membre superieur (TVPMS) touchant les sujets jeunes et sans comorbidite. Le diagnostic n’est pas toujours facilement evoque. Cas clinique Nous rapportons le cas d’une jeune femme de 23 ans, professeur de francais, droitiere, sous contraception estroprogestative, violoniste, ayant recemment modifie sa facon de jouer, qui presentait un œdeme de la racine du bras droit associe a une erythrocyanose de declivite et a une circulation collaterale du moignon de l’epaule. Les D-dimeres etaient negatifs. La TVP sous-claviere droite n’etait objectivee que sur le deuxieme echo-Doppler. Le choix etait fait d’un traitement anticoagulant seul par heparine de bas poids moleculaire relaye par rivaroxaban, permettant une evolution tres satisfaisante a 48 heures, et ce jusqu’a 4 mois de l’episode, date ou la patiente a ete revue. Discussion Le diagnostic de TVPMS est avant tout un diagnostic clinique. Un score de probabilite clinique existe et permet d’introduire une anticoagulation meme si la TVP n’est pas objectivee par echo-Doppler, ce qui est possible compte tenu de la superposition claviculaire dans cette region. La suspicion de TVP d’effort doit faire rechercher une activite pouvant paraitre peu intense mais repetee (en hyper-abduction) comme ici la pratique du violon. Le traitement de ces thromboses repose sur les anticoagulants tandis que la place de la chirurgie et des methodes pharmaco-mecaniques doit encore etre precisee. Conclusion Devant une thrombose du membre superieur chez un sujet jeune et sans comorbidite, une thrombose d’effort (syndrome de Paget-Schroetter) doit etre evoquee facilement. Des etudes comparant les differentes options therapeutiques pourraient permettre d’homogeneiser les prises en charge, malgre l’heterogeneite des situations cliniques.

Background Smoking is a strong risk factor for cancer and atherosclerosis. Cancer mortality, especially from lung cancer, overtakes cardiovascular (CV) death rate in patients with peripheral arterial disease (PAD). Only a few patients with lung cancer after PAD management may benefit from surgical excision. Circulating tumor cells (CTC) associated with low-dose chest CT (LDCT) may improve early cancer detection. This study focuses on a screening strategy that can address not only lung cancer but all tobacco-related cancers in this high-risk population. Methods DETECTOR Project is a prospective cohort study in two French University hospitals. Participants are smokers or former smokers (≥30 pack-years, quitted ≤15 years), aged ≥55 to 80 years, with atherosclerotic PAD or abdominal aortic aneurysm. After the first screening round combining LDCT and CTC search on a blood sample, two other screening rounds will be performed at one-year interval. Incidental lung nodule volume, volume doubling time and presence of CTC will be taken into consideration for adapted diagnostic management. In case of negative LDCT and presence of CTC, a contrast enhanced whole-body PET/CT will be performed for extra-pulmonary malignancy screening. Psychological impact of this screening strategy will be evaluated in population study using a qualitative methodology. Assuming 10% prevalence of smoking-associated cancer in the studied population, a total of at least 300 participants will be enrolled. Discussion Epidemiological data underline an increase incidence in cancer and related death in the follow-up of patients with PAD, compared with the general population, particularly for tobacco-related cancers. The clinical benefit of a special workup for neoplasms in patients with PAD and a history of cigarette smoking has never been investigated. By considering CTCs detection in this very high-risk selected PAD population for tobacco-induced cancer, we expect to detect earlier pulmonary and extra-pulmonary malignancies, at a potentially curable stage. Trial registration The study was registered in the French National Agency for Medicines and Health Products Safety (No N° EUDRACT_ID RCB: 2016-A00657–44) and was approved by the ethics Committee for Persons Protection (IRB number 1072 and n° initial agreement 2016-08-02; ClinicalTrials.gov identifier NCT02849041).

In-plane phase-contrast (PC) imaging is now a routine component of MRI of regional blood flow in the heart and great vessels. In-plane PC MRI provides a volumetric, isotropic, time-resolved cine sequence that enables three-directional velocity encoding, a technique known as four-dimensional (4D) flow MRI. Recent advances in 4D flow MRI have shortened imaging times, while progress in big-data processing has improved dataset pre- and postprocessing, thereby increasing the feasibility of 4D flow MRI in clinical practice. Important technical issues include selection of the optimal velocity-encoding sensitivity before acquisition and preprocessing of the raw data for phase-offset corrections. Four-dimensional flow MRI provides unprecedented capabilities for comprehensive analysis of complex blood flow patterns using new visualization tools such as streamlines and velocity vectors. Retrospective multiplanar navigation enables flexible retrospective flow quantification through any plane across the volume with good accuracy. Current flow parameters include forward flow, reverse flow, regurgitation fraction, and peak velocity. Four-dimensional flow MRI also supplies advanced flow parameters of use for research, such as wall shear stress. The vigorous burgeoning of new applications indicates that 4D flow MRI is becoming an important imaging modality for cardiovascular disorders. This article reviews the main technical issues of 4D flow MRI and the different parameters provided by it and describes the main applications in cardiovascular diseases, including congenital heart disease, cardiac valvular disease, aortic disease, and pulmonary hypertension.

Objectif La greffe en pastille est une technique largement utilisee dans notre pratique quotidienne. Elle peut accelerer l’epithelialisation des ulceres de jambe veineux (UJ). Compte tenu des resultats cliniques tres positifs observes lorsque nous traitions les UJ avec des pansements a base de TLC- NOSF (UrgoStart) associes a un systeme de compression a deux bandes (UrgoK2), nous avons concu un essai clinique ouvert pour evaluer de facon objective et independante, l’effet de ce protocole de soin sur la cicatrisation de ces plaies chroniques traitees par des greffes en pastille. Methodes Cinquante patients ambulatoires pour lesquels une greffe en pastille a ete realisee pour traiter tout ulcere de jambe veineux non infecte, meme en phase de detersion, ont ete inclus. Une evaluation clinique et des photographies ont ete realisees toutes les 2 semaines pendant une periode de 12 semaines maximum ou jusqu’a epithelialisation complete. Les pansements et les bandes de compression ont ete changes une fois par semaine. Resultats Une analyse intermediaire a ete menee sur 25 des 50 patients inclus. La taille mediane des plaies etait de 12,7 cm2 et leur anciennete etait de 83 semaines. Tous les patients analyses (âge moyen 72,7 ans ) ont cicatrise en 30 jours (mediane, extremes : 14 a 72 jours). Les resultats finaux sur les 50 patients inclus seront presentes. Discussion L’utilisation combinee presentee accelere la cicatrisation des ulceres de jambe veineux traites par des greffes en pastille. Les tres bons resultats cliniques, sont conformes a ceux d’une analyse retrospective portant sur les 3 dernieres annees avec cette procedure dans notre departement clinique.

In vascular medicine, wound care requires pluridisciplinary expertise and nursing skill. Care must be perfectly adapted to each individual patient, the specificities of each particular wound, and the underlying vascular disease. The goal is to achieve wound healing. Inappropriate care can retard healing or even aggravate the wound. The skin should be cleaned with water a non-allergic detergent and should concern the entire limb in addition to the wound itself. Fibrin or necrosis detersion is an important step that can be painful. Different tools are available. The skin around the wound should be hydrated and protected, focusing on fragile areas, such as the tibial crest and heals, in order to prevent the development of new wounds. Other more complex interventions include tenosynovectomy, bone gouging and reduction of the necrotic toe that when properly performed can prevent a new passage in the operating room. If the ischemia becomes critical, the foot should be held warm with a carded cotton, taking care to separate the toes with dry dressings in order to preserve the healthy tissue and avoid induced wounds. Finally, compression bands are indispensable in cases with edema or venous hyperpressure. A skillful banding technique is essential, especially for legs with complex morphology.

Resume Les douleurs liees aux plaies chroniques d’origine vasculaire sont frequentes. Elles peuvent etre presentes quelle que soit l’etiologie de l’ulcere, au moment du soin infirmier mais egalement en dehors du temps de pansements. La composante douloureuse est souvent multiple, associant douleurs nociceptives, douleurs neuropathiques, anxiete du soin et souffrance emotionnelle liee a la maladie chronique. La prise en charge du patient douloureux devra prendre en consideration ces differents aspects. Elle repose sur une strategie medicamenteuse variee, sur des soins locaux adaptes avec differents outils antalgiques possibles, et une prise en charge psychoaffective.

Resume Objectifs Evaluer si l’expertise des premiers intervenants extra-hospitaliers (les medecins generalistes) est suffisante dans le domaine des ulceres de jambe. Methode Enquete transversale aupres de 179 generalistes d’Ile-de-France soit maitres de stage de Paris VI soit medecins du 14 e arrondissement de Paris, evaluant l’application des recommandations de la HAS de 2006 sur les ulceres de jambe. Resultats Soixante et onze maitres de stage et 29 medecins du 14 e representaient les 100 premiers generalistes ayant fourni des reponses exploitables (65 %). Ils n’avaient connaissance des recommandations que dans 40 % des cas sans difference significative entre maitres de stage et medecins du 14 e . Neuf medecins sur 10 examinaient moins de 10 patients/an avec ulcere. L’examen etait conduit selon les recommandations et, dans les deux tiers des cas, un echodoppler veineux etait prescrit. L’index de pression systolique (IPS) indispensable pour identifier une arteriopathie associee n’etait mesure que chez 10 % des patients. Conformement aux recommandations, la compression figurait au premier plan (73 %) loin devant les pansements (37 %) comme traitement de base mais la compression proposee n’etait conforme que dans un tiers des cas. Malgre des criteres d’evolution defavorable de l’ulcere (caracteristiques et duree d’evolution), le recours a un avis specialise etait rare (seuls 2 medecins sur 3 adressaient leur patient en cas d’arteriopathie associee). Conclusion Sans toujours connaitre les details des recommandations, les generalistes les appliquent souvent mais l’IPS doit etre mesure, la compression mieux utilisee et l’arteriopathie mieux diagnostiquee et traitee. Une expertise hospitaliere est souhaitable afin d’ameliorer la prise en charge des ulceres.

In France, approximately 3000 people are repatriated every year, either in a civil situation by insurers. Repatriation also concerns French army soldiers. The literature is scarce on the topic of venous thromboembolic risk and its prevention during repatriation for medical reasons, a common situation. Most studies have focused on the association between venous thrombosis and travel, a relationship recognized more than 60 years ago but still subject to debate. Examining the degree of venous thromboembolic risk during repatriation for medical reasons must take into account several parameters, related to the patient, to comorbid conditions and to repatriation modalities. Appropriate prevention must be determined on an individual basis.

Pelvic congestion syndrome is a chronic pelvic pain syndrome related to pelvic varices developed in the setting of primary venous insufficiency or secondary to venous obstruction.We report the case of a 35-year-old patient undergoing anticoagulant therapy for an extensive unprovoked left iliac vein thrombosis, who developed a disabling pelvic congestion syndrome secondary to chronic obstruction of the left iliac vein. Recanalization with stenting of the left iliac vein, combined with antithrombotic treatment with antiplatelet therapy (aspirin 100mg) and anticoagulation (rivaroxaban 20mg) for three months, followed by antiplatelet therapy alone, led to a complete and lasting regression of symptoms.Management of pelvic congestion syndrome secondary to post-thrombotic lesions must take into account its pathophysiology. It involves iliac venous angioplasty with stent placement in combination with antithrombotic therapy, which modalities remain to be specified in long-term follow-up.

Resume Introduction La leishmaniose cutanee est une maladie parasitaire qui se manifeste typiquement sous la forme d’une ulceration crouteuse nommee bouton d’Orient, dont la localisation au niveau des membres inferieurs realise un ulcere de jambe de presentation trompeuse. Observation Un patient de 81 ans, d’origine algerienne, diabetique de type 2, hypertendu et arteriopathe presentait des ulcerations chroniques de la cheville et du pied droits evoquant un pied diabetique infectieux. L’absence d’amelioration sous antibiotiques, soins locaux et repos, ainsi que le caractere non hemodynamique de l’arteriopathie conduisaient a realiser des biopsies cutanees. La Polymerase Chain Reaction realisee sur des biopsies a visee parasitologique permettait de retenir le diagnostic de leishmaniose cutanee a Leishmania major . La cicatrisation complete etait obtenue sous soins locaux seuls, le traitement etiologique ayant ete refuse par le patient. Discussion La leishmaniose cutanee fait partie des etiologies infectieuses rares a evoquer devant un ulcere chronique de jambe. Plusieurs options therapeutiques dont l’abstention peuvent etre proposees.

Abdominal aortic aneurysm (AAA) is a silent pathology with often fatal consequences in case of rupture. AAA screening, recommended in France and many other countries, has shown its effectiveness in reducing specific mortality. However, AAA screening rate remains insufficient.To identify barriers to AAA screening in general practice.Qualitative study carried out during 2016 among general practitioners based in Paris.Fourteen physicians were included. Most of the barriers were related to the physician: unawareness about AAA and screening recommendations, considering AAA as a secondary question not discussed with the patient, abdominal aorta not included in cardiovascular assessment, no search for a familial history of AAA, AAA considered a question for the specialist, lack of time, lack of training, numerous screenings to propose, oversight. Some barriers are related to the patient: unawareness of the pathology and family history of AAA, refusal, questioning the pertinence of the doctor's comments, failure to respect the care pathway. Others are related to AAA: source of anxiety, low prevalence, rarity of complications. The remaining barriers are related to screening: cost-benefit and risk-benefit ratios, sonographer unavailability, constraint for the patient, overmedicalization.Information and training of general practitioners about AAA must be strengthened in order to optimize AAA screening and reduce specific mortality.