Identified were characteristics of individuals with skin damage related to chronic venous disease... more Identified were characteristics of individuals with skin damage related to chronic venous disease. Patients with chronic venous disease (n = 164) were evaluated with duplex ultrasound imaging and were placed in classes 4, 5, and 6 according to the CEAP classification. Their findings were compared with 100 class 2 controls. The prevalence of deep venous thrombosis was higher in the study group (23.7%) versus controls (5.1%; P < .0001), as was the prevalence of deep, perforator, and combined patterns of disease (P < .0001, P < .0007, and P < .0001). The mean duration of disease in controls 2 was shorter compared with the study group (P = .0019). The prevalence of reflux and obstruction within the study group was higher than in controls (P = .0021). Skin changes accurately reflect severity of chronic venous disease. Superficial and perforator vein reflux is the major cause of disease.
Aortic thrombus complicated by mesenteric ischemia is a rare but rather challenging entity. With ... more Aortic thrombus complicated by mesenteric ischemia is a rare but rather challenging entity. With the recent advancements of endovascular techniques there is a trend to replace the traditional open surgery with an endovascular approach. We report a patient with paravisceral aortic thrombus involving the celiac artery (CA) and superior mesenteric artery (SMA). The patient was complaining of worsening abdominal pain, with clinical findings of leukocytosis, normal lactate, and diagnostic laparoscopy demonstrating a segment of threatened jejunum. We describe the novel use of vacuum-assisted suction filtration device in combination with over-the-wire thrombectomy and stenting in order to successfully restore blood flow within the SMA. The patient had resolution of her symptoms with improved blood flow to the bowel and no need for resection.
Sepsis is characterized by hypotension, acidosis, and increased nitric oxide (NO) production. The... more Sepsis is characterized by hypotension, acidosis, and increased nitric oxide (NO) production. The role of NO in the development of sepsis-related hypotension is still unclear. The relationship among exhaled nitric oxide (ENO), arterial blood pressure (BP), and pH after administration of lipopolysaccharide (LPS) and tumor necrosis factor alpha (TNFalpha) was investigated in anesthetized rats. Forty-three adult male Sprague-Dawley rats were randomized into five groups: group 1 (C, n = 8) received normal saline; group 2 (LPS-I, n = 8) received Escherichia coli (LPS) 10 mg/kg intravenously (i.v.); group 3 (LPS-h, n = 10) received 100 mg/kg LPS i.v.; group 4 (n = 9) was treated with 100 mg/kg i.v. aminoguanidine (AG) 1 h after receiving 100 mg/kg i.v. LPS; group 5 (TNFalpha, n = 8) received 1 microg recombinant rat TNFalpha i.v.. ENO, BP, and pH were measured every 30 min for 4 h whereas arterial blood gases and pH were measured every hour. LPS administration induced a dose-related increase in ENO and a dose-related decrease in BP and pH. AG blocked the increase in ENO after LPS but had minimal effect on BP and pH. TNFalpha administration increased ENO without changing BP and pH. In LPS-treated rats, no significant correlation was found between ENO and BP (r2 = 0.13, P= ns). However, there was a significant correlation between pH and BP (r2 = 0.7, P < 0.01). Our results suggest that, in this animal model, ENO may not be a key mediator in the development of systemic hypotension during sepsis, while acidosis may significantly contribute to it.
Quintessence international (Berlin, Germany : 1985), 2016
Implantable cardiac pacemakers and cardiac defibrillators (ICDs) have been introduced in the care... more Implantable cardiac pacemakers and cardiac defibrillators (ICDs) have been introduced in the care of patients with cardiac dysrhythmias. Most dental practitioners demonstrate extreme caution when treating patients with ICDs. This paper presents a review of the available literature on these devices and how they interact with dental electrosurgery and ultrasonic device use. Based on the analysis of the literature, this view is not corroborated by the current clinical data, and appears to be misguided. While further in-vivo studies are needed to truly determine the true level of risk, the evidence suggests that there is no contraindication for electrosurgery or ultrasonics use in patients with ICDs. Using the precautions stated in this analysis, the risk of any deleterious effect on ICD function is minimal.
Aortic thrombus complicated by mesenteric ischemia is a rare but rather challenging entity. With ... more Aortic thrombus complicated by mesenteric ischemia is a rare but rather challenging entity. With the recent advancements of endovascular techniques there is a trend to replace the traditional open surgery with an endovascular approach. We report a patient with paravisceral aortic thrombus involving the celiac artery (CA) and superior mesenteric artery (SMA). The patient was complaining of worsening abdominal pain, with clinical findings of leukocytosis, normal lactate, and diagnostic laparoscopy demonstrating a segment of threatened jejunum. We describe the novel use of vacuum-assisted suction filtration device in combination with over-the-wire thrombectomy and stenting in order to successfully restore blood flow within the SMA. The patient had resolution of her symptoms with improved blood flow to the bowel and no need for resection.
Phlebology / Venous Forum of the Royal Society of Medicine, Jan 8, 2015
This study was presented at Scientific Session 3 at the 2015 American Venous Forum, Palm Springs,... more This study was presented at Scientific Session 3 at the 2015 American Venous Forum, Palm Springs, California, February 2015Proper assessment of venous thromboembolism (VTE) risk level in hospitalized patients is vital to providing adequate prophylaxis. Clinical decision support (CDS) tools with electronic medical record (EMR) have been used by institutions to improve assessment and prophylaxis. As such, this study was conducted after implementing such a system to compare admitting service (AS) assessment of VTE risk level to the VTE consult service (CS) assessment. In addition, compliance of ordered prophylaxis based on AS assessment was evaluated. At a tertiary care center, we performed a review of randomly selected patients assessed within 18 h of admission for VTE risk over a five-month period. A total of 104 patients were evaluated, four of which were excluded because of VTE presence on admission. Patients were assessed for VTE risk independently, first by the AS, followed by th...
Journal of Vascular Surgery Official Publication the Society For Vascular Surgery and International Society For Cardiovascular Surgery North American Chapter, Jan 5, 2011
To provide follow-up in patients treated with pharmacomechanical thrombolysis (PhMT) for lower ex... more To provide follow-up in patients treated with pharmacomechanical thrombolysis (PhMT) for lower extremity deep venous thrombosis (DVT). Retrospective analysis of prospectively collected data. Patients underwent clinical evaluation, duplex ultrasound, venous clinical severity scoring, venous segmental disease scoring, and venous disability scoring. Fourteen patients were available for evaluation. Median age was 40 years (19-58). Median follow-up was 24 months (13-69 months). Thirteen of 14 patients (93%) had a venous disability score < 1 and 13 of 14 patients (93%) had a venous clinical severity scoring < 5. In all but 1 patient the venous segmental disease scoring score was < 5. All iliac segments were patent, all but 3 patients had partial infrainguinal obstruction and 5 of 14 (36%) had reflux. Our data demonstrate that the good early clinical results after PhMT can be sustained on longer follow-up and may prevent the development of advanced postthrombotic syndrome.
International angiology: a journal of the International Union of Angiology
Evaluate the short and longterm outcomes of percutaneous transluminal angioplasty in patients wit... more Evaluate the short and longterm outcomes of percutaneous transluminal angioplasty in patients with hypertension and renal artery fibromuscular dysplasia (FMD) and identify specific patient factors that may affect outcomes. 29 patients with uncontrolled hypertension and renal artery FMD diagnosed by duplex ultrasound and angiography were prospectively enrolled. All patients underwent percutaneous transluminal angioplasty (PTA) with the goal of cure or improvement of hypertension. Follow-up was at onemonth, 6 months, 12 months and then yearly with minimum follow-up of 2 years and maximum of 5 years. Technical success from the intervention was 100%. 21 patients were included in the final analysis. One month after PTA mean SBP (138.1 mm Hg), DBP (78.6 mm Hg), and number of medications (1.4) were significantly reduced. 14/121 (67%) showed improvement of blood pressure and 7/21 (33%) showed no improvement. These two groups (improved vs. not improved) differed significantly in mean age at ...
Http Dx Doi Org 10 1163 156856200744200, Apr 2, 2012
Both cardiovascular implants and therapeutic interventions on native arteries fail due to biologi... more Both cardiovascular implants and therapeutic interventions on native arteries fail due to biologic responses occurring at the blood/prosthesis/arterial wall and tissue/prosthesis/arterial wall interfaces, resulting in the failure modes of thrombosis and myointimal hyperplasia. Systemic pharmacologic approaches including use of anti-coagulant and anti-platelet agents have significant untoward side effects and have not resulted in a dramatic impact on failure modes in many applications, including small diameter vascular grafts. Local delivery of therapeutic agents via surface attachment with defined release kinetics may alter thrombogenicity and/or myointimal hyperplasia. Therapeutic agents may include a spectrum of biologic agents from peptides to endothelial cells. Efficient attachment and release of these agents in biologically active form is dependent upon improved methods of surface modification. The intended action of the biologic agent may similarly be impacted by the surface and bulk characteristics of the underlying biomaterial. It is often assumed, without concrete data. that surface re-endothelialization may have a beneficial impact on both thrombogenicity and myointimal hyperplasia. New clinical data on endothelial cell seeding has been supportive. Spontaneous re-endothelialization may be stimulated via an induced directed angiogenesis resulting in trans-interstitial capillarization and surface endothelialization. Recent advances in therapeutic angiogenesis have suggested the power of angiogenic factors to induce neovascularization of ischemic tissue beds. These concepts have been used to surface modify prosthetic devices with either VEGF or FGF and both in vitro and animal data suggest a potent stimulation of surface re-endothelialization. Neither of these growth factors is likely to be ideal. VEGF is relatively endothelial cell specific but is a relatively weak endothelial cell mitogen. FGF-1 and FGF-2 are more potent mitogens but are less cell specific. Recent work has led to the generation of mutant growth factors via site-induced mutagenesis and results of several such FGF mutants on endothelial cell and smooth muscle cell proliferative response have been studied. The use of 'designer growth factors' on cardiovascular implants and on manipulated native vessels may have a significant positive impact on re-endothelialization and thereby on the failure modes of thrombosis and myointimal hyperplasia.
ABSTRACT Introduction Venous thromboembolism (VTE) is an omnipresent threat encountered in the da... more ABSTRACT Introduction Venous thromboembolism (VTE) is an omnipresent threat encountered in the daily routine of every surgical unit. Neurosurgical patients are furthermore characterized by two mutually aggravating particularities: integral risk for VTE and ominous outcomes in the case of post-operative intracranial haemorrhage. Hence, it comes as no surprise that no satisfactory level of evidence has yet been reached regarding the efficacy and safety of thromboprophylaxis, nor has an accurate and cost-effective means of screening test been developed for promptly diagnosing VTE. Aims 1) Determine the incidence of VTE, as well as the efficacy and safety of thromboprophylaxis in the neurosurgical patient population. 2) Study the potential of developing an accurate and cost-effective means of screening and promptly diagnosing VTE in the same population. Materials & Methods A comprehensive review of literature from 1975 to date was performed through PubMed, regarding the incidence of VTE in neurosurgical patients; the efficacy and safety of various thromboprophylactic measures; and the potential role of Duplex Ultrasound (DU) as a screening test in this special population. Results Evidence in the literature is conflicting as concerns the incidence of VTE, the safety of thromboprophylaxis and the role of DU as a screening tool in neurosurgery. Conclusions Neurosurgical patients comprise a population with great variability (periods of immobilization; malignant versus non-malignant biological background; duration of surgery; intracranial versus spinal operation), each one yielding a conflicting impact on the incidence of VTE and/or ICH. Moreover, pertinent literature itself is heterogeneous, in terms of objectives and study design, as well as the diagnostic and therapeutic methods according to the integration of scientific innovations into clinical practice. DU is an appealing option as a screening tool for selecting those patients at increased risk for VTE and applying targeted thromboprophylaxis schemes. Nevertheless, most relevant studies have been performed in the Neurosurgical ICU setting, a feature that compromises their power to extrapolate results in the general Neurosurgical population.
Identified were characteristics of individuals with skin damage related to chronic venous disease... more Identified were characteristics of individuals with skin damage related to chronic venous disease. Patients with chronic venous disease (n = 164) were evaluated with duplex ultrasound imaging and were placed in classes 4, 5, and 6 according to the CEAP classification. Their findings were compared with 100 class 2 controls. The prevalence of deep venous thrombosis was higher in the study group (23.7%) versus controls (5.1%; P < .0001), as was the prevalence of deep, perforator, and combined patterns of disease (P < .0001, P < .0007, and P < .0001). The mean duration of disease in controls 2 was shorter compared with the study group (P = .0019). The prevalence of reflux and obstruction within the study group was higher than in controls (P = .0021). Skin changes accurately reflect severity of chronic venous disease. Superficial and perforator vein reflux is the major cause of disease.
Aortic thrombus complicated by mesenteric ischemia is a rare but rather challenging entity. With ... more Aortic thrombus complicated by mesenteric ischemia is a rare but rather challenging entity. With the recent advancements of endovascular techniques there is a trend to replace the traditional open surgery with an endovascular approach. We report a patient with paravisceral aortic thrombus involving the celiac artery (CA) and superior mesenteric artery (SMA). The patient was complaining of worsening abdominal pain, with clinical findings of leukocytosis, normal lactate, and diagnostic laparoscopy demonstrating a segment of threatened jejunum. We describe the novel use of vacuum-assisted suction filtration device in combination with over-the-wire thrombectomy and stenting in order to successfully restore blood flow within the SMA. The patient had resolution of her symptoms with improved blood flow to the bowel and no need for resection.
Sepsis is characterized by hypotension, acidosis, and increased nitric oxide (NO) production. The... more Sepsis is characterized by hypotension, acidosis, and increased nitric oxide (NO) production. The role of NO in the development of sepsis-related hypotension is still unclear. The relationship among exhaled nitric oxide (ENO), arterial blood pressure (BP), and pH after administration of lipopolysaccharide (LPS) and tumor necrosis factor alpha (TNFalpha) was investigated in anesthetized rats. Forty-three adult male Sprague-Dawley rats were randomized into five groups: group 1 (C, n = 8) received normal saline; group 2 (LPS-I, n = 8) received Escherichia coli (LPS) 10 mg/kg intravenously (i.v.); group 3 (LPS-h, n = 10) received 100 mg/kg LPS i.v.; group 4 (n = 9) was treated with 100 mg/kg i.v. aminoguanidine (AG) 1 h after receiving 100 mg/kg i.v. LPS; group 5 (TNFalpha, n = 8) received 1 microg recombinant rat TNFalpha i.v.. ENO, BP, and pH were measured every 30 min for 4 h whereas arterial blood gases and pH were measured every hour. LPS administration induced a dose-related increase in ENO and a dose-related decrease in BP and pH. AG blocked the increase in ENO after LPS but had minimal effect on BP and pH. TNFalpha administration increased ENO without changing BP and pH. In LPS-treated rats, no significant correlation was found between ENO and BP (r2 = 0.13, P= ns). However, there was a significant correlation between pH and BP (r2 = 0.7, P < 0.01). Our results suggest that, in this animal model, ENO may not be a key mediator in the development of systemic hypotension during sepsis, while acidosis may significantly contribute to it.
Quintessence international (Berlin, Germany : 1985), 2016
Implantable cardiac pacemakers and cardiac defibrillators (ICDs) have been introduced in the care... more Implantable cardiac pacemakers and cardiac defibrillators (ICDs) have been introduced in the care of patients with cardiac dysrhythmias. Most dental practitioners demonstrate extreme caution when treating patients with ICDs. This paper presents a review of the available literature on these devices and how they interact with dental electrosurgery and ultrasonic device use. Based on the analysis of the literature, this view is not corroborated by the current clinical data, and appears to be misguided. While further in-vivo studies are needed to truly determine the true level of risk, the evidence suggests that there is no contraindication for electrosurgery or ultrasonics use in patients with ICDs. Using the precautions stated in this analysis, the risk of any deleterious effect on ICD function is minimal.
Aortic thrombus complicated by mesenteric ischemia is a rare but rather challenging entity. With ... more Aortic thrombus complicated by mesenteric ischemia is a rare but rather challenging entity. With the recent advancements of endovascular techniques there is a trend to replace the traditional open surgery with an endovascular approach. We report a patient with paravisceral aortic thrombus involving the celiac artery (CA) and superior mesenteric artery (SMA). The patient was complaining of worsening abdominal pain, with clinical findings of leukocytosis, normal lactate, and diagnostic laparoscopy demonstrating a segment of threatened jejunum. We describe the novel use of vacuum-assisted suction filtration device in combination with over-the-wire thrombectomy and stenting in order to successfully restore blood flow within the SMA. The patient had resolution of her symptoms with improved blood flow to the bowel and no need for resection.
Phlebology / Venous Forum of the Royal Society of Medicine, Jan 8, 2015
This study was presented at Scientific Session 3 at the 2015 American Venous Forum, Palm Springs,... more This study was presented at Scientific Session 3 at the 2015 American Venous Forum, Palm Springs, California, February 2015Proper assessment of venous thromboembolism (VTE) risk level in hospitalized patients is vital to providing adequate prophylaxis. Clinical decision support (CDS) tools with electronic medical record (EMR) have been used by institutions to improve assessment and prophylaxis. As such, this study was conducted after implementing such a system to compare admitting service (AS) assessment of VTE risk level to the VTE consult service (CS) assessment. In addition, compliance of ordered prophylaxis based on AS assessment was evaluated. At a tertiary care center, we performed a review of randomly selected patients assessed within 18 h of admission for VTE risk over a five-month period. A total of 104 patients were evaluated, four of which were excluded because of VTE presence on admission. Patients were assessed for VTE risk independently, first by the AS, followed by th...
Journal of Vascular Surgery Official Publication the Society For Vascular Surgery and International Society For Cardiovascular Surgery North American Chapter, Jan 5, 2011
To provide follow-up in patients treated with pharmacomechanical thrombolysis (PhMT) for lower ex... more To provide follow-up in patients treated with pharmacomechanical thrombolysis (PhMT) for lower extremity deep venous thrombosis (DVT). Retrospective analysis of prospectively collected data. Patients underwent clinical evaluation, duplex ultrasound, venous clinical severity scoring, venous segmental disease scoring, and venous disability scoring. Fourteen patients were available for evaluation. Median age was 40 years (19-58). Median follow-up was 24 months (13-69 months). Thirteen of 14 patients (93%) had a venous disability score < 1 and 13 of 14 patients (93%) had a venous clinical severity scoring < 5. In all but 1 patient the venous segmental disease scoring score was < 5. All iliac segments were patent, all but 3 patients had partial infrainguinal obstruction and 5 of 14 (36%) had reflux. Our data demonstrate that the good early clinical results after PhMT can be sustained on longer follow-up and may prevent the development of advanced postthrombotic syndrome.
International angiology: a journal of the International Union of Angiology
Evaluate the short and longterm outcomes of percutaneous transluminal angioplasty in patients wit... more Evaluate the short and longterm outcomes of percutaneous transluminal angioplasty in patients with hypertension and renal artery fibromuscular dysplasia (FMD) and identify specific patient factors that may affect outcomes. 29 patients with uncontrolled hypertension and renal artery FMD diagnosed by duplex ultrasound and angiography were prospectively enrolled. All patients underwent percutaneous transluminal angioplasty (PTA) with the goal of cure or improvement of hypertension. Follow-up was at onemonth, 6 months, 12 months and then yearly with minimum follow-up of 2 years and maximum of 5 years. Technical success from the intervention was 100%. 21 patients were included in the final analysis. One month after PTA mean SBP (138.1 mm Hg), DBP (78.6 mm Hg), and number of medications (1.4) were significantly reduced. 14/121 (67%) showed improvement of blood pressure and 7/21 (33%) showed no improvement. These two groups (improved vs. not improved) differed significantly in mean age at ...
Http Dx Doi Org 10 1163 156856200744200, Apr 2, 2012
Both cardiovascular implants and therapeutic interventions on native arteries fail due to biologi... more Both cardiovascular implants and therapeutic interventions on native arteries fail due to biologic responses occurring at the blood/prosthesis/arterial wall and tissue/prosthesis/arterial wall interfaces, resulting in the failure modes of thrombosis and myointimal hyperplasia. Systemic pharmacologic approaches including use of anti-coagulant and anti-platelet agents have significant untoward side effects and have not resulted in a dramatic impact on failure modes in many applications, including small diameter vascular grafts. Local delivery of therapeutic agents via surface attachment with defined release kinetics may alter thrombogenicity and/or myointimal hyperplasia. Therapeutic agents may include a spectrum of biologic agents from peptides to endothelial cells. Efficient attachment and release of these agents in biologically active form is dependent upon improved methods of surface modification. The intended action of the biologic agent may similarly be impacted by the surface and bulk characteristics of the underlying biomaterial. It is often assumed, without concrete data. that surface re-endothelialization may have a beneficial impact on both thrombogenicity and myointimal hyperplasia. New clinical data on endothelial cell seeding has been supportive. Spontaneous re-endothelialization may be stimulated via an induced directed angiogenesis resulting in trans-interstitial capillarization and surface endothelialization. Recent advances in therapeutic angiogenesis have suggested the power of angiogenic factors to induce neovascularization of ischemic tissue beds. These concepts have been used to surface modify prosthetic devices with either VEGF or FGF and both in vitro and animal data suggest a potent stimulation of surface re-endothelialization. Neither of these growth factors is likely to be ideal. VEGF is relatively endothelial cell specific but is a relatively weak endothelial cell mitogen. FGF-1 and FGF-2 are more potent mitogens but are less cell specific. Recent work has led to the generation of mutant growth factors via site-induced mutagenesis and results of several such FGF mutants on endothelial cell and smooth muscle cell proliferative response have been studied. The use of 'designer growth factors' on cardiovascular implants and on manipulated native vessels may have a significant positive impact on re-endothelialization and thereby on the failure modes of thrombosis and myointimal hyperplasia.
ABSTRACT Introduction Venous thromboembolism (VTE) is an omnipresent threat encountered in the da... more ABSTRACT Introduction Venous thromboembolism (VTE) is an omnipresent threat encountered in the daily routine of every surgical unit. Neurosurgical patients are furthermore characterized by two mutually aggravating particularities: integral risk for VTE and ominous outcomes in the case of post-operative intracranial haemorrhage. Hence, it comes as no surprise that no satisfactory level of evidence has yet been reached regarding the efficacy and safety of thromboprophylaxis, nor has an accurate and cost-effective means of screening test been developed for promptly diagnosing VTE. Aims 1) Determine the incidence of VTE, as well as the efficacy and safety of thromboprophylaxis in the neurosurgical patient population. 2) Study the potential of developing an accurate and cost-effective means of screening and promptly diagnosing VTE in the same population. Materials & Methods A comprehensive review of literature from 1975 to date was performed through PubMed, regarding the incidence of VTE in neurosurgical patients; the efficacy and safety of various thromboprophylactic measures; and the potential role of Duplex Ultrasound (DU) as a screening test in this special population. Results Evidence in the literature is conflicting as concerns the incidence of VTE, the safety of thromboprophylaxis and the role of DU as a screening tool in neurosurgery. Conclusions Neurosurgical patients comprise a population with great variability (periods of immobilization; malignant versus non-malignant biological background; duration of surgery; intracranial versus spinal operation), each one yielding a conflicting impact on the incidence of VTE and/or ICH. Moreover, pertinent literature itself is heterogeneous, in terms of objectives and study design, as well as the diagnostic and therapeutic methods according to the integration of scientific innovations into clinical practice. DU is an appealing option as a screening tool for selecting those patients at increased risk for VTE and applying targeted thromboprophylaxis schemes. Nevertheless, most relevant studies have been performed in the Neurosurgical ICU setting, a feature that compromises their power to extrapolate results in the general Neurosurgical population.
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Papers by Apostolos Tassiopoulos