Efstratios Georgakarakos

Associate Professor
Vascular Surgeon with a demonstrated history of working in the hospital
  • Function: Consultant
  • Speciality: Vascular Surgery
  • Country: GR
  • Working place: University Hospital of Alexandroupolis, Greece, Alexandroupolis, GR

Activities

Case report

Carotid-subclavian bypass to manage steal syndrome and hand ischemia after failed endovascular attempt

We present a case of failed endovascular attempt to treat a severely calcified and stenosed left subclavian artery complicated by injury and occlusion of the brachial artery with resultant hand ischemia. A carotid-subclavian artery bypass augmented the inflow in both the vertebral artery and the upper limb managing successfully both issues, avoiding the need for further bypass to the arm.

This case reminds the significance and the irreplaceable role of open revascularazation procedures and highlights the educational need for every vascular trainee.

Efstratios Georgakarakos
February 27, 2024 No Comments
Show presentation
Comment on Dec 26, 2023

Efstratios Georgakarakos commented on presentation Management of vascular trauma of the upper limbs.

»Very thorough presentation, directly to the point! Brings up the combination of endo- and open repair techniques in modern trauma era. Also, take into consideration the the incidence of upper limb trauma is increased due to iatrogenic traumas (i.e,, catheterization-related traumas). Every hospital (regardless of its trauma-level type) should be able to provide basic vascular trauma handling.«
Comment on Dec 26, 2023

Efstratios Georgakarakos commented on presentation Vascupedia @ PVI 2023 | Open surgery for peripheral occlusive disease: How to do it?.

»Very nice presentation, indeed showing that the classic TASC-decision making era is outdated, since the TASC not-incorporated modern hybrid approach dictates endo-first, leaving for complementary open approach what cannot be endo-fixed! I'd like to ask whether you use a special re-entry device such as an Outback catheter to entry the true lumen from the subintimal space. Also, when to use simple stents or covered stents? According to my personal experience, when you treat with simple-stents (i.e, self-expandable) lesions which are proven thrombotic rather than atherosclerotic, the immediate or direct thrombotic effect is very likely; in that case, i'd use covered-stents. The same may apply for heavily calcified iliac lesions (such as the one presented and debated in the approx. 6th minute of the presentation), where inflating and covering with a bare stent may lead inadvertently to rupture. Once again, thank you for sharing the presentation.«
Comment on Apr 06, 2020

Efstratios Georgakarakos commented on presentation How to perform a clampless hybrid aortic anastomosis.

»very impressive technique!!!! do you concern about the mid-and long term latency of the anastomotic stent? I mean, isn’t it risky to rely the efficacy of such anastomosis on the radial fords of a balloon-expandable stent (or is it stent-graft?) what are your results with this manuever?«
Review of the literature

Hemodynamic and mechanical interpretation of the clinical performance of abdominal aortic endografts: principles and considerations

What are the factors predisposing to migration of endografts after EVAR? How are the stresses, pressure and forces distributed postiperatively? Can the geometric parameters predict future adverse effects? How are mechanical, hemodynamic and geometrical changes interconnected postinterventionally? This presentation introduces some basic hemodynamic pronciples and terminology as a means to comprehend the phenomena taking place after endograft implantation.

Efstratios Georgakarakos
June 19, 2018 2 Comments
Show presentation
Comment on Jun 18, 2018

Konstantinos Stavroulakis replied to your comment on presentation Surgical thrombectomy and DCB angioplasty for AV fistula salvage.

»Dear Stratos, thank you for your comment. To be honest, I am not sure which is the best treatment strategy for these lesions. Based on our algorithm we try to avoid any permanent scaffolding. Nonetheless, in the absence of head to head comparisons it is not possible to make any evidence based recommendations.«
Comment on Jun 14, 2018

Roberto Ferraresi commented on presentation Endovascular treatment of a complex case of ischemic diabetic foot syndrome in a chronic kidney disease patient.

»1) I use roadmap very rarely. I didn't try with CO2, however I think it could be possible 2) Endoluminal or subintimal have similar outcomes, however in my experience, in case of diffuse calcification like in this case, to maintain an endoluminal route is better, because the two exit and re-entry points are difficult to manage and often require stenting. 3) My first approach is the "leaving nothing behind stategy". After DCB treatment, if I consider the result acceptable, I don't use stent. Obviously, at least in part, this approach is due to economical reason. 4) Spasm is due to our maneuvers, and is generally resistant to drugs. I always inject TNG intra-arterial or Verapamil. If I want to inject drugs locally I use the OTW balloon (wire hole!) and not long sheaths. 5) There is a paper by Flavio Airoldi describing the omolateral approach in treating ostial SFA lesion: he stated that we need at least 2 cm to be able to do a proper treatment. In the vast majority of the cases I maintain an antegrade 4F femoral approach. I shift to contralateral only in case of ostial SFA lesion and high bifurcation Ciao, Roberto«
Comment on Jun 13, 2018

Konstantinos Stavroulakis replied to your comment on presentation Successful treatment of an occluded drug-eluting stent (DES).

»Surely, the RELINE trial (J Endovasc Ther. 2015 Feb;22(1):1-10.) is a very interesting study, which, however, included also a small number of patients (39 in the stent graft group) and reported patency rates of 54% at 24 months. Moreover, and similar to the findings of this retrospective single center study, the multi center SALAVAGE registry (Catheter Cardiovasc Interv. 2012 Nov 1;80(5):852-9) reported 12 months primary patency rates of 48% following laser atherectomy and stent graft implantation for ISR. This study included also a small number of patients. There is no doubt that a physical barrier might be useful in selected cases but there is no body of evidence to support the use of grafts as primary treatment option of ISR.«
Comment on Jun 13, 2018

Konstantinos Donas replied to your comment on presentation Successful treatment of an occluded drug-eluting stent (DES).

»Thank you Kostas for your comment. I had in my mind writing about superiority of covered stents in ISR, the multicenter randomized trial (RELINE trial), which was published in 2015 from Bosiers M, et al and showed significant better outcomes for the covered stents compared to PTA. I believe that this study has a much better impact and value than the retrospective single center study of ca. 25 patients, which you mentioned. There is no doubt, that we have more than one options to treat complex SFA lesions with pros and cons for each approach. In my case the possible presence of residual thrombus material after the use of Rotarex was the major argument to deploy a covered stent minimizing the risk of peripheral embolization. Further FU is off course mandatory in order to ensure patency and durability of this treatment option. Again, many thanks for your comment and keep in touch.«
Comment on Jun 13, 2018

Konstantinos Stavroulakis replied to your comment on presentation Successful treatment of an occluded drug-eluting stent (DES).

»Dear Kostas, just two comments. I am not so sure that the current literature supports the primary use of stent grafts for the treatment of ISR. A real world study evaluating the performance of stents grafts for denovo and ISRs in femoro- popliteal arterial obstructive disease concluded that stent grafts have high restenosis and failure rates, of both stent patency and limb outcomes (Catheter Cardiovasc Interv. 2018;91:1130–1135.). Quite the contrary, numerous studies support the use of DCBs +/- debulking (laser atherectomy, rotation atherectomy etc) and some registry data the use of DES. Regarding the gold standard of SFA treatment, I totally agree that the preservation of the collateral network is crucial. Nonetheless, this can be achieved with all available treatment options except stent grafts (and not only with BMS). Thus, a more individualized approach based on lesions (CTO, calcification, length etc) and patients characteristics (CKD, compliance) seems more reasonable.«
Comment on Jun 12, 2018

Konstantinos Donas commented on presentation Successful treatment of an occluded drug-eluting stent (DES).

»Thank you Efstratios for your comment! I am considering the use of covered stents as first-line treatment in case of thrombotic occlusion with suspicion of residual thrombus formation after succesful recanalisation, or in case of accidental perforation of the SFA during endovascular maneuvers. Finally, the current literature supports also the use of covered stents as first line treatment in case of in-stent stenosis in the SFA. However, my first choice for the SFA, in general, remains the use of a bare metal stent, because I believe that patent collateral pathway of the SFA is very crucial and should be always preserved.«
Comment on Jun 12, 2018

Efstratios Georgakarakos commented on presentation Endovascular treatment of a complex case of ischemic diabetic foot syndrome in a chronic kidney disease patient.

»Thank you Dr. Farraresi for the presentation. Please enlighten me with regard to the following questions: 1) were you able with the CO2-technique to have get a roadmap route during your procedure? 2) I understood you were very keen with the advancing and crossing the 0,018”-wire intraluminally based solely on the calcification landmarks of the SFA but does it suffice? I mean, can we be so sure about the proper route of the wire? What if it takes the subintimal plane at a certain point of the passage? Wouldn’t a roadmap help to stay in the intraluminal task? 3) would you of consider a prophylactic use of stent in such a high risk for reccurence patient after the SFA revanalization or we follow the “leave-nothing-behind”approach? 4) regarding the PTA spasm, would you consider delivering a dose os vasodilating drug locally via eg. a long sheath and when would you consider that? 5) as I notice, a short proximal segment of the SFA was considerably stenosed; I personally had a recent case of mine where the proximal passage of a 5fr sheath through such SFA proximal segment led to inadvertent serious compromization of the femoral bifurcation and proximal SFA, leading to open conversion under local anesthesia, limited endarterectomy with GSV patch restoration. Would you consider the contralateral over-the-bifurcation approach as a safer technique? Many thanks!«
Comment on Jun 07, 2018

Efstratios Georgakarakos replied to your comment on presentation A case of bilateral symptomatic aneurysms of common femoral arteries: surgical management.

»Hi Theo and thanks for your attention. I usually suggest a FU examination at 1-, 6- and 12months postoperatively. If a femoral aneurysm is asymptomatic most authors suggest intervention at a diameter greater than 2.5-3.0cm. Depending on the size of the inflow and outflow vessel to be clamped, i prefer Dacron for large diameters or PTFE if the vessel sizes are smaller. I certainly perform a CTA scan to rule out comcomitant aneurysms in remote locations, since femoral aneurysms -although rare, accounting for 3-4% of all peripheral aneurysms- are bilateral in 1/3 of cases while associated with aortic- or popliteal aneurysms in 66%. Therefore, a CTA is mandatory.«
Comment on Jun 07, 2018

Özgün Sensebat replied to your comment on presentation Transcubital Onyx Embolization of a Type 2 Endoleak after EVAR.

»Maybe I expressed myself not clearly. An Endoleak Type 1 or 3 is of course detectable by a duplex-scan very well. What I meant is something different. I am talking about an upcoming problem (I think I wrote that word in my former reply). Degenerations of the necks or a beginning stent migration weren’t the endpoints of this study. Just the detection of the endoleak was examined. This is not what I am talking about. For me, a CT scan is still the only tool we have, which can detect anatomically or graft-related problems before a Type 1 or 3 Endoleak is existing. You can’t get this information from a duplex scan. I hope, you understand now my comment. Thank you for mentioning the studies above, but they are really well known. Even for me. Warm regards«
Comment on Jun 07, 2018

Özgün Sensebat replied to your comment on presentation Transcubital Onyx Embolization of a Type 2 Endoleak after EVAR.

»Maybe I expressed myself not clearly. An Endoleak Type 1 or 3 is of course detectable by a duplex-scan very well. What I meant is something different. I am talking about an upcoming problem (I think I wrote that word in my former reply). Degenerations of the necks or a beginning stent migration weren't the endpoints of this study. Just the detection of the endoleak was examined. This is not what I am talking about. For me, a CT scan is still the only tool we have, which can detect anatomically or graft-related problems before a Type 1 or 3 Endoleak is existing. You can't get this information from a duplex scan. I hope, you understand now my comment. Thank you for mentioning the studies above, but they are really well known. Even for me. Warm regards«
Comment on Jun 07, 2018

Konstantinos Stavroulakis commented on presentation Transcubital Onyx Embolization of a Type 2 Endoleak after EVAR.

»Özgün allow me to disagree. In a metaanalysis published in BJS (Br J Surg. 2012 Nov;99(11):1514-23.) duplex ultrasound was found to be specific for detection of types 1 and 3 endoleaks. Moreover, in a single center experience published from Antonello et al (J Vasc Surg. 2013 Oct;58(4):886-93.) EVAR was associated with a higher decline in renal function compared to open repair. The post-operative survaillance with CT scan might be the main reason for this finding.«
Comment on Jun 06, 2018

Özgün Sensebat commented on presentation Transcubital Onyx Embolization of a Type 2 Endoleak after EVAR.

»Of course, the aneurysm diameter is the most important factor for a treatment indication. But a regularly CT-Scan detects an upcoming Type-1-EL due to a neck degeneration or stent-migration. I think the duplex scan is not a proper tool to detect those problems. So for me, an EVAR-patient normally needs a continuous follow up including a CT-scan. The exception might be the patient with a complete decreasing of its aneurysm diameter down to the graft diameter or the patient with long aneurysm-necks, which are able to be examined accurately by a KM enhanced duplex-ultrasound«
Comment on Jun 06, 2018

Özgün Sensebat commented on presentation Transcubital Onyx Embolization of a Type 2 Endoleak after EVAR.

»Thank you for your kind words. Here are my answers to your questions. 1) Usually, I use for the treatment of Type2-EL Onyx. In case of bigger vessels eventually coils as an add-on. In case of a Type1-EL for example due to a gutter-EL after CHEVAR or periscope-technique, we have good experiences with coils (Penumbra or Concerto). We prefer to treat classic Type 1 EL with an extension, a type 1a eventually with the support of an endoanchor (Heli-FX), a type 1b with an iliac-side-branch if possible. 2) Generally, we try to embolize as little as possible and to treat exactly the feeding branch. Especially the treatment of the IMA has to be done precious. We are afraid of embolizing bigger or accompanying vessels like the superior rectal artery or the complete internal iliac. Even in the lumbar territory you never know the exact effects of the embolization. Till now we luckily never had a spinal ischemia, so we are a bit more generous. If we can't reach the main feeding vessel branch, we accept a distance embolization of lumbar arteries with Onyx. 3) Our postop protocol requires a Duplex-scan after three months and a CT-scan after six months if the embolization was successful. Our main objective is the aneurysm diameter. If this is stable or decreasing, we plan the next CT-scan every 12 months, if not again after six months. If the artifacts are enormous, we check ta possible endoleak with an invasive angiogram. I hope I could answer your questions. Feel free to contact me any time. Thank you for your interest.«
Comment on Jun 06, 2018

Efstratios Georgakarakos commented on presentation Transcubital Onyx Embolization of a Type 2 Endoleak after EVAR.

»Excellent demostration of the devices and materials, step-by-step, really illuminating for me, thank you very much Özgun. Just three short questions: 1) what is your preference criteria for Onyx over other embolizing agents, such as coils or NBCA, coils or other agents? 2) apart from the feeding vessel (i.e. IMA), do you usually take care of any outflow vessels (eg lumbar arteries)? 3) What is your standard visualization protocol of follow-up after embolozation? I usually have difficulties to detect any angiographic leak reccurence with CTAngiography postoperatively due to artifacts caused by the embolic agent...«
Comment on Jun 05, 2018

Fernando Gallardo commented on presentation Two technical tips for severely angulated infrarenal necks during EVAR.

»Thanks for sharing your tricks. For this maniouver I have used as Pr Efstratios comments a Relliant Ballon partially inflated to straight the neck is much us possible, but also using the contralateral limb sistems works, and probably a long big sheat or anything that could make righter the neck could works... Anyway for more 70 angulation we should be careful, my option now for this neck is more Aorfix or even Gore with Aptus, more comfortable grafts. The battle stentgrafts VS hostile anatomy will be always won by the anatomy at mid-long term!! Also consider that Endurant suprarrenal stent is totally straight, difference with COOK suprarrenal stent, and in cases with severe angulations I have seen total apposition of the suprarrenal stent one half side and the half of the suprarrenal stent free in the aorta without wall contact... Best regards Fernando«
Comment on Jun 05, 2018

Giovanni Torsello commented on presentation Carotid artery endarterectomy with patchplasty: step by step procedure.

»Thank you, Dr. Dr. Georgakarakos for your comment. I have no personal experience with bovine pericardium but a long positive experience with Dacron patch. Therefore I have not changed my strategy. Until 1997 I have used autologous vein as patch material. However, by Duplex US I found increased dilatation of the treated segment sometimes also with parietal thrombus load. This is the reason why I switched to alloplastic material. For elongated ICA our preferred technique is the eversion. For the next weeks we are preparing a video. In case you have alternatives please feel free to show your own experience. Warm regards G.Torsello«
Comment on Jun 05, 2018

Efstratios Georgakarakos commented on presentation Treatment of a challenging case of acute limb ischemia.

»Theo, thanks for your interest and your prompt reply! Certainly this was an embolism after all, since the angiographic picture left no doubt about that. I just raised a concern about the initial approach of this case, leaving a place for thrombosis in the differential diagnosis based on the peculiar -according to my opinion- picture of 3-sites embolization. Certainly, the pros and cos of each approach encourage the scientific dialog and enrich the phycisian's armamentarium!«
Comment on Jun 05, 2018

Theodosios Bisdas replied to your comment on presentation Treatment of a challenging case of acute limb ischemia.

»Hi Stratos! Thank you for your comment. Your approach is also safe and easy, but we do not have any evidence about cost effectiveness. Let me please disagree with your concept. The angiography after the aspiration thrombectomy showed no atherosclerotic lesions at the level of the CFA or even popliteal artery. Thus, I still believe that this was an embolism. The total amount of contrast agent used was 60ml. If we had an atherosclerotic lesion in the CFA, your approach would be the treatment of choice. In our case, we prevented any wound complication, we reduced the hospital stay, we did not use lysis and of course also no ICU. The total operation time was 49 minutes. I am looking forward to your comment on this.«
Comment on Jun 03, 2018

Efstratios Georgakarakos commented on presentation Treatment of a challenging case of acute limb ischemia.

»Nice try! Did the patient experienced reperfusion syndrome postoperatively with need for fasciotomies? It seems a bit ackward to me the multiplicity of occlusive lesions on the basis of an emboli phenomenon eg. 3 remote sites infespopliteal, CFA as well as iliac axis thrombus from a single atrial thrombus? I would personally put into play the scenario of a atheromatous steno-occlusive lesion either in the popliteal or CFA site. In such case, an open CFA preparation with proximal and distal embolectomy effort would immediately remove thrombus and would decrease the amount of subsequent contrast agent needed to check for remnant stenotic disease proximally or centrally i.e., in order to differentiate the thrombotic vs. embologenic phenomenon and proceed immediately with primary stenting. This would also be faster. Admittedly, remnant thrombus in the popliteal segment would necessitate local injection of theombolytic agent with potential need for further thrombectomies distally; but then, again, such approach would be time and cost effective, let alone the fact that it would enable-if needed- CFA endarterectomy and hybrid approach.«
Comment on Jun 03, 2018

Theodosios Bisdas replied to your comment on presentation Two technical tips for severely angulated infrarenal necks during EVAR.

»Exactly Stratos! You could not describe it by a better way. The risk of angulated necks is the poor apposition of the proximal stents on the wall. This is a good solution. Your suggestion is also good and works fine. I have tried it in the past. The only advantage of my tip is that you win some time because you do not need to remove the sheath of the contralateral extension. After implanting the ETLW you do not remove it but you further open the main body. Then, you connect the top cap and you advance the sheath of contralateral extension at the height of the top cap. In any case, both work fine.«
Comment on Jun 03, 2018

Efstratios Georgakarakos commented on presentation Two technical tips for severely angulated infrarenal necks during EVAR.

»Nice information and demonstration. If i get it right, the philoshophy of the “pushing-up”maneuver of the mainbody after the top-cap release (and before the contralateral limb release) is to shrink the fabric between the 1st and 2nd covered stent, thereby reducing the distance between these covered stents and aproximating them in order to achieve the optimal position of these within the infrarenal neck length; therefore, you should start pushing-up the whole device just after the deployment of the 1st stent-top cap release and before the deployment of the 2nd covered stent, so that the latter could actually be positioned as close as it gets to the 1st one, leaving perhaps extra place for the third stent etc., isn’t it? Regarding the 2nd excellent tip of yours i.e., engagement of cap with suprarenal stent, an alternative maneuver would be to inflate a Relay molding balloon mildly leaving a pathway through which the top cap could withdraw safely without the aforementioned problem.«
Comment on Jun 03, 2018

Theodosios Bisdas commented on presentation Two technical tips for severely angulated infrarenal necks during EVAR.

»Thank you, Philippe, for your comment. Of course, you need experience with this maneuver. The trick here is to 'cram' the prosthesis into the angulated neck. I have not seen an upward migration yet, but there is sure a risk for this. Thus, you have to do smooth movements and to use some landmarks of the vertebral bodies for your renal arteries. An important issue is also the oversizing in those cases: we recommend at least 30%.«
Comment on Jun 03, 2018

commented on presentation Two technical tips for severely angulated infrarenal necks during EVAR.

»Hi Theo, very nice case! By what means you judge the pushing-up manoueuvre of the main body once the struts are opened? I'm sure in your hands this reflects experience, but is it not a quite risky step for some less experienced operators? I like a lot the move with the contralateral limb, never thought about this! Very smart indeed!!! Best, P«
Comment on Jun 02, 2018

Theodosios Bisdas commented on presentation Treatment of a severely calcified lesion with Supera and balloon-expandable stents.

»Thank you Stratos for the comment. The total duration was about 1 hour. Of course, the most challenging part was the recanalization. Regarding your second question, the nose cone is moved through the advancement of the thumb slide. By advancing the thumb slide the outer sheath retracts proximally and the stent is deployed. Actually, the full advancement of the thumb slide is prespecified by the manufacturer and allows the deployment of a short section of the stent. I prefer short thumb slide advancement at the beginning of the stent implantation and full thumb slide advancement afterward.«
Review of the literature

TIPS AND TRICKS FOR FACILITATING TEACHING OF DOPPLER WAVEFORMS AND ANKLE-BRACHIAL-INDEX IN UNDERGRADUATE LEVEL: A PRACTICAL GUIDE

Although the measurement of Ankle-brachial-Index (ABI) is considered a fundamental skill in the diagnosis and assessment of peripheral arterial disease as well as predictive tool for cardiovascular events, real-world practice shows that current teaching and practice in undergraduate medical curricula is far from ideal. this article provides twelve easy-to-follow useful tips to enhance the comprehension and teaching of ABI and favors the simultaneous teaching of Dopler waveform examination.

Efstratios Georgakarakos
May 31, 2018 No Comments
Show presentation
Poll 13/04/2018 – 30/06/2018

Topic: Asymptomatic juxta- and pararenal aortic aneurysms

Patient’s characteristics

Gender: Female
Age: 75 years old
Comorbidity: Arterial hypertension, hypercholesterinemia, previous aortocoronary bypass grafting, previous myocardial infarction, previous smoker, peripheral arterial disease, atrial fibrillation
Symptoms: None
Previous operations: None

 

Aneurysm characteristics:

Max. aneurysm diameter: 54 mm

Length of proximal infrarenal neck: 0 mm

Distance between SMA and LRA: 20 mm

Diameter of renal arteries: RRA: 5,3 mm, LRA: 6 mm

Suprarenal angulation: 60°

Diameter of distal neck: 30 mm

Minimum diameter of common iliac arteries: R: 11 mm, L:9 mm

Maximum diameter of common iliac arteries: R: 11 mm, L: 14 mm

Minimum diameter of external iliac arteries: R: 7 mm, L: 6,2 mm

Go to poll