Kosmas I Paraskevas

Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, England, United Kingdom

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Publications (199)748.26 Total impact

  • Kosmas I Paraskevas, Frank J Veith
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    ABSTRACT: According to the 2011, as well as the 2014 updated American Heart Association/American Stroke Association Guidelines, carotid artery stenting (CAS) is indicated as an alternative to carotid endarterectomy (CEA) for the management of symptomatic carotid patients. According to these recommendations, CAS is preferred over CEA in symptomatic patients with specific technical, anatomic or physiologic characteristics that render these individuals at "high risk" for surgery (e.g. contralateral carotid occlusion, previous neck irradiation, recurrent carotid stenosis, etc.). This article will present emerging data suggesting that most of these criteria do not comprise contraindications for CEA. In fact, CEA is associated with similar (or even better) outcomes compared with CAS in many such "high-risk" patients. Based on these results, the indications of CAS in symptomatic patients may need to be reconsidered.
    Annals of Vascular Surgery 10/2014; · 0.99 Impact Factor
  • Edward M Mulkern, Kosmas I Paraskevas, Philip Chan
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    ABSTRACT: Experimental models of recovery from limb ischemia are required for evaluating novel means of treating ischemia. We describe a mouse model to assess gait after inducing limb ischemia. Gait analysis was performed using a Plexiglass tube, the floor of which contained load cells. Gait was measured in 20 mice; 10 underwent ligation of the right hind limb artery and the other 10 underwent a sham operation. The gait of the animals was measured at 1, 2, and 4 weeks following the procedure. In sham-operated animals, the gait showed no measurable change. In the ligated animals, the ratio of the right fore-to-hind limb changed from 1.07 at baseline to 1.4 at day 0 (P = .001), 1.16 (P = .012 compared with control), and 1.04 (P = .37 compared with control) at weeks 2 and 4, respectively. Gait returned to normal within 4 weeks of induction of ischemia. This model may be helpful in testing potential novel therapies.
    Angiology 09/2014; · 2.37 Impact Factor
  • Kosmas I Paraskevas, Frank J Veith
    Journal of vascular surgery. 09/2014; 60(3):837.
  • Kosmas I Paraskevas, Frank J Veith
    Angiology 08/2014; · 2.37 Impact Factor
  • Kosmas I Paraskevas, Jonathan D Beard, Frank J Veith
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    ABSTRACT: With increasing carotid artery stenting (CAS) expertise and improved CAS equipment, recent trials have demonstrated better results for CAS compared with earlier studies. As a result, it may be argued that CAS is currently non-inferior to carotid endarterectomy (CEA), at least in some patient subgroups. Consequently, there have been recent calls for extending CAS indications to include average surgical risk patients with symptomatic or asymptomatic carotid stenosis. However, CAS remains a less cost-effective option than CEA. Opening the floodgates to unrestricted CAS for both symptomatic and asymptomatic carotid patients would have considerable cost implications for any health system. Appropriate patient selection and keeping to the indications are crucial to optimize CAS outcomes.
    Expert Review of Cardiovascular Therapy 07/2014; 12(7):783-6.
  • Source
    European journal of vascular and endovascular surgery: the official journal of the European Society for Vascular Surgery 04/2014; · 2.92 Impact Factor
  • Kosmas I Paraskevas, Wesley S Moore, Frank J Veith
    Journal of Endovascular Therapy 04/2014; 21(2):303-5. · 2.70 Impact Factor
  • International journal of cardiology 03/2014; · 6.18 Impact Factor
  • Kosmas I Paraskevas, Anne L Abbott, Frank J Veith
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    ABSTRACT: The optimal management of patients with symptomatic and asymptomatic carotid artery stenosis remains a subject of extensive debate. Several international societies and associations have published guidelines for the management of carotid patients. Although these recommendations are based on the same randomized trials, differences in interpretation of available knowledge have often led to different (or even conflicting) recommendations. This special report summarizes the current evidence-based optimal management of patients with symptomatic and asymptomatic carotid stenosis and compares key international guidelines. Finally, issues requiring further research are identified and discussed.
    Expert Review of Cardiovascular Therapy 03/2014;
  • Kosmas I Paraskevas, Frank J Veith
    JAMA The Journal of the American Medical Association 02/2014; 311(5):526-7. · 29.98 Impact Factor
  • The American journal of cardiology 02/2014; 113(3):570-1. · 3.58 Impact Factor
  • Source
    European Journal of Vascular and Endovascular Surgery. 01/2014;
  • Kosmas I Paraskevas, Dimitri P Mikhailidis, Frank J Veith
    BioMed Research International 01/2014; 2014:930738. · 2.71 Impact Factor
  • K I Paraskevas, D P Mikhailidis, A D Giannoukas
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    ABSTRACT: Dear Editor, Luo et al. (2014) reported that the combination of atorvastatin plus ezetimibe de-creased carotid intima media thickness (cIMT) significantly more than atorvastatin mono-therapy. We would like to add a few comments. The ENHANCE trial (Kastelein et al., 2008) did not compare the effect of atorvastatin plus ezetimibe versus atorvastatin monotherapy on cIMT, as mentioned by Luo et al. (2014). The statin used was simvastatin. As Luo et al. (2014) state, the cIMT in ENHANCE was set too low and could not be reduced further. There are other deficiencies in the ENHANCE trial; these are discussed by us in Paraskevas et al. (2011). Briefly, the latter article also comments on other trials that show that ezetimibe, used together with a statin, decreases cIMT. Furthermore, this article also considers evidence that atorvas-tatin 80 mg/day did not reduce the cIMT when compared with placebo (CASHMERE study), probably because the cIMT was too low (virtually identical to that in ENHANCE). How-ever, ENHANCE produced useful information. The C-reactive protein (CRP) level dropped significantly more in the simvastatin plus ezetimibe group compared with the simvastatin monotherapy group (Kastelein et al., 2008). The same pattern was reported by Luo et al. (2014), in which the fall in high sensitivity CRP (hsCRP) level was significantly greater in the atorvastatin plus ezetimibe group compared with the atorvastatin monotherapy group. Indeed as Luo et al. (2014) state, doubling the dose of a statin only results in about 6% further fall in low density lipoprotein cholesterol (LDL-C) levels. A meta-analysis by our group showed that adding ezetimibe to a statin results in an average 23.6% fall in LDL-C levels compared with statin monotherapy (Mikhailidis et al., 2007). This meta-analysis also showed that the addition of ezetimibe to a statin increased the fall in CRP levels. Another meta-analysis showed that adding ezetimibe to a statin is more effective than doubling the dose of the statin (Mikhailidis et al., 2011). Ezetimibe has several potentially useful actions other than altering the lipid pro-file (Lioudaki et al., 2011). However, it is difficult to assess the contribution of these effects on vascular risk. Other researchers, as well as our group, have observed that high triglyceride levels fall to a greater extent than low levels when ezetimibe is added to a statin (Gazi et al., 2007; Fras and Mikhailidis, 2008; Migdalis et al., 2009; Shigematsu et al., 2012). Therefore, it would be useful to know if the fall in triglyceride levels was greater in the atorvastatin plus ezetimibe group compared with the atorvastatin monotherapy group if only triglyceride levels ≥1.7 or ≥2.0 mM are considered in the Luo et al. (2014) study. Also, it would be interesting to know if Luo et al. (2014) performed kidney function tests, since there is some evidence that adding ezetimibe to a statin will improve that variable (Gazi et al., 2007; Migdalis et al., 2009). The debate about the evidence supporting the use of ezetimibe to reduce the risk of vascular events continues (Gouni-Berthold et al., 2012). However, the findings of Luo et al. (2014) further support the conclusion that the cIMT results of the ENHANCE trial should not be included in this debate. Secondly, it is relevant that several guidelines mention that the use of ezetimibe is appropriate if LDL-C targets are not reached by statin monotherapy (Catapano et al., 2011; Perk et al., 2012; Teramoto et al., 2013; Anderson et al., 2013; Wanner and Tonelli, 2014; IAS Position Paper, 2014). The recent dyslipidemia guidelines issued by the American College of Cardiology/American Heart Association (Stone et al., 2013) focus on statins and only briefly mentions other lipid lowering options (Mikhailidis et al., 2014).
    Genetics and molecular research: GMR 01/2014; 13(3):4805-7. · 0.99 Impact Factor
  • Anne L Abbott, Kosmas I Paraskevas, J David Spence
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    ABSTRACT: To the Editor: We are less certain than Grotta (Sept. 19 issue)(1) that the female patient with recently symptomatic internal-carotid-artery stenosis described in the case vignette of his Clinical Practice article should be treated with carotid endarterectomy or stenting. On the basis of a published risk-prediction model(2) (available at www.stroke.ox.ac.uk), her 5-year risk of recurrent ipsilateral stroke could be as high as 25% but is probably considerably lower. This model is based on data from large, randomized trials that enrolled patients from 1981 through 1996. These trials showed the benefit of early carotid endarterectomy over medical treatment alone in cases . . .
    New England Journal of Medicine 12/2013; 369(24):2359-2361. · 54.42 Impact Factor
  • Angiology 10/2013; 64(7):489-91. · 2.37 Impact Factor
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    ABSTRACT: We investigated the role of oral vitamin K antagonists (VKAs) in graft patency, limb salvage, major and minor bleeding rates in patients undergoing infrainguinal bypass surgery. Five randomized-controlled trials (RCTs; n = 3746 patients) comparing VKA versus non-VKA treatment outcomes in patients undergoing infrainguinal bypass surgery were analyzed. The VKA treatment was associated with improved graft patency rates when a vein graft was used (risk ratio [RR]: 0.74; P = .0004), while there was no difference with prosthetic grafts (RR: 1.07; P = .39). The VKA treatment was also associated with improved limb salvage rates (RR: 0.33; P = .0008). Major and minor bleeding complications were higher in the VKA group. In conclusion, VKA treatment is associated with improved graft patency and limb salvage rates when a vein graft is used at the price of an increased risk of bleeding. Due to the inconsistent results, further well-designed RCTs are needed.
    Angiology 09/2013; · 2.37 Impact Factor
  • Kosmas I Paraskevas, Athanasios D Giannoukas
    JACC. Cardiovascular Interventions 09/2013; 6(9):987-8. · 1.07 Impact Factor
  • International journal of cardiology 07/2013; · 6.18 Impact Factor
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    ABSTRACT: The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) has been used to support the equivalence of carotid artery stenting (CAS) and carotid endarterectomy (CEA) in the treatment of carotid stenosis in both symptomatic and asymptomatic patients. This inclusion of two different forms of the disease decreased the power and significance of the CREST results and weakened the trial. Other flaws in CREST were the equal weighting of mostly minor myocardial infarctions (MIs) with strokes and death in the peri-procedural, composite 'end' point, but not in the 4-year, long-term 'end' point. Although CAS was associated with 50% fewer peri-procedural MIs compared with CEA, there were >2.5-fold more MIs after CAS than CEA at 4 years. The 4-year MI rate, however, was not a component of the primary 'end' point. Additionally, although the initial CREST report indicated that there was no difference in the outcomes of CAS and CEA according to symptomatic status or sex, subsequent subgroup analyses showed that CAS was associated with significantly higher stroke and death rates than CEA in symptomatic patients, in females and in individuals ≥65 years of age. The present article will examine these and other flaws and the details of CREST's results derived from the trial's preplanned subanalyses to show why the claims that CREST demonstrates equivalence of the two therapeutic procedures are unjustified.
    European journal of vascular and endovascular surgery: the official journal of the European Society for Vascular Surgery 04/2013; · 2.92 Impact Factor

Publication Stats

893 Citations
748.26 Total Impact Points

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Institutions

  • 2014
    • Sheffield Teaching Hospitals NHS Foundation Trust
      Sheffield, England, United Kingdom
  • 2013–2014
    • General University Hospital of Larissa
      Lárissa, Thessaly, Greece
    • Monash University (Australia)
      • School of Public Health and Preventive Medicine
      Melbourne, Victoria, Australia
  • 2008–2013
    • Red Cross Hospital, Athens
      Athínai, Attica, Greece
    • Aristotle University of Thessaloniki
      • Faculty of Medicine
      Thessaloníki, Kentriki Makedonia, Greece
    • University College London
      • Royal Free Hospital
      London, ENG, United Kingdom
    • University of London
      Londinium, England, United Kingdom
    • University of Toronto
      • Division of Neurology
      Toronto, Ontario, Canada
  • 2012
    • Baker IDI Heart and Diabetes Institute
      Melbourne, Victoria, Australia
  • 2008–2012
    • Red Cross
      Washington, Washington, D.C., United States
  • 2011
    • State University of New York Downstate Medical Center
      • Division of Vascular Surgery
      Brooklyn, NY, United States
  • 2003–2010
    • National and Kapodistrian University of Athens
      • • Faculty of Medicine
      • • Division of Vascular Surgery
      Athens, Attiki, Greece
  • 2006–2008
    • Κωνσταντοπούλειο νοσοκομείο Νέας Ιωνίας (Η Αγία Όλγα)
      Athínai, Attica, Greece
  • 2007
    • Athens Medical Center
      Athínai, Attica, Greece
  • 2003–2006
    • University of Pécs
      Fuenfkirchen, Baranya county, Hungary