Marc Righini

• MD
• University of Geneva

Background/Introduction Risk stratification is used for decisions about imaging in patients with clinically suspected acute pulmonary embolism (PE). Purpose To develop a clinical prediction model that provides an individualized, accurate probability estimate for acute pulmonary embolism (PE) based on readily available clinical items and D-dimer co...

Les problématiques posées par la prise en charge de la femme enceinte suspecte d’embolie pulmonaire (EP) aux urgences sont multiples. Les modifications physiologiques au cours de la grossesse majorent les sollicitations médicales pour des tableaux de douleur thoracique, de dyspnée, de malaise… En parallèle, ces manifestations aux cours de la grosse...

Background Improved imaging techniques have increased the incidence of subsegmental pulmonary embolism (ssPE). Indirect evidence is suggesting that ssPE may represent a more benign presentation of venous thromboembolism not necessarily requiring anticoagulant treatment. However, correctly diagnosing ssPE is challenging with reported low interobserv...

Background In pulmonary embolism (PE) suspicion, several strategies based on clinical criteria and D-dimer (Dd) measurement have been developed in order to reduce resource utilization. However, they used different clinical probability (CP) assessment methods limiting their combination. Purpose To develop and validate a unique probability score int...

Résumé Le diagnostic de l’embolie pulmonaire (EP) repose à l’heure actuelle sur l’utilisation séquentielle de tests diagnostiques, intégrés dans le cadre d’un algorithme ou d’une stratégie diagnostique, et non sur un test unique. L’étape initiale de ces stratégies diagnostiques est l’établissement de la probabilité clinique pré-test. Plusieurs scor...

Background Growth arrest‐specific gene 6 (Gas6) is a pro‐hemostatic protein with an unknown predictive ability for recurrent venous thromboembolism (VTE). In the elderly, VTE carries a higher mortality but not a higher rate of VTE recurrence than in younger patients. Consequently, anticoagulation management in the elderly is challenging. Objective...

2214 Malformations artérioveineuses : prise en charge complexe Les malformations artérioveineuses (MAV) constituent des affections rares présentes dès la naissance. Il est important que le médecin généraliste puisse évoquer ce diagnostic vu la gravité potentielle de ces lésions et leur prise en charge complexe. Les caractéristiques anatomiques et h...

Background Diagnosing pulmonary embolism in suspected patients is notoriously difficult as signs and symptoms are non-specific. Different diagnostic strategies have been developed, usually combining clinical probability assessment with D-dimer testing. However, their predictive performance differs across different healthcare settings, patient subgr...

Existing clinical scores do not perform well in predicting bleeding in elderly patients with acute venous thromboembolism (VTE). We sought to derive an easy-to-use clinical score to help physicians identify elderly patients with VTE who are at high-risk of bleeding during extended anticoagulation (>3 months). Our derivation sample included 743 pati...

Background: Massive pulmonary embolism (PE) during pregnancy or the postpartum period is a rare but dramatic event. Our aim was to systematically review the evidence to guide its management. Methods: We searched Pubmed, Embase, conference proceedings and the RIETE registry for published cases of severe (submassive/massive) PE treated with thromb...

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 vita...

Background: Pretest probability assessment by a clinical prediction rule (CPR) is an important step in the management of patients with suspected pulmonary embolism (PE). A limitation to the use of CPR is that their constitutive variables and corresponding number of points are difficult to memorize. A simplified version of the Geneva score (i.e. at...

Advances in the management of patients with suspected pulmonary embolism (PE) have improved diagnostic accuracy and made management algorithms safer, easier to use, and well standardized. These diagnostic algorithms are mainly based on the assessment of clinical pretest probability, D-dimer measurement, and imaging tests—predominantly computed tomo...

Background: Cancer patients frequently present with suspected pulmonary embolism (PE). The D-dimer (DD) test is less useful in excluding PE in cancer patients due to the lower specificity. In the general population, the age-adjusted cutoff for DD combined with a clinical decision rule (CDR) improved specificity in the diagnosis of PE. Objectives:...

Several themes were selected from those that marked the year 2016. The analysis of registries with real life data regarding the use of direct oral anticoagulants is reassuring and overall confirm the data of the pivotal studies. We also present the validation of a prediction rule for risk stratification of thromboembolism recurrence and duration of...

Vascular access complications following endovascular procedures remain an important cause of morbidity when using a femoral approach. In this review, we describe the risk factors, clinical presentation and management of hematoma, retroperitoneal bleeding, pseudoaneurysms, arteriovenous fistulae and arterial thrombosis.

Modern diagnostic strategies for pulmonary embolism (PE) rely on the sequential use of clinical probability assessment, D-dimer and thoracic imaging when necessary. Computed tomography pulmonary angiography (CTPA) has become the imaging modality of choice. Diagnostic strategies using CTPA are very safe for the diagnosis of PE and have been well val...

The widespread introduction of direct oral anticoagulants (DOAC) represents a major step forward in the therapeutic management of patients with venous thromboembolic disease and atrial fibrillation, accompanied by new challenges. A thorough knowledge of the available evidence needs to be associated with pragmatism in order to address patients' indi...

The ultrasound-guided foam sclerotherapy (UGFS) involves the injection of a sclerosing agent into a target vein under ultrasonographic guidance. The goal of this treatment is to harm the venous endothelium to achieve the destruction of the vein wall by a fibrosis phenomenon. In this article, we discuss indications and contraindications of UGFS. We...

Background: The small diameter of radial arteries remains a major limitation of the transradial approach for percutaneous coronary intervention (PCI). Sheathless guiding catheters (GCs) might offer an advantage over standard GCs. Methods: Between 2011 and 2013, we randomized 233 transradial PCIs performed in men with ostial or bifurcation lesion...

Introduction Patients with cancer frequently present with suspected pulmonary embolism (PE). The D-dimer test is less useful to rule out PE in cancer patients due to a lower specificity, whereas the safety of the combination of a clinical decision rule (CDR) and D-dimer test to rule out PE in these patients is unclear. In the general population, us...

In recent years, small oral compounds that specifically block activated coagulation factor X (FXa) or thrombin (FIIa) have become alternatives to the anticoagulants that had been used for several decades. As of today, these direct oral anticoagulants (DOACs) include dabigatran etexilate (thrombin inhibitor) and apixaban, edoxaban and rivaroxaban (i...

Whether anticoagulation management practices are associated with improved outcomes in elderly patients with acute venous thromboembolism (VTE) is uncertain. Thus, we aimed to examine whether practices recommended by the American College of Chest Physicians guidelines are associated with outcomes in elderly patients with VTE. We studied 991 patients...

Background: There is scant information on the optimal management and clinical outcome of deep and superficial vein thrombosis of the upper extremity (UEDVT and UESVT). Objectives: To explore treatment strategies and the incidence of recurrent venous thromboembolism (VTE), mortality, postthrombotic symptoms and bleeding in patients with UEDVT and...

Background: Venous thromboembolism (VTE) and subclinical thyroid dysfunction (SCTD) are both common in elderly patients. SCTD has been related to a hypercoagulable state and increased thromboembolic risk. However, prospective data on the relationship between SCTD and VTE are lacking. Objectives: To investigate the relationship between SCTD and r...

Modern diagnostic non-invasive strategies for pulmonary embolism (PE) rely on the sequential use of clinical probability assessment, D-dimer measurement and thoracic imaging tests. Planar ventilation/perfusion (V/Q) scintigraphy was the cornerstone for more than two decades and has now been replaced by computed tomography pulmonary angiography (CTP...

Pulmonary embolism is the third cause of mortality by cardiovascular disease after coronary artery disease and stroke, and its incidence is around 1/1000 per year. During the last two decades, many different non-invasive diagnostic tests have been developed and validated. For hemodynamically stable outpatients, the diagnosis of acute pulmonary embo...

Background: Compression ultrasonography is the mainstay of diagnosis of deep-vein thrombosis (DVT) of the legs. Compression ultrasonography can be extended to the entire deep venous system (whole-leg) or restricted to the proximal veins only (limited), and the two approaches are clinically equivalent. We aimed to assess the diagnostic value of an...

L’embolie pulmonaire et la thrombose veineuse profonde (TVP) sont deux manifestations cliniques différentes de la même maladie, la maladie thromboembolique veineuse. Traditionnellement, toutes deux étaient traitées à l’hôpital par héparine non fractionnée intraveineuse. Avec l’introduction, il y a plus de 30 ans, des héparines de bas poids molécula...

Les strategies diagnostiques de l’embolie pulmonaire sont tres largement validees et se basent sur l’utilisation sequentielle de l’evaluation de la probabilite clinique, le dosage des D-dimeres et le scanner multi-barrettes. Les D-dimeres sont en general utilises chez les patients qui ont une probabilite clinique faible ou intermediaire. De multipl...

A 67-year-old man with dyslipidemia, obesity (body mass index, 34), past tobacco use, anxiety, and borderline hypertension presented to the emergency department (ED) after 3 days of shortness of breath on exertion. He described increased anxiety and a pleuritic chest pain that began a few hours prior to his ED visit, but no hemoptysis. He had no pe...

Over the last decades, important advances have been made in the diagnosis of venous thromboembolism (VTE). Current diagnostic strategies rely on the sequential use of non-invasive diagnostic tests, based on the pretest clinical probability of disease. Diagnostic tests include D-dimer measurement, leg vein compression ultrasonography, chest computed...

We would like to thank Laroche et al. for their thoughtful comments and interest in our study (1) . As suggested by Laroche et al. the only real danger of imaging the asymptomatic leg lies in the false positive tests. However, we respectfully disagree that the risk of false positive tests is similar in both legs. Indeed, our retrospective study sug...

D-dimers result from the fibrinolysis of acute thrombi. Enzyme-linked immunosorbent assay (ELISA) and immunoturbidimetric D-dimer assays are highly sensitive for the diagnosis of PE. The D-dimer test should be used in combination with a pretest clinical probability assessment (Table 2). The D-dimer is useful only in patients with a low-intermediate...

The incidence of upper extremity deep vein thrombosis (UEDVT) is constantly increasing due to frequent insertion of intravenous devices for various indications. Secondary UEDVT represent more than two thirds of cases. Primary UEDVT generally include UEDVT occurring without any triggering factor and UEDVT following intense or repeated efforts or in...

The diagnosis of venous thromboembolism relies on the sequential use of diagnostic tests, in validated diagnostic algorithms, based on the prior assessment of the pretest probability. Main diagnostic tests are D-Dimer and lower limb vein compression ultrasonography for deep vein thrombosis; and D-Dimer, computed tomography pulmonary angiography or...

Both, underuse and overuse of thromboprophylaxis in hospitalised medical patients is common. We aimed to explore clinical factors associated with the use of pharmacological or mechanical thromboprophylaxis in acutely ill medical patients at high (Geneva Risk Score ≥ 3 points) vs low (Geneva Risk Score < 3 points) risk of venous thromboembolism. Ove...

Venous ultrasonography is the cornerstone of the diagnostic work-up in patients with suspected deep vein thrombosis (DVT). Significant variations exist in clinical practice between centers and/or countries, e.g. proximal vs. whole-leg ultrasound, serial vs. single test, combination with clinical probability and D-Dimer. Less data exist on the need...

Recent advances in the management of patients with suspected VTE have both improved diagnostic accuracy and made management algorithms safer, easier to use and well standardised. These diagnostic algorithms are mainly based on the assessment of clinical pretest probability, D-dimer measurement and imaging tests, mainly represented by compression ul...

Background Although the possibility of bleeding during anticoagulant treatment may limit patients from taking part in physical activity, the association between physical activity and anticoagulation-related bleeding is uncertain.Objectives To determine whether physical activity is associated with bleeding in elderly patients taking anticoagulants.P...

No diagnostic strategy for pulmonary embo- lism (PE) during pregnancy is based on strong evidence and unanimously accepted. Clinical scores are not validated. The diagnostic yield of the non radiating tests is low: D-dimer is rarely negative in pregnant women and lower limb venous compression ultrasonography is poorly sensitive. Nevertheless, they...

Plasma D-dimer measurement is the first diagnostic test performed in patients with a non-high or an unlikely clinical probability of pulmonary embolism (PE) but its clinical usefulness is limited in elderly patients due to a low specificity in this subgroup. PE can be excluded based on D-dimers and clinical probability only in about 5% of patients...

Objectifs Devant un épisode isolé de maladie thromboembolique veineuse (MTEV), il est usuel de rechercher un néoplasie occulte. Cependant, aucun bénéfice en termes d’amélioration de la morbi-mortalité en lien avec cette pratique n’est démontré. Nous avons cherché à isoler un sous-groupe de patient pour lequel la question du dépistage de cancer vaut...

L’intérêt théorique d’utiliser la thrombolyse chez les patients avec une TVP aiguë se base sur le concept de la veine ouverte (« open vein » des anglo-saxons), c’est-à-dire sur le concept que la reperméabilisation rapide de la veine va améliorer les symptômes du patient en phase aiguë et diminuer le risque de syndrome post-thrombotique. Une méta-an...

Background Venous thromboembolism (VTE) is a major contributor of maternal morbidity and mortality. Whether maternal race/ethnicity is associated with the risk of postpartum VTE remains unclear.Methods and ResultsWe conducted a population-based, case-control study in Washington State, from 1987 through 2011. Cases comprised all women with selected...

Objective To determine the prognostic accuracy of cardiac biomarkers alone and in combination with clinical scores in elderly patients with non-high-risk pulmonary embolism (PE).DesignAncillary analysis of a Swiss multicentre prospective cohort study.SubjectsA total of 230 patients aged ≥65 years with non-high-risk PE.Main outcome measuresThe study...

Introduction The diagnosis of deep vein thrombosis (DVT) in pregnant women remains a challenge for physicians. The ‘LEFt’ clinical decision rule was recently derived, that might help in estimating the pretest probability of DVT during pregnancy. Our aim was to externally validate the LEFt clinical decision rule among pregnant women included in the...

BACKGROUND Polypharmacy, defined as the concomitant use of multiple medications, is very common in the elderly and may trigger drug-drug interactions and increase the risk of falls in patients receiving vitamin K antagonists. OBJECTIVE To examine whether polypharmacy increases the risk of bleeding in elderly patients who receive vitamin K antago...

In Reply Mr Colombo and colleagues asked whether all D-dimer assays perform equally when using the age-adjusted D-dimer cutoff to rule out pulmonary embolism or whether different patient characteristics could explain the variability in the proportion of patients with negative D-dimer levels. We favor the latter hypothesis. There were important diff...

BACKGROUND: We aimed to assess whether elderly patients with acute venous thromboembolism (VTE) receive recommended initial processes of care and to identify predictors of process adherence. METHODS: We prospectively studied in- and outpatients aged ≥65 years with acute symptomatic VTE in a multicenter cohort study from nine Swiss university- and n...

Clinical probability and D-dimer measurement play an essential role in the non-invasive diagnostic strategies for pulmonary embolism (PE). PE can be ruled out without further imaging in patients with non-high clinical probability and negative D-dimer. D-dimer level is increased in patients with renal impairment. Whether its diagnostic usefulness is...

Unintentional intraarterial injections are rare but may have devastating consequences. No consensus on treatment has been established owing to the wide variety of possible injected substances, incomplete understanding of the underlying pathophysiology, and the absence of case-controlled, prospective human studies. The aim of the present study and l...

Elderly patients are a population not only at particularly high risk of venous thromboembolism including pulmonary embolism (PE), but also at high risk of adverse clinical outcomes and treatment-related complications. Major progresses have been achieved in the diagnosis and treatment of PE over the last two decades. Nevertheless, some of elderly pa...

Although well-established for suspected lower limb deep venous thrombosis, an algorithm combining a clinical decision score, d-dimer testing, and ultrasonography has not been evaluated for suspected upper extremity deep venous thrombosis (UEDVT). To assess the safety and feasibility of a new diagnostic algorithm in patients with clinically suspecte...

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 in...

Objective Whether or not a high risk of falls increases the risk of bleeding in patients receiving anticoagulants remains a matter of debate.Methods We conducted a prospective cohort study involving 991 patients ≥65 years of age who received anticoagulants for acute venous thromboembolism (VTE) at 9 Swiss hospitals between September 2009 and Septem...

Available since the 1960s, the use of inferior vena cava filter has now become an alternative therapeutic approach in the management of venous thromboembolism in case of a contraindication to or a complication of anticoagulation. Their effectiveness in protecting against pulmonary embolism seems obvious in patients in whom anticoagulant treatment c...

There is a need to validate risk assessment tools for hospitalised medical patients at risk of venous thromboembolism (VTE). We investigated whether a predefined cut-off of the Geneva Risk Score, as compared to the Padua Prediction Score, accurately distinguishes low-risk from high-risk patients regardless of the use of thromboprophylaxis. In the m...

D-dimer measurement is an important step in diagnostic strategies for venous thromboembolism. It allows the safe ruling out of the diagnosis with no need for imaging tests in approximately 30% of outpatients. However, the usefulness of d-dimer is limited in elderly patients; the likelihood of a negative d-dimer strongly decreases with age, making p...

Aims: Pulmonary embolism (PE) associated with haemodynamic instability has exceedingly high mortality. While intravenous thrombolysis is considered the therapy of choice, percutaneous mechanical thrombectomy may represent an alternative treatment. Methods and results: The impact of AngioJet® rheolytic thrombectomy (RT) in PE associated with card...

Aims: To assess the clinical performance of pro-B-type natriuretic peptide 1-108 (proBNP) for the prognosis of acute pulmonary embolism. Methods: This study was ancillary to a recently published multicentre study including 570 patients with acute pulmonary embolism. ProBNP values were analysed using a new sandwich immunoassay proBNP1-108, Biople...

The usefulness of anticoagulation in patients with suspected non-massive pulmonary embolism (PE) is uncertain. We recently published a decision analysis model suggesting a benefit for preemptive anticoagulation in patients with an intermediate or high probability of PE, even with short diagnostic delays (0-3 h). In case of a low probability of PE,...

Background: Pulmonary embolism (PE) with hemodynamic instability is associated with high mortality. While thrombolysis remains the treatment of choice for massive PE, percutaneous mechanical thrombectomy may be an alternative in selected cases. Methods & results: We performed a systematic review of the literature for articles dealing with the use o...

Venous thromboembolism (VTE) is common and has a high impact on morbidity, mortality, and costs of care. Although most of the patients with VTE are aged ≥65 years, there is little data about the medical outcomes in the elderly with VTE. The Swiss Cohort of Elderly Patients with VTE (SWITCO65+) is a prospective multicenter cohort study of in- and ou...

Deep-vein thrombosis (DVT) is a common disease. However, unlike varicose veins that have been depicted since antiquity in art and literature, its description was more recent in the history of medicine. The first well-documented case of DVT was reported during the Middle Ages: in 1271 Raoul developed an unilateral edema in the ankle which then exten...

Background: The Outpatient Bleeding Risk Index (OBRI) and the Kuijer, RIETE and Kearon scores are clinical prognostic scores for bleeding in patients receiving oral anticoagulants for venous thromboembolism (VTE). We prospectively compared the performance of these scores in elderly patients with VTE. Methods: In a prospective multicenter Swiss c...

We analysed a cohort of patients with normotensive pulmonary embolism (PE) in order to assess whether combining echocardiography and biomarkers with the pulmonary embolism severity index (PESI) improves the risk stratification in comparison to the PESI alone. The PESI was calculated in normotensive patients with PE who also underwent echocardiograp...

Background. The assessment of clinical probability represents an important step in the diagnostic strategy of patients with suspected deep vein thrombosis. The recently derived "LEFt" clinical prediction rule for pregnant women combines three variables: symptoms in the left leg ("L"), calf circumference difference ≥ 2 centimeters ("E" for edema) an...

Background: The Geneva Prognostic Score (GPS), the Pulmonary Embolism Severity Index (PESI) and its simplified version (sPESI) are well-known clinical prognostic scores for a pulmonary embolism (PE). Objectives: To compare the prognostic performance of these scores in elderly patients with a PE. Patients and methods: In a multicenter Swiss cohort o...

  The introduction of computed tomography pulmonary angiography (CTPA) has led to an increase in the incidence of pulmonary embolism (PE) diagnosis. However, the case fatality rate is lower and the mortality rates of PE have remained unchanged, suggesting a lower severity of illness. Specifically, the multiple-detector CTPA increased the rate of su...