Coronary Artery Disease: Liapis CD

Liapis CD, Bell PR, Mikhailidis D, Sivenius J, Nicolaides A, Fernandes e Fernandes J, Biasi G, Norgren L, Anonymous00081. · Department of Vascular Surgery, Athens University Medical School, Attikon University Hospital, Athens, Greece. · Eur J Vasc Endovasc Surg. · Pubmed #19286127 No free full text.

Abstract: The European Society for Vascular Surgery brought together a group of experts in the field of carotid artery disease to produce updated guidelines for the invasive treatment of carotid disease. The recommendations were rated according to the level of evidence. Carotid endarterectomy (CEA) is recommended in symptomatic patients with >50% stenosis if the perioperative stroke/death rate is <6% [A], preferably within 2 weeks of the patient's last symptoms [A]. CEA is also recommended in asymptomatic men <75 years old with 70-99% stenosis if the perioperative stroke/death risk is <3% [A]. The benefit from CEA in asymptomatic women is significantly less than in men [A]. CEA should therefore be considered only in younger, fit women [A]. Carotid patch angioplasty is preferable to primary closure [A]. Aspirin at a dose of 75-325 mg daily and statins should be given before, during and following CEA. [A] Carotid artery stenting (CAS) should be performed only in high-risk for CEA patients, in high-volume centres with documented low peri-operative stroke and death rates or inside a randomized controlled trial [C]. CAS should be performed under dual antiplatelet treatment with aspirin and clopidogrel [A]. Carotid protection devices are probably of benefit [C].

Kadoglou NP, Iliadis F, Liapis CD. · Department of Vascular Surgery, Medical School, University of Athens, Greece. · Eur J Vasc Endovasc Surg. · Pubmed #17988901 No free full text.

Abstract: OBJECTIVES: Both carotid atherosclerosis or increased carotid intima-media thickness (IMT) are common manifestations of generalized atherosclerosis, closely associated with increased risk of stroke and myocardial infarction. Despite the predominant involvement of physical activity in cardiovascular prevention and rehabilitation strategies, its role in carotid atherosclerosis progression is less evaluated. The aim of our study was to review the literature for the contribution of increased physical activity or structured exercise to the prevention and treatment of carotid atherosclerosis. MATERIALS/METHODS: A systematic review was performed of all cross-sectional, interventional, prospective or retrospective, clinical studies. Using the following terms: carotid atherosclerosis, intima-media thickness, physical activity, exercise, life-style, stroke, cardiovascular risk factors, we searched MEDLINE and EMBASE databases from 1985 to 2007. Carotids ultrasonography and relevant quantitative indexes were prerequisites for our search. RESULTS: The majority of cross-sectional studies have demonstrated that physical inactivity is associated with increased carotid IMT, while structured lifestyle interventions have conferred inconsistent results on the progression of carotid thickening. The increment of cardiorespiratory fitness and the modification of numerous cardiovascular risk factors, such as hyperglycemia, insulin resistance, hyperlipidemia, hypertension and obesity provide plausible mechanisms by which exercise training may suppress the evolution of carotid atherosclerosis. CONCLUSIONS: It remains questionable whether long-term exercise can decelerate the development of carotid atherosclerosis. Perhaps increased physical activity suppresses the overall cardiovascular risk and hence curtails the progression of carotid atherosclerosis. If carotid artery disease is regarded as a coronary artery disease equivalent, it is reasonable to recommend similar patterns of physical activity in patients with subclinical or manifest carotid atherosclerosis as for those with coronary atherosclerosis.

Daskalopoulou SS, Daskalopoulos ME, Perrea D, Nicolaides AN, Liapis CD. · Department of Medicine, Division of Clinical Epidemiology, McGill University, Montreal, QC, Canada. · Curr Pharm Des. · Pubmed #17430176 No free full text.

Abstract: Carotid artery disease is a well-established cause of cerebrovascular events. This risk is predicted by the severity of stenosis and other plaque characteristics that can be documented using imaging techniques. Among these techniques, ultrasound is the most widely available. Increased carotid intima-media thickness (IMT) measured ultrasonically is associated with a higher risk for cerebrovascular as well as coronary heart disease. Furthermore, it is increasingly recognized that echolucent and heterogeneous carotid plaques in patients with high-grade carotid stenosis are associated with a greater risk for cerebrovascular events. Several local and systemic factors can influence plaque stability. Identifying the high-risk carotid plaque could improve selection for vascular intervention (surgery/angioplasty) and increase cost-effectiveness. Aggressive medical treatment should always be provided for these high-risk patients. For example, lipid-lowering, anthihypertensive and antiplatelet drugs decrease the carotid IMT, stabilize carotid plaques or reduce the risk of cerebrovascular and systemic events. Continuously evolving technology will lead to more accurate identification of high-risk carotid plaques. A combination of comprehensive non- or minimally-invasive imaging techniques together with measuring clinical and systemic biochemical markers of risk may facilitate the identification of the vulnerable plaque in the vulnerable patient, and help select the best treatment options.

Kadoglou NP, Daskalopoulou SS, Perrea D, Liapis CD. · Department of Vascular Surgery, Athens University Medical School, Athens, Greece. · Angiology. · Pubmed #15793607 No free full text.

Abstract: Diabetes mellitus (DM) is associated with an increased incidence of cardiovascular events and microvascular complications. These complications contribute to the morbidity and mortality associated with DM. There is increasing evidence supporting a role for matrix metalloproteinases (MMPs) and their inhibitors (tissue inhibitors of matrix metalloproteinases - TIMPs) in the atherosclerotic process. However, the relationship between MMPs/TIMPs and diabetic angiopathy is less well defined. Hyperglycemia directly or indirectly (eg, via oxidative stress or advanced glycation products) increases MMP expression and activity. These changes are associated with histologic alterations in large vessels. On the other hand, low proteolytic activity of MMPs contributes to diabetic nephropathy. Within atherosclerotic plaques an imbalance between MMPs and TIMPs may induce matrix degradation, resulting in an increased risk of plaque rupture. Furthermore, because MMPs enhance blood coagulability, MMPs and TIMPs may play a role in acute thrombotic occlusion of vessels and consequent cardiovascular events. Some drugs can inhibit MMP activity. However, the precise mechanisms involved are still not defined. Further research is required to demonstrate the causative relationship between MMPs/TIMPs and diabetic atherosclerosis. It also remains to be established if the long-term administration of MMP inhibitors can prevent acute cardiovascular events.

Liapis CD, Kakisis JD, Kostakis AG. · Second Department of Propedeutic Surgery, Athens University Medical School, Laiko Hospital, Athens, Greece. · Stroke. · Pubmed #11739973 links to  free full text

Abstract: BACKGROUND AND PURPOSE: The ability to predict future strokes in asymptomatic patients with carotid stenosis is currently limited. The management of symptomatic patients with <50% stenosis is also debatable. In this context, we performed the following open prospective study to identify factors affecting symptomatology in patients with carotid stenosis. METHODS: During 1988-1997, 442 arteries with various degrees of stenosis were followed with the use of color Duplex ultrasonography every 6 months. The main outcome measures were development of symptoms related to the carotid territory and progression in the degree of stenosis. Results of follow-up were analyzed in relation to the traditional risk factors for atherosclerosis as well as the ultrasonographic characteristics of the plaques. Statistical analysis was performed by multiple linear and Cox regression analysis. RESULTS: Mean duration of follow-up was 44 months (range, 12 to 120 months). Significant progression of stenosis occurred in 18.5% of the cases and was more frequent in younger patients (P=0.09), in patients with coronary artery disease (P=0.02), and in patients with echolucent plaques (P=0.02). In regard to clinical presentation, men (P=0.07), hypertensives (P=0.07), and patients with echolucent plaques (P=0.09) showed a trend toward higher frequency of stroke in their history. During the follow-up period, neurological events developed in 12.4% of the cases and were associated with the severity of carotid disease (P<0.001), history of neurological events (P=0.02), progression of stenosis (P=0.002), echolucent plaques (P=0.01), and hypertension (P=0.02). CONCLUSIONS: Factors other than degree of stenosis and history of neurological events are also important in determining high-risk carotid plaque. In our study hypertension, echolucent plaques, and progressive lesions were associated with an increased risk of neurological events. These factors should be taken into consideration in determining treatment strategies for carotid stenosis.

Paraskevas KI, Mikhailidis DP, Liapis CD. · Department of Clinical Biochemistry and Academic Department of Surgery, Royal Free Hospital, London, United Kingdom. · Angiology. · Pubmed #17626988 No free full text.

Abstract: The aim of this article is to investigate the association between internal carotid artery occlusion (ICAO) and the presence of atherosclerotic disease and vascular risk factors. The clinical characteristics and risk factors of 120 patients presenting with ICAO were retrospectively reviewed. All patients (n = 120) had at least 1 of the 4 vascular risk factor (diabetes, smoking, hypercholesterolemia, and hypertension); 2, 3, or all 4 risk factors were present in 14 to 82 of the patients (11.7% to 68.3%), 10 to 39 of the patients (8.3% to 32.5%), and 9 of the patients (7.5%), respectively. A total of 84 patients (70%) with ICAO had disease in at least 1 additional vascular bed (aorta, coronary or lower limb arteries). In addition to ICAO, vascular disease was present in 2 and all 3 of these arterial beds in 42 (35%) and 9 (7.5%) patients, respectively. Furthermore, stenosis or occlusion of the ipsilateral or contralateral vertebral arteries was recorded in 19 of 120 patients (15.8%). Regarding the contralateral carotid artery, 1 patient had bilateral ICAO. One patient had contralateral common carotid artery occlusion, and 1 patient was excluded from the analysis because of surgery to the contralateral carotid artery. Of the remaining 117 patients, 34 (29.0%) had less than 50% contralateral carotid artery stenosis. Thirty-two patients (27.4%) had 50% to 69%, and 51 (43.6%) had 70% to 99% stenosis. Ultrasonographic imaging of the carotid plaque of the contralateral carotid artery revealed that 52 of the 120 arteries (43.3%) were uniformly or predominantly echolucent (types I and II, respectively). Fifty-nine (49.2%) were predominantly or uniformly echogenic (types III and IV), and 9 (7.5%) could not be classified. A similar distribution of echomorphology was observed on the occluded side. ICAO is associated with widespread atherosclerotic disease and a high prevalence of vascular risk factors. Detection of ICAO should prompt the investigation of other arterial beds and treatment of risk factors.

Liapis CD, Kakisis JD, Dimitroulis DA, Daskalopoulos M, Nikolaou A, Kostakis AG. · 2nd Department of Propedeutic Surgery, Athens University Medical School, Laiko Hospital, 131 Vas Sofias Avenue, 11521 Athens, Greece. · J Vasc Surg. · Pubmed #14681618 No free full text.

Abstract: PURPOSE: Several factors have been related to long-term survival after open abdominal aortic aneurysm (AAA) repair. The effect of carotid stenosis on outcome has not yet been examined. We performed an open prospective study to evaluate the prognostic significance of carotid stenosis on long-term survival of patients who had undergone elective operative repair of AAA. METHODS: Two hundred eight patients who underwent elective open AAA repair in our department between March 1987 and December 2001 were included in the study. All patients were evaluated preoperatively with color duplex ultrasound (US) scanning of the carotid arteries, and were followed up with clinical examination and carotid duplex US scanning 1 month after the operation and every 6 months thereafter. Median duration of follow-up was 50 months (range, 5-181 months). Cardiovascular morbidity and mortality, as well as all causes of mortality, were recorded and analyzed with regard to traditional risk factors and carotid US findings. RESULTS: Twenty-seven fatal and 46 nonfatal cardiovascular events were recorded. Both univariate and multivariate analysis showed that carotid stenosis 50% or greater and echolucent plaque were significantly associated with cardiovascular mortality and morbidity. Carotid stenosis was a stronger predictor of cardiovascular death than was ankle/brachial index. Age, hypercholesterolemia, coronary artery disease, and diabetes mellitus were also associated with higher mortality and morbidity from cardiovascular causes. CONCLUSION: Patients electively operated on for AAA repair and with stenosis 50% or greater and echolucent plaque at duplex US scanning are at significantly increased risk for cardiovascular mortality and morbidity. Carotid US can therefore be used to select a subgroup of patients with AAA who might benefit from medical intervention, including antiplatelet and lipid-lowering agents.

Liapis CD, Kakisis JD, Dimitroulis DA, Kostakis AG. · 2nd Department of Propedeutic Surgery, Athens University Medical School, Laiko Hospital, Athens, Greece. · Eur J Vasc Endovasc Surg. · Pubmed #12217286 No free full text.

Abstract: OBJECTIVES: to evaluate the impact of the carotid plaque type on recurrent carotid stenosis, future cardiovascular events and patients' survival. DESIGN: open prospective study. PATIENTS AND METHODS: three hundred and eight patients who underwent a total of 338 carotid endarterectomies were included in the study. All of the patients were evaluated postoperatively with clinical examination and colour duplex 1 month after the operation and every 6 months thereafter. Mean duration of follow-up was 63 months (range: 12-144). Eight patients (3%) were lost to follow-up. Restenoses, cardiovascular events and deaths were recorded and analysed with regard to the traditional risk factors and the ultrasonographic characteristics of the plaques. Statistical analysis was performed using the Kaplan-Meier method, the log rank test and Cox regression analysis. RESULTS: cumulative restenosis rate at 10 years of follow-up was 21% and was associated with coronary artery disease (p=0.01) and echolucent plaques (p=0.02). Life-table analysis showed a 10-year survival rate of 64% and a 10-year rate of cardiovascular events of 41%. Hypertension (p=0.003), coronary artery disease (p=0.002) and echolucent plaques (p=0.01) were associated with a higher incidence of cardiovascular events.

Liapis CD, Kakisis JD, Kostakis AG. · 2nd Department of Propedeutic Surgery, Athens University Medical School, Laiko Hospital, Athens, Greece. · Int Angiol. · Pubmed #11782700 No free full text.

Abstract: BACKGROUND: The aim of this study was to evaluate the impact of various risk factors, excluding the type of closure of the arteriotomy, on the development of recurrent carotid stenosis after carotid endarterectomy. Type of study: single-center, open prospective. METHODS: Three hundred and eight patients, who underwent a total of 338 carotid endarterectomies, were evaluated postoperatively with color duplex 1 month after the operation and every 6 months thereafter, the mean duration of follow-up being 52 months (range: 6-144). Only patients submitted to primary closure of the arteriotomy were included. Statistical analysis was performed using the Kaplan Meier method, the log rank test and Cox regression analysis. RESULTS: Three patients (0.9%) died during the perioperative period. Three (0.9%) patients had a transient ischemic attack and 7 (2.1%) a nonfatal stroke. Recurrent carotid stenosis of >50% was identified in 11 patients, leading to a 21.6% cumulative restenosis rate at 10 years of follow-up. Only one of the 11 patients with restenosis developed neurological symptoms during the follow-up period. Both univariate and multivariate analyses showed that coronary artery disease was significantly associated with restenosis, while patients with uniformly echogenic plaques as well as those with hypercholesterolemia showed a lower incidence of restenosis. CONCLUSIONS: The cumulative recurrent stenosis rate following carotid endarterectomy was 21.6% at 10 years of follow-up. Restenosis was symptomatic in 1 patient. Coronary artery disease was associated with an increased risk of restenosis, while uniformly echogenic plaques and hypercholesterolemia were associated with a lower risk.