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MacLeod CS, Nagy J, Radley A, Khan F, Rae N, Wilson MSJ, Suttie SA. REPAIRS Delphi: A UK and Ireland Consensus Statement on the Management of Infected Arterial Pseudoaneurysms Secondary to Groin Injecting Drug Use. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00352-6. [PMID: 38663765 DOI: 10.1016/j.ejvs.2024.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 02/29/2024] [Accepted: 04/15/2024] [Indexed: 06/27/2024]
Abstract
OBJECTIVE Consensus guidelines on the optimal management of infected arterial pseudoaneurysms secondary to groin injecting drug use are lacking. This pathology is a problem in the UK and globally, yet operative management options remain contentious. This study was designed to establish consensus to promote better management of these patients, drawing on the expert experience of those in a location with a high prevalence of illicit drug use. METHODS A three round modified Delphi was undertaken, systematically surveying consultant vascular surgeons in the UK and Ireland using an online platform. Seventy five vascular surgery units were invited to participate, with one consultant providing the unit consensus practice. Round one responses were thematically analysed to generate statements for round two. These statements were evaluated by participants using a five point Likert scale. Consensus was achieved at a threshold of 70% or more agreement or disagreement. Those statements not reaching consensus were assessed and modified for round three. The results of the Delphi process constituted the consensus statement. RESULTS Round one received 64 (86%) responses, round two 59 (79%) responses, and round three 62 (83%) responses; 73 (97%) of 75 units contributed. Round two comprised 150 statements and round three 24 statements. Ninety one statements achieved consensus agreement and 15 consensus disagreement. The Delphi statements covered sequential management of these patients from diagnosis and imaging, antibiotics and microbiology, surgical approach, wound management, follow up, and additional considerations. Pre-operative imaging achieved consensus agreement (97%), with computerised tomography angiography being the modality of choice (97%). Ligation and debridement without arterial reconstruction was the preferred approach at initial surgical intervention (89%). Multidisciplinary management, ensuring holistic care and access to substance use services, also gained consensus agreement. CONCLUSION This comprehensive consensus statement provides a strong insight into the standard of care for these patients.
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Affiliation(s)
- Caitlin S MacLeod
- Department of Vascular Surgery, Ninewells Hospital, NHS Tayside, Dundee, UK; Division of Systems Medicine, University of Dundee, Dundee, UK.
| | - John Nagy
- Department of Vascular Surgery, Ninewells Hospital, NHS Tayside, Dundee, UK
| | - Andrew Radley
- Directorate of Public Health, Kings Cross Hospital, NHS Tayside, Dundee, UK; Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Faisel Khan
- Division of Systems Medicine, University of Dundee, Dundee, UK
| | - Nikolas Rae
- Department of Infectious Diseases, Ninewells Hospital, NHS Tayside, Dundee, UK
| | | | - Stuart A Suttie
- Department of Vascular Surgery, Ninewells Hospital, NHS Tayside, Dundee, UK
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Zeng Y, Yuan P, He Q. Comparison between covered-stents grafting and ligation in the treatment of infected femoral pseudoaneurysm due to intravenous drug abuse. Vascular 2024:17085381241240237. [PMID: 38490959 DOI: 10.1177/17085381241240237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2024]
Abstract
OBJECTIVES The study compared the outcomes between covered-stents grafting (CSG) and ligation of femoral artery (LFA) in the treatment of infected femoral pseudoaneurysm (IFP) caused by intravenous drug injection. METHODS From 1st January 2016 to 30th November 2021, the clinical data of patients with IFP caused by intravenous drug injection who underwent CSG (n = 31, 55.4%) and LFA (n = 25, 45.4%) are retrospectively analyzed. We compared the baseline characteristics and clinical outcomes of the two groups, including early and late mortality and morbidity. RESULTS A total of 56 patients were enrolled in the study, comprising 50 (89.3%) men and 6 (10.7%) women, with a mean age of 34.3 years. There was no significant difference observed between the two groups in terms of 30-day mortality (3.2% vs 0%, p = .365) and length of stay (9 [7, 12] vs 11 [8.5, 12.5] days, p = .236). However, group CSG exhibited a lower rate of intermittent claudication (0% vs 32%, p = .001), less blood loss (67.1 ± 22.5 mL vs 177.0 ± 59.8 mL, p < .001), and shorter surgery duration (57.5 ± 9.9 min vs 84.4 ± 22.8 min, p < .001) compared to group LFA. The LFA group were divided into subgroups according to the ligation site. The amputation rate of superficial femoral artery ligation group (0 vs 27.3%, p = .014) was significantly lower than common femoral artery ligation. CONCLUSIONS Covered-stents grafting may be a preferable treatment to LFA for IFP due to intravenous drug abuse, particularly when the entry tear is located in the common femoral artery.
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Affiliation(s)
- Yanzhang Zeng
- Department of Vascular and Thyroid Surgery, Guizhou Provincial People's Hospital, Guiyang, China
| | - Ping Yuan
- Department of Vascular and Thyroid Surgery, Guizhou Provincial People's Hospital, Guiyang, China
| | - Qiang He
- Department of Intervention, Guizhou Provincial People's Hospital, Guiyang, China
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Alhewy MA, Ghazala EAE, Gado H, Abd‐Elgawad WAA, Khamis AA. Infected femoral artery pseudoaneurysm ligation and revascularisation: A case report. Clin Case Rep 2024; 12:e8693. [PMID: 38523822 PMCID: PMC10957489 DOI: 10.1002/ccr3.8693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 03/05/2024] [Accepted: 03/07/2024] [Indexed: 03/26/2024] Open
Abstract
Key Clinical Message Although ligating femoral pseudoaneurysm is a safe procedure, some cases require revascularization, and the appropriate treatment should be tailored to the patient. Abstract In this case report, we highlight the challenge in treating infected femoral artery pseudoaneurysm. The patient, a 37-year-old male intravenous drug abuser, presented to the emergency department with a 2-month history of a progressively growing lump over his right groin. Two days before the presentation the swelling became hot and painful. After physical examination, it was revealed that the localized swelling is about 15 × 15 cm in size. It is pulsating, expanding in all directions, moving from side to side, and has been reduced in size due to proximal artery compression with the inflamed overlying skin causing slight flexion of the right hip joint and there was serosanguineous discharge as well. The affected leg was warm with intact motor and sensory function, palpable femoral, and popliteal arterial pulses, but non-palpable left posterior tibial and anterior tibial arterial pulses, both of which had triphasic wave signals on a portable hand-held Doppler (there was below knee marked edema). CT angiography (CTA) revealed a large well-defined heterogeneous cystic structure at the right groin with an average diameter of 11 × 10 × 9 cm, with a connection with the common femoral artery. After proximal and distal control, excision of the infected femoral pseudoaneurysm, a swab was taken, and ligation of the common femoral artery superficial femoral artery, and profunda femoral artery. No signals were detected on the posterior or anterior tibial arteries by hand-held Doppler and oxygen saturation on the big toe was markedly decreased, so we did an extra-anatomic lateral ilio-femoral anastomosis using silver-impregnated vascular graft.
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Affiliation(s)
| | | | - Hassan Gado
- Department of Vascular and Endovascular Surgery, Faculty of MedicineAl‐Azhar UniversityAssiutEgypt
| | | | - Ahmed Atef Khamis
- Department of Vascular and Endovascular Surgery, Faculty of MedicineAl‐Azhar UniversityAssiutEgypt
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MacLeod CS, Radley A, Strachan D, Khan F, Nagy J, Suttie S. Management of the infected arterial pseudoaneurysm secondary to groin injecting drug use and outcomes: a systematic review protocol. BMJ Open 2023; 13:e070615. [PMID: 37321813 PMCID: PMC10277064 DOI: 10.1136/bmjopen-2022-070615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 05/31/2023] [Indexed: 06/17/2023] Open
Abstract
INTRODUCTION People who inject drugs are at risk of a range of injecting-related infections and injuries, which can threaten life and limb. In parallel to escalating rates of drug-related deaths seen in Scotland and the UK, there has also been an increase in hospital admissions for skin and soft tissue infections related to injecting drug use. One such injecting complication is the infected arterial pseudoaneurysm, which risks rupture and life-threatening haemorrhage. Surgical management options for the infected arterial pseudoaneurysm secondary to groin injecting drug use remain contentious, with some advocates for ligation and debridement alone, whilst others promote acute arterial reconstruction (suture or patch repair, bypass or, more recently, endovascular stent-graft placement). Rates of major lower limb amputations related to surgical management for this pathology vary in the literature. This review aims to evaluate the outcomes of arterial ligation alone compared with arterial reconstruction, including open and endovascular options, for the infected arterial pseudoaneurysm secondary to groin injecting drug use. METHODS AND ANALYSIS The methods will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Three electronic databases will be searched and the resultant papers screened according to the study inclusion and exclusion criteria (detailed in the Population, Intervention, Comparison, Outcomes and Study design statement). Grey literature will be excluded. All papers at each stage will be screened by two independent authors, with disagreements arbitrated by a third. Papers will be subject to appropriate standardised quality assessments. PRIMARY OUTCOME Major lower limb amputation. SECONDARY OUTCOMES Reintervention rate, rebleeding rate, development of chronic limb-threatening ischaemia 30-day mortality and claudication. ETHICS AND DISSEMINATION This is a systematic review based on previously conducted studies, therefore, no ethical approval is required. The results of this work will be published in a peer-reviewed journal and presented at relevant conferences. PROSPERO REGISTRATION NUMBER CRD42022358209.
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Affiliation(s)
- Caitlin Sara MacLeod
- Department of Vascular Surgery, NHS Tayside, Dundee, UK
- School of Medicine, University of Dundee, Dundee, UK
| | - Andrew Radley
- School of Medicine, University of Dundee, Dundee, UK
- Public Health Directorate, NHS Tayside, Dundee, UK
| | | | - Faisel Khan
- School of Medicine, University of Dundee, Dundee, UK
| | - John Nagy
- Department of Vascular Surgery, NHS Tayside, Dundee, UK
| | - Stuart Suttie
- Department of Vascular Surgery, NHS Tayside, Dundee, UK
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Zhang M, Zhang H, Tang B, Fu J, Yan H, Luo H. Outcomes of Covered Stents With Vacuum Sealing Drainage For Treatment of Infected Femoral Pseudoaneurysms in Intravenous Drug Addicts. Ann Vasc Surg 2021; 81:300-307. [PMID: 34780965 DOI: 10.1016/j.avsg.2021.09.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 09/05/2021] [Accepted: 09/11/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE For treatment of infected femoral artery pseudoaneurysms (IFAPs) with the covered stent, debridement technique is important but frequently ignored. Our study aims to review our experience and outcomes of patients undergoing covered stents placement and debridement with vacuum sealing drainage (VSD). METHODS This study retrospectively analyzed 41 intravenous drug addicts with IFAP who received covered stent implantation and debridement with VSD from January 2015 to December 2020. The diagnosis was based on the previous history of local injection and the presence of pulsatile mass at the injection site. All cases were confirmed by CT angiography (CTA), ultrasound, or digital subtraction angiography (DSA). Technical success, time of wound care, and clinical outcomes were evaluated. RESULTS Technical success was achieved in all patients. The interval from diagnosis to treatment was 26 ± 11 hours. The time of continuous drainage with VSD was 18.79 ± 6.56 days. 38 patients (92.68%) with fresh granulation tissue were sutured and discharged from the hospital. Stents in 31(91.18%) of 34 cases were patent during follow-ups. Three patients had stent occlusion caused by thrombosis, and two of them were complicated with stent infection. The two infectious stents were removed and the femoral arteries were ligated. One of them received open-surgical reconstruction with the great saphenous because of claudication. Two patients were admitted to the hospital for rebleeding caused by drug abuse relapse. CONCLUSIONS Covered stents placement is convenient and rapid to control massive hemorrhage in IFAPs of intravenous drug abuse. Early debridement of infected tissue with continued VSD may shorten the time of wound care and make the incidence of stent infection relatively low. Meanwhile, the patency in a short time follow-up is acceptable. These results indicate that covered stents implantation with VSD may be a safe, effective, and feasible measure for the treatment of IFAPs.
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Affiliation(s)
- Mingyi Zhang
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Haolong Zhang
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Bo Tang
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jian Fu
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Haiyan Yan
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hailong Luo
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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Bonnin E, Lermusiaux P, Chakfé J, Dion D, Heim F, Chakfé N, Lejay A. Disruption of a Covered Nitinol Self Expanding Stent Graft Implanted in the Common Femoral Artery. EJVES Vasc Forum 2020; 47:55-59. [PMID: 33078155 PMCID: PMC7320214 DOI: 10.1016/j.ejvsvf.2020.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 04/01/2020] [Accepted: 04/21/2020] [Indexed: 11/10/2022] Open
Abstract
Introduction Common femoral artery aneurysm is a rare condition and can be treated by open or endovascular surgery. There is a general understanding that open surgery is the recommended option because of the anatomical location and the biomechanical constraints posed by hip flexion. Report The case of a 66 year old man treated with an endograft for an asymptomatic abdominal aortic aneurysm followed by the implantation of a nitinol covered stent graft (Fluency™, Bard Peripheral Vascular, Temple, AZ) for a 25 mm diameter left common femoral artery aneurysm is reported. Two years later, follow up revealed a rupture of the nitinol covered stent graft, requiring an open iliofemoral reconstruction. Discussion Systematic analysis with protocolised cleaning, and macroscopic and microscopic evaluation (Keyence VHX-600 digital microscope) of the explanted nitinol covered stent graft showed membrane perforation at the level of an acute angle formed by the struts.
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Affiliation(s)
- Emilie Bonnin
- GEPROVAS, European Research Group on Grafts used in Vascular Surgery, Strasbourg, France.,Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, France
| | | | - Julien Chakfé
- GEPROVAS, European Research Group on Grafts used in Vascular Surgery, Strasbourg, France
| | - Delphine Dion
- GEPROVAS, European Research Group on Grafts used in Vascular Surgery, Strasbourg, France
| | - Frédéric Heim
- GEPROVAS, European Research Group on Grafts used in Vascular Surgery, Strasbourg, France.,Laboratoire de Physique et Mécanique Textile, Mulhouse, France
| | - Nabil Chakfé
- GEPROVAS, European Research Group on Grafts used in Vascular Surgery, Strasbourg, France.,Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, France
| | - Anne Lejay
- GEPROVAS, European Research Group on Grafts used in Vascular Surgery, Strasbourg, France.,Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, France
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Bianchini Massoni C, Mariani E, De Troia A, Perini P, Nabulsi B, D'Ospina RM, Freyrie A. Outcomes of Surgical and Endovascular Treatment for Arterial Lesions in Intravenous Drug Abusers. Ann Vasc Surg 2020; 69:133-140. [PMID: 32561239 DOI: 10.1016/j.avsg.2020.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 05/28/2020] [Accepted: 06/01/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND The objective of this study is to report an 18-year single-center experience in the surgical and endovascular treatment of arterial complications due to self-injection in drug abuser patients. METHODS This retrospective single-center study was conducted analyzing a prospectively collected database including all endovascular or surgical procedures performed from January 2007 to December 2019 for any arterial complication due to self-injection in drug abuser patient. Collected data were patient demographic and comorbidity, site and type of arterial lesion (pseudoaneurysm [PA], arteriovenous fistula [AVF]), signs of systemic or local infection, and procedural data (endovascular/surgical treatment). End points were rate of postoperative complications, reintervention rate, limb salvage, and patients' early and long-term survival. RESULTS In 11 patients (median age 36 years, range 27-47; male 73%), 13 arterial lesions were treated: 10 (77%) PA, 2 (15%) PA associated with AVF, and 1 (8%) isolated AVF. Arterial lesion involved common femoral artery in 5 (38%), superficial femoral artery in 4 (31%), profunda femoral artery in 1 (8%), brachial artery in 2 (15%), and subclavian artery in 1 (8%). Signs of infections were present in 9 of the 13 cases (69%). The treatment was surgical in 11 (85%) cases: 7 interposition graft (6 great saphenous vein, 1 arterial cryopreserved homograft), 2 direct reconstruction, 1 patch plasty with pericardium bovine patch, and 1 arterial ligation. Endovascular treatment was performed in 2 cases: 1 noninfected PA of the superficial femoral artery, and 1 55-mm PA of the postvertebral segment of the right subclavian artery with clinical sign of hemodynamic instability. At 1 month, postoperative complication rate was 8% (one lower limb claudication after superficial femoral artery ligation). Reintervention rate was 8% (interposition graft rupture for repeated self-injections). Limb salvage and patient survival were both 100%. Median follow-up was 5 years (range 1 month to 11.3 years); surgical group: median 8.2 years (range 2 months to 11.3 years); endovascular group: median 3.5 months (range 1-6). During follow-up, neither complications nor reinterventions occurred, and limb salvage was 100% for both groups. At 2, 4, and 6 years, overall estimated patient survival was 91%, 81%, and 81%, respectively, with no procedure-related death. CONCLUSIONS After surgical or endovascular management of arterial lesions due to self-injection in drug abuser patients, complications occur mainly in the postoperative period. During follow-up, the surgical procedures have low rate of complications, reinterventions, and procedure-related mortality, whereas for the endovascular treatment the mid-term outcomes remain unknown.
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Affiliation(s)
| | - Erica Mariani
- Department of Medicine and Surgery, Vascular Surgery, University of Parma, Parma, Italy
| | - Alessandro De Troia
- Department of Medicine and Surgery, Vascular Surgery, University of Parma, Parma, Italy
| | - Paolo Perini
- Department of Medicine and Surgery, Vascular Surgery, University of Parma, Parma, Italy
| | - Bilal Nabulsi
- Department of Medicine and Surgery, Vascular Surgery, University of Parma, Parma, Italy
| | - Rita Maria D'Ospina
- Department of Medicine and Surgery, Vascular Surgery, University of Parma, Parma, Italy
| | - Antonio Freyrie
- Department of Medicine and Surgery, Vascular Surgery, University of Parma, Parma, Italy
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“In situ” endografting in the treatment of arterial and graft infections. J Vasc Surg 2017; 65:1824-1829. [DOI: 10.1016/j.jvs.2016.12.134] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 12/13/2016] [Indexed: 12/27/2022]
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Mehta T, Dey R, Chaudhuri A. Ilioprofunda Endobypass Can Successfully Treat a Post-Operative Femoral Pseudo-Aneurysm. EJVES Short Rep 2016; 34:9-12. [PMID: 28856325 PMCID: PMC5576153 DOI: 10.1016/j.ejvssr.2016.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 11/02/2016] [Accepted: 11/07/2016] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION A 75-year-old male patient with significant cardiopulmonary comorbidity presented with a 70-mm left femoral pseudoaneurysm 6 years after aortobifemoral bypass (and prior femoral endarterectomy). REPORT As the left superficial femoral artery was occluded, an ilioprofunda endobypass was undertaken following extraperitoneal exposure of the left limb of the bypass graft with subsequent deployment of four Viabahn endoprostheses via the left limb into the proximal left deep femoral artery with successful exclusion of the pseudoaneurysm. The endografts remain patent at 6 months with regression noted in the pseudoaneurysm itself. DISCUSSION Post-operative femoral pseudoaneurysm following anastomotic dehiscence has traditionally been treated by open surgical repair. Re-re-do open femoral vascular surgery has a high complication rate. Scarring and potential graft infection may necessitate ligation of involved arteries and extra-anatomic bypasses with an attendant risk of limb loss. Although the common femoral artery is conventionally contraindicated for endograft deployment because of the perceived high risk of stent fracture in a highly mobile zone, an endobypass can avoid the potential complications of open revision groin surgery in an unfit, high-risk patient.
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Affiliation(s)
- T Mehta
- Bedfordshire-Milton Keynes Vascular Centre, Bedford Hospital NHS Trust, UK
| | - R Dey
- Bedfordshire-Milton Keynes Vascular Centre, Bedford Hospital NHS Trust, UK
| | - A Chaudhuri
- Bedfordshire-Milton Keynes Vascular Centre, Bedford Hospital NHS Trust, UK
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Endovascular Management of Infected Femoral Artery Pseudoaneurysms in High-Risk Patients: A Case Series. Cardiovasc Intervent Radiol 2016; 40:616-620. [DOI: 10.1007/s00270-016-1527-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 12/01/2016] [Indexed: 10/20/2022]
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