Thomas Baldi

Contrast-enhanced ultrasound for assessing carotid atherosclerotic plaque lesions

OBJECTIVE Contrast-enhanced ultrasound that is used to assess atherosclerotic carotid plaques improves visualization of vessel wall irregularities and provides direct visualization of intraplaque neovascularization. This article illustrates the use of contrast-enhanced ultrasound in the assessment of carotid atherosclerotic lesions. CONCLUSION Contrast-enhanced ultrasound is a new, noninvasive, and safe procedure for imaging carotid atherosclerotic lesions. It is a valuable tool for evaluating the vulnerable plaque at risk for rupture and for evaluating both the development and severity of systemic atherosclerotic disease.

Long-term anticoagulation treatment for acute venous thromboembolism in patients with and without cancer The SWIss Venous ThromboEmbolism Registry (SWIVTER) II

In patients with acute cancer-associated thrombosis, current consensus guidelines recommend anticoagulation therapy for an indefinite duration or until the cancer is resolved. Among 1,247 patients with acute venous thromboembolism (VTE) enrolled in the prospective Swiss Venous Thromboembolism Registry (SWIVTER) II from 18 hospitals, 315 (25%) had cancer of whom 179 (57%) had metastatic disease, 159 (50%) ongoing or recent chemotherapy, 83 (26%) prior cancer surgery, and 63 (20%) recurrent VTE. Long-term anticoagulation treatment for >12 months was more often planned in patients with versus without cancer (47% vs. 19%; p<0.001), with recurrent cancer-associated versus first cancer-associated VTE (70% vs. 41%; p<0.001), and with metastatic versus non-metastatic cancer (59% vs. 31%; p<0.001). In patients with cancer, recurrent VTE (OR 3.46; 95%CI 1.83-6.53), metastatic disease (OR 3.04; 95%CI 1.86-4.97), and the absence of an acute infection (OR 3.55; 95%CI 1.65-7.65) were independently associated with the intention to maintain anticoagulation for >12 months. In conclusion, long-term anticoagulation treatment for more than 12 months was planned in less than half of the cancer patients with acute VTE. The low rates of long-term anticoagulation in cancer patients with a first episode of VTE and in patients with non-metastatic cancer require particular attention.

Cardiac troponin testing and the simplified Pulmonary Embolism Severity Index : The SWIss Venous ThromboEmbolism Registry (SWIVTER)

A low simplified Pulmonary Embolism Severity Index (sPESI), defined as age ≤80 years and absence of systemic hypotension, tachycardia, hypoxia, cancer, heart failure, and lung disease, identifies low-risk patients with acute pulmonary embolism (PE). It is unknown whether cardiac troponin testing improves the prediction of clinical outcomes if the sPESI is not low. In the prospective Swiss Venous Thromboembolism Registry, 369 patients with acute PE and a troponin test (conventional troponin T or I, highly sensitive troponin T) were enrolled from 18 hospitals. A positive test result was defined as a troponin level above the manufacturers assay threshold. Among the 106 (29%) patients with low sPESI, the rate of mortality or PE recurrence at 30 days was 1.0%. Among the 263 (71%) patients with high sPESI, 177 (67%) were troponin-negative and 86 (33%) troponin-positive; the rate of mortality or PE recurrence at 30 days was 4.6% vs. 12.8% (p=0.015), respectively. Overall, risk assessment with a troponin test (hazard ratio [HR] 3.39, 95% confidence interval [CI] 1.38-8.37; p=0.008) maintained its prognostic value for mortality or PE recurrence when adjusted for sPESI (HR 5.80, 95%CI 0.76-44.10; p=0.09). The combination of sPESI with a troponin test resulted in a greater area under the receiver-operating characteristic curve (HR 0.72, 95% CI 0.63-0.81) than sPESI alone (HR 0.63, 95% CI 0.57-0.68) (p=0.023). In conclusion, although cardiac troponin testing may not be required in patients with a low sPESI, it adds prognostic value for early death and recurrence for patients with a high sPESI.

Predictors of in-hospital mortality in elderly patients with acute venous thrombo-embolism: the SWIss Venous ThromboEmbolism Registry (SWIVTER)

AIMS Although acute venous thrombo-embolism (VTE) often afflicts patients with advanced age, the predictors of in-hospital mortality for elderly VTE patients are unknown. METHODS AND RESULTS Among 1247 consecutive patients with acute VTE from the prospective SWIss Venous ThromboEmbolism Registry (SWIVTER), 644 (52%) were elderly (≥65 years of age). In comparison to younger patients, the elderly more often had pulmonary embolism (PE) (60 vs. 42%; P< 0.001), cancer (30 vs. 20%; P< 0.001), chronic lung disease (14 vs. 8%; P= 0.001), and congestive heart failure (12 vs. 2%; P< 0.001). Elderly VTE patients were more often hospitalized (75 vs. 52%; P< 0.001), and there was no difference in the use of thrombolysis, catheter intervention, or surgical embolectomy between the elderly and younger PE patients (5 vs. 6%; P= 0.54), despite a trend towards a higher rate of massive PE in the elderly (8 vs. 4%; P= 0.07). The overall in-hospital mortality rate was 6.6% in the elderly vs. 3.2% in the younger VTE patients (P= 0.033). Cancer was associated with in-hospital death both in the elderly [hazard ratio (HR) 4.91, 95% confidence interval (CI) 2.32-10.38; P< 0.001] and in the younger patients (HR 4.90, 95% CI 1.37-17.59; P= 0.015); massive PE was a predictor of in-hospital death in the elderly only (HR 3.77, 95% CI 1.63-8.74; P= 0.002). CONCLUSION Elderly patients had more serious VTE than younger patients, and massive PE was particularly life-threatening in the elderly.

Rivaroxaban for the treatment of venous thromboembolism: The SWIss Venous ThromboEmbolism Registry (SWIVTER)

We investigated three-month clinical outcomes in patients with venous thromboembolism (VTE) treated with rivaroxaban or conventional anticoagulation in routine clinical practice. Between November 2012 and February 2015, 2,062 consecutive patients with VTE from 11 acute care hospitals in Switzerland were enrolled in the SWIss Venous ThromboEmbolism Registry (SWIVTER). Overall, 417 (20 %) patients were treated with rivaroxaban. In comparison to 1,645 patients on conventional anticoagulation, patients on rivaroxaban were younger (56 ± 18 vs. 65 ± 17 years; p<0.001), less often had pulmonary embolism (38 % vs 66 %; p<0.001), hypertension (26 % vs 41 %; p<0.001), cancer (10 % vs 28 %; p<0.001), congestive heart failure (10 % vs 17 %; p=0.001), diabetes (8 % vs 15 %; p<0.001), chronic lung disease (7 % vs 13 %; p=0.001), renal insufficiency (7 % vs 13 %; p=0.001), recent surgery (7 % vs 14 %; p<0.001), and acute coronary syndrome (1 % vs 4 %; p=0.009). VTE reperfusion therapy was more frequently used (28 % vs 9 %; p<0.001) and indefinite-duration anticoagulation treatment less often planned (26 % vs 39 %; p<0.001), respectively. In the propensity score-adjusted population, the risk of recurrent VTE was similar in patients on rivaroxaban vs conventional anticoagulation (1.2 % vs 2.1 %, hazard ratio [HR] 0.55, 95 % confidence interval [CI] 0.18-1.65; p=0.29); the risk of major bleeding was also similar, respectively (0.5 % vs 0.5 %, HR 1.00, 95 %CI 0.14-7.07; p=1.00). Conventional anticoagulation is still frequently used for the treatment of VTE, particularly in the elderly and those with comorbidities. Early clinical outcomes were comparable between propensity score-adjusted patient populations on rivaroxaban and conventional anticoagulation.

Outpatient management of acute deep vein thrombosis: results from the OTIS-DVT registry.

OBJECTIVES We aimed to investigate clinical practice patterns for the outpatient management of acute deep vein thrombosis (DVT). METHODS In the prospective Outpatient Treatment of Deep Vein Thrombosis in Switzerland (OTIS-DVT) registry, 534 consecutive outpatients with acute DVT (49% proximal, 24% recurrent, and 12% cancer-associated) were enrolled: 41% patients were managed in private angiology practice, 34% in an outpatient hospital department, and 25% in private general or internal medicine practice. RESULTS For diagnosis, ultrasound was used in 95% and D-dimer testing in 53%. Low-molecular-weight heparin (LMWH) was prescribed for a median (IQR) duration of 7 (5-12) days in 83% of patients, and vitamin K-antagonists for 163 (92-183) days in 81%. Mechanical measures to prevent post-thrombotic syndrome were prescribed in 83%; compression stockings or bandages for a median (IQR) duration of 364 (101-730) days from hospital physicians, and 92 (45-183) days from private practice physicians (p < 0.001). Among patients with symptomatic proximal DVT, mechanical measures were prescribed for at least 2 years in 24% patients; 55% in hospital, and 6% in private practice (p < 0.001). Among patients with cancer-associated DVT, the median (IQR) duration of LMWH therapy was 16 (8-45) days, and 35% received LMWH for less than 90 days. CONCLUSIONS The OTIS-DVT registry provides representative information on clinical practice patterns for outpatients with acute DVT managed by hospital or private practice physicians. The use of mechanical measures in patients with symptomatic proximal DVT and the administration of LMWH for a long-term therapy of cancer-associated DVT require improvement to comply with current guidelines.

Assessment of microcirculation by contrast-enhanced ultrasound: a new approach in vascular medicine

Contrast-enhanced ultrasound (CEUS) has emerged as a valuable imaging modality that complements and enhances standard vascular ultrasound imaging. Ultrasound contrast agents are gas-filled microbubbles that are injected intravenously and serve as intravascular tracers. Based on the properties to enhance and to quantify the macro- and microcirculation down to the capillary perfusion level in different vascular territories and organs, CEUS imaging has the potential to improve the diagnostic performance in the detection and characterisation of various vascular disorders reviewed in this article. In carotid atherosclerotic disease, CEUS imaging provides additional information on plaque vulnerability by illustrating the presence and extent of intraplaque neovascularisation. This new imaging modality may be helpful for further risk stratification of arteriosclerotic lesions and for detecting patients at risk for vascular events, eventually leading to more specific individually tailored therapeutic recommendations. CEUS imaging is also a helpful tool for the diagnosis and for monitoring of inflammatory vascular diseases. It increases the diagnostic performance of ultrasound in detecting inflammatory changes of the vessel wall such as hypervascularisation and hyperaemia. Changes in vessel wall enhancement may also reflect the response to anti-inflammatory therapy. Moreover, CEUS imaging is also a valuable tool for the assessment of the microcirculation and the tissue perfusion in solid organs including native and transplanted kidneys. The technique provides more accurate information on perfusion deficits of the parenchyma in patients with kidney infarction, necrosis or graft dysfunction. CEUS also has great potential in the assessment of the microcirculation of the skeletal muscle, particularly in patients with peripheral artery disease or diabetic microangiopathy. In the future, the use of targeted on site microbubbles could further enhance and expand the diagnostic capabilities of current vascular ultrasound by assessing specific molecular processes that play a role in the pathophysiology of vascular diseases. Furthermore, ultrasound-directed, site-specific drug and gene delivery using microbubble contrast agents could gain great clinical value in the future. The combination of CEUS for diagnosis and therapy will provide unique opportunities for vascular clinicians to image the microcirculation and directly treat vascular diseases.

Inconsistencies in the planning of the duration of anticoagulation among outpatients with acute deep-vein thrombosis. Results from the OTIS-DVT Registry.

Three-month anticoagulation is recommended to treat provoked or first distal deep-vein thrombosis (DVT), and indefinite-duration anticoagulation should be considered for patients with unprovoked proximal, unprovoked recurrent, or cancer-associated DVT. In the prospective Outpatient Treatment of Deep Vein Thrombosis in Switzerland (OTIS-DVT) Registry of 502 patients with acute objectively confirmed lower extremity DVT (59% provoked or first distal DVT; 41% unprovoked proximal, unprovoked recurrent, or cancer-associated DVT) from 53 private practices and 11 hospitals, we investigated the planned duration of anticoagulation at the time of treatment initiation. The decision to administer limited-duration anticoagulation therapy was made in 343 (68%) patients with a median duration of 107 (interquartile range 91-182) days for provoked or first distal DVT, and 182 (interquartile range 111-184) days for unprovoked proximal, unprovoked recurrent, or cancer-associated DVT. Among patients with provoked or first distal DVT, anticoagulation was recommended for < 3 months in 11%, ≥ 3 months in 63%, and for an indefinite period in 26%. Among patients with unprovoked proximal, unprovoked recurrent, or cancer-associated DVT, anticoagulation was recommended for < 6 months in 22%, 6-12 months in 38%, and for an indefinite period in 40%. Overall, there was more frequent planning of indefinite-duration therapy from hospital physicians as compared with private practice physicians (39% vs. 28%; p=0.019). Considerable inconsistency in planning the duration of anticoagulation therapy mandates an improvement in risk stratification of outpatients with acute DVT.

The Modified Ottawa Score and Clinical Events in Hospitalized Patients with Cancer-Associated Thrombosis from the Swiss VTE Registry.

Abstract The modified Ottawa score (MOS) predicted venous thromboembolism (VTE) recurrence in a cohort of patients with cancer‐associated thrombosis mainly managed on an outpatient basis. We aimed to assess the prognostic value of the MOS in hospitalized patients with cancer‐associated thrombosis. In 383 hospitalized patients with cancer‐associated VTE from the SWIss VTE Registry, 98 (25%) were classified as low risk, 175 (46%) as intermediate risk, and 110 (29%) as high risk for VTE recurrence based on the MOS. Clinical end points were recurrent VTE, fatal VTE, major bleeding, and overall mortality at 90 days. Overall, 179 (47%) patients were female, 172 (45%) had metastatic disease, and 72 (19%) prior VTE. The primary site of cancer was lung in 48 (13%) patients and breast in 43 (11%). According to the MOS, the rate of VTE recurrence was 4.1% for low, 6.3% intermediate, and 5.5% high risk (p = 0.75); the rate of fatal VTE was 0.8, 1.9, and 2.0% (p = 0.69); the rate of major bleeding was 3.1, 4.1, and 3.6% (p = 0.92); and the rate of death was 6.1, 12.0, and 28.2% (p < 0.001), respectively. None of the MOS items was associated with VTE recurrence: female gender hazard ratio (HR) 1.26 (95% confidence interval [CI], 0.53‐2.96), lung cancer HR 1.17 (95% CI, 0.35‐3.98), prior VTE HR 0.44 (95% CI, 0.10‐1.91), breast cancer HR 0.83 (95% CI, 0.19‐3.58), and absence of metastases HR 0.74 (95% CI, 0.31‐1.74). In hospitalized patients with cancer‐associated VTE, the MOS failed to predict VTE recurrence at 3 months but was associated with early mortality.

Evaluation of Varicose Veins of the Lower Extremity: the Value of the Duplex Ultrasound (Part 1).

Correspondence Dr. Luca Spinedi Abteilung für Angiologie, Universitätsspital Basel Petersgraben 4 4031 Basel Switzerland Tel.: ++ 41/4176/3 6670 96 Fax: ++ 41/4161/2 6553 56 Luca.Spinedi@usb.ch Learning objectives ▼ ▶Basic knowledge of the physiology, pathophysiology, classification, and epidemiology of chronic venous disease ▶Basic knowledge of the anatomy of the venous system in the lower extremities ▶Duplex ultrasound criteria for diagnosing varicosis