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Koudounas G, Giannopoulos S, Houser A, Karkos C, Volteas P, Virvilis D. Basilic vein tunnel transposition versus elevation transposition for brachiobasilic arteriovenous fistula creation: A systematic review and meta-analysis. J Vasc Access 2024:11297298241226993. [PMID: 38336667 DOI: 10.1177/11297298241226993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2024] Open
Abstract
This study aimed to compare basilic vein tunnel transposition (BVTT) to basilic vein elevation transposition (BVET) technique for superficialization of a basilic arteriovenous fistula. This is a systematic review and meta-analysis comparing outcomes between BVTT and BVET for brachiobasilic arteriovenous fistula (AVF) creation. Primary endpoints were primary patency at several time intervals during follow-up and postoperative local complications, whereas secondary endpoints included primary assisted patency and secondary patency. A random effects model meta-analysis was conducted, and the I2 statistic was used to assess heterogeneity. Nine eligible studies were identified, including 543 patients (247 in the BVTT group and 296 in the BVET group). BVTT group was associated with inferior primary patency rate at 6 months compared to BVET group (three studies; OR: 0.43; 95% CI: 0.22-0.83; I2 = 0%; p = 0.012). However, primary patency rates were similar between the two study groups at 12 months (six studies; OR: 0.64; 95% CI: 0.33-1.22; I2 = 40.7%; p = 0.176), and at 24 months (six studies; OR: 0.86; 95% CI: 0.32-2.29; I2 = 74.9%; p = 0.764). No significant differences in terms of primary assisted patency, secondary patency, and postoperative complications were detected between the groups. More specifically, wound infection (BVTT: n = 9/150; BVET: n = 6/186; OR: 1.39; 95% CI: 0.48-4.06; I2 = 0%; p = 0.542) and healing of the scar, particularly regarding arm edema (BVTT: n = 18/100; BVET: n = 27/165; OR: 1.11; 95% CI: 0.57-2.18; I2 = 0%; p = 0.755) and hematoma formation (BVTT: n = 14/173; BVET: n = 42/209; OR: 0.40; 95% CI: 0.13-1.19; I2 = 49%; p = 0.101), did not differ significantly between the two study groups. BVET achieved superior primary patency at 6 months compared to BVTT, but this benefit seems to be lost during longer follow-up intervals. Therefore, both surgical techniques provide similar long-term outcomes.
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Affiliation(s)
- Georgios Koudounas
- Vascular Unit, 5th Department of Surgery, Aristotle University Medical School, Hippokratio Hospital, Thessaloniki, Greece
| | - Stefanos Giannopoulos
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Alex Houser
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Christos Karkos
- Vascular Unit, 5th Department of Surgery, Aristotle University Medical School, Hippokratio Hospital, Thessaloniki, Greece
| | - Panagiotis Volteas
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Dimitrios Virvilis
- Department of Vascular and Endovascular Surgery, St Francis Hospital & Heart Center, Roslyn, NY, USA
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Volteas P, Giannopoulos S, Vatsa S, Cheung EC, Virvilis D. A Unique Case Of A Giant Popliteal Artery Aneurysm Presenting As Popliteal Mass. Port J Card Thorac Vasc Surg 2024; 30:75-79. [PMID: 38345877 DOI: 10.48729/pjctvs.390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 12/02/2023] [Indexed: 02/15/2024]
Abstract
INTRODUCTION Popliteal artery aneurysms (PAA) can be very challenging, especially in cases of very large PAAs, with a minimal number of case reports published in the literature. METHODS This is a case report of a 68-year-old male patient with hypertension, hyperlipidemia, diabetes, and schizophrenia who was found to have a giant (10x8x6cm) partially thrombosed PAA, treated with interposition polytetrafluoroethylene (PTFE) graft via a posterior approach. RESULTS Under general anesthesia, the patient was placed in a prone position, and an extended lazy "S" incision was made on the popliteal fossa. After obtaining proximal and distal exposure, the aneurysm sac was skeletonized, preserving the popliteal vein and the tibial nerve. After proximal and distal control was obtained, the patient was systemically heparinized, and the aneurysm sac was opened. Some genicular branches were ligated inside the aneurysm, and part of the aneurysm sac was excised. A 7 mm PTFE graft was used for reconstruction in an end-to-end fashion. Suction drains were placed in the popliteal space, and the fascia and skin were approximated. The patient was discharged home on the 2nd postoperative day on aspirin and statin with ultrasound surveillance. The patient has remained asymptomatic during follow-up with a patent graft. CONCLUSIONS Open surgical repair constitutes the gold standard of care for huge PAAs to prevent distal thromboembolic events and mass pressure effects from the aneurysm. Documentation of additional experience with open repair of huge PAAs would be beneficial and could help clinical decision-making.
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Affiliation(s)
- Panagiotis Volteas
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Stefanos Giannopoulos
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Sonakshi Vatsa
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Edwin C Cheung
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Dimitrios Virvilis
- Department of Vascular and Endovascular Surgery, St Francis Hospital & Heart Center, Roslyn, NY, USA
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Koudounas G, Giannopoulos S, Volteas P, Aljobeh A, Karkos C, Virvilis D. Arteriovenous Fistula Maturation in Patients with Ipsilateral Versus Contralateral Tunneled Dialysis Catheter: A Systematic Review and Meta-analysis. Ann Vasc Surg 2024; 103:14-21. [PMID: 38307236 DOI: 10.1016/j.avsg.2023.11.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 11/10/2023] [Accepted: 11/25/2023] [Indexed: 02/04/2024]
Abstract
BACKGROUND Although it is evident that a prior history of tunneled dialysis catheter (TDC) affects arteriovenous fistula (AVF) function, it is unclear whether its location (contralateral versus ipsilateral to AVF) has any effect on AVF maturation and failure rates. We aimed to document this possible effect. METHODS This systematic review and meta-analysis were performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies comparing outcomes between patients with contralateral TDC (CONTRA group) and those with ipsilateral one (IPSI group) were examined for inclusion. A random effects model meta-analysis of the odds ratio (OR) was conducted. Primary outcomes were AVF functional maturation, assisted maturation, and failure rates. RESULTS Four eligible studies comprising 763 patients were included in the meta-analysis. There were no significant differences in terms of AVF functional maturation (OR: 1.49; 95% confidence interval [CI]: 0.64-3.47; I2 = 83.4%), assisted maturation (OR: 0.59; 95% CI: 0.29-1.19; I2 = 61.4%), and failure rates (OR: 0.67; 95% CI: 0.29-1.58; I2 = 83.3%) between the 2 study groups. CONCLUSIONS TDC laterality seems not to affect fistula maturation rate in patients requiring TDC placement and concurrent AVF creation, but rather, vein- and patient-related characteristics might play a more important role in choosing TDC access site. Further studies are needed to validate these results.
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Affiliation(s)
- Georgios Koudounas
- Vascular Unit, 5th Department of Surgery, Medical School, Aristotle University of Thessaloniki, Hippokratio Hospital, Thessaloniki, Greece
| | - Stefanos Giannopoulos
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY
| | - Panagiotis Volteas
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY
| | - Ahmad Aljobeh
- Department of Surgery, Stony Brook University Hospital, Stony Brook, NY
| | - Christos Karkos
- Vascular Unit, 5th Department of Surgery, Medical School, Aristotle University of Thessaloniki, Hippokratio Hospital, Thessaloniki, Greece
| | - Dimitrios Virvilis
- Department of Vascular and Endovascular Surgery, St Francis Hospital & Heart Center, Roslyn, NY.
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Loufopoulos G, Tasoudis P, Koudounas G, Zoupas I, Madouros N, Sá MP, Karkos CD, Giannopoulos S, Tassiopoulos AK. Long-Term Outcomes of Open Versus Endovascular Treatment for Abdominal Aortic Aneurysm: Systematic Review and Meta-Analysis With Reconstructed Time-to-Event Data. J Endovasc Ther 2023:15266028231204805. [PMID: 37855415 DOI: 10.1177/15266028231204805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
Abstract
BACKGROUND The advent of endovascular techniques has revolutionized the care of patients with uncomplicated abdominal aortic aneurysms. This analysis compares the overall survival and the freedom from reintervention rate between open surgical repair (OSR) and endovascular repair (EVAR) in patients undergoing elective abdominal aortic aneurysm (AAA) repair. METHODS PubMed, Scopus, and Cochrane databases were searched for studies including patients who underwent either OSR or EVAR for uncomplicated AAA. All randomized controlled trials and propensity-score-matched cohort studies reporting on the outcomes of interest were considered eligible for inclusion. The systematic search of the literature was performed by 2 independent investigators in accordance with the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. We conducted 1-stage and 2-stage meta-analyses with Kaplan-Meier-derived time-to-event data and meta-analysis with a random-effects model. RESULTS Thirteen studies met our eligibility criteria, incorporating 13 409 and 13 450 patients in the OSR and EVAR arms, respectively. Patients who underwent open repair had improved overall survival rates compared with those who underwent EVAR (hazard ratio [HR]=0.93, 95% confidence interval [CI]=0.88-0.98, p=0.004) during a mean follow-up of 53.8 (SD=29.8) months and this was validated by the 2-stage meta-analysis (HR=0.89, 95% CI=0.8-0.99, p=0.03, I2=62.25%). Splitting timepoint analysis suggested that EVAR offers better survival outcome compared with OSR in the first 11 months following elective intervention (HR=1.37, 95% CI=1.22-1.54, p<0.0001), while OSR offers a significant survival advantage after the 11-month timepoint and up to 180 months (HR=0.84, 95% CI=0.8-0.89, p<0.0001). Similarly, freedom from reintervention was found to be significantly better in EVAR patients (HR=1.28, 95% CI=1.14-1.44, p<0.0001) within the first 30 days. After the first month postrepair, however, OSR demonstrated higher freedom-from-reintervention rates compared with EVAR that remained significant for up to 168 months during follow-up (HR=0.73, 95% CI=0.66-0.79, p<0.0001). CONCLUSIONS Despite the first-year survival advantage of EVAR in patients undergoing elective AAA repair, OSR was associated with a late survival benefit and decreased risk for reintervention in long-term follow-up. CLINICAL IMPACT Open surgical repair for uncomplicated abdominal aortic aneurysm offers better long-term outcomes in terms of survival and freedom from reintervention rate compared to the endovascular approach but in the first year it carries a higher risk of mortality. The novelty of our study lies that instead of comparing study-level effect estimates, we analyzed reconstructed individual patient-level data. This offered us the opportunity to perform our analyses with mathematically robust and flexible survival models, which was proved to be crucial since there was evidence of different hazard over time. Our findings underline the need for additional investigation to clarify the significance of open surgical repair when compared to the latest endovascular devices and techniques within the evolving era of minimally invasive procedures.
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Affiliation(s)
- Georgios Loufopoulos
- Cardiothoracic and Vascular Surgery Working Group, Society of Junior Doctors, Athens, Greece
- Department of Surgery, Saint-Imier Hospital, Saint-Imier, Switzerland
| | - Panagiotis Tasoudis
- Cardiothoracic and Vascular Surgery Working Group, Society of Junior Doctors, Athens, Greece
| | - Georgios Koudounas
- Cardiothoracic and Vascular Surgery Working Group, Society of Junior Doctors, Athens, Greece
| | - Ioannis Zoupas
- Cardiothoracic and Vascular Surgery Working Group, Society of Junior Doctors, Athens, Greece
| | - Nikolaos Madouros
- Cardiothoracic and Vascular Surgery Working Group, Society of Junior Doctors, Athens, Greece
| | - Michel Pompeu Sá
- UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Christos D Karkos
- Department of Vascular Surgery, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Stefanos Giannopoulos
- Department of Vascular Surgery, Stony Brook University School of Medicine, Stony Brook, NY, USA
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Tsouknidas I, Giannopoulos S, Tassiopoulos A, Koullias G. Treatment of arteriovenous access pseudoaneurysms using ultrasound guided balloon assisted thrombin injection: Two cases and systematic review of the literature. J Vasc Access 2023:11297298231182158. [PMID: 37337453 DOI: 10.1177/11297298231182158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND Arteriovenous fistula pseudoaneurysm (AVF-PSA) is a common complication, usually caused during dialysis cannulation, which traditionally has been treated with open and less frequently endovascular techniques. Thrombin injection, although established in the treatment of arterial pseudoaneurysms, has barely been used in the treatment of AVF-PSA, due to concerns for AVF thrombosis or proximal embolization. METHODS A systematic review was performed according to the PRISMA 2020 guidelines. PubMed and Cochrane Central databases were reviewed and all clinical reports on AVF-PSA balloon assisted percutaneous thrombin injection through July 2022 were included. The electronic search yielded five case reports. Due to between-study differences and small sample size, the findings were summarized from each report, but the results were not pooled. Additionally, we present our own experience on two patients with AVF-PSA that were treated with balloon assisted percutaneous thrombin injection. RESULTS A total of five case reports (no of patients: 7, including ours) were included for review. Most of the patients were male (n = 6) and the mean age was 65.9 years. The average size of the PSA was 1.6 cm. In all cases a balloon was inflated to prevent thrombin and thrombotic material intrusion into the fistula lumen, prior to thrombin injection. In one patient n-butyl cyanoacrylate and Lipiodol were used, due to thrombin non availability. Recurrence was reported in only one patient, and average follow-up is 16 months. CONCLUSIONS Thrombin injection with concomitant balloon inflation seems to be a safe and effective treatment for arteriovenous fistula pseudoaneurysms. Future studies should be aimed at evaluating the long-term outcomes of such minimally invasive techniques.
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Affiliation(s)
- Ioannis Tsouknidas
- Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Stefanos Giannopoulos
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Apostolos Tassiopoulos
- Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - George Koullias
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
- Limb Preservation Center, Division of Vascular and Endovascular Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
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Melian CM, Giannopoulos S, Volteas P, Virvilis D. Intravascular Ultrasound in Treating Iliac Vein Compression With Endovascular Stenting: A Necessary Tool for Optimal Outcomes. Vasc Endovascular Surg 2023; 57:299-305. [PMID: 36472054 DOI: 10.1177/15385744221145143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Symptomatic compression of the left common iliac vein between the right common iliac artery and spinal vertebrae is referred to as May-Thurner Syndrome (MTS). Atypical cases of MTS including compression of the left external iliac vein, right iliac vein or the inferior vena cava can also coexist and cause double vein compression. Current literature suggests that endovascular treatment including thrombolysis, thrombectomy, venoplasty and stent placement to correct the mechanical obstruction together with anticoagulation therapy is safe and a reasonable management for patients with MTS. Intravascular ultrasound (IVUS) can aid in the diagnosis and the operative planning of MTS, especially regarding sizing and precise deployment of venous stents. Here we present 2 unique atypical cases of MTS with double left iliac vein compression treated endovascularly with stent placement along the common and external iliac vein with the assistance of IVUS.
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Affiliation(s)
- Christina M Melian
- 480303Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Stefanos Giannopoulos
- Division of Vascular and Endovascular Surgery, Department of Surgery, 22161Stony Brook University Hospital, Stony Brook, NY, USA
| | - Panagiotis Volteas
- Division of Vascular and Endovascular Surgery, Department of Surgery, 22161Stony Brook University Hospital, Stony Brook, NY, USA
| | - Dimitrios Virvilis
- Division of Vascular and Endovascular Surgery, Department of Surgery, 22161Stony Brook University Hospital, Stony Brook, NY, USA
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Koullias G, Tsouknidas I, Tibbets G, Giannopoulos S, Tassiopoulos A. Amputation Stumps Complicated by Dehiscence with Bone Exposure: Preserving Valuable Real Estate. J Vasc Surg 2023. [DOI: 10.1016/j.jvs.2023.01.140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
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Volteas P, Giannopoulos S, Cheung E, Virvilis D. A Giant Popliteal Artery Aneurysm Presenting as Popliteal Mass: Surgery as a Getaway in the Endovascular Era. J Vasc Surg 2023. [DOI: 10.1016/j.jvs.2023.01.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
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Melian CM, Giannopoulos S, Tsouknidas I, Volteas P, Virvilis D, Koullias GJ. Geniculate Artery Endovascular Embolization Post-Total Knee Arthroplasty for Hemarthrosis Treatment: A Systematic Review of the Literature. J Endovasc Ther 2023:15266028231157642. [PMID: 36869681 DOI: 10.1177/15266028231157642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
PURPOSE To provide an updated systematic review on the use of geniculate artery embolization (GAE) in the management of recurrent hemarthrosis post-total knee arthroplasty (TKA). MATERIALS AND METHODS A systematic literature review was conducted, and all clinical reports in the English language from inception to July 2022 were identified. References were manually reviewed to identify additional studies. Demographics, procedural techniques, post-procedural complications, and follow-up data were extracted and analyzed using STATA 14.1. RESULTS A total of 20 studies (9 case reports, 11 case series; n= 214) were included for review. In all cases, patients underwent coil embolization of one or more geniculate arteries. Procedure success was reported in 94.8% (n=203/214) of cases without perioperative adverse events. Improvement of symptoms was seen in 72.6% (n=119/164) of cases, with 30.7% (n=58/189) of cases requiring repeat embolization. Recurrent hemarthrosis occurred in 22.2% (n=22/99) of cases over a mean follow-up of 48 months. CONCLUSION GAE appears to be a safe and effective treatment for recurrent hemarthrosis following TKA. Future studies in the form of randomized controlled trials should be conducted to further evaluate such embolization techniques and compare outcomes between GAE and standard techniques. CLINICAL IMPACT Conservative management of post total knee arthroplasty (TKA) hemarthrosis is successful in only one third of cases. Geniculate artery embolization (GAE) has recently gained attention due to its minimally invasive nature compared to open or arthroscopic synovectomy promising faster rehabilitation, decreased infection rates and less additional surgeries. The purpose of this article was to summarize current literature, provide an updated review on the use of GAE in the management of recurrent hemarthrosis post-TKA and describe immediate and long-term outcomes in an effort to help optimize current treatment algorithms.
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Affiliation(s)
- Christina M Melian
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Stefanos Giannopoulos
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Ioannis Tsouknidas
- Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Panagiotis Volteas
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Dimitrios Virvilis
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - George J Koullias
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
- Limb Preservation Center, Division of Vascular and Endovascular Surgery, Stony Brook University Hospital, Stony Brook, NY
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Volteas P, Giannopoulos S, Aljobeh AZ, Koudounas G, Pesce AR, Virvilis D. Superficial Femoral Artery Remote Endarterectomy: A Systematic Review And Meta-analysis. Ann Vasc Surg 2023:S0890-5096(23)00124-3. [PMID: 36868461 DOI: 10.1016/j.avsg.2023.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 02/19/2023] [Accepted: 02/20/2023] [Indexed: 03/05/2023]
Abstract
BACKGROUND Objective: Remote Superficial Femoral Artery Endarterectomy (RSFAE) is a hybrid procedure with low risk for peri-operative complications and promising patency rates over time. The aim of this study was to summarize current literature and to determine the role of RSFAE in limb salvage with regards to technical success, limitations, patency rates and long-term outcomes. METHODS This systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS Overall 19 studies were identified, comprising 1,200 patients with extensive femoropopliteal disease among whom 40% presented with chronic limb threatening ischemia. The average technical success rate was 96%, with a 7% rate for peri-operative distal embolization and 13% rate for SFA perforation. The primary patency was 64% and 56%, primary assisted patency was 82% and 77% and secondary patency was 89% and 72% at 12 and 24 months follow up respectively. CONCLUSION For long femoropopliteal TASC C/D lesions, RSFAE appears to be a minimally invasive hybrid procedure with acceptable perioperative morbidity, low mortality, and acceptable patency rates. RSFAE should be considered an alternative to open surgery or a bridge to bypass procedure.
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Affiliation(s)
- Panagiotis Volteas
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Stefanos Giannopoulos
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Ahmad Z Aljobeh
- Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Georgios Koudounas
- Vascular Unit, 5th Department of Surgery, Medical School, Aristotle University of Thessaloniki, Hippokratio Hospital, Thessaloniki, Greece
| | - Alexa Rae Pesce
- Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Dimitrios Virvilis
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA.
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Melian CM, Giannopoulos S, Tsouknidas I, Volteas P, Virvilis D, Nicholson J, Koullias GJ. Endovascular Repair Of Popliteal Artery Injury Post-Total Knee Arthroplasty is Safe and Effective: A Case Report And Systematic Review Of the Literature. Ann Vasc Surg 2023:S0890-5096(23)00105-X. [PMID: 36868455 DOI: 10.1016/j.avsg.2023.01.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 01/16/2023] [Accepted: 01/30/2023] [Indexed: 03/05/2023]
Abstract
BACKGROUND Objective: Popliteal artery pseudoaneurysms are a rare but serious complication following total knee arthroplasty (TKA) that have been traditionally managed with open surgical repair. Endovascular stenting, while relatively new, offers a promising alternative that is less invasive and may reduce the risk of peri-operative complications. MATERIALS AND METHODS A systematic literature review was conducted and all clinical reports in the English language from inception to July 2022 were identified. References were manually reviewed to identify additional studies. Demographics, procedural techniques, post-procedural complications and follow-up data were extracted and analyzed using STATA 14.1. Additionally, we present a case of a patient with a popliteal pseudoaneurysm treated with a covered endovascular stent. RESULTS A total of 14 studies (12 case reports, 2 case series; n= 17) were included for review. In all cases a stent-graft was placed across the popliteal artery lesion. In 5 out of 11 cases popliteal artery thrombus was present and treated with adjacent modalities (i.e. mechanical thrombectomy, balloon angioplasty, etc). Procedure success was reported in all cases without perioperative adverse events. Stents remained patent over a median follow up of 32 weeks (Interquartile range IQR: 36). In all but one case the patients experienced immediate symptom relief and had an uneventful recovery. For our case, at 12 months follow up the patient was asymptomatic, and ultrasound demonstrated vessel patency. CONCLUSION Endovascular stenting is a safe and effective treatment for popliteal pseudoaneurysms. Future studies should be aimed at evaluating the long-term outcomes of such minimally invasive techniques.
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Affiliation(s)
- Christina M Melian
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Stefanos Giannopoulos
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA, Limb Preservation Center, Division of Vascular and Endovascular Surgery, Stony Brook University Hospital, Stony Brook, NY
| | - Ioannis Tsouknidas
- Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Panagiotis Volteas
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA, Limb Preservation Center, Division of Vascular and Endovascular Surgery, Stony Brook University Hospital, Stony Brook, NY
| | - Dimitrios Virvilis
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA, Limb Preservation Center, Division of Vascular and Endovascular Surgery, Stony Brook University Hospital, Stony Brook, NY
| | - James Nicholson
- Department of Orthopaedic Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - George J Koullias
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA, Limb Preservation Center, Division of Vascular and Endovascular Surgery, Stony Brook University Hospital, Stony Brook, NY; Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
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Volteas P, Giannopoulos S, Tassiopoulos A, Virvilis D. Impact of vaccination status and anticoagulation on venous thromboembolism risk and outcomes in coronavirus disease 2019 patients. J Vasc Surg Venous Lymphat Disord 2023; 11:474-475. [PMID: 36822799 PMCID: PMC9943528 DOI: 10.1016/j.jvsv.2022.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 10/28/2022] [Indexed: 02/24/2023]
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Giannopoulos S, Volteas P, Virvilis D. Specialty Balloons for Vessel Preparation During Infrainguinal Endovascular Revascularization Procedures: A Review of Literature. Vasc Endovascular Surg 2023:15385744231156077. [PMID: 36745906 DOI: 10.1177/15385744231156077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Balloon angioplasty with/without utilizing drug eluting technology or stenting constitutes the treatment of choice for a significant percentage of patients with peripheral artery disease requiring an intervention. However, in cases of diffuse disease and plaque complexity, angioplasty may lead to dissection, recoil, and/or early restenosis, making vessel preparation a key component for successful and durable endovascular revascularization outcome. This review of literature aims to present contemporary data for several commercially available specialty balloons that have been designed to minimize the arterial wall stress of conventional balloon angioplasty and facilitate technical success, as well as long-term patency.
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Affiliation(s)
- Stefanos Giannopoulos
- Division of Vascular and Endovascular Surgery, Department of Surgery, 22161Stony Brook University Hospital, Stony Brook, NY, USA
| | - Panagiotis Volteas
- Division of Vascular and Endovascular Surgery, Department of Surgery, 22161Stony Brook University Hospital, Stony Brook, NY, USA
| | - Dimitrios Virvilis
- Division of Vascular and Endovascular Surgery, Department of Surgery, 22161Stony Brook University Hospital, Stony Brook, NY, USA
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Koudounas G, Giannopoulos S, Volteas P, Karkos C, Virvilis D, Tassiopoulos AK. De Novo Acute Type B Aortic Dissection in Two Patients with Previous Infrarenal Endovascular Aortic Aneurysm Repair with Endo-Anchors. J Vasc Surg Cases Innov Tech 2023. [DOI: 10.1016/j.jvscit.2023.101120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
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15
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Nagraj S, Tzoumas A, Kakargias F, Giannopoulos S, Ntoumaziou A, Kokkinidis DG, Alvarez Villela M, Latib A. Hybrid coronary revascularization (HCR) versus coronary artery bypass grafting (CABG) in multivessel coronary artery disease (MVCAD): A meta-analysis of 14 studies comprising 4226 patients. Catheter Cardiovasc Interv 2022; 100:1182-1194. [PMID: 36335643 DOI: 10.1002/ccd.30446] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 09/08/2022] [Accepted: 10/08/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To compare the outcomes of hybrid coronary revascularization (HCR) with traditional coronary artery bypass grafting (CABG) in multivessel coronary artery disease (MVCAD). BACKGROUND HCR has emerged as an alternative to CABG in patients with MVCAD. Through minimally invasive surgical techniques, HCR carries the potential for faster recovery postoperatively, fewer complications, and lower utilization of resources. METHODS Systematic search of electronic databases was conducted up to December 2021 and studies comparing HCR with CABG in the treatment of MVCAD were included in this meta-analysis. Primary outcomes of interest were incidence of 5-year mortality and major adverse cardiac and cerebral event (MACCE). RESULTS Fourteen studies (12 observational studies and 2 randomized controlled trials) comprising 4226 patients were included. The rates of 5-year mortality (odds ratios [OR]: 1.55; 95% confidence interval [CI]: 0.92-2.62; I2 = 83.0%) and long-term MACCE (OR: 0.97; 95% CI: 0.47-2.01; I2 = 74.7%) were comparable between HCR and CABG groups. HCR was associated with a significantly lower likelihood of perioperative blood transfusion (OR: 0.36; 95% CI: 0.25-0.51; I2 = 55.9%), shorter mean hospital stay (weighted mean difference: -2.04; 95% CI: -2.60 to -1.47; I2 = 54%), and risk of postoperative acute kidney injury (OR: 0.45; 95% CI: 0.23-0.88; p = 0.02). CABG demonstrated a lower likelihood of requiring long-term repeat revascularization (OR: 1.51; 95% CI: 1.03-2.20; I2 = 18%) over a follow-up duration of 29.14 ± 21.75 months. CONCLUSION This meta-analysis suggests that HCR is feasible and safe for the treatment of MVCAD. However, benefits of HCR should be carefully weighed against the increased long-term risk of repeat-revascularization when selecting patients, and further studies evaluating differences in long-term mortality between HCR and CABG are required.
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Affiliation(s)
- Sanjana Nagraj
- Jacobi Medical Center/Albert Einstein College of Medicine, The Bronx, New York, USA
| | - Andreas Tzoumas
- University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Fotis Kakargias
- Department of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
| | | | - Damianos G Kokkinidis
- Section of Cardiovascular Medicine, Yale University School of Medicine, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Miguel Alvarez Villela
- Division of Cardiology, Jacobi Medical Center/Albert Einstein College of Medicine, The Bronx, New York, USA
| | - Azeem Latib
- Department of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, New York City, New York, USA
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16
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Giannopoulos S, Sagris M, Giannopoulos S, Tzoumas A, Kokkinidis DG, Texakalidis P, Koutsias G, Volteas P, Jing L, Malgor RD. Embolic protection devices for carotid artery stenting: A network meta-analysis. Vascular 2022:17085381221140616. [PMID: 36394946 DOI: 10.1177/17085381221140616] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
OBJECTIVES Carotid artery stenting (CAS) is an alternative treatment option for patients at high risk for carotid endarterectomy (CEA) but has been correlated with increased risk for distal embolization and periprocedural stroke despite the use of adjunctive embolic protection devices (EPD). This study compared four types of EPDs and their intra and periprocedural related complications. METHODS A systematic review of the literature was conducted in PubMed/Medline to identify studies that investigated the outcomes of CAS with adjuvant use of EPDs, including Proximal Balloon (PB), Distal Filter (DF), and Distal Balloon (DB) strategy. Continuous flow reversal performed via transcarotid approach by a commercially available device as an embolic protection strategy was intentionally excluded based on its distinct procedural characteristics and lack of availability outside of the United States. This network meta-analysis was performed according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. RESULTS Overall, 45 studies, consisting of 7600 participants satisfied the predetermined search criteria and were included in this network meta-analysis. Overall, 13 studies provided data regarding the number of patients with new ischemic lesions detected in the DW-MRI. DF (OR: 3.15; 95% CI: 1.54-6.44; p = 0.002) and DB (OR: 2.28; 95% CI: 1.58-3.29; p < 0.001) were associated with higher odds of new ischemic lesions compared to PB on DW-MRI imaging. No statistical difference was identified between DB versus DF groups (OR: 1.48; 95% CI: 0.73-2.59; p = 0.317). 36 and 27 studies reported on periprocedural stroke and transient ischemic attack (TIA) rates, respectively, showing similar odds of neurologic adverse events between all three groups. CONCLUSIONS PB deployment during CAS is superior to DF and DB in preventing distal embolization phenomena. However, no statistically significant difference in TIA and stroke rate was found among any of the analyzed EPD groups. Further research is warranted to investigate the association of embolic phenomena on imaging after CAS with clinically significant neurologic deficits.
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Affiliation(s)
- Stefanos Giannopoulos
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | | | - Spyridon Giannopoulos
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Andreas Tzoumas
- Department of Medicine, University of Cincinnati Health, Cincinnati, OH, USA
| | - Damianos G Kokkinidis
- Section of Cardiovascular Medicine, Yale University/Yale New Haven Hospital, New Haven, CT, USA
| | - Pavlos Texakalidis
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - George Koutsias
- 37783Aristotle University of Thessaloniki, Division of Vascular Surgery, 2(nd) Department of Surgery, Thessaloniki, Greece
| | - Panagiotis Volteas
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Li Jing
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Rafael D Malgor
- Division of Vascular Surgery and Endovascular Therapy, 129263University of Colorado, Anschutz Medical Center, Aurora, CO, USA
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Melian CM, Giannopoulos S, Lee M, Kokkosis AA. A unique case of acute bilateral internal iliac deep vein thrombosis leading to right iliofemoral venous outflow obstruction. J Vasc Surg Cases Innov Tech 2022; 9:101053. [PMID: 36852315 PMCID: PMC9958087 DOI: 10.1016/j.jvscit.2022.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 10/18/2022] [Indexed: 11/16/2022] Open
Abstract
Venous thromboembolism has been associated with high morbidity and mortality, with a cost burden for the U.S. health care system owing to secondary complications such as pulmonary embolism and post-thrombotic syndrome. The current standard of therapy for acute deep vein thrombosis (DVT) is anticoagulation. For patients with venous outflow obstruction of the iliac vein system, several minimally invasive recanalization techniques are now available. In the present report, we have described a case of bilateral internal iliac DVT that had progressed to right-sided iliofemoral DVT in a young athletic adult, in the absence of anatomic abnormalities, that was treated with thrombolysis-free mechanical thrombectomy.
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Affiliation(s)
- Christina M. Melian
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY
| | - Stefanos Giannopoulos
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY
| | - Mary Lee
- Jerry Pettis Memorial Veterans Hospital, VA Loma Linda Healthcare System, Loma Linda, CA
| | - Angela A. Kokkosis
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY,Correspondence: Angela A. Kokkosis, MD, Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, 101 Nicolls Rd, Stony Brook, NY 11794
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18
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Koudounas G, Giannopoulos S, Volteas P, Virvilis D. A unique case of hypoplastic inferior vena cava leading to bilateral iliofemoral venous outflow obstruction and review of literature. J Vasc Surg Cases Innov Tech 2022; 8:842-849. [PMID: 36561354 PMCID: PMC9763364 DOI: 10.1016/j.jvscit.2022.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 10/17/2022] [Indexed: 11/07/2022] Open
Abstract
Venous thromboembolism (VTE) is a common cardiovascular disease associated with high rates of morbidity and mortality whereas it induces substantial health care costs and increased use of resources. The current standard of treatment for acute deep vein thrombosis (DVT) is anticoagulation, although revascularization can be considered in younger patients with severe symptoms and extensive thrombus burden to prevent long-term sequalae of VTE (eg, recurrent DVTs, post-thrombotic syndrome post-pulmonary embolism syndrome, and chronic thromboembolic pulmonary hypertension). A rare cause of VTE is anomalous development of the inferior vena cava (IVC) and can challenge endovascular revascularization. This case report describes a case of hypoplastic supra hepatic IVC, associated with distal IVC occlusion and bilateral lower extremity DVTs treated successfully with suction thrombectomy and on table only thrombolysis, avoiding the higher risk for major bleeding, intensive care unit admission and prolonged hospitalization associated with prolonged tissue plasminogen activator infusion.
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Affiliation(s)
| | | | | | - Dimitrios Virvilis
- Correspondence: Dimitrios Virvilis, MD, Stony Brook University Hospital, 101 Nicolls Rd, Stony Brook, NY 11794
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19
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Archontakis-Barakakis P, Li W, Kalaitzoglou D, Tzelves L, Manolopoulos A, Giannopoulos S, Giamouzis G, Giannakoulas G, Batsidis A, Palaiodimos L, Ntaios G, Lip GYH, Kokkinidis DG. Effectiveness and Safety of Intracranial Events associated with the use of Direct Oral Anticoagulants for Atrial Fibrillation: A Systematic Review and Meta-analysis of 92 Studies. Br J Clin Pharmacol 2022; 88:4663-4675. [PMID: 35853612 DOI: 10.1111/bcp.15464] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 04/17/2022] [Accepted: 07/14/2022] [Indexed: 11/28/2022] Open
Abstract
AIM Observational studies have investigated the effectiveness and safety of Direct Oral Anticoagulants (DOACs) and Vitamin K antagonists (VKA) used in Non-Valvular Atrial Fibrillation. We performed a systematic review and meta-analysis assessing the risk of ischemic stroke, Thromboembolism (TE) and Intracranial Hemorrhage (ICH) associated with the use of DOACs and VKA. METHODS Medline and Embase were systematically searched until April 2021. Observational studies were gathered and hazard ratios (HRs) with 95% confidence intervals (CI) were extracted. Subgroup analyses based on DOAC doses, history of chronic kidney disease, stroke, exposure to VKA, age, and gender were performed. A random-effects model was used. RESULTS We included 92 studies and performed 107 comparisons. Apixaban was associated with lower risk of stroke [HR: 0.82, 95% CI: 0.68-0.99] compared to Dabigatran. Rivaroxaban was associated with lower risk of stroke [HR: 0.90, 95% CI: 0.83-0.98] compared to VKA. Dabigatran [HR: 0.85, 95% CI: 0.80-0.91], Rivaroxaban [HR: 0.83, 95% CI: 0.77-0.89] and Apixaban [HR: 0.75, 95% CI: 0.65-0.86] were associated with lower risk for TE/stroke compared to VKA. Apixaban [HR: 1.32, 95% CI: 1.03-1.68] and Rivaroxaban [HR: 1.58, 95% CI: 1.31-1.89] were associated with higher risk of ICH compared to Dabigatran. Dabigatran [HR: 0.48, 95% CI: 0.44-0.52], Apixaban [HR: 0.60, 95% CI: 0.49-0.73] and Rivaroxaban [HR: 0.73, 95% CI: 0.65-0.81] were associated with lower risk of ICH compared to VKA. CONCLUSIONS Our study demonstrated significant differences in the risk of ischemic stroke, TE/stroke, and ICH associated with individual DOACs compared to both other DOACs and VKA.
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Affiliation(s)
| | - Weijia Li
- Department of Medicine, Albert Einstein College of Medicine/Jacobi Medical Center, Bronx, NY, USA
| | - Dimitrios Kalaitzoglou
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Lazaros Tzelves
- 2nd Department of Urology, National and Kapodistrian University of Athens, Sismanogleion Hospital, Athens, Greece
| | | | - Stefanos Giannopoulos
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | | | - George Giannakoulas
- Division of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Leonidas Palaiodimos
- Department of Medicine, Albert Einstein College of Medicine/Jacobi Medical Center, Bronx, NY, USA
| | - George Ntaios
- Department of Internal Medicine, University of Thessaly, Larissa, Greece
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Damianos G Kokkinidis
- Section of Cardiovascular Medicine, Yale University School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
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20
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Sagris M, Katsaros I, Giannopoulos S, Rosenberg RD, Altin SE, Rallidis L, Mena-Hurtado C, Armstrong EJ, Kokkinidis DG. Statins and statin intensity in peripheral artery disease. VASA 2022; 51:198-211. [PMID: 35673949 DOI: 10.1024/0301-1526/a001012] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background: Peripheral artery disease (PAD) affects more than 202 million people worldwide. Several studies have shown that patients with PAD are often undertreated, and that statin utilization is suboptimal. European and American guidelines highlight statins as the first-line lipid-lowering therapy to treat patients with PAD. Our objective with this meta-analysis was to further explore the impact of statins on lower extremities PAD endpoints and examine whether statin dose (high vs. low intensity) impacts outcomes. Patients and methods: We performed a systematic review and meta-analysis according to the PRISMA guidelines. Any study that presented a comparison of use of statins vs. no statins for PAD patients or studies comparing high vs. low intensity statins were considered to be potentially eligible. We excluded studies with only critical limb threatening ischemia (CLTI) patients. The Medline (PubMed) database was searched up to January 31, 2021. A random effects meta-analysis was performed. Results: In total, 39 studies and 275,670 patients were included in this meta-analysis. In total, 136,025 (49.34%) patients were on statins vs. 139,645 (50.66%) who were not on statins. Statin use was associated with a reduction in all cause-mortality by 42% (HR: 0.58, 95% CI: 0.49-0.67, p<0.01) and cardiovascular death by 43% (HR: 0.57, 95% CI: 0.40-0.74, p<0.01). Statin use was associated with an increase in amputation-free survival by 56% (HR: 0.44, 95% CI: 0.30-0.58, p<0.01). The risk of amputation and loss of patency were reduced by 35% (HR: 0.65, 95% CI: 0.41-0.89, p<0.01) and 46% (HR: 0.54, 95% CI: 0.34-0.74, p<0.01), respectively. Statin use was also associated with a reduction in the risk of major adverse cardiovascular events (MACE) by 35% (HR: 0.65, 95% CI: 0.51-0.80, p<0.01) and myocardial infarction rates by 41% (HR: 0.59, 95% CI: 0.33-0.86, p<0.01). Among patients treated with statins, the high-intensity treatment group was associated with a reduction in all cause-mortality by 36% (HR: 0.64, 95% CI: 0.54-0.74, p<0.01) compared to patients treated with low intensity statins. Conclusions: Statin treatment among patients with PAD was associated with a statistically significant reduction in all-cause mortality, cardiovascular mortality, MACE, risk for amputation, or loss of patency. Higher statin dose seems to be associated with improved outcomes.
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Affiliation(s)
- Marios Sagris
- Department of Internal Medicine, General Hospital of Nikaia, Piraeus, Athens, Greece
| | | | - Stefanos Giannopoulos
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, New York, USA
| | - Russell D Rosenberg
- Section of Cardiovascular Medicine, Yale University School of Medicine/Yale New Haven Hospital, New Haven, CT, USA.,Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - S Elissa Altin
- Section of Cardiovascular Medicine, Yale University School of Medicine/Yale New Haven Hospital, New Haven, CT, USA
| | - Loukianos Rallidis
- Department of Cardiology, University General Hospital Attikon, Medical School, National and Kapodistrian University of Athens, Greece
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Ehrin J Armstrong
- Adventist Heart & Vascular Institute, Adventist Health St. Helena, CA, USA
| | - Damianos G Kokkinidis
- Section of Cardiovascular Medicine, Yale University School of Medicine/Yale New Haven Hospital, New Haven, CT, USA
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21
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Volteas P, Drakos P, Alkadaa LN, Cleri NA, Asencio AA, Oganov A, Giannopoulos S, Saadon JR, Mikell CB, Rubano JA, Labropoulos N, Tassiopoulos AK, Mofakham S, Bannazadeh M. Low-Molecular-Weight Heparin Compared to Unfractionated Heparin in Critically Ill COVID-19 Patients. J Vasc Surg Venous Lymphat Disord 2022; 10:1128-1136. [PMID: 35716998 PMCID: PMC9212478 DOI: 10.1016/j.jvsv.2022.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 04/05/2022] [Accepted: 04/26/2022] [Indexed: 11/30/2022]
Abstract
Background Thrombosis in COVID-19 worsens mortality. In our study, we sought to investigate how the dose and type of anticoagulation (AC) can influence patient outcomes. Methods This is a single-center retrospective analysis of critically ill intubated patients with COVID-19, comparing low-molecular-weight heparin (LMWH) and unfractionated heparin (UFH) at therapeutic and prophylactic doses. Of 218 patients, 135 received LMWH (70 prophylactic, 65 therapeutic) and 83 UFH (11 prophylactic, 72 therapeutic). The primary outcome was mortality. Secondary outcomes were thromboembolic complications confirmed on imaging and major bleeding complications. Cox proportional-hazards regression models were used to determine whether the type and dose of AC were independent predictors of survival. We performed Kaplan-Meier survival analysis to compare the cumulative survivals. Results Overall, therapeutic AC, with either LMWH (65% vs 79%, P = .09) or UFH (32% vs 46%, P = .73), conveyed no survival benefit over prophylactic AC. UFH was associated with a higher mortality rate than LMWH (66% vs 28%, P = .001), which was also evident in the multivariable analysis (LMWH vs UFH mortality, hazard ratio: 0.47, P = .001) and in the Kaplan-Meier survival analysis. Thrombotic and bleeding complications did not depend on the AC type (prophylactic LMWH vs UFH: thrombosis P = .49, bleeding P = .075; therapeutic LMWH vs UFH: thrombosis P = .5, bleeding P = .17). When comparing prophylactic with therapeutic AC, the rate of both thrombotic and bleeding complications was higher with the use of LMWH compared with UFH. In addition, transfusion requirements were significantly higher with both therapeutic LMWH and UFH. Conclusions Among intubated critically ill COVID-19 intensive care unit patients, therapeutic AC, with either LMWH or UFH, conveyed no survival benefit over prophylactic AC. AC with LMWH was associated with higher cumulative survival compared with AC with UFH.
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Affiliation(s)
- Panagiotis Volteas
- Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, USA
| | - Panagiotis Drakos
- Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, USA
| | - Leor N Alkadaa
- Department of Neurosurgery, Renaissance School of Medicine, Stony Brook, NY, USA
| | - Nathaniel A Cleri
- Department of Neurosurgery, Renaissance School of Medicine, Stony Brook, NY, USA
| | - Anthony A Asencio
- Department of Neurosurgery, Renaissance School of Medicine, Stony Brook, NY, USA
| | - Anthony Oganov
- Department of Neurosurgery, Renaissance School of Medicine, Stony Brook, NY, USA
| | - Stefanos Giannopoulos
- Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, USA; Division of Vascular Surgery, Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, USA
| | - Jordan R Saadon
- Department of Neurosurgery, Renaissance School of Medicine, Stony Brook, NY, USA
| | - Charles B Mikell
- Department of Neurosurgery, Renaissance School of Medicine, Stony Brook, NY, USA
| | - Jerry A Rubano
- Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, USA
| | - Nicos Labropoulos
- Division of Vascular Surgery, Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, USA
| | - Apostolos K Tassiopoulos
- Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, USA; Division of Vascular Surgery, Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, USA
| | - Sima Mofakham
- Department of Neurosurgery, Renaissance School of Medicine, Stony Brook, NY, USA.
| | - Mohsen Bannazadeh
- Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, USA; Division of Vascular Surgery, Department of Surgery, Renaissance School of Medicine, Stony Brook, NY, USA.
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22
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Giannopoulos S, Secemsky EA, Schneider PA, Armstrong EJ. Concomitant Drug-Coated Balloon Angioplasty With Bail-Out Use of Eluvia Drug-Eluting Stent: Is There Any Downside to a Double Dose of Paclitaxel? J Invasive Cardiol 2022; 34:E469-E476. [PMID: 35652710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE The application of 2 distinct and simultaneously applied drug-delivery platforms for the treatment of peripheral artery disease (PAD) has not been studied. This study investigated the outcomes of femoropopliteal disease treated with drug-coated balloon (DCB) followed by placement of drug-eluting stent (DES) when a bail-out procedure is required. METHODS This was a single-center, retrospective study enrolling 22 consecutive patients (23 limbs) treated with DCB + DES. Bail-out stenting was performed for flow-limiting postangioplasty dissections and/or suboptimal angiographic result, such as residual stenosis. Procedural success (<30% residual stenosis) and the incidence of major adverse limb event (MALE) during an average follow-up of 15.2 months were estimated. RESULTS Among the 22 patients (23 limbs), 14 presented with claudication and 8 with critical limb ischemia. The majority of the lesions were Trans-Atlantic Inter-Society Consensus class C/D, with a mean lesion length of 321 ± 130 mm. DCB angioplasty was performed with Stellarex (Philips) in 6 cases and In.Pact DCB (Medtronic) in 16 cases. Eluvia DES (Boston Scientific) was used for bail-out stenting in all cases (in 10 limbs for flow-limiting dissection and in 13 limbs for suboptimal angiographic result due to significant residual stenosis and/or recoil). A single Eluvia DES was used in 15 cases, while multiple Eluvia DESs were used in 8 cases. Procedural success was achieved in all but 1 case where persistent recoil occurred in a heavily calcified lesion. During an average follow-up of 15 months, restenosis or reocclusion of the target vessel was observed in 6 cases (26.1%), although only 3 patients required repeat revascularization (13.0%). During follow-up, 1 death and 1 major amputation occurred, both in patients who had originally presented with critical limb ischemia. Additionally, on routine duplex ultrasound, there were no cases of aneurysm formation at the sites of Eluvia stent placement. CONCLUSION DCB with provisional DES implantation could be a viable treatment option for cases of suboptimal DCB results, without apparent additional cardiovascular or limb-related risks. Additional studies are needed to determine the risks and benefits of double-dose paclitaxel approach, especially for those patients with significant residual stenosis after DCB.
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Affiliation(s)
| | | | | | - Ehrin J Armstrong
- University of Colorado, 1600 N Wheeling Street, Aurora, CO 80045 USA.
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Siada S, Malgor EA, Al-Musawi M, Giannopoulos S, Jacobs DL, Malgor RD. Iliac Artery Endoconduits Should be the Preferred Adjunctive Access Procedure to Facilitate Complex Endovascular Aortic Aneurysm Repair. Vasc Endovascular Surg 2022; 56:376-384. [PMID: 35200054 DOI: 10.1177/15385744211037616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Iliac artery anatomy can have a dramatic impact on the success of endovascular complex aortic aneurysm (CAA) procedures as endograft delivery systems need to be advanced and manipulated through these access vessels. The aim of this study was to evaluate the outcomes of iliac artery conduits with emphasizes on open vs endovascular conduits performed to facilitate CAA endovascular repair. METHODS All patients who had open or endovascular iliac conduits prior to endovascular CAA repair to treat thoracoabdominal, juxtarenal, or suprarenal aneurysms at the University of Colorado Hospital from January 2009 through January 2019 were included. Patients who presented with symptomatic or ruptured aortic aneurysms were excluded. Outcomes of interest included postoperative complications and mortality in patients undergoing iliac conduits. RESULTS Twenty-seven patients with a total of 42 conduits were included in the study. The majority of patients (N = 15, 56%) were female and the average age was 72 ± 9 years. The calculated VQI cardiac index was .6% (range, .3%-.8%). Eighteen (43%) endovascular and 24 (57%) open iliac conduits were performed during the study period. Thirty (71%) conduits were performed in a staged fashion, while 12 (29%) were performed at the same time as endovascular CAA repair. The mean time between conduit and definitive aneurysm repair surgery was 130 ± 68 days in the endovascular and 107 ± 79 days in the open groups (P = .87). No aneurysm rupture occurred during the staging period in either group. The median follow-up for the entire cohort was 18 ± 22 months. The median length of hospital stay for patients undergoing endovascular and open ICs was 6 (ranging, 1-28 days) and 7 days (ranging, 3-18 days), respectively. Patients undergoing open conduits had significantly more complications than those undergoing endovascular conduit (endoconduit) creation. A total of 4 (15%) patients died within 30 days after aneurysm repair. Out of 23 survivors, 18 (78%) patients were discharged home, 4 (18%) patients were discharged to a skilled nursing facility, and 1 (4%) patient was discharged to an acute rehabilitation facility. No mortality difference based on type of conduit was found. CONCLUSIONS Overall complication rate associated with creation of open iliac artery conduits is not negligible. Endoconduits, which carry less morbidity than open conduits, are preferred as a first-line adjunctive access procedure to facilitate complex endovascular aortic aneurysm repair.
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Affiliation(s)
- Sammy Siada
- Division of Vascular Surgery, University of California at Fresno, Fresno, CA, USA
| | - Emily A Malgor
- Division of Vascular and Endovascular Surgery, 129263University of Colorado, Anschutz Medical Center, Aurora, CO, USA
| | - Mohammed Al-Musawi
- Division of Vascular and Endovascular Surgery, 129263University of Colorado, Anschutz Medical Center, Aurora, CO, USA
| | - Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Donald L Jacobs
- Division of Vascular and Endovascular Surgery, 129263University of Colorado, Anschutz Medical Center, Aurora, CO, USA
| | - Rafael D Malgor
- Division of Vascular and Endovascular Surgery, 129263University of Colorado, Anschutz Medical Center, Aurora, CO, USA
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Giannopoulos S, Strobel A, Rudofker E, Kovach C, Kokkosis AA, Armstrong EJ. Outcomes of Stented vs Nonstented Femoropopliteal Lesions Treated With Drug-Coated Balloon Angioplasty. J Endovasc Ther 2022; 30:194-203. [PMID: 35179065 DOI: 10.1177/15266028221079770] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE Drug-coated balloon (DCB) angioplasty has been increasingly used for the treatment of lower limb peripheral artery disease (PAD). However, bail-out stenting may be necessary in cases of suboptimal angioplasty. This study investigated the outcomes of femoropopliteal disease treated with DCB with/without bail-out stenting. MATERIALS AND METHODS This was a single-center retrospective study enrolling 166 consecutive patients (DCB+stent: n=81 vs DCB: n=85) with 253 femoropopliteal lesions (DCB+stent: n=99 vs DCB: n=154) treated with DCB with/without stenting. Bail-out stenting was performed at the operator discretion for postangioplasty dissections or otherwise suboptimal angiographic result (>30% residual stenosis). Cox regression analysis was performed to examine the outcomes of DCB with/without stenting during 2-year follow-up. RESULTS The baseline clinical characteristics were similar between the 2 groups. About half of the patients presented with critical limb ischemia, with most of the lesions located at the superficial femoral artery. The overall mean lesion length was 147±67 mm. The most frequent bail-out stent types were bare metal stents (BMS) (53.5%) followed by drug-eluting stents (DES) (41.4%). Lesions requiring bail-out stenting were on average longer (177±67 mm vs 127±59 mm; p<0.01) and on average had higher prevalence of flow-limiting postangioplasty dissections. The overall procedural success rate was 94% without any differences between the 2 groups. Both the stented and nonstented treatment modalities were effective and safe, demonstrating similar rates of 2-year freedom from major adverse limb event (stented: 71.3% vs nonstented: 64.4%) and 2-year freedom from target lesion revascularization (stented: 77.1% vs nonstented: 72.3%) during following up. The use of DES as bail-out therapy was associated with a lower risk of 2-year death compared with the use of BMS (DES: 97.2% vs BMS: 75.8%; p=0.01). CONCLUSION Drug-coated balloon with bail-out stenting is a viable treatment option for cases of suboptimal DCB results, promising similar efficacy with DCB-alone procedures. However, as the patency of stents at the femoropopliteal segment may be a challenge due to the biomechanical stress of the artery, the efficacy of DCB+bail-out stenting should be further evaluated. In addition, future studies are needed to determine which grades of post-DCB dissections should be treated and optimize current bail-out strategies.
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Affiliation(s)
- Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado Denver, Denver, CO, USA
| | - Aaron Strobel
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado Denver, Denver, CO, USA
| | - Eric Rudofker
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado Denver, Denver, CO, USA
| | - Christopher Kovach
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado Denver, Denver, CO, USA
| | - Angela A Kokkosis
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado Denver, Denver, CO, USA.,Adventist Health St. Helena, St. Helena, CA, USA
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Giannopoulos S, Armstrong EJ. Intravascular Lithotripsy for Optimal Angioplasty of Infrapopliteal Calcified Lesions. J Invasive Cardiol 2022; 34:E132-E141. [PMID: 35100556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Infrapopliteal arterial disease results from 2 major etiologies: medial calcification and intimal atheromatous plaque. Lesion calcification constitutes one of the most widely encountered risk factors for percutaneous transluminal angioplasty failure. Intravascular lithotripsy (IVL) creates selective fracturing of calcium deposits in the arterial wall, increasing the compliance of the target artery and facilitating angioplasty. Results regarding IVL utilization at femoropopliteal and infrapopliteal lesions have been very promising in terms of safety and efficacy. This review presents currently available data on IVL outcomes for infrapopliteal lesions and provides technical information for optimal use of IVL in these challenging lesions.
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Affiliation(s)
| | - Ehrin J Armstrong
- Adventist Health St. Helena, 6 Woodland Rd #304, St. Helena, CA 94574 USA.
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Zeller T, Giannopoulos S, Brodmann M, Werner M, Andrassy M, Schmidt A, Blessing E, Tepe G, Armstrong EJ. Orbital Atherectomy Prior to Drug-Coated Balloon Angioplasty in Calcified Infrapopliteal Lesions: A Randomized, Multicenter Pilot Study. J Endovasc Ther 2022; 29:874-884. [PMID: 35086385 DOI: 10.1177/15266028211070968] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE Optimal balloon angioplasty for infrapopliteal lesions is often limited by severe calcification, which has been associated with decreased procedural success and lower long-term patency. MATERIALS AND METHODS This was a prospective, randomized, multicenter pilot trial that included adult subjects with calcified lesions located from the popliteal segment below the knee (BTK) joint to within 5 cm above the ankle with ≥70% diameter stenosis by angiography. Patients were randomized 1:1 to undergo orbital atherectomy (OA) with adjunctive drug-coated balloon (DCB) angioplasty versus plain balloon angioplasty (BA) and DCB angioplasty (control). The periprocedural and 12 month outcomes of both procedures were compared. RESULTS Overall, 66 subjects (OA + DCB = 32 vs control = 34) were included in an intention to treat analysis. Baseline demographics and lesion characteristics were well-balanced. The mean lesion length was 101.3 mm (SD = 72.8 mm) and 78.8 (SD = 61.0 mm) in the OA + DCB and control groups, respectively, with almost all lesions having severe calcification per the Peripheral Academic Research Consortium (PARC) criteria. Chronic total occlusions (CTOs) were present in 43.8% and 35.3% of the patients in the OA + DCB and control groups, respectively. The technical success of OA + DCB versus DCB was 81.8% and 89.2%, respectively, with 3 slow flow/no reflow, 1 perforation, 1 severe dissection occurred in OA + DCB group, and one distal embolization occurred in the control group. The target lesion primary patency rate was numerically higher in the OA + DCB versus control group at 6 (88.2% vs 50.0%, p=0.065) and 12 month follow-up (88.2% vs 54.5%, p=0.076). The 12 month freedom from major adverse events, clinically-driven target lesion revascularization, major amputation, and all-cause mortality rates were similar between both groups. CONCLUSION The results of the Orbital Vessel PreparaTIon to MaximIZe Dcb Efficacy in Calcified BTK (OPTIMIZE BTK) pilot study indicated that utilization of OA + DCB is safe for infrapopliteal disease. Further prospective adequately powered studies should investigate the potential benefit of combined OA + DCB for BTK lesions.
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Affiliation(s)
- Thomas Zeller
- Universitäts-Herzzentrum Bad Krozingen, Bad Krozingen, Germany
| | - Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | | | | | | | | | - Erwin Blessing
- SRH Klinikum Karlsbad-Langensteinbach, Karlsbad, Germany
| | - Gunnar Tepe
- RoMed Klinikum Rosenheim, Rosenheim, Germany
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
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Peppas S, Sagris M, Bikakis I, Giannopoulos S, Tzoumas A, Kokkinidis DG, Ahmed Z, Korosoglou G, Malgor EA, Malgor RD. A Systematic Review and Meta-analysis on the Efficacy and Safety of Direct Oral Anticoagulants in Patients with Peripheral Artery Disease. Ann Vasc Surg 2021; 80:1-11. [PMID: 34644644 DOI: 10.1016/j.avsg.2021.07.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/29/2021] [Accepted: 07/04/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND-OBJECTIVE PAD is a significant cause of morbidity and mortality affecting over 200 million people worldwide. Current guidelines recommend at least a single antiplatelet or anticoagulant agent in symptomatic PAD and lifelong antithrombotic treatment after a revascularization procedure. The aim of this systematic review and meta-analysis was to investigate the efficacy and safety of direct oral anticoagulants (DOACs) in patients with peripheral artery disease (PAD). PAD is a significant cause of morbidity and mortality affecting over 200 million people worldwide. METHODS The present systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Risk ratios (RR) were calculated using the random effects model. RESULTS Overall, ten studies were included in this systematic review and meta-analysis. In four studies, 14,257 patients with PAD were enrolled and they were assigned to receive either aspirin (ASA)+/- clopidogrel (N=5,894) or DOAC+/- anti-platelet (e.g., ASA, clopidogrel) (N=8,363). Non DOAC users were found to have higher reintervention rates (RR 1.12; 95% CI 1.01-1.24; p=0.025) compared to DOAC users. No statistically significant difference was observed between the two groups, in terms of major bleeding (RR 0.78; 95% CI 0.50-1.23; p=0.285), all-cause mortality (RR 0.98; 95% CI: 0.83-1.16; p=0.818) and cardiovascular mortality (RR: 0.99; 95% CI: 0.73-1.333; p=0.946) mortality. In addition, two real-world studies comparing DOAC with warfarin showed decreased rates of major cardiovascular events in the DOAC group. CONCLUSIONS DOAC use alone or combined with an anti-platelet agent could be associated with lower re-intervention rates, without increasing the risk for adverse bleeding events. However, this study failed to detect any difference in terms of all-cause mortality, MACEs and MALEs between DOAC users and DOAC naïve patients. Future studies are needed to better determine the efficacy and safety of DOACs in patients with PAD.
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Affiliation(s)
- Spyros Peppas
- Second Department of Internal Medicine, Athens Naval Hospital, Athens, Greece
| | | | - Iosif Bikakis
- 401 General Military Hospital of Athens, Athens, Greece; Society of Junior Doctors, Athens, Greece
| | - Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | | | - Damianos G Kokkinidis
- Section of Cardiovascular Medicine, Yale University/Yale New Haven Hospital, New Haven, CT, USA
| | - Zain Ahmed
- Section of Cardiovascular Medicine, Yale University/Yale New Haven Hospital, New Haven, CT, USA
| | | | - Emily A Malgor
- Division of Vascular Surgery and Endovascular Therapy, University of Colorado, Anschutz Medical Center, Aurora, CO
| | - Rafael D Malgor
- Division of Vascular Surgery and Endovascular Therapy, University of Colorado, Anschutz Medical Center, Aurora, CO.
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Kokkinidis DG, Katamreddy A, Giannopoulos S, Schizas D, Georgopoulos S, Liakakos T, Armstrong EJ, Bakoyiannis C. Risk Models and Scores in Patients with Peripheral Artery Disease and Chronic Limb-threatening Ischemia: A Comprehensive Review. Curr Pharm Des 2021; 27:1277-1288. [PMID: 32472995 DOI: 10.2174/1381612826666200530214459] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 05/12/2020] [Indexed: 11/22/2022]
Abstract
Peripheral artery disease (PAD) affects more than 200 million patients worldwide and chronic limbthreatening ischemia (CLTI) is the most advanced stage of PAD with very high morbidity and mortality rates. Cardiovascular medicine is trending towards a more personalized approach where each individual patient will be managed according to specific risk factors, disease characteristics, expectations related to their disease and individualized assessment of potential outcomes. For this reason, a number of risk models and scores have been developed during the last few years. Our aim in this comprehensive review article is to provide an overview of selected risk models and scores for patients with PAD and CLTI. Given that some of the published scores were of low quality (minimal discriminatory ability), we included scores that were already externally validated or scores that had promising initial findings. Available scoring systems were grouped in the five following categories according to their utility: i) scores that can detect asymptomatic patients who should be screened for PAD, ii) scores for assessment of functional status and quality of life in patients with PAD, iii) scores assessing risk for amputation and other major adverse limb events among patients with CLTI, iv) scores for the optimal revascularization strategy in each patient and scores predicting successful procedural outcomes; v) scores predicting short or long-term cardiovascular and limb related outcomes after either revascularization or at least angiographic assessment. Limitations of available scoring systems include development and validation in specific populations, lack of external validation (for some of them) and also lack of synchrony with current era endovascular technology. However, with further optimization of current scores and the development of new scores, the field of PAD and CLI can be transitioned to a personalized medicine approach.
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Affiliation(s)
- Damianos G Kokkinidis
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Adarsh Katamreddy
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Aurora, CO, United States
| | - Dimitrios Schizas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Sotirios Georgopoulos
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Theodore Liakakos
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Aurora, CO, United States
| | - Christos Bakoyiannis
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
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29
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Salahuddin T, Giannopoulos S, Adams G, Armstrong EJ. Anterior, posterior, or all-vessel infrapopliteal revascularization in patients with moderate-severe claudication: Insights from the LIBERTY 360 study. Catheter Cardiovasc Interv 2021; 98:559-569. [PMID: 34057276 DOI: 10.1002/ccd.29780] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 04/14/2021] [Accepted: 05/17/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Little data guides revascularization of infrapopliteal peripheral arterial disease (PAD) in patients with claudication. We assessed outcomes after infrapopliteal-only intervention for claudication in the LIBERTY 360 observational study. METHODS In this post hoc analysis, LIBERTY 360 patients (N = 128) with claudication and isolated infrapopliteal disease undergoing endovascular revascularization were divided by territory into anterior-vessel, posterior-vessel, or all-vessel groups. Patients were followed for periprocedural, in-hospital, and long-term outcomes. Logistic regression for odds ratios, Cox proportional hazard models, ANOVA, and Kaplan-Meier estimates were utilized to compare outcomes. RESULTS Patients underwent anterior (N = 37), posterior (N = 76), or all-vessel (N = 15) infrapopliteal revascularization. Initial procedural success was 86%, 86%, and 69% for anterior, posterior, and all-vessel groups, respectively. Each group had improvements in Rutherford classification (RC) from baseline to 2 years (mean RC change: -1.3, -1.5, and -1.5, respectively). Compared with all-vessel intervention, both anterior and posterior groups had lower rate of major adverse events (MAE) and target vessel revascularization (TVR) at 3 years (MAE: 12% and 15% in anterior and posterior groups, respectively compared with 51% in the all-vessel group; hazard ratios and 95% CIs 0.22 [0.06-0.74], p = .015; 0.24 [0.09-0.64], p = .004). Other outcomes were similar among the three groups. The anterior group showed more improvement in pain subdomain and total VascuQoL scores compared with posterior and all-vessel groups at 2 years (p = .016, p = .020 and p = .068, p = .009, respectively). CONCLUSIONS Both anterior or posterior revascularization have favorable outcomes and may be beneficial for improvement of symptoms in claudicants with isolated infrapopliteal PAD.
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Affiliation(s)
- Taufiq Salahuddin
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, Colorado, USA
| | - Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, Colorado, USA
| | - George Adams
- North Carolina Heart and Vascular, Rex Hospital, UNC School of Medicine, Raleigh, North Carolina, USA
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, Colorado, USA
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Tzoumas A, Xenos D, Giannopoulos S, Sagris M, Kokkinidis DG, Bakoyiannis C, Schizas D. Revascularization approaches in patients with radiation-induced carotid stenosis: an updated systematic review and meta-analysis. Kardiol Pol 2021; 79:645-653. [PMID: 33885270 DOI: 10.33963/kp.15956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Ionizing radiation remains a well-known risk factor of carotid artery stenosis. The survival rates of head and neck cancer patients undergoing radiotherapy have risen owing to medical advancements in the field. As a consequence, the incidence of carotid artery stenosis in these high-risk patients has increased. AIMS In this study we sought to compare the outcomes of carotid endarterectomy (CEA) vs carotid artery stenting (CAS) for radiation-induced carotid artery stenosis. METHODS This study was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Eligible studies were identified through a comprehensive search of PubMed, Scopus and Cochrane Central until July 2020. A random-effects model meta-analysis was conducted, and odds ratios (ORs) were calculated. The I-square statistic was used to assess for heterogeneity. RESULTS Seven studies and 201 patients were included. Periprocedural stroke, myocardial infarction (MI), and death rates were similar between the two revascularization approaches. However, the risk for cranial nerve (CN) injury was higher in the CEA group (OR, 7.40; 95% CI, 1.58-34.59; I2 = 0%). Analysis revealed no significant difference in terms of long-term mortality (OR, 0.41; 95% CI, 0.14-1.16; I2 = 0%) and restenosis rates (OR, 0.69; 95% CI, 0.29-1.66; I2 = 0%) between CEA and CAS after a mean follow-up of 40.5 months. CONCLUSIONS CAS and CEA appear to have a similar safety and efficacy profile in patients with radiation-induced carotid artery stenosis. Patients treated with CEA have a higher risk for periprocedural CN injuries. Future prospective studies are warranted to validate these results.
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Affiliation(s)
| | | | - Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, United States
| | | | - Damianos G Kokkinidis
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine New York, NY, United States
| | - Christos Bakoyiannis
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Dimitrios Schizas
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
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Giannopoulos S, Strobel A, Rudofker E, Kovach C, Schneider PA, Armstrong EJ. Association of Postangioplasty Femoropopliteal Dissections With Outcomes After Drug-Coated Balloon Angioplasty in the Femoropopliteal Arteries. J Endovasc Ther 2021; 28:593-603. [PMID: 34002659 DOI: 10.1177/15266028211016441] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
PURPOSE Balloon angioplasty for the treatment of femoropopliteal lesions is often complicated by postangioplasty dissections. While dissections are known to affect patency and reintervention after balloon angioplasty, the association between dissections and major adverse limb event (MALE) after drug-coated balloon (DCB) angioplasty remains uncertain. Thus, the postangioplasty dissection and bailout stenting patterns were investigated. MATERIALS AND METHODS This was a single-center retrospective study enrolling patients with de novo femoropopliteal lesions treated with DCB with/without stenting. Postangioplasty target vessel dissection was graded based to the coronary artery classification grades A-F, with grade C-F considered "severe." Cox regression analysis was performed to examine the association of dissection severity with outcomes during 2-year follow up, among nonstented cases. RESULTS In 85.3% of the cases (N=203/238) a postangioplasty dissection was observed. The average dissection length was 55.57 mm (SD 36.71 mm), with 1 dissection present in 91.8% (N=180/196) and 2 or more dissections present in 8.2% (N=16/196). Dissection severity was grade A (19.8%), B (20.6%), C (23.1%), D (10.9%), E (10.1%), and F (0.8%). Bailout stenting was required in 40.4% of the patients, being more prevalent among grade C and grade E cases. Among 142 nonstented cases, dissections were present in 85.2%. A total of 75 (52.8%) of these dissections were grade A and B, while 46 (32.4%) were grade C to F. Among nonstented cases, grade C (hazard ratio [HR] 5.83; 95% CI 1.25 to 27.31; p=0.025) and grade D (HR 6.32; 95% CI 1.39 to 28.86; p=0.017) vs grade A dissections were associated with a higher risk for 2-year MALE. Multivariate analysis adjusting for several lesion characteristics demonstrated a statistically significant higher risk for 2-year MALE among the severe dissection group (HR 2.94; 95% CI 1.27 to 6.79; p = 0.012). Interestingly, the risks of limb loss (HR 1.30; 95% CI 0.22 to 7.79; p=0.774) and repeat revascularization (HR 0.95; 95% CI 0.40 to 2.26; p=0.905) during follow-up were similar between the 2 groups. CONCLUSION This study indicated that nonstented moderate and severe postangioplasty dissections after DCB angioplasty were associated with higher risk for MALE. Future studies are needed to validate our results and determine other dissection characteristics (eg, total dissection length, lumen area, total number of dissections) that may affect the efficacy of DCB.
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Affiliation(s)
- Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Aaron Strobel
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Eric Rudofker
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Christopher Kovach
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California at San Francisco, CA, USA
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
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Lodha A, Giannopoulos S, Sumar R, Ratcliffe J, Gorenchtein M, Green P, Rollefson W, Stout CL, Armstrong EJ. Transradial endovascular intervention: Results from the Radial accEss for nAvigation to your CHosen lesion for Peripheral Vascular Intervention (REACH PVI) study. Cardiovasc Revasc Med 2021; 36:115-120. [PMID: 34020900 DOI: 10.1016/j.carrev.2021.05.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 05/04/2021] [Accepted: 05/13/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND/PURPOSE The transradial approach has been proposed as an alternative to traditional transfemoral access for diagnostic and therapeutic purposes in several catheterization procedures. Historically, extended length devices for lower limb endovascular interventions have been limited. The aim of this study was to investigate the acute clinical outcomes of orbital atherectomy (OA) via transradial access (TRA) for the treatment of lower extremity peripheral artery disease (PAD). METHODS/MATERIALS REACH PVI was a multicenter, prospective, observational study (NCT03943160) including subjects with PAD and target lesion morphology appropriate for OA. All patients were followed post-procedure through the first standard of care follow-up visit. RESULTS A total of 50 patients were enrolled. In most cases the indication for intervention was disabling claudication (74.0%). Overall, 50 target lesions were treated, 92.0% of lesions were femoropopliteal and 8.0% were infrapopliteal. The average lesion length was 98.3 ± 87.5 mm and 78.0% of the lesions were severely calcified. Balloon angioplasty was performed in 98.0% of target lesions, while a stent was deployed in 16.0%. Treatment success was 98.0%; in only one case the result was sub-optimal (>30% stenosis with stent placement) and a significant dissection was reported. No serious distal embolization, serious thrombus formation or serious acute vessel closure were observed intra- or post-procedurally. CONCLUSIONS Transradial OA followed by percutaneous transluminal angioplasty for lower extremity PAD is feasible and demonstrates a favorable safety profile. Extended length devices such as the Extended Length Orbital Atherectomy System could further facilitate transradial endovascular procedures by increasing its spectrum of application.
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Affiliation(s)
- Ankur Lodha
- Cardiovascular Institute of the South - Lafayette, Lafayette, LA, United States
| | - Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, United States
| | - Riyaz Sumar
- Arizona Cardiovascular Research Center, Phoenix, AZ, United States
| | | | | | | | | | | | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, United States.
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Sagris M, Katsaros J, Giannopoulos S, Kokkinidis DG. A systematic review and meta-analysis of the role of statins and their intensity in peripheral artery disease. Eur J Prev Cardiol 2021. [DOI: 10.1093/eurjpc/zwab061.133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
Peripheral artery disease (PAD) affects more than eight million Americans. However, several studies have shown that those patients are often undertreated, and that statin utilization is suboptimal. American Heart Association guidelines highlight statins as the first-line lipid-lowering therapy to treat patients with PAD. Our objective with this meta-analysis was to further explore the impact of statins on PAD outcomes and examine whether the actual statin (high vs low intensity) dose impacts outcomes.
Methods
We performed a systematic review and meta-analysis according to the PRISMA guidelines. Any study that presented a comparison of statins vs no statins for PAD patients or compared high vs low intensity statins and provided outcomes with hazard ratio was considered as potentially eligible. The Medline (PubMed) database was searched up to August 30, 2020. A random effects meta-analysis was performed.
Results
In total, 38 studies and 275,670 patients were included in this meta-analysis. In total, 136,025 (49.34%) were on statins vs 139,645 (50.66%) who were not on statins. Statins had an association with a reduction in all cause-mortality by 42% (HR:0.58, 95% CI: 0.49-0.67, I2= 96.26%) and cardiovascular death by 43% (HR:0.57, 95% CI: 0.40-0.74, I2= 80.39%). Statins use was associated with an increase in amputation-free survival by 56% (HR:0.44, 95% CI: 0.30-0.58, I2 = 15%). The risk of amputation and loss of patency was reduced by 35% (HR:0.65, 95% CI:0.41-0.89, I2 = 86.91%), 46% (HR:0.54, 95% CI: 0.34-0.74, Ι2 = 0%), respectively. Statins use was also associated with a reduction in the risk of major adverse cardiovascular events (MACE) by 35% (HR:0.65, 95% CI: 0.51-0.80, I2= 93.22%) and the incidence of myocardial infarction (MI) by 41% (HR:0.59, 95% CI: 0.33-0.86, I2 = 76.78%). Among patients treated with statins, high-intensity treatment group was associated with a reduction in all cause-mortality by 36% (HR:0.64, 95% CI: 0.54-0.74, I2 = 96.49%) compared to patients treated with low intensity statins.
Conclusion
Statin treatment among patients with PAD was associated with a statistically significant reduction in all-cause mortality, cardiovascular mortality, MI, MACE, risk for amputation or loss of patency. Statins were also associated with a higher amputation free survival.
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Affiliation(s)
- M Sagris
- General Hospital of Nikaia-Piraeus Agios Panteleimon, Piraeus, Greece
| | | | - S Giannopoulos
- University of Colorado, Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, C, Denver, United States of America
| | - DG Kokkinidis
- Yale-New Haven Hospital, Yale New Haven Health System, New Haven, United States of America
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Giannopoulos S, Pliagas G, Armstrong EJ. Procedural and 3-Year Outcomes of Peripheral Vascular Interventions Performed in Office-Based Labs: LIBERTY 360 Sub-Analysis. J Invasive Cardiol 2021; 33:E365-E377. [PMID: 33932282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Few data are available on the safety of interventions for peripheral arterial disease (PAD) performed in the office-based laboratory (OBL) setting. Thus, the aim of this study was to investigate the short- and late-term outcomes of patients treated in OBL vs hospital settings. METHODS We included patients with PAD treated with any United States Food and Drug Administration approved or cleared devices for distal femoropopliteal and/or infrapopliteal disease. Data were retrieved from the LIBERTY 360 study. A propensity-scored, matched analysis was conducted and hazard ratios with the respective 95% confidence intervals were synthesized to examine the outcomes after interventions at OBL vs non-OBL settings. RESULTS A total of 710 propensity-scored patients (355 OBL patients and 355 non-OBL patients) with 907 treated lesions (454 OBL lesions and 453 non-OBL lesions), were included. For almost all subjects, balloon angioplasty was the preferred treatment approach (341 [96.1%] in the OBL group vs 353 [99.4%] in the non-OBL group; P<.01), with bail-out stenting necessary in 5.1% of the OBL group and 3.1% of the non-OBL group. Overall, significant angiographic complications occurred in 7.8% of all patients treated, with no differences between the 2 groups. The risk for all-cause death, target-vessel revascularization, and major amputation and death combined was similar between the 2 groups during 3-year follow-up. CONCLUSIONS Peripheral artery endovascular interventions in patients with chronic threatening ischemia or claudication, performed in the OBL setting, are safe and associated with favorable outcomes at 3 years of follow-up. These results demonstrate that treatment at OBLs is comparable to non-OBL settings. Further comparative studies and larger registries are needed to benchmark procedural quality and long-term outcomes.
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Affiliation(s)
| | | | - Ehrin J Armstrong
- University of Colorado, 1600 N. Wheeling Street, Aurora, CO 80045 USA.
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Mallory A, Giannopoulos S, Lee P, Kokkinidis DG, Armstrong EJ. Covered Stents for Endovascular Treatment of Aortoiliac Occlusive Disease: A Systematic Review and Meta-Analysis. Vasc Endovascular Surg 2021; 55:560-570. [PMID: 33902342 DOI: 10.1177/15385744211010381] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE The treatment of aortoiliac occlusive disease (AIOD) has largely shifted to endovascular techniques, with primary stenting constituting the preferred treatment approach. The goal of the current study was to summarize available literature and to determine whether covered stents are superior to bare metal stents for the treatment of AIOD, in terms of both periprocedural and long-term outcomes. METHODS A meta-analysis of 47 studies was conducted with the use of random effects modeling. The incidence of adverse events during follow up among the individual included studies was synthesized. RESULTS Most of the lesions were located at the common iliac arteries and were chronic total occlusions. The procedure was technically successful in almost all cases in both groups, with a low rate of periprocedural complications observed in both groups. The reported primary patency rates for the non-covered and covered stent group during an average follow up of 24.3 months among the individual studies, were 84% and 92% respectively, while surgical or endovascular re-intervention was required in 10% of non-covered stent cases and in 6% of covered stent cases. Eight studies comparing covered vs non-covered stents in terms of patency demonstrated superiority of covered stents (OR: 2.47; 95% CI: 1.01-6.01; p = 0.047 Combining TASC C/D lesions together 12 studies reported 92% (95%CI:89%-95%) primary patency in the covered stent group, while 7 studies reported 75% (95%CI: 60%-88%) primary patency for cases treated with non-covered stents. CONCLUSION This study demonstrated that covered stents are safe and effective when utilized for the treatment of AIOD. Covered stents were associated with a statistically significant higher odds of primary patency in both the overall cohort and in more complex TASC C/D lesions. However, additional high-quality comparative analyses between covered vs bare metal stents and between several types of covered stents are needed to determine the most optimal treatment modality for AIOD.
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Affiliation(s)
- Austin Mallory
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Paul Lee
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Damianos G Kokkinidis
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
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Li WJ, Archontakis-Barakakis P, Palaiodimos L, Kalaitzoglou D, Tzelves L, Manolopoulos A, Wang YC, Giannopoulos S, Faillace R, Kokkinidis DG. Dabigatran, rivaroxaban, and apixaban are superior to warfarin in Asian patients with non-valvular atrial fibrillation: An updated meta-analysis. World J Cardiol 2021; 13:82-94. [PMID: 33968307 PMCID: PMC8069517 DOI: 10.4330/wjc.v13.i4.82] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 02/21/2021] [Accepted: 04/14/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Most of the randomized clinical trials that led to the wide use of non-vitamin K antagonist oral anticoagulants for stroke prevention in patients with atrial fibrillation (AF) originated from western countries.
AIM To systematically review and quantitatively synthesize the real-world data regarding the efficacy and safety of dabigatran, rivaroxaban, and apixaban compared to warfarin for stroke prevention in Asian patients with non-valvular AF.
METHODS Medline, Cochrane, and ClinicalTrial.gov databases were reviewed. A random-effect model meta-analysis was used and I-square was utilized to assess the heterogeneity. The primary outcome was ischemic stroke. The secondary outcomes were all-cause mortality, major bleeding, intracranial hemorrhage, and gastrointestinal bleeding.
RESULTS Twelve studies from East Asia or Southeast Asia and 441450 patients were included. Dabigatran, rivaroxaban, and apixaban were associated with a significant reduction in the incidence of ischemic stroke [hazard ratio (HR) = 0.78, 95% confidence interval (CI): 0.65-0.94; HR = 0.79, 95%CI: 0.74-0.85, HR = 0.70, 95%CI: 0.62-0.78; respectively], all-cause mortality (HR = 0.68, 95%CI: 0.56-0.83; HR = 0.66, 95%CI: 0.52-0.84; HR = 0.66, 95%CI: 0.49-0.90; respectively), and major bleeding (HR = 0.61, 95%CI: 0.54-0.69; HR = 0.70, 95%CI: 0.54-0.90; HR = 0.58, 95%CI: 0.43-0.78; respectively) compared to warfarin.
CONCLUSION Dabigatran, rivaroxaban, and apixaban appear to be superior to warfarin in both efficacy and safety in Asians with non-valvular AF.
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Affiliation(s)
- Wei-Jia Li
- Department of Medicine, Jacobi Medical Center, Bronx, NY 10461, United States
| | | | | | - Dimitrios Kalaitzoglou
- Department of Surgery, 424 General Army Hospital of Thessaloniki, Thessaloniki 56429, Greece
| | - Lazaros Tzelves
- Department of Urology, Sismanogleio Hospital, Athens 15126, Greece
| | - Apostolos Manolopoulos
- Clinical Research and Evidence-Based Medicine Unit, Aristotle University of Thessaloniki, Thessaloniki 54124, Greece
| | - Yu-Chiang Wang
- Department of Medicine, Jacobi Medical Center, Bronx, NY 10461, United States
| | - Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, Denver, CO 80045, United States
| | - Robert Faillace
- Department of Medicine, Jacobi Medical Center, Bronx, NY 10461, United States
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Giannopoulos S, Malgor RD, Sobreira ML, Siada SS, Rodrigues D, Al-Musawi M, Malgor EA, Jacobs DL. Iliac Conduits for Endovascular Treatment of Aortic Pathologies: A Systematic Review and Meta-analysis. J Endovasc Ther 2021; 28:499-509. [PMID: 33899572 DOI: 10.1177/15266028211007468] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The treatment of thoracoabdominal aortic aneurysm has largely shifted to endovascular techniques. However, severe iliofemoral arterial disease often presents a challenge during these interventions. As a result, iliac conduits have been introduced to facilitate aortic endovascular therapy. The goal of the current study was to gauge utilization and to analyze iliac artery conduit outcomes to facilitate endovascular therapy to treat aortic pathologies. MATERIALS AND METHODS A meta-analysis of 14 studies was conducted with the use of random effects modeling. The incidence of periprocedural adverse events was gauged based on iliac conduit vs nonconduit cases and planned vs unplanned iliac conduit placement. Outcomes of interest included length of hospital stay, morbidity and mortality associated to conduits, and all-cause mortality. RESULTS Iliac conduits, either open or endo-conduits, were utilized in 17% (95% CI: 9%-27%) of 16,855 cases, with technical successful rate of 94% (95% CI: 80%-100%). Periprocedural complications occurred in 32% (95% CI: 22%-42%) of the cases, with overall bleeding complication rate being 10% (95% CI: 5%-16%). Female patients, positive history for smoking, pulmonary disease, and peripheral artery disease at baseline were associated with more frequent utilization of iliac conduits. Conduit use was associated with longer hospitalization, higher periprocedural all-cause mortality (OR: 2.85; 95% CI: 1.75-4.64; p<0.001), and bleeding complication rate (OR: 2.38; 95% CI: 1.58-3.58; p<0.001). Sensitivity analysis among conduit cases showed that planned conduits were associated with fewer periprocedural complications compared to unplanned conduits (OR: 0.38; 95% CI: 0.20-0.73; p=0.004). CONCLUSION Iliac conduit placement is a feasible strategy, associated with high technical success to facilitate complex aortic endovascular repair. However, periprocedural adverse event rate, including bleeding complications is not negligible. All-cause mortality and morbidity rates among cases that require iliac conduits should be strongly considered during clinical decision making. High-quality comparative analyses between iliac conduit vs nonconduit cases and between several types of iliac conduit grafts aiming at facilitating endovascular aortic repair are still needed to determine the best strategy to address challenging iliac artery accesses.
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Affiliation(s)
- Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Aurora, CO, USA
| | - Rafael D Malgor
- Anschutz Medical Center, Division of Vascular Surgery and Endovascular Therapy, University of Colorado, Aurora, CO, USA
| | - Marcone L Sobreira
- Division of Vascular Surgery, Sao Paulo State University, Botucatu School of Medicine, Botucatu, Brazil
| | - Sammy S Siada
- Division of Vascular Surgery, University of California San Francisco, Fresno, CA, USA
| | - Diego Rodrigues
- Division of Vascular Surgery, Federal University of Maranhao, Sao Luiz, Brazil
| | - Mohammed Al-Musawi
- Anschutz Medical Center, Division of Vascular Surgery and Endovascular Therapy, University of Colorado, Aurora, CO, USA
| | - Emily A Malgor
- Anschutz Medical Center, Division of Vascular Surgery and Endovascular Therapy, University of Colorado, Aurora, CO, USA
| | - Donald L Jacobs
- Anschutz Medical Center, Division of Vascular Surgery and Endovascular Therapy, University of Colorado, Aurora, CO, USA
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Giannopoulos S, Armstrong EJ. Clinical considerations after endovascular therapy of peripheral artery disease. Expert Rev Cardiovasc Ther 2021; 19:369-378. [PMID: 33870848 DOI: 10.1080/14779072.2021.1914590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Introduction: Patients with peripheral artery disease (PAD) are at higher risk for all-cause mortality, driven by increased cardiovascular mortality rates. In this manuscript we review the literature on guideline-recommended therapies and discuss the major clinical considerations after endovascular therapy of PAD.Areas covered: Current guidelines recommend smoking cessation, aspirin, statin, and renin-angiotensin system inhibitors in order to reduce the risk of cardiovascular and limb-related adverse events. Nonetheless, studies have shown that patients with PAD are undertreated with these important medical therapies. Additionally, there is lack in evidence regarding the most optimal follow up imaging approach for early detection of disease recurrence and re-intervention among patients undergoing endovascular therapy for PAD. We also describe the benefits of supervised walking exercise for patients with PAD that undergo revascularization procedures and are fit for such interventions.Expert opinion: Adherence to guideline recommended medical therapy is crucial for improved outcomes in PAD management. Systematic assessment of risk-reduction interventions could help increase adherence to clinically beneficial interventions and improve the overall prognosis of patients with PAD undergoing revascularization procedures. Additionally, optimization of current follow up protocols is needed, with the optimal goal to develop standardized cost-effective algorithms regarding early detection of disease recurrence and re-intervention.
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Affiliation(s)
- Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
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Giannopoulos S, Mustapha J, Gray WA, Ansel G, Adams G, Secemsky EA, Armstrong EJ. Three-Year Outcomes From the LIBERTY 360 Study of Endovascular Interventions for Peripheral Artery Disease Stratified by Rutherford Category. J Endovasc Ther 2021; 28:262-274. [DOI: 10.1177/1526602820962972] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Purpose: To report the 3-year results of the LIBERTY 360 study, which investigated outcomes of endovascular treatment of symptomatic peripheral artery disease (PAD). Materials and Methods: The LIBERTY trial ( ClinicalTrials.gov identifier NCT01855412) was a prospective, observational, core laboratory–assessed, multicenter study of endovascular interventions enrolling >1200 participants treated at 51 sites. Data from 1189 patients were stratified according to Rutherford category (RC) and analyzed [RC 2-3 (n=500), RC 4-5 (n=589), and RC 6 (n=100)]. The primary outcomes were major amputation of the target limb and all-cause death; secondary outcomes were target vessel revascularization (TVR) or target lesion revascularization (TLR); major adverse events (MAEs; death within 30 days, TVR or TLR, and major amputation); death or major amputation combined; and change in self-reported quality of life (QoL) measures (VascuQol-25). The Kaplan-Meier (KM) method was employed to estimate the outcomes; estimates are presented with the 95% confidence intervals (CI). Predictors of 3-year MAE, death, TVR, and major amputation were analyzed using Cox proportional hazard regression modeling. Results: The 36-month KM survival rates were 86.0% in RC 2-3, 79.8% in RC 4-5, and 62.0% in RC 6 groups. The KM estimates of freedom from major amputation at 36 months were 98.5% in RC 2-3, 94.0% in RC 4-5, and 79.9% in RC 6. The 36-month KM estimates for freedom from TVR/TLR were 71.1% in RC 2-3, 64.2% in RC 4-5 and 61.9% in RC 6 groups. Patients with claudication at baseline were at lower risk for MAEs compared with RC 4-5 and RC 6 patients during the 36-month follow-up. Vascular QoL improved from baseline and persisted up to 36 months in all patients. Conclusion: Endovascular therapy is a viable treatment option for patients with symptomatic PAD, with sustained improved quality of life in both claudicants and patients with chronic limb-threatening ischemia. These results provide important point estimates for midterm outcomes after modern endovascular interventions for PAD.
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Affiliation(s)
- Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Jihad Mustapha
- Advanced Cardiac and Vascular Centers for Amputation Prevention, Grand Rapids, MI, USA
| | - William A. Gray
- Lankenau Heart Institute/Main Line Health, Philadelphia, PA, USA
| | - Gary Ansel
- OhioHealth Heart and Vascular Physicians, Columbus, OH, USA
| | - George Adams
- Department of Cardiology, North Carolina Heart and Vascular, Rex Hospital, UNC School of Medicine, Raleigh, NC, USA
| | - Eric A. Secemsky
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ehrin J. Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
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Tzoumas A, Giannopoulos S, Kakargias F, Kokkinidis DG, Giannakoulas G, Faillace RT, Bakoyiannis C, Doulamis IP, Avgerinos DV. Repeat Coronary Artery Bypass Grafting: A Meta-Analysis of Off-Pump versus On-Pump Techniques in a Large Cohort of Patients. Heart Lung Circ 2021; 30:1281-1291. [PMID: 33810970 DOI: 10.1016/j.hlc.2021.02.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 02/03/2021] [Accepted: 02/08/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Redo coronary artery bypass grafting (CABG) can be performed with either the off-pump (OPCAB) or the on-pump (ONCAB) technique. METHOD Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), this meta-analysis compared the safety and efficacy of OPCAB versus ONCAB redo CABG. RESULTS Twenty-three (23) eligible studies were included (OPCAB, n=2,085; ONCAB, n=3,245). Off-pump CABG significantly reduced the risk of perioperative death (defined as in-hospital or 30-day death rate), myocardial infarction, atrial fibrillation, and acute kidney injury. The two treatment approaches were comparable regarding 30-day stroke and late all-cause mortality. CONCLUSIONS Off-pump redo CABG resulted in lower perioperative death and periprocedural complication rates. No difference was observed in perioperative stroke rates and long-term survival between the two techniques.
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Affiliation(s)
| | - Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | | | - Damianos G Kokkinidis
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - George Giannakoulas
- Department of Cardiology, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Robert T Faillace
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Christos Bakoyiannis
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Ilias P Doulamis
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Dimitrios V Avgerinos
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York Presbyterian, New York, NY, USA
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Theochari NA, Theochari CA, Kokkinidis DG, Kechagias A, Lyros O, Giannopoulos S, Mantziari S, Schizas D. Venous thromboembolism after esophagectomy for cancer: a systematic review of the literature to evaluate incidence, risk factors, and prophylaxis. Surg Today 2021; 52:171-181. [PMID: 33713198 DOI: 10.1007/s00595-021-02260-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 12/16/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE Although esophagectomy remains the preferred treatment for esophageal cancer, it is still associated with a number of complications, including post-operative venous thromboembolism (VTE). The aim of this study was to summarize the reported incidence of VTE after esophagectomy, its risk factors, and prevention strategies. METHODS We conducted a systematic search of the literature in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS Fourteen studies met our inclusion criteria and were selected in the present review. Overall, we identified 9768 patients who underwent esophagectomy, with a post-operative VTE rate of 4% (440 patients). The reported risk factors for VTE included advanced age, American Society of Anesthesiologists (ASA) class III or IV, a history of cardiovascular or pulmonary disease, and the implementation of preoperative chemo-radiotherapy. Postoperative acute respiratory distress syndrome was also associated with VTE. No universally applied prevention strategies for VTE after esophagectomy were identified in the literature. CONCLUSIONS Despite advances in perioperative care, VTE after esophagectomy still represents a source of morbidity for about 4% of patients. Low molecular weight heparin is suggested as the routine standard prophylactic regimen after esophageal cancer surgery.
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Affiliation(s)
- Nikoletta A Theochari
- Department of Surgery, Amalia Fleming General Hospital, 29 Parnithos, 16344, Athens, Ilioupolis, Greece.
| | - Christina A Theochari
- Third Department of Internal Medicine, National and Kapodistrian University of Athens, Thoracic Diseases General Hospital Sotiria, Athens, Greece
| | - Damianos G Kokkinidis
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Aristotelis Kechagias
- Department of Gastrointestinal Surgery, Kanta-Häme Central Hospital, Hämeenlinna, Finland
| | - Orestis Lyros
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
| | | | - Styliani Mantziari
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Dimitrios Schizas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
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Sagris M, Kokkinidis DG, Lempesis IG, Giannopoulos S, Rallidis L, Mena-Hurtado C, Bakoyiannis C. Nutrition, dietary habits, and weight management to prevent and treat patients with peripheral artery disease. Rev Cardiovasc Med 2021; 21:565-575. [PMID: 33388001 DOI: 10.31083/j.rcm.2020.04.202] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 10/29/2020] [Accepted: 11/03/2020] [Indexed: 11/06/2022] Open
Abstract
Peripheral artery disease (PAD) affects 3%-10% of the Western population and if remains untreated can have devastating consequences to patients and their families. This review article analyzes how healthy dietary habits can decrease PAD rates when applied in the general population. The aim is to focus on dietary, nutritional and weight management interventions in patients with established PAD. Most adults with PAD are overweight or obese, while three out of four patients are characterized by deficiencies in vitamins and minerals. Weight loss interventions when needed and specialized dietary plans should be routinely recommended in patients with PAD. Appropriate nutritional support is of paramount importance in patients with advanced stages of PAD (critical limb ischemia).
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Affiliation(s)
- Marios Sagris
- General Hospital of Nikaia, Piraeus, 184 54, Athens, Greece
| | - Damianos G Kokkinidis
- Section of Cardiovascular Medicine, Yale University/Yale New Haven Hospital, New Haven, 06519, CT, USA.,Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, 06510, CT, USA
| | - Ioannis G Lempesis
- Institute of Metabolism and Systems Research (IMSR), College of Medical and Dental Sciences, University of Birmingham, B15 2TT, Birmingham, UK.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, B15 2TT, Birmingham, UK.,Department of Human Biology, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre, 6229 HX, Maastricht, the Netherlands
| | - Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, 80309, CO, USA
| | - Loukianos Rallidis
- 2nd Department of Cardiology, University General Hospital Attikon, Medical School, National and Kapodistrian University of Athens, 10561, Athens, Greece
| | - Carlos Mena-Hurtado
- Section of Cardiovascular Medicine, Yale University/Yale New Haven Hospital, New Haven, 06519, CT, USA.,Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, 06510, CT, USA
| | - Christos Bakoyiannis
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, 11527, Athens, Greece
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Abstract
Critical limb ischemia (CLI) constitutes the most advanced form of peripheral artery disease (PAD) and is characterized by ischemic rest pain, tissue loss and/or gangrene. Optimized medical care and risk factor modification in addition to revascularization could reduce the incidence of cardiovascular events and major adverse limb events, improving patients' quality of life and promising higher survival rates. Adequate adherence to cardioprotective medications, including antithrombotic therapy (e.g., antiplatelets, anticoagulants), cholesterol-lowering agents (e.g., statins, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors), angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), and smoking cessation should be strongly encouraged for patients with CLI. This review examines these guideline-recommended therapies in terms of cardiovascular and limb-related risk reduction in patients with CLI.
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Affiliation(s)
- Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
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Giannopoulos S, Kokkinidis DG, Avgerinos ED, Armstrong EJ. Association of Abdominal Aortic Aneurysm and Simple Renal Cysts: A Systematic Review and Meta-Analysis. Ann Vasc Surg 2021; 74:450-459. [PMID: 33556506 DOI: 10.1016/j.avsg.2021.01.075] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 12/31/2020] [Accepted: 01/06/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND-OBJECTIVE Prior studies have suggested a higher prevalence of simple renal cysts (SRC) among patients with aortic disease, including abdominal aortic aneurysms (AAA). Thus, the aim of this study was to systematically review all currently available literature and investigate whether patients with AAA are more likely to have SRC. METHODS This study was performed according to the PRISMA guidelines. A meta-analysis was conducted with the use of random effects modeling and the I-square was used to assess heterogeneity. Odds ratios (OR) and the corresponding 95% confidence intervals (CI) were synthesized to compare the prevalence of several patients' characteristics between AAA vs. no-AAA cases. RESULTS Eleven retrospective studies, 9 comparative (AAA vs. no-AAA groups) and 3 single-arm (AAA group), were included in this meta-analysis, enrolling patients (AAA: N = 2,297 vs. no-AAA: N = 35,873) who underwent computed tomography angiography as part of screening or preoperative evaluation for reasons other than AAA. The cumulative incidence of SRC among patients with AAA and no-AAA was 55% (95% CI: 49%-61%) and 32% (95% CI: 22%-42%) respectively, with a statistically higher odds of SRC among patients with AAA (OR: 3.02; 95% CI: 2.01-4.56; P< 0.001). The difference in SRC prevalence remained statistically significant in a sensitivity analysis, after excluding the study with the largest sample size (OR: 2.71; 95% CI: 1.91-3.84; P< 0.001). CONCLUSIONS Our meta-analysis demonstrated a 3-fold increased prevalence of SRC in patients with AAA compared to no-AAA cases, indicating that the pathogenic processes underlying SRC and AAA could share a common pathophysiologic mechanism. Thus, patients with SRC could be considered at high risk for AAA formation, potentially warranting an earlier AAA screening.
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Affiliation(s)
- Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO
| | | | - Efthymios D Avgerinos
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO.
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Tzoumas A, Giannopoulos S, Kokkinidis DG. Screening for carotid artery stenosis before coronary artery bypass graft. Kardiol Pol 2021; 79:1-2. [PMID: 33494570 DOI: 10.33963/kp.15764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Magnuson EA, Li H, Vilain K, Armstrong EJ, Secemsky EA, Giannopoulos S, Adams GL, Mustapha J, Cohen DJ. Two-year PAD-related health care costs in patients undergoing lower extremity endovascular revascularization: results from the LIBERTY 360° trial. J Med Econ 2021; 24:570-580. [PMID: 33866936 DOI: 10.1080/13696998.2021.1917141] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Multiple studies have demonstrated the high economic burden related to the management of lower extremity peripheral artery disease (PAD). This is the first study to examine long-term PAD-related costs among unselected patients undergoing endovascular intervention, and to investigate how clinical and anatomic factors impact cost outcomes over time. METHODS AND RESULTS We performed a prospective health economic study alongside the LIBERTY 360° trial (ClinicalTrials.gov; identifier NCT01855412) - a prospective, multi-center study evaluating the long-term outcomes of endovascular revascularization to treat claudication or critical limb ischemia. Costs (2018) were calculated using a combination of standard "bottom-up" cost accounting methods (for index procedures), itemized hospital charges and department level cost-to-charge ratios (for non-procedural hospital resources), national Medicare Severity-Diagnosis Related Group-specific average reimbursements (for follow-up hospitalizations) and Medicare payments (for outpatient/chronic care). Methods for the analysis of censored cost data were used to adjust cost estimates for patients with incomplete follow-up. Independent predictors of cumulative 2-year costs were explored using generalized linear models. A total of 1,189 patients were included (500 Rutherford 2-3, 589 Rutherford 4-5, 100 Rutherford 6). Mean total costs associated with the index procedure hospitalization increased with Rutherford classification ($10,304, $11,418, and $19,403 for Rutherford 2-3, 4-5, and 6, respectively; p < 0.01 in all pairwise comparisons). Mean total 2-year follow-up costs were $11,416, $24,846, and $25,720 for Rutherford 2-3, 4-5, and 6, respectively (p < 0.001 comparing Rutherford 2-3 to the other 2 groups; p = 0.09 comparing Rutherford 4-5 and Rutherford 6). Key predictors of higher cumulative 2-year costs included female sex, pedal lesion location, severe lesion calcification, the presence of one or more chronic total occlusions, the number of wounds present on the target limb at baseline, and Rutherford classification. CONCLUSIONS Among patients with symptomatic lower extremity PAD undergoing endovascular revascularization, initial treatment costs and total 2-year costs vary significantly according to clinical and lesion-level characteristics, as well as symptom burden.
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Affiliation(s)
- Elizabeth A Magnuson
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
- University of Missouri - Kansas City School of Medicine, Kansas City, MO, USA
| | - Haiyan Li
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | | | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Eric A Secemsky
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - George L Adams
- North Carolina Heart and Vascular, Rex Hospital, UNC School of Medicine, Raleigh, NC, USA
| | - Jihad Mustapha
- Advanced Cardiac and Vascular Amputation Prevention Centers, Grand Rapids, MI, USA
| | - David J Cohen
- University of Missouri - Kansas City School of Medicine, Kansas City, MO, USA
- Cardiovascular Research Foundation, New York, NY, USA
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Giannopoulos S, Palena LM, Armstrong EJ. Technical Success and Complication Rates of Retrograde Arterial Access for Endovascular Therapy for Critical Limb Ischaemia: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2020; 61:270-279. [PMID: 33358346 DOI: 10.1016/j.ejvs.2020.11.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 10/26/2020] [Accepted: 11/12/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Antegrade crossing techniques via transfemoral access are often challenging and may be associated with technical and clinical failure when treating patients with critical limb ischaemia (CLI). The objective of this study was to summarise all available literature regarding retrograde endovascular treatment of patients with CLI and to investigate the technical success and complication rate of retrograde access. METHODS A systematic literature search was performed in PubMed, Scopus, and Cochrane Central until May 2020. A meta-analysis of 31 observational studies (29 retrospective and two prospective; 26 and five studies with low and moderate risk of bias, respectively) was conducted with random effects modelling. The incidence of adverse events peri-procedurally and during follow up were calculated. RESULTS The 31 studies enrolled 1 910 patients who were treated endovascularly for femoropopliteal and/or infrapopliteal lesions causing CLI. Most of the patients had diabetes while more than half of the overall population had coronary artery disease and dyslipidaemia. All lesions were located in the infra-inguinal segment and most were chronic total occlusions (96%; 95% CI 85%-100%). Seven studies reported moderate or severe calcification in approximately half of the cases (45%; 95% CI 30%-60%). The overall technical success of the retrograde approach was 96% (18 studies; 95% CI 92%-100%). Perforation, flow limiting dissection, distal embolisation, and local haematoma at the retrograde access site were infrequent and observed in 2.1%, 0.6%, 0.1%, and 1.3% of the patients, respectively. The six month primary patency rate was 78% (five studies; 95% CI 46%-99%), the six month limb salvage rate was 77% (four studies; 95% CI 70%-84%). CONCLUSION The results indicated that the retrograde or bidirectional antegrade/retrograde approach is safe and effective and facilitates angioplasty when antegrade treatment fails. However, prospective studies with standardised wound care and surveillance protocols are needed to investigate retrograde techniques in patients with CLI who failed antegrade revascularisation, to improve long term limb salvage and survival.
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Affiliation(s)
- Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Centre, University of Colorado, Denver, CO, USA
| | - Luis M Palena
- Endovascular Surgery Unit, Endovascular Interventions & Research, Foot & Ankle Clinic, Maria Cecilia Hospital, Cotignola, Italy
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Centre, University of Colorado, Denver, CO, USA.
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Jagirdar RM, Papazoglou ED, Pitaraki E, Kouliou OA, Rouka E, Giannakou L, Giannopoulos S, Sinis SI, Hatzoglou C, Gourgoulianis KI, Zarogiannis SG. Cell and extracellular matrix interaction models in benign mesothelial and malignant pleural mesothelioma cells in 2D and 3D in-vitro. Clin Exp Pharmacol Physiol 2020; 48:543-552. [PMID: 33336399 DOI: 10.1111/1440-1681.13446] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 11/27/2020] [Indexed: 10/22/2022]
Abstract
Malignant pleural mesothelioma (MPM) is an aggressive tumour that grows in the pleural cavity. MPM spheroids released in the pleural fluid can form new tumour foci. Cell-cell, cell-extracellular matrix (ECM) interactions in 2D and 3D impact malignant cell behaviour during cell adhesion, migration, proliferation and epithelial-mesenchymal transition (EMT). In this study, epithelioid, biphasic and sarcomatoid MPM cell types as well as benign mesothelial cells were tested with regards to the above phenotypes. Fibronectin (FN) and homologous cell-derived extracellular matrix (hcd-ECM) treated substratum differentially affected the above phenotypes. 3D MPM spheroid invasion was higher in FN-collagen matrices in the epithelioid and biphasic cells, while 3D cell cultures of epithelioid and sarcomatoid MPM cells in FN-collagen showed a higher contractility compared to hcd-ECM-collagen. Cell aggregates demonstrated invasive behaviour in hcd-ECM matrices alone. Our results suggest that ECM and the dimensionality affect malignant cell behaviour during cell culture studies.
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Affiliation(s)
- Rajesh M Jagirdar
- Department of Physiology, Faculty of Medicine, University of Thessaly, BIOPOLIS, Larissa, Greece
| | - Eleftherios D Papazoglou
- Department of Physiology, Faculty of Medicine, University of Thessaly, BIOPOLIS, Larissa, Greece
| | - Eleanna Pitaraki
- Department of Physiology, Faculty of Medicine, University of Thessaly, BIOPOLIS, Larissa, Greece
| | - Olympia A Kouliou
- Department of Physiology, Faculty of Medicine, University of Thessaly, BIOPOLIS, Larissa, Greece
| | - Erasmia Rouka
- Department of Physiology, Faculty of Medicine, University of Thessaly, BIOPOLIS, Larissa, Greece.,Department of Respiratory Medicine, Faculty of Medicine, University of Thessaly, BIOPOLIS, Larissa, Greece
| | - Lydia Giannakou
- Department of Physiology, Faculty of Medicine, University of Thessaly, BIOPOLIS, Larissa, Greece
| | - Stefanos Giannopoulos
- Department of Physiology, Faculty of Medicine, University of Thessaly, BIOPOLIS, Larissa, Greece
| | - Sotirios I Sinis
- Department of Physiology, Faculty of Medicine, University of Thessaly, BIOPOLIS, Larissa, Greece
| | - Chrissi Hatzoglou
- Department of Physiology, Faculty of Medicine, University of Thessaly, BIOPOLIS, Larissa, Greece.,Department of Respiratory Medicine, Faculty of Medicine, University of Thessaly, BIOPOLIS, Larissa, Greece
| | | | - Sotirios G Zarogiannis
- Department of Physiology, Faculty of Medicine, University of Thessaly, BIOPOLIS, Larissa, Greece.,Department of Respiratory Medicine, Faculty of Medicine, University of Thessaly, BIOPOLIS, Larissa, Greece
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Schizas D, Peppas S, Giannopoulos S, Lagopoulou V, Mylonas KS, Giannopoulos S, Moris D, Felekouras E, Toutouzas K. The Impact of Cirrhosis on Pancreatic Cancer Surgery: A Systematic Review and Meta-Analysis. World J Surg 2020; 45:562-570. [PMID: 33073316 DOI: 10.1007/s00268-020-05821-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cirrhosis has been considered a contraindication to major abdominal surgeries, due to increased risk for postoperative morbidity and mortality. The aim of this study was to assess the safety of pancreatectomy in cirrhotic versus non-cirrhotic patients. METHODS The present systematic review and meta-analysis was performed according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. All meta-analyses were performed using the random effects model. RESULTS Eight studies were eventually included, enrolling 1229 patients (cirrhotics: 722; and Child-Pugh A: 593; Child-Pugh B/C: 129) who underwent surgery for pancreatic cancer. The overall postoperative morbidity rate was 66% (51%-80%). Infections (26%) and ascites formation/worsening (23%) were the most common postoperative complications, followed by anastomotic leak/fistula (17%). Non-cirrhotic patients were less likely to suffer from anastomotic leak/fistula (OR: 0.39; 95% CI: 0.23-0.65) and infections (OR: 0.41; 95% CI: 0.25-0.67). Postoperative mortality rate was statistically significantly lower in non-cirrhotic versus cirrhotic patients (OR: 0.18; 95% CI:0.18-0.39). The odds ratios of 1 year (OR: 0.62; 95% CI: 0.30-1.30), 2 year (OR: 0.67; 95% CI: 0.25-1.83) and 3 year all-cause mortality (OR: 0.32; 95% CI: 20.03-2.99) were not significantly different between cirrhotic versus non-cirrhotic patients. CONCLUSION This study demonstrated that non-cirrhotic patients were less likely to undergo any type of re-intervention and had statistically significant lower postoperative mortality rates compared to patients with cirrhosis.
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Affiliation(s)
- Dimitrios Schizas
- First Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece.
| | - Spyridon Peppas
- Department of Gastroenterology, Athens Naval Hospital, Athens, Greece
| | | | - Vasiliki Lagopoulou
- Department of Surgery, 251 VA and Hellenic Air Force Hospital, Athens, Greece
| | - Konstantinos S Mylonas
- First Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Spyridon Giannopoulos
- First Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Moris
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Evangelos Felekouras
- First Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Toutouzas
- First Propedeutic Department of Surgery, Hippocration General Hospital, National and Kapodistrian University of Athens, Athens, Greece
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50
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Texakalidis P, Giannopoulos S, Karasavvidis T, Rangel-Castilla L, Rivet DJ, Reavey-Cantwell J. Mechanical Thrombectomy in Acute Ischemic Stroke: A Meta-Analysis of Stent Retrievers vs Direct Aspiration vs a Combined Approach. Neurosurgery 2020; 86:464-477. [PMID: 31313819 DOI: 10.1093/neuros/nyz258] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 04/15/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Recent randomized control trials (RCTs) established that mechanical thrombectomy is superior to medical therapy for patients with stroke due to a large vessel occlusion. OBJECTIVE To compare the safety and efficacy profile of the different mechanical thrombectomy strategies. METHODS A random-effects meta-analysis was performed and the I2 statistic was used to assess heterogeneity according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. RESULTS Nineteen studies with a total of 2449 patients were included. No differences were identified between the stent retrieval and direct aspiration groups in terms of modified Thrombolysis in Cerebral Infarction (mTICI) 2b/3 and mTICI 3 recanalization rates, and favorable outcomes (modified Rankin Scale [mRS] ≤ 2). Adverse event rates, including 90-d mortality, symptomatic intracerebral hemorrhage (sICH), and subarachnoid hemorrhage (SAH), were similar between the stent retrieval and direct aspiration groups. The use of the stent retrieval was associated with a higher risk of vasospasm (odds ratio [OR]: 2.98; 95% confidence interval [CI]: 1.10-8.09; I2: 0%) compared to direct aspiration. When compared with the direct aspiration group, the subgroup of patients who underwent thrombectomy with the combined approach as a first-line strategy had a higher likelihood of successful mTICI 2b/3 (OR: 1.47; 95% CI: 1.02-2.12; I2: 0%) and mTICI 3 recanalization (OR: 3.65; 95% CI: 1.56-8.54), although with a higher risk of SAH (OR: 4.33; 95% CI: 1.15-16.32). CONCLUSION Stent retrieval thrombectomy and direct aspiration did not show significant differences. Current available evidence is not sufficient to draw conclusions on the best surgical approach. The combined use of a stent retriever and aspiration as a first-line strategy was associated with higher mTICI 2b/3 and mTICI 3 recanalization rates, although with a higher risk of 24-h SAH, when compared with direct aspiration.
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Affiliation(s)
- Pavlos Texakalidis
- Department of Neurosurgery, School of Medicine, Emory University, Atlanta, Georgia
| | | | | | | | - Dennis J Rivet
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia
| | - John Reavey-Cantwell
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia
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