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Mousa AY, AbuRahma AF, Bozzay J, Broce M, Barsoum E, Bates M. Anatomic and clinical predictors of reintervention after subclavian artery stenting. J Vasc Surg 2015; 62:106-14. [DOI: 10.1016/j.jvs.2015.01.055] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 01/23/2015] [Indexed: 10/23/2022]
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Mousa AY, AbuRahma AF, Bozzay J, Broce M, Kali M, Yacoub M, Stone P, Bates MC. Long-term Comparative Outcomes of Carotid Artery Stenting Following Previous Carotid Endarterectomy vs De Novo Lesions. J Endovasc Ther 2015; 22:449-56. [PMID: 25878023 DOI: 10.1177/1526602815581597] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To report the long-term outcomes of patients who underwent carotid artery stenting (CAS) for de novo carotid stenosis vs patients treated for restenosis after carotid endarterectomy (CEA). METHODS A retrospective review was conducted of all 385 patients (mean age 68.6±9.6 years; 231 men) who underwent 435 CAS procedures at a large tertiary care center between January 1999 and December 2013. For analysis, patients were stratified based on their lesion type [de novo (dn) vs post-CEA restenosis (res)] and subclassified by symptoms status [symptomatic (Sx) or asymptomatic (Asx)], creating 4 groups: (1) CAS-dn Asx, (2) CAS-dn Sx, (3) CAS-res Asx, and (4) CAS-res Sx. For the CAS-res group, the mean elapsed time from CEA to CAS was 72.4±63.6 months. Outcomes included target vessel reintervention (TVR) and in-stent restenosis (ISR), the latter defined by a carotid duplex ultrasound velocity >275 cm/s. RESULTS The main indication for initial carotid angiography with possible revascularization was severe carotid stenosis (≥70%-99% on duplex) in both CAS-dn and CAS-res groups (83.6% vs 83.7%, p=0.999). There were no significant differences in the percentage of patients with postintervention residual stenosis (<30%; 100% each arm) or complications between CAS-res vs CAS-dn: in-hospital stroke (1.4% vs 1.8%, respectively), myocardial infarction (0.9% vs 0%), or death (0.9% vs 0%). Mean follow-up was 62.4±45.6 months (median 53.5, range 1-180). Average clinical/TVR follow-up was greater for the CAS-res group (71.9±48.6 months) compared with 53.3±40.5 months for the CAS-dn group (p<0.001). Across the 4 study groups, there were no differences in freedom from ISR (p=0.174) or TVR (p=0.856). Multivariate analysis found peripheral vascular disease (PVD) as the sole ISR independent predictor [hazard ratio (HR) 1.92, 95% confidence interval (CI) 1.03 to 3.62, p=0.041], while significant predictors for TVR were age <65 years at the time of the procedure (HR 2.55, 95% CI 1.05 to 6.18, p=0.039) and PVD (HR 2.46, 95% CI 1.03 to 5.87, p=0.043). CONCLUSION The current study suggests that CAS is a feasible and durable therapeutic option for recurrent restenosis after CEA. Long-term outcomes were similar for patients treated for de novo lesions or post-CEA restenosis. Age and PVD appear to influence long-term CAS durability.
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Affiliation(s)
- Albeir Y Mousa
- Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, WV, USA
| | - Ali F AbuRahma
- Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, WV, USA
| | - Joseph Bozzay
- Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, WV, USA
| | - Mike Broce
- Center for Health Services and Outcomes Research, Charleston Area Medical Center Health Education and Research Institute, Charleston, WV, USA
| | - Maher Kali
- Center for Health Services and Outcomes Research, Charleston Area Medical Center Health Education and Research Institute, Charleston, WV, USA
| | - Michael Yacoub
- Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, WV, USA
| | - Patrick Stone
- Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, WV, USA
| | - Mark C Bates
- Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, WV, USA
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Stenting versus endarterectomy for restenosis following prior ipsilateral carotid endarterectomy: an individual patient data meta-analysis. Ann Surg 2015; 261:598-604. [PMID: 24979605 DOI: 10.1097/sla.0000000000000799] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To study perioperative results and restenosis during follow-up of carotid artery stenting (CAS) versus carotid endarterectomy (CEA) for restenosis after prior ipsilateral CEA in an individual patient data (IPD) meta-analysis. BACKGROUND The optimal treatment strategy for patients with restenosis after CEA remains unknown. METHODS A comprehensive search of electronic databases (Medline, Embase) until July 1, 2013, was performed, supplemented by a review of references. Studies were considered for inclusion if they reported procedural outcome of CAS or CEA after prior ipsilateral CEA of a minimum of 5 patients. IPD were combined into 1 data set and an IPD meta-analysis was performed. The primary endpoint was perioperative stroke or death and the secondary endpoint was restenosis greater than 50% during follow-up, comparing CAS and CEA. RESULTS In total, 13 studies were included, contributing to 1132 unique patients treated by CAS (10 studies, n = 653) or CEA (7 studies; n = 479). Among CAS and CEA patients, 30% versus 40% were symptomatic, respectively (P < 0.01). After adjusting for potential confounders, the primary endpoint did not differ between CAS and CEA groups (2.3% vs 2.7%, adjusted odds ratio 0.8, 95% confidence interval (CI): 0.4-1.8). Also, the risk of restenosis during a median follow-up of 13 months was similar for both groups (hazard ratio 1.4, 95% (CI): 0.9-2.2). Cranial nerve injury (CNI) was 5.5% in the CEA group, while CAS was in 5% associated with other procedural related complications. CONCLUSIONS In patients with restenosis after CEA, CAS and CEA showed similar low rates of stroke, death, and restenosis at short-term follow-up. Still, the risk of CNI and other procedure-related complications should be taken into account.
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Tu J, Wang S, Huo Z, Wu R, Yao C, Wang S. Repeated carotid endarterectomy versus carotid artery stenting for patients with carotid restenosis after carotid endarterectomy: Systematic review and meta-analysis. Surgery 2015; 157:1166-73. [PMID: 25840718 DOI: 10.1016/j.surg.2015.02.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Revised: 01/16/2015] [Accepted: 02/13/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Carotid restenosis (CRS) after carotid endarterectomy (CEA) is an issue that cannot be ignored. This study was undertaken to compare the outcomes of repeated CEA (redo CEA) and carotid artery stenting (CAS) for CRS after CEA. METHODS We performed a systematic analysis using the search terms "CEA restenosis," "carotid restenosis," or "CEA recurrent stenosis" in the MEDLINE, EMBASE, PubMed, and Cochrane Library databases. After applying the inclusion criteria, all available data were summarized to evaluate the effects of redo CEA and CAS for patients with CRS after prior CEA. RESULTS Fifty articles (9 comparative studies and 41 noncomparative studies) involving 4,399 patients were included. No differences were observed in the 30-day perioperative mortality, stroke and transient ischemic attack rates in the comparative studies (P > .05) and the noncomparative studies (P > .05). Patients undergoing redo CEA suffered more cranial nerve injuries (CNIs) than those undergoing CAS (P < .05), but most of these cases recovered within 3 months. Patients treated with redo CEA exhibited similar myocardial infarction (MI) rates to those treated with CAS in the comparative studies (P = .53), but the rate was higher in the noncomparative studies (P < .01). However, a nonsignificant difference was noted in freedom from stroke at 36 months in the comparative studies (P = .47) and at 12 months in the noncomparative studies (P = .89). The risk of restenosis was greater in the CAS patients than in the redo CEA patients (P < .05 for comparative and noncomparative studies). CONCLUSION Both redo CEA and CAS are safe and feasible for CRS after CEA. Although the incidences of CNI and MI were increased in the redo CEA group, most of the CNI cases were reversible. Patients treated with CAS were more likely to develop restenosis than those treated with redo CEA over long-term follow-up.
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Affiliation(s)
- Jian Tu
- Department of Vascular Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou City, Guangzhou, China; 8-year Program, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Siwen Wang
- Department of Vascular Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou City, Guangzhou, China
| | - Zijun Huo
- Department of Vascular Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou City, Guangzhou, China; 8-year Program, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Ridong Wu
- Department of Vascular Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou City, Guangzhou, China
| | - Chen Yao
- Department of Vascular Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou City, Guangzhou, China.
| | - Shenming Wang
- Department of Vascular Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou City, Guangzhou, China.
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Demirel S, Chen D, Mei Y, Partovi S, von Tengg-Kobligk H, Dadrich M, Böckler D, Kauczor HU, Müller-Eschner M. Comparison of morphological and rheological conditions between conventional and eversion carotid endarterectomy using computational fluid dynamics – a pilot study. Vascular 2014; 23:474-82. [DOI: 10.1177/1708538114552836] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: To compare postoperative morphological and rheological conditions after eversion carotid endarterectomy versus conventional carotid endarterectomy using computational fluid dynamics. Basic methods: Hemodynamic metrics (velocity, wall shear stress, time-averaged wall shear stress and temporal gradient wall shear stress) in the carotid arteries were simulated in one patient after conventional carotid endarterectomy and one patient after eversion carotid endarterectomy by computational fluid dynamics analysis based on patient specific data. Principal findings: Systolic peak of the eversion carotid endarterectomy model showed a gradually decreased pressure along the stream path, the conventional carotid endarterectomy model revealed high pressure (about 180 Pa) at the carotid bulb. Regions of low wall shear stress in the conventional carotid endarterectomy model were much larger than that in the eversion carotid endarterectomy model and with lower time-averaged wall shear stress values (conventional carotid endarterectomy: 0.03–5.46 Pa vs. eversion carotid endarterectomy: 0.12–5.22 Pa). Conclusions: Computational fluid dynamics after conventional carotid endarterectomy and eversion carotid endarterectomy disclosed differences in hemodynamic patterns. Larger studies are necessary to assess whether these differences are consistent and might explain different rates of restenosis in both techniques.
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Affiliation(s)
- S Demirel
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - D Chen
- Department of Biomedical Engineering, School of Life Science, Beijing Institute of Technology, Beijing, China
| | - Y Mei
- Department of Biomedical Engineering, School of Life Science, Beijing Institute of Technology, Beijing, China
| | - S Partovi
- Department of Radiology, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, USA
| | - H von Tengg-Kobligk
- Institute of Diagnostic, Interventional and Pediatric Radiology, University Hospital Bern, Inselspital, Bern, Switzerland
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany
| | - M Dadrich
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany
- Department of Radiology, German Cancer Research Center (dkfz), Heidelberg, Germany
| | - D Böckler
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - HU Kauczor
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany
| | - M Müller-Eschner
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany
- Department of Radiology, German Cancer Research Center (dkfz), Heidelberg, Germany
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Radak D, Sotirovic V, Obradovic M, Isenovic ER. Practical Use of Near-Infrared Spectroscopy in Carotid Surgery. Angiology 2014; 65:769-772. [DOI: 10.1177/0003319713508642] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Carotid endarterectomy (CEA) is the gold standard for the treatment of symptomatic patients with atherosclerotic carotid disease. However, benefit of the CEA procedure depends on the rate of peri- and postoperative adverse neurological events. Therefore, brain monitoring is important in detecting cerebral ischemia during and after CEA and also allows to prompt appropriate action. Traditional methods of cerebral monitoring are being replaced by novel, easy-to-use techniques that allow continued monitoring of regional cerebral oxygen saturation. In this review, we present the recent literature data related to the mechanism of cerebral oximetry and its practical use during and after CEA.
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Affiliation(s)
- Djordje Radak
- Department of Vascular Surgery, Dedinje Cardiovascular Institute, Belgrade University School of Medicine, Belgrade, Serbia
| | - Vuk Sotirovic
- Department of Vascular Surgery, Dedinje Cardiovascular Institute, Belgrade University School of Medicine, Belgrade, Serbia
| | - Milan Obradovic
- Laboratory of Radiobiology and Molecular Genetics, Institute Vinca, University of Belgrade, Belgrade, Serbia
| | - Esma R. Isenovic
- Laboratory of Radiobiology and Molecular Genetics, Institute Vinca, University of Belgrade, Belgrade, Serbia
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Radak D, Tanaskovic S, Sagic D, Antonic Z, Babic S, Popov P, Matic P, Rancic Z. Carotid angioplasty and stenting is safe and effective for treatment of recurrent stenosis after eversion endarterectomy. J Vasc Surg 2014; 60:645-51. [DOI: 10.1016/j.jvs.2014.03.288] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 03/27/2014] [Indexed: 11/26/2022]
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Radak D, Davidovic L, Tanaskovic S, Banzic I, Matic P, Babic S, Kostic D, Isenovic ER. A tailored approach to operative repair of extracranial carotid aneurysms based on anatomic types and kinks. Am J Surg 2014; 208:235-42. [DOI: 10.1016/j.amjsurg.2013.10.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Revised: 10/21/2013] [Accepted: 10/24/2013] [Indexed: 11/24/2022]
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Carotid restenosis after endarterectomy and stenting: a critical issue? Ann Vasc Surg 2014; 27:888-93. [PMID: 23993106 DOI: 10.1016/j.avsg.2013.02.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2012] [Revised: 02/10/2013] [Accepted: 02/12/2013] [Indexed: 11/22/2022]
Abstract
BACKGROUND Carotid artery stenting (CAS) is currently considered a valid alternative to carotid endarterectomy (CEA) for the prevention of stroke in high-risk patients. One of the most important issues for both of these techniques is carotid restenosis. The aim of our study was to evaluate the incidence of post-CEA and post-CAS restenosis in a large cohort of patients in a single high-volume center. METHODS Between December 2000 and December 2010, 2453 CEA and 2628 CAS procedures were performed in the Vascular and Endovascular Surgery Unit at our institution. The mean age of patients was 73.8 years (range 55‒89 years), 78% of whom were men. Indications for carotid revascularization were: presence of symptomatic carotid artery stenosis of >70%, or asymptomatic stenosis of at least 80%, especially in patients with vulnerable plaques. RESULTS Mild and long-term results after CEA and CAS were similar. The overall perioperative neurologic complication rate (minor and major stroke) was similar in the 2 groups. At 1-year follow-up the restenosis rate after CEA was 1.58%. In-stent restenosis after CAS occurred in 1.67% of the procedures. All but 3 arteries had been treated for postsurgical restenosis. All lesions were approached secondarily with endovascular procedures. Statistical analysis demonstrated that post-CEA restenosis was the most important predictive factor for the development of in-stent restenosis after CAS. CONCLUSIONS This review of our 10-year experience confirms that patients who develop restenosis after CEA are also prone to developing in-stent restenosis after CAS.
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Mendes GAC, Zabramski JM, Elhadi AM, Kalani MYS, Preul MC, Nakaji P, Spetzler RF. Carotid Endarterectomy. Neurosurgery 2014; 75:110-6; discussion 116. [DOI: 10.1227/neu.0000000000000356] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Cranial nerve injury (CNI) is the most common neurological complication associated with carotid endarterectomy (CEA). Some authors postulate that the transverse skin incision leads to increased risk of CNI.
OBJECTIVE:
We compared the incidence of CNI associated with the transverse and longitudinal skin incisions in a high-volume cerebrovascular center.
METHODS:
We reviewed the charts of 226 consecutive patients who underwent CEAs between January 2007 and August 2009. Pre- and postoperative standardized neurological evaluations were performed by faculty neurologists and neurosurgeons.
RESULTS:
One hundred sixty nine of 226 (75%) CEAs were performed with the use of a transverse incision. The longitudinal incision was generally reserved for patients with a high-riding carotid bifurcation. Mean patient age was 69 years (range, 45–91 years); 62% were men; 59% of patients were symptomatic and had high-grade stenosis (70%-99%). CNI occurred in 8 cases (3.5%): 5 (3%) in transverse and 3 (5.3%) with longitudinal incisions (P = .42). There were 2 marginal mandibular nerve injuries, 1 (0.6%) transverse and 1 longitudinal; 5 recurrent laryngeal nerve injuries, 4 transverse and 1 longitudinal; and 1 case of hypoglossal nerve injury associated with longitudinal incision. One hematoma was associated with CNI. All injuries were transient. Fourteen wound hematomas required surgical evacuation.
CONCLUSION:
The transverse skin incision for CEAs is not associated with an increased risk of CNI (P =.42). In this study, the incidence of CNI associated with the transverse incision was 3% (n = 5) vs 5% (n = 3) for longitudinal incisions. All CNIs were temporary.
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Affiliation(s)
- George A. C. Mendes
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Joseph M. Zabramski
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ali M. Elhadi
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - M. Yashar S. Kalani
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Mark C. Preul
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Peter Nakaji
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Robert F. Spetzler
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Radak D, Sotirovic V, Tanaskovic S, Isenovic ER. Intracranial Aneurysms in Patients With Carotid Disease. Angiology 2013; 65:12-6. [DOI: 10.1177/0003319712468938] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Before the routine use of computed tomography (CT) angiography, decisions for carotid artery treatment were mostly based on ultrasound findings and conventional angiography. Implementation and increasing use of CT angiography provided better visualization of the carotid and vertebrobasilar arteries system leading to an unexpected more frequent detection of unruptured intracranial aneurysms (UIAs). Concomitant presence of intracranial aneurysms in patients with severe carotid stenosis is a potential cause of significant mortality and morbidity. Due to the possible higher risk of aneurysm rupture after carotid procedures and ischemic events after aneurysm repair, the simultaneous presence of both lesions creates several therapeutic dilemmas. We review the prevalence of UIAs in patients with carotid occlusive disease and management difficulties and the current treatment strategies for handling the concomitant presence of these life-threatening diseases.
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Affiliation(s)
- Djordje Radak
- Vascular Surgery Clinic, “Dedinje” Cardiovascular Institute, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Vuk Sotirovic
- Vascular Surgery Clinic, “Dedinje” Cardiovascular Institute, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Slobodan Tanaskovic
- Vascular Surgery Clinic, “Dedinje” Cardiovascular Institute, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Esma R. Isenovic
- Institute Vinca, Laboratory for Radiobiology and Molecular Genetics, University of Belgrade, Belgrade, Serbia
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