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Osman A, Das R, Pinas A, Hartopp R, Livermore D, Hawthorn B, Chun JY, Mailli L, Morgan R, Ratnam L. Outcome evaluation of prophylactic internal iliac balloon occlusion in the management of patients with placenta accreta spectrum. CVIR Endovasc 2024; 7:57. [PMID: 39039376 PMCID: PMC11263516 DOI: 10.1186/s42155-024-00466-2] [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: 03/18/2024] [Accepted: 06/24/2024] [Indexed: 07/24/2024] Open
Abstract
PURPOSE To evaluate outcomes and complications of prophylactic internal iliac balloon occlusion (PIIBO) in the management of patients with placenta accreta spectrum (PAS) at a large regional referral centre. MATERIALS AND METHODS A retrospective review of all PIIBO for PAS performed over a 12-year period (2010-2022). Information for analysis was gathered from the local RIS/PACS and clinical documentation. Collected data included patient demographics, indication for procedure, sheath insertion and removal time, total duration of balloon inflation and complications that occurred. RESULTS 106 patients underwent temporary internal iliac artery balloon occlusion within the 12-year period. All procedures utilised bilateral common femoral artery punctures, 6Fr sheath and 5Fr Le Maitre occlusion balloons. Catheters were successfully positioned and balloons inflated in obstetric theatre following caesarean delivery in 100% of the cases. The uterus was conserved in every case. There was no maternal mortality or foetal morbidity. Twenty patients (18.9%) had some form of complication that required further intervention. Of these, 7(6.6%) had post-operative PPH, which was treated with uterine artery embolisation; and 13 (12.3%) had arterial thrombus which required aspiration thrombectomy. All procedures were technically successful with no long-term sequelae. CONCLUSION PIIBO plays an important part in reducing morbidity and mortality in patients with PAS. Clear pathways and multidisciplinary team working is critical in the management of these patients to ensure that any complications are dealt with promptly to avoid long-term sequelae.
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Affiliation(s)
- Asaad Osman
- Department of Radiology, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK
| | - Raj Das
- Department of Radiology, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK
| | - Ana Pinas
- Department of Obstetrics and Gynaecology, St George's Hospital University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK
| | - Richard Hartopp
- Department of Anaesthetics, St George's Hospital University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK
| | - Deborah Livermore
- Department of Obstetrics and Gynaecology, St George's Hospital University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK
| | - Benjamin Hawthorn
- Department of Radiology, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK
| | - Joo-Young Chun
- Department of Radiology, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK
| | - Leto Mailli
- Department of Radiology, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK
| | - Robert Morgan
- Department of Radiology, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK
| | - Lakshmi Ratnam
- Department of Radiology, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK.
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Machado M, Dionísio T, Rocha D, Campos M, Sousa P. Placenta Accreta: A Case Report on the Role of Interventional Radiology. Cureus 2023; 15:e47680. [PMID: 38022115 PMCID: PMC10673647 DOI: 10.7759/cureus.47680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2023] [Indexed: 12/01/2023] Open
Abstract
Placenta accreta spectrum disorder is a pregnancy-related disorder responsible for important post-partum morbimortality, associated with intractable or massive hemorrhage, leading to uterine loss in up to 64% of women. Despite international recommendations advocating planned preterm cesarean hysterectomy for the management of these patients, uterus preservation management is being continuously reported with the implementation of minimally invasive bleeding reduction strategies, such as prophylactic balloon-assisted occlusion. We present the case of a 40-year-old pregnant woman with a previous cesarean, diagnosed with placenta previa and suspected placenta accreta on magnetic resonance after having second-trimester vaginal bleeding. A peri-operative multidisciplinary panel was involved, in collaboration with the interventional radiologist, and the c-section was scheduled for 36 weeks of gestation. The prophylactic balloon-assisted occlusion was successfully performed, minimizing the blood loss and allowing a uterus-preserving approach.
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Affiliation(s)
- Mafalda Machado
- Radiology, Centro Hospitalar Universitário do Algarve, Faro, PRT
| | - Teresa Dionísio
- Radiology, Centro Hospitalar Vila Nova de Gaia-Espinho, Vila Nova de Gaia, PRT
| | - Diogo Rocha
- Radiology, Centro Hospitalar Vila Nova de Gaia-Espinho, Vila Nova de Gaia, PRT
| | - Marta Campos
- Obstetrics and Gynaecology, Centro Hospitalar Vila Nova de Gaia-Espinho, Vila Nova de Gaia, PRT
| | - Pedro Sousa
- Radiology, Centro Hospitalar Vila Nova de Gaia-Espinho, Vila Nova de Gaia, PRT
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Hawthorn BR, Ratnam LA. Role of interventional radiology in placenta accreta spectrum (PAS) disorders. Best Pract Res Clin Obstet Gynaecol 2021; 72:25-37. [PMID: 33640296 DOI: 10.1016/j.bpobgyn.2021.01.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 01/27/2021] [Indexed: 10/22/2022]
Abstract
Placenta accreta spectrum (PAS) disorders are rare but potentially life-threatening obstetric conditions, which can result in severe post-partum haemorrhage (PPH). Traditional management necessitates peripartum hysterectomy, but this carries high rates of morbidity and mortality. More recently, interventional radiology techniques have been developed in order to reduce morbidity and preserve fertility. This article summarises and compares the various reported interventional radiology techniques. Arterial embolisation performed to treat PPH is the therapeutic option which is supported by the highest degree of evidence. The role of preventative procedures, such as temporary balloon occlusion of the internal iliac arteries or distal aorta, continues to be debated due to conflicting outcome data and concerns regarding associated morbidity. The choice of which, if any, interventional radiological technique is utilised is determined by local expertise, available resources and the planned obstetric approach. The most complex patients are likely to benefit from multidisciplinary management in high-volume centres.
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Affiliation(s)
- Benjamin R Hawthorn
- St George's Hospital University Hospitals NHS Foundation Trust, London, SW17 0QT, United Kingdom.
| | - Lakshmi A Ratnam
- St George's Hospital University Hospitals NHS Foundation Trust, London, SW17 0QT, United Kingdom.
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4
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Radiation dose during fluoroscopically guided central venous access device insertion: Retrospective observational study. RADIOLOGIA 2021. [DOI: 10.1016/j.rxeng.2020.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Estimating the radiation dose to the fetus during prophylactic internal iliac occlusion in patients with abnormal placentation. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2020; 165:435-440. [PMID: 33252114 DOI: 10.5507/bp.2020.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 10/02/2020] [Indexed: 11/23/2022] Open
Abstract
AIMS To evaluate the estimated fetal radiation dose during prophylactic internal iliac arterial occlusion in patients with abnormal placenta and to estimate the risk of radiation induced cancer in child age. METHODS Prophylactic occlusion of the internal iliac arteries during Caesarean section was performed in 42 patients with placenta praevia and/or placenta accreta spectrum. Fogarty embolectomy catheters were used for prophylactic occlusion of the internal iliac arteries. All procedures were performed in the hybrid operating room using Philips Allura Xper FD 20 X-ray system. Low dose X-ray fluoroscopy (7.5 frames per second) was used. The CODE (Conceptus dose estimation) Software was used to estimate the fetal dose and the risk of radiation induced carcinoma. RESULTS Fluoroscopy times required for insertion of Fogarty catheters were 0.5-4.2 min (mean: 1.7 min, median: 1.5 min). The estimated radiation dose to the fetus was 0.26-3.36 mGy (mean: 1.49 mGy, median: 1.25 mGy). The risk of radiation induced cancer in child age was 0.01-0.04% (mean 0.02%, median 0.01%). One patient developed thrombosis of a common femoral artery. CONCLUSION Prophylactic occlusion of the internal iliac arteries is a simple and safe procedure with minimal risk of complications and with a very low estimated radiation dose to the fetus.
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Preoperative Prophylactic Balloon-Assisted Occlusion of the Internal Iliac Arteries in the Management of Placenta Increta/Percreta. ACTA ACUST UNITED AC 2020; 56:medicina56080368. [PMID: 32717928 PMCID: PMC7466236 DOI: 10.3390/medicina56080368] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 07/22/2020] [Indexed: 11/18/2022]
Abstract
Background and Objectives: Preoperative prophylactic balloon-assisted occlusion (PBAO) of the internal iliac arteries minimizes blood loss and facilitates surgery performance, through reductions in the rate of uterine perfusion, which allow for better control in hysterectomy performance, with decreased rates of bleeding and surgical complications. We aimed to investigate the maternal and fetal outcomes associated with PBAO use in women with placenta increta or percreta. Material and Methods: The records of 42 consecutive patients with a diagnosis of placenta increta or percreta were retrospectively reviewed. Of 42 patients, 17 patients (40.5%) with placenta increta or percreta underwent cesarean delivery after prophylactic balloon catheter placement in the bilateral internal iliac artery (balloon group). The blood loss volume, transfusion volume, postoperative hemoglobin changes, rates of hysterectomy and hospitalization, and infant Apgar score in this group were compared to those of 25 similar women who underwent cesarean delivery without balloon placement (surgical group). Results: The mean intraoperative blood loss volume in the balloon group (2319 ± 1191 mL, range 1000–4500 mL) was significantly lower than that in the surgical group (4435 ± 1376 mL, range 1500–10,500 mL) (p = 0.037). The mean blood unit volume transfused in the balloon group (2060 ± 1154 mL, range 1200–8000 mL) was significantly lower than that in the surgical group (3840 ± 1464 mL, range 1800–15,200 mL) (p = 0.043). There was no significant difference in the postoperative hemoglobin change, hysterectomy rates, length of hospitalization, or infant Apgar score between the groups. Conclusion: PBAO of the internal iliac artery prior to cesarean delivery in patients with placenta increta or percreta is a safe and minimally invasive technique that reduces the rate of intraoperative blood loss and transfusion requirements.
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Soyer P, Barat M, Loffroy R, Barral M, Dautry R, Vidal V, Pellerin O, Cornelis F, Kohi MP, Dohan A. The role of interventional radiology in the management of abnormally invasive placenta: a systematic review of current evidences. Quant Imaging Med Surg 2020; 10:1370-1391. [PMID: 32550143 DOI: 10.21037/qims-20-548] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Abnormally invasive placenta (AIP) is a potentially severe condition. To date, arterial embolization in women with postpartum hemorrhage due to AIP is the treatment option for which highest degrees of evidence are available. However, other techniques have been tested, including prophylactic catheter placement, balloon occlusion of the iliac arteries and abdominal aorta balloon occlusion. In this systematic review, we provide an overview of the currently reported interventional radiology procedures that are used for the treatment of postpartum hemorrhage due to AIP and suggest recommendations based on current evidences. Owing to a high rate of adverse events, prophylactic occlusion of internal iliac arteries should be used with caution and applied when the endpoint is hysterectomy. On the opposite, when a conservative management is considered to preserve future fertility, uterine artery embolization should be the preferred option as it is associated with a hysterectomy rate of 15.5% compared to 76.5% with prophylactic balloon occlusion of the internal iliac arteries and does not result in fetal irradiation. Limited data are available regarding the application of systematic prophylactic embolization and no comparative studies with arterial embolization are available.
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Affiliation(s)
- Philippe Soyer
- Department of Radiology, Hopital Cochin, Assistance Publique - Hopitaux de Paris, Paris, France.,Université de Paris, Descartes-Paris 5, Paris, France
| | - Maxime Barat
- Department of Radiology, Hopital Cochin, Assistance Publique - Hopitaux de Paris, Paris, France.,Université de Paris, Descartes-Paris 5, Paris, France
| | - Romaric Loffroy
- Department of Vascular and Interventional Radiology, François-Mitterrand University Hospital, UFR des Sciences de Santé, Université de Bourgogne/Franche-Comté, Dijon, France
| | - Matthias Barral
- Department of Radiology, Hopital Tenon, Assistance Publique - Hopitaux de Paris, Paris, France.,Sorbonne University, Paris, France
| | - Raphael Dautry
- Department of Radiology, Hopital Cochin, Assistance Publique - Hopitaux de Paris, Paris, France
| | - Vincent Vidal
- Interventional Radiology Section, Department of Medical Imaging, University Hospital Timone APHM, LIIE, CERIMED Aix Marseille Univ, Marseille, France
| | - Olivier Pellerin
- Université de Paris, Descartes-Paris 5, Paris, France.,Department of Interventional Radiology, Hopital Européen Georges Pompidou, Assistance Publique-Hopitaux de Paris, Paris, France
| | - Francois Cornelis
- Department of Radiology, Hopital Tenon, Assistance Publique - Hopitaux de Paris, Paris, France
| | - Maureen P Kohi
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Anthony Dohan
- Department of Radiology, Hopital Cochin, Assistance Publique - Hopitaux de Paris, Paris, France.,Université de Paris, Descartes-Paris 5, Paris, France
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Nicholson PJ, O'Connor O, Buckley J, Spence LD, Greene RA, Tuite DJ. Prophylactic Placement of Internal Iliac Balloons in Patients with Abnormal Placental Implantation: Maternal and Foetal Outcomes. Cardiovasc Intervent Radiol 2018; 41:1488-1493. [PMID: 29777276 DOI: 10.1007/s00270-018-1983-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 05/06/2018] [Indexed: 10/16/2022]
Abstract
PURPOSE To report on outcomes following the use of prophylactic internal iliac artery occlusion balloons in patients with abnormal placental implantation. METHODS A retrospective analysis was undertaken of patients with abnormal placental implantation who underwent prophylactic iliac balloon placement prior to delivery in a University Maternity Hospital. Various clinical and technical factors were analysed, including technical success of balloon placement, blood loss and number of blood units transfused, duration of surgery, length of stay, hysterectomy rates, complications related to the balloon insertion, foetal pH and infant Apgar scores. RESULTS Twenty-two patients with placenta accreta or a variant thereof underwent caesarean section after first undergoing prophylactic placement of bilateral internal artery balloons. Average follow-up duration was 2.08 years. The average gestational age was 37 weeks 6 days, and the mean gravidity was 2.8. The mean number of previous caesarean sections was 2.4, while the mean maternal age was 35 years. The mean intraoperative blood loss was 1.4 L, and the mean number of blood units transfused was 2. Mean duration of surgery was 90 min, mean total length of hospital stay 7.5 days, while the mean duration of ICU/HDU stay was 1.2 days. The balloons were inflated in 60% of cases and two patients (2/22-9%) underwent subsequent hysterectomy. There were no major maternal complications due to the procedure. CONCLUSION Prophylactic placement of arterial balloons prior to caesarean section in patients with placenta accreta is well tolerated and leads to satisfactory maternal and foetal outcomes with minimal complications.
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Affiliation(s)
| | - Owen O'Connor
- Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland
| | - John Buckley
- Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland
| | - Liam D Spence
- Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland
| | - Richard A Greene
- National Perinatal Epidemiology Centre, Cork University Maternity Hospital, Wilton, Cork, Ireland
| | - David J Tuite
- Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland
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Angileri SA, Mailli L, Raspanti C, Ierardi AM, Carrafiello G, Belli AM. Prophylactic occlusion balloon placement in internal iliac arteries for the prevention of postpartum haemorrhage due to morbidly adherent placenta: short term outcomes. Radiol Med 2017; 122:798-806. [PMID: 28551762 DOI: 10.1007/s11547-017-0777-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 05/15/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE To evaluate outcomes of uterine conserving surgery with occlusion balloon technique. A critical review of the complications was performed. MATERIALS AND METHODS Between 2010 and 2016, pregnant women, with a prenatal diagnosis of morbidly adherent placenta (MAP), were treated with occlusion balloon catheters in both internal iliac arteries. Parameters such as need for hysterectomy, incidence of PPH, grade of MAP, estimated blood loss during delivery (EBL) and transfusion requirements, mean recovery time and duration of the balloon inflation, were collected and reviewed. Complications requiring further management were analysed. RESULTS Thirty-seven women with MAP underwent prophylactic occlusion balloon placement (POBC). Mean recovery was 4.48 days (range 2-10). Catheters were successfully positioned and balloons inflated in obstetric theatre following caesarean delivery in 100% of the cases. The uterus was conserved in every case. The MAP grades were 20 percreta, 3 increta and 14 accreta. The EBL was not statistically different between the different grades of placentation. There was a statistically significant association in the number of patients requiring blood transfusions and the degree of placental invasion (p = 0. 0119). PPH occurred in 5 patients (13.5%) and arterial thrombosis in 4 patients (11%). The EBL during delivery was significantly higher (2811 mL) in patients with complications (p = 0.0102). Furthermore, the group of patients that had complications required statistically significant more blood transfusions compared to those without complications (p = 0.0001). No maternal mortality or foetal morbidity occurred. CONCLUSION The utilisation of Prophylactic occlusion balloon catheters allows uterine conserving surgery to be performed safely with few maternal complications.
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Affiliation(s)
- Salvatore Alessio Angileri
- Diagnostic and Interventional Radiology Unit, Department of Health Sciences, San Paolo Hospital, University of Milan, Via A. di Rudinì 8, Milan, 20142, Italy
| | - Leto Mailli
- Radiology Department, St. George's Hospital, Blackshaw Road, London, SW17 0QT, UK
| | - Claudio Raspanti
- Interventional Radiology Unit, Careggi Academic and Regional Hospital of Florence, Largo Brambilla 3, Florence, 50134, Italy
| | - Anna Maria Ierardi
- Diagnostic and Interventional Radiology Unit, Department of Health Sciences, San Paolo Hospital, University of Milan, Via A. di Rudinì 8, Milan, 20142, Italy
| | - Gianpaolo Carrafiello
- Diagnostic and Interventional Radiology Unit, Department of Health Sciences, San Paolo Hospital, University of Milan, Via A. di Rudinì 8, Milan, 20142, Italy.
| | - Anna-Maria Belli
- Radiology Department, St. George's Hospital, Blackshaw Road, London, SW17 0QT, UK
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Solomou G, Perisinakis K, Tsetis D, Stratakis J, Damilakis J. Data and methods to estimate fetal dose from fluoroscopically guided prophylactic hypogastric artery balloon occlusion. Med Phys 2016; 43:2990-2997. [PMID: 27277047 DOI: 10.1118/1.4950718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE To provide data for estimation of fetal radiation dose (DF) from prophylactic hypogastric artery balloon occlusion (HABO) procedures. METHODS The Monte-Carlo-N-particle (MCNP) transport code and mathematical phantoms representing a pregnant patient at the ninth month of gestation were employed. PA, RAO 20° and LAO 20° fluoroscopy projections of left and right internal iliac arteries were simulated. Projection-specific normalized fetal dose (NFD) data were produced for various beam qualities. The effects of projection angle, x-ray field location relative to the fetus, field size, maternal body size, and fetal size on NFD were investigated. Presented NFD values were compared to corresponding values derived using a physical anthropomorphic phantom simulating pregnancy at the third trimester and thermoluminescence dosimeters. RESULTS NFD did not considerably vary when projection angle was altered by ±5°, whereas it was found to markedly depend on tube voltage, filtration, x-ray field location and size, and maternal body size. Differences in NFD < 7.5% were observed for naturally expected variations in fetal size. A difference of less than 13.5% was observed between NFD values estimated by MCNP and direct measurements. CONCLUSIONS Data and methods provided allow for reliable estimation of radiation burden to the fetus from HABO.
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Affiliation(s)
- G Solomou
- Department of Medical Physics, Faculty of Medicine, University of Crete, P.O. Box 2208, Heraklion, Crete 71003, Greece
| | - K Perisinakis
- Department of Medical Physics, Faculty of Medicine, University of Crete, P.O. Box 2208, Heraklion, Crete 71003, Greece and Department of Medical Physics, University Hospital of Heraklion, P.O. Box 1352, Heraklion, Crete 71110, Greece
| | - D Tsetis
- Department of Medical Physics, Faculty of Medicine, University of Crete, P.O. Box 2208, Heraklion, Crete 71003, Greece
| | - J Stratakis
- Department of Medical Physics, Faculty of Medicine, University of Crete, P.O. Box 2208, Heraklion, Crete 71003, Greece and Department of Medical Physics, University Hospital of Heraklion, P.O. Box 1352, Heraklion, Crete 71110, Greece
| | - J Damilakis
- Department of Medical Physics, Faculty of Medicine, University of Crete, P.O. Box 2208, Heraklion, Crete 71003, Greece
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