Publications by authors named "Miltiadis Matsagkas"

85 Publications

Clinical effect of accessory renal artery coverage after endovascular repair of aneurysms in abdominal and thoracoabdominal aorta.

J Vasc Surg 2021 Jun 29. Epub 2021 Jun 29.

Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.

Background: The aim of our systematic review and meta-analysis was to assess the effect of accessory renal artery (ARA) coverage on renal function in terms of acute kidney injury (AKI), renal infarction, chronic renal failure (CRF), and mortality in patients undergoing standard endovascular aortic aneurysm repair (EVAR) or endovascular repair of complex aneurysms.

Methods: An electronic search of the English language medical literature from 2000 to September 2020 was conducted using the MEDLINE, EMBASE, and Cochrane databases with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) method for studies reporting on ARA management in patients undergoing endovascular repair of aneurysms in the abdominal and thoracoabdominal aorta. The patients were divided into two groups: group 1, patients with ARA coverage; and group 2, patients without an ARA or without coverage of the ARA. Each group included two arms, one of patients who had undergone standard EVAR and one of patients who had undergone endovascular treatment of a complex aortic aneurysm. The GRADE (grading of recommendations assessment, development, evaluation) approach was used to evaluate the quality of evidence and summary of the findings. The primary outcomes included the incidence of AKI, renal infarction, CRF, and mortality.

Results: Ten retrospective, nonrandomized, control studies were included in the systematic review reporting on 1014 patients (302 with a covered ARA vs 712 without an ARA or without ARA coverage). In six studies, the mean diameter of the covered ARA was <4 mm (range, 2.7-3.4 mm). The mean follow-up was 22.74 months (range, 1-42 months). In the standard EVAR subgroup, the risk of AKI (odds ratio [OR], 0.72; 95% confidence interval [CI], 0.21-2.51; I = 0%] in the early period, and CRF (OR, 4.44; 95% CI, 0.46-42.61; I = 87%) and death (OR, 0.91; 95% CI, 0.36-2.31; I = 0%) during follow-up were similar between groups 1 and 2. Only the risk of renal infarction was greater in group 1 than in group 2 (OR, 93.3; 95% CI, 1.48-5869; I = 92%). In the complex aneurysm repair subgroup, the risk of AKI (OR, 1.85; 95% CI, 0.61-5.64; I = 42%) in early period and CRF (OR, 1.64; 95% CI, 0.88-3.07; I = not applicable) and death (OR, 3.63; 95% CI, 0.14-96.29; I = 56%) during follow-up were similar between groups 1 and 2. Only the risk of renal infarction was greater for group 1 compared with group 2 (OR, 8.58; 95% CI, 4.59-16.04; I = 0%).

Conclusions: ARA (<4 mm) coverage in patients undergoing standard EVAR or endovascular repair of complex aneurysms is associated with an increased risk of renal infarction. However, we found no clinical effects of ARA coverage on renal function or mortality in early postoperative and follow-up period. Preservation of an ARA >4 mm should be considered.
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http://dx.doi.org/10.1016/j.jvs.2021.06.032DOI Listing
June 2021

Postdischarge thromboembolic outcomes and mortality of hospitalized patients with COVID-19: the CORE-19 registry.

Blood 2021 05;137(20):2838-2847

Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY.

Thromboembolic events, including venous thromboembolism (VTE) and arterial thromboembolism (ATE), and mortality from subclinical thrombotic events occur frequently in coronavirus disease 2019 (COVID-19) inpatients. Whether the risk extends postdischarge has been controversial. Our prospective registry included consecutive patients with COVID-19 hospitalized within our multihospital system from 1 March to 31 May 2020. We captured demographics, comorbidities, laboratory parameters, medications, postdischarge thromboprophylaxis, and 90-day outcomes. Data from electronic health records, health informatics exchange, radiology database, and telephonic follow-up were merged. Primary outcome was a composite of adjudicated VTE, ATE, and all-cause mortality (ACM). Principal safety outcome was major bleeding (MB). Among 4906 patients (53.7% male), mean age was 61.7 years. Comorbidities included hypertension (38.6%), diabetes (25.1%), obesity (18.9%), and cancer history (13.1%). Postdischarge thromboprophylaxis was prescribed in 13.2%. VTE rate was 1.55%; ATE, 1.71%; ΑCM, 4.83%; and MB, 1.73%. Composite primary outcome rate was 7.13% and significantly associated with advanced age (odds ratio [OR], 3.66; 95% CI, 2.84-4.71), prior VTE (OR, 2.99; 95% CI, 2.00-4.47), intensive care unit (ICU) stay (OR, 2.22; 95% CI, 1.78-2.93), chronic kidney disease (CKD; OR, 2.10; 95% CI, 1.47-3.0), peripheral arterial disease (OR, 2.04; 95% CI, 1.10-3.80), carotid occlusive disease (OR, 2.02; 95% CI, 1.30-3.14), IMPROVE-DD VTE score ≥4 (OR, 1.51; 95% CI, 1.06-2.14), and coronary artery disease (OR, 1.50; 95% CI, 1.04-2.17). Postdischarge anticoagulation was significantly associated with reduction in primary outcome (OR, 0.54; 95% CI, 0.47-0.81). Postdischarge VTE, ATE, and ACM occurred frequently after COVID-19 hospitalization. Advanced age, cardiovascular risk factors, CKD, IMPROVE-DD VTE score ≥4, and ICU stay increased risk. Postdischarge anticoagulation reduced risk by 46%.
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http://dx.doi.org/10.1182/blood.2020010529DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8032474PMC
May 2021

Modeling and Computational Comparison of the Displacement Forces Exerted between the AFX Unibody Aortic Stent Graft and its Hybrid Combination with a Nitinol-based Proximal Aortic Cuff.

Ann Vasc Surg 2021 Jul 2;74:400-409. Epub 2021 Apr 2.

Laboratory for Vascular Simulations, Institute of Vascular Diseases, Larissa, Greece; Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.

Background: The bifurcated AFX (Endologix, Inc, Irvine, CA, USA) aortic stent-graft is the sole unibody endograft for the management of Abdominal Aortic Aneurysms (AAA). In order to improve the AFX central sealing and clinical efficacy in challenging cases, a replacement of the central chromium-cobaltium AFX extension with a Nitinol-based proximal aortic cuff has been suggested. Yet, comparative data regarding the hemodynamic performance of this design is missing. Aim of this study was to compare the displacement forces (DF) acting on the hybrid AFX-Endurant design, with the classic AFX and Endurant endografts, in angulated and non-angulated cases based on patient-specific Computational Fluid Dynamics (CFD) simulations.

Methods: 3D endograft models of 11 treated AAA cases were reconstructed from Computed Tomography Angiography (CTA) imaging data: 5 cases of AFX, 3 cases of the combination AFX-Endurant and 3 cases of the classic Endurant design. The DF on the main-body, the iliac limbs, and the entire stent-graft was calculated by processing the velocity and pressure fields generated by pulsatile CFD simulations.

Results: The range of total DF (acting on the whole endograft structure) in the AFX, hybrid AFX-Endurant and Endurant group was 2.5-5.2N, 2.0-5.9N and 1.9-2.9N respectively, with the maximum total DF being lower for Endurant. The DF on the main-body of the classic and hybrid AFX cases were higher than the right and left iliac limbs (2.5-4.9N vs. 0.6-5.3N and 0.7-3.6N respectively). Conversely, the DF on the main-body of the Endurant cases was comparable to the force exerted on the right and left limbs. When separating the cases with respect to their neck angulation, the DF on all endograft parts (main-body, limbs) and on the endograft as a whole were lower for the hybrid AFX-Endurant group compared to the classic AFX and Endurant groups, for cases with almost straight neck.

Conclusion: The off-label use of the hybrid AFX-Endurant stent-graft does not seem superior to the conventional AFX or Endurant endografts in angulated cases but was associated with lower DF than AFX or Endurant in non-angulated cases. The clinical value and utility of these findings remain to be elucidated.
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http://dx.doi.org/10.1016/j.avsg.2021.02.017DOI Listing
July 2021

Association of Neutrophil-Lymphocyte and Platelet-Lymphocyte Ratio with Adverse Events in Endovascular Repair for Abdominal Aortic Aneurysm.

J Clin Med 2021 Mar 5;10(5). Epub 2021 Mar 5.

Department of Anesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41110 Larissa, Greece.

The association of chronic inflammatory markers with the clinical outcome after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) was investigated. We included 230 patients, treated electively with EVAR. The values of neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) were measured pre- and postoperatively. Any major adverse cardiovascular event (MACE) and acute kidney injury (AKI) were recorded. Adverse events occurred in 12 patients (5.2%). Seven patients suffered from MACE and five from AKI. Median NLR and PLR values were significantly increased after the procedure (NLR: from 3.34 to 8.64, < 0.001 and PLR: from 11.37 to 17.21, < 0.001). None of the patients or procedure characteristics were associated with the occurrence of either a MACE or AKI. Receiver operating characteristic curve analysis showed that postoperative NLR and PLR were strongly associated with AKI. A threshold postoperative NLR value of 9.9 was associated with the occurrence of AKI, with a sensitivity of 80% and specificity of 81%. A threshold postoperative PLR value of 22.8 was associated with the occurrence of AKI, with a sensitivity of 80% and specificity of 83%. Postoperative NLR and PLR have been associated with the occurrence of AKI after EVAR for AAA.
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http://dx.doi.org/10.3390/jcm10051083DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7961355PMC
March 2021

Early Outcomes of Carotid Revascularization in Retrospective Case Series.

J Clin Med 2021 Mar 1;10(5). Epub 2021 Mar 1.

Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41334 Larissa, Greece.

Background: Most data in carotid stenosis treatment arise from randomized control trials (RCTs) and cohort studies. The aim of this meta-analysis was to compare 30-day outcomes in real-world practice from centers providing both modalities.

Methods: A data search of the English literature was conducted, using PubMed, EMBASE and CENTRAL databases, until December 2019, using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement (PRISMA) guidelines. Only studies reporting on 30-day outcomes from centers, where both techniques were performed, were eligible for this analysis.

Results: In total, 15 articles were included (16,043 patients). Of the patients, 68.1% were asymptomatic. Carotid artery stenting (CAS) did not differ from carotid endarterectomy (CEA) in terms of stroke (odds ratio (OR) 0.98; 0.77-1.25; = 0%), myocardial ischemic events (OR 1.03; 0.72-1.48; = 0%) and all events (OR 1.0; 0.82-1.21; = 0%). Pooled stroke incidence in asymptomatic patients was 1% (95% CI: 0-2%) for CEA and 1% for CAS (95% CI: 0-2%). Pooled stroke rate in symptomatic patients was 3% (95% CI: 1-4%) for CEA and 3% (95% CI: 1-4%) for CAS. The two techniques did not differ in either outcome both in asymptomatic and symptomatic patients.

Conclusion: Carotid revascularization, performed in centers providing both CAS and CEA, is safe and effective. Both techniques did not differ in terms of post-procedural neurological and cardiac events, both in asymptomatic and symptomatic patients. These findings reiterate the importance of a tailored therapeutic strategy and that "real-world" outcomes may only be valid from centers providing both treatments.
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http://dx.doi.org/10.3390/jcm10050935DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7957582PMC
March 2021

Ten-year single center experience in elective standard endovascular abdominal aortic aneurysm repair.

Int Angiol 2021 Jun 19;40(3):240-247. Epub 2021 Mar 19.

School of Health Sciences, Department of Vascular Surgery, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, Larissa, Greece.

Background: Endovascular aneurysm repair (EVAR) has become the treatment of choice for abdominal aortic aneurysm (AAA), demonstrating excellent early outcomes. However, EVAR durability has been questioned in the long-term period. The aim of this study was to assess EVAR outcomes in terms of survival and freedom from re-intervention during a long-term period.

Methods: All consecutive patients being treated, with elective standard EVAR, in a single tertiary center, were included between 2008 and 2018. Outcomes were defined as survival and freedom from re-intervention and were reported using Kaplan-Meyer lifetables. In subgroup analyses, sex, age (threshold at 65 and 80 years), neck diameter>28mm and type of fixation were also analyzed. Type of re-intervention and endoleak type I (ETIa) were also reported.

Results: Five hundred and eight patients (94% males, mean age 72±7.3, mean AAA diameter 59±9mm) were included. The median follow-up was 3 years (range 0-10 years). The survival rate was 92.8% (SE 1.5%), 76.5% (SE 3.1%) and 41.6% (SE 6%), at 2, 5 and 10 years of follow-up, respectively. In total, 78 patients died; 8 deaths (8/75, 10%) were aneurysm related. In multivariate regression analysis, age (CI. 1.02-1.14; p=0.006) and ever tobacco use (CI. 1.02-6.12, P=0.045) were associated with the long-term mortality. Freedom from re-intervention was 96% (SE 1.1%), 93% (SE 1.8%), 85.5% (SE 5%) at 2, 5 and 9 years of follow-up. Limb occlusion was a common complication (n/n; 30% of re-intervention), particularly within the first 2 postoperative years. Six patients presented with rupture and were treated with open conversion. EVAR cases with supra-renal fixation graft presented lower rates of ETIa (CI. 76-87.27, P<0.001).

Conclusions: Elective standard EVAR is associated with good long-term survival showing low aneurysm-related mortality. Common risk factors such as advanced age and smoking are associated to higher mortality. The procedure presents low re-intervention rates, while limb occlusion is a complication presented within the first 2 postoperative years.
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http://dx.doi.org/10.23736/S0392-9590.21.04648-4DOI Listing
June 2021

Management of Descending Thoracic Aortic Diseases: Similarities and Differences Among Cardiovascular Guidelines.

J Endovasc Ther 2021 Apr 13;28(2):323-331. Epub 2021 Jan 13.

German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany.

Cardiovascular societies have developed recommendations regarding the management of thoracic aortic diseases. While improvements in treatment have been observed during the past decade in regard to patient selection, thoracic endovascular aortic repair (TEVAR) and associated techniques, and high-volume centralization, the broad expansion of TEVAR has raised considerations about its indications, appropriateness, limitations, and application. The aim of this systematic review was to assess the similarities and differences among current cardiovascular societies' guidelines for the management of thoracic aortic diseases. The MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials were searched from January 2009 to May 2020. The initial search identified 990 articles. After exclusion of duplicate or inappropriate articles, the final analysis included 5 articles from cardiovascular societies published between 2010 and 2020. Selected controversial topics were analyzed, including diagnosis, imaging, spinal cord ischemia prevention, and management of the most important thoracic aortic pathologies. The analysis included data concerning the therapeutic approach in acute and chronic type B aortic dissection, penetrating aortic ulcer, intramural hematoma, thoracic aortic aneurysm, and traumatic aortic injury, as well a discussion of inflammatory aneurysms, aortitis, and genetic syndromes. The review presents consistent and controversial recommendations, as well as "gray zone" issues that need further investigation. There was significant overlap and agreement among the 5 societies regarding the management of thoracic aortic diseases. Especially in dissection and aneurysm management, TEVAR has established its role as the treatment of choice. However, robust evidence is still needed in many aspects of the management of thoracic aortic pathologies.
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http://dx.doi.org/10.1177/1526602820987808DOI Listing
April 2021

The TAXINOMISIS Project: A multidisciplinary approach for the development of a new risk stratification model for patients with asymptomatic carotid artery stenosis.

Eur J Clin Invest 2020 Dec 2;50(12):e13411. Epub 2020 Oct 2.

Department of Materials Science and Engineering, Unit of Medical Technology and Intelligent Information Systems, University of Ioannina, Ioannina, Greece.

Introduction: Asymptomatic carotid artery stenosis (ACAS) may cause future stroke and therefore patients with ACAS require best medical treatment. Patients at high risk for stroke may opt for additional revascularization (either surgery or stenting) but the future stroke risk should outweigh the risk for peri/post-operative stroke/death. Current risk stratification for patients with ACAS is largely based on outdated randomized-controlled trials that lack the integration of improved medical therapies and risk factor control. Furthermore, recent circulating and imaging biomarkers for stroke have never been included in a risk stratification model. The TAXINOMISIS Project aims to develop a new risk stratification model for cerebrovascular complications in patients with ACAS and this will be tested through a prospective observational multicentre clinical trial performed in six major European vascular surgery centres.

Methods And Analysis: The risk stratification model will compromise clinical, circulating, plaque and imaging biomarkers. The prospective multicentre observational study will include 300 patients with 50%-99% ACAS. The primary endpoint is the three-year incidence of cerebrovascular complications. Biomarkers will be retrieved from plasma samples, brain MRI, carotid MRA and duplex ultrasound. The TAXINOMISIS Project will serve as a platform for the development of new computer tools that assess plaque progression based on radiology images and a lab-on-chip with genetic variants that could predict medication response in individual patients.

Conclusion: Results from the TAXINOMISIS study could potentially improve future risk stratification in patients with ACAS to assist personalized evidence-based treatment decision-making.
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http://dx.doi.org/10.1111/eci.13411DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7757200PMC
December 2020

Multicenter Mid-term Results After Endovascular Aortic Aneurysm Repair with the Incraft® Device.

Ann Vasc Surg 2021 Apr 16;72:464-478. Epub 2020 Sep 16.

Department of Vascular Surgery, University of Thessaly, Larissa, Greece.

Objectives: Durability after endovascular aortic aneurysm repair (EVAR) is considered an ongoing topic of investigation and was always a point of concern with smaller profile devices. Recently released five-year clinical trial results using the Incraft® ultralow profile device are encouraging. However, additional real-life experience will need to assist these initial findings. Herein, we investigated the outcomes after EVAR, in real world practice using the Incraft® endograft (EG).

Material And Methods: Seventy-seven patients with infrarenal abdominal aortic aneurysms (AAA) ≥50 mm in diameter treated with the Incraft® device in three vascular centers were enrolled from November 2015 to July 2018. Follow-up was completed in August 2020. Selection of EVAR using the Incraft® device was individualized according to aorto-iliac morphologic features, comorbidities, history of previous abdominal surgery and preference of the patient. At the early phase of the study, we specifically opted for preferential use of this low profile EG mainly in cases of small and tortuous iliac vessels (more challenging access routes). At later stages, it was used according to surgeon preference and not specifically in complex anatomies (real-world conditions). End-points included technical success, perioperative complications, 30-day survival, endoleg patency, presence of endoleaks, sac enlargement >5 mm and clinical success.

Results: The primary technical success rate was 97.4% before the addition of an aortic cuff and iliac extension for a type Ia and type Ib endoleak respectively, and the repair of a maldeployment iliac component (primary-assisted and secondary technical success, 100%). Intraoperative small type II endoleaks (visible in final angiogram) were noted in 19 patients (24.7%). There were no intraoperative deaths from AAA rupture, primary conversions or conversions to aortounilateral grafts. Two complications occurred, necessitating hybrid techniques for repair (replaced of a dislodged endoleg and distal external iliac artery hemostasis). No deaths were reported within 30 days. Occlusion of an endoleg, was observed in two patients, 6 and 14 months respectively after implantation (2.6%), and were treated by femoral-femoral PTFE bypass after unsuccessful endovascular recanalization. The latter required open conversion, 3 mo later, to repair compromised flow to the inflow iliac axis. Three patients (3.9%) experienced sac enlargement >5 mm in diameter compared with the 1-month CT scan. All of these had type II endoleaks and two received embolization procedures. Eleven patients died from causes unrelated to AAA repair. Clinical success was 97.3%, 92.8% and 89.4% through 1, 2 and 3 years respectively.

Conclusions: EVAR with the Incraft® device might be considered a reliable option in real-world conditions and not specifically only in complex iliac anatomies.
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http://dx.doi.org/10.1016/j.avsg.2020.09.018DOI Listing
April 2021

Management of Abdominal Aortic Aneurysm Disease: Similarities and Differences Among Cardiovascular Guidelines and NICE Guidance.

J Endovasc Ther 2020 Dec 19;27(6):889-901. Epub 2020 Aug 19.

German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany.

The development of endovascular techniques has improved abdominal aortic aneurysm (AAA) management over the past 2 decades. Different cardiovascular societies worldwide have recommended the endovascular approach as the standard of care in their currently available guidelines. While endovascular treatment has established its role in daily clinical practice, a new debate has arisen regarding the indications, appropriateness, limitations, and role of open surgery. To inform this debate, the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases were searched from 2010 to May 2020; the systematic search identified 5 articles published between 2011 and 2020 by 4 cardiovascular societies and the National Institute of Health and Care Excellence (NICE). Four debatable domains were assessed and analyzed: diagnostic methods and screening, preoperative management, indications and treatment modalities, and postoperative follow-up and endoleak management. The review addresses controversial proposals as well as widely accepted recommendations and "gray zone" issues that need to be further investigated and analyzed, such as screening in women, medical management, and follow-up imaging. While the recommendations for AAA management have significant overlap and agreement among international cardiovascular societies, the NICE guidelines diverge regarding the role of open repair in aortic disease, recommending conventional surgery in most elective cases.
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http://dx.doi.org/10.1177/1526602820951265DOI Listing
December 2020

A systematic review and meta-analysis of carotid artery stenting using the transcervical approach.

Int Angiol 2020 Oct 12;39(5):372-380. Epub 2020 Jun 12.

Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, Larissa, Greece.

Introduction: Carotid artery stenting (CAS) via a transcarotid revascularization (TCAR) approach has emerged as an alternative when carotid endarterectomy or conventional CAS is contraindicated. The present study was conducted to assess the feasibility and safety of TCAR in patients with carotid artery stenosis.

Evidence Acquisition: A systematic review of the literature was performed, according to PRISMA guidelines (Preferred Reporting Items for Systematic reviews and Meta-Analyses), using PubMed, EMBASE and CENTRAL databases. The primary outcomes included technical success, perioperative neurological event, myocardial ischemic events, death and their composite. Operational duration, flow reversal time and any local procedure related complication (carotid dissection and cranial nerve injury) were also recorded.

Evidence Synthesis: Twenty-three studies were included, reporting on 3130 patients, undergoing TCAR. Thirty-five per cent of them were symptomatic. Technical success was 98% (95% CI: 0.97-0.99; P=0.11, I2=32%). Early (30-day) new neurological event rate was estimated at 2% (95% CI: 0.01-0.02; P=1.0, I2=0%, respectively) while early death rate was 1% (95% CI: 0.00-0.01; P=1.0, I2=0%). Myocardial ischemic (MI) event rate was 1% (95% CI, 0.00-0.01, P=0.97, I2=6.6%). The composite outcome of neurological event/MI/death at 30-day follow-up was 2% (95% CI: 0.01-0.02, P=0.79, I2=14%). Carotid dissection rate during the intervention was 2% (95% CI: 0.01-0.03, P=0.58, I2=2.9%) while the post-operatively detected cranial nerve injury rate was 1% (95% CI, 0.00-0.01, P=1.0, I2=0%). Regarding the technical aspects of the procedures, operational and flow reversal time were at 73.8 min and 13.7 min, respectively (95% CI: 68.2-79.3, P=0.18, I2=37.6% and 95% CI: 11.3-16.1, P=0.48, I2=0%, respectively).

Conclusions: TCAR is feasible with high technical success rate. The procedure presents low incidence of local complications, neurological events, myocardial complications and mortality during the early postoperative period and should be considered an acceptable alternative for patients treated for carotid artery stenosis.
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http://dx.doi.org/10.23736/S0392-9590.20.04434-XDOI Listing
October 2020

Completion imaging techniques and their clinical role after carotid endarterectomy: Systematic review of the literature.

Vascular 2020 Dec 3;28(6):794-807. Epub 2020 Jun 3.

Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.

Background: Completion imaging has been suggested for the intraoperative quality control assessment of the carotid endarterectomy technical success, in order to immediately resolve pathologic findings and accordingly improve patients' outcome. The aim of this study was to present existing evidence of different completion imaging techniques after carotid endarterectomy and their role on clinical outcome.

Material And Methods: A systematic review was performed searching in MEDLINE, CENTRAL, and Cochrane databases including studies reporting on completion imaging techniques after carotid endarterectomy.

Results: A total of 12,378 patients in 35 studies (20 retrospective and 15 prospective) underwent a completion imaging technique after carotid endarterectomy: in 19 studies, 5340 patients underwent arteriography; in 5 studies, 2095 angioscopy; in 21 studies, 5722 DUS; and in 2 studies, 150 patients underwent transcranial Doppler. Ten studies assessed > 1 imaging technique. The mean age was 67 ± 7 years old (69% males) with common co-morbidities to be hypertension (74%), smoking (64%), and hyperlipidemia (54%). Almost half of the patients (4949; 44%) were treated for symptomatic disease. In 1104 (9.7%) patients, a major defect was identified intra-operatively, while in 329 patients (2.9%), a minor defect. Common pathological findings were the presence of mural thrombus, carotid dissection, residual stenosis, and intimal flaps. An immediate re-intervention was undertaken in 75% (790/1053) of the patients to treat a major intra-operative imaging finding. In patients with re-intervention, only 2.3% (14/609) had an intra-operative stroke and 0.8% (5/609), a transient ischemic attack, while only 1.4% (8/575) had a stroke and 0.2% a transient ischemic attack (1/575) during 30-day post-operative period. No intra-operative death was reported. In the same period, the restenosis rate of internal and common carotid artery was 0.5% (3/575) and 0.2% (1/575), respectively.

Conclusion: Completion imaging techniques can detect defects in almost 10% of patients that may lead to immediate intra-operative surgical revision with low intra-operative stroke/transient ischemic attack rate and low early carotid restenosis. During the 30-day follow-up period, in those patients, the incidence of stroke/transient ischemic attack may be low but present. This review cannot provide any evidence on which completion imaging technique is better, and the clinical impact conferred by each technique in the absence of a randomized control studies.
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http://dx.doi.org/10.1177/1708538120929793DOI Listing
December 2020

Distal Renal Artery Aneurysm Repair: "More than Meets the Eye".

Eur J Vasc Endovasc Surg 2020 08 25;60(2):219. Epub 2020 May 25.

Department of Vascular Surgery, Larissa University Hospital, School of Health Sciences, Faculty of Medicine, University of Thessaly, Larissa, Greece.

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http://dx.doi.org/10.1016/j.ejvs.2020.04.041DOI Listing
August 2020

Frequency and predictors of chemotherapy-associated venous thromboembolism: the prospective PREVENT study.

Int Angiol 2020 Apr 13;39(2):112-117. Epub 2020 Feb 13.

Department of Vascular Surgery, University of Thessaly, Larissa, Greece -

Background: Our knowledge on the burden of symptomatic and asymptomatic venous thromboembolism (VTE) in patients with cancer undergoing chemotherapy is limited. The aim of our study was to prospectively investigate the frequency of symptomatic VTE and asymptomatic deep vein thrombosis of the lower limbs among cancer patients undergoing chemotherapy.

Methods: We studied 231 patients (164 men) with pancreatic (N.=36), lung (N.=136), ovarian (N.=32) or prostate (N.=27) cancer receiving first line (N.=192, 83.1%) or adjuvant chemotherapy, followed-up for 3-6 months.

Results: Some 17 patients were diagnosed with VTE, either asymptomatic detected on leg ultrasound (N.=7) or symptomatic (N.=10). The total frequency of VTE was 10.3% (17/165 with follow-up). Pancreatic cancer had the highest frequency of VTE (4/25, 16%) followed by ovarian (3/26, 11.5%) and lung cancer (10/94, 10.6%). There was no statistically significant difference in VTE rates among cancer types (P=0.36). VTE occurred more frequently in the presence of metastases (13/85, 15.3% vs. 4/80, 5.0%, for the remainder, P=0.03, OR 3.4). In the subgroup of patients receiving first line treatment, VTE occurred more frequently in patients with metastases (13/84, 15.5% vs. 2/53, 3.8%, for the remainder, P=0.033). In patients with pancreatic, lung or ovarian cancer receiving first line treatment, VTE occurred more frequently in patients with metastatic disease (19.1% vs. 4.0%, for the remainder, P=0.015).

Conclusions: VTE occurrence in this real-world patient cohort was high, reaching almost 20% in certain groups, like those with disseminated pancreatic, lung or ovarian cancer receiving first-line chemotherapy. Furthermore, VTE occurs mostly as a symptomatic event, being likely a result of the prothrombotic state of malignancy.
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http://dx.doi.org/10.23736/S0392-9590.20.04272-8DOI Listing
April 2020

The effect of Endovascular Aneurysm Repair on Renal Function in Patients Treated for Abdominal Aortic Aneurysm.

Curr Pharm Des 2019 ;25(44):4675-4685

Department of Vascular Surgery, Medical School, University of Thessaly, Larissa, Greece.

Aim: The effect of endovascular aneurysm repair in patients treated for abdominal aortic aneurysm has not been clearly defined. The objective of the present article was to provide a contemporary literature review and perform an analysis to determine the effect of EVAR on renal function in the early post-operative period and during follow-up.

Methods: A systematic review of the literature was undertaken to identify all studies reporting the effect of EVAR on renal function. Outcome data were pooled and combined overall effect sizes were calculated using fixed or random-effects models.

Results: Thirty-two studies reporting on 24846 patients were included. Acute renal failure after EVAR occurred with an estimated frequency of 9% (95%CI: 5-16%; I2=97%). Median follow-up period was 19.5 months (range 1-60 months). The estimated frequency of chronic renal failure during follow-up was 7% (95%CI: 3-17%; I2=98%). Hemodialysis was required in 2% (1-3%; I2=97%) of the cases.

Conclusion: High-level evidence demonstrating the effect of EVAR on the incidence of acute and chronic renal failure is lacking. Based on the current available data, nearly 10% of patients undergoing EVAR for AAA have an increased risk for renal dysfunction after the procedure. Whether this deterioration may lead to a worse outcome has not been adequately proved.
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http://dx.doi.org/10.2174/1381612825666191129094923DOI Listing
June 2020

Anatomical Differences Between Intact and Ruptured Large Abdominal Aortic Aneurysms.

J Endovasc Ther 2020 02 11;27(1):117-123. Epub 2019 Nov 11.

Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.

To compare different anatomical characteristics between intact and ruptured large abdominal aortic aneurysms (rAAA >80 mm) with the goal of refining the process of estimating rupture risk. A retrospective study involving 62 male patients with large (>80 mm) aneurysms matched for age and smoking produced a 31-patient elective group with a mean maximum aneurysm diameter of 92±9.7 mm and a 31-patient rAAA group (mean maximum aneurysm diameter 95.7±12 mm). Preoperative computed tomography angiography scans were analyzed with a dedicated workstation, and anatomical characteristics of the aortic neck, iliac arteries, and aneurysm were compared in multivariable regression analyses; the outcomes are given as the odds ratio (OR) with 95% confidence interval (CI). The prognostic utility of several characteristics as predictors of rupture occurrence was examined with receiver operating characteristic (ROC) curves. Anatomical characteristics differing significantly between elective and ruptured aneurysms were the infrarenal aortic neck diameters at 5 mm, 10 mm and 15 mm; the neck length and calcification; the common iliac artery (CIA) lengths; the iliac artery indexes; the left CIA and external iliac artery diameters; and the total and true lumen aneurysm volumes. Intraluminal thrombus (ILT) volume did not differ (p=0.76), although its distribution in elective vs ruptured cases did [absent: 0% vs 19%, respectively (p=0.025); circumferential: 61% vs 35%, respectively (p=0.04)]. Total aneurysm volume was higher in rAAA (442±140 mL) vs intact AAA (331±143 mL, p=0.014), while the ILT/total aneurysm volume rate was lower in rAAA (55%) vs intact AAA (70%, p=0.02). Multivariate analysis determined that a shorter left CIA (OR 1.07, 95% CI 1.01 to 1.1, p=0.016) and a smaller total aneurysm volume (OR 1.007, CI. 1.001 to 1.014, p=0.016) were associated with intact AAA. After a ROC curve analysis, left CIA length <50 mm demonstrated a lower incidence of rupture (sensitivity 60% and specificity 78%), while total aneurysm volume <380 mL had 60% sensitivity and specificity. Large rAAAs seem to have different anatomical characteristics than similarly sized intact AAAs. Large intact AAAs have lower total aneurysm volumes and shorter left CIAs, with higher ILT/aneurysm volume rates.
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http://dx.doi.org/10.1177/1526602819886568DOI Listing
February 2020

Endograft Specific Haemodynamics After Endovascular Aneurysm Repair: Flow Characteristics of Four Stent Graft Systems.

Eur J Vasc Endovasc Surg 2019 Oct 17;58(4):538-547. Epub 2019 Aug 17.

Laboratory for Vascular Simulations, Institute of Vascular Diseases, Larissa, Greece; Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece. Electronic address:

Objectives: The implication of haemodynamics in the occurrence of complications after endovascular aneurysm repair (EVAR) has been raised in the literature. Different aortic stent graft configurations may lead to different haemodynamic properties. The current study deals with the post-operative haemodynamic variability between four stent graft systems with different structure, material, and type of fixation.

Methods: Computed tomography data of 32 patients were used, equally distributed among the four endograft groups, namely the AFX, Endurant, Excluder, and Nellix. Velocity, wall shear stress (WSS), and helicity statistics were calculated, in regions around the flow division where disturbances are expected. The haemodynamic data were compared between and within the groups.

Results: The morphology of AAAs pre-operatively did not vary significantly among the four groups. Before the flow division, lowest velocity was observed in Endurant cases and highest in Nellix cases. Endurant induced the lowest peak WSS and Nellix the highest (p = .03). The helicity levels were low in AFX and Nellix cases and high in Endurant and Excluder cases. After the flow division, the trend in the results was preserved. Nellix induced the highest velocity and WSS, followed closely by Excluder and AFX. There was a significant increase of helicity before and after flow division in AFX (p <0.001, R = 0.09) and Nellix (p <0.001) cases.

Conclusions: It has been shown that different types of endografts induce variable haemodynamic conditions around the flow division. The parallel limb structure, featured by Nellix, seems to induce favourable flow conditions in terms of velocity and WSS, while helical flow before the flow division is suppressed. High WSS is generally considered to be a desirable flow characteristic in endovascular devices, whereas helicity extremes (very low or high) are potentially a negative sign. Endurant, with the stiffer material and the short neck structure, was associated with the lowest blood velocity and WSS values but preserved high helicity levels. The AFX and Excluder, which include the same material, induced similar haemodynamic conditions.
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http://dx.doi.org/10.1016/j.ejvs.2019.04.017DOI Listing
October 2019

Suprarenal Aortic Remodeling after Endovascular Aortic Aneurysm Repair among Three Endografts with Different Types of Proximal Fixation System.

Ann Vasc Surg 2019 Nov 5;61:341-349. Epub 2019 Aug 5.

Vascular Surgery Department, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.

Background: Remodeling of suprarenal aorta after endovascular aortic aneurysm repair (EVAR) in relation to different endograft designs has not been thoroughly investigated. The aim of this study is to assess the anatomical configuration of the suprarenal aorta after using endografts with different proximal fixation during the first post-EVAR year.

Methods: A retrospective study including EVAR patients using 3 types of endografts with different proximal fixation systems according to Instructions for Use was undertaken (50: Ovation, Endologix, Irvin, CA; 25: Endurant IIs, Medtronic, Santa Rosa, CA; 25: Excluder C3, W. L. Gore & Associates, Flagstaff, AZ). Comorbidities were recorded. Anatomic variables of the supra-aortic anatomy, abdominal aortic aneurysm (AAA) maximum diameter, and neck angulation were analyzed. Computed tomography angiography was obtained preoperatively at 1 and 12 months post-EVAR, while a duplex scan was undertaken at 6 months.

Results: Comorbidities were not different across the 3 groups. Presence and amount of neck calcification (P = 0.139) and thrombus (P = 0.116) was similar among groups. Maximum aortic diameter showed significant reduction from preoperative measurements to 12-month postoperative ones, for all groups. (Ovation: 56.5 to 53 mm, P < 0.001; Endurant: 57 to 51 mm, P < 0.001; Excluder: 55 to 50 mm, P < 0.001). Suprarenal angulation was decreased significantly in the Ovation (P < 0.001) and Excluder groups (P = 0.05), while the infrarenal angulation was decreased in all groups. Among endografts, the decrease in AAA maximum diameter was similar (P = 0.99), while the suprarenal aortic diameter was significantly increased in Ovation patients in comparison to the other 2 endografts at the level of 5 mm (P = 0.02) and 25 mm (P = 0.01). Suprarenal angulation reduction was similar (P = 0.7), while infrarenal angulation was significantly more decreased in Ovation endograft than the other 2 systems (P < 0.001).

Conclusions: Proximal endograft configuration appears to have different impact on supra-aortic anatomy. Longer follow-up is needed to clarify future remodeling and clinical impact of these observations.
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http://dx.doi.org/10.1016/j.avsg.2019.05.048DOI Listing
November 2019

Factors associated with elimination of type II endoleak during the first year after endovascular aneurysm repair.

J Vasc Surg 2020 01 18;71(1):56-63. Epub 2019 May 18.

Vascular Surgery Department, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Department of Surgery, Vascular Surgery Unit, University of Ioannina, Medical School, Ioannina, Greece.

Objective: The natural history of endoleak type II (ET II) after endovascular aneurysm repair (EVAR) is still debatable. The aim of this study was to examine the presence of preoperative and postoperative factors associated with persistence of ET II during the initial 12-month follow-up period.

Methods: A two-center retrospective study including patients subjected to EVAR from 2006 to 2017 was undertaken. Patients with ET II at 1-month computed tomography angiography (CTA) were categorized into two groups, resolution (group 1) vs persistence (group 2) of ET II at 12-month CTA. Preoperative demographics, comorbidities, aneurysm anatomic details, and pelvic artery index were assessed. Intraoperative details were also recorded.

Results: Of 825 patients, 140 (17%) patients (mean age, 71.7 ± 8.5 years; 94% male) presented with ET II at 1-month CTA. Group 1 included 58 patients (41%) and group 2, 82 patients (59%). The anatomic characteristics of the inferior mesenteric artery and lumbar arteries and the pelvic artery indices were not associated with ET II persistence. All patients in group 1 had presence of intraluminal thrombus (ILT) on preoperative CTA (group 1, 100%; group 2, 67%; P = .001), and the circular pattern of ILT was more common in group 1 (group 1, 44%; group 2, 24%; P = .01). At 12-month CTA, the mean sac regression was higher in group 1 (group 1, -3 ± 4 mm; group 2, 0.55 ± 3 mm; P = .000). After multivariate analysis, persistence of ET II was directly associated only with intraoperative internal iliac occlusion (odds ratio [OR], 0.232; 95% confidence interval [CI], 0.06-0.86; P = .03) and inversely with statin therapy (OR, 2.6; 95% CI, 1.01- 6.8; P = .047) and sac regression (OR, 1.24; 95% CI, 1.11-1.39; P = .001).

Conclusions: Induced occlusion of the internal iliac artery during EVAR was the only factor associated with persistence of ET II during the first year after EVAR. The presence and pattern of ILT may play a role in ET II persistence, whereas the number of patent infrarenal aortic branches and their diameter as well as the pelvic artery indices were not associated with ET II. The use of statins may have a positive effect on ET II resolution during the first postoperative year. Sac diameter is more likely to regress in patients with ET II resolution.
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http://dx.doi.org/10.1016/j.jvs.2019.01.064DOI Listing
January 2020

Large Diameter (≥29 mm) Proximal Aortic Necks Are Associated with Increased Complication Rates after Endovascular Repair for Abdominal Aortic Aneurysm.

Ann Vasc Surg 2019 Oct 8;60:70-75. Epub 2019 May 8.

Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Department of Surgery, Vascular Surgery Unit, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece.

Background: The aim of this study is to investigate the impact of proximal aortic diameter on outcome after endovascular aneurysm repair (EVAR) of infrarenal abdominal aortic aneurysms (AAAs).

Methods: This is a case-control (1:1) retrospective analysis of prospectively collected data on 732 AAA patients treated with EVAR in 2 university centers. Patients with an infrarenal neck diameter of 29-32 mm (wide neck, WN group) were compared with patients with a neck diameter of 26-28.9 mm (control group) matched for age, gender, and maximum aneurysmal sac diameter. Any patients treated outside the instructions for use of each endograft or with no adequate follow-up were excluded. The primary end point was any neck-related adverse event (a composite of type Ia endoleak, neck-related secondary intervention, and endograft migration) during follow-up.

Results: Sixty-four patients with a proximal neck diameter of 29-32 mm (WN group) were compared with a matched control group of 64 patients with a neck diameter of 26-28.9 mm (control group). Oversizing was significantly higher in the study group (17.9% vs. 15.5%, P = 0.001). Overall median available follow-up was 24 months (range 12-84) (WN group 24 months vs. control group 18.5 months, P = 0.943). Primary end point was recorded in 8 patients (12.5%) of the WN group and in 1 patient (1.6%) of the control group. Freedom from the primary end point at 36 months (standard error <10%) was 87.3% for the study versus 98.4% for the control group (log rank = 4.66, P = 0.03). On multiple regression analysis, the presence of a proximal aortic neck >29 mm was the only independent risk factor for neck-related adverse events (odds ratio 7.4, 95% confidence interval 1.2-47.1).

Conclusions: EVAR in the presence of a wide proximal aortic neck is likely to be associated with higher adverse neck-related event rates and thus, in such cases closer follow-up may be required.
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http://dx.doi.org/10.1016/j.avsg.2019.02.031DOI Listing
October 2019

Endovascular aneurysm repair in patients with a wide proximal aortic neck: a systematic review and meta-analysis of comparative studies.

J Cardiovasc Surg (Torino) 2019 Apr 18;60(2):167-174. Epub 2019 Jan 18.

Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.

Introduction: The aim was to investigate the impact of wide proximal aortic diameter on outcome after standard endovascular repair (sEVAR) of infrarenal abdominal aortic aneurysms.

Evidence Acquisition: A systematic search of the literature was undertaken using the PUBMED, EMBASE, and Cochrane databases for articles comparing outcome after sEVAR in patients with large versus small diameter aortic neck. The prognostic factor of interest was large diameter proximal aortic neck and the results were reported as odds ratio (OR) or mean difference (MD) and 95% confidence interval (CI). A time-to-event data meta-analysis for late outcomes was performed using the inverse-variance method and reported the results as summary hazard ratio (HR) and 95% CI.

Evidence Synthesis: We identified 6 observational studies reporting on a total of 6602 patients (1616 with large and 4986 with small diameter neck). Patients with large proximal aortic neck were older (MD 0.87, 95% CI: 0.35-1.39; P=0.001). The prevalence of male gender (OR=1.63, 95% CI: 1.34-1.98; P<0.001), coronary artery disease (OR=1.20, 95% CI: 1.06-1.36; P=0.004), chronic obstructive pulmonary disease (OR=1.18, 95% CI: 1.03-1.36; P=0.02) and chronic kidney disease (OR=1.43, 95% CI: 1.23-1.66; P<0.001) was higher in the wide neck group. Patients with large diameter proximal neck had shorter proximal neck (MD=-1.91, 95% CI: -2.04 to -1.77; P<0.001) and a larger aneurysm diameter compared to those with small diameter neck (MD=3.40, 95% CI: 2.71-4.10; P<0.001). Patients with small diameter proximal neck had significantly higher freedom from aneurysm-related reintervention (HR=2.06, 95% CI: 1.23-3.45; P=0.006), freedom from type Ia endoleak (HR=6.69, 95% CI: 4.39-10.20; P<0.001), freedom from sac expansion (HR=10.07, 95% CI: 1.80-56.53; P=0.009), freedom from aneurysm rupture (HR 5.10, 95% CI: 1.40-18.58; P=0.01), and survival (HR=1.55, 95% CI: 1.08-2.24; P=0.02).

Conclusions: Patients with a wide proximal aortic neck undergoing standard EVAR were found to have worse outcome, as indicated by a lower freedom from aneurysm-related reintervention, type Ia endoleak, sac expansion and aneurysm rupture, and a higher overall survival. This anatomic characteristic should be considered in decision making. In such patients, closer imaging surveillance after EVAR in the long term may be required to identify early and treat timely the complications.
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http://dx.doi.org/10.23736/S0021-9509.19.10869-5DOI Listing
April 2019

Perioperative Management of DOACs in Vascular Surgery: A Practical Approach.

Curr Pharm Des 2018 ;24(38):4518-4524

Department of Anesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.

Background: Approximately 10-15% of patients on DOACs have to interrupt their anticoagulant before an invasive procedure every year. The perioperative management and monitoring of DOACs have proved to be challenging, as differences in patients' status and in the invasiveness of each procedure develop different situations that need a tailored therapeutic approach to each patient's needs.

Methods: This review aims to summarize current evidence on the perioperative management of DOACs in patients undergoing a vascular surgical procedure focusing with a practical approach on three key clinical questions: (i) can we stop DOAC therapy before the vascular procedure? (ii) is bridging therapy necessary? and (iii) which is the best perioperative strategy for interruption and resumption of the anticoagulant therapy?

Results: No specific data exist for the perioperative management of vascular surgery patients on DOACs, as most studies include low number of such patients. Therapeutic strategy on how to handle DOACs perioperatively must be based on their half-life, the bleeding risk of the invasive procedures, and on the thromboembolic risk of the patient. Renal function plays a crucial role in such situations, increasing thromboembolic and bleeding risk. In general, DOACs should be stopped 2 days for high bleed risk, 1 day for low risk and should be resumed 48-72 hrs after high risk, 24 hrs after low-risk procedure. Bridging is almost never needed.

Conclusion: Further perioperative research studies on patients undergoing vascular surgery are needed to confirm whether currently accepted therapeutic perioperative strategy is appropriate for these patients.
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http://dx.doi.org/10.2174/1381612825666181226154746DOI Listing
November 2019

Abdominal aortic aneurysm endovascular repair: profiling post-implantation morphometry and hemodynamics with image-based computational fluid dynamics.

J Biomech Eng 2018 May 23. Epub 2018 May 23.

Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Torino 10129, Italy.

Endovascular aneurysm repair (EVAR) has disseminated rapidly as an alternative to open surgical repair for the treatment of abdominal aortic aneurysms (AAAs), because of its reduced invasiveness, low mortality and morbidity rate. The effectiveness of the endovascular devices used in EVAR is always at question as postoperative adverse events can lead to re-intervention or to a possible fatal scenario for the circulatory system. Motivated by the assessment of the risks related to thrombus formation, here the impact of two different commercial endovascular grafts on local hemodynamics is explored through 20 image-based computational hemodynamic models of EVAR-treated patients (N=10 per each endograft model). Hemodynamic features, susceptible to promote thrombus formation, such as flow separation and recirculation, are quantitatively assessed and compared with the local hemodynamics established in image-based infrarenal abdominal aortic models of healthy subjects (N=10). The hemodynamic analysis is complemented by a geometrical characterization of the EVAR-induced reshaping of the infrarenal abdominal aortic vascular region. The findings of this study indicate that: (1) the clinically observed propensity to thrombus formation in devices used in EVAR strategies can be explained in terms of local hemodynamics by means of image-based computational hemodynamics approach; (2) reportedly pro-thrombotic hemodynamic structures are strongly correlated with the geometry of the aortoiliac tract postoperatively. In perspective, our study suggests that future clinical follow up studies could include a geometric analysis of the region of the implant, monitoring shape variations that can lead to hemodynamic disturbances of clinical significance.
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http://dx.doi.org/10.1115/1.4040337DOI Listing
May 2018

Regarding "Early Experience With Endovascular Aneurysm Sealing in Combination With Parallel Grafts for the Treatment of Complex Abdominal Aneurysms: The ASCEND Registry".

J Endovasc Ther 2018 04;25(2):261-262

1 Vascular Surgery Department, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.

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http://dx.doi.org/10.1177/1526602818759758DOI Listing
April 2018

Hostility of proximal aortic neck anatomy in relation to abdominal aortic aneurysm size and its impact on the outcome of endovascular repair with the new generation endografts.

J Cardiovasc Surg (Torino) 2020 Feb 9;61(1):60-66. Epub 2018 Jan 9.

Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, Larissa, Greece.

Background: To assess the relation of abdominal aortic aneurysm (AAA) diameter with the proximal neck anatomy (PNA) hostility and to evaluate its impact on the endovascular aneurysm repair (EVAR) outcomes with the use of newer generation endografts.

Methods: Retrospective analysis of single institution's recorded data from February 2009 to April 2016. Patients' characteristics, comorbidities, aortic morphology, perioperative characteristics and outcomes were analyzed. In relation to AAA diameter 2 groups were identified: group A (50-55 mm) and group B (>55 mm). Hostile PNA was defined based on: neck diameter >28 mm, length <15 mm, angulation >60o, and circumferential thrombus and/or calcification >50%. The aortic neck scoring system was calculated. Multiple logistic regression analysis with a forward likelihood ratio method adjusted for age and gender was undertaken.

Results: Three hundred seventeen patients (96% males, mean age 72.4±9 years, 80% elective) were follow-up for a mean of 23.4 months (range, 3-86 months). No differences were observed in demographics and co-morbidities between the two groups (group A: 134, 42% vs. group B: 183, 58%). Hostile PNA was present in 147/317 (46%) patients and significantly more likely to be present in group B (P<0.001). In group B the aortic neck score was higher (P<0.001), the likelihood for having hostile PNA increased for neck diameter by 2.2-fold (OR 2.2, P=0.013, 95% CI: 1.18-4.03), length by 2.3-fold (OR 2.3, P=0.012, 95% CI: 1.20-4.51), angle by 4.8-fold (OR 4.8, P=0.002, 95% CI: 1.79-13.24) and presence of thrombus by 1.5-fold (OR 1.5, P=0.037, 95% CI: 1.45-10.34). No association existed for neck calcification (P=0.071). Technical success, adjunctive procedures, perioperative characteristics and outcomes were comparable in friendly and hostile PNAs.

Conclusions: PNA hostility is more likely in AAA with diameter >55 mm but with the use of newer generation endografts this did not influence the short- and mid-term EVAR outcomes. Longer follow-up is needed for a more definite conclusion.
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http://dx.doi.org/10.23736/S0021-9509.18.10001-2DOI Listing
February 2020

Haemodynamic performance of AFX and Nellix endografts: a computational fluid dynamics study.

Interact Cardiovasc Thorac Surg 2018 05;26(5):826-833

Laboratory for Vascular Simulations, Institute of Vascular Diseases, Ioannina, Greece.

Objectives: The objective of this study is to analyse the flow conditions in the AFX and Nellix endografts (EGs) accounting for their postimplantation configuration in patients with an endovascular aneurysm repair-treated abdominal aortic aneurysm.

Methods: We reconstructed post-endovascular aneurysm repair computed tomography scans of patients treated with an AFX or Nellix EG creating post-implantation EG models. We examined 16 patients, 8 in each group. The blood flow properties were obtained by computational fluid dynamics simulations and were subsequently compared with physiological infrarenal blood flow properties measured in 5 healthy subjects. Specifically, pressure drop, maximum velocity and wall shear stress were measured at peak systole and mean helicity at mid-diastole.

Results: Our statistical analyses showed that the haemodynamic properties in both control regions did not vary statistically after the implantation of either the AFX or the Nellix EG, except for helicity that was significantly lower in the abdominal part of the Nellix EG compared with the expected physiological measurement. Regardless of the overall blood flow restoration, it is important to note that low pressure drop was detected along the limbs of the AFX and suppressed blood helical motion was detected at the entrance of the Nellix device.

Conclusions: It is observed from the results that the AFX EG has achieved absolute restoration of blood flow after endovascular aneurysm repair, although the development of secondary flow in the upper part of the EG and the low pressure drop in its limbs should be acknowledged. The Nellix EG also seems to be haemodynamically efficient. However, the suppression of helical flow before blood enters the device might raise concerns about its clinical application.
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http://dx.doi.org/10.1093/icvts/ivx414DOI Listing
May 2018

Balloon Angioplasty Versus Stenting for the Treatment of Failing Arteriovenous Grafts: A Meta-Analysis.

Eur J Vasc Endovasc Surg 2018 Feb 16;55(2):249-256. Epub 2017 Dec 16.

Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.

Purpose: To assess the outcomes of plain balloon angioplasty versus stenting for the treatment of failed or malfunctioning chronic haemodialysis arteriovenous grafts (AVGs).

Methods: A systematic search of the literature was undertaken using the PUBMED, EMBASE, and Cochrane databases from January 2000 to September 2016 for articles comparing balloon angioplasty versus stenting in the management of failed or malfunctioning chronic haemodialysis AVGs. Results are reported as OR and 95% CI.

Results: The search identified eight studies (1051 patients). Balloon angioplasty alone was used in 521 patients (49.6%) and stenting in 530 patients (50.4%). At the time of the endovascular re-intervention, the mean life of AVGs was 807.7±115.4 days for the balloon angioplasty and 714.2±96.3 days for the stenting group (p=.92). All AVGs were located in the arm. Most procedures (98.1%) were performed across the venous anastomosis, while 88% of the patients in the stenting group received a stent graft. The technical success rate was significantly higher in the stenting group (OR 0.16, 95% CI 0.08-0.31, p<.001). At 12 months, loss of primary and secondary patency was significantly higher in patients undergoing plain balloon angioplasty compared with stenting (OR 3.54, 95% CI 2.18-5.74, p<.001, and OR 1.82, 95% 1.17-2.82, p=.008, respectively).

Conclusion: Stenting is associated with better technical success and patency rates compared with plain angioplasty in treating failed or malfunctioning chronic haemodialysis AVGs, and thus it should be considered as the first line therapeutic option.
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http://dx.doi.org/10.1016/j.ejvs.2017.11.011DOI Listing
February 2018

Current status of endovascular treatment of aortoenteric fistula.

Semin Vasc Surg 2017 Jun - Sep;30(2-3):80-84. Epub 2017 Oct 26.

Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Mezourlo, 41334 Larissa, Greece. Electronic address:

Aortoenteric fistula (AEF) is one of the most challenging diagnostic and therapeutic entities in vascular surgery. AEF can occur either primarily involving the aorta and the gastrointestinal tract or, more commonly, secondary to previous aortic reconstructive surgery. Traditionally, the treatment of AEF includes graft excision and extra-anatomic bypass surgery or in situ graft replacement. However, recently endovascular repair has emerged as an alternative therapeutic option. In this article, we present published and current evidence for endovascular repair of primary and secondary AEF. When endovascular treatment is applied where appropriate, early outcomes seem to be superior compared to open surgery. This benefit may be lost during long-term follow-up, implying that a staged approach with early conversion to in situ grafting may realize the best patient survival and morbidity. Lifelong administration of antibiotics is associated with a reduction in re-infection. An endovascular approach used as a bridging procedure in unstable patients is recommended, followed by definitive open therapy, if feasible, in patients with good life expectancy.
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http://dx.doi.org/10.1053/j.semvascsurg.2017.10.004DOI Listing
January 2018

Commentary: Postimplantation Syndrome: An Underrecognized EVAR Complication.

J Endovasc Ther 2017 10 21;24(5):675-676. Epub 2017 Aug 21.

1 Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.

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http://dx.doi.org/10.1177/1526602817727279DOI Listing
October 2017

Regarding "Standard endovascular aneurysm repair in patients with wide infrarenal aneurysm necks is associated with increased risk of adverse events".

J Vasc Surg 2017 08;66(2):679

Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.

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http://dx.doi.org/10.1016/j.jvs.2017.03.423DOI Listing
August 2017
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