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rue Saint Pierre, France

Endovenous laser ablation has become a very popular technique in the treatment of saphenous vein reflux. Even if this treatment obtains high occlusion rates, still some side-effects can be expected. Certain problems such as postoperative ecchymosis, bruising and pain jeopardise the recovery. In the past ten years, the endovenous technique evolved quickly and became more performant. Adaptions in protocol, energy use, laser wavelength and new fibres was been proposed. These in order to prevent some of the known complications. First there has been a switch from the use of lower wavelength lasers to higher wavelength lasers. The emitted light energy of lower wavelength lasers (810, 940, 980 nm) is less specific absorbed by their chromophores (hemoglobin, water, proteins)compared to higher wavelength lasers (1320,1470,1500nm). The clinical use of higher wavelength lasers should result in equal occlusion rates and less postoperative pain. Unfortunally there is only one trial comparing the use of lower versus higher wavelength lasers. Also most studies publishing results of the use of higher wavelengths report the use of lower energy deposits compared to the use of lower wavelength lasers. This makes it difficult to make any conclusions regarding the post procedural sequelae. In our opinion most of the side-effects of EVLA are due to the use of a bare fibre. The direct contact between the 'bare' fiber-tip and the vein wall causes a very uneven energy distribution to the vein wall. This results in a destruction and ulceration or perforation of the vein while other parts of the vein wall are unaffected. The resulting uneven application of energy may be the cause of some of the complications of EVLA, such as postoperative ecchymosis, inflammation around the treated vein and pain. In order to have a more even energy distribution to the vein wall, several new fibre designs have been developed. First the "Tulip-tip" was developed to eliminate contact of the tip from the vein wall by means of geometric constraints. The 'Tulip-like petals act as an elastic resistance against the vein wall and center the fiber-tip intraluminal. A histological study showed that avoiding the direct contact between the fibre tip and the vein wall, and centring the fibre tip intraluminally, results in a more homogeneous vein wall destruction, fewer vein wall perforations and less perivenous tissue destruction. The "NeverTouch™ fiber" is similar to the bare fiber except a tube with a lens has been placed over the distal tip. This causes the light to be more divergent thus lowering the energy density. The claim is that it diffuses the energy over a 2.2x larger area, causing a 56% lower energy density. Finally the "Radial tip", is a quartz tip with a cone shape inside in order to reflect the laser light in a radial direction and broaden the area. In some studies it has been shown that the use of those new fibers results in less side-effects, such as less postoperative ecchymosis, bruising and pain. However, for most new fibre-types, there still is a lack of randomized comparative clinical trials necessary to make any final conclusion. Source

Legout L.,Coty | D'Elia P.V.,Center hospitalier Dron | Sarraz-Bournet B.,Center hospitalier Dron | Haulon S.,Service de chirurgie vasculaire | And 3 more authors.
Medecine et Maladies Infectieuses

Prosthetic vascular graft infection is a rare but very severe complication with a high death rate. Its optimal management requires appropriate surgical procedures combined with adequate antimicrobial treatment in reference center. The authors wanted to focus on the management of prosthetic vascular graft infection and define the clinical, microbiological, biological, and radiological criteria of vascular graft infection. Complementary investigations, although these are small series, include CT scan, the gold standard for the diagnosis of acute infection with a sensitivity and specificity reaching 100%, but decreased to 55% in case of chronic infection. More recently, PET-scanning was studied and yielded good results in chronic infections (sensitivity 98%, specificity 75.6%, positive predictive value 88.5%, and negative predictive value 84.4%). Managing prosthetic vascular graft infection, as with the orthopedic and vascular infections, requires replacing the vascular prosthesis. There is no correlation between the microbiological data and the location or type of vascular infection. Thus, the postoperative intravenous antibiotherapy should be bactericidal with a broad-spectrum. After obtaining intra-operative microbiological results, de-escalation therapy must include at least one anti-adherence agent, such as rifampicin in staphylococcal infections. © 2012 Elsevier Masson SAS. Source

Peripheral arterial disease (PAD) is under-diagnosed despite its predictive value for cardiovascular mortality. The ankle brachial index (ABI), a simple reliable measure recommended by the French health authorities to detect and evaluate the severity of PAD, is used by too few general practitioners (GPs). Objective: This study aimed at identifying motivations and barriers for using ABI in general practice. Method: A representative, descriptive, cross-sectional survey was conducted amongst 165GPs practicing in Île-de-France who were interviewed using stratified quotas. Results: Although 1out of 5GPs considered ABI to be an irrelevant indicator, most had a favorable opinion about its use (OR: 4.9 [CI 95%: 4.2-5.7]). Only 42% (CI 95%: 34%-49%) of GPs knew ABI was recommended by the health authorities. This information had a critical impact on the acceptance of ABI relevancy (OR: 3.7 [CI 95%: 3.2-4.2]). Training reinforced acceptance (OR: 5.0 [CI 95%: 4.4-5.6]) and pre-residency education provided a better understanding of ABI (OR: 2.8 [CI 95%: 2.3-3.4]). Time needed to measure ABI was the main barrier (OR: 0.6 [CI 95%: 0.6-0.7]). A Doppler-calculation kit (OR: 11.8 [CI 95%: 8.9-15.6]), equipment cost ≤ 300. Euros (OR: 3.4 [CI 99%: 3.0-3.9]), a specific fee in addition to the regular consultation fee (OR: 2.6 [CI 95%: 2.3-3.0]) and inclusion of ABI in the GP's evaluation scheme (OR: 2.6 [CI 95%: 2.3-2.9]) would motivate more GPs. Seven out of 10GPs agreed that ABI has a positive impact on patient adherence to treatment and follow-up, but ABI remained underexploited for symptomatic patients (OR: 0.4 [CI 95%: 0.3-0.4]). Conclusion: Better communication and training together with an upgraded status for ABI would provide motivation for GPs to measure ABI. © 2013 Elsevier Masson SAS. Source

Leroy O.,Service de Reanimation et Maladies Infectieuses | Meybeck A.,Service de Reanimation et Maladies Infectieuses | Sarraz-Bournet B.,Service de chirurgie vasculaire | D'Elia P.,Service de chirurgie vasculaire | Legout L.,Service University des Maladies Infectieuses et du Voyageur
Current Opinion in Infectious Diseases

PURPOSE OF REVIEW: This review provides a focus on infections of prosthetic vascular grafts used to treat peripheral arterial diseases. RECENT FINDINGS: The incidence of infections varies between 1 and 6%. Risk factors of infection are not well identified. Main causative pathogens are Gram-negative bacilli, Staphylococcus aureus, and coagulase-negative staphylococci, without clear differences according to location of graft and time of onset of infection. There is no consensual diagnostic criterion. The basic principles for management of graft infections have been known for many years. A surgical approach combining graft excision, complete debridement, and maintaining distal vascular flow is required. Antimicrobial therapy is always instituted to reduce sepsis and prevent secondary graft infection, but there are no evidence-based data to recommend any regimen. However, antibiotics should have bactericidal activity whatever the bacteria growth phase, reduce the microbial burden, penetrate within the biofilm, and prevent further biofilm formation. Mortality and morbidity from these infections remain significant. SUMMARY: A multidisciplinary approach with a limited number of reference centres, recruiting sufficient numbers of patients to perform controlled trials, and to provide expert recommendations, could be the best way to answer unresolved questions and improve the prognosis. © 2012 Lippincott Williams & Wilkins, Inc. Source

Saadoun D.,Service de Medecine Interne 2 | Saadoun D.,Laboratory I3 Immunology | Lambert M.,French Institute of Health and Medical Research | Lambert M.,Lille University Hospital Center | And 12 more authors.

Background-With recent advances in endovascular treatment, percutaneous endoluminal angioplasty has become particularly attractive for arterial lesions of Takayasu arteritis. However, data came from case reports or small series, and the long-term outcome has not been reported. The incidence of potential vascular complications after surgery or endovascular treatment is still to be determined. Methods and Results-This retrospective multicenter study analyzed the results and outcomes of 79 consecutive patients with Takayasu arteritis (median age, 39 years; interquartile range [IQR], 25-50 years; 63 women [79.7%]) who underwent 166 vascular procedures (surgery, 104 [62.7%]; endovascular repair, 62 [37.3%]) for the management of arterial complications. After a follow-up of 6.5 years (IQR, 2.2-11.5 years), 70 complications were observed, including restenosis (n=53), thrombosis (n=7), bleeding (n=6), and stroke (n=4). The overall 1-, 3-, 5-, and 10-year arterial complication-free survival rates were 78% (IQR, 69%-88%), 67% (IQR, 57%-78%), 56% (IQR, 46%-70%), and 45% (IQR, 34%-60%), respectively. Among the 104 surgical procedures, 39 (37.5%) presented a complication compared with 31 of the 62 (50%) with endovascular repair. In multivariate analysis, biological inflammation at the time of revascularization (odds ratio, 7.48; 95% confidence interval, 1.42-39.39; P=0.04) was independently associated with the occurrence of arterial complications after the vascular procedure. Patients who experienced complications had higher erythrocyte sedimentation rates (P< 0.001) and C-reactive protein (P< 0.001) and fibrinogen (P< 0.005) serum levels compared with those without complications. Conclusions-The overall 5-year arterial complication rate was 44%. Biological inflammation increased the likelihood of complications after revascularization in patients with Takayasu arteritis. Copyright © 2012 American Heart Association. All rights reserved. Source

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