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Lioudaki S, Verikokos C, Kouraklis G, Ioannou C, Chatziioannou E, Perrea D, Klonaris C. Paraoxonase-1: Characteristics and Role in Atherosclerosis and Carotid Artery Disease. Curr Vasc Pharmacol 2020; 17:141-146. [PMID: 29189170 DOI: 10.2174/1570161115666171129212359] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 07/11/2017] [Revised: 10/16/2017] [Accepted: 11/01/2017] [Indexed: 11/22/2022]
Abstract
Paraoxonase-1 (PON-1) is a calcium-dependent enzyme that is synthesized in the liver and then secreted in blood where it is bound to high density lipoprotein (HDL). PON-1 is a hydrolase with a wide range of substrates, including lipid peroxides. It is considered responsible for many of the antiatherogenic properties of HDL. PON-1 prevents low density lipoprotein (LDL) oxidation, a process that is considered to contribute to the initiation and development of atherosclerosis. PON-1 activity and levels are influenced by gene polymorphisms; of the 2 common variants, one is in position 192 (Q192R) and one in position 55 (M55L). Also, many drugs affect PON-1 activity. The role of PON-1 in carotid atherosclerosis is inconsistent. Some studies show an association of PON-1 polymorphisms with carotid plaque formation, whereas others do not. The aim of this review is to summarize the characteristics of PON-1, its interactions with drugs and its role in atherosclerosis and especially its relationship with carotid artery disease.
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Affiliation(s)
- S Lioudaki
- Vascular Department, University Hospital of Heraklion, Medical School of Crete, University of Crete, Heraklion, Greece
| | - C Verikokos
- 2nd Department of Surgery, "Laiko Hospital", Medical School of Athens, National and Kapodistrian University of Athens, Athens, Greece
| | - G Kouraklis
- 2nd Department of Surgery, "Laiko Hospital", Medical School of Athens, National and Kapodistrian University of Athens, Athens, Greece
| | - C Ioannou
- Vascular Department, University Hospital of Heraklion, Medical School of Crete, University of Crete, Heraklion, Greece
| | - E Chatziioannou
- Medical School of Athens, National and Kapodistrian University of Athens, Athens, Greece
| | - D Perrea
- Laboratory for Experimental Surgery and Surgical Research "N.S. Christeas", Medical School of Athens, National and Kapodistrian University of Athens, Athens, Greece
| | - C Klonaris
- 1st Department of Surgery, "Laiko Hospital", Medical School of Athens, National and Kapodistrian University of Athens, Athens, Greece
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Henry M, Amor M, Henry I, Klonaris C, Chati Z, Masson I, Kownator S, Luizy F, Hugel M. Carotid Stenting with Cerebral Protection: First Clinical Experience Using the PercuSurge GuardWire System. J Endovasc Ther 2016; 6:321-31. [PMID: 10893133 DOI: 10.1177/152660289900600405] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: To study the feasibility and safety of carotid angioplasty and stenting using a new cerebral protection device that temporarily occludes the distal internal carotid artery (ICA). Methods: Forty-eight high-risk patients (39 men, mean age 69.1 ± 8 years, range 54 to 86) with 53 ICA stenoses underwent percutaneous angioplasty and stenting via the femoral approach under cerebral protection afforded by a 0.014-inch GuardWire balloon occlusion device. Mean stenosis was 82.1% ± 9.65% (range 70 to 96) and mean lesion length was 16.0 ± 7.5 mm (range 6 to 50). Thirty-three (62%) lesions were calcified, and 38 (72%) were ulcerated. Thirty-two (60%) of the lesions were asymptomatic. With the occlusion balloon inflated in the distal ICA, the lesion was dilated and stented. The area was cleaned by aspiration and flushed via an aspiration catheter advanced over the wire. Blood samples were collected from the external carotid artery (ECA) and analyzed to measure the size and number of particles collected. Computed tomography and neurological examinations were performed the day after the procedure. Results: Immediate technical success was achieved in all patients with the implantation of 38 Palmaz stents, 8 Expander stents, and 11 Wallstents. Carotid occlusion was well tolerated in all patients but 1 who had multiple, severe carotid lesions and poor collateralization. Mean cerebral flow occlusion time was 346 ± 153 seconds during predilation and 303 ± 143 seconds during stent placement. Total mean flow occlusion time was 542 ± 243 seconds. One immediate neurological complication (transient amaurosis) occurred in a patient who had an anastomosis between the external carotid (EC) and ICA territories. Debris was removed in all patients with a mean 0.8-mm diameter catheter. Conclusion: Cerebral protection with the GuardWire device is easy, safe, and effective in protecting the brain from cerebral embolism. Larger studies are warranted.
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Affiliation(s)
- M Henry
- UCCI, Polyclinique, Essey-les-Nancy, France.
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Katsargyris A, Oikonomou K, Klonaris C, Bal A, Yanar F, Verhoeven EL. Common iliac and hypogastric aneurysms: open and endovascular repair. J Cardiovasc Surg (Torino) 2015; 56:249-255. [PMID: 25512317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Currently, there are a variety of open surgical, endovascular, and hybrid options to treat iliac artery aneurysms (IAA). Anatomy of the common iliac artery (CIA) with regard to proximal and distal neck, involvement of the iliac bifurcation, and choice to preserve the ipsilateral internal iliac artery (IIA) all play a role in the decision process towards the preferred treatment method. This manuscript describes the available open surgical and endovascular techniques for the treatment of IAA. Indications, advantages and limitations, and outcomes of each technique are discussed.
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Affiliation(s)
- A Katsargyris
- Department of Vascular and Endovascular Surgery, Paracelsus Medical University, Nürnberg, Germany -
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Klonaris C, Kouvelos G, Kafeza M, Koutsoumpelis A, Katsargyris A, Tsigris C. Common Carotid Artery Occlusion Treatment: Revealing a Gap in the Current Guidelines. J Vasc Surg 2013. [DOI: 10.1016/j.jvs.2013.07.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Georgopoulos S, Kouvelos GN, Koutsoumpelis A, Bakoyiannis C, Lymperi M, Klonaris C, Tsigris C. The effect of revascularization procedures on healing of mixed arterial and venous leg ulcers. INT ANGIOL 2013; 32:368-374. [PMID: 23822939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
AIM The optimal management of venous leg ulcers in patients with concomitant peripheral artery disease (PAD) remains unclear. The aim of the present study was to evaluate the effectiveness of revascularization procedures in healing of the ulcers of mixed etiology. METHODS During a 6-year period a total of 20 patients with evidence of chronic venous insufficiency, impaired arterial perfusion (ABI<0.75) and active leg ulcer were treated. Patients with moderate PAD (0.5<ABI<0.75) were treated conservatively with modified compression and were considered for revascularization if the ulcer did not heal, while those with severe PAD (ABI<0.5) underwent revascularization. RESULTS Eleven out of seventeen (64.7%) limbs with moderate arterial disease showed a significant healing progress after modified compression and healed at an average time of 24.7±3.1 weeks, while the other 6 limbs (35.3%) failed to improve underwent revascularization and healed at an average time of 16±2.6 weeks. Three limbs with severe arterial disease underwent revascularization and healed at an average time of 17.6±2.5 weeks. Overall the nine arterial interventions had a 100% technical success rate, while ABI improved from 0.54±0.07 to 0.94±0.04 after the intervention. The 30-day mortality was null. Healing time in patients treated with revascularization was significantly lower compared to those treated conservatively (16.6±2.6 weeks vs. 24.7±3.2 weeks, P<0.001). During the follow-up period (48.7±14.3 months), there were 9 ulcer recurrences, 6 in the group of conservative treatment and 3 in the group of revascularization. No significant difference in recurrences between the two groups (log rank=0.772, P=0.38) was demonstrated. CONCLUSION A protocol-driven therapeutic strategy that includes a revascularization procedure as a therapeutic option in patients with ulcers of mixed etiology may be beneficial. Based on the current data, it is essential the therapeutic strategy to be individualized by including an overall risk assessment accounting for comorbidities of the patient and the risk of the procedure.
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Affiliation(s)
- S Georgopoulos
- Unit of Vascular Surgery, 1st Department of Surgery, University of Athens, Medical School, Athens, Greece.
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Klonaris C, Kouvelos GN, Kafeza M, Koutsoumpelis A, Katsargyris A, Tsigris C. Common carotid artery occlusion treatment: revealing a gap in the current guidelines. Eur J Vasc Endovasc Surg 2013; 46:291-8. [PMID: 23870716 DOI: 10.1016/j.ejvs.2013.06.006] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [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: 01/29/2013] [Accepted: 06/09/2013] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To review the literature on the management of common carotid artery occlusion (CCAO). METHODS A review of English-language medical literature from 1965 to 2012 was conducted using the PubMed and EMBASE databases to find all studies involving management of CCAO. The search identified 21 articles encompassing 146 patients/arteries (73.2% men; mean age 65 ± 6.9 years). RESULTS The majority of the patients (93.8%) were symptomatic. Most of the patients (61.5%) had ipsilateral internal carotid artery (ICA) and external carotid artery (ECA) patent, while an occluded ICA and a patent ECA were found in 26.6% of the patients. Eighty per cent of the patients treated underwent a surgical bypass procedure, with the subclavian artery as the most common inflow vessel (64.1%). During the first 30 days of the procedure two strokes (1.5%) were reported. During a follow-up period spanning an average of 25.6 ± 11.2 months nine patients (6.6%) experienced a clinical cerebrovascular event. Seven restenoses (5.1%) and two reocclusions (1.5%) also occurred-eight after open surgical and one after endovascular repair. CONCLUSION The necessity to intervene to a CCAO remains controversial. This review shows that open surgical management of symptomatic CCA occlusive disease is a safe, durable, and effective therapeutic strategy with low perioperative cerebrovascular morbidity.
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Affiliation(s)
- C Klonaris
- 1st Department of Surgery - Division of Vascular Surgery, Laiko General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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Bakoyiannis CN, Tsekouras NS, Georgopoulos S, Klonaris C, Bastounis EE, Filis K, Papalambros E, Bastounis E. ICU transfer after elective abdominal aortic aneurysm repair can be succesfully reduced with a modified protocol. A fourteen year experience from a University Hospital. INT ANGIOL 2011; 30:43-51. [PMID: 21248672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
AIM To compare different selective criteria for Internal Care Unit (ICU) admission in two different timeframes, after abdominal aortic aneurysm (AAA) repair. A retrospective audit of acquired data was performed. METHODS During a period of fourteen years (1994-2008), 1152 patients underwent an elective open operation for infrarenal abdominal aortic aneurysm, in our department. Six hundred and two patients (Group A) were treated in the period January 1994-January 2003, and 550 patients (Group B) between January 2003 and August 2008. Postoperatively, all patients were transferred to postanesthesia unit (PAU). After a 2 hours period of close observation, they were transferred either to the ICU or to the surgical ward, according to certain selective criteria (SC). In group A we used SC-A, for admission to an ICU, and in group B we used new, stricter, criteria (SC-B). Thirty-day mortality and morbidity, elective admissions to ICU, rate of subsequent ICU admission, from ward to ICU, and the mean hospital and ICU length of stay, were compared between the two groups. RESULTS The use of SC-B resulted in a significant reduction of elective admissions to ICU (3.1% vs 8.5%, P<0.001). Nevertheless, the portion of patients, which were transferred with a severe postoperative complication from the ward to ICU, remained similar between the two groups (1.1% vs 0,9%, in group A and B, respectively). All other endpoints were similar in both groups. CONCLUSION Modifying the protocol of ICU transfer, after elective abdominal aortic aneurysm repair, we can reduce the number of patients requiring ICU, without compromising patients' safety.
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Affiliation(s)
- C N Bakoyiannis
- First Department of Surgery, Vascular Department, University of Athens Medical School, Laiko General Hospital, Athens, Greece.
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Bastounis E, Bakoyiannis C, Cagiannos C, Klonaris C, Filis C, Bastouni EE, Georgopoulos S. A Short Incision for Carotid Endarterectomy Results in Decreased Morbidity. Eur J Vasc Endovasc Surg 2007; 33:652-6. [PMID: 17336106 DOI: 10.1016/j.ejvs.2006.12.028] [Citation(s) in RCA: 14] [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] [Received: 08/22/2006] [Accepted: 12/23/2006] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To investigate the effect of a short incision (<5 cm) on the complication rate of the carotid endarterectomy (CEA). DESIGN A retrospective cohort study. PATIENTS AND METHODS From January 1994 to December 2005, 874 patients underwent 1048 primary carotid endarterectomy (CEA) procedures. Seven hundred and sixty nine operations were performed through a long neck incision (group A), while 279 were performed through a smaller incision (<5 cm) according to a standard protocol (group B). Preoperative and postoperative cranial nerve assessment was completed on all patients. The main outcome measures were stroke, death, cranial and cervical nerve injuries rates. RESULTS The 30-day mortality rate was 0.26% in group A and 0.35% in group B (p=.792). The stroke rate was 0.13% and 0% in group A and B respectively (p=.839). The mean length of stay was 2.59 days in group A and 1.67 days in group B (p<.0001). In group A the overall incidence of motor and sensory nerve deficits was 13.5% (104 CEA, 92 patients) but in group B 2.9% (8 CEA, 7 patients, p<.0001, odds ratio [OR] 0.189, 95% confidence interval [CI] 0.091-0.393). CONCLUSIONS Carotid endarterectomy through a small incision is a feasible and safe approach that provides cosmetic results and fewer nerve complications without compromising the safety of the procedure.
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Affiliation(s)
- E Bastounis
- First Department of Surgery, University of Athens Medical School, Laiko General Hospital, Athens, Greece
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Klonaris C, Katsargyris A, Bakoyannis C, Georgopoulos S, Michail O, Giannopoulos A, Bastounis E. Renal artery aneurysm endovascular repair. INT ANGIOL 2007; 26:189-92. [PMID: 17489084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
A 68-year-old woman with a left renal artery aneurysm underwent successful endovascular repair with the use of a commercial type self-expanding stent-graft. Complete aneurysm exclusion was achieved after stent-graft expansion. A side branch vessel was occluded after stent-placement, resulting in a small upper lobe renal perfusion defect. There were no other complications. The aneurysm remained excluded and its greatest diameter has been reduced from 2.6 cm to 1.95 cm, 10 months after treatment. Renal function remained normal.
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Affiliation(s)
- C Klonaris
- Vascular Division, 1st Surgical Department, Athens University Medical School, Athens, Greece.
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Klonaris C, Georgopoulos S, Katsargyris A, Tsekouras N, Bakoyiannis C, Giannopoulos A, Bastounis E. Changing patterns in the etiology of acute lower limb ischemia. INT ANGIOL 2007; 26:49-52. [PMID: 17353888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
AIM The aim of this study was to examine the causes of acute lower limb ischemia (ALLI) in a major referral center in Greece. METHODS Hospital records of patients that were admitted with ALLI between January 1, 2000 and December 31, 2004, were retrospectively reviewed for this purpose. A total of 440 cases of ALLI in 351 patients were identified. RESULTS In 174 (39.54%) cases, the ischemia was attributed to embolism; in 221 (50.23%) to thrombosis and in the remaining 45 (10.23%) to less common causes of ALLI (trauma [iatrogenic and non], vasculitis, dissection). Of 174 cases of embolism, 136 (78.16%) were of cardiac origin, 22 (12.64%) were due to non-cardiac emboli, while in the remaining 16 cases (9.2%) no specific origin of embolism was found. Of 221 cases of thrombosis 66 (29.86%) concerned native arterial thrombosis, while 155 (70.14%) concerned postinterventional thrombosis, including 144 (65.16%) cases of bypass graft thrombosis and 11 (4.98%) cases of iliac or femoral stent thrombosis. Sixty patients were admitted more than once with ALLI, most commonly due to repeated bypass graft thrombosis (85%). The latter was diagnosed in 32.73% of all ALLI cases and presented more often than native arterial thrombosis by a ratio of approximately 2.2:1. CONCLUSION This study indicates that currently the leading cause for hospital admissions in patients with ALLI is thrombosis which most commonly occurs in bypass grafts rather than in native arteries.
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Affiliation(s)
- C Klonaris
- Vascular Division, 1st Department of Surgery, Athens University Medical School, Athens, Greece.
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Henry M, Polydorou A, Klonaris C, Henry I, Polydorou AD, Hugel M. Carotid angioplasty and stenting under protection. State of the art. Minerva Cardioangiol 2007; 55:19-56. [PMID: 17287680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
A carotid stenosis is responsible for about 30% of strokes occurring. Carotid endarterectomy (CEA) is considered to be the gold standard treatment of a carotid stenosis. Carotid angioplasty and stenting (CAS) is emerging as a new alternative treatment for a carotid artery stenosis, but the risk of neurological complications and brain embolism remain the major drawback to this procedure. So as to reduce the risk, we need: good indications, good patient and lesion selection; correct techniques; brain protection devices (cerebral protection devices should be routinely used and are mandatory for any procedure. Three types of protection devices are available: filters are the most commonly used. Nevertheless, all protection devices have limitations and cannot prevent from embolic events. However neurological complications can be reduced by 60%. New protection devices will be discussed); good choice of the stent and correct implantation (all stents are not equivalent and have different geometrical effects); pharmacological adjuncts; good team. Indications are well accepted for high-risk patients and recent studies have shown that CAS has superior short-term outcomes than CEA in this group of patients. Indications for low-risk and asymptomatic patients are controversial. New selection criteria have to be discussed. But there are enough reported data to conclude that CAS is also not inferior to CEA in low-risk and asymptomatic patients. In our series of 844 procedures, without protection (n = 187) 30-day death and stroke rate was 3.7% and with protection (n = 657) 1% (1.3% for symptomatic patients, 0.9% for asymptomatic patients, 1.4% in high-risk patients, 0.4% in low-risk patients). CAS under protection is the standard of care and is maybe becoming the gold standard treatment of a carotid stenosis at least in some subgroups of patients.
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Affiliation(s)
- M Henry
- Cabinet de Cardiologie, Nancy, France.
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Georgopoulos S, Filis K, Vourliotakis G, Bakoyannis C, Papapetrou A, Klonaris C, Papalambros E, Bastounis E. Lower Extremity Bypass Procedures in Diabetic Patients with End-Stage Renal Disease: Is It Worthwhile? ACTA ACUST UNITED AC 2004; 99:c37-41. [PMID: 15627791 DOI: 10.1159/000082865] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2003] [Accepted: 07/08/2004] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Limb-threatening ischemia in patients with end-stage renal disease (ESRD) represents a challenging therapeutic problem. Furthermore, diabetes mellitus is frequently associated with ischemic gangrene, persistent infection and impaired wound healing. The present study was undertaken to examine graft patency, limb salvage and survival in patients with ESRD and diabetes following bypass grafting to treat lower limb critical ischemia. METHODS A retrospective analysis of 56 arterial reconstructions performed in 39 patients with diabetes mellitus and ESRD during a period of 8 years. The indications for bypass grafting were: ischemic rest pain (n = 13), non-healing ulcer (n = 18) or foot gangrene (n = 25). Risk factors in association with surgical morbidity and mortality, limb loss and graft patency were evaluated. RESULTS Thirty-four patients were on hemodialysis and 5 on peritoneal dialysis. Forty-nine infrainguinal reconstructions were performed; the site of distal anastomosis was the below knee popliteal artery (n = 22), the anterior tibial artery (n = 12), the posterior tibial artery (n = 8), and the peroneal artery (n = 7). Seven axillofemoral reconstructions were also performed; the site of distal anastomosis was the common femoral artery (n = 5) and the above knee popliteal artery (n = 2). The 30-day operative mortality rate was 18% (7 patients). The mean follow-up was 11.5 (range 1-93) months. Patient survival rate at 1 and 2 years was 63 and 45%, respectively. Primary patency rate was 64% at 1 year and 58% at 2 years. The limb salvage rate was 65% in the first year. CONCLUSION Limb salvage rate in patients with ESRD and diabetes justifies an aggressive policy of revascularization, despite decreased survival of this population.
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Affiliation(s)
- S Georgopoulos
- Division of Vascular Surgery, First Department of Surgery, University of Athens Medical School, Athens, Greece
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Bastounis E, Filis K, Georgopoulos S, Klonaris C, Xeromeritis N, Papalambros E. Current practice--routine use of shunting in carotid endarterectomy. Cost reduction and surgical training. INT ANGIOL 2001; 20:218-24. [PMID: 11573056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
BACKGROUND Sophisticated methods of determining cerebral blood flow have reduced the use of shunting in carotid endarterectomy in 6-25% of cases. However teaching university hospitals still have to provide their young vascular surgeons with experience in the shunting procedure. Since complications of shunting have been related to the surgeon's experience in the technique, our study aimed to evaluate a policy of the routine use of shunting in carotid endarterectomy by vascular surgeons in training. In addition to concluding how this policy would affect the optimum outcome of our patients. The probable reduction of hospital charges was also evaluated. METHODS A prospective audit of the results of 423 consecutive carotid endarterectomies performed by a senior vascular surgeon (the first 97 cases) and a vascular surgeon in training under the supervision of a senior vascular surgeon (326 cases), with routine use of an indwelling intraluminal shunt, in a university hospital in Athens. RESULTS During the study period, 337 patients admitted to our department were managed surgically independently of any demanding surgery due to the anatomy and the extension of internal carotid artery disease. The perioperative stroke/death rate at 30 days was 0.47%, but the stroke rate alone was 0%. Minor complications amounted to 5.4%, with an increased but not significant difference in patients presenting contralateral internal carotid occlusion. There was no difference in complication rates when a young surgeon performed the shunting procedure compared with the experienced senior surgeon's results, but this was achieved after training in the method in the first 97 cases. The reduction of the total cost was related to avoidance of cost of the devices necessary for determination of the cerebral circulation during carotid clamping and the cost of specially trained personnel. Our policy resulted in only eight patients having to be treated in the intensive care unit for a total of 13 days. CONCLUSIONS Experience in a large number of shunting procedures are required for a young vascular surgeon's training, in order to achieve optimum results. This can be done in teaching hospitals by using the method more frequently than required. Moreover in the contest of continuing changes in the practice of carotid endarterectomy and the economic restrictions on health expenditure, the routine use of shunting resulted in cost saving without jeopardizing the patients' outcome.
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Affiliation(s)
- E Bastounis
- Vascular Unit, First Department of Surgery, University of Athens, Athens, Greece
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Henry M, Klonaris C, Henry I, Tzetanov K, Le Borgne E, Foliguet B, Hugel M. Protected renal stenting with the PercuSurge GuardWire device: a pilot study. J Endovasc Ther 2001; 8:227-37. [PMID: 11491256 DOI: 10.1177/152660280100800301] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To evaluate the feasibility and safety of renal artery angioplasty and stenting utilizing a distal protection device to reduce the risk of intraprocedural atheroembolism. METHODS Twenty-eight hypertensive patients (18 men; mean age 71.3 +/- 8.6 years, range 49-87) with atherosclerotic renal artery stenosis (4 bilateral) underwent angioplasty and stenting with distal protection in 32 renal arteries (29 ostial lesions). The lesion was crossed with a GuardWire temporary occlusion balloon, which was inflated to provide parenchymal protection. Generated debris was aspirated and analyzed. Blood pressure and serum creatinine levels were followed. RESULTS Immediate technical success was 100%. All lesions were stented, either directly (14 ostial lesions), after predilation (15 ostial lesions), or owing to suboptimal angioplasty (3 nonostial lesions). Visible debris was aspirated from all patients. Mean particle number and diameter were 98.1 +/- 60.0 per procedure (range 13-208) and 201.2 +/- 76.0 microm (range 38-6206), respectively. Mean renal artery occlusion time was 6.55 +/- 2.46 min (range 2.29-13.21). Mean follow-up was 6.7 +/- 2.9 months (range 2-17). Systolic and diastolic blood pressure declined from 167.0 +/- 15.2 and 103.0 +/- 12.0 mm Hg, respectively, to 154.7 +/- 12.3 and 93.2 +/- 6.8 mm Hg after the procedure. The mean creatinine level dropped from 1.34 +/- 0.35 mg/dL preprocedurally to 1.22 +/- 0.36 mg/dL at 24 hours and remained constant. At 6-month follow-up, renal function did not deteriorate in any patient, whereas 5 patients with baseline renal insufficiency improved after the procedure. CONCLUSIONS These preliminary results suggest the feasibility and safety of distal balloon occlusion during renal interventions to protect against atheroembolism. This technique's beneficial effects should be evaluated by randomized studies.
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Henry M, Amor M, Henry I, Klonaris C, Tzvetanov K, Buniet JM, Amicabile C, Drawin T. Percutaneous endovascular treatment of peripheral aneurysms. J Cardiovasc Surg (Torino) 2000; 41:871-83. [PMID: 11232970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
BACKGROUND To evaluate the feasibility and efficacy of percutaneous endovascular treatment of peripheral aneurysms. METHODS Forty-eight patients, M: 41, F: 7, mean age: 65.7 +/- 10.1 years (47-85 years), with 50 aneurysms were treated: 45 with covered stents (Cragg/Passager 22, Corvita 21, Wallgraft 1, Endotex 1) 4 with non-covered stents and 1 with stent graft. Twenty-six aneurysms located at the iliac artery, 12 at the femoral and 12 at the popliteal artery. Mean lesion length: 61.1 +/- 21.3 mm. Percutaneous approach used in all cases, femoral antegrade (n=24), retrograde (n=23), contralateral (n=2), popliteal (n=1). Stents used were 6-12 mm in diameter and 30-120 mm in length. Multiple stents used to cover all lesions in 20 cases. RESULTS Immediate technical success was 96% (48/50). In 1 case of long, tortuous femoropopliteal aneurysm, it was impossible to cover the low part, due to rigidity of the device used, in 1 case of large iliac aneurysm there was incomplete immediate exclusion. No complication during the procedure. Four patients developed non-infectious fever/local pain. Eight thromboses occurred: 2 at iliac, 1 at femoral and 5 at the popliteal level. All other stents remained patent, the aneurysms completely excluded over a mean follow-up of 20.6 +/- 13.2 m, maximum 61 m. Primary patency: all lesions 82%, iliac 92%, femoropopliteal 78%. Secondary patency: all lesions 88%, iliac 96%, femoropopliteal 86%. CONCLUSION Percutaneous endoluminal treatment of peripheral aneurysms seems safe and effective with high technical success and good long-term results, except for popliteal localization. It could be an alternative to surgery.
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Affiliation(s)
- M Henry
- Polyclinique, Essey-les-Nancy, France
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Xiromeritis N, Klonaris C, Papas S, Valsamis M, Bastounis E. Recurrent peripheral arterial embolism from pulmonary cancer. Case report and review of the literature. INT ANGIOL 2000; 19:79-83. [PMID: 10853691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Peripheral arterial embolism arising from a malignant tumour is an infrequent manifestation of neoplastic disease and also a rare cause of acute arterial occlusion. A case of recurrent arterial embolism of the lower extremities due to a primary lung cancer is reported and the literature on this topic is reviewed.
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Affiliation(s)
- N Xiromeritis
- 1st Department of Surgery, University of Athens, Greece
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17
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Abstract
PURPOSE To describe an open approach to subintimal angioplasty. TECHNIQUE Through a subinguinal incision and arteriotomy over the superficial femoral artery origin, the opening of a subintimal channel is created surgically. The subintimal plane is advanced distally with a guidewire, and this neolumen is expanded with sequential balloon dilations. The atherosclerotic core is dissected proximally in the common femoral artery and tacked down to ensure inflow. A patch graft closes the arteriotomy. CONCLUSIONS Open subintimal angioplasty is a simple, minimally invasive alternative treatment for complete SFA occlusion. Long-term follow-up in a large group of patients will be necessary to determine the durability of the false arterial lumen.
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Affiliation(s)
- P Balas
- Department of Vascular Surgery, Hygeia Hospital, Athens, Greece.
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Henry M, Klonaris C, Amor M, Henry I, Tzvetanov K. State of the art: which stent for which lesion in peripheral interventions? Tex Heart Inst J 2000; 27:119-26. [PMID: 10928499 PMCID: PMC101046] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Applications of endovascular procedures have been expanded dramatically throughout the human body for both occlusive and aneurysmal disease; arteries at the aortoiliac and femoropopliteal levels are no exception. Currently, interventional procedures are the 1st treatment option for most patients who have peripheral artery disease. Although balloon angioplasty alone offers good immediate and long-term results, the addition of stents has been proposed to improve the procedural success of angioplasty and extend its application to more patients with vascular disease. Stenting, however, is controversial. Its use is considered acceptable in the aortoiliac vessels but is more in dispute for the femoropopliteal vessels. Moreover, the rapid development of endovascular stents for peripheral applications has made stent selection a complicated task for clinical practitioners. Many factors influence the type of stent selected; therefore, knowledge of the stents available--including various designs and individual properties--is mandatory. Appropriate selection depends on adequate preprocedural evaluation of the lesion; the choice of approach; the choice of primary versus selective stent placement; the location and characteristics of the lesion; the availability of stents in the intervention suite; and the experience of the operator Several stents are now available, but they are not equivalent; it is important to select the stent that is best suited to the lesion. On the basis of our experience using different types of stents, as well as our review of the world medical literature, we summarize the properties of various stents and specific indications for their application. This report is intended for use as a practical guide to stent selection.
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Affiliation(s)
- M Henry
- Department of Interventional Cardiology, UCCI Polyclinique d'Essey, Essey-les-Nancy, France
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Henry M, Amor M, Klonaris C, Henry I, Masson I, Chati Z, Leborgne E, Hugel M. Angioplasty and stenting of the extracranial carotid arteries. Tex Heart Inst J 2000; 27:150-8. [PMID: 10928503 PMCID: PMC101050] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
We performed percutaneous transluminal angioplasty and stenting in patients with carotid artery stenosis to determine the efficacy of these techniques as an alternative to surgical endarterectomy. From April 1995 through July 1999, 315 carotid angioplasty procedures were performed (right, 151; left, 164) in 290 patients ranging in age from 40 to 93 years. Of these patients, 42% were symptomatic and 58% were asymptomatic. Twenty-five patients underwent bilateral procedures. The mean percentage of stenosis was 82.3%+/-8.7% SD. Angioplasty and stenting were performed without cerebral protection in 165 arteries and with protection in 150. Two methods of protection were used: the Theron technique and the PercuSurge Guardwire temporary occlusion and aspiration system. Balloon dilation and stent placement were successful in 289 patients; in the last patient, severe arterial tortuosity prevented catheterization and stenting. We observed 13 periprocedural neurologic complications due to ischemia (4.2%): 4 transient ischemic attacks (1.3%), 4 minor strokes (1.3%), and 5 major strokes (1.6%), including 1 death. At 6 months, 210 patients had a follow-up angiogram (155) or duplex ultrasound (55). There were 10 restenoses (4.7%), 1 of which was symptomatic and 2 of which showed mild compression of a Palmaz stent without marked stenosis. Primary and secondary 4-year patency rates were 96% and 99%, respectively. These results demonstrate acceptable mortality and morbidity rates related to carotid angioplasty and stenting. However, we found the risk of embolic stroke to be substantial. Cerebral protection may improve the results of carotid angioplasty and expand the indications for this procedure.
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Affiliation(s)
- M Henry
- The Department of Interventional Cardiology, UCCI Polyclinique d'Essey, Essey-les-Nancy, France
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Henry M, Amor M, Henry I, Klonaris C, Chati Z, Masson I, Kownator S, Luizy F, Hugel M. Carotid stenting with cerebral protection: first clinical experience using the PercuSurge GuardWire system. J Endovasc Surg 1999. [PMID: 10893133 DOI: 10.1583/1074-6218(1999)006<0321:cswcpf>2.0.co;2] [Citation(s) in RCA: 101] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE To study the feasibility and safety of carotid angioplasty and stenting using a new cerebral protection device that temporarily occludes the distal internal carotid artery (ICA). METHODS Forty-eight high-risk patients (39 men, mean age 69.1 +/- 8 years, range 54 to 86) with 53 ICA stenoses underwent percutaneous angioplasty and stenting via the femoral approach under cerebral protection afforded by a 0.014-inch GuardWire balloon occlusion device. Mean stenosis was 82.1% +/- 9.65% (range 70 to 96) and mean lesion length was 16.0 +/- 7.5 mm (range 6 to 50). Thirty-three (62%) lesions were calcified, and 38 (72%) were ulcerated. Thirty-two (60%) of the lesions were asymptomatic. With the occlusion balloon inflated in the distal ICA, the lesion was dilated and stented. The area was cleaned by aspiration and flushed via an aspiration catheter advanced over the wire. Blood samples were collected from the external carotid artery (ECA) and analyzed to measure the size and number of particles collected. Computed tomography and neurological examinations were performed the day after the procedure. RESULTS Immediate technical success was achieved in all patients with the implantation of 38 Palmaz stents, 8 Expander stents, and 11 Wallstents. Carotid occlusion was well tolerated in all patients but 1 who had multiple, severe carotid lesions and poor collateralization. Mean cerebral flow occlusion time was 346 +/- 153 seconds during predilation and 303 +/- 143 seconds during stent placement. Total mean flow occlusion time was 542 +/- 243 seconds. One immediate neurological complication (transient amaurosis) occurred in a patient who had an anastomosis between the external carotid (EC) and ICA territories. Debris was removed in all patients with a mean 0.8-mm diameter catheter. CONCLUSION Cerebral protection with the GuardWire device is easy, safe, and effective in protecting the brain from cerebral embolism. Larger studies are warranted.
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Affiliation(s)
- M Henry
- UCCI, Polyclinique, Essey-les-Nancy, France.
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Abstract
OBJECTIVE To evaluate our results of the treatment of patients with carotid body tumours. DESIGN Retrospective study. SETTING University hospital, Greece. SUBJECTS 17 patients operated on for a carotid body tumour during the past 20 years. MAIN OUTCOME MEASURES Hospital mortality and morbidity, long-term outcome. RESULTS 3 patients had temporary cranial nerve lesions postoperatively, all of which resolved within three months. One patient developed a severe stroke and died seven days postoperatively. During follow-up that ranged from 7 months to 20 years, two patients died of unrelated causes. 5 patients were lost to follow up, and the remaining 10 were doing well with no signs of recurrence at the time of writing. CONCLUSION Excision of a carotid body tumour is recommended at the time of initial diagnosis in good-risk patients to avoid the difficulty of subsequent excision of an enlarging and highly vascular tumour with possible encasement of the carotid artery.
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Affiliation(s)
- E Bastounis
- First Department of Surgery, University of Athens Medical School, Laikon General Hospital, Greece
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22
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Balas P, Ioannou N, Milas P, Klonaris C. Surgical treatment of spontaneous internal carotid dissection. INT ANGIOL 1998; 17:125-8. [PMID: 9754902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Spontaneous dissection of the internal carotid artery is rarely submitted to surgery. We report a case successfully operated on with complete restoration of the cerebral blood flow. A 43-year-old male was admitted to our hospital 10 days after an episode of amaurosis fugax of the left eye, left sided headache and paresis of the right arm of a few hours duration. A diagnosis of dissection of the left internal carotid artery was made by duplex and triplex ultrasound examination and was confirmed by cerebral arteriography in contrast to magnetic resonance angiography which was misleading. Due to the slow arterial flow from the right to the left cerebral hemisphere through only the posterior communicating arteries we envisaged the possibility of a cerebral infarction if the dissection were to be extended. For this reason a surgical procedure was performed by excising the dissected segment and inserting a venous graft for the re-establishment of the arterial flow. Surgical treatment of spontaneous internal carotid dissection should be considered very carefully when the clinical and laboratory findings suggest the possibility of an impending stroke.
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Affiliation(s)
- P Balas
- Athens University Medical School, Greece
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Tsavaris NB, Tentas K, Kosmidis P, Mylonakis N, Sakelaropoulos N, Kosmas C, Lisaios B, Soumilas A, Mandrekois D, Tsetis A, Klonaris C. 5-Fluorouracil, epirubicin, and mitomycin C versus 5-fluorouracil, epirubicin, mitomycin C, and leucovorin in advanced gastric carcinoma. A randomized trial. Am J Clin Oncol 1996; 19:517-21. [PMID: 8823483 DOI: 10.1097/00000421-199610000-00018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Leucovorin (LV) enhances the activity of 5-fluorouracil (5FU). Based on these data, we performed a randomized trial with 5FU, epirubicin (EPI), mitomycin C(MMC) with/ without LV in advanced gastric cancer (AGC). The purpose of our study was to investigate if the addition of LV improved the response rate of the combination 5FU EPI, MMC (FEM) over FEM. From January 1988 until April 1994, 88 patients with recurrent or metastatic AGC were randomly received 5FU, EPI, MMC with (group A) or without (group B) LV. Between the two arms of the study no difference was noticed in sex, performance status, primary site of tumor, and lymph node metastases. Therapy included group A (5FU 600 mg/m2/day, i.v. bolus, on days 1, 8, 29, 36, and EPI 45 mg/m2/day, i.v. bolus, on days 1 and 29, MMC 10 mg/m2/day, i.v. bolus, on day 1) and group B (the same as group A plus LV 200 mg/m2/day by 2 h intravenous infusion with 5FU intravenous push at midinfusion). No significant difference in response rate was noticed between the two treatment arms; there were two (5%) patients with complete response in group A, and five (12%) in A and 11 (26%) partial responders in group B (p < 0.1). A significantly higher number of patients achieving stable disease was observed in group B; 19 (44%) in comparison to group A 10 (24%) (p < 0.048). There were more patients with progressive disease in group A 25 (59%) than in group B 12 (28%) (p < 0.003) (Table 2). No difference was noted in mean duration of response: group A, 15.8 (6-31) weeks; and group B, 17.6 (6-28) weeks. The mean time to progression was for group A [11.4 (6-35) weeks] and for group B [17.6 (8-33) weeks]. Mean survival was for group A [27.4 (12-59) weeks] and for group B [30.6 (17-53) weeks], for 50% of patients. Causes of death were, for group A, 40 patients from disease progression and two sudden deaths; for group B, causes of death were for 41 patients disease progression and two sudden deaths. There were two patients in group A and one in group B that were not evaluable because they abandoned therapy after the first cycle. Toxicity was increased in group B; anemia, nausea and vomiting, and alopecia (p < 0.055) were more severe in group B, but not statistically different when compared to group A. Neutropenia, thrombocytopenia, mucositis, and fatigue of any grade were significantly more common and severe in group B. Significant dose reductions due to toxicity were required more commonly in group B. We conclude that the response rate was increased in the schedule with the addition of LV, at the cost of increased toxicity and with no difference in survival. A randomized trial comparing FEM-LV with new generation regimens would determine whether the addition of LV qualifies FAM equally active with these.
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Affiliation(s)
- N B Tsavaris
- Department of Pathology Physiology, Athens University School of Medicine, Greece
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Tsavaris N, Tentas K, Kosmidis P, Mylonakis N, Sakelaropoulos N, Kosmas C, Lisaios B, Soumilas A, Mandrekas D, Tsetis A, Klonaris C. A randomized trial comparing adjuvant fluorouracil, epirubicin, and mitomycin with no treatment in operable gastric cancer. Chemotherapy 1996; 42:220-6. [PMID: 8983891 DOI: 10.1159/000239446] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Combination chemotherapy (CT) has, in some groups of patients with gastric cancer (GC), who are at a high risk for relapse, resulted in a small but measurable improvement in palliation and patient survival not reaching statistical significance and therefore remaining applicable in an investigational setting. Based on the above data, we studied adjuvant CT with FEM (5-fluorouracil (5-FU), epirubicin, mitomycin C) in a randomized study of patients with completely resected stage III GC and patients with stages T1-3 with a low histologic grade. CT was started 2-3 weeks after surgery. From August 1988 until February 1994, 84 patients with completely resected tumors and lymph nodes were randomized to either group A (FEM) or group B (no treatment). Patients were eligible for randomization if they had a Karnofsky score > 60, no postoperative evidence of residual tumor, and normal cardiac, hepatic and renal functions. Forty-two patients were randomized to each group, with no significant differences regarding: age distribution, group A 53 years (41-65), group B 57 years (35-66); sex, group A 32/10, group B 25/17 (men/women); site of primary tumor, group A 22/20, group B 25/17 (pylorus/antrum); histologic grade, group A 0/19/23, group B 0/25/17 (grades I/II/III); lymph node metastases, group A 30, group B 32, and surgical procedure, group A 33/9/6, group B 35/7/9 (total gastrectomy/partial gastrectomy/splenectomy). Group A received 5-FU 600 mg/m2/day i.v. on days 1, 8, 29 and 36, epirubicin 45 mg/m2/day i.v. on days 1 and 29, and mitomycin C 10 mg/m2 i.v. on day 1. The schedule was repeated every 56 days for 3 cycles. Group B received no treatment odd was only subjected to the regular follow-up. At the last follow-up at 66 months, 27/42 patients in group A (64%) had relapsed or died, compared to 34/42 patients in group B (81%). The differences in the relapse and the disease-free and the overall survival rates were not statistically significant. Only the subgroup of patients with histologic grade III tumors receiving adjuvant FEM demonstrated a trend towards improved survival (p = 0.085). Main therapy-related toxicities for the treatment group were grade I-II anemia, neutropenia, and throbocytopenia in 16, 45, and 22% of patients, respectively, and grade I-II nausea and vomiting in 29% of patients. Based on the present findings and those of previous studies, even if one considers the difference reaching statistical significance in the latter for histologic grade III tumors, it becomes evident that with current therapeutic modalities adjuvant therapy has no established role in the management of resectable GC. Studies of new-generation regimens, such as FAMTX (5-FU, Adriamycin and methotrexate) as well as ELF (etoposide, Leucoverin, and 5-FU), should be conducted in the adjuvant therapy setting with a nontherapy control group, in order to clarify the issue of adjuvant CT in resectable GC.
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Affiliation(s)
- N Tsavaris
- Second Department of Medical Oncology, Metaxa Cancer Hospital Piraeus, Greece
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