J.-P. Galanaud

Incidence and predictors of venous thromboembolism recurrence after a first isolated distal deep vein thrombosis

Isolated distal deep vein thrombosis (iDDVT) (i.e. without proximal DVT or pulmonary embolism) represents half of all cases of lower limb DVT. Its clinical significance and management are controversial. Data on long‐term follow‐up are scarce, especially concerning risk and predictors of venous thromboembolism (VTE) recurrence.

The history and historical treatments of deep vein thrombosis

Deep vein thrombosis (DVT) is a common disease. However, unlike that of varicose veins, which have been depicted since antiquity in art and literature, its description was more recent in the history of medicine. The first well‐documented case of DVT was reported during the Middle Ages: in 1271, Raoul developed a unilateral edema in the ankle, which then extended to the leg. The number of reported DVT cases steadily increased thereafter, particularly in pregnant and postpartum women. During the first half of the 20th century, well before the discovery of anticoagulants, many therapeutic approaches were used, and arose from the pathologic hypotheses that prevailed at their time. Despite the development of anticoagulants, and the fact that they were thought to dramatically decrease DVT mortality, numerous complementary treatments have also been developed during the last 50 years: they include vena cava clips and surgical thrombectomy, and are intended to decrease mortality or to prevent late complications. Most of these treatments have now been abandoned, or even forgotten. In this review, we recall also the discovery and the use of vitamin K antagonists and heparin, which have constituted the mainstay of treatment for decades. We also bring some perspective to historical aspects of this disease and its treatment, notably regarding elastic compression and early mobilization, but also abandoned and complementary treatments. In these times of change regarding DVT treatment, mainly marked by the arrival of new oral anticoagulants, efforts of physicians through the ages to treat this common disease provide a beautiful example of the history of knowledge.

Observational study of pregnant women with a previous spontaneous abortion before the 10th gestation week with and without antiphospholipid antibodies.

Summary.  Background: A clinical subtype of purely obstetrical antiphospholipid antibody (aPL‐Ab) syndrome (APS) requires three or more unexplained consecutive embryonic losses before the 10th week of gestation associated with persistently positive lupus anticoagulant (LAC), and/or anticardiolipin IgG or IgM, and/or anti‐β2‐glycoprotein I (aβ2GpI) IgG or IgM. Although this diagnostic classification of APS appeared to be the most sensitive, the APS‐associated serological criteria are still debated. Patients/methods: We prospectively observed the second pregnancy of 284 women with a previous embryonic loss, both with and without aPL‐Ab. Results: aPL‐Ab‐positive women were more prone to pregnancy loss, embryonic loss, pre‐eclampsia, placental abruption and intrauterine fetal growth restriction. Type IIa aPL‐Ab positivity (LAC present alone) was associated with the highest risk of recurrent embryonic loss and intrauterine growth restriction. Type I aPL‐Ab positivity (combinations of aPL‐Ab type positivity) was associated with the strongest risks of late complications, pre‐eclampsia and placental abruption. Finally, aβ2GpI‐M positivities were not clinically relevant in these women. Conclusion: Patients with a first unexplained pregnancy loss before the 10th week of gestation who are also positive for aPL‐Abs have a higher risk of various complications in their second pregnancy. In this study, measurement of aβ2GpI‐M had a questionable prognostic value.

Superficial vein thrombosis and recurrent venous thromboembolism: a pooled analysis of two observational studies

Summary.  Background:  The management strategies for symptomatic isolated superficial vein thrombosis (SVT) (without concomitant deep vein thrombosis [DVT] or pulmonary embolism [PE]) have yet to achieve widespread consensus. Concerns have been raised regarding the usefulness of prescribing anticoagulant treatments to all patients with isolated SVT. Determining the isolated SVT subgroups who have the highest risks of venous thromboembolism (VTE) recurrence (composite of DVT, PE, and new SVT) may facilitate the identification of patients who are likely to benefit from anticoagulant treatment.

Paternal endothelial protein C receptor 219Gly variant as a mild and limited risk factor for deep vein thrombosis during pregnancy.

Summary.  Background: Half of all venous thromboembolism (VTE) cases during pregnancy are associated with a maternal thrombophilia. The influence of paternal genotype on the placenta and in the genesis of VTE has not been described. Objectives: To determine if the maternal and paternal Ser219Gly dimorphism of the endothelial protein C receptor (EPCR), evaluated through detection of the PROCR 6936G allele, is a risk factor for VTE during pregnancy. Methods: Using a case‐control study nested in the NOHA first cohort of primigravidae, 66 patient couples with a first episode of gestational VTE and randomly selected non‐thrombotic control couples were investigated. For each couple, factor V gene (F5) G1691A, factor II gene (F2) G20210A, factor XII gene (F12) C46T and PROCR A6936G polymorphisms were determined. Results: Only maternal F5 1691A, F2 20210A and F12 46T alleles were independently associated with iliac and infra‐iliac deep vein thromboses (DVT). The maternal PROCR 6936G allele was a mild risk factor for iliac DVT (OR = 5.5 [2.3–13.0]). The paternal PROCR 6936G allele was also a mild independent risk factor for iliac DVT (OR = 2.6 [1.1–6.2]) and only during pregnancy (rather than postpartum) among maternal carriers of the F5 1691A allele (OR = 77.6 [4.2 to > 999.9]). Conclusions: The paternal PROCR 6936G allele could be a risk factor for maternal iliac DVT. Its impact was milder than the F5 1691A and F2 20210A polymorphisms in mothers. We hypothesize that the prothrombotic effect of the paternal PROCR 6936G allele is localized. Therefore, DVT during pregnancy may be influenced by trophoblastic cell‐surface proteins inherited from both maternal and paternal alleles.

Comparative evolution of carotidynia on ultrasound and magnetic resonance imaging

Carotidynia is rare and associates neck pain with tenderness to palpation usually over the carotid bifurcation, the diagnosis of which is based on magnetic resonance imaging (MRI). Ultrasounds (US) are also frequently used but their accuracy in predicting the course of the disease is unknown. We are reporting the case of a 52-year-old man who presented a typical carotidynia. Clinical symptoms, ultrasound and MRI imaging evolution were closely correlated. Our case suggest that after a first MRI to set a positive diagnosis of carotidynia and exclude differential diagnoses, US which is more widely available and less expensive could constitute the imaging of reference for the follow-up.

[Management of pulmonary embolism: A 2015 update].

Pulmonary embolism (PE) is a frequent, serious and multifactorial disease, the incidence of which increases with advanced age. In the absence of pathognomonic clinical signs or symptoms, diagnostic management lies in the evaluation of clinical pre-test probability followed by a laboratory or an imaging test. So far, multidetector computed tomography angiography is the diagnostic test of choice to make a positive diagnosis of PE. Anticoagulants at therapeutic dose for at least 3 months constitute the cornerstones of PE therapeutic management. Duration of anticoagulant treatment is modulated according to the presence of transient (surgery, plaster immobilization, bed rest/hospitalization) and chronic/persistent (age, cancer, clinical or biological thrombophilia…) risk factors of PE. Thrombolysis is usually prescribed only for cases of severe PE with arterial hypotension. Arrival of new oral anticoagulants, which have recently been shown to be as effective and as safe as vitamin K antagonist, should simplify and ease ambulatory management of PE and favor more prolonged treatments with anticoagulant for cases of unprovoked PE or PE provoked by a chronic/persistent risk factor.

L’écho Doppler veineux dans le diagnostic des thromboses veineuses périphériques a 30 ans !

14 ’écho Doppler veineux dans le diagnostic des hromboses veineuses périphériques a 30 ans ! .-P. Laroche a,∗, A. Khau Van Kien a, J.-P. Galanaud a, D. Brisot a, . Böge a, M. Nou a, M. Dauzat b, I. Quéré a Médecine vasculaire, hôpital Saint-Eloi, 80, avenue ugustin-Fliche, 34295 Montpellier cedex 5, France Équipe d’accueil EA 2992, dynamique des incohérences ardiovasculaires, université Montpellier-1, UFR médecine ontpellier-Nîmes, site de Nîmes, avenue Kennedy, 30907 Nîmes, rance