Das Risiko einer Embolisation, ausgehend von einer Karotisstenose, ist nicht nur abhängig vom Grad der Stenosierung, sondern auch von der Zusammensetzung der entsprechenden arteriosklerotischen Plaque. Insbesondere das Vorliegen von Ulzerationen, die Inflammation, die dünne fibröse Kappe, der große nekrotische Lipidkern sowie die Vaskularisation innerhalb der Plaque, ausgehend von Vasa vasorum und assoziierten Intraplaque-Hämorrhagien, sind Zeichen einer solchen vulnerablen arteriosklerotischen Läsion.

p=0.3).The median SUVmax was 3.0 [1.8-8.6]without significative difference between GCA and TA: 3.4 (2.1-8.6)versus 2.6 (1.8-7.1)(p=0.4),respectively.Eleven PET (61%) were performed under treatment, which consisted of steroids with a median dose at 30 mg/day [3-240].Among 11 patients with active disease, 8 had inflammatory patterns and 3 had normal PET/MR, i.e a sensibility of 73%, and the sensibility increased to 100% in patients with active TA disease.Median SUVmax were 4.7 [2.1-8.6] in patients with active disease versus 2 [1.8-2.6] in patients with remission (p=0.003).Conclusions: PET/MR is a new hybrid modality of imaging which is interesting for the diagnosis and the follow-up of large-vessel vasculitis.

Über die letzten Jahre hat die Wichtigkeit der Bildgebung bei der Frage nach Vorliegen einer Großgefäßvaskulitis massiv zugenommen. Der Ultraschall hat trotz gewisser Limitationen (z. B. fehlende Beurteilbarkeit der thorakalen Aorta) dank der raschen Verfügbarkeit, fehlender Strahlenbelastung, aber auch wegen seiner im Vergleich geringen Kosten einen nicht mehr wegzudenkenden Platz im Abklärungsalgorithmus.

Background Ultrasound (US) is a cornerstone in the diagnosis of GCA. Only limited data on how US documented large vessel wall thickening changes during treatment is available. Objectives To assess arterial vessel wall findings by US during long term follow-up in GCA patients with large vessel vasculitis (LVV) and to correlate findings with the disease course Methods Patients with GCA and US defined LV vasculitis were scheduled semiannually for clinical and laboratory assessment as well as US of the temporal (TA), vertebral (VA), carotid (common, internal, external), subclavian (SA), axillary (AXA), deep (DFA), superficial (SFA) and common (CFA) femoral, and popliteal arteries (PA). US findings were classified as normal, moderate or marked vessel wall thickening. Results From 42 patients (16 male) with a median age of 75 years at diagnosis 28 had typical vessel wall thickening in the temporal artery and in at least one LV segment and 14 in the LV only. The following vessels (marked/moderate) were most often involved: PA in 11/21, SFA in 13/20, AxA in 14/5, SA in 8/13 patients respectively. A reduction of the vessel wall thickening in the temporal artery during follow-up was found in 79% of patients after in median 7 months, with bilateral normalisation in 10 patients after in median 13 months. In contrast 55% had no, 43% a partial and only one patient a complete reduction of thickening of all LV walls during follow-up. From initially marked supra-aortic LV segments 35% were moderate and 16% normal and from initially moderate LV 13% were normal at 1 year FU. From initially marked infra-aortic LV segments 36% were moderate and 3% normal and from initially moderate 10% were normal at 1 year FU. Progression of vessel wall thickening in the LV during FU was seen in a total of 3 patients, in 2 of those, a clinical relapse of GCA was diagnosed one respectively 2 months before US. There was no difference between patients with reduction of the vessel wall thickening and without during follow-up in respect to clinical parameters (relapse rate over the observation time, cumulative steroid dose after one year). Conclusions Regression of US morphological documented thickening of LV in patients with GCA is rare despite clinical remission. US remains sensitive for the diagnosis of LVV long after treatment initiation. Most plasticity is seen in the TA and more rarely in the supra-aortic segments. Disclosure of Interest None declared

Poplitealaneurysmen sind mit Abstand die häufigsten peripheren Aneurysmen. Endovaskuläre Therapieformen ersetzen auch bei den Poplitealaneurysmen zunehmend die offene Operation. Wir beschreiben einen Patienten mit ungünstigem Verlauf nach endovaskulärer Versorgung eines Poplitealaneurysmas.

Die Varikose mit ihren klinischen teils relevanten Auswirkungen ist vor allem in den Industrienationen weit verbreitet. Neben der Anamnese und der klinischen Untersuchung stellt die Duplexsonografie die Bildgebung der Wahl bei der Beurteilung der Varikose der unteren Extremitäten dar. Neben ihrer diagnostischen Zuverlässigkeit ist sie, im Vergleich zu anderen Formen, der Bildgebung kostengünstig, nicht invasiv, nebenwirkungsfrei [1] und ermöglicht nicht zuletzt die Mitbeurteilung der perivaskulären Umgebung. Die Duplexsonografie erlaubt eine systematische und in der Regel abschließende Beurteilung der relevanten anatomischen und funktionellen Aspekte des Venenleidens und ist wegweisend bei der Entscheidung bezüglich des Therapieplans. In den letzten Jahren wurden Anstrengungen unternommen, Untersuchung und Interpretation in der Abklärung der Varikose zu standardisieren. Hier sind insbesondere die Konsensusempfehlungen der Union Internationale de Phlébologie (UIP) bezüglich der Nomenklatur [2] und der duplexsonografischen Methodik [3] zu erwähnen.

Essentials The long-term effects of VKORC1 and CYP2C9 variants on clinical outcomes remains unclear. We followed 774 patients ≥65 years with venous thromboembolism for a median duration of 30 months. Patients with CYP2C9 variants are at increased risk of death and non-major bleeding. Patients with genetic variants have a slightly lower anticoagulation quality only. SUMMARY:Background The long-term effect of polymorphisms of the vitamin K-epoxide reductase (VKORC1) and the cytochrome P450 enzyme gene (CYP2C9) on clinical outcomes remains unclear. Objectives We examined the association between CYP2C9/VKORC1 variants and long-term clinical outcomes in a prospective cohort study of elderly patients treated with vitamin K antagonists for venous thromboembolism (VTE). Methods We followed 774 consecutive patients aged ≥ 65 years with acute VTE from nine Swiss hospitals for a median duration of 30 months. The median duration of initial anticoagulant treatment was 9.4 months. The primary outcome was the time to any clinical event (i.e. the composite endpoint of overall mortality, major and non-major bleeding, and recurrent VTE. Results Overall, 604 (78%) patients had a CYP2C9 or VKORC1 variant. Three hundred and thirty-four patients (43.2%) had any clinical event, 119 (15.4%) died, 100 (12.9%) had major and 167 (21.6%) non-major bleeding, and 100 had (12.9%) recurrent VTE. After adjustment, CYP2C9 (but not VKORC1) variants were associated with any clinical event (hazard ratio [HR], 1.34; 95% confidence interval [CI], 1.08-1.66), death (HR, 1.74; 95% CI, 1.19-2.52) and clinically relevant non-major bleeding (sub-hazard ratio [SHR], 1.39; 95% CI, 1.02-1.89), but not with major bleeding (SHR, 1.03; 95% CI, 0.69-1.55) or recurrent VTE (SHR, 0.95; 95% CI, 0.62-1.44). Patients with genetic variants had a slightly lower anticoagulation quality. Conclusions CYP2C9 was associated with long-term overall mortality and non-major bleeding. Although genetic variants were associated with a slightly lower anticoagulation quality, there was no relationship between genetic variants and major bleeding or VTE recurrence.

Basic knowledge of the physiology, pathophysiology, classification, and epidemiology of chronic venous disease

Background Venous thromboembolism (VTE) and subclinical thyroid dysfunction (SCTD) are both common in elderly patients. SCTD has been related to a hypercoagulable state and an increased thromboembolic risk. However, prospective data on the relationship between SCTD and VTE are lacking.Objectives To investigate the relationship between SCTD and recurrent VTE (rVTE), all-cause mortality, and thrombophilic biomarkers.Patients Elderly patients with VTE were studied.Methods In a prospective multicenter cohort, thyroid hormones and thrombophilic biomarkers were measured 1 year after acute VTE, as both may be influenced by acute thrombosis. We defined subclinical hypothyroidism (SHypo) as elevated thyroid-stimulating hormone (TSH) levels (4.50-19.99 mIU L-1), and subclinical hyperthyroidism (SHyper) as TSH levels of < 0.45 mIU L-1, both with normal free thyroxine levels. Outcomes were incidence of rVTE and overall mortality during follow-up starting after the 1-year blood sampling.Results Of 561 participants (58% with anticoagulation), 6% had SHypo and 5% had SHyper. After 20.8 months of mean follow-up, 9% developed rVTE and 10% died. The rVTE incidence rate was 7.2 (95% confidence interval [CI] 2.7-19.2) per 100 patient-years in SHypo participants, 0.0 (95% CI 0.0-7.6) in SHyper participants, and 5.9 (95% CI 4.4-7.8) in euthyroid participants. In multivariate analyses, the sub-hazard ratio for rVTE was 0.00 (95% CI 0.00-0.58) in SHyper participants and 1.50 (95% CI 0.52-4.34) in SHypo participants as compared with euthyroid participants, without increased levels of thrombophilic biomarkers. SHyper (hazard ratio [HR] 0.80, 95% CI 0.23-2.81) and SHypo (HR 0.99, 95% CI 0.30-3.29) were not associated with mortality.Conclusion In elderly patients, SHyper may be associated with lower rVTE risks. SHypo showed a non-statistically significant pattern of an association with rVTE, without increased mortality or differences in thrombophilic biomarkers.

OBJECTIVES To compare the diagnostic performance between a vascular specialist and a rheumatologist not familiar with vascular ultrasound when applying the compression sign for the diagnosis of temporal arteritis. METHODS Sixty consecutive patients with suspicion of giant cell arteritis were examined by both examiners. Compression of the temporal artery on both sides (stem and both branches) was performed to define whether signs of vasculitis, no vasculitis or an indefinite result were present. Each examiner was blinded to the result of the other. RESULTS In 59/60 patients, the examiners found an identical result. The interobserver agreement (Krippendorf alpha) was 0.92. CONCLUSIONS The new compression sign for the diagnosis of temporal arteritis is a simple and robust sonographic marker with an excellent interobserver agreement.

Drug Prescribing for Patients with Chronic Kidney Disease in General Practice: a Cross-Sectional Study

The authors (Christina Jeanneret, Markus Aschwanden and Daniel Staub) would like to highlight the following correction to their review article, DOI: 10.1177/0268355514529212. The review was printed in Phlebology 2014; 29(1S): 71–77. The authors would like to apologise for any inconvenience the change will cause.

Background. Jehovah's Witnesses (JW) refuse to receive blood products due to their religious beliefs. Bloodless transplantation programs have made the successful transplantation of solid organs like heart, liver, kidney, and pancreas in JW feasible. In this study we present the third and fourth case of a successful bloodless lung transplantation and analyze perioperative parameters and outcome with a strictly selected matched control group (CG).Methods. Two JW patients suffering from idiopathic pulmonary fibrosis had single lung transplantation in the transfusion-free program. Ten of 113 patients (8.8%) undergoing lung transplantation fulfilled the matching criteria and served as CO. Perioperative parameters including blood loss and transfusions were collected from the charts. Regarding outcome parameters arterial blood gas, lung function testing, length of stay, and survival were analyzed.Results. Concerning perioperative parameters no significant differences could be found between both groups except for the creatinine level, which was significantly lower in the JW group on postoperative day 0 (P = .037), and the hemoglobin and hematocrit levels, which were significantly higher in the JW group on postoperative day 3 (P = .032 and P = .041, respectively). The analysis of the outcome parameters revealed significantly higher postoperative lung functional testing values forced expiratory volume after 1 second (FEV1) and forced vital capacity (FVC) in the JW group compared with the CO (P = .037 and P = .036, respectively).Conclusion. Bloodless lung transplantation is feasible in carefully selected JW recipients. Comparing JW to CG, no statistically significant difference in the perioperative course and a trend towards a favorable postoperative lung function outcome were detected.

PURPOSE:To prospectively evaluate the accuracy of noninvasive central venous pressure (CVP) assessment by compression ultrasound of a forearm vein (CUS), inferior vena cava (IVC-C) and internal jugular vein collapsibility (IJV-C) compared to invasive CVP measurement (invCVP) as the gold standard. MATERIALS AND METHODS:CUS, IVC-C and IJV-C were performed in a random sequence in 81 consecutive intensive care patients with simultaneous invCVP monitoring. Examiners were blinded to invCVP and previous examinations. RESULTS:Median invCVP was 12.0 mmHg (range 1 - 23). CUS, IVC-C and IJV-C could be obtained in 89 %, 95 % and 100 % of cases, respectively, within a median time of 188 sec [IQR 125; 270], 133 sec [IQR 100; 211] and 60 sec [IQR 50; 109], respectively. The Spearman correlation coefficient between invCVP and CUS, IVC-C, and IJV-C was 0.485 95 %-CI [0.25; 0.65], -0.186 [-0.42; 0.07], and -0.408 [-0.59; -0.18], respectively. The median absolute difference between CUS and invCVP was 3 mmHg [IQR 2; 6.75]. CVP was categorized as low (< 7 mmHg; collapsibility > 0.6), normal (7 - 12 mmHg; collapsibility 0.6 - 0.2) and high (> 12 mmHg; collapsibility < 0.2) as prespecified. The proportions of identical CVP classifications compared to invCVP were 61.4% 95%-CI [49.3%; 72.4%] with CUS, 48.7% [37.4%; 60%] with IVC-C and 51.3% [40.3%; 62.3%] with IJV-C (p > 0.10 for all pair-wise comparisons). CONCLUSION:The overall ability of CUS, IVC-C and IJV-C to assess invCVP was only moderate. CUS seems to be the preferable method if absolute CVP values are needed. IJV-C seems to be the fastest and most easily acquirable method, and thus may be especially valuable in emergency rooms.

Abstract Purpose: In patients with suspected giant cell arteritis (GCA), a search for the perivascular halo sign, a sophisticated color duplex ultrasound (CDU) finding, at experienced centers reliably identifies inflamed temporal arteries (TA). We tested whether TA compression in patients with GCA, a simple, largely operator-independent maneuver, elicits contrasting echogenicity between the diseased artery wall and the surrounding tissue (compression sign). Materials and Methods: 80 individuals with suspected GCA were prospectively enrolled in this single-center study. In all study participants, bilateral ultrasound examination of the TA established the presence/absence of the halo and compression sign. A positive compression sign was defined as visibility of the TA upon transducer-imposed compression of the artery. Based on ACR criteria, a team of specialized physicians independently grouped patients as GCA versus non-GCA. Results: 43/80 study participants were grouped as GCA. Both the halo sign and the compression sign were positive in 34/43 patients in the GCA group, and negative in all 37/37 of the non-GCA group, resulting in a sensitivity of 79 % and a specificity of 100 % for both the halo and the compression sign. Conclusion: In this cohort of individuals with suspected GCA, the halo sign and the compression sign were equal in their diagnostic performance. The simplicity of the compression sign suggests a level of reliability warranting further evaluation.

Idiopathic retroperitoneal fibrosis and inflammatory abdominal aortic aneurysms share a similar pathogenesis and can therefore be included under the umbrella term chronic periaortitis (CP). The underlying autoimmune or inflammatory process involves typically the abdominal aorta and the proximal part of the iliac arteries, and might encase adjacent structures leading to clinically relevant obstructions. The idiopathic form of retroperitoneal fibrosis is a rare disease typically affecting men with a mean age between 50 and 60 years and accounts for approximately two-thirds of cases. The remaining secondary forms are attributable to other factors such as neoplasms, infections, drugs, and trauma. Diagnosis of CP is usually suggested by ultrasound and will be confirmed by other cross-sectional imaging modalities including computer tomography (CT) and magnetic resonance imaging (MRI). CT- or MRI-contrast-enhancement is a typical finding supporting the diagnosis of CP by demonstrating the hypervascularized inflammatory tissue surrounding the aortic lumen and to monitor the response to anti-inflammatory and immunosuppressive therapy. In this case report we assessed the utility of CEUS in CP for initial diagnosis and for follow-up after steroid treatment.