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Paraskevas KI, Mikhailidis DP, Ringleb PA, Brown MM, Dardik A, Poredos P, Gray WA, Nicolaides AN, Lal BK, Mansilha A, Antignani PL, de Borst GJ, Cambria RP, Loftus IM, Lavie CJ, Blinc A, Lyden SP, Matsumura JS, Jezovnik MK, Bacharach JM, Meschia JF, Clair DG, Zeebregts CJ, Lanza G, Capoccia L, Spinelli F, Liapis CD, Jawien A, Parikh SA, Svetlikov A, Menyhei G, Davies AH, Musialek P, Roubin G, Stilo F, Sultan S, Proczka RM, Faggioli G, Geroulakos G, Fernandes E Fernandes J, Ricco JB, Saba L, Secemsky EA, Pini R, Myrcha P, Rundek T, Martinelli O, Kakkos SK, Sachar R, Goudot G, Schlachetzki F, Lavenson GS, Ricci S, Topakian R, Millon A, Di Lazzaro V, Silvestrini M, Chaturvedi S, Eckstein HH, Gloviczki P, White CJ. An international, multispecialty, expert-based Delphi Consensus document on controversial issues in the management of patients with asymptomatic and symptomatic carotid stenosis. J Vasc Surg 2024; 79:420-435.e1. [PMID: 37944771 DOI: 10.1016/j.jvs.2023.09.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 09/25/2023] [Accepted: 09/25/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE Despite the publication of various national/international guidelines, several questions concerning the management of patients with asymptomatic (AsxCS) and symptomatic (SxCS) carotid stenosis remain unanswered. The aim of this international, multi-specialty, expert-based Delphi Consensus document was to address these issues to help clinicians make decisions when guidelines are unclear. METHODS Fourteen controversial topics were identified. A three-round Delphi Consensus process was performed including 61 experts. The aim of Round 1 was to investigate the differing views and opinions regarding these unresolved topics. In Round 2, clarifications were asked from each participant. In Round 3, the questionnaire was resent to all participants for their final vote. Consensus was reached when ≥75% of experts agreed on a specific response. RESULTS Most experts agreed that: (1) the current periprocedural/in-hospital stroke/death thresholds for performing a carotid intervention should be lowered from 6% to 4% in patients with SxCS and from 3% to 2% in patients with AsxCS; (2) the time threshold for a patient being considered "recently symptomatic" should be reduced from the current definition of "6 months" to 3 months or less; (3) 80% to 99% AsxCS carries a higher risk of stroke compared with 60% to 79% AsxCS; (4) factors beyond the grade of stenosis and symptoms should be added to the indications for revascularization in AsxCS patients (eg, plaque features of vulnerability and silent infarctions on brain computed tomography scans); and (5) shunting should be used selectively, rather than always or never. Consensus could not be reached on the remaining topics due to conflicting, inadequate, or controversial evidence. CONCLUSIONS The present international, multi-specialty expert-based Delphi Consensus document attempted to provide responses to several unanswered/unresolved issues. However, consensus could not be achieved on some topics, highlighting areas requiring future research.
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Affiliation(s)
| | - Dimitri P Mikhailidis
- Division of Surgery and Interventional Science, Department of Surgical Biotechnology, University College London Medical School, University College London (UCL) and Department of Clinical Biochemistry, Royal Free Hospital Campus, UCL, London, United Kingdom
| | | | - Martin M Brown
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
| | - Alan Dardik
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Pavel Poredos
- Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | | | - Andrew N Nicolaides
- Vascular Screening and Diagnostic Center, Nicosia, Cyprus; University of Nicosia Medical School, Nicosia, Cyprus; Department of Vascular Surgery, Imperial College, London, United Kingdom
| | - Brajesh K Lal
- Department of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD; Department of Vascular Surgery, Baltimore VA Medical Center, Baltimore, MD; Department of Neurology, Mayo Clinic, Rochester, MN
| | - Armando Mansilha
- Faculty of Medicine of the University of Porto, Porto, Portugal; Department of Angiology and Vascular Surgery, Hospital de S. Joao, Porto, Portugal
| | | | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Richard P Cambria
- Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Boston, MA
| | - Ian M Loftus
- St George's Vascular Institute, St George's University London, London, United Kingdom
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA
| | - Ales Blinc
- Division of Internal Medicine, Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Sean P Lyden
- Department of Vascular Surgery, The Cleveland Clinic, Cleveland, OH
| | - Jon S Matsumura
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX
| | - J Michael Bacharach
- Department of Vascular Medicine and Endovascular Intervention, North Central Heart Institute and the Avera Heart Hospital, Sioux Falls, SD
| | | | - Daniel G Clair
- Department of Vascular Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Clark J Zeebregts
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Gaetano Lanza
- Vascular Surgery Department, IRCSS Multimedica Hospital, Castellanza, Italy
| | - Laura Capoccia
- Vascular Surgery Division, Department of Surgery, SS. Filippo e Nicola Hospital, Avezzano, Italy
| | - Francesco Spinelli
- Vascular Surgery Division, Department of Medicine and Surgery, Campus Bio-Medico University of Rome, Rome, Italy
| | | | - Arkadiusz Jawien
- Department of Vascular Surgery and Angiology, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Sahil A Parikh
- Division of Cardiology, Department of Medicine, New York-Presbyterian Hospital/ Columbia University Irving Medical Center, New York, NY; Center for Interventional Cardiovascular Care and Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Alexei Svetlikov
- Division of Vascular and Endovascular Surgery, North-Western Scientific Clinical Center of Federal Medical Biological Agency of Russia, St Petersburg, Russia
| | - Gabor Menyhei
- Department of Vascular Surgery, University of Pecs, Pecs, Hungary
| | - Alun H Davies
- Department of Surgery and Cancer, Section of Vascular Surgery, Imperial College London, Charing Cross Hospital, London, United Kingdom
| | - Piotr Musialek
- Jagiellonian University Department of Cardiac and Vascular Diseases, John Paul II Hospital, Krakow, Poland
| | - Gary Roubin
- Department of Cardiology, Cardiovascular Associates of the Southeast/ Brookwood, Baptist Medical Center, Birmingham, AL
| | - Francesco Stilo
- Vascular Surgery Division, Department of Medicine and Surgery, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sherif Sultan
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, University of Galway, Galway, Ireland
| | - Robert M Proczka
- First Department of Vascular Surgery, Medicover Hospital, Warsaw, Poland, Lazarski University Faculty of Medicine, Warsaw, Poland
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | - George Geroulakos
- Department of Vascular Surgery, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Jose Fernandes E Fernandes
- Faculty of Medicine, Lisbon Academic Medical Center, University of Lisbon, Portugal, Hospital da Luz Torres de Lisboa, Lisbon, Portugal
| | - Jean-Baptiste Ricco
- Department of Vascular Surgery, University Hospital of Toulouse, Toulouse, France
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria Di Cagliari, Cagliari, Italy
| | - Eric A Secemsky
- Division of Cardiology, Department of Medicine, Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| | - Rodolfo Pini
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Piotr Myrcha
- Department of General and Vascular Surgery, Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL
| | - Ombretta Martinelli
- Faculty of Medicine, Sapienza University of Rome, Rome, Italy; Vascular Surgery Unit, "Umberto I." Hospital, Rome, Italy
| | - Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Ravish Sachar
- North Carolina Heart and Vascular Hospital, UNC-REX Healthcare, University of North Carolina, Raleigh, NC
| | - Guillaume Goudot
- Vascular Medicine Department, Georges Pompidou European Hospital, APHP, Université Paris Cité, Paris, France
| | - Felix Schlachetzki
- Department of Neurology, University Hospital of Regensburg, Regensburg, Germany
| | | | - Stefano Ricci
- Neurology Department-Stroke Unit, Gubbio-Gualdo Tadino and Citta di Castello Hospitals, USL Umbria 1, Perugia, Italy
| | - Raffi Topakian
- Department of Neurology, Academic Teaching Hospital Wels-Grieskirchen, Wels, Austria
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, Louis Pradel Hospital, Hospices Civil de Lyon, Bron, France
| | - Vincenzo Di Lazzaro
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Universita Campus Bio-Medico di Roma, Roma, Italy; Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
| | - Mauro Silvestrini
- Department of Experimental and Clinical Medicine, Neurological Clinic, Marche Polytechnic University, Ancona, Italy
| | - Seemant Chaturvedi
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Christopher J White
- Department of Medicine and Cardiology, Ochsner Clinical School, University of Queensland, Brisbane, Australia; Department of Cardiology, The John Ochsner Heart and Vascular Institute, New Orleans, LA
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Antignani PL, Jezovnik MK, Blinc A, Mikhailidis DP, Anagnostis P, Schernthaner GH, Jensterle M, Studen KB, Sabovic M, Poredos P. Hyperparathyroidism and Peripheral Arterial Disease. Curr Vasc Pharmacol 2024; 22:CVP-EPUB-137918. [PMID: 38284694 DOI: 10.2174/0115701611280905231227045826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 12/08/2023] [Accepted: 12/13/2023] [Indexed: 01/30/2024]
Abstract
Primary hyperparathyroidism (PHPT) is presented in various forms, including classic PHPT, characterised by increased parathyroid hormone (PTH) secretion, normohormonal PHPT, and normocalcaemic PHPT. Secondary hyperparathyroidism is characterised by increased PTH secretion triggered by factors such as vitamin D deficiency and kidney failure. This review aims to discuss the involvement of hyperparathyroidism (HPT) in atherosclerosis, including peripheral arterial disease (PAD). The increased level of PTH is involved in developing subclinical and overt vascular diseases, encompassing endothelial dysfunction, vascular stiffness, hypertension, and coronary and peripheral arterial diseases. It has been consistently associated with an augmented risk of cardiovascular morbidity and mortality, independent of classical risk factors for atherosclerosis. Chronic hypercalcemia associated with increased levels of PTH contributes to the development of calcification of vessel walls and atherosclerotic plaques. Vascular calcification can occur in the intima or media of the arterial wall and is associated with stiffness of peripheral arteries, which the formation of atherosclerotic plaques and narrowing of the vessel lumen can follow. For treating hyperparathyroidism, particularly SHPT, calcimimetics, novel phosphorus binders and novel vitamin D receptor activators are used. However, they are ineffective in severe PHPT. Therefore, parathyroidectomy remains the primary therapeutic option of PHPT.
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Affiliation(s)
| | - Mateja K Jezovnik
- The University of Texas Health Science Center at Houston, Department of Advanced, Cardiopulmonary Therapies and Transplantation, Houston, Texas, USA
| | - Ales Blinc
- Department of Vascular Disease, University Medical Centre, Ljubljana, Slovenia
- Faculty of Medicine, Department of Internal Medicine, University of Ljubljana, Slovenia
| | - Dimitri P Mikhailidis
- Department of Surgical Biotechnology, Division of Surgery and Interventional Science, University College London Medical School, University College London (UCL) and Department of Clinical Biochemistry, Royal Free Hospital Campus (UCL), London, UK
| | - Panagiotis Anagnostis
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical, School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Mojca Jensterle
- Faculty of Medicine, Department of Internal Medicine, University of Ljubljana, Slovenia
- Department of Endocrinology, Diabetes and Metabolic Diseases, University Medical Centre, Ljubljana, Slovenia
| | - Katica Bajuk Studen
- Faculty of Medicine, Department of Internal Medicine, University of Ljubljana, Slovenia
- Department of Nuclear Medicine, University Medical Centre, Ljubljana, Slovenia
| | - Miso Sabovic
- Department of Vascular Disease, University Medical Centre, Ljubljana, Slovenia
- Faculty of Medicine, Department of Internal Medicine, University of Ljubljana, Slovenia
| | - Pavel Poredos
- Department of Vascular Disease, University Medical Centre, Ljubljana, Slovenia
- Faculty of Medicine, Department of Internal Medicine, University of Ljubljana, Slovenia
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Poredos P, Schernthaner GH, Blinc A, Mikhailidis DP, Jensterle M, Anagnostis P, Antignani PL, Studen KB, Šabović M, Jezovnik MK. Endocrine Disorders and Peripheral Arterial Disease - A Series of Reviews Cushing Syndrome-Cortisol Excess. Curr Vasc Pharmacol 2023; 21:CVP-EPUB-136449. [PMID: 38038006 DOI: 10.2174/0115701611272145231106053914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 10/06/2023] [Accepted: 10/12/2023] [Indexed: 12/02/2023]
Abstract
Cushing syndrome (CS), characterised by endogenous or exogenous glucocorticoid hormone excess, is associated with several systemic complications, including impaired glucose metabolism, which often becomes clinically manifest as diabetes mellitus (DM). In addition, CS can harm the arterial wall because of hyperglycaemia, dyslipidaemia, hepatic steatosis, and central obesity. These metabolic disorders promote atherosclerosis by synthesising adipokines, leptin, and proinflammatory cytokines. Lower limb arterial complications in CS are common and significantly impact morbidity and mortality. Furthermore, CS, in combination with DM, is likely to cause more diffuse vascular disease that predominantly affects distal arterial beds. In conclusion, CS promotes atherosclerosis, including peripheral artery disease, by causing functional and morphological deterioration of the arterial vessel wall and increasing the presence of classical risk factors of atherosclerosis.
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Affiliation(s)
- P Poredos
- Department of Vascular Diseases, University Medical Centre, Ljubljana, Slovenia
- Faculty of Medicine, Department of Internal Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - G H Schernthaner
- Department of Medicine 2, Division of Angiology, Medical University of Vienna, Vienna, Austria
| | - A Blinc
- Department of Vascular Diseases, University Medical Centre, Ljubljana, Slovenia
- Faculty of Medicine, Department of Internal Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - D P Mikhailidis
- Department of Surgical Biotechnology, Division of Surgery and Interventional Science, University College London Medical School, University College London (UCL) and Department of Clinical Biochemistry, Royal Free Hospital Campus (UCL), London, UK
| | - M Jensterle
- Vascular Centre Nuova Villa Claudia, Rome, Italy
- Faculty of Medicine, Department of Internal Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - P Anagnostis
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - P L Antignani
- Department of Endocrinology, Diabetes and Metabolic Diseases, University Medical Centre, Ljubljana, Slovenia
| | - K Bajuk Studen
- Department of Nuclear Medicine, University Medical Centre, Ljubljana, Slovenia
- Faculty of Medicine, Department of Internal Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - M Šabović
- Department of Vascular Diseases, University Medical Centre, Ljubljana, Slovenia
- Faculty of Medicine, Department of Internal Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - M K Jezovnik
- The University of Texas Health Science Center at Houston, Department of Advanced Cardiopulmonary Therapies and Transplantation, Houston, Texas, USA
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4
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Gregoric ID, Patel M, Akay MH, Salas De Armas I, Patel J, Jezovnik MK, Radovancevic R, Kar B. Off-pump Left Ventricular Assist Device Implantation Through Median Sternotomy Versus Sternal Sparing Approach. ASAIO J 2023; 69:e265-e266. [PMID: 36521006 DOI: 10.1097/mat.0000000000001847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Igor D Gregoric
- From the Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston, Houston, Texas
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Abstract
Varicose veins (VVs) mostly represent benign disease. However, in some cases, they can lead to serious complications including deep venous thrombosis (DVT) and pulmonary embolism (PE). Besides deteriorated blood flow caused by VVs inflammation is most probably a common denominator of VVs and DVT, which promotes a procoagulant state and thrombus formation also in deep veins. Patients with VVs have increased levels of interleukins, the most specific inflammatory markers of vascular wall inflammation that promote coagulation. The studies showed that VVs may increase the risk for DVT. However, the evidence of the risk and incidence of DVT in patients with VVs and without additional risk factors is poor. The increased risk is associated with previous venous thromboembolism (VTE), malignancy, estrogen use, pregnancy and postpartum, hospitalization in the last 6 months, age, and obesity. Varicose veins represent also an increased risk for VTE during long-term immobilization and long air travel or road trip. Further, superficial venous thrombosis is related to an increased risk for DVT, particularly if the thrombus in the superficial vein extends close to the saphenofemoral or femoropopliteal junction. Increased risk for DVT is increased during and after invasive treatment of VVs. Thromboprophylaxis after invasive procedures is recommended in subjects older than 60 years and those with another thrombophilic state.
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Affiliation(s)
- Pavel Poredos
- Department of Vascular Disease, University Medical Center, Ljubljana, Slovenia -
| | - Matija Kozak
- Department of Vascular Disease, University Medical Center, Ljubljana, Slovenia
| | | | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston, Houston, TX, USA
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Paraskevas KI, Eckstein HH, Mansilha A, Ricco JB, Geroulakos G, Di Lazzaro V, Rundek T, Lanza G, Fraedrich G, Svetlikov AS, Suri JS, Zeebregts CJ, Davies AH, Capoccia L, Proczka RM, Myrcha P, Antignani PL, Fernandes E Fernandes J, Spence JD, Dardik A, Jezovnik MK, Knoflach M, Lavenson GS, Kakkos SK, Jawien A, Silvestrini M, Blinc A, Spinelli F, Stilo F, Musiałek P, Sultan S, Goudot G, Liapis CD, Saba L, Faggioli G, Pini R, Poredos P, Mikhailidis DP, Gloviczki P, Nicolaides AN. Screening for asymptomatic carotid stenosis in patients with non-valvular atrial fibrillation. Int J Cardiol 2023; 372:120-121. [PMID: 36435330 DOI: 10.1016/j.ijcard.2022.11.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 11/21/2022] [Indexed: 11/24/2022]
Affiliation(s)
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Armando Mansilha
- Faculty of Medicine of the University of Porto, Porto, Portugal; Department of Angiology and Vascular Surgery, Hospital de S. Joao, Porto, Portugal
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - George Geroulakos
- Department of Vascular Surgery, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Vincenzo Di Lazzaro
- Neurology, Neurophysiology and Neurobiology Unit, Department of Medicine, Universita Campus Bio-Medico di Roma, Rome, Italy
| | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Gaetano Lanza
- Vascular Surgery Department, IRCSS Multimedica Hospital, Castellanza, Italy
| | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Alexei S Svetlikov
- Division of Vascular and Endovascular Surgery, North-Western Scientific Clinical Center of Federal Medical Biological Agency of Russia, St. Petersburg, Russia
| | - Jasjit S Suri
- Stroke Diagnostic and Monitoring Division, Atheropoint™, Roseville, CA, USA
| | - Clark J Zeebregts
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Alun H Davies
- Department of Surgery and Cancer, Section of Vascular Surgery, Imperial College London, Charing Cross Hospital, London, UK
| | - Laura Capoccia
- Department of Surgery "Paride Stefanini", Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | - Robert M Proczka
- 1st Department of Vascular Surgery, Medicover Hospital, Warsaw, Poland
| | - Piotr Myrcha
- Department of General and Vascular Surgery, Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| | | | | | - J David Spence
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, ON, Canada
| | - Alan Dardik
- Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT, USA
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX, USA
| | - Michael Knoflach
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - George S Lavenson
- Department of Surgery, Uniformed Services University, Bethesda, MD, USA
| | - Stavros K Kakkos
- Department of Vascular Surgery, University Hospital of Patras, Patras, Greece
| | - Arkadiusz Jawien
- Department of Vascular Surgery and Angiology, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Mauro Silvestrini
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Aleš Blinc
- Department of Vascular Diseases, Division of Internal Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Francesco Spinelli
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Piotr Musiałek
- Jagiellonian University Department of Cardiac and Vascular Diseases, John Paul II Hospital, Krakow, Poland
| | - Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Guillaume Goudot
- Vascular Medicine Department, Georges Pompidou European hospital, APHP, Université de Paris Cité, Paris, France
| | | | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria Di Cagliari, Cagliari, Italy
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Rodolfo Pini
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Pavel Poredos
- Department of Vascular Diseases, University Medical Centre Ljubljana, Slovenia
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Andrew N Nicolaides
- Department of Surgery, University of Nicosia Medical School, Nicosia, Cyprus
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7
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Paraskevas KI, Spence JD, Mikhailidis DP, Antignani PL, Gloviczki P, Eckstein HH, Spinelli F, Stilo F, Saba L, Poredos P, Dardik A, Liapis CD, Mansilha A, Faggioli G, Pini R, Jezovnik MK, Sultan S, Musiałek P, Goudot G, Lavenson GS, Jawien A, Blinc A, Myrcha P, Fernandes E Fernandes J, Geroulakos G, Kakkos SK, Knoflach M, Proczka RM, Capoccia L, Rundek T, Svetlikov AS, Silvestrini M, Ricco JB, Davies AH, Di Lazzaro V, Suri JS, Lanza G, Fraedrich G, Zeebregts CJ, Nicolaides AN. Why do guidelines recommend screening for abdominal aortic aneurysms, but not for asymptomatic carotid stenosis? A plea for a randomized controlled trial. Int J Cardiol 2023; 371:406-412. [PMID: 36162523 DOI: 10.1016/j.ijcard.2022.09.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 09/18/2022] [Accepted: 09/20/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Current guidelines do not recommend screening for asymptomatic carotid artery stenosis (AsxCS). The rationale behind this recommendation is that detection of AsxCS may lead to an unnecessary carotid intervention. In contrast, screening for abdominal aortic aneurysms is strongly recommended. METHODS A critical analysis of the literature was performed to evaluate the implications of detecting AsxCS. RESULTS Patients with AsxCS are at high risk for future stroke, myocardial infarction and vascular death. Population-wide screening for AsxCS should not be recommended. Additionally, screening of high-risk individuals for AsxCS with the purpose of identifying candidates for a carotid intervention is inappropriate. Instead, selective screening for AsxCS should be considered and should be viewed as an opportunity to identify individuals at high risk for atherosclerotic cardiovascular disease and future cardiovascular events for the timely initiation of intensive medical therapy and risk factor modification. CONCLUSIONS Although mass screening should not be recommended, there are several arguments suggesting that selective screening for AsxCS should be considered. The rationale supporting such selective screening is to optimize risk factor control and to initiate intensive medical therapy for prevention of future cardiovascular events, rather than to identify candidates for an intervention.
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Affiliation(s)
| | - J David Spence
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, ON, Canada
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | | | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Francesco Spinelli
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria Di Cagliari, Cagliari, Italy
| | - Pavel Poredos
- Department of Vascular Disease, University Medical Centre Ljubljana, Slovenia
| | - Alan Dardik
- Division of Vascular and Endovascular Surgery, Yale University School of Medicine, New Haven, CT, USA
| | | | - Armando Mansilha
- Faculty of Medicine of the University of Porto, Porto, Portugal; Department of Angiology and Vascular Surgery, Hospital de S. Joao, Porto, Portugal
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Rodolfo Pini
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX, USA
| | - Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Piotr Musiałek
- Jagiellonian University Department of Cardiac and Vascular Diseases, John Paul II Hospital, Krakow, Poland
| | - Guillaume Goudot
- Vascular medicine department, Georges Pompidou European hospital, APHP, Université de Paris Cité, Paris, France
| | - George S Lavenson
- Department of Surgery, Uniformed Services University, Bethesda, MD, USA
| | - Arkadiusz Jawien
- Department of Vascular Surgery and Angiology, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Aleš Blinc
- Department of Vascular Diseases, Division of Internal Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Piotr Myrcha
- Department of General and Vascular Surgery, Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| | | | - George Geroulakos
- Department of Vascular Surgery, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Stavros K Kakkos
- Department of Vascular Surgery, University Hospital of Patras, Patras, Greece
| | - Michael Knoflach
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Robert M Proczka
- 1(st) Department of Vascular Surgery, Medicover Hospital, Warsaw, Poland
| | - Laura Capoccia
- Department of Surgery "Paride Stefanini", Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Alexei S Svetlikov
- Division of Vascular and Endovascular Surgery, North-Western Scientific Clinical Center of Federal Medical Biological Agency of Russia, St. Petersburg, Russia
| | - Mauro Silvestrini
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - Alun H Davies
- Department of Surgery and Cancer, Section of Vascular Surgery, Imperial College London, Charing Cross Hospital, London, UK
| | - Vincenzo Di Lazzaro
- Neurology, Neurophysiology and Neurobiology Unit, Department of Medicine, Universita Campus Bio-Medico di Roma, Rome, Italy
| | - Jasjit S Suri
- Stroke Diagnostic and Monitoring Division, Atheropoint™, Roseville, CA, USA
| | - Gaetano Lanza
- Vascular Surgery Department, IRCSS Multimedica Hospital, Castellanza, Italy
| | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Clark J Zeebregts
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Andrew N Nicolaides
- Department of Surgery, University of Nicosia Medical School, Nicosia, Cyprus
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8
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Akay MH, Jezovnik MK, Salas De Armas IA, Ilic M, Karabulut MN, Alagoz M, Patel M, Radovancevic R, Kar B, Gregoric ID. Delayed versus primary sternal closure for left ventricular assist device implantation: Impact on mechanical circulatory support infections. J Heart Lung Transplant 2022; 42:645-650. [PMID: 36641296 DOI: 10.1016/j.healun.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 10/31/2022] [Accepted: 12/06/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Delayed sternal closure may be required after left ventricular assist device (LVAD) implantation due to coagulopathy or hemodynamic instability. There is conflicting data regarding infection risk. METHODS We performed a single-center, retrospective analysis of patients who received their first LVAD between May 2012 and January 2021. Patients were divided into delayed sternal closure (DSC) and primary sternal closure (PSC) groups. We used chi-squared or Fisher Exact tests, as appropriate, to compare the incidence of postoperative LVAD-related infections (mediastinal/sternal wound) and LVAD-specific infections (driveline and pump pocket) after definitive chest closure between these two groups. RESULTS A total of 327 patients met eligibility criteria, including 127 (39%) patients that underwent DSC and 200 (61%) patients that had a PSC. Demographic and clinical characteristics were similar except for an overrepresentation of men (87% vs. 75%, p = .016), Interagency Registry of Mechanically Assisted Circulatory Support class I-II patients (89% vs 66%, p < .001), patients with a previous sternotomy (43% vs 13%, p < .001), and patients with chronic kidney disease (55% vs 43%, p = .030) in the DSC group. The median DSC time was 24 (IQR: 24-48) hours. The incidence of LVAD-related mediastinal/sternal wound infection was similar between the DSC and PSC groups (4.7% vs 3.0%, p = .419). There was no difference between DSC and PSC groups in the incidence of driveline infection (6.3% vs 9%, p = .411) and pump pocket infection (1.6% vs 1.5%, p =.901), respectively. CONCLUSIONS DSC does not seem to increase the incidence of LVAD-related or LVAD-specific infection rates in heart failure patients undergoing device implantation surgery.
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Affiliation(s)
- Mehmet H Akay
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, The University of Texas Health Science Center-Houston/Memorial Hermann Hospital-Texas Medical Center, Houston, TX
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, The University of Texas Health Science Center-Houston/Memorial Hermann Hospital-Texas Medical Center, Houston, TX
| | - Ismael A Salas De Armas
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, The University of Texas Health Science Center-Houston/Memorial Hermann Hospital-Texas Medical Center, Houston, TX
| | - Milica Ilic
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, The University of Texas Health Science Center-Houston/Memorial Hermann Hospital-Texas Medical Center, Houston, TX
| | - Mehmet N Karabulut
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, The University of Texas Health Science Center-Houston/Memorial Hermann Hospital-Texas Medical Center, Houston, TX
| | - Mehmet Alagoz
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, The University of Texas Health Science Center-Houston/Memorial Hermann Hospital-Texas Medical Center, Houston, TX
| | - Manish Patel
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, The University of Texas Health Science Center-Houston/Memorial Hermann Hospital-Texas Medical Center, Houston, TX
| | - Rajko Radovancevic
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, The University of Texas Health Science Center-Houston/Memorial Hermann Hospital-Texas Medical Center, Houston, TX
| | - Biswajit Kar
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, The University of Texas Health Science Center-Houston/Memorial Hermann Hospital-Texas Medical Center, Houston, TX
| | - Igor D Gregoric
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, The University of Texas Health Science Center-Houston/Memorial Hermann Hospital-Texas Medical Center, Houston, TX.
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9
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Mihalj M, Jezovnik MK, Benk J, Heg D, Podstatzky-Lichtenstein T, Beyersdorf F, Radovancevic R, Gregoric ID, Hunziker L, Siepe M, Reineke D. Concomitant tricuspid valve repair in left ventricular assist device implantation may increase the risk for temporary right ventricular support but does not impact overall outcomes. Eur J Cardiothorac Surg 2022; 63:6873742. [PMID: 36469336 DOI: 10.1093/ejcts/ezac555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 11/08/2022] [Accepted: 12/02/2022] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Tricuspid valve repair in left ventricular assist device implantation continues to pose a challenge and may impact the occurrence of early and late right heart failure. We investigated the effects of concomitant tricuspid repair on clinical outcomes. METHODS A retrospective, multicentre study enrolled adult patients who received continuous-flow left ventricular assist devices between 2005 and 2017 and compared those who received concomitant tricuspid valve repair to those who did not. Primary outcomes were early right heart failure necessitating temporary ventricular assist devices and right heart failure-related rehospitalizations requiring inotropic or diuretic treatment. RESULTS Out of 526 patients who underwent left ventricular assist device implantation, 110 (21%) received a concomitant tricuspid valve repair. Those patients were sicker, and most had moderate or severe tricuspid regurgitation. A significantly higher incidence of temporary right ventricular assist devices was observed in the group with concomitant tricupid valve repair (18% vs. 11%, P = 0.049), with a significantly elevated risk for temporary right heart assist device (sHR 1.68, 95% CI 1.04-2.72; P = 0.037). After adjusting for confounders, no significant differences were found in the incidence of and risk for most clinical outcomes, including right heart failure-related rehospitalizations (P = 0.891) and death (P = 0.563). CONCLUSIONS Concomitant tricuspid valve repair, when deemed necessary in left ventricular assist device implantation, may increase the risk of early right heart failure requiring a temporary right ventricular assist device but does not impact the incidence or risk of death or rehospitalizations due to late right heart failure.
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Affiliation(s)
- Maks Mihalj
- Department of Cardiac Surgery, University Hospital Bern, University of Bern, Bern, Switzerland.,Department of Advanced Cardiopulmonary Therapies and Transplantation, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Julia Benk
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, University of Freiburg, Freiburg, Germany.,Faculty of Medicine of the Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Dik Heg
- CTU Bern, University of Bern, Bern, Switzerland
| | | | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, University of Freiburg, Freiburg, Germany.,Faculty of Medicine of the Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Rajko Radovancevic
- Department of Advanced Cardiopulmonary Therapies and Transplantation, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Igor D Gregoric
- Department of Advanced Cardiopulmonary Therapies and Transplantation, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Lukas Hunziker
- Department of Cardiology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Matthias Siepe
- Department of Cardiac Surgery, University Hospital Bern, University of Bern, Bern, Switzerland
| | - David Reineke
- Department of Cardiac Surgery, University Hospital Bern, University of Bern, Bern, Switzerland
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10
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McDonald MM, Mihalj M, Zhao B, Nathan S, Matejin S, Ottaviani G, Jezovnik MK, Radovancevic R, Kar B, Gregoric ID, Buja LM. Clinicopathological correlations in heart transplantation recipients complicated by death or re-transplantation. Front Cardiovasc Med 2022; 9:1014796. [PMID: 36407445 PMCID: PMC9669710 DOI: 10.3389/fcvm.2022.1014796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022] Open
Abstract
Purpose This study aimed to identify and correlate pathological findings with clinical outcomes in patients after orthotopic heart transplantation (OHT) who either died or underwent a re-transplantation. Methodology and study design Single-center retrospective analysis of primary OHT patients who died or were re-transplanted between October 2012 and July 2021. Clinical data were matched with corresponding pathological findings from endomyocardial biopsies on antibody-mediated rejection, cellular rejection, and cardiac allograft vasculopathy. Re-assessment of available tissue samples was performed to investigate acute myocardial injury (AMI) as a distinct phenomenon. These were correlated with clinical outcomes, which included severe primary graft dysfunction. Patients were grouped according to the presence of AMI and compared. Results We identified 47 patients with truncated outcomes after the first OHT. The median age was 59 years, 36 patients (76%) were male, 25 patients (53%) had a prior history of cardiac operation, and 21 patients (45%) were supported with a durable assist device before OHT. Of those, AMI was identified in 22 (47%) patients (AMI group), and 25 patients had no AMI (non-AMI group). Groups were comparable in baseline and perioperative data. Histopathological observations in AMI group included a non-significant higher incidence of antibody-mediated rejection Grade 1 or higher (pAMR ≥ 1) (32% vs. 12%, P = 0.154), and non-significant lower incidence of severe acute cellular rejection (ACR ≥ 2R) (32% vs. 40%, P = 0.762). Clinical observations in the AMI group found a significantly higher occurrence of severe primary graft dysfunction (68% vs. 20%, P = 0.001) and a highly significant shorter duration from transplantation to death or re-transplantation (42 days [IQR 26, 120] vs. 1,133 days [711–1,664], P < 0.0001). Those patients had a significantly higher occurrence of cardiac-related deaths (64% vs. 24%, P = 0.020). No difference was observed in other outcomes. Conclusion In heart transplant recipients with a truncated postoperative course leading to either death or re-transplantation, AMI in endomyocardial biopsies was a common pathological phenomenon, which correlated with the clinical occurrence of severe primary graft dysfunction. Those patients had significantly shorter survival times and higher cardiac-related deaths. The presence of AMI suggests a truncated course after OHT.
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Affiliation(s)
- Michelle M. McDonald
- Department of Pathology and Laboratory Medicine, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Maks Mihalj
- Department of Advanced Cardiopulmonary Therapies and Transplantation, University of Texas Health Science Center at Houston, Houston, TX, United States
- Department of Cardiac Surgery, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Bihong Zhao
- Department of Pathology and Laboratory Medicine, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Sriram Nathan
- Department of Advanced Cardiopulmonary Therapies and Transplantation, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Stanislava Matejin
- Department of Advanced Cardiopulmonary Therapies and Transplantation, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Giulia Ottaviani
- Department of Pathology and Laboratory Medicine, University of Texas Health Science Center at Houston, Houston, TX, United States
- Cardiovascular Pathology, Lino Rossi Research Center, Department of Biomedical, Surgical and Dental Sciences, Università degli Studi di Milano, Milan, Italy
| | - Mateja K. Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Rajko Radovancevic
- Department of Advanced Cardiopulmonary Therapies and Transplantation, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Biswajit Kar
- Department of Advanced Cardiopulmonary Therapies and Transplantation, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Igor D. Gregoric
- Department of Advanced Cardiopulmonary Therapies and Transplantation, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - L. Maximilian Buja
- Department of Pathology and Laboratory Medicine, University of Texas Health Science Center at Houston, Houston, TX, United States
- *Correspondence: L. Maximilian Buja,
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11
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Paraskevas KI, Mikhailidis DP, Antignani PL, Ascher E, Baradaran H, Bokkers RPH, Cambria RP, Comerota AJ, Dardik A, Davies AH, Eckstein HH, Faggioli G, Fernandes E Fernandes J, Fraedrich G, Geroulakos G, Gloviczki P, Golledge J, Gupta A, Jezovnik MK, Kakkos SK, Katsiki N, Knoflach M, Eline Kooi M, Lanza G, Lavenson GS, Liapis CD, Loftus IM, Mansilha A, Millon A, Nicolaides AN, Pini R, Poredos P, Proczka RM, Ricco JB, Riles TS, Ringleb PA, Rundek T, Saba L, Schlachetzki F, Silvestrini M, Spinelli F, Stilo F, Sultan S, Suri JS, Svetlikov AV, Zeebregts CJ, Chaturvedi S. Comparison of Recent Practice Guidelines for the Management of Patients With Asymptomatic Carotid Stenosis. Angiology 2022; 73:903-910. [PMID: 35412377 DOI: 10.1177/00033197221081914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Despite the publication of several national/international guidelines, the optimal management of patients with asymptomatic carotid stenosis (AsxCS) remains controversial. This article compares 3 recently released guidelines (the 2020 German-Austrian, the 2021 European Stroke Organization [ESO], and the 2021 Society for Vascular Surgery [SVS] guidelines) vs the 2017 European Society for Vascular Surgery (ESVS) guidelines regarding the optimal management of AsxCS patients.The 2017 ESVS guidelines defined specific imaging/clinical parameters that may identify patient subgroups at high future stroke risk and recommended that carotid endarterectomy (CEA) should or carotid artery stenting (CAS) may be considered for these individuals. The 2020 German-Austrian guidelines provided similar recommendations with the 2017 ESVS Guidelines. The 2021 ESO Guidelines also recommended CEA for AsxCS patients at high risk for stroke on best medical treatment (BMT), but recommended against routine use of CAS in these patients. Finally, the SVS guidelines provided a strong recommendation for CEA+BMT vs BMT alone for low-surgical risk patients with >70% AsxCS. Thus, the ESVS, German-Austrian, and ESO guidelines concurred that all AsxCS patients should receive risk factor modification and BMT, but CEA should or CAS may also be considered for certain AsxCS patient subgroups at high risk for future ipsilateral ischemic stroke.
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Affiliation(s)
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | | | - Enrico Ascher
- Division of Vascular Surgery, 12297Vascular Institute of New York, Brooklyn, NY, USA
| | - Hediyeh Baradaran
- Department of Radiology, 14434University of Utah, Salt Lake City, UT, USA
| | - Reinoud P H Bokkers
- Department of Radiology, Medical Imaging Center, 10173University Medical Center Groningen, Groningen, The Netherlands
| | - Richard P Cambria
- Division of Vascular and Endovascular Surgery, St Elizabeth's Medical Center, Boston, MA, USA
| | - Anthony J Comerota
- Inova Heart and Vascular Institute, Inova Alexandria Hospital, Alexandria, VA, USA
| | - Alan Dardik
- Division of Vascular and Endovascular Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Alun H Davies
- Section of Vascular Surgery, Imperial College and Imperial Healthcare NHS Trust, London, UK
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | | | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - George Geroulakos
- Department of Vascular Surgery, 69038"Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, 6915Mayo Clinic, Rochester, MN, USA
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, James Cook University and Townsville University Hospital, Townsville, Queensland, Australia
| | - Ajay Gupta
- Department of Radiology, 466371Weill Cornell Medicine, New York, NY, USA
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX, U.S.A
| | - Stavros K Kakkos
- Department of Vascular Surgery, 37795University of Patras Medical School, Patras, Greece
| | - Niki Katsiki
- First Department of Internal Medicine, 37782AHEPA University Hospital, Thessaloniki, Greece
| | - Michael Knoflach
- Department of Neurology, 27280Medical University of Innsbruck, Innsbruck, Austria
| | - M Eline Kooi
- CARIM School for Cardiovascular Disease, 46837Maastricht University, Maaastricht, The Netherlands.,Department of Radiology and Nuclear Medicine, 46837Maastricht University Medical Center, Maastricht, The Netherlands
| | - Gaetano Lanza
- Vascular Surgery Department, 46837IRCSS MultiMedica Hospital, Castellanza, Italy
| | - George S Lavenson
- Department of Surgery, 1685Uniformed Services University, Bethesda, MD, USA
| | | | - Ian M Loftus
- St George's Vascular Institute, St George's University London, London, UK
| | - Armando Mansilha
- Faculty of Medicine of the University of Porto, Porto, Portugal.,Department of Angiology and Vascular Surgery, Hospital de S. Joao, Porto, Portugal
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, 26899Louis Pradel Hospital, Hospices Civils de Lyon, France
| | - Andrew N Nicolaides
- Department of Surgery, 121343University of Nicosia Medical School, Nicosia, Cyprus
| | - Rodolfo Pini
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Pavel Poredos
- Department of Vascular Disease, University Medical Centre Ljubljana, Slovenia
| | - Robert M Proczka
- 1stDepartment of Vascular Surgery, Medicover Hospital, Warsaw, Poland
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - Thomas S Riles
- Department of Surgery, Division of Vascular Surgery, 12297New York University Langone Medical Centre, New York, NY, USA
| | | | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, 12235University of Miami, Miami, FL, USA
| | - Luca Saba
- Department of Radiology, 97863Azienda Ospedaliera Universitaria Di Cagliari, Cagliari, Italy
| | - Felix Schlachetzki
- Department of Neurology, 210419University of Regensburg, Regensburg, Germany
| | - Mauro Silvestrini
- Neurological Clinic, Department of Experimental and Clinical Medicine, 9294Marche Polytechnic University, Ancona, Italy
| | - Francesco Spinelli
- Vascular Surgery Division, 9311Campus Bio-Medico University of Rome, Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, 9311Campus Bio-Medico University of Rome, Rome, Italy
| | - Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Jasjit S Suri
- Stroke Diagnosis and Monitoring Division, AtheroPointTM, Roseville, USA
| | - Alexei V Svetlikov
- Division of Vascular and Endovascular Surgery, North-Western Scientific Clinical Center of Federal Medical Biological Agency of Russia, St Petersburgh, Russia
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Seemant Chaturvedi
- Department of Neurology & Stroke Program, 12264University of Maryland School of Medicine, Baltimore, MD, USA
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12
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Nascimbene A, McAlister CA, Yo D, Kumar S, Hernandez M, Jezovnik MK, Feng H, Miao H, Basra S, Salas de Armas IA, Radovancevic R, Gregoric ID, Kar B. Periprocedural Outcomes in TAVR: Focus on Calcium, Valve Position, and Pre-Existing Conduction Defects. JACC Cardiovasc Interv 2022; 15:466-468. [PMID: 35210056 DOI: 10.1016/j.jcin.2021.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/30/2021] [Accepted: 12/07/2021] [Indexed: 11/16/2022]
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13
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Paraskevas KI, Mikhailidis DP, Baradaran H, Bokkers RPH, Davies AH, Eckstein HH, Faggioli G, Fernandes E Fernandes J, Gargiulo M, Jawien A, Jezovnik MK, Kakkos SK, Knoflach M, Kooi ME, Lanza G, Liapis CD, Loftus IM, Mansilha A, Mechtouff L, Millon A, Myrcha P, Nicolaides AN, Pini R, Poredos P, Ricco JB, Rundek T, Saba L, Silvestrini M, Spinelli F, Stilo F, Sultan S, Suri JS, Svetlikov AV, Wijeratne T, Zeebregts CJ, Gloviczki P. The burden of carotid-related strokes. Ann Transl Med 2022; 10:159. [PMID: 35284552 PMCID: PMC8904971 DOI: 10.21037/atm-2021-12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 12/24/2021] [Indexed: 11/06/2022]
Affiliation(s)
| | - Dimitri P. Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | - Hediyeh Baradaran
- Department of Radiology and Imaging Sciences, Neuroradiology Division, University of Utah Health, Salt Lake City, UT, USA
| | - Reinoud P. H. Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, The Netherlands
| | - Alun H. Davies
- Section of Vascular Surgery, Imperial College & Imperial Healthcare NHS Trust, London, UK
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gianluca Faggioli
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCSS Policlinico di Sant’Orsola, Bologna, Italy
| | | | - Mauro Gargiulo
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCSS Policlinico di Sant’Orsola, Bologna, Italy
| | - Arkadiusz Jawien
- Department for Vascular Surgery and Angiology, L. Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
| | - Mateja K. Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX, USA
| | - Stavros K. Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Michael Knoflach
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - M. Eline Kooi
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Gaetano Lanza
- Vascular Surgery Department, IRCSS MultiMedica Hospital, Castellanza, Italy
| | | | - Ian M. Loftus
- St. George’s Vascular Institute, St. George’s University London, London, UK
| | | | | | - Antoine Millon
- Vascular Surgery Department, Hospices Civils de Lyon, Lyon, France
| | - Piotr Myrcha
- First Chair and Department of General and Vascular Surgery, Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| | | | - Rodolfo Pini
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCSS Policlinico di Sant’Orsola, Bologna, Italy
| | - Pavel Poredos
- Department of Vascular Disease, University Medical Centre Ljubljana, Slovenia
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria Di Cagliari, Cagliari, Italy
| | - Mauro Silvestrini
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Francesco Spinelli
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Jasjit S. Suri
- Stroke Diagnosis and Monitoring Division, AtheroPointTM, Roseville, USA
| | - Alexei V. Svetlikov
- Division of Vascular and Endovascular Surgery, North-Western Scientific Clinical Center of Federal Medical Biological Agency of Russia, St. Petersburgh, Russia
| | - Tissa Wijeratne
- Department of Neurology, Sunshine Hospital and Melbourne Medical School, St. Albans, Victoria, Australia
| | - Clark J. Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
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14
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Paraskevas KI, Mikhailidis DP, Baradaran H, Davies AH, Eckstein HH, Faggioli G, Fernandes JFE, Gupta A, Jezovnik MK, Kakkos SK, Katsiki N, Kooi ME, Lanza G, Liapis CD, Loftus IM, Millon A, Nicolaides AN, Poredos P, Pini R, Ricco JB, Rundek T, Saba L, Spinelli F, Stilo F, Sultan S, Zeebregts CJ, Chaturvedi S. Optimal Management of Asymptomatic Carotid Stenosis: Counterbalancing the Benefits with the Potential Risks. J Stroke 2022; 24:163-165. [PMID: 35135072 PMCID: PMC8829475 DOI: 10.5853/jos.2021.04420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 12/31/2021] [Indexed: 11/12/2022] Open
Affiliation(s)
- Kosmas I. Paraskevas
- Department of Vascular Surgery, Central Clinic of Athens, Athens, Greece
- Correspondence: Kosmas I. Paraskevas Department of Vascular Surgery, Central Clinic of Athens, 24, Alexander Papagou Street, N. Iraklio 14122, Athens, Greece Tel: +30-698-3133883 Fax: +30-210-3215792 E-mail:
| | - Dimitri P. Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | - Hediyeh Baradaran
- Department of Radiology, University of Utah, Salt Lake City, UT, USA
| | - Alun H. Davies
- Section of Vascular Surgery, Imperial College & Imperial Healthcare NHS Trust, London, UK
| | - Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna “Alma Mater Studiorum”, S. Orsola-Malpighi Polyclinic, Bologna, Italy
| | | | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Mateja K. Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX, USA
| | - Stavros K. Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Niki Katsiki
- First Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - M. Eline Kooi
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Gaetano Lanza
- Vascular Surgery Department, IRCSS MultiMedica Hospital, Castellanza, Italy
| | | | - Ian M. Loftus
- St. George’s Vascular Institute, St. George’s University London, London, UK
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | | | - Pavel Poredos
- Department of Vascular Disease, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Rodolfo Pini
- Vascular Surgery, University of Bologna “Alma Mater Studiorum”, S. Orsola-Malpighi Polyclinic, Bologna, Italy
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Luca Saba
- Department of Radiology, University Hospital Center of Cagliari, Cagliari, Italy
| | - Francesco Spinelli
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Clark J. Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Seemant Chaturvedi
- Department of Neurology & Stroke Program, University of Maryland School of Medicine, Baltimore, MD, USA
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15
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Paraskevas KI, Mikhailidis DP, Antignani PL, Baradaran H, Bokkers RP, Cambria RP, Dardik A, Davies AH, Eckstein HH, Faggioli G, Fernandes E Fernandes J, Fraedrich G, Geroulakos G, Gloviczki P, Golledge J, Gupta A, Jezovnik MK, Kakkos SK, Katsiki N, Knoflach M, Kooi ME, Lanza G, Liapis CD, Loftus IM, Mansilha A, Millon A, Nicolaides AN, Pini R, Poredos P, Ricco JB, Riles TS, Ringleb PA, Rundek T, Saba L, Schlachetzki F, Silvestrini M, Spinelli F, Stilo F, Sultan S, Suri JS, Zeebregts CJ, Chaturvedi S. Optimal management of asymptomatic carotid stenosis in 2021: the jury is still out. An International, multispecialty, expert review and position statement. INT ANGIOL 2021; 41:158-169. [PMID: 34913633 DOI: 10.23736/s0392-9590.21.04825-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVES The recommendations of international guidelines for the management of asymptomatic carotid stenosis (ACS) often vary considerably and extend from a conservative approach with risk factor modification and best medical treatment (BMT) alone, to a more aggressive approach with a carotid intervention plus BMT. The aim of the current multispecialty position statement is to reconcile the conflicting views on the topic. MATERIALS AND METHODS A literature review was performed with a focus on data from recent studies. RESULTS Several clinical and imaging high-risk features have been identified that are associated with an increased long-term ipsilateral ischemic stroke risk in patients with ACS. Such high-risk clinical/imaging features include intraplaque hemorrhage, impaired cerebrovascular reserve, carotid plaque echolucency/ulceration/ neovascularization, a lipid-rich necrotic core, a thin or ruptured fibrous cap, silent brain infarction, a contralateral transient ischemic attack/stroke episode, male patients <75 years and microembolic signals on transcranial Doppler. There is growing evidence that 80-99% ACS indicate a higher stroke risk than 50-79% stenoses. CONCLUSIONS Although aggressive risk factor control and BMT should be implemented in all ACS patients, several high-risk features that may increase the risk of a future cerebrovascular event are now documented. Consequently, some guidelines recommend a prophylactic carotid intervention in high-risk patients to prevent future cerebrovascular events. Until the results of the much-anticipated randomized controlled trials emerge, the jury is still out regarding the optimal management of ACS patients.
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Affiliation(s)
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | | | - Hediyeh Baradaran
- Department of Radiology, University of Utah, Salt Lake City, UT, USA
| | - Reinoud P Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, The Netherlands
| | - Richard P Cambria
- Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Brighton, MA, USA
| | - Alan Dardik
- Division of Vascular and Endovascular Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Alun H Davies
- Section of Vascular Surgery, Imperial College & Imperial Healthcare NHS Trust, London, UK
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gianluca Faggioli
- Vascular Surgery, Policlinico S. Orsola Malpighi, University of Bologna Alma Mater Studiorum, Bologna, Italy
| | | | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - George Geroulakos
- Department of Vascular Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, James Cook University and Townsville University Hospital, Townsville, Australia
| | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, Texas, USA
| | - Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Niki Katsiki
- First Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - Michael Knoflach
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - M Eline Kooi
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Gaetano Lanza
- Vascular Surgery Department, IRCSS MultiMedica Hospital, Castellanza, Varese, Italy
| | | | - Ian M Loftus
- St. George's Vascular Institute, St. George's University London, London, UK
| | - Armando Mansilha
- Faculty of Medicine of the University of Porto, Porto, Portugal.,Department of Angiology and Vascular Surgery, Hospital de S. Joao, Porto, Portugal
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - Andrew N Nicolaides
- Department of Surgery, University of Nicosia Medical School, Nicosia, Cyprus
| | - Rodolfo Pini
- Vascular Surgery, Policlinico S. Orsola Malpighi, University of Bologna Alma Mater Studiorum, Bologna, Italy
| | - Pavel Poredos
- Department of Vascular Disease, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - Thomas S Riles
- Department of Surgery, Division of Vascular Surgery, New York University Langone Medical Centre, New York, NY, USA
| | | | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria di Cagliari, Cagliari, Italy
| | | | - Mauro Silvestrini
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Francesco Spinelli
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Jasjit S Suri
- Stroke Diagnosis and Monitoring Division, AtheroPointTM, Roseville, CA, USA
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Seemant Chaturvedi
- Department of Neurology & Stroke Program, University of Maryland School of Medicine, Baltimore, MD, USA
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16
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Paraskevas KI, Mikhailidis DP, Antignani PL, Baradaran H, Bokkers RPH, Cambria RP, Dardik A, Davies AH, Eckstein HH, Faggioli G, E Fernandes JF, Fraedrich G, Geroulakos G, Gloviczki P, Golledge J, Gupta A, Jezovnik MK, Kakkos SK, Katsiki N, Knoflach M, Kooi ME, Lanza G, Liapis CD, Loftus IM, Mansilha A, Millon A, Nicolaides AN, Pini R, Poredos P, Ricco JB, Riles TS, Ringleb PA, Rundek T, Saba L, Schlachetzki F, Silvestrini M, Spinelli F, Stilo F, Sultan S, Suri JS, Zeebregts CJ, Chaturvedi S. Optimal Management of Asymptomatic Carotid Stenosis in 2021: The Jury is Still Out. An International, Multispecialty, Expert Review and Position Statement. J Stroke Cerebrovasc Dis 2021; 31:106182. [PMID: 34735900 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106182] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/14/2021] [Accepted: 10/17/2021] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES The recommendations of international guidelines for the management of asymptomatic carotid stenosis (ACS) often vary considerably and extend from a conservative approach with risk factor modification and best medical treatment (BMT) alone, to a more aggressive approach with a carotid intervention plus BMT. The aim of the current multispecialty position statement is to reconcile the conflicting views on the topic. MATERIALS AND METHODS A literature review was performed with a focus on data from recent studies. RESULTS Several clinical and imaging high-risk features have been identified that are associated with an increased long-term ipsilateral ischemic stroke risk in patients with ACS. Such high-risk clinical/imaging features include intraplaque hemorrhage, impaired cerebrovascular reserve, carotid plaque echolucency/ulceration/ neovascularization, a lipid-rich necrotic core, a thin or ruptured fibrous cap, silent brain infarction, a contralateral transient ischemic attack/stroke episode, male patients < 75 years and microembolic signals on transcranial Doppler. There is growing evidence that 80-99% ACS indicate a higher stroke risk than 50-79% stenoses. CONCLUSIONS Although aggressive risk factor control and BMT should be implemented in all ACS patients, several high-risk features that may increase the risk of a future cerebrovascular event are now documented. Consequently, some guidelines recommend a prophylactic carotid intervention in high-risk patients to prevent future cerebrovascular events. Until the results of the much-anticipated randomized controlled trials emerge, the jury is still out regarding the optimal management of ACS patients.
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Affiliation(s)
- Kosmas I Paraskevas
- Department of Vascular Surgery, Central Clinic of Athens, 24, Alexander Papagou street, N. Iraklio, Athens 14122, Greece.
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | | | - Hediyeh Baradaran
- Department of Radiology, University of Utah, Salt Lake City, UT, United States
| | - Reinoud P H Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, the Netherland
| | - Richard P Cambria
- Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Brighton, MA, United States
| | - Alan Dardik
- Division of Vascular and Endovascular Surgery, Yale University School of Medicine, New Haven, CT, United States
| | - Alun H Davies
- Section of Vascular Surgery, Imperial College and Imperial Healthcare NHS Trust, London, UK
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | | | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - George Geroulakos
- Department of Vascular Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, United States
| | - Jonathan Golledge
- Queensland Research Center for Peripheral Vascular Disease, James Cook University, Townsville University Hospital, Townsville, Queensland, Australia
| | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, United States
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center, Houston, TX, United States
| | - Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Niki Katsiki
- First Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - Michael Knoflach
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - M Eline Kooi
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherland; Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, the Netherland
| | - Gaetano Lanza
- Vascular Surgery Department, IRCSS MultiMedica Hospital, Castellanza, Italy
| | | | - Ian M Loftus
- St. George's Vascular Institute, St. George's University of London, London, UK
| | - Armando Mansilha
- Faculty of Medicine of the University of Porto, Porto, Portugal; Department of Angiology and Vascular Surgery, Hospital de S. Joao, Porto, Portugal
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, Louis Pradel Hospital, Hospices Civils de Lyon, France
| | - Andrew N Nicolaides
- Department of Surgery, University of Nicosia Medical School, Nicosia, Cyprus
| | - Rodolfo Pini
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Pavel Poredos
- Department of Vascular Disease, University Medical Center, Ljubljana, Slovenia
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - Thomas S Riles
- Department of Surgery, Division of Vascular Surgery, New York University, Langone Medical Center, New York, United States
| | | | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria Di Cagliari, Cagliari, Italy
| | | | - Mauro Silvestrini
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Francesco Spinelli
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sherif Sultan
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Jasjit S Suri
- Stroke Diagnosis and Monitoring Division, AtheroPointTM, Roseville, United States
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherland
| | - Seemant Chaturvedi
- Department of Neurology and Stroke Program, University of Maryland School of Medicine, Baltimore, MD, United States
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17
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Poredos P, Jezovnik MK. Preclinical carotid atherosclerosis as an indicator of polyvascular disease: a narrative review. Ann Transl Med 2021; 9:1204. [PMID: 34430645 PMCID: PMC8350699 DOI: 10.21037/atm-20-5570] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 06/29/2021] [Indexed: 12/15/2022]
Abstract
Carotid atherosclerotic lesions are correlated with atherosclerotic deterioration of the arterial wall in other vascular territories and with cardiovascular events. The detection of pre-symptomatic carotid lesions like intima-media thickness (IMT) and asymptomatic carotid plaques is possible by non-invasive ultrasound duplex scanning. Current measurement guidelines suggest an average measurement of IMT within 10 mm of the segment of the common carotid artery. The thickening of intima-media appears in a long subclinical period of atherosclerosis. Therefore, the determination of IMT has emerged as one of the methods for determining early structural deterioration of the arterial wall. A close interrelationship was shown between IMT and risk factors of atherosclerosis, their duration, and intensity. Different studies demonstrated that increased IMT is a powerful predictor of coronary, cerebrovascular, and peripheral arterial occlusive disease and their complication. A recent meta-analysis indicated a minimal improvement in the risk estimation of cardiovascular events after adding IMT to the Framingham Risk Score. These findings influenced the latest ACC/AHA guidelines which again recommend the use of carotid IMT measurement for individual risk assessment. The presence of atherosclerotic plaques indicates that the atherosclerotic process is already ongoing. The findings of different studies are equivocal that carotid plaques independently predict cardiovascular events and improve risk predictions for coronary artery disease when added to the Framingham Risk Score. However, besides the size of plaque and grade of stenosis, the structure of plaque calcification, vascularization, lipid core, and the surface of plaques are important indicators of related risks for cardiovascular events.
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Affiliation(s)
- Pavel Poredos
- Department of Vascular Disease, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX, USA
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX, USA
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18
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Paraskevas KI, Mikhailidis DP, Baradaran H, Davies AH, Eckstein HH, Faggioli G, Fernandes E Fernandes J, Gupta A, Jezovnik MK, Kakkos SK, Katsiki N, Kooi ME, Lanza G, Liapis CD, Loftus IM, Millon A, Nicolaides AN, Poredos P, Pini R, Ricco JB, Rundek T, Saba L, Spinelli F, Stilo F, Sultan S, Zeebregts CJ, Chaturvedi S. Management of patients with asymptomatic carotid stenosis may need to be individualized: a multidisciplinary call for action. Republication of J Stroke 2021;23:202-212. INT ANGIOL 2021; 40:487-496. [PMID: 34313413 DOI: 10.23736/s0392-9590.21.04751-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The optimal management of patients with asymptomatic carotid stenosis (ACS) is the subject of extensive debate. According to the 2017 European Society for Vascular Surgery guidelines, carotid endarterectomy should (Class IIa; Level of Evidence: B) or carotid artery stenting may be considered (Class IIb; Level of Evidence: B) in the presence of one or more clinical/imaging characteristics that may be associated with an increased risk of late ipsilateral stroke (e.g. silent embolic infarcts on brain computed tomography/magnetic resonance imaging, progression in the severity of ACS, a history of contralateral transient ischemic attack/stroke, microemboli detection on transcranial Doppler, etc.), provided documented perioperative stroke/death rates are <3% and the patient's life expectancy is >5 years. Besides these clinical/imaging characteristics, there are additional individual, ethnic/racial or social factors that should probably be evaluated in the decision process regarding the optimal management of these patients, such as individual patient needs/patient choice, patient compliance with best medical treatment, patient sex, culture, race/ethnicity, age and comorbidities, as well as improvements in imaging/operative techniques/outcomes. The present multispecialty position paper will present the rationale why the management of patients with ACS may need to be individualized.
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Affiliation(s)
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | - Hediyeh Baradaran
- Department of Radiology, University of Utah, Salt Lake City, UT, USA
| | - Alun H Davies
- Section of Vascular Surgery, Imperial College & Imperial Healthcare NHS Trust, London, UK
| | - Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna Alma Mater Studiorum, Policlinico S. Orsola Malpighi, Bologna, Italy
| | | | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX, USA
| | - Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Niki Katsiki
- First Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - M Eline Kooi
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Gaetano Lanza
- Vascular Surgery Department, IRCSS MultiMedica Hospital, Castellanza, Varese, Italy
| | | | - Ian M Loftus
- St. George's Vascular Institute, St. George's University London, London, UK
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - Andrew N Nicolaides
- Department of Surgery, University of Nicosia Medical School, Nicosia, Cyprus
| | - Pavel Poredos
- Department of Vascular Disease, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Rodolfo Pini
- Vascular Surgery, University of Bologna Alma Mater Studiorum, Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria di Cagliari, Cagliari, Italy
| | - Francesco Spinelli
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Seemant Chaturvedi
- Department of Neurology & Stroke Program, University of Maryland School of Medicine, Baltimore, MD, USA
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Paraskevas KI, Mikhailidis DP, Baradaran H, Davies AH, Eckstein HH, Faggioli G, Fernandes JFE, Gupta A, Jezovnik MK, Kakkos SK, Katsiki N, Kooi ME, Lanza G, Liapis CD, Loftus IM, Millon A, Nicolaides AN, Poredos P, Pini R, Ricco JB, Rundek T, Saba L, Spinelli F, Stilo F, Sultan S, Zeebregts CJ, Chaturvedi S. Management of Patients with Asymptomatic Carotid Stenosis May Need to Be Individualized: A Multidisciplinary Call for Action. J Stroke 2021; 23:202-212. [PMID: 34102755 PMCID: PMC8189852 DOI: 10.5853/jos.2020.04273] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 04/12/2021] [Indexed: 12/15/2022] Open
Abstract
The optimal management of patients with asymptomatic carotid stenosis (ACS) is the subject of extensive debate. According to the 2017 European Society for Vascular Surgery guidelines, carotid endarterectomy should (Class IIa; Level of Evidence: B) or carotid artery stenting may be considered (Class IIb; Level of Evidence: B) in the presence of one or more clinical/imaging characteristics that may be associated with an increased risk of late ipsilateral stroke (e.g., silent embolic infarcts on brain computed tomography/magnetic resonance imaging, progression in the severity of ACS, a history of contralateral transient ischemic attack/stroke, microemboli detection on transcranial Doppler, etc.), provided documented perioperative stroke/death rates are <3% and the patient’s life expectancy is >5 years. Besides these clinical/imaging characteristics, there are additional individual, ethnic/racial or social factors that should probably be evaluated in the decision process regarding the optimal management of these patients, such as individual patient needs/patient choice, patient compliance with best medical treatment, patient sex, culture, race/ethnicity, age and comorbidities, as well as improvements in imaging/operative techniques/outcomes. The present multispecialty position paper will present the rationale why the management of patients with ACS may need to be individualized.
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Affiliation(s)
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | - Hediyeh Baradaran
- Department of Radiology, University of Utah, Salt Lake City, UT, USA
| | - Alun H Davies
- Section of Vascular Surgery, Imperial College & Imperial Healthcare NHS Trust, London, UK
| | - Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | | | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX, USA
| | - Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Niki Katsiki
- First Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - M Eline Kooi
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Gaetano Lanza
- Vascular Surgery Department, IRCSS MultiMedica Hospital, Castellanza, Italy
| | | | - Ian M Loftus
- St. George's Vascular Institute, St. George's University London, London, UK
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, Louis Pradel Hospital, Hospices Civils de Lyon, France
| | - Andrew N Nicolaides
- Department of Surgery, University of Nicosia Medical School, Nicosia, Cyprus
| | - Pavel Poredos
- Department of Vascular Disease, University Medical Centre Ljubljana, Slovenia
| | - Rodolfo Pini
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria Di Cagliari, Cagliari, Italy
| | - Francesco Spinelli
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Seemant Chaturvedi
- Department of Neurology & Stroke Program, University of Maryland School of Medicine, Baltimore, MD, USA
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20
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Poredos P, Antignani PL, Blinc A, Fras Z, Jezovnik MK, Fareed J, Mansilha A. Do we have a unified consensus on antithrombotic management of PAD? INT ANGIOL 2021; 40:229-239. [PMID: 33739074 DOI: 10.23736/s0392-9590.21.04597-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Peripheral artery disease (PAD) is one of the most frequent manifestations of atherosclerosis with high rates of morbidity and mortality. Platelets and coagulation are involved in the progression of atherosclerosis and thromboembolic complications. PAD patients have increased prothrombotic potential, which includes platelet hyperaggregability and increased pro-coagulant state. Therefore, antithrombotic treatment is of utmost importance for the prevention of cardiovascular events in this group of patients. Aspirin is the basic antiplatelet drug, but with limited efficacy in PAD. In contrast to coronary artery disease, its effect on the prevention of cardiovascular events in PAD has been limited proven. Particularly in asymptomatic PAD, there is no evidence for risk reduction with aspirin. Clopidogrel and ticagrelor are more effective than aspirin. Clopidogrel is thus an effective alternative to aspirin for prevention of cardiovascular events in symptomatic PAD. In patients who are non-responders to clopidogrel, ticagrelor is indicated. Dual antiplatelet treatment (DAPT) with aspirin and ticagrelor in patients with coronary artery disease and concomitant PAD significantly decreased the rate of major adverse cardiovascular events, including adverse limb events. However, in the CHARISMA Trial, aspirin and clopidogrel were not more effective than aspirin alone and increased bleeding complications. Therefore, DAPT seems effective only in PAD accompanied by coronary artery disease. Anticoagulant treatment for symptomatic PAD with vitamin K antagonists alone or in combination with aspirin is not more effective than single antiplatelet treatment but increases the rate of major bleeding. Low dose rivaroxaban combined with aspirin in PAD patients significantly reduces cardiovascular events, including limb-threatening ischemia and limb amputations. Anticoagulation and antiplatelet treatment after percutaneous or surgical revascularization of PAD improve the patency of treated vessels. Aspirin with or without dipyridamole improved patency of infra-inguinal by-pass grafts at one year. The combination of clopidogrel with aspirin was more effective than aspirin alone in the prevention of prosthetic graft occlusions in patients undergoing below-knee by-pass-grafting. Oral vitamin K antagonists were not more effective than aspirin in the prevention of infra-inguinal by-pass occlusion. The combination of low dose rivaroxaban and aspirin was effective in preventing major adverse cardiovascular events and adverse limb events after infrainguinal endovascular or surgical revascularization in patients with intermittent claudication. However, the data on antithrombotic treatment after revascularization for limb-threatening ischemia is scanty and inconclusive. In conclusion: Antithrombotic treatment of PAD is a cornerstone for the management of these patients. Antiplatelet drugs prevent the initiation and progression of atherosclerosis and are effective also in the prevention of thromboembolic events. Simultaneous use of antiplatelet and anticoagulation drugs is accompanied by an increased risk of bleeding. However, combined treatment with aspirin and low-dose rivaroxaban is more effective than single antithrombotic treatment and safer than full-dose combined treatment.
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Affiliation(s)
- Pavel Poredos
- Department of Vascular Disease, University Medical Center Ljubljana, Ljubljana, Slovenia
| | | | - Ales Blinc
- Department of Vascular Disease, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Zlatko Fras
- Department of Vascular Disease, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Health Science Center, University of Texas, Houston, TX, USA
| | - Jawed Fareed
- Loyola University Medical Center, Maywood, IL, USA
| | - Armando Mansilha
- Department of Angiology and Vascular Surgery, Hospital CUF Porto, Porto, Portugal
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21
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Abstract
Background: A significant consequence of peripheral arterial disease (PAD) is an impaired functional capacity and deteriorated quality of life. Therefore, our study aimed to investigate the usefulness of a symptom questionnaire and walk tests for the determination of the functional capacity of patients with intermittent claudication. Patients and methods: The study included 53 patients (38 males) with stable claudication distance (50-300m). A detailed history and physical examination, ankle-brachial index (ABI), treadmill exercise test, and 6-minute walk test were performed and compared to walking impairment questionnaire (WIQ). Results: Claudication distance reported from patients' history and 6-minute walk test were significantly correlated with ABI (p=0.033, p=0.044). There were no significant correlations between ABI and treadmill walk test or WIQ. Results of WIQ were significantly correlated with the history and the most of performed walk tests: treadmill initial and maximal claudication distance (p=0.004 and 0.012, respectively) and 6-minute walk test (p=0.026). 6-minute walk test was correlated with maximal claudication distance of treadmill (p=0.018), but not with an initial claudication distance. Conclusions: The validity of WIQ is comparable to walk tests and represents the useful technique for the investigation of the functional capacity of patients with PAD. A self-report based on WIQ enables a longer period of observation. It should be routinely used as a basic diagnostic tool for the estimation of the functional capacity of PAD patients with stable intermittent claudication.
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Affiliation(s)
- Pavel Poredos
- Department of Vascular Disease, University Medical Center Ljubljana, Slovenia.,Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston, Texas, USA
| | - Urska Zlajpah
- Department of Vascular Disease, University Medical Center Ljubljana, Slovenia
| | - Peter Poredos
- Department of Anesthesiology and Intensive Care, University Medical Center Ljubljana, Slovenia
| | | | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston, Texas, USA
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22
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Poredos P, Poredos P, Jezovnik MK, Mavric A, Leben L, Mijovski MB, Maia P, Haddad S, Fareed J. Time Course of Inflammatory and Procoagulant Markers in the Early Period After Total Hip Replacement. Clin Appl Thromb Hemost 2021; 27:1076029620985941. [PMID: 33529054 PMCID: PMC7863137 DOI: 10.1177/1076029620985941] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Our study aimed to investigate the levels and time-course of systemic inflammatory and hemostasis markers in the early postoperative period in patients undergoing total hip replacement (THR). The study included 70 patients of both sexes, average age 68.4 ± 10.9 years. Levels of inflammatory and hemostasis markers were measured before surgery (POD 0), a day after the surgery (POD 1) and 5 days after surgery (POD 5). In the postoperative period inflammatory markers increased. The operation provoked a significant increase of CRP on POD 1 in comparison to POD 0 (68.5 ± 5.4 vs 6.8 ± 2.2 μg/mL, p < 0.001) and the additional increase was registered on POD 5 (87.5 ± 8.1 vs 68.5 ± 5.4 μg/mL, p < 0.001). Interleukin-6 significantly increased on POD 1 (251.5 ± 21.6 vs 14.6 ± 7.1 μg/mL, p < 0.001) and after that (POD 5) decreased. After surgery leukocyte count, neutrophil/lymphocyte ratio and platelet/lymphocyte ratio were significantly higher compared to POD 0. Activation of coagulation in the postoperative period was shown by increased peak thrombin on POD 5 in comparison to POD 0 (185 ± 27 vs. 124 ± 31 nM, p < 0.001). D-dimer was increased on POD 1 and an additional rise was observed on POD 5. vWF also progressively increased in the observed period. Results of our study showed that after THR systemic inflammatory markers increased and coagulation function was enhanced. Determination of inflammatory and procoagulant markers could help identify patients at risk for cardiovascular thromboembolic events.
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Affiliation(s)
- Peter Poredos
- Department of Anesthesiology and Perioperative Intensive Care, University Medical Centre Ljubljana, Slovenia
| | - Pavel Poredos
- Department of Vascular Disease, University Medical Centre Ljubljana, Slovenia.,Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, TX, USA
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, TX, USA
| | - Ana Mavric
- Department of Vascular Disease, University Medical Centre Ljubljana, Slovenia
| | - Lara Leben
- Department of Vascular Disease, University Medical Centre Ljubljana, Slovenia
| | | | - Paula Maia
- Loyola University Medical Centre, Maywood, IL, USA
| | | | - Jawed Fareed
- Loyola University Medical Centre, Maywood, IL, USA
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23
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Abstract
Carotid atherosclerotic plaques represent a risk for ischemic stroke. The data indicate that the risk for distal embolization from atherosclerotic lesions in internal carotid arteries is not related only to the degree of stenosis but also to the composition of plaques. The stability of atherosclerotic plaque depends on the thickness of the fibrous cap and plaque hemorrhage. Recent research indicated that the inflammatory activity of atherosclerotic lesions is pivotal in the progression of atherosclerotic plaques. It also promotes the development of unstable atherosclerotic lesions and is related to thromboembolic cerebrovascular complications. Inflammation destabilizes atherosclerotic plaques through the degradation of their fibrotic structure. Inflammation of atherosclerotic plaques was confirmed by histopathologic findings and levels of circulating inflammatory markers which were correlated to the intensity of the inflammation in atherosclerotic lesions. Recently, new techniques like fluorodeoxyglucose positron emission tomography (18-FDG PET) were developed for the identification of inflammation of atherosclerotic lesions in the vessel wall in vivo. Systemic inflammatory markers, particularly interleukins, tumor necrosis factor-alpha and metalloproteinases were shown to be related to the intensity of the inflammatory process in atherosclerotic lesions and the cerebrovascular events. Identification of inflamed atherosclerotic plaques may help to identify unstable atherosclerotic lesions and subjects at high risk for cerebrovascular incidents who need intensive preventive measures including anti-inflammatory medication.
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Affiliation(s)
- Pavel Poredos
- Department of Vascular Disease, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX, USA
| | - Igor D Gregoric
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX, USA
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX, USA
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24
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Abstract
The endothelium plays a crucial role in maintaining cardiovascular homeostasis. Shear stress generated by flowing blood regulates the release of substances that provide adequate tissue perfusion. The extent of damage to endothelial cells depends on locally disturbed shear stress caused by the deteriorated flow. Patients with heart failure have reduced cardiac output, which results in reduced blood flow and negative shear stress. Reduced shear stress also affects microcirculation and reduces tissue perfusion. Consequently, the production of free oxygen radicals is increased and bioavailability of nitric oxide is additionally decreased. Therefore, endothelial dysfunction is involved in the progression of heart failure and cardiovascular events. Left ventricular assist devices (LVAD) are used for the treatment of patients with advanced heart failure. Older pulsatile flow LVADs were mostly substituted by continuous-flow LVADs (cf-LVADs). Despite the advantages of the cf-LVADs, the loss of pulsatility leads to different complications on the micro- and macrovascular levels. One of the pathogenetic mechanisms of cardiovascular complications with cf-LVADs may be endothelial dysfunction, which after the implantation of the device does not improve and may even deteriorate. In contrast, the pulsatile pattern of LVADs on blood flow could preserve endothelial function.
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Affiliation(s)
- Pavel Poredos
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, 12340The University of Texas Health Science Center at Houston, Houston, TX, USA.,Department of Vascular Disease, 37663University Medical Center, Ljubljana, Slovenia
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, 12340The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Rajko Radovancevic
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, 12340The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Igor D Gregoric
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, 12340The University of Texas Health Science Center at Houston, Houston, TX, USA
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25
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Szymanski TW, Weeks PA, Patel CJ, Jezovnik MK, Gulbis B, Nathan SS, Jumean MF, Radovancevic R, Kar B, Gregoric ID. Risk of pump thrombosis and stroke in patients with continuous‐flow left ventricular assist devices and gastrointestinal bleeding. Artif Organs 2020; 44:1171-1175. [DOI: 10.1111/aor.13751] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 05/26/2020] [Accepted: 06/05/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Thomas W. Szymanski
- Department of Pharmacy Memorial Hermann Hospital‐Texas Medical Center Houston TX USA
| | - Phillip A. Weeks
- Department of Pharmacy Memorial Hermann Hospital‐Texas Medical Center Houston TX USA
| | - Chandni J. Patel
- Department of Advanced Cardiopulmonary Therapies and Transplantation Center for Advanced Heart Failure University of Texas Health Science Center at Houston Houston TX USA
| | - Mateja K. Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation Center for Advanced Heart Failure University of Texas Health Science Center at Houston Houston TX USA
| | - Brian Gulbis
- Department of Pharmacy Memorial Hermann Hospital‐Texas Medical Center Houston TX USA
| | - Sriram S. Nathan
- Department of Advanced Cardiopulmonary Therapies and Transplantation Center for Advanced Heart Failure University of Texas Health Science Center at Houston Houston TX USA
| | - Marwan F. Jumean
- Department of Advanced Cardiopulmonary Therapies and Transplantation Center for Advanced Heart Failure University of Texas Health Science Center at Houston Houston TX USA
| | - Rajko Radovancevic
- Department of Advanced Cardiopulmonary Therapies and Transplantation Center for Advanced Heart Failure University of Texas Health Science Center at Houston Houston TX USA
| | - Biswajit Kar
- Department of Advanced Cardiopulmonary Therapies and Transplantation Center for Advanced Heart Failure University of Texas Health Science Center at Houston Houston TX USA
| | - Igor D. Gregoric
- Department of Advanced Cardiopulmonary Therapies and Transplantation Center for Advanced Heart Failure University of Texas Health Science Center at Houston Houston TX USA
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Abstract
Summary: In patients with peripheral arterial disease (PAD), the ability to perform physical exercise is an essential and most important indicator of a patient’s health and quality of life. In many cases, there exists a discrepancy between lower extremity blood flow, the extent of arterial occlusion shown by morphological investigation and functional impairment. Reversal of lower extremity arterial obstruction with revascularization does not always reverse functional impairment of diseased leg. Further, training exercise and drug treatment can improve functional performance although they are not associated with an improvement in arterial obstruction. Therefore, the determination of functional impairment and its recovery after different therapeutic procedures should be determined using objective tests. The most frequently used functional tests are treadmill exercise testing and a 6-minute walk test. The constant load test, in which results are expressed as a walked distance, does not always permit an accurate assessment of the full range of functional impairment of PAD patients. Recently, as a substitute for a constant-load test, the graded treadmill test is used. With this test, it is possible to identify those individuals with exercise limitations who are not caused only by deterioration of the blood flow of lower limbs. The 6-minute walk test is simple to perform and requires minimal equipment. However, the correlation between the 6-minute walk test and the graded treadmill test is relatively weak, indicating that peak performance on a graded treadmill may reflect different pathophysiological mechanisms of limitations. In conclusion: for the determination of limitations of mobility and quality of life in patients with PAD, objective measures of functional impairment are needed. The determination of functional capacity is related to the quality of life and is a useful tool for investigation of the success of revascularization of peripheral arteries and conservative treatment.
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Affiliation(s)
- Pavel Poredoš
- The University of Texas, Health Science Center at Houston, Houston, TX, USA
| | - Mateja K. Jezovnik
- The University Medical Center Ljubljana, Department of Vascular Disease, Ljubljana, Slovenia
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28
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Poredos P, Jezovnik MK. The Role of Inflammatory Biomarkers in the Detection and Therapy of Atherosclerotic Disease. Curr Vasc Pharmacol 2017; 14:534-546. [PMID: 27357185 DOI: 10.2174/1570161114666160625080104] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 04/19/2016] [Accepted: 05/17/2016] [Indexed: 11/22/2022]
Abstract
The estimation of risk for atherosclerotic cardiovascular (CV) events based only on the presence of classical risk factors is often insufficient. Therefore, efforts have been made to find markers that indicate the presence of preclinical or clinical disease. Inflammation mediates all stages of the disease, from initiation to the thrombotic complications of atherosclerosis. Raised levels of several circulating markers, particularly inflammatory mediators, have been reported in subjects with atherosclerosis. Increased risk for CV events is associated with increased levels of cytokines, celladhesion molecules, P-selectin and E-selectin, and acute phase reactants, such a highsensitivity C-reactive protein and serum amyloid-A. Elevation of some of these markers predicts the outcomes of patients with acute coronary syndromes. However, because of their non-specificity, these biomarkers represent only a moderate added predicting value after considering conventional CV risk factors. Consequently, recent research has focused on the detection of vulnerable plaque, using vascular bed-specific biomarkers that can help identify individuals at highest risk and help guide how to intervene to prevent CV events. Considerable progress in the understanding of the role of the inflammation in atherogenesis has opened new possibilities for the management of atherosclerosis. Recently new drugs mediating the direct inhibition of circulating markers of inflammation were developed. These drugs could provide a novel therapeutic approach and further enhance the understanding of the role of inflammation in atherosclerosis.
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Affiliation(s)
- Pavel Poredos
- Department of Vascular Disease, University Medical Centre Ljubljana, Zaloska cesta 7, 1000 Ljubljana, Slovenia..
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29
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Affiliation(s)
- Pavel Poredos
- Department of Vascular Disease, University Medical Centre Ljubljana & The Medical Faculty of The University of Ljubljana, Division of Internal Medicine, Ljubljana, Slovenia
| | - Mateja K. Jezovnik
- Center for Advanced Cardiopulmonary Therapies and Transplantation, Health Science Center at Houston, University of Texas, Houston, TX, USA
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30
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Besic H, Jeraj L, Spirkoska A, Jezovnik MK, Poredoš P. Deterioration of endothelial function of micro- and macrocirculation in patients with diabetes type 1 and 2. INT ANGIOL 2016; 36:354-361. [PMID: 28001011 DOI: 10.23736/s0392-9590.16.03798-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Vascular complications are an important cause of morbidity in patients with diabetes mellitus (DM). Endothelial dysfunction is an early marker of atherosclerosis and has already been shown in macrocirculation of diabetic patients; however, data on endothelial function of microcirculation is scarce. Our aim was to evaluate endothelial function in macro- and microcirculation and their interrelationship in patients with type 1 and 2 DM. METHODS The study included 30 patients with type 1 DM, 30 patients with type 2 DM and 25 healthy controls. The endothelial function of large arteries was studied measuring flow-mediated dilation (FMD). Peripheral arterial tonometry was used for investigation of the endothelial function of microcirculation, measuring Reactive Hyperemia Index (RHI) and Augmentation Index (AI). RESULTS In comparison to controls, both DM groups had decreased FMD: type 1 (4.0±5.0% vs. 10.0±7.8%, P=0.005) and type 2 (5.0±0.6% vs. 10.0±7.8%, P=0.007). However, only type 2 DM group had a lower RHI (1.71±0.44 vs. 2.05±0.54, P=0.017) in comparison to controls. CONCLUSIONS Patients with type 1 and 2 DM had deteriorated functional capability of macrocirculation. However, endothelial dysfunction of microcirculation was present only in type 2 DM patients. Type 2 DM patients were also at higher risk for atherosclerosis because of the more frequent presence of risk factors.
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Affiliation(s)
- Hana Besic
- Department of Vascular Disease, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Luka Jeraj
- Department of Vascular Disease, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Ana Spirkoska
- Department of Vascular Disease, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Mateja K Jezovnik
- Department of Vascular Disease, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Pavel Poredoš
- Department of Vascular Disease, University Medical Centre Ljubljana, Ljubljana, Slovenia -
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31
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Jezovnik MK, Jensterle Sever M, Janez A, Pfeifer M, Spirkoska A, Kravos NA, Poredos P. Comparison of different methods investigating functional and morphological markers of early atherogenesis in obese women with polycystic ovary syndrome. INT ANGIOL 2016; 35:446-454. [PMID: 26017763] [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: 06/04/2023]
Abstract
BACKGROUND The prognostic importance of preclinical markers of atherosclerosis and their interrelationship are inconclusive. In this study interrelationship between different methods investigating endothelial function and intima media thickness (IMT) was investigated in patients with polycystic ovary syndrome (PCOS). METHODS Endothelial function was assessed by endothelium-dependent flow-mediated dilation (FMD), nitrate-mediated dilation (NMD), low-flow-mediated constriction (L-FMC) and peripheral arterial tonometry (PAT). Arterial stiffness was determined by pulse wave velocity (PWV) and the Augmentation Index (AI). The IMT of carotid arteries was measured. RESULTS Twenty-eight obese women were recruited with the diagnosis of PCOS, mean age 27±7.2 years and Body Mass Index 38.8±6.3 kg/m2. A relationship between FMD and NMD (r=0.44, P=0.02) was shown. FMD as well as NMD of the brachial artery were not correlated with L-FMC or PAT. The AI and PWV, indicators of arterial stiffness were not interrelated with FMD, and there was no significant interrelationship between IMT and FMD or NMD. The AI was related only to IMT (r=0.45, P=0.30). CONCLUSIONS The relationship between available methods for evaluation of endothelial function/dysfunction is weak in PCOS. This indicates that different methods investigate different mechanisms and various sections of the circulatory system.
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Affiliation(s)
- Mateja K Jezovnik
- Department of Vascular Disease, University Medical Centre Ljubljana, Ljubljana, Slovenia -
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Abstract
Antiplatelet drugs represent one of the basic options for management of patients with different atherosclerotic diseases. Aspirin is the oldest and most often prescribed antiplatelet drug. The efficacy of aspirin depends on the clinical characteristics of the treated population and probably also on the type or location of atherosclerotic disease. It seems that it is most effective in coronary patients with clinically unstable disease, less effective in prevention of cerebrovascular incidents, and its efficacy is uncertain in peripheral artery disease (PAD) patients. One of the first meta-analyses (Antithrombotic Trialists Collaboration - ATC) indicated that antiplatelet drugs also significantly reduce cardiovascular events in patients with PAD. However, only one third of the PAD patients included were treated with aspirin, while the rest received other anti-platelet drugs. The latest ATC meta-analysis of randomized control trials of aspirin therapy involving patients with diabetes and PAD demonstrated no benefit of aspirin in reducing cardiovascular events. Also in patients with preclinical PAD (pathological ankle brachial index) aspirin did not result in a significant reduction of vascular events. The new anti-platelet drugs prasugrel, ticagrelor and picotamide seem to be more effective than aspirin in PAD patients, particularly in diabetic patients with PAD. In conclusion, antiplatelet drugs are effective in prevention of cardiovascular events in different atherosclerotic diseases, including PAD. However, recent studies indicated that in PAD patients aspirin is less effective than in coronary artery disease. New anti-platelet drugs showed marginal superiority over aspirin without definite advantages. Aspirin thus remains the first line of antiplatelet drug for secondary prevention of cardiovascular events in PAD patients and clopidogrel as its effective alternative. Further, new studies on PAD patients are necessary to better define the role of anti-platelet agents in these patients and one of the promising ways of access to anti-platelet treatment would be personalized anti-platelet therapy.
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Affiliation(s)
- Pavel Poredos
- Department of Vascular Disease, University Medical Centre Ljubljana, Slovenia
| | - Mateja K. Jezovnik
- Department of Vascular Disease, University Medical Centre Ljubljana, Slovenia
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Poredos P, Jezovnik MK. Enlargement of the diameter of the peripheral arteries in patients with idiopathic venous thrombosis. Ultraschall Med 2012; 33:E268-E274. [PMID: 21863540 DOI: 10.1055/s-0031-1273471] [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] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
PURPOSE Recent findings indicate that enlargement of the diameter of the peripheral arteries represents a risk of atherosclerotic cardiovascular events. As the data indicate a relationship between atherosclerosis and venous thrombosis (VT), we investigated whether the diameter of the peripheral arteries is larger in patients with idiopathic VT than in healthy subjects. MATERIALS AND METHODS The study included 49 patients with idiopathic VT and 48 age-matched healthy controls. Diameters of the brachial, common carotid and common femoral arteries as well as the intima media thickness (IMT) of the carotid and femoral arteries were measured with the high frequency ultrasound method. RESULTS Patients had significantly higher values for the diameter of the common carotid artery than the controls: 7.9 mm (7.4 - 8.4 mm) vs. 7.4 mm (7.0 - 7.9 mm), p < 0.001, and for the common femoral artery: 10.3 mm (9.2 - 11.1 mm) vs. 9.5 mm (8.9 - 10.4 mm), p = 0.025. Both the carotid and femoral diameters showed significant correlations with gender, age, body mass index and IMT. Linear regression analysis confirmed that the presence of VT significantly and independently influenced the diameter of the carotid and femoral artery but not the brachial artery. CONCLUSION The results of our study showed that carotid and femoral artery diameters are enlarged in patients with idiopathic VT in comparison to healthy subjects. Since enlargement of the investigated arterial diameters is an indicator of atherosclerosis, our findings are consistent with the presumption that there is some interrelationship between VT and arterial atherosclerotic disease.
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Affiliation(s)
- P Poredos
- Department of Vascular Disease, University Medical Centre Ljubljana
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Jezovnik MK, Poredos P. Factors influencing the recanalisation rate of deep venous thrombosis . INT ANGIOL 2012; 31:169-175. [PMID: 22466983] [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: 05/31/2023]
Abstract
AIM After an acute episode of deep venous thrombosis (DVT) resolution of venous thrombi is followed. However, the complete recanalisation occurs only in about a half of the patients. Therefore, the disease is accompanied by different sequellae like post-thrombotic syndrome. Factors that contribute to lysis of thrombi remain poorly understood. Therefore, the aim of our study was to investigate whether levels of the circulating inflammatory markers and other factors like fibrinolytic parameters, sex, and extent of the thrombotic occlusion are related to the recanalisation rate. METHODS The study included 49 patients with idiopathic DVT in the stable phase of the disease (4-6 months after the diagnosis). All patients were evaluated for the presence of risk factors of atherosclerosis. Using Duplex ultrasound patients were examined in acute phase of the disease (before start of treatment), and at the end of the observation period (after 4 to 6 months). Each affected venous segment was classified as completely recanalised, partially obstructed, or completely occluded. Blood was collected for laboratory analysis of the fibrinolytic activity and circulating inflammatory markers. RESULTS Complete recanalisation occurred more frequently in distal (popliteal) than in proximal venous thrombosis (57% vs. 43%, P≤0.01), and the recanalisation rate was lower in patients with more extended thrombosis (increased thrombus load). The recanalisation rate (partial and total) was higher in females than in males: 87% vs. 73%, P=<0.05. Risk factors of atherosclerosis had no influence on the recanalisation rate of the occluded deep veins. Out of the endogenic fibrinolytic markers, t-PA activity only was significantly related to the recanalisation rate. The recanalisation was shown to be related to some circulating cytokines. The multivariate analysis, including inflammatory markers and the recanalisation of deep veins as dependent variables showed that IL-6 and P-selectin were the only statistically significant independent predictors of the recanalisation rate. CONCLUSION The results of our study show that 4 - 6 months after an acute episode of DVT complete recanalisation of the occluded veins occurred in about 50%. The recanalisation rate is related to the extent of venous thrombosis, is lower in proximal occlusions and is higher in females than in males. In patients with increased cytokine levels and decreased t-PA activity recanalisation is less likely.
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Affiliation(s)
- M K Jezovnik
- Department of Vascular Disease, Ljubljana University Medical Centre, Zaloska 7, Ljubljana, Slovenia
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Stalc M, Tomsic M, Jezovnik MK, Poredos P. Endothelium-dependent and independent dilation capability of peripheral arteries in patients with systemic lupus erythematosus and antiphospholipid syndrome. Clin Exp Rheumatol 2011; 29:616-623. [PMID: 21813059] [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] [Received: 12/03/2010] [Accepted: 02/14/2011] [Indexed: 05/31/2023]
Abstract
OBJECTIVES The study evaluated the systemic inflammatory response and endothelium-dependent and independent function of the brachial artery (BA) in systemic lupus erythematosus (SLE) patients with and without antiphospholipid syndrome (APS). METHODS The study group consisted of 42 women with SLE (21 without APS; mean age 36.1 ± 9.1, and 21 with APS; mean age 43.9 ± 13.1) and 22 healthy controls (mean age 43.5 ± 10.3). Endothelium-dependent functional response was evacuate using the flow-mediated vasodilatation (FMD) of brachial artery and endothelium-independent vasodilatation by application of glyceryl trinitrate (GTN). Using biochemical methods, circulating inflammatory markers were determined. RESULTS In comparison to controls, in both groups of patients endothelium-dependent dilation of BA was significantly reduced, and there were no differences in FMD between patients with or without APS: SLE - 7.7% (11.9-12.1), SLE+APS 7.8% (2.4-12.8), controls - 14.6% (11.2-21.1), p<0.001. However, endothelium-independent dilation of the brachial artery was significantly lower in SLE-APS patients than in controls and also lower than in the SLE group: SLE - 24.3% (15.0-28.6), SLE+APS-17.4% (13.1-22.6), controls - 23.0% (17.8-30.1), p=0.015 vs. p=0.027. Patients with SLE had significantly higher values of VCAM-1, hs-CRP, and fibrinogen than controls. In patients with SLE+APS, an additional significant increase of inflammatory markers was registered. CONCLUSIONS The results of our study indicate that patients with SLE have deteriorated endothelium-dependent and those with APS also independent vascular function which could be, together with increased inflammatory response, involved in vascular complications in these patients. The presence of APS aggravates systemic inflammatory response.
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Affiliation(s)
- M Stalc
- Department of Vascular Diseases, University Medical Centre Ljubljana, Slovenia
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Jezovnik MK, Poredos P. Idiopathic venous thrombosis is related to systemic inflammatory response and to increased levels of circulating markers of endothelial dysfunction. INT ANGIOL 2010; 29:226-231. [PMID: 20502419] [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: 05/29/2023]
Abstract
AIM During the past decade, the role of inflammation in the pathophysiology of arterial thrombosis has been elucidated. However, little is known about the relationship between inflammation and venous thrombosis. Recently, inflammation has been accepted as a possible mechanism through which different risk factors trigger thrombus formation in veins. The aim of the present study was to investigate the inflammatory markers and their relationship to idiopathic venous thrombosis. METHODS Fourty-nine patients with first idiopathic venous thrombosis and 48 age matched control subjects were included in the study. Patients were studied 2-4 months after the acute event. Patients and control subjects did not differ in the classical risk factors of atherosclerosis, except in body mass index. In both groups, blood markers of inflammation, namely high sensitive C-reactive protein (hs CRP), interleukins (IL-6, IL-8) and tumour necrosis factor alpha (TNF-a), and circulating markers of endothelial dysfunction/damage namely von Willebrand factor (vWF), P-selectin and the vascular adhesion molecule (VCAM-1) were measured. RESULTS In comparison to healthy subjects patients had significantly higher levels of inflammatory markers: hs CRP: 2.58 mg/L (1.37-6.61), vs. 1.67 mg/L (0.97-3.24) P=0.044, IL-6: 2.37 pg/mL (1.59-4.10), vs. 2.03 pg/mL (1.45-2.59), P=0.025, IL-8: 3.53 pg/mL (2.94-5.3), vs. 2.25 pg/mL (1.77-2.90) P < or = 0.0001. However, concentrations of TNF-a did not differ significantly between the groups. Also in patients higher levels of circulating markers of endothelial dysfunction: vWF 150.0 g/L (121.0-195.0) vs. 91.5 g/L (70.5-104.0), P < or = 0.0001, P-selectin 39.5 pg/L (34.0-40.6) vs. 34.8 pg/L (32.5-38.6) P=0.009. In contrast, levels of VCAM-1 were comparable between the groups. The levels of some inflammatory markers were related to the concentration of von Willebrand factor and P-selectin - IL-6: vWF (r=0.36, P=0.08), hs CRP: P-selectin (r=0.44, P=0.018), IL-6: P-selectin (r=0.51, P=0.0002), IL-8: P-selectin (r=0.38, P=0.043). CONCLUSION Patients with idiopathic venous thrombosis have increased levels of circulating markers of inflammation and blood markers of endothelial dysfunction. Higher levels of both groups of markers indicate that patients in the stable phase of the disease have an increased systemic inflammatory response. The interrelationship between inflammatory markers and markers of endothelial dysfunction favour the hypothesis that inflammation could be involved in the etiopathogenesis of idiopathic venous thrombosis.
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Affiliation(s)
- M K Jezovnik
- Department of Vascular Disease, University Medical Centre Ljubljana, Slovenia
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Poredos P, Jezovnik MK. Antiplatelet and antithrombotic treatment of patients with peripheral arterial disease. INT ANGIOL 2010; 29:20-26. [PMID: 20224527] [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: 05/28/2023]
Abstract
Platelets and coagulation system play a pivotal part in the progression of peripheral arterial disease (PAD) and the genesis of complications. Therefore, antiplatelet and antithrombotic drugs represent one of the basic options for prevention and the treatment in such patients. As the data on the efficacy of these drugs in PAD patients are limited and contradictory, authors prepared an overview of the literature and recommendations for the use of these drugs. Antiplatelet therapy significantly reduces the incidence of death and cardiovascular events and prevents progression of local disease in PAD patients. Aspirin represents the first-line of antiplatelet drugs. Low-dose aspirin (75-325 mg) is as effective as higher doses. However, higher doses of aspirin result in increased risk of gastrointestinal (GI) bleeding and very low-doses (<75 mg) are less effective. Clopidogrel is used in place of low-dose aspirin in patients who have aspirin-related intolerance or allergy. Combined antiplatelet therapy is slightly more effective than aspirin alone only in patients with a history of established vascular disease. Oral anticoagulant therapy alone or in combination with aspirin was in PAD patients not shown to be more effective than aspirin alone in prevention of cardiovascular events, but is probably more effective in prevention of graft occlusion. However the combination is related to an increased risk of bleeding. Moderate intensity of warfarin treatment would be acceptable in the presence of coexisting indications such as atrial fibrillation or recent venous thrombosis.
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Affiliation(s)
- P Poredos
- University Medical Centre, Department for Vascular Diseases, Ljubljana, Slovenia.
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Poredos P, Jezovnik MK. Does the preventive effect of different drugs depend on location of the atherosclerotic process? INT ANGIOL 2008; 27:274-280. [PMID: 18677288] [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: 05/26/2023]
Abstract
Atherosclerosis can affect nearly any part of the arterial system. Therefore, it is considered as a generalized disease. As most probably similar or identical etiopathogenetic mechanisms are involved in different atherosclerotic diseases, a different effect of treatment of risk factors on atherosclerotic lesions in different parts of the vascular system is expected. Until now, great emphasis has been placed on the aggressive pharmacological management of coronary artery disease, less attention has been devoted to the management of cerebrovascular and much less to peripheral arterial disease, despite their significant morbidity and mortality. The data from recent trials have indicated that treatment of patients with antiplatelet drugs, statins, antihypertensive and antidiabetic drugs prevents the progression of coronary atherosclerosis, reduces cardiovascular events and improves prognosis of coronary patients. Subgroup analyses from large studies have also shown that treatment of risk factors for atherosclerosis with drugs reduces cardiovascular events and improves prognosis of cerebrovascular and peripheral arterial occlusive disease. Although some studies indicate that the effects of distinct preventive procedures are to some extent dependent on the locations of atherosclerotic disease, it seems that the success of preventive measures is mostly related to the progression of the disease or the risk of treated population and not on the treated vascular bed.
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Affiliation(s)
- P Poredos
- Department of Vascular Diseases, University Medical Center Ljubljana, Slovenia.
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Poredos P, Jezovnik MK. The role of inflammation in venous thromboembolism and the link between arterial and venous thrombosis. INT ANGIOL 2007; 26:306-311. [PMID: 18091697] [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: 05/25/2023]
Abstract
During the last decade, the role of inflammation in the etiopathogenesis of arterial thrombosis has been elucidated. However, little is known about the relationship between inflammation and venous thrombosis. Recently, inflammation has been accepted as a possible mechanism through which different risk factors trigger thrombus formation in veins. The data indicate that inflammation of the vessel wall initiates thrombus formation in an intact vein and that inflammation and coagulation systems are coupled by a common activation pathway. The first event in thrombus formation is most probably activation of endothelial cells, platelets and leucocytes, with initiation of inflammation and formation of microparticles that trigger the coagulation system through the induction of a tissue factor. Therefore, the key event in the initiation of venous thrombus formation is most probably vein wall inflammation. However, expected relationship between inflammatory markers as indicators of inflammatory process and clinical venous thromboembolism (VTE) has not yet been elucidated. C-reactive protein does not appear to be useful in predicting future venous thrombosis or to be useful in the diagnosis of VTE. Recently, it was demonstrated that probable association between VTE and several other markers of inflammation such as: interleukin (IL)-6, IL-8 and tumor necrosis factor-a exists. While these markers of inflammation were studied during or after acute venous thrombosis, further prospective studies are needed to determine the predictive value of inflammatory markers for VTE. The identification and elucidation of inflammatory markers relevant to venous thrombosis could provide targets for future therapy. That inflammation is the basic etiopathogenetic process of VTE is also supported by the relation of some risk factors to both arterial and venous thrombosis: age, increased body mass index, hypercholesterolemia, hypertension, lupus anticoagulant and hyperhomocysteinemia. A relation was also found between preclinical and clinical atherosclerotic disease and VTE. Also in line with these arguments are the preventive effects of aspirin and statins in both arterial and venous disease.
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Affiliation(s)
- P Poredos
- Department for Vascular Disease, University Medical Centre, Ljubljana, Slovenia.
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