Olivier Sanchez

Université René Descartes - Paris 5, Lutetia Parisorum, Île-de-France, France

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Publications (129)572.97 Total impact

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    ABSTRACT: Although retrievable inferior vena cava filters are frequently used in addition to anticoagulation in patients with acute venous thromboembolism, their benefit-risk ratio is unclear. To evaluate the efficacy and safety of retrievable vena cava filters plus anticoagulation vs anticoagulation alone for preventing pulmonary embolism recurrence in patients presenting with acute pulmonary embolism and a high risk of recurrence. Randomized, open-label, blinded end point trial (PREPIC2) with 6-month follow-up conducted from August 2006 to January 2013. Hospitalized patients with acute, symptomatic pulmonary embolism associated with lower-limb vein thrombosis and at least 1 criterion for severity were assigned to retrievable inferior vena cava filter implantation plus anticoagulation (filter group; n = 200) or anticoagulation alone with no filter implantation (control group; n = 199). Initial hospitalization with ambulatory follow-up occurred in 17 French centers. Full-dose anticoagulation for at least 6 months in all patients. Insertion of a retrievable inferior vena cava filter in patients randomized to the filter group. Filter retrieval was planned at 3 months from placement. Primary efficacy outcome was symptomatic recurrent pulmonary embolism at 3 months. Secondary outcomes were recurrent pulmonary embolism at 6 months, symptomatic deep vein thrombosis, major bleeding, death at 3 and 6 months, and filter complications. In the filter group, the filter was successfully inserted in 193 patients and was retrieved as planned in 153 of the 164 patients in whom retrieval was attempted. By 3 months, recurrent pulmonary embolism had occurred in 6 patients (3.0%; all fatal) in the filter group and in 3 patients (1.5%; 2 fatal) in the control group (relative risk with filter, 2.00 [95% CI, 0.51-7.89]; P = .50). Results were similar at 6 months. No difference was observed between the 2 groups regarding the other outcomes. Filter thrombosis occurred in 3 patients. Among hospitalized patients with severe acute pulmonary embolism, the use of a retrievable inferior vena cava filter plus anticoagulation compared with anticoagulation alone did not reduce the risk of symptomatic recurrent pulmonary embolism at 3 months. These findings do not support the use of this type of filter in patients who can be treated with anticoagulation. clinicaltrials.gov Identifier: NCT00457158.
    JAMA The Journal of the American Medical Association 04/2015; 313(16):1627-1635. DOI:10.1001/jama.2015.3780 · 30.39 Impact Factor
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    ABSTRACT: Low molecular weight heparin is recommended for the treatment of venous thromboembolism (VTE) during pregnancy. However, there are few reliable data regarding the safety of therapeutic doses of tinzaparin in this setting. The objective of this study was to assess the safety of once-daily therapeutic doses of tinzaparin for the treatment of VTE during pregnancy. A retrospective study was carried out in 3 tertiary care centres in France, from 1998 to 2009, including consecutive pregnant women who received once-daily therapeutic doses of tinzaparin (175 IU/kg/day). We analyzed 87 pregnancies in 83 women, representing a total of 13,320 patient-days of treatment. Live-birth rate was 97.8%, with one case of miscarriage (<20 weeks of gestation) and one case of intrauterine foetal death (≥20 weeks). There was no antenatal major bleeding. Major bleeding occurred in 4 women during an emergency caesarean section. No case of heparin-induced thrombocytopenia and no maternal death were reported. There was no neonatal haemorrhage and no case of congenital abnormality. VTE recurred on treatment in one patient and after treatment interruption for several days in 2 other patients. These results support the safety of once-daily tinzaparin at therapeutic dose for the treatment of VTE during pregnancy. © 2015 S. Karger AG, Basel.
    Gynecologic and Obstetric Investigation 04/2015; DOI:10.1159/000367846 · 1.25 Impact Factor
  • G. Meyer, O. Sanchez, B. Planquette
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    ABSTRACT: La létalité de l’embolie pulmonaire (EP) compliquée d’état de choc varie de 25 à plus de 50 %. Dans cette circonstance, le traitement fibrinolytique réduit vraisemblablement la mortalité, ce qui semble justifier son emploi, malgré l’augmentation du risque hémorragique. En l’absence d’état de choc franc, la létalité de l’EP est beaucoup plus faible sous simple traitement anticoagulant et ne semble pas justifier l’emploi de thérapeutiques plus agressives. Des études suggèrent toutefois l’existence d’un groupe de malades à risque intermédiaire défini par une dysfonction ventriculaire droite objectivée par l’échocardiographie ou le scanner et par l’élévation de la troponine ou des peptides natriurétiques. Si la fibrinolyse diminue significativement les décompensations hémodynamiques et la mortalité liée à l’EP chez de tels malades, son emploi s’accompagne d’une augmentation sensible des complications hémorragiques graves et ne diminue pas la mortalité globale. Son emploi ne se conçoit donc que chez des malades dont l’état hémodynamique se décompense sous traitement anticoagulant et peut-être chez quelques malades jeunes sans facteur de risque hémorragique.
    Réanimation 03/2015; 24(2):98-103. DOI:10.1007/s13546-015-1039-5
  • Guy Meyer, Olivier Sanchez, Benjamin Planquette
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    ABSTRACT: IntroductionThrombolytic therapy is associated with faster hemodynamic, echocardiographic and angiographic improvements than heparin alone in patients with pulmonary embolism (PE) and right ventricular dysfunction, but this is obtained at the expense of an increased risk of bleeding. The use of thrombolytic therapy in patients with PE should therefore be decided on the estimation of the benefit-to-risk ratio depending both on the risk of death due to PE and to treatment-associated bleeding complications.Thrombolytic therapy induces faster angiographic and hemodynamic improvements than heparin alone in patients with PEThrombolytic treatment induces a rapid decline of pulmonary artery resistance in patients with acute PE and pulmonary hypertension. Alteplase significantly reduces mean pulmonary artery pressure and increases the cardiac index after 2 h, whereas no significant change is observed with heparin [1]. Alteplase produces an earlier reversal of right ventricular dysfunction than ...
    Internal and Emergency Medicine 02/2015; 10(3). DOI:10.1007/s11739-015-1194-8 · 2.41 Impact Factor
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    ABSTRACT: For patients diagnosed with acute symptomatic pulmonary embolism (PE), the Bova score classifies their risk of developing PE-related complications within 30 days after PE diagnosis. The original Bova score study derived the model from 2,874 normotensive patients that had acute PE and participated in one of six prospective PE studies. We retrospectively assessed the validity of the Bova risk model in normotensive patients with acute PE diagnosed in an academic urban emergency department. Two clinician investigators used baseline data for the model's 4 prognostic variables to stratify patients into the three Bova risk classes (I-III) for 30-day PE-related complications. Intraclass correlation coefficient (ICC) and the kappa statistic assessed inter-rater variability. The Bova risk score classified the majority of the cohort of 1,083 patients into the lowest Bova risk stage (stage I, 80%; stage II, 15%; stage III, 5%), The primary endpoint occurred in 91 of the 1,083 (8.4%; 95% confidence interval [CI], 6.7-10%) patients during the 30 days after the PE diagnosis. Risk class correlated with the PE-related complication rate (class I 4.4%, class II 18%, and class III 42%; ICC 0.93 [95% CI, 0.92-0.94]; kappa statistic 0.80 [P < 0.001]), in-hospital complication rate (class I 3.7%, class II 15%, and class III 37%), and 30-day PE-related mortality (class I 3.1%, class II 6.8%, and class III 10.5%). The Bova risk score accurately stratifies normotensive patients with acute PE into stages of increasing risk of PE-related complications that occur within 30 days of PE diagnosis.
    Chest 01/2015; DOI:10.1378/chest.14-2551 · 7.13 Impact Factor
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    ABSTRACT: Le plus souvent asymptomatique, la maladie veineuse thromboembolique (MVTE) est fréquente (9 %) en réanimation et altère le pronostic des patients. Le risque de MVTE en réanimation est multifactoriel et inclut l’obésité. Plus de la moitié des patients de réanimation sont en surpoids et un quart est obèse (index de masse corporelle [IMC]>30 kg/m2). La thromboprophylaxie de ces patients est donc un problème quotidien. Aucune recommandation spécifique n’existe à ce jour, essentiellement du fait de l’absence d’études randomisées conduites dans cette population. Ces patients sont à haut risque de MVTE en réanimation et doivent, sauf contre-indication, bénéficier d’une prophylaxie pharmacologique. Les héparines de bas poids moléculaire (HBPM) sont les anticoagulants les mieux documentés chez le patient obèse. Il n’a été prouvé, ni en réanimation ni en chirurgie bariatrique, de bénéfice à l’adaptation de la posologie au poids. La surveillance de l’activité anti-Xa n’a pas été étudiée en réanimation. Les moyens de prévention mécanique, bas de contention veineuse ou compression pneumatique intermittente, n’ont pas fait l’objet d’études spécifiques chez le patient obèse en réanimation et sont souvent sousutilisés. Faute d’essai clinique ayant inclus des patients obèses en réanimation et comparant plusieurs modalités de prévention, il semble aujourd’hui logique de suivre les recommandations de l’American College of Chest Physicians en proposant une prophylaxie pharmacologique par HBPM. L’association d’une prévention mécanique systématique aux membres inférieurs ne peut être recommandée. Abstract Venous thromboembolism (VTE) affects about 9% of ICU patients but is frequently asymptomatic. VTE increases ventilation duration, length of stay and mortality in intensive care unit (ICU) patients. Risk factors for VTE in critically ill patients are multiple, including obesity (body mass index [BMI]>30 kg/m2). As obesity concerns about 25%of ICU patients, VTE prophylaxis for ICU obese patients (OP) remains an important issue. Because of lack of large randomized and adequately powered trials, no specific guidelines are available in ICU OP. As those patients have an increased VTE risk, pharmacological prophylaxis is necessary. Using low molecular weight heparin (LWMHs) is logical, because LWMHs remain the best-documented anticoagulant class in OP. Benefit of weight based dosing regimens for LMWH in VTE prevention is not proven for OP in ICU or in bariatric surgery. Pharmacodymanic approach using anti-Xa monitoring has not been studied in ICU OP. Mechanical methods, such as graduated compression stockings or intermittent pneumatic compression devices, have not been sufficiently studied but remain underused in potentially suitable patients. In the absence of specific clinical trial about VTE prophylaxis in overweight patients, we suggest to follow the 9th American College of Chest Physicians guidelines by using LWMHs with standard dose. The routine association of mechanical methods cannot be recommended.
    Réanimation 01/2015; 24(1). DOI:10.1007/s13546-015-1022-1
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    ABSTRACT: Diagnostic algorithms for pulmonary embolism (PE) have been validated in patients attending hospital emergency departments. However, general practitioners (GPs) are often the professionals of first resort for the majority of non-critical cases of PE. To evaluate the knowledge of the diagnostic algorithm for PE among GPs in France. Questionnaire-based survey of GPs with a private practice. All GPs in the study area were sent a questionnaire including several questions on the diagnosis of PE and two clinical cases scenario with suspected PE. Factors associated with knowledge of the diagnostic algorithm were analysed by univariate and multivariate analyses. Five-hundred and eight questionnaires were distributed and 155 (30.5%) were available for analysis. Only 55% of the GPs did know about clinical scores for the assessment of clinical probability of PE and 42% of the GPs were aware that clinical probability is needed to interpret the result of D-dimer testing. Forty GPs (26%) gave valid responses to both clinical cases, 54 GPs (35%) had one valid case out of the two and 61 (39%) gave invalid responses to both clinical cases. Participation in specific training on PE was significantly associated with valid responses to the two clinical cases in multivariate analysis (p<0.017). The majority of GPs were unaware of the diagnostic algorithm for PE. Clinical probability was rarely assessed and knowledge about D-dimers was poor. Specific training on PE and greater awareness of clinical probability scores may promote knowledge of PE algorithm diagnosis. Copyright © 2014 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
    European Journal of Internal Medicine 12/2014; 26(1). DOI:10.1016/j.ejim.2014.11.005 · 2.30 Impact Factor
  • M. Dres, A. Ferre, O. Sanchez
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    ABSTRACT: La enfermedad pulmonar obstructiva crónica (EPOC) es un grave problema de salud pública, tanto por la morbilidad y la mortalidad como por los costes que genera. Debido a las comorbilidades frecuentes (sobre todo cardiovasculares), el tratamiento debe ser multidisciplinario. La evolución de la enfermedad incluye episodios agudos que agravan el pronóstico a largo plazo y que, en los casos más graves, comprometen el pronóstico vital. El tratamiento sintomático de las descompensaciones ha sido objeto de numerosas recomendaciones que, en su mayoría, se basan en estudios heterogéneos cuyo punto más controvertido sigue siendo la corticoterapia sistémica. En cambio, los broncodilatadores por inhalación han demostrado ser eficaces. Tratar el factor etiológico de la descompensación es primordial: el factor más frecuente es una infección respiratoria. El uso de los antibióticos está ampliamente extendido, pero debe limitarse a las neumonías o a las exacerbaciones de la EPOC con otra infección añadida en los pacientes de los estadios GOLD (global initiative for chronic obstructive lung disease) más graves (estadios definidos en función del volumen espiratorio máximo en el primer segundo [VEMS]). Existen varios trabajos relativos a la determinación de la concentración de biomarcadores para guiar la prescripción de la antibioticoterapia, pero hasta ahora ninguno de ellos se recomienda de rutina. En lo que se refiere a las descompensaciones más graves que justifican la hospitalización en cuidados intensivos, la disponibilidad de la ventilación no invasiva desde hace más de dos décadas ha modificado el tratamiento y el pronóstico. Debe seguir siendo el método de asistencia ventilatoria de elección, respetando las indicaciones y las contraindicaciones para no retrasar, llegado el caso, el comienzo de la ventilación invasiva. La experiencia de los equipos que usan estas técnicas garantiza su eficacia. Por último, después de la fase aguda, habrá que pensar en el seguimiento, los medios de prevención de las exacerbaciones y, si fuera necesario, la rehabilitación respiratoria en el contexto de un tratamiento general y multidisciplinario.
    11/2014; 40(4). DOI:10.1016/S1280-4703(14)68954-4
  • M. Dres, A. Ferre, O. Sanchez
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    ABSTRACT: La broncopneumopatia cronica ostruttiva (BPCO) è un problema importante di salute pubblica sia per la morbilità e la mortalità che per i costi sanitari che essa genera. Tenuto conto delle frequenti comorbilità (in particolare cardiovascolari), la gestione deve essere multidisciplinare. L’evoluzione di questa malattia è costellata di episodi acuti che aggravano la prognosi a lungo termine e che, nei casi più gravi, mettono in gioco la prognosi vitale. Il trattamento sintomatico degli scompensi è stato oggetto di numerose raccomandazioni basate, per la maggior parte, su degli studi disomogenei, il cui elemento più dibattuto resta quello dei corticosteroidi sistemici. Viceversa, i broncodilatatori per via inalata hanno dimostrato la loro efficacia. Il trattamento del fattore eziologico dello scompenso è fondamentale: il fattore più frequente è un’infezione respiratoria. L’utilizzo degli antibiotici è ampiamente diffuso, ma deve limitarsi ai casi di polmoniti o di riacutizzazioni di BPCO con sovrainfezione nei pazienti agli stadi GOLD (global initiative for chronic obstructive lung disease) più gravi (stadi definiti in funzione del volume espiratorio massimo durante il primo secondo [VEMS]). Diversi lavori si interessano ai dosaggi di bioindicatori per orientare la prescrizione della terapia antibiotica; nessuno è consigliato di routine a tutt’oggi. A proposito degli scompensi più gravi che giustificano un ricovero in terapia intensiva, l’avvento della ventilazione non invasiva da più di due decenni ha trasformato la gestione e la prognosi di questi pazienti. Essa deve restare la metodica di assistenza ventilatoria di elezione, sempre rispettando le sue indicazioni e controindicazioni per non ritardare l’instaurazione di una ventilazione invasiva, in caso di necessità. L’esperienza delle equipe che praticano queste tecniche è garanzia della loro efficacia. Infine, dopo la fase acuta, occorrerà pensare all’implementazione di un follow-up e dei mezzi di prevenzione delle esacerbazioni e, all’occorrenza, a una riabilitazione respiratoria nel quadro di una gestione globale e multidisciplinare.
    11/2014; 19(4):1–10. DOI:10.1016/S1283-0771(14)68865-4
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    ABSTRACT: Six months of treatment for VTE in patients with cancer are needed.•Be careful of a « provoked » first event (after surgery).•The recurrent rate was mainly higher during the six first months.•When anticoagulation was stopped before sixth month, the risk was eight fold higher.•After six months: no impact of the type of anticoagulation on the recurrent rate.
    Thrombosis Research 11/2014; DOI:10.1016/j.thromres.2014.10.030 · 2.43 Impact Factor
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    Revue des Maladies Respiratoires 09/2014; 31(7):661–662. DOI:10.1016/j.rmr.2014.04.039 · 0.49 Impact Factor
  • Olivier Sanchez, Benjamin Planquette, Guy Meyer
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    ABSTRACT: Although early pulmonary revascularization is the treatment of choice for patients with high-risk (massive) pulmonary embolism, it remains controversial in patients with intermediate-risk (submassive) pulmonary embolism until recently. Recent published data on the management of high-risk and intermediate-risk pulmonary embolism patients will be the main focus of this review.
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    ABSTRACT: AIM: Thrombolytic therapy induces faster clot dissolution than anticoagulation in patients with acute pulmonary embolism (PE) but is associated with an increased risk of haemorrhage. We reviewed the risks and benefits of thrombolytic therapy in the management of patients with acute PE. METHODS AND RESULTS: We systematically reviewed randomized controlled studies comparing systemic thrombolytic therapy plus anticoagulation with anticoagulation alone in patients with acute PE. Fifteen trials involving 2057 patients were included in our meta-analysis. Compared with heparin, thrombolytic therapy was associated with a significant reduction of overall mortality (OR; 0.59, 95% CI: 0.36-0.96). This reduction was not statistically significant after exclusion of studies including high-risk PE (OR; 0.64, 95% CI: 0.35-1.17). Thrombolytic therapy was associated with a significant reduction in the combined endpoint of death or treatment escalation (OR: 0.34, 95% CI: 0.22-0.53), PE-related mortality (OR: 0.29; 95% CI: 0.14-0.60) and PE recurrence (OR: 0.50; 95% CI: 0.27-0.94). Major haemorrhage (OR; 2.91, 95% CI: 1.95-4.36) and fatal or intracranial bleeding (OR: 3.18, 95% CI: 1.25-8.11) were significantly more frequent among patients receiving thrombolysis. CONCLUSIONS: Thrombolytic therapy reduces total mortality, PE recurrence, and PE-related mortality in patients with acute PE. The decrease in overall mortality is, however, not significant in haemodynamically stable patients with acute PE. Thrombolytic therapy is associated with an increase of major and fatal or intracranial haemorrhage.
    European Heart Journal 06/2014; 36(10). DOI:10.1093/eurheartj/ehu218 · 14.72 Impact Factor
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    ABSTRACT: Chronic thromboembolic pulmonary hypertension (CTEPH) has been estimated to occur in 0.1-0.5% of patients who survive a pulmonary embolism (PE), but more recent prospective studies suggest that its incidence may be much higher. The absence of initial haemodynamic evaluation at the time of PE should explain this discrepancy. We performed a prospective multicentre study including patients with PE in order to assess the prevalence and to describe risk factors of CTEPH. Follow-up every year included an evaluation of dyspnea and echocardiography using a predefined algorithm. In case of suspected CTEPH, the diagnosis was confirmed using right heart catheterisation (RHC). Signs of CTEPH were searched on the multidetector computed tomography (CT) and echocardiography performed at the time of PE. Of the 146 patients analysed, eight patients (5.4%) had suspected CTEPH during a median follow-up of 26 months. CTEPH was confirmed using RHC in seven cases (4.8%; 95%CI, 2.3 - 9.6) and ruled-out in one. Patients with CTEPH were older, had more frequently previous venous thromboembolic events and more proximal PE than those without CTEPH. At the time of PE diagnosis, patients with CTEPH had a higher systolic pulmonary artery pressure and at least two signs of CTEPH on the initial CT. After acute PE, the prevalence of CTEPH appears high. However, initial echocardiography and CT data at the time of the index PE suggest that a majority of patients with CTEPH had previously unknown pulmonary hypertension, indicating that a first clinical presentation of CTEPH may mimic acute PE.
    Thrombosis and Haemostasis 06/2014; 112(3). DOI:10.1160/TH13-07-0538 · 5.76 Impact Factor
  • Guy Meyer, Olivier Sanchez
    European Respiratory Journal 06/2014; 43(6):1554-1555. DOI:10.1183/09031936.00038414 · 7.13 Impact Factor
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    ABSTRACT: The identification of normotensive patients with acute pulmonary embolism (PE) at high risk of adverse PE-related clinical events (i.e. intermediate-risk group) is a major challenge.We combined individual patient data from six studies involving 2874 normotensive patients with PE. We developed a prognostic model for intermediate-risk PE based on the clinical presentation and the assessment of right ventricular dysfunction and myocardial injury. We used a composite of PE-related death, haemodynamic collapse or recurrent PE within 30 days of follow-up as the main outcome measure.The primary outcome occurred in 198 (6.9%) patients. Predictors of complications included systolic blood pressure 90-100 mmHg (adjusted odds ratio (aOR) 2.45, 95% CI 1.50-3.99), heart rate ≥110 beats per min (aOR 1.87, 95% CI 1.31-2.69), elevated cardiac troponin (aOR 2.49, 95% CI 1.71-3.69) and right ventricular dysfunction (aOR 2.28, 95% CI 1.58-3.29). We used these variables to construct a multidimensional seven-point risk index; the odds ratio for complications per one-point increase in the score was 1.55 (95% CI 1.43-1.68; p<0.001). The model identified three stages (I, II and III) with 30-day PE-related complication rates of 4.2%, 10.8% and 29.2%, respectively.In conclusion, a simple grading system may assist clinicians in identifying intermediate-risk PE.
    European Respiratory Journal 04/2014; 44(3). DOI:10.1183/09031936.00006114 · 7.13 Impact Factor
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    ABSTRACT: Purpose To report the implantation and retrieval vena cava filter success rate of the ALN filter in a the setting of a prospective randomized trial (PREPIC 2) trial filter subgroup. Materials and Methods Prepic 2 is a prospective open randomized study with a blind evaluation that compared retrievable ALN vena cava filter (ALN Implant Chirurgicaux) maintained for 3 months with no filter insertion in patients receiving anticoagulant therapy for acute symptomatic pulmonary embolism (PE) associated to deep vein thrombosis. The filter retrieval was systematically scheduled at 3 months. The primary goal of this ancillary study is to report the technical success rate of filter implantation and removal. The secondary goal is to report filter related complications. Results Between 08-2006 and 07-2012; 399 patients (median 76 years) with acute PE and no contradiction to anticoagulation were enrolled in 18 centres. 193 patients received an ALN filter after randomization in the filter arm in addition to anticoagulation therapy, using femoral (162) basilic (15) or jugular vein (16), access. Filter wasn’t implanted because of 2(1%) technical failure; 3 (1.5%) non confirmation of PE diagnosis after randomization; and 2 (1%) patients’ death before implantation. post implantation cavogram showed >15° tilting in 19 (9.8%) cases. Minor complications were observed in 20 cases (11.9%): 4 (2%) <20 mm migration; 10 (5.2%) >3 mm filters struts penetration outside the cavogram and 3 1.6%) puncture site hematoma; 5 (2.6%) tilt increase were reported. Among the 166 (92.2%) patients who were referred for extraction after 3 months (93 days [89-98]), retrieval was successfully performed in 92.2% (153). 3 (1.8%) asymptomatic filter thrombosis were observed. Failure of extraction was observed in 13 (7.8%) case, because of >15° tilt (n=9, 5.4%) or non removable fibrotic bridge to IVC n=4/2.4%. Filter removal was successfully performed in an median of 20 min [15-40]. Conclusion The ALN filter was successfully extracted in 92.2% in this multicenter experience with a little complication rate.
    SIR 2014, 3S84; 03/2014
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    ABSTRACT: IMPORTANCE D-dimer measurement is an important step in the diagnostic strategy of clinically suspected acute pulmonary embolism (PE), but its clinical usefulness is limited in elderly patients. OBJECTIVE To prospectively validate whether an age-adjusted D-dimer cutoff, defined as age × 10 in patients 50 years or older, is associated with an increased diagnostic yield of D-dimer in elderly patients with suspected PE. DESIGN, SETTINGS, AND PATIENTS A multicenter, multinational, prospective management outcome study in 19 centers in Belgium, France, the Netherlands, and Switzerland between January 1, 2010, and February 28, 2013. INTERVENTIONS All consecutive outpatients who presented to the emergency department with clinically suspected PE were assessed by a sequential diagnostic strategy based on the clinical probability assessed using either the simplified, revised Geneva score or the 2-level Wells score for PE; highly sensitive D-dimer measurement; and computed tomography pulmonary angiography (CTPA). Patients with a D-dimer value between the conventional cutoff of 500 µg/L and their age-adjusted cutoff did not undergo CTPA and were left untreated and formally followed-up for a 3-month period. MAIN OUTCOMES AND MEASURES The primary outcome was the failure rate of the diagnostic strategy, defined as adjudicated thromboembolic events during the 3-month follow-up period among patients not treated with anticoagulants on the basis of a negative age-adjusted D-dimer cutoff result. RESULTS Of the 3346 patients with suspected PE included, the prevalence of PE was 19%. Among the 2898 patients with a nonhigh or an unlikely clinical probability, 817 patients (28.2%) had a D-dimer level lower than 500 µg/L (95% CI, 26.6%-29.9%) and 337 patients (11.6%) had a D-dimer between 500 µg/L and their age-adjusted cutoff (95% CI, 10.5%-12.9%). The 3-month failure rate in patients with a D-dimer level higher than 500 µg/L but below the age-adjusted cutoff was 1 of 331 patients (0.3% [95% CI, 0.1%-1.7%]). Among the 766 patients 75 years or older, of whom 673 had a nonhigh clinical probability, using the age-adjusted cutoff instead of the 500 µg/L cutoff increased the proportion of patients in whom PE could be excluded on the basis of D-dimer from 43 of 673 patients (6.4% [95% CI, 4.8%-8.5%) to 200 of 673 patients (29.7% [95% CI, 26.4%-33.3%), without any additional false-negative findings. CONCLUSIONS AND RELEVANCE Compared with a fixed D-dimer cutoff of 500 µg/L, the combination of pretest clinical probability assessment with age-adjusted D-dimer cutoff was associated with a larger number of patients in whom PE could be considered ruled out with a low likelihood of subsequent clinical venous thromboembolism. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01134068.
    JAMA The Journal of the American Medical Association 03/2014; 311(11):1117-1124. DOI:10.1001/jama.2014.2135 · 30.39 Impact Factor
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    ABSTRACT: Rationale: Not all patients with acute pulmonary embolism (PE) have a high risk of an adverse short-term outcome. Objectives: This prospective cohort study aimed to develop a multimarker prognostic model that accurately classifies normotensive patients with PE into low and high categories of risk of adverse medical outcomes. Methods: The study enrolled 848 outpatients from the PROTECT study (derivation cohort), and 529 patients from the PREP study (validation cohort). Investigators assessed study participants for a 30-day complicated course, defined as death from any cause, haemodynamic collapse, and/or adjudicated recurrent PE. Measurements and Main Results: A complicated course occurred in 63 (7.4%) of the 848 normotensive patients with acute symptomatic PE in the derivation cohort, and in 24 patients (4.5%) in the validation cohort. The final model included the simplified Pulmonary Embolism Severity Index (sPESI), cardiac troponin I (cTnI), brain natriuretic peptide (BNP), and lower limb ultrasound testing (CCUS). The model performed similarly in the derivation (c-index of 0.75) and validation (c-index of 0.85) cohorts. The combination of the sPESI and BNP testing showed a negative predictive value for a complicated course of 99.1% and 100% in the derivation and validation cohorts, respectively. The combination of all modalities had a positive predictive value for the prediction of a complicated course of 25.8% in the derivation cohort and 21.2% in the validation cohort. Conclusions: For normotensive patients that have acute PE, we derived and validated a multimarker model that predicts all-cause mortality, haemodynamic collapse, and/or recurrent PE within the following 30 days.
    American Journal of Respiratory and Critical Care Medicine 01/2014; 189(6). DOI:10.1164/rccm.201311-2040OC · 11.99 Impact Factor

Publication Stats

3k Citations
572.97 Total Impact Points

Institutions

  • 2009–2014
    • Université René Descartes - Paris 5
      • Faculté de Médecine
      Lutetia Parisorum, Île-de-France, France
  • 2005–2014
    • Hôpital Européen Georges-Pompidou (Hôpitaux Universitaires Paris-Ouest)
      • Service de Microbiologie
      Lutetia Parisorum, Île-de-France, France
  • 2013
    • Cliniques Universitaires Saint-Luc
      Bruxelles, Brussels Capital Region, Belgium
  • 2011
    • Unité Inserm U1077
      Caen, Lower Normandy, France
  • 2006–2009
    • Centre Hospitalier Universitaire de Brest
      • Département de Médecine Interne et de Pneumologie
      Brest, Brittany, France
    • University of Lausanne
      Lausanne, Vaud, Switzerland
    • Hôpital Henri Mondor (Hôpitaux Universitaires Henri Mondor)
      Créteil, Île-de-France, France
  • 2006–2007
    • Université Paris-Sud 11
      • Faculty of Medicine
      Orsay, Île-de-France, France
  • 2003
    • University of Angers
      Angers, Pays de la Loire, France
  • 1998
    • Hôpital Antoine-Béclère – Hôpitaux universitaires Paris-Sud
      Clamart, Île-de-France, France