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Objective: To evaluate the efficacy and safety of gelified ethanol, a newly developed sclerosing agent for slow-flow vascular malformations.Methods: 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.Results: 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.Conclusion: 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. [ABSTRACT FROM AUTHOR]

Background: Superficial venous thrombosis (SVT) is perceived to have a benign prognosis. Objective: To assess the prevalence of venous thromboembolism in patients with SVT and to determine the 3-month incidence of thromboembolic complications. Design: National cross-sectional and prospective epidemiologic cohort study. (ClinicalTrials.gov registration number: NCT00818688) Setting: French office- and hospital-based vascular medicine specialists. Patients: 844 consecutive patients with symptomatic SVT of the lower limbs that was at least 5 cm on compression ultrasonography. Measurements: Incidence of venous thromboembolism and extension or recurrence of SVT in patients with isolated SVT at presentation. Results: Among 844 patients with SVT at inclusion (median age, 65 years; 547 women), 210 (24.9%) also had deep venous thrombosis (DVT) or symptomatic pulmonary embolism. Among 600 patients without DVT or pulmonary embolism at inclusion who were eligible for 3-month follow-up, 58 (10.2%) developed thromboembolic complications at 3 months (pulmonary embolism, 3 [0.5%]; DVT, 15 [2.8%]; extension of SVT, 18 [3.3%]; and recurrence of SVT, 10 [1.9%]), despite 540 patients (90.5%) having received anticoagulants. Risk factors for complications at 3 months were male sex, history of DVT or pulmonary embolism, previous cancer, and absence of varicose veins. Limitation: The findings are from a specialist referral setting, and the study was terminated before the target patient population was reached because of slow recruitment. Conclusion: A substantial number of patients with SVT exhibit venous thromboembolism at presentation, and some that do not can develop this complication in the subsequent 3 months. Primary Funding Source: GlaxoSmithKline, sanofi-aventis, and the Ministère Francais de la Santé et des Sports (Programme Hospitalier de Recherche Clinique). [ABSTRACT FROM AUTHOR]

Background: 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., Methods: 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., Findings: 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], p non-inferiority =0·0062; relative risk 0·93, 95% CI 0·65 to 1·33). Results remained similar after imputation of missing data in patients we were authorised to do so: the cumulative proportion of PTS was 45 (29%) of 154 in the 25 mm Hg ECS group versus 52 (35%) of 148 in the 35 mm Hg ECS group (relative risk 0·83, 95% CI 0·60 to 1·16). Absolute difference was -5·9%, (90% CI -14·7 to 2·9), p=0·0003 for non-inferiority. Adherence was optimal (>80% and modified GIRERD score of 0-2) for 75 (51%) of 146 patients assigned to 25 mm Hg ECS and for 56 (42%) of 134 patients assigned to 35 mm Hg ECS (p=0·11). Regarding major adverse events related to ECS, there were no between-group differences in rates of deep vein thrombosis (0 vs 1 [0·6%]), ipsilateral leg ulcer (0 vs 1 [0·6%]), infection (0 vs 0), or death (0 vs 0) between the 169 patients evaluated in the 25 mm Hg ECS group and the 159 patients in the 35 mm Hg ECS group. Two (1%) of 328 patients who ever wore ESC developed ECS-related serious adverse events, one distal DVT and one leg ulcer (both in the 35 mm Hg ECS group). In the 25 mm Hg group, 6 patients died, 14 had a venous thromboembolic recurrence (proximal DVT or pulmonary embolism), and 7 had a major bleed. In the 35 mm Hg group, 5 patients died, 10 had a venous thromboembolic recurrence (proximal DVT or pulmonary embolism), and 6 had a major bleed., Interpretation: Although 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., Funding: Laboratoires Innothera, France., Competing Interests: Declaration of interests All authors declare financial support from Laboratoires Innothera for the submitted work through their institutions. VJ and FV are employees of Laboratoires Innothera but were not involved in the analysis and interpretation of data, or in writing the Article. AB-R declares consultant fees and travel grants from Bristol-Myers Squibb Pfizer and Bayer. SB declares honoraria from Urgo and Thuasne., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: 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., (© 2020 International Society on Thrombosis and Haemostasis.)

Introduction: 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., Materials and Methods: 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., Results: 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 by >4mm are sufficient to confirm the diagnosis of DVT recurrence. In contrast, an increase in diameter of <2mm 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., Conclusions: Ultrasound remains the most useful test for the diagnosis of recurrent DVT. Further imaging tests need to be validated., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objective: To describe characteristics and long-term outcomes of the rare symptomatic lower-limb giant-cell arteritis (LL-GCA)., Methods: Retrospective analysis of 8 patients (6 women; mean±SD age, 63.6±10.9 years; follow-up, 137.3±57.3 months)., Results: Four patients satisfied≥3 American College of Rheumatology (ACR) GCA-classification criteria; 4 had<3 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., Conclusion: Symptomatic LL-GCA attributable long-term mortality seems to be low despite frequent relapses and corticosteroid-dependence., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

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., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Aim: To analyze localizations of duplex ultrasonography-diagnosed lower-limb venous thrombosis in young women in hormonal periods in order to optimize the ultrasound exploration., Patients and Methods: 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., Results: In the contraception group, pulmonary symptoms at presentation were much more frequent than in the obstetrical group: 69% vs 20% (P < 0.001). 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., Conclusion: 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., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Background: In several small studies, anticoagulant therapy reduced the incidence of venous thromboembolism (VTE) in patients with isolated lower-limb injuries., Objectives: To compare the efficacy and safety of fondaparinux 2.5 mg (1.5 mg in patients with a creatinine clearance between 30 and 50 mL min(-1) ) over nadroparin 2850 anti-factor Xa IU., Patients and Methods: In this international, multicenter, randomized, open-label study, patients with an isolated non-surgical unilateral below-knee injury having at least one additional major risk factor for VTE and requiring, in the Investigator's opinion, rigid or semi-rigid immobilization for 21-45 days with thromboprophylaxis up to complete mobilization received subcutaneously once-daily either fondaparinux or nadroparin. The primary efficacy outcome was the composite of VTE (symptomatic or ultrasonographically detected asymptomatic deep vein thrombosis of the lower limb or symptomatic pulmonary embolism) and death up to complete mobilization. The main safety outcome was major bleeding., Results: We randomized 1349 patients (mean age 46 years): 88.7% had a bone fracture, and 83.8% had a plaster cast fitted (mean duration of immobilization, 34 days). The primary efficacy outcome occurred in 15 of 584 patients (2.6%) in the fondaparinux group and 48 of 586 patients (8.2%) in the nadroparin group (odds ratio, 0.30; 95% confidence interval [CI], 0.15-0.54; P < 0.001). A single major bleed was experienced by fondaparinux-treated patients and none by nadroparin-treated patients. These results were maintained up to the end of follow-up., Conclusions: Fondaparinux 2.5 mg day(-1) may be a valuable therapeutic option over nadroparin 2850 anti-FXa IU day(-1) for preventing VTE after below-knee injury requiring prolonged immobilization in patients with additional risk factors., (© 2013 International Society on Thrombosis and Haemostasis.)

Unlabelled: 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., Patients and Methods: 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., Results: 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., Conclusion: 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., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Unlabelled: 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., Materials and Methods: 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., Results: 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., Conclusion: 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., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Background: A current debate concerning suspected superficial vein thrombosis (SVT) focuses on the need of performing a compression ultrasound (CUS) exploration for confirming the diagnosis of SVT. This study was conducted to determine the clinical relevance and optimal CUS exploration in patients with symptomatic SVT., Methods: We analyzed the characteristics of SVT and concomitant deep vein thrombosis (DVT) in patients included in the Prospective Observational Superficial Thrombophlebitis (POST) multicenter, observational prospective study. All patients underwent complete bilateral lower limb CUS, exploring both the superficial and deep venous systems., Results: A total of 844 patients with clinical symptoms of SVT were recruited, of which 99 isolated SVTs (21.4%) had saphenofemoral/popliteal junction involvement, and 198 (23.5%) had a concomitant DVT, with 41.8% of them proximal DVTs. In 83 patients (41.9%), DVT and SVT were not contiguous. Five of 639 patients (1%) had an isolated contralateral DVT (ie, not bilateral). Age ≥ 75 years (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.6-3.4), inpatient status (OR, 5.4; 95% CI, 3.4-8.7), a personal history of DVT or pulmonary embolism (OR, 1.8; 95% CI, 1.2-2.8), and SVT on nonvaricose veins (OR, 3.3; 95% CI, 2.1-5.0) were significantly and independently associated with an increased risk of concomitant DVT. Half of the patients exhibited none of these risk factors, and the prevalence of concomitant DVT dropped to 11%., Conclusions: In patients with symptomatic SVT, a CUS exploration screening the whole venous system of the affected limb is useful because it provides information that has important consequences for the management of these patients., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

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., (Copyright © 2012. Published by Elsevier Masson SAS.)

Aim: 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., Patients and Methods: 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., Results: 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)., Conclusion: 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., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Introduction: The optimal duration of thromboprophylaxis after total knee arthroplasty remains uncertain., Material and Methods: We performed a randomized, open trial to determine whether to stop thromboprophylactic therapy at Day 10±2 ('short thromboprophylaxis') was non-inferior to continue thromboprophylactic therapy up to Day 35±5 ('extended thromboprophylaxis') after total knee arthroplasty. At Day 7±2, subjects were screened by ultrasonography for asymptomatic deep-vein thrombosis and randomized. The primary outcome was a composite of proximal deep-vein thrombosis, any symptomatic deep-vein thrombosis, non-fatal symptomatic pulmonary embolism, major bleeding, heparin-induced thrombocytopenia, or all-cause death up to Day 35±5. The secondary outcome was ultrasonographic (extension or new onset) distal deep-vein thrombosis at Day 35±5., Results: Twenty-one patients (2.4%) were not randomized, because of asymptomatic proximal deep-vein thrombosis on systematic ultrasonography at Day 7±2. Among the 857 randomized patients, mean (SD) duration of anticoagulant treatment was 11.2 (6.7) and 33.9 (3.7) days in the short and extended thromboprophylaxis groups, respectively. The respective rates of the primary outcome were 4.0% (17/420) and 2.4% (10/422), with an absolute difference of 1.7% (90% confidence interval, -0.3 to 3.7). In 285 patients with asymptomatic distal deep-vein thrombosis at Day 7±2, the respective rates of the primary outcome were 7.8% and 2.8% (p=0.067). The rates of the secondary outcome were 14.8% (62/420) and 4.5% (19/422), respectively (p<0.001)., Conclusions: Short thromboprophylaxis was not non-inferior to extended thromboprophylaxis after total knee arthroplasty. In this setting, the thromboembolic risk persisted longer than seven days, notably in patients with asymptomatic distal deep-vein thrombosis at discharge. ClinicalTrials.gov number: NCT00362492., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

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 >or=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).

Background: Thromboprophylaxis in elderly patients, including post-acute care patients, is at variance with scientific evidence. The purpose of this study was to determine whether a multifaceted intervention was followed by a decrease in deep venous thrombosis (DVT)., Methods: A prospective preintervention-postintervention study was conducted in 1373 patients (preintervention phase, n = 709; postintervention phase, n = 664), aged 65 years or older, enrolled in 33 hospital-based post-acute care facilities in France. An evidence-based guideline addressing pharmacologic and mechanical prophylaxis was implemented through a multifaceted intervention. The main outcome measure was any DVT diagnosed at routine comprehensive ultrasonography performed by registered angiologists., Results: A DVT was found in 91 patients (12.8%) in the preintervention phase and in 52 patients (7.8%) in the postintervention phase (P = .002). The decrease in DVT involved the calf (7.1% vs 3.6%; P = .005) and the proximal venous segments (5.8% vs 4.2%; P = .18) and remained significant after adjusting for risk factors (adjusted odds ratio of any DVT, 0.58; 95% confidence interval, 0.39-0.86). Pharmacologic prophylaxis with either low-molecular-weight heparin at the high-risk dose, unfractionated heparin, and vitamin K antagonist was similar in the 2 study groups, whereas patients in the postintervention group were more likely to use graduated compression stockings (27.4% vs 34.6%; P = .004) and less likely to receive low-molecular-weight heparin at the low-risk dose (24.7% vs 18.5%; P = .006), which was not recommended by our guideline., Conclusions: A multifaceted intervention addressing venous thromboembolism prophylaxis in post-acute care patients can be followed by a significant decrease in the rate of any DVT in elderly patients. More active interventions are needed to enforce compliance with evidence-based guidelines.

Background: Oral estrogen use and elevated body mass index (BMI) increase the risk of venous thromboembolism (VTE). Recent data suggest that transdermal estrogen might be safe with respect to thrombotic risk. However, the impact of transdermal estrogen on the association between overweight (25 kg m(-2) < BMI < or = 30 kg m(-2)) or obesity (BMI >30 kg m(-2)) and VTE risk has not been investigated., Methods: We carried a multicenter case-control study of VTE among postmenopausal women aged 45-70 years, between 1999 and 2005, in France. Case population consisted of women with a first documented idiopathic VTE. We recruited 191 hospital cases matched with 416 hospital controls and 62 outpatient cases matched with 181 community controls., Results: The odds ratio (OR) for VTE was 2.5 [95% confidence interval (CI):1.7-3.7] for overweight and 3.9 (95% CI: 2.2-6.9) for obesity. Oral, not transdermal, estrogen was associated with an increased VTE risk (OR = 4.5; 95% CI: 2.6-7.7 and OR = 1.1; 95% CI: 0.7-1.7, respectively). Compared with non-users with normal weight, the combination of oral estrogen use and overweight or obesity further enhanced VTE risk (OR = 10.2; 95% CI: 3.5-30.2 and OR = 20.6; 95% CI: 4.8-88.1, respectively). However, transdermal users with increased BMI had similar risk as non-users with increased BMI (OR = 2.9; 95% CI: 1.5-5.8 and OR = 2.7; 95% CI: 1.7-4.5 respectively for overweight; OR = 5.4; 95% CI: 2.1-14.1 and OR = 4.0; 95% CI: 2.1-7.8 respectively for obesity)., Conclusions: In contrast to oral estrogen, transdermal estrogen does not confer an additional risk of idiopathic VTE in women with increased BMI. The safety of transdermal estrogen on thrombotic risk has to be confirmed.

Background: Lifetime estrogen exposure has been related to breast cancer risk, osteoporosis, and cardiovascular disease but data on venous thromboembolism (VTE) risk are limited., Methods: Data from a hospital-based case-control study among 608 postmenopausal women (191 with a first episode of idiopathic VTE and 417 age-matched controls) were used to determine whether estrogen exposure, as assessed by age at menopause [classified as early (< or = 45 years), normal (46-54 years) and late menopause (> or = 55 years)] and parity, was associated with the risk of VTE., Results: After adjustment for potential confounding variables, the risk of VTE was increased with each year's delay in the menopause [odds ratio (OR) = 1.06, 95% confidence interval (CI) = 1.02-1.10, P < 0.0075]. When compared with women with normal menopause used as a reference, the adjusted OR for VTE was 0.59 (95% CI = 0.36-0.97) and 2.53 (95% CI = 1.28-4.99) for women with early menopause and late menopause, respectively (P = 0.001). Adjusted OR for VTE was also higher for women with more than two children when compared with those with less than or equal to two children (1.56, 95% CI = 1.03-2.34, P = 0.03). The lowest risk of VTE was observed in women with early menopause and lower parity (adjusted OR = 0.60, 95% CI = 0.30-1.24), the highest risk was among women with late menopause who have had more than two children (adjusted OR = 3.41, 95% CI = 1.46-9.25)., Conclusion: These results show that the longer exposure to endogenous estrogen is associated with an increased VTE risk.

Summary: Absolute ethanol is the most effective agent in the treatment of venous malformation (VM) although it is quite risky to use because of the danger of diffusion beyond the target. To reduce this risk, we have developed an alcoholic sclerosing solution that is less diffusible. The viscosity of absolute ethanol was enhanced with monographic ethyl-cellulose at a concentration of 5.88% ie 0.75 g in 15 ml of absolute ethanol 95%. 23 patients with VM located on the buttock (1), hand (2), leg (1) and face (19) were treated. A mean volume of 1.99 ml of the solution was injected directly into the VM. Each patient had an average of 2.8 procedures. Sixteen patients were done under general anaesthesia and seven with local anaesthesia. Evaluation was performed by the patient, the dermatologist of the treating multidisciplinary team and a dermatological group not involved in the treatment of the patients. Patients were evaluated after a mean delay of 24.52 months. Evaluation of the cosmetic result was made with a five point scale and the global result with a three point scale. VM pain was evaluated by the patients with a Visual Analogue Scale. The aesthetic results were graded as satisfactory (> 3) for the patient and the dermatologist of the multidisciplinary team. However the results were not as good with the independent dermatological group evaluation. The pain was significantly less important after the treatment (p << 0.001). Among the 23 patients, the local adverse events were nine necrosis with or without ethylcellulose fistula followed by only two surgical procedures. There were no systemic adverse events. Sclerotherapy of VM is usually performed with absolute ethanol or ethibloc. The main advantage of our sclerosing mixture is that it expands like a balloon when injected slowly in a aqueous media. Because of the important increase in viscosity the volume of injected solution is much lower than ethanol alone and the risk of systemic reactions is lower. Contrary to ethibloc, post-sclerosing surgery is not necessary because sub-cutaneous ethylcellulose disappears secondarily.

Nasal haemangiomas may cause great social distress. Complete involution of these haemangiomas does not usually result in a return to normality. The subcutaneous tumour infiltrates the alar cartilages, resulting in a globular aspect of the nasal tip. In this location, haemangiomas are slow to regress, and contour deformities result from the fibrofatty tissue that remains after total involution and also from definitive deformation of the nasal cartilages. Surgery to remove the affected tissue and preserve the anatomy seems to be the best treatment for these tumours. We report six cases of nasal haemangiomas removed using the Rethi incision and a double rim incision. This procedure allows complete dissection of the tumour, and leaves only a small scar. The alar cartilages are returned to their anatomical position to allow normal growth. Surgery is performed at around 2 years of age; skin excision is not necessary because spontaneous skin retraction occurs. Our patients were evaluated by their parents, the surgeon and members of the dermatology staff not involved in their treatment. Pain, scar and final aspect were evaluated using statistical analysis. The parents and surgeon rated the postoperative results as very satisfactory or satisfactory. The dermatology staff also reported improvement after surgery. The scar is nearly invisible and the procedure allows excision of large nasal haemangiomas.

Unlabelled: Isolated iliac venous thrombosis (IIVT) is uncommon. Duplex ultrasonography of the iliac vessels is not recommended and not generally performed., Objective: 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., Material and Methods: 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., Results: 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., Conclusion: 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.

Objectives: 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., Material and Methods: 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., Results: 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., Conclusions: 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.

A patient presented with a large arteriovenous malformation (AVM) of the scalp. Afferent arterial embolisation followed by repeated surgical partial excision did not prevent recurrence and haemorrhage. The malformation was controlled with a latissimus dorsi muscle free flap which was positioned on the malformation. Five years later, haemorrhages did not recur and the nidus has disappeared on the angiogram. The positioning of a well-vascularised free tissue transfer provided long-term palliation and the authors believe that this flap acted as a 'regulating flap'. As repeated surgery of these large AVMs always leads to rapid recurrences, the authors recommend treating large AVMs directly with a regulating flap when total excision is not possible.

Objectives: 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., Patients and 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., Results: 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., Discussion: 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.

Introduction: 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., Material and Methods: 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 (p < 10(-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., Results: 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., Discussion: 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., Conclusion: 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.

Unlabelled: The authors report the results of duplex ultrasound scanning investigation for the detection of deep venous thrombosis after orthopedic surgery and compare asymptomatic and symptomatic populations., Purpose of the Study: To estimate the rate of deep venous thrombosis diagnosed by duplex scanning in those 2 populations and precise their features., Material: A total of 1,647 in-patients all receiving low-molecular-weight heparin and investigated from 1989 to 1993. either for screening because of 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 were significant (p < 10(-8)., Methods: 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 transverse view from caval site to both ankles. Retrospective analysis of patients database results has been achieved., Results: There was no significant difference in deep vein thrombosis rate between screening asymptomatic group (356/930:38%) and symptomatic group (253/717: 35%). There was a linear relation, in the 2 groups, between age and deep vein thrombosis rate, from 10% before twenty to 45% 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% (87/1,647) of patients. Distal muscular soleal veins were the most usual involved sites of thrombosis. Isolated soleal thrombosis were detected in 16% (270/1,647) of patients. There was non 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 arthroplaty during the last 6 months., Discussion: Pessimistic results previously reported for duplex screening among asymptomatic patients are not confirmed. Calf vein thrombosis rate assessed by duplex scanning exceeds by 15 a 20% usual rates assessed by contrast venography, among patients receiving low-molecular-weight heparins. That difference could be assigned to the isolated muscular soleal thrombosis usually missed at contrast venography., Conclusion: 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. Screening for deep venous thrombosis by duplex scanning in orthopedic surgery is as efficient among asymptomatic as among symptomatic patients and could become soon a systematic screening. Soleal vein thrombosis are the most usual. 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.

The elderly population is particularly exposed to risk of venous thromboembolism because the risk of thrombosis increases with age but also because of the side effects of anticoagulant therapy. Clinical signs are neither sensitive nor specific and systematic screen for deep vein thrombosis in elderly patients could be justified using noninvasive techniques such as echo-Doppler or assay of D-Dimers. The aim of this study was to determine the prevalence of venous thrombosis diagnosed by echo-Doppler screening in a population of institutionalized elderly subjects. The frequency of risk factors and the cost of screening and subsequent health care were also evaluated. This study included 96 patients who underwent systematic echo-Doppler measurements. Clinical, biological and echographic data were recorded on individual file-cards for analysis. The prevalence of deep vein thrombosis diagnosis was 13.5% (13/96). All the deep vein thromboses discovered were in the popliteal area. No high risk group was found and there was found and there was no significant link with clinical signs or the level of D-Dimers. The cost of diagnosis and treatment in the particular conditions of our study were 5000 and 10,700 FRF respectively for each deep vein thrombosis diagnosed. The cost of diagnostic screening and treatment should be considered in light of the life expectancy and quality of life in this population. Thus in elderly institutionalized subjects, it would appear not to be reasonable to undertake systematic screening for venous thrombosis using echo-Doppler or D-Dimer assay.

The study concerned 106 superficial venous thrombosis (SVT) diagnosed thanks to an echo-Doppler, between october 1989 and february 1993 in 42 men and 63 women aged 59 +/- 18 years and 64 +/- 18 years respectively. In nearly half cases, clinical sign was a suspicion of a deep venous thrombosis (DVT) (34 cases) or a pulmonary embolism (PE) (14 cases). A supposed precipitating factor was found in 65 cases out of 105: a cancer already known in 11 cases. The SVT was located in the left lower limb in 56 cases, in the right lower limb in 41 cases and a bilateral one in 9 cases. The long saphenous vein was affected in 60 cases, the short saphenous vein in 22 cases, both saphenous veins in 6 cases and a non-collateral saphenous vein in 17 cases. In 38 cases, a DVT added to a SVT, either separately in 19 cases, 9 of which in controlateral or by proximity extension from an arch in 7 cases or from a more distal perforating vein in 8 cases. In total, complications, either DVT or SVT, appeared in 46 cases out of 105. The age of > or = 60 has been associated with the presence of complications. In 3 cases, a cancer was discovered in the month following the SVT. These results question the benignancy of SVT. They match those of two series of SVT diagnosed thanks to echo-Doppler and recently reported. They urge to explore systematically both venous networks, superficial and deep and to achieve an etiologic balance either for SVT or unexplained DVT.

More than hundred medical treatments for lymphedema have been described. This very high number shows the evidence of difficulties: lymphatics are very small vessels, under low pression and velocity respondent to spontaneous quiet lymphatic contractions. The treatments can be listed in 3 groups: 1) physiotherapeutic methods, increasing lymphatic flow: cold, field stimulation, manual lymph drainage, intermittent compression, heat; 2) drugs: venous agents (flavone, benzo-pyrone), and intraarterial lymphocytes injection, promoting lymphatic flow or increasing normal proteolysis by macrophages in order to remove trapped proteins from interstitial fluid; 3) surgical procedures subdivided in 2 groups: excisional techniques and bridging drainage techniques; radical or partial excision removes involved subcutaneous tissue, recently by the way of liposuction; Efforts to drain lymphedema by subcutaneous implants, pedical flaps, myocutaneous flaps, omental transposition and intestinal flaps are historical. Microsurgical lymphatic anastomosis to vein (nodo-venous then lymphovenous), and to lymphatic themselves are now performed: lymphatic collectors or venous autografts are interpositioned to by-pass lymphatic blockade with end-to end anastomosis. The free transplantation of a lymphatic flap with its own vascularisation from healthy inguinal nodes to axillary blockade is the last described procedure. Lymphatic anastomosis are not needed. Actually, physiotherapy is always first indicated. Benzo-pyrones are additive drugs. Excisional procedures concern monstruous lymphedema. Microsurgical bridging procedures can be attempted only for secondary lymphedemas. They could be of benefit if physiotherapy and elastic bandages, stockings or sleeves, could then be avoided. Studies assessing independently the efficiency of each procedure are needed.

Duplex ultrasound imaging provides both an ultrasound picture of the tissue being explored and the sound of the flow speed in a particular area. Colour Doppler imaging gives colour codes for the different flow rates. Venous pathology is always investigated, with ultrasound, on both sides, at the iliac and caval, femoral, and foreleg levels. For the latter, excellent equipment and patient position are required. Ultrasound criteria of deep venous thrombosis (DVT) are the incompressibility of the vein being investigated, and detection of the thrombosis with the ultrasound probe. Doppler criteria are asymmetric spontaneous flows, the loss of their respiratory rhythm, and the lack of flow induced by contraction of muscle. The colour Doppler draws provides the contours of a partial or floating thrombus. Compared with phlebography, ultrasound imaging has a sensitivity and specificity of 96%. Colour Doppler imaging is even more accurate: both sensitivity and specificity increase to 100%. The limitations of ultrasound are: its dependence on the investigator, the difficulty of making the diagnosis of recurring DVT when there already are previous sequellae, obesity, intra-abdominal gas, skin lesions or inflammatory oedema. Phlebography remains necessary in 5% of cases. The advantages of this technique are its non invasiveness, excellent diagnostic performance, low cost, and the possibility of diagnosing another cause, whether responsible for the clinical signs or not. It is indicated for the diagnosis of DVT, routine screening in patients at risk, and the early and late follow-up of patients. Today, ultrasound imaging should always be carried out before other investigations.(ABSTRACT TRUNCATED AT 250 WORDS)

The operator-dependent nature of venous Duplex-ultrasonography diagnosis of deep venous thrombosis (DVT) of the leg is the principal reproach applied to it and a reason for delaying use. The aim of the present study was to evaluate concordance between two operators, with rigorous application of the same methodology of exploration of the venous axes. The study included 82 patients under hospital care, randomly selected from among those referred for the first Duplex-ultrasonography examination for DVT, and having accepted to undergo 2 consecutive explorations, one by each of the two operators. The two operators evaluated independently, for the 19 venous axes of the legs: 1: the interpretability of the examination, 2: the differential diagnosis between: absence of thrombus, presence of thrombus, nonconclusive examination, and 3: the score for the DVT extension. Evaluation of concordance of diagnosis was by Cohen's kappa coefficient, calculated on the positive diagnosis of DVT and the site of the most proximal thrombus. Extension scores were compared by calculation of the coefficient of correlation "r". Interpretability rates were 92% and 91% respectively for the two operators, 35 DVT being diagnosed in 27 patients by operator A and 36 DVT in 27 patients by operator B. The kappa coefficient for diagnosis of DVT with localization in the affected leg was 0.90 [0.81-0.98]. It was 0.89 [0.73-1] for proximal lesions, 0.86 [0.74-0.97] for the lower leg level, and 0.79 for localization of the proximal extremity of the thrombus. Extension scores evaluated by the two operators were 2.88 and 3.14 respectively, with a coefficient of correlation between the extension scores of 0.96. The 5 diagnostic divergences concerned the lower leg level; the 2 localization discordances concerned: the frontier zones leg-lower popliteal, lower femoral-upper popliteal. Good concordance between results of the two operators using Duplex-ultrasonography exploration was obtained even though the majority of the DVT were in the calf, a region known to be explored with difficulty. Overcoming the operator-dependent character of Duplex-ultrasonography by a rigorous exploratory methodology could make it the future reference examination for the diagnosis of DVT.

Etiology of deep vein thrombosis in ambulant patients (DVTA = TVPA in text) varies: cancer, blood disease, infectious focus, dysimmunity syndrome, dysglobulinemia, extrinsic compression, metabolic disorder, anomaly of hemostasis. A prospective study was carried out between June 1988 and September 1989 by angiologists in 5 regions of France to evaluate the diagnostic rentability of an epidemiologic survey and to determine possible distinctive characters of DVTA. The survey was comprised of a questionnaire, a full clinical examination and screening tests: chest x-ray, abdominopelvic ultrasound imaging, a-uro/gynecologic examination, full blood count, serum iron, ferritin, uric acid, triglycerides, cholesterol, protein electrophoresis, antinuclear antibodies, circulating anticoagulant, hemostasis factors and liver function tests. The study included 128 patients, mean age 60 +/- 16 years with a DVTA developing without a previous immobilization. The usual predominance in the left leg was not observed. The etiology was identified in 33 cases, including 20 (15.6%) as a result of the screening tests: anomalies of hemostasis (8), blood diseases (3), dysimmunity syndromes (4), extrinsic compression (3), cancer metastasis (1) and hypertriglyceridemia in a diabetic (1). The screening procedure was of no greater value in the absence of a triggering or predisposing factor, on the contrary. An anomaly of hemostasis was detected more frequently in the presence of local or regional triggering factors in the men (4 out of 4) and in the women on the pill (4 out of 4). The number of cancers discovered following screening (2%) was smaller than that expected according to the literature (10%).(ABSTRACT TRUNCATED AT 250 WORDS)

Two criticisms are levelled against venous ultrasonography: its operator-dependent nature and the absence of any overall imaging document which can serve as a reference and be read by all. A very precise investigation technique is suggested to deal with the first criticism. This describes the investigation in detail, level by level from the inferior vena cava to the lower third of the leg and indicates the optimal position of patient and operator, in particular concerning the leg. A method of imaging presentation is proposed to deal with the second criticism. The site and extent of venous thromboses are shown on a precise anatomical diagram including muscle veins. This diagram reproduced by reduction on a four-fold card is given to the patient to be used during subsequent follow-up. It can be used as a reference document in case of suspected extension or recurrence. Ultrasonography has several advantages over phlebography: a better reliability rate, better sensitivity for lesions in muscles and where there are twin veins, possibilities of differential diagnosis of DVT and of the discovery of concomitant pathology. It should now always be performed as the investigation of primary intention.

Hyperparathyroidism secondary to chronic renal failure is often accompanied by metastatic calcification with involvement of the skin. The cutaneous lesions appear to be of two types: in the first there was massive calcification of the skin and the subcutaneous tissue; in the second there was necrotic purpura due to intimal proliferation and medial calcification of the cutaneous arterioles. We report the case of a 75-year-old-woman with osteodystrophy who had painful necrotic ulcer and reticulated purpura of the legs (fig. 1 a, b). The new lesions progressed by lateral extension and central necrosis. Biopsy of the skin underlying the purpuric areas revealed intimal proliferation with narrowing of the lumen (fig. 2 a, 3). The most prominent feature was the considerable intimal and internal elastic membrane calcification in several small arteries (fig. 4 a, 5). Von Kossa's stain showed calcium to be present (fig. 2 b, 4 b). There was no calcification of the tunica media. Serum calcium phosphorus product was increased (table I). Tubular reabsorption of phosphate was abnormally low. The serum immunoreactive parathyroid hormone was normal. An iliac crest biopsy revealed the classical lesions of osteodystrophy. Her skin lesions showed spontaneous resolution without parathyroidectomy: the ulcers were healing within two months. A progressive reticulated necrotic purpura has previously been reported in chronic renal failure with secondary hyperparathyroidism. These black ischemic lesions bear a strong resemblance to those accompany atheromatous necrotic angiodermatitis. The metastatic calcification seen in uremia often involves the media; the present case is the first to be reported with intimal calcification.(ABSTRACT TRUNCATED AT 250 WORDS)

With the aim of determining criteria by which results of a sclerosant treatment could be assessed in a multicentric study, 35 sapheno-femoral junctions (26 long saphenous veins and 9 short saphenous veins) treated by sclerotherapy beforehand, were controlled separately and confidentially by two examiners, first clinically, then using the Doppler. The concordance rates were analysed for each of the tests carried out: fascial palpation, clinical and ultrasound percussive permeability, clinical and ultrasound search for reflux, measurement of length of reflux. The results confirm the superiority of the Doppler technique, both in the diagnosis of ostial permeability and reflux (concordance superior at 90% as opposed to 68 to 80% for the clinical tests), and in the quantification of the reflux (strong positive correlation, r = 0.83, between the values given by the two examiners). The doppler technique provides an excellent concordance of differentiated clinical sensibility between the examiners. The permeability, by Doppler, and the length of the audible reflux are proposed as criteria for assessment of the result of a sclerosant treatment, during the follow-up.