Samir Henni

Exercise Transcutaneous Oximetry of the Buttocks ― External Validation With Computed Tomography Angiography ―

BACKGROUND Exercise transcutaneous oximetry (Ex-tcPO2) is a non-invasive test for exercise-induced buttock ischemia. Prior study defined Ex-tcPO2 normal/abnormal cut-offs against arteriography but no external validation was available. The aims of this study were therefore to (1) determine the diagnostic performance of Ex-tcPO2 against CTA; (2) determine the cut-off point for detection of stenosis >75% in arteries toward the hypogastric circulation; and (3) determine the effect of chest profile classification on the diagnostic performance of Ex-tcPO2.Methods and Results:A total of 207 patients referred for Ex-tcPO2 were analyzed. DROP during Ex-tcPO2 was compared with the CTA results. Chest-tcPO2 changes were automatically classified into pre-defined profiles representing normal or abnormal responses. Using DROP <-15 mmHg as a cut-off, Ex-tcPO2 had 80.2% sensitivity, 72.3% specificity, 43.1% PPV, 93.3% NPV and 73.9% accuracy, to detect 1 stenosis >75% in arteries toward the hypogastric circulation. Optimal DROP to detect stenosis was: -15 mmHg. The overall diagnostic performance of Ex-tcPO2 was independent of chest profile classification. CONCLUSIONS Ex-tcPO2 has satisfactory diagnostic performance to detect arterial stenoses towards the hypogastric circulation. Abnormal chest-tcPO2 profile does not impair the overall diagnostic performance of the test.

Nonrevascularizable buttock claudication improved with Sildenafil: A case report

Rationale: Sildenafil, a phosphodiesterase-5-inhibitor (PDE5i), could represent a new treatment in addition to the medical treatment and advice to walk in peripheral arterial disease (PAD). Patient concerns and Diagnoses: We report a case of a 62-year-old heavy smoker man who developed a buttock claudication and a severe walking limitation following an aorto-bi-femoral bypass in 1992. Since 2003, each year, he has been referred for investigation of bilateral buttock claudication on treadmill using transcutaneous oxygen pressure (tcpO2) measurement during exercise to argue for the vascular origin of the walking impairment. He had a severe bilateral buttock ischemia and the maximum walking distance (MWD) he reached was 258 m in 2011 despite the medical optimal treatment and walking rehabilitation. Ethical approval is not necessary for this case report according to the French legislation and written consent to publication was obtained from the patient. Interventions: Sildenafil, 100 mg/d, was introduced in February 2015 and the MWD increased to 310 m only after 2 h after the first oral intake, then to 713 m after 3 weeks, and finally to 1313 m in January 2017. Outcomes: Recently, the patient is treated with Sildenafil 100 mg/d. He has no more pain during walking and his quality of life has improved. Main lessons to learn: Sildenafil, a PDE5i, may represent a new therapeutic option in addition to the conventional optimal medical therapy in patients with arterial claudication. tcpO2 measurement during exercise is a promising technique for the diagnosis and monitoring of patients with PAD. A crossover, double-blind, prospective randomized monocenter study (ARTERIOFIL-NCT02832570) and a double-blind prospective randomized multicenter study (VALSTAR-NCT02930811) are ongoing to confirm our original observation.

High prevalence of known and unknown pulmonary diseases in patients with claudication during exercise oximetry: A retrospective analysis

AbstractThe prevalence of pulmonary disease in patients with peripheral artery disease (PAD) has not been extensively studied. Recent evidence has shown that ∼20% of the patients have an atypical chest transcutaneous oxygen pressure (TcpO2) pattern during exercise, which suggests walking-induced hypoxemia. The main objectives of this study were to: (1) describe in a retrospective way the characteristics of the patients suffering from claudication, who attended a treadmill testing in our laboratory, (2) assess the prevalence of known or unknown pulmonary disease. The second aim of this study was to evaluate the impact of the therapeutic interventions on the walking capacities, after treatment, of the eventually detected pulmonary disorders.We retrospectively analyzed 1482 exercise TcpO2 test results. Patients that had no history of pulmonary disease, but either reported severe dyspnea or showed atypical profiles on their chest exercise-TcpO2, were advised to refer to the department of pneumology for additional investigations.In addition to the 166 patients with a history of pulmonary disease, 158 patients were suspected of unknown pulmonary disease from the result of their TcpO2 test. Many patients (n = 99/158, 62.7%) did not attend a pulmonologist visit. A pulmonary disease was established in 55 (93.2%) of the other 59 patients. Obstructive sleep apnea syndrome (OSAS) was the one and only diagnosis retained in 42/59 patients (71.2%). Among the 47 patients who had a second evaluation of their walking capacity on treadmill, 38 had treatment of the pulmonary disease found, vascular surgery treatment or a severe restricted diet, 9 had no treatment. Only the “treated” group showed a significant improvement in the maximal walking distance on treadmill between the 2 evaluations, 313 ± 251 m to 433 ± 317 m (P = 0.03).This retrospective pilot study underlines the high prevalence of both known and unknown pulmonary disease in patients whose primary complaint was lower limb claudication. Systematic screening and treatment of pulmonary disease in patients with claudication might be justified, to improve walking ability of such patients and possibly reduce or delay the requirement for revascularization. Prospective studies are required to confirm these preliminary results.

Exercise transcutaneous oximetry significantly modifies the diagnostic hypotheses and impacts scheduled investigations or treatments of patients with exertional limb pain

INTRODUCTION In lower extremity peripheral artery disease (PAD), transcutaneous oximetry at exercise (Ex-TcpO2) has been largely validated in research practice, but evidence of routine practice in various vascular laboratories is missing. We hypothesized that Ex-TcPO2 would change the diagnosis hypotheses, investigations and treatments for patients referred for exertional limb pain. MATERIAL & METHODS A multicenter prospective trial was conducted in nine different referral centers. Investigators performed Ex-TcpO2 and recorded investigations and treatments already scheduled for the patient. We encoded referral physicians diagnostic hypothesis. Before Ex-TcpO2, vascular physicians were asked to give their diagnosis hypotheses. A minimal decrease from rest of oxygen pressure (DROP)<minus 15mmHg defined the presence of exercise-induced ischemia on the area of interest. After Ex-TcPO2, we recorded post-test diagnostic hypothesis and investigations and treatments to be cancelled or performed. We compared the diagnosis hypotheses, scheduled investigations and treatments, before and after the Ex-TcpO2. RESULTS We included 603 patients (485 males: 80.4%), aged 64.7±9.8years. The post-test diagnosis hypothesis differed in 266 patients (44.1%; p<0.0001) and in 96 patients (15.9%) from the pre-test hypothesis of referring and vascular physician, respectively. This led to the recommendation to cancel 27 scheduled investigations or treatments of a total cost of ~130,000 euros. DISCUSSION Ex-TcPO2 in patients with exertional limb pain is applicable in various vascular institutions, and significantly modifies the diagnostic hypotheses and impacts scheduled investigations or treatments of patients with exertional limb pain.

Simultaneous pain intensity rating and quantification of ischemia throughout exercise and recovery in proximal versus distal arterial claudication

Data on simultaneous hemodynamic changes and pain rating estimation in arterial claudication while walking are lacking. This study was conducted to determine if a difference in transcutaneous oxygen pressure (tcpO2) exists between proximal and distal localization at pain appearance (PAINapp), maximal pain (PAINmax) and pain relief (PAINrel) in proximal or distal claudication and if a relationship exists between tcpO2 changes and pain intensity. We analyzed the pain rating (Visual Analog Scale (VAS)) to lower limb ischemia, measured with the decrease from rest of oxygen pressure (DROP) tcpO2 index during constant-load treadmill tests in patients with calf (n = 41) or buttock (n = 19) claudication. Calves versus buttocks results were analyzed with ANOVA tests. The R2 correlation coefficient between individual VAS versus DROP was calculated. Ischemia intensity versus pain rating changes were correlated. Significant ischemia was required for pain appearance, but pain disappeared despite the persistence of ischemia. We observed no statistical difference for DROP at PAINapp, PAINmax or PAINrel between proximal or distal claudication. A significant correlation between pain rating versus DROP was found: from PAINapp to PAINmax, R2 = 0.750 (calves) and 0.829 (buttocks), and from PAINmax to PAINrel, R2 = 0.608 (calves) and 0.560 (buttocks); p<0.05. Pain appeared after a significant decrease of hemodynamic parameters but disappeared while parameters were not normalized. No difference in pain rating was found in proximal versus distal claudication.

Muscle Oxygen content at exercise in patients with claudication

to the editor: We read with great interest the study by Dr. Luck et al. ([4][1]) in which the authors show that, when fatigued, patients with peripheral artery disease (PAD) experience a greater reduction in muscle saturation (SmO2) than subjects matched for age, sex, and body mass index. The

Bi-dimensional variational mode decomposition of laser speckle contrast imaging data: a clinical approach to critical limb ischemia?

The number of patients suffering from peripheral arterial occlusive disease (PAOD) is growing worldwide. PAOD corresponds to an impairment of perfusion in the distal portion of some arteries that can generate critical limb ischemia. For some patients, the pathology leads to the necessity of amputation. PAOD may be diagnosed and studied with transcutaneous oxygen (tcpO2) measurements. However, the tcpO2 technique is a contact technique: probes have to be positioned on the limb, which may be impossible in case of ulcers and can lead to infection risks. We therefore herein propose to study if the laser speckle contrast imaging (LSCI) technique, an optical contactless technique, could be of interest in studying limb ischemia. For this purpose, tcpO2 and LSCI data were recorded in 48 persons suffering or not from PAOD (different levels of criticality). The LSCI data were then processed with the recently introduced bi-dimensional variational mode decomposition (2D-VMD). 2D-VMD leads to band-limited intrinsic mode functions (LSCI 2D-BLIMFs in our case). From these LSCI 2D-BLIMFs, we propose a new index. Our results show that this index and the tcpO2 values have a Pearsons r correlation coefficient of -0.401. Moreover, the Bland-Altman graph shows that the LSCI 2D-BLIMFs-based index and the tcpO2 values are consistent. LSCI might therefore be of interest for a contactless study of limb ischemia.

Laser Speckle Contrast Imaging of Skin Changes in Arteriovenous Malformation.

A 7-month-old child had an arteriovenous malformation (AVM) manifesting with redness of the skin of her left upper arm and shoulder (Figure). The diagnosis had been confirmed by magnetic resonance imaging performed under general anesthesia with a 3-T whole-body MR scanner (MAGNETOM Skyra; Siemens Medical Solutions, Erlangen, Germany; Figure). Axial fat-suppressed gadolinium-enhanced T1-weighted image in the coronal plane demonstrated a soft-tissue AVM characterized by direct fistulous and plexiform connections between arteries and veins without parenchymal staining. Tubular flow voids indicated high flow velocity within enlarged vascular channels. No surrounding soft-tissue signal abnormality or mass effect was observed. Figure. Data recorded from the subject and resulting images obtained with multidimensional complete ensemble empirical mode decomposition with adaptive noise (MCEEMDAN). Ultrasound duplex sonography (US) showed, …

Skin blood flow measurements during exposures to emotionally charged movies

A recent report in the journal evaluated microvascular response at the facial and peripheral level during various types and levels of emotional stresses with laser speckle contrast imaging. Our short letter aims at underlying the importance of artifact removal in this situation and suggest directions for improving the results of this kind of experiment.

Letter by Henni et al Regarding Article, “Aspirin Monotherapy Should Not Be Recommended for Cardioprotection in Patients With Symptomatic Peripheral Artery Disease”

We read with interest Brass and Hiatt’s1 article, which proposes that aspirin monotherapy should not be recommended for cardioprotection in patients with symptomatic peripheral artery disease. Low-dose aspirin (75–325 mg) is a unique product on the market and in its application in clinical medicine. No other drug has such a large range of therapeutic recommended dose (from 1–4 times the minimal range). Using the …