2.6 Other
Behcet disease: an atypical DVT. Diagnosis and treatment.
M. Bouayed
Behcet’s disease (BD) is a primitive multisystematic vasculitis nonautoimmune disease of unknown etiology. It is exceptional after the age of 60 and common in the Mediterranean basin and in Japan.
The International Clinical Criteria from 1990 are recurrent oral ulcers, recurrent ulcers more than three times in 12 months, and two of the following: recurrent genital ulcerations, eye-injury, skin-lesions, and a positive pathergy test (sensitivity, 91% and specificity, 96%).
The vascular lesions are highly suggestive of an attack on the arteries and veins of any caliber. In the vascular lesions, the great majority is deep venous thrombosis (DVT; 90%). Superficial venous thrombosis (SVT) is a major criterion according to the Japan Committee for Behcet’s disease.
The new criteria for the classification of BD is according to points attributed to clinical conditions: oral ulcers (1 point), genital ulceration (2 points), skin lesions as pseudofolliculitis or erythema nodosum (1 point), ocular involvement (2 points), vascular disease as superficial thrombophlebitis, DVT, arterial thrombosis, aneurysm (1 point), and positive pathergy test (1 point). The diagnosis is made if there are ≥3 positive points.
The treatment recommendation for vascular involvement is corticosteroids and immunosuppressants, but with formal proof; no formal proof exists regarding the effectiveness of anticoagulants or antiplatelet agents on vascular thrombosis of the BD. In DVT, anticoagulants are essential, used long-term, sometimes for life after repeated offenses. An immunosuppressant bolus limits thrombus extension and prevents recurrence.
Reference:
International Study Group for Behcet’s Disease. Criteria for diagnosis of Behcet’s disease. Lancet. 1990;335:1078-1080.
Does long-term follow-up confirm that high ligation and stripping is an obsolete procedure?
O. Pichot
Saphenofemoral junction (SFJ) residual stump and neovascularization are considered to be the main causes of recurrence after surgery; that is why surgeons have emphasized the necessity of performing an extended high ligation, even if no artifice has been demonstrated to effectively avoid SFJ neovascularization. Thermal ablation introduced the concept based on trunk ablation alone with preservation of the SFJ. Mid-term followup already demonstrated that this approach significantly decreases the incidence of neovascularization.
The author concluded that there is no inferiority of endogenous procedures compared with surgery in the long-term follow-up. Clinically significant reflux in the residual great saphenous vein stump is rare. Valsalva-induced reflux into lymph node veins is frequent, is different from neovascularization seen after surgery, and appears to stay quiescent over time. High ligation is definitely an obsolete procedure.
