Sébastien Gaertner

Long-Term Outcomes of Direct and Indirect Below-The-Knee Open Revascularization Based on the Angiosome Concept in Diabetic Patients with Critical Limb Ischemia

BACKGROUND We compared long-term outcomes of isolated below-the-knee (BTK) bypass revascularization in diabetic patients presenting with critical limb ischemia (CLI) with and without achieving the bypass on the artery corresponding to the territory of the lesion based on the angiosome concept. MATERIALS We analyzed outcomes of 58 consecutive CLI limbs of 54 diabetic patients presenting with tissue loss who underwent isolated BTK bypasses from 2003 to 2009 for crural occlusive arterial disease. Bypasses were classified into direct and indirect groups based on the angiosome concept, whether feeding artery flow to the site of ischemic tissue loss was achieved or not. We compared median ulcer-healing time, survival, primary patency, and limb salvage rates between both groups by Kaplan-Meier analysis and log-rank test. Independent factors of major amputations were explored by univariate analysis. Variables with P < 0.2 in univariate analysis were submitted to multivariable analysis. RESULTS Median ulcer-healing time was 56 ± 18 days in direct group (n = 36) and 112 ± 45 days in indirect group (n = 22, P = 0.01). There was no difference between both groups in terms of survival or primary patency. Limb salvage rate was significantly higher in direct group than in indirect group: 91% vs. 66% at 1 year, 65% vs. 24% at 3 years, and 58% vs. 18% at 5 years, respectively (P = 0.03). After multivariable Cox proportional analysis, independent factors associated with major amputation were end-stage renal disease (P = 0.030) and C-reactive protein level (P = 0.025). CONCLUSIONS Achieving a direct arterial flow based on angiosome concept in CLI diabetic patients presenting with tissue loss appears to be important for ulcer healing and limb salvage.

A critical appraisal of the guidelines from France, the UK, Europe and the USA for the management of hypertension in adults

Hypertension is the leading cause of death in developed countries; its management is the subject of guidelines that are regularly reviewed and updated. However, the guidelines from France, the UK, Europe and the USA differ. Some recommendations are graded, whereas others are not. All recommendations emphasize the role of alternative methods for clinical measurement of blood pressure, such as ambulatory blood pressure measurement (ABPM) or self-measurement. The UK guideline recommends that the diagnosis of hypertension should be established by ABPM. The USA guideline recommends a target of ≤ 150/90 mmHg for patients aged >60 years. The French guideline recommends that the target blood pressure remains at <140/90 mmHg, with <150 mmHg for patients aged >80 years. Systolic blood pressure between 130 and 139 mmHg and diastolic blood pressure <90 mmHg are recommended for diabetic patients and those with chronic kidney disease. The French Society of Hypertension (SFHTA) guideline is unique in recommending a dedicated consultation to announce the diagnosis to the patient. In the French and European guidelines, diuretics, beta-blockers, calcium antagonists, angiotensin-converting enzyme (ACE) inhibitors and angiotensin II type 1 receptor blockers (ARBs) remain indicated as first-line therapy for hypertension; if the target blood pressure is not achieved, they recommend combining two active substances. The UK guideline recommends ACE inhibitors or ARBs as first-line therapy for patients aged <55 years; calcium antagonists are advised for patients aged >55 years and for black patients. The USA guideline advises treating non-black patients, including those with diabetes, with thiazides, calcium antagonists, ACE inhibitors or ARBs; for black patients, including those with diabetes, it recommends thiazide and calcium antagonists.

Rivaroxaban versus standard anticoagulation for symptomatic venous thromboembolism (REMOTEV observational study): Analysis of 6-month outcomes

BACKGROUND This study aimed to provide safety and efficacy data of rivaroxaban in routine patient care in a non-selected symptomatic venous thromboembolism (VTE) population. METHODS AND RESULTS REMOTEV is a prospective, non-interventional study of patients with acute symptomatic VTE, treated with oral rivaroxaban, VKA or parenteral heparin/fondaparinux alone for at least 3months and who are followed up for 6months. From Nov. 2013 to July 2015, 499 consecutive patients were retained for baseline analysis and 445 for safety analysis. The mean age was 65.1years, 7.6% had previously known active cancer, 18.6% had creatinine clearance 30≤CrCl<60mL/min, and 87.8% had pulmonary embolism with or without deep venous thrombosis. The major and clinically relevant bleeding rate was 5.4% (15/280) in the rivaroxaban group, 9.4%/(9/96) in the VKA group and 7.2% (5/69) in the heparin/fondaparinux group. The recurrent VTE rate was 1.4% (4/280) in the rivaroxaban group, 3.1% (3/96) in the VKA group and 11.6% (8/69) in the heparin/fondaparinux group. In the propensity score-adjusted samples, major and clinically relevant non-major bleeding (HR 0.37 [95% CI, 0.15 to 0.93], p<0.05), all-cause death (HR 0.21 [95% CI, 0.06 to 0.66], p<0.01) and the composite of recurrent VTE, major and clinically relevant non-major bleeding and all-cause mortality (HR 0.35 [95% CI, 0.17 to 0.71], p<0.01), were significantly lower in the rivaroxaban group compared to the VKA group. CONCLUSION In REMOTEV 6-month outcomes are consistent with the findings of the phase 3 randomized trials and post-marketing data, with low rates of major bleeding and symptomatic recurrent VTE.

Statins and prevention of venous thromboembolism: Myth or reality?

The pleiotropic effects of statins, beyond their cholesterol-lowering properties, are much debated. In primary prevention, several observational cohort and case-control studies appear to show that statins reduce the incidence of venous thromboembolism by about 30%. In a single randomized placebo-controlled clinical trial (JUPITER), which included 17,000 patients, rosuvastatin 20mg/day reduced the risk of venous thromboembolism by 43%. However, these patients were at low risk of venous thromboembolism, and the frequency of the event was, in principle, low. In secondary prevention, several observational studies and post-hoc analyses of randomized clinical trials have suggested that statins may prevent recurrence of venous thromboembolism. However, none of these studies had enough scientific weight to form the basis of a recommendation to use statins for secondary prevention. The putative preventive effect of statins appears to be independent of plasma cholesterol concentration and could be a pharmacological property of the statin class, although a dose-effect relationship has not been demonstrated. The mechanism through which statins might prevent venous thrombosis is thought to involve their anti-inflammatory and antioxidant effects or perhaps a more specific action, by blocking the degradation of antithrombotic proteins. A mechanism involving the action of statins on interactions between risk factors for atherosclerosis and venous thromboembolism is supported by some studies, but not all. In the absence of firm evidence, statins cannot currently be recommended for primary or secondary prevention of venous thromboembolism.

Increased risk and severity of unprovoked venous thromboembolism with clustering cardiovascular risk factors for atherosclerosis: Results of the REMOTEV registry

BACKGROUND The role of cardiovascular risk factors (CVRF) for atherosclerosis in venous thromboembolic disease (VTE) is controversial. The aim of this study was to evaluate the impact of CVRF and their cumulative effects on the occurrence of unprovoked VTE, severity, recurrence and survival. METHODS AND RESULTS This is a prospective cohort from the REMOTEV registry including all consecutively hospitalized patients for acute symptomatic VTE. From November 2013 to December 2016, 515 patients with 6months follow-up (FU) were selected for the analysis. Events were classified as unprovoked or provoked VTE. In univariate analysis, hypertension (OR 1.44, [95% CI 1.01-2.06]), diabetes (OR 2.07, [95% CI: 1.25-3.55]) and age (OR 1.94, [95% CI: 1.31-2.88]) were significantly associated with the risk of unprovoked VTE. After adjustment, diabetes (OR 1.82, [95% CI: 1.07-3.18]) and age (OR 1.79, [95% CI: 1.15-2.8]) remained associated with the risk of unprovoked VTE. The proportion of unprovoked VTE increased significantly with the number of CVRF adjusted for thrombophilia (1 CVRF: OR 3 [95% CI: 1.44-6.52]) 2 CVRF: OR 4.33 [95% CI: 2.07-9.49] and ≥3 CVRF: OR 4.58 [95% CI: 2.27-9.7]). The severity of pulmonary embolism was significantly associated with CVRF clustering. There were more VTE recurrences and deaths during the 6months of FU with cumulative CVRF. CONCLUSION The risks of unprovoked VTE and PE severity are associated with clustering CVRF. The role of cumulative CVRF predominates rather than the specific burden of each of the CVRF in the risk of VTE occurrence.

Promising Results of the Forearm Basilic Fistula Reveal a Worthwhile Option between Radial Cephalic and Brachial Fistula.

BACKGROUND Use of the forearm basilic vein for the creation of an arteriovenous fistula has been codified as second-choice vascular access for hemodialysis in the last clinical guidelines of the Society for Vascular Surgery in 2008. Poor literature data on this technical option and on its evaluation and outcomes led us to initiate a retrospective single-center study. METHODS We analyzed the outcomes of every arteriovenous fistula using the forearm basilic vein created in our department. It is a retrospective study in which we collected data prospectively by contacting dialysis centers, nephrologists, and patients. Primary end point was primary patency rate at 1 year. Secondary end points were secondary patency rate at 1 year, time of maturation, and Doppler flow measurement before the first puncture. RESULTS From February 2004 to June 2014, 49 forearm basilic arteriovenous fistulas were created: 33 ulnar-basilic and 16 radial basilic arteriovenous fistulas. Initial technical success rate was 98%. Functional success rate was 60%. Primary and secondary patency rates at 1 year were respectively 21% and 48%. Median time of maturation was 81 days, and mean Doppler flow measurement was 678 mL/min. Ulnar-basilic fistulas had a statistically significant shorter time of maturation than radial basilic fistulas (P ≤ 0.05). CONCLUSIONS Despite poor primary patency rate and a long time of maturation, forearm basilic arteriovenous fistula has satisfactory secondary patency rate and keeps all the advantages of a distal-located vascular access concerning complications. It is worth its second-choice place in the current algorithm of creation of vascular access for hemodialysis.

Stroke revealing celiac disease associated with multiple arterial thrombotic locations.

La Presse Medicale - In Press.Proof corrected by the author Available online since mercredi 15 avril 2015

Incidence and risk factors of venous thromboembolism: Peculiarities in psychiatric institutions

INTRODUCTION The objectives of this study were to assess the incidence and risk factors for venous thromboembolism (VTE) in a population of patients hospitalized in a psychiatric setting. MATERIAL AND METHODS Episodes of VTE occurring in patients hospitalized at the Erstein Hospital (France), specialized in psychiatry, were retrospectively identified from a computerized database. The clinical, somatic, psychiatric and therapeutic characteristics of each patient were analyzed in comparison with a control population composed of patients of similar age and sex, hospitalized during the same period in a psychiatric setting but who did not suffer from VTE. RESULTS Between January 2012 and October 2015, 12,320 patients were hospitalized. Forty-one patients experienced an episode of VTE, giving an incidence of 47.8per1000patient-years (3.32 cases per 1000 patients). Restriction of mobility (restraint or confinement), somatic clinical profile, psychiatric diagnosis or psychotropic treatment were not associated with an increased risk of VTE. The event occurred within the first 48h of hospitalization for 31.7% of patients, and within the first week for 56.1%. Time to onset for the occurrence of VTE between admission and the end of the first week was significantly associated with acute decompensation of a chronic psychiatric pathology (p=0.003). CONCLUSION The incidence of VTE in a psychiatric setting is high. Acute decompensation of a chronic psychiatric pathology is associated with a risk of VTE.

Turner's syndrome: is there a risk of widespread vascular abnormalities?

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Real-life practices of chronic thromboembolic pulmonary hypertension screening: Results from the REMOTEV observational study

Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare but curable complication of pulmonary embolism (PE) associated with its severity. CTEPH is defined by a mean pulmonary artery pressure (mPAP) 25 mm Hg and a pulmonary capillary wedge pressure (PCWP) <15 mm Hg measured by right heart catheterization (RHC), in the presence of perfusional defects on a ventilation/perfusion (V/Q) scan performed at least 3 months after acute PE. In case of suggestive symptoms, transthoracic echocardiography (TTE) is the first-line procedure allowing the assessment of a probability of CTEPH (low, intermediate and high) according to peak tricuspid regurgitation velocity (TRv) and additional