Venous thromboembolism (VTE) rarely occurs during childhood and, with few exceptions, should be considered as a disease of sick children. Current recommendations concerning the duration of anticoagulant treatment for paediatric VTE are essentially based on the results of clinical trials conducted in adults. Yet the underlying medical conditions, incidence, and anatomical locations of the disease, as well as the rates of unprovoked VTE, morbidity, and mortality, differ between adults and children. Unprovoked VTE is uncommon in childhood. Most children experiencing VTE present risk factors, such as the presence of a central venous catheter (CVC), cancer, chemotherapy (in particular with asparaginase or steroids), obesity, severe infection, congenital cardiopathy (notably in conjunction with hepatic venous stasis), serious trauma, an anatomical venous anomaly (such as atresia or agenesia) or a nephrotic syndrome (inducing a deficit in antithrombin or protein S), premature birth, or maternal combined oral contraception. The recent possibility of administering direct oral anticoagulants (DOAC) to children undoubtedly constitutes the greatest change in the treatment of paediatric VTE. The advantages of this therapy include the possibility of its oral administration, even in infants, the absence of any need for laboratory follow-up, and the lack of food interactions. With the approval of the direct factor Xa inhibitor rivaroxaban (by the European Medicines Agency and Health Canada), and the direct thrombin inhibitor dabigatran (by the European Medicines Agency and the US Food and Drug Administration), paediatric anticoagulant therapy is changing. Only rivaroxaban currently has a Marketing Authorisation in France for the treatment of childhood VTE.
Introduction Venous thromboembolism (VTE) poses a significant challenge in cancer patients, particularly those with advanced malignancies. The management of recurrent VTE is complicated by the need for effective anticoagulation while addressing the underlying cancer progression. Cases We present two clinical cases from the gastroenterology department at Percy French military hospital involving patients with progressive malignant digestive diseases. Patient 1, a 62-year-old woman, developed recurrent pulmonary embolism despite appropriate anticoagulation with low molecular weight heparin (LMWH). After treatment adjustments, she ultimately succumbed to tumor progression. Patient 2, a 54-year-old man hospitalized for pulmonary embolism, faced upper gastrointestinal bleeding and delayed anticoagulation initiation. Although he showed initial improvement with immunotherapy and stabilization of thrombotic events, he experienced oncological progression and recurrent VTE, leading to palliative care. Discussion These cases illustrate the difficulties of managing recurrent VTE, even with curative anticoagulation and dose escalation. In case of VTE recurrence, it is essential to investigate for cancer progression and ensure patient adherence to treatment. A comprehensive management strategy should involve both the malignancy and the thrombotic complications. Conclusion The management of recurrent VTE in cancer patients requires a multidisciplinary approach to evaluate the benefit-risk ratio of anticoagulation adjustments. These clinical cases highlight the necessity for integrated care that addresses both oncological and thrombotic concerns, emphasizing the importance of timely intervention and collaboration among healthcare providers.
Fenestration of the vertebral artery is a rare vascular anatomical variant that can mimic a dissection if discovered during cervical trauma. It is important to diagnose it through computed tomography (CT) angiography or magnetic resonance (MR) angiography in order to best guide the patient's management.
Complication after carotid artery revascularization is mainly represented by stroke. Reversible cerebral vasoconstriction syndrome triggering by carotid artery revascularization is exceptional but it is an unrecognized aetiology of stroke. It could be associated with brain edema and henceforth, a posterior reversible encephalopathy syndrome can be confused with post-carotid artery revascularization cerebral hyperperfusion syndrome. We reported three cases about reversible cerebral vasoconstriction syndrome following revascularization therapy whose one had also a posterior reversible encephalopathy syndrome. This complication occurred within two weeks after carotid artery revascularization. All took nimodipine and all had a functional improvement at 3-months follow-up. Reversible cerebral vasoconstriction syndrome with posterior reversible encephalopathy syndrome after carotid artery revascularization may mimic cerebral hyperperfusion syndrome. After a comprehensive review, nineteen cases of reversible cerebral vasoconstriction syndrome post-carotid artery revascularization have been reported in the literature mainly after symptoms. It occurs mainly in women around sixty years of age. The onset is expected four days after revascularization.
Background Breast cancer-related lymphedema (BCRL) is a chronic complication of breast cancer that requires long-term management. This condition imposes significant disturbance on breast cancer survivors (BCSs) physically, emotionally, and, financially. The purpose of this study was to approach the financial burden of BCRL in Iran. Methods This qualitative study was performed based on the standards for reporting qualitative research (SRQR) guidelines. Semi-structured and in-depth interviews were conducted using a voice recorder. Data analysis was performed based on the content analysis method of Graneheim and Lundman. Nine women with BCRL participated in the study. Results Three major themes were generated based on the captured data: (1) direct costs related to BCRL management, (2) indirect costs imposed by BCRL at work or home, and, (3) benefits of costs which was a great concern of BCSs that how much these costs eventually make their condition better. High costs of garments, lack of insurance coverage, and, difficulties in accessing lymphedema care were among the frequently mentioned problems by BCSs with BCRL. Conclusion The financial burden of BCRL is significant on BCSs in Iran. The establishment of insurance coverage policies, easier access to health services, and, implanting patient-centered measures in evidence-based lymphedema guidelines, could be proper interventions to lower the financial burden of BCRL.
La prise en charge des thromboses veineuses splanchniques, obstruction veineuse portale extrahepatique (OVPEH) et syndrome de Budd-Chiari (SBC), a ete transformee au cours des dix dernieres annees : 1) diagnostic moins invasif grâce aux progres de l’imagerie ; 2) syndromes myeloproliferatifs (SMP), identifies dans 20 a 50 % des cas par la mise en evidence de la mutation JAK2 V617F ; 3) strategies therapeutiques par etape en fonction de la reponse au traitement precedent. La presence d’une affection prothrombotique frequente, comprenant les syndromes myeloproliferatifs, deficit en proteine C ou S, mutation du facteur V Leiden ou du facteur II, et le syndrome des antiphospholipides, necessite une exploration complete, sans oublier la recherche de maladies systemiques ou de causes plus rares associees. L’echographie doppler doit etre effectuee par un operateur experimente, informe de la suspicion diagnostique, pour documenter un obstacle et/ou des collaterales. Les manifestations revelatrices de la thrombose aigue portale associent dans 80 % des cas des douleurs epigastriques a un syndrome inflammatoire marque. En l’absence de diagnostic, un cavernome portal se developpe ; les manifestations cliniques sont alors une hypertension portale et ses complications, des symptomes biliaires secondaires a une compression des voies biliaires par les veines du cavernome ou bien des douleurs et un syndrome inflammatoire en cas de thrombose d’une veine du cavernome. Chez les patients vus au stade precoce de la thrombose recente, un traitement anticoagulant precoce est recommande de meme que la recherche du traitement d’une affection prothrombotique. Le traitement anticoagulant permet la recanalisation de la veine porte dans 30 % des cas et previent la necrose mesenterique chez un grand nombre de patients. Au cours du SBC, la survie a cinq ans des patients traites selon la strategie therapeutique par etapes (anticoagulant, traitement de la cause et repermeabilisation, puis trans-jugular intra-hepatic porto-systemic shunt (TIPS), enfin greffe hepatique), en fonction de la reponse au traitement, est superieure a 80 %.
An accurate diagnosis of lower limb deep vein thrombosis (DVT) recurrence is mandatory. The diagnosis is difficult and has not been well investigated. Our objective was to define the role of clinical probability assessment, D-dimer assay, venous ultrasound and other imaging methods in the diagnosis of this condition based on a review of published data. Our review did not find any clinical prediction rule (CPR) specific to the diagnosis of DVT recurrence. D-dimer assays have not been sufficiently validated or proved effective either alone or when combined with the assessment of clinical probability or with ultrasound. The only validated ultrasound criteria are a new non-compressible vein segment and a≥2mm or>4mm increase in diameter of the common femoral or popliteal vein under compression in the transverse plane between two examinations. Limitations of these criteria include poor inter-observer agreement, non-availability of previous ultrasound reports and measurements, a high percentage of non-diagnostic ultrasound results, lack of power in diagnostic accuracy and diagnostic management studies, and lack of external validation. The analysis of venous obstruction, thrombus appearance, vein diameter and blood flow based on colour Doppler ultrasound criteria has not yet been validated in studies. Magnetic resonance direct thrombus imaging (MRDTI) is a new promising diagnostic imaging method, but is hardly accessible, costly and needs large scale validation studies. Based on this review, an update of the guidance for clinical practice is proposed for the diagnostic management of patients with clinically suspected lower limb DVT recurrence.
Behçet's disease is a systemic vasculitis of unknown origin. It mainly affects young men. Vascular involvement mainly affects the veins and may manifest as deep or superficial thrombosis. Arterial involvement is rare and serious. Arterial thrombosis or aneurysms/false aneurysms can be life threatening in case of rupture. All the arteries in the body can be affected, with widely varying frequencies. Involvement of the renal arteries is very rare. We report the case of a young patient followed for schizophrenia and known to have Behçet's disease, in whom a false aneurysm of the right renal artery was diagnosed during hematuria. He unfortunately refused any type of intervention.
Several aspects of the management of post-thrombotic syndrome (PTS) are still a matter of debate, or not yet addressed in international guidelines. The objective of this expert consensus from the French Society of Vascular Medicine (SFMV) and the French Society of Cardiovascular Imaging (SFICV) was to define the main elements of diagnosis and treatment of this syndrome, and to develop a proposal for its preoperative, procedural and follow-up management. In this consensus, the following issues were addressed: clinical and ultrasound diagnosis; pre-procedural workup; indications and contraindications to venous recanalisation; procedures; clinical and duplex ultrasound reports; follow-up; long-term treatment; management of great saphenous vein incompetency; anticoagulant and antiplatelet therapy after venous stenting.
Obesity is an alarming worldwide public health issue and is defined as a body mass index (BMI) of 30kg/m2 or more. It is considered as a risk factor for first thrombotic event and is associated with a significant risk of recurrence. Consequently, obese patients are often treated by anticoagulant therapy but data from randomised control trial are scarce. We will review in this narrative review the state of the art of the prescription of anticoagulant for the prevention and treatment of venous thromboembolism (VTE) in obese patients.
Plusieurs pistes sont actuellement explorées pour tenter d'améliorer le traitement et le contrôle de l'hypertension artérielle en France et dans le monde, et donc d'en diminuer l'impact. Rappelons que l'hypertension artérielle est le malfaiteur numéro 1 avec plus de 10 millions de décès annuels qui lui sont attribuables. Six pistes sont actuellement explorées en matière d'innovation thérapeutique dans l'hypertension artérielle : 1) les devices pour lesquels une recherche est très active depuis plusieurs années. C'est la dénervation artérielle rénale qui est, en 2024, la plus en pointe sur ces thérapeutiques non médicamenteuses ; néanmoins, il est encore difficile de définir leur place dans le traitement de l'hypertension artérielle ; 2) certains vieux médicaments « reprennent du service », ils ont probablement été insuffisamment évalués par le passé et mériteraient qu'on puisse s'attarder sur leurs propriétés. Même si l'absence de bénéfice financier limitera probablement l'ampleur des études les évaluant. Deux drogues sont actuellement en regain d'intérêt : il s'agit d'épargneurs potassiques, notamment l'amiloride et le triamtérène ; 3) certains médicaments qui ne sont pas référencés comme des antihypertenseurs ont une action antihypertensive et pourraient dans l'avenir jouer un rôle non négligeable dans la prise en charge de l'hypertension artérielle. Les deux médicaments qui répondent à ces propriétés sont le sacubitril et les inhibiteurs des SGLT 2 ; 4) le médicament pour lequel les espoirs sont actuellement les plus forts est la finérénone qui n'a peut-être pas de fortes propriétés antihypertensives, mais qui semble avoir des propriétés néphroprotectrices qui lui confèrent un intérêt majeur et peut-être une prescription large en association avec d'autres antihypertenseurs ; 5) les petits ARN interférents qui ont clairement révolutionné la prise en charge de certaines pathologies rares comme l'amylose héréditaire à la transthyrétine pourraient s'attaquer maintenant à des maladies très fréquentes comme l'hypertension artérielle avec un intérêt majeur en matière d'observance, qui est qu'une injection tous les 6, 12 ou 18 mois « ferait le job » ; 6) enfin, de nombreux experts estiment qu'il faut associer beaucoup plus fréquemment et beaucoup plus largement les antihypertenseurs. Il n'est pas exclu qu'une telle utilisation de vieilles molécules qui ont fait leurs preuves corresponde finalement au plus grand espoir thérapeutique dans l'hypertension artérielle.
Superficial vein thrombosis (SVT), a manifestation of venous thromboembolism (VTE), is a common condition, yet of all the types of VTE, it has been the least well studied. Recent studies have challenged the conception that SVT is a benign disease, showing that its risk factors overlap with those of deep-vein thrombosis (DVT) and that it is frequently associated with DVT or pulmonary embolism (PE). In 2010, the CALISTO trial demonstrated the benefit of treatment with fondaparinux at the dose of 2.5mg (one injection per day) for 45days for lower limb SVT. Prior to CALISTO, the treatment of SVT was based on venous compression therapy, nonsteroidal anti-inflammatory drugs (NSAID) and anticoagulation using various therapeutic regimens. Surgery could also be envisaged in certain cases. In CALISTO, the inclusion criteria designed to obtain a homogeneous population meant that numerous questions remained unanswered with respect to SVT occurring in other locations and under other circumstances, notably in pregnant women, patients with renal insufficiency, and patients with recurrent SVT or superficial vein thrombosis less than 5cm long. The aim of this section is to review the current state of knowledge of SVT and to propose or recommend therapeutic strategies for the management of SVT according to the clinical context, the location of the thrombosis, and the presence of particular risk factors.
Venous leg ulcer refers to chronic wounds, generally difficult to heal and often prone to recurrence. The objective of this research was to assess a double layered compression stocking VenoTrain® ulcertec on a population with mostly severe pathologies. This prospective, multicenter, interventional type II study was conducted between September 2018 and January 2022. Out of 124 patients enrolled, 97.6% had a history of previous leg ulceration, 72.6% were already being followed for leg ulcerations, 30.9% were severely overweight and 24.2% diabetic. Overall, a majority of target ulcers were present for 6months or more, and the ulcer surface area was larger than 8cm2 in nearly one in every five cases. The primary endpoint was the rate of closed ulcer after a maximum follow-up of 20weeks. While most of the treated venous leg ulcerations may be regarded as hard-to-heal wounds, closure rate at 20weeks ranged between 50.0% (two severity criteria) and 69.0% (no severity criteria) according to baseline wound severity criteria. Besides, VenoTrain® ulcertec device was particularly well accepted and tolerated by patients. In 93.2% of visits, patients stated using it every day. When managing venous ulcerations not requiring strongly thick absorbent dressings, VenoTrain® ulcertec device represents an efficient and more suitable alternative to venous compression bandaging.
