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Çay F, Eldem G, Sevim GA, Özdemir KÇ, Çil BE, Vargel İ, Peynircioğlu B. Endovascular Treatment of Peripheral Arteriovenous Malformations (AVMs): Do Angiographic Outcomes Relate to the Quality of Life? J Endovasc Ther 2024; 31:797-804. [PMID: 37086015 DOI: 10.1177/15266028231166546] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/23/2023]
Abstract
PURPOSE Patients with arteriovenous malformations (AVMs) have a lower health-related quality of life (QoL) than the general population. QoL assessment of patients with peripheral AVMs after endovascular treatment is scarce in the literature. Radiologic and clinical outcomes are not always correlated in vascular malformation treatment. This study aimed to investigate the relationship between clinical outcomes, QoL, and angiographic outcomes. MATERIALS AND METHODS Patients with peripheral AVM that underwent endovascular treatment between January 2009 and December 2021 in a single center were retrospectively evaluated. Patients' characteristics (age, sex), AVM characteristics (Schobinger classification, location, angiographic architecture), previous treatment, treatment characteristics (type of endovascular approach, embolizing agent and number of sessions), percentages of angiographic response, complications, and recurrence were evaluated. The angiographic architecture was evaluated according to the Yakes classification. The questionnaire was applied for evaluation of clinical response and QoL. Patients older than 12 years and those who can be contacted were included in clinical and QoL analysis. Clinical response was defined as improvement in the patient's most important pretreatment symptom. Treatment response was defined as clinical response plus >50% angiographic response. RESULTS Eighty-six patients (41 males [47.7%], 45 females [52.3%]) were included in angiographic analysis. The mean age was 28.44±12.99 years (range=5-61). Forty-three patients (50%) had previous treatment. The median number of sessions was 2 (range 1-15, InterQuartile Range [IOR]=2). Sixty-one patients (30 males [49.2%], 31 females [50.8%]) were included in clinical analysis. The clinical response rate was 73.8%, 95% confidence interval (CI) [0.60, 0.84]. The treatment response rate was 45.9%, 95% CI [0.33, 0.59]. The complication rate was 8.2%. Before treatment, 48 patients (78.7%) reported a negative impact on their QoL. Thirty-three of 48 patients (68.8%) reported improvement on their QoL after treatment. Higher Schobinger stages were related to a negative impact on QoL before treatment (p<0.01). Yakes types were not related to QoL (p=0.065). Clinical response was related to improvement on QoL after treatment (p<0.01). Angiographic and treatment responses were not related to improved QoL after treatment (p=0.52 and p=0.055, respectively). CONCLUSION Angiographic architecture and outcomes were not always reflected in QoL after endovascular treatment. CLINICAL IMPACT This study's findings will help clinicians with what to focus on in AVM treatment and how to monitor patients with peripheral AVM after endovascular treatment. Rather than relying too much on the angiographic response, patients should be checked for symptoms and quality of life improvement. No clear data in the literature regarding the applicability of the Yakes Classification in patients with previous treatment. This study questioned the applicability of the Yakes Classification in patients with previous treatments. In this study, type 4 AVMs were more common in patients with previous treatment.
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Affiliation(s)
- Ferdi Çay
- Department of Radiology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Gonca Eldem
- Department of Radiology, Hacettepe University School of Medicine, Ankara, Turkey
| | | | | | - Barbaros Erhan Çil
- Department of Radiology, Koç University School of Medicine, Istanbul, Turkey
| | - İbrahim Vargel
- Department of Plastic and Reconstructive Surgery, Hacettepe University School of Medicine, Ankara, Turkey
| | - Bora Peynircioğlu
- Department of Radiology, Hacettepe University School of Medicine, Ankara, Turkey
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Nava Y Hurtado F, Monzon Manzano E, Viana-Huete V, Triana Junco P, Alvarez-Roman MT, Arias-Salgado EG, Butta N, Lopez Gutierrez JC. Assessing coagulopathy and endothelial dysfunction in pediatric venous malformation: A thromboelastometry and syndecan-1 study. Pediatr Blood Cancer 2024; 71:e30915. [PMID: 38369689 DOI: 10.1002/pbc.30915] [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: 11/16/2023] [Revised: 01/15/2024] [Accepted: 01/28/2024] [Indexed: 02/20/2024]
Abstract
OBJECTIVE The occurrence of unpredictable pain crises are the principal determinant of the quality of life for patients with venous malformations (VM). A definite coagulation phenomenon, characterized by an increase in D-dimer levels and the presence of phleboliths within the malformation, has been previously reported. By applying Virchow's triad and evaluating intralesional samples, our objective is to delineate the coagulation profile and the extent of endothelial dysfunction within the malformation. METHODS With the authorization of the Ethics Committee, a research project was undertaken on intralesional and extralesional blood samples from 30 pediatric patients afflicted with spongiform VM. Thromboelastometry analyses were performed using ROTEM Sigma, and the concentration of syndecan-1 was determined by ELISA. RESULTS In the ROTEM analyses, the A5, A10, and maximum clot firmness (MCF) values were below the established reference ranges in the intralesional samples in both the EXTEM and INTEM assays, indicating that intralesional clots had significant instability. Furthermore, during the investigation of the delayed fibrinolysis phase using recombinant tissue plasminogen activator (rtPA) in EXTEM analysis, widespread hyperfibrinolysis was observed intralesional. Additionally, analysis of syndecan-1 showed significant differences between extralesional and intralesional levels (p < .026) and controls (p < .03), suggesting differences in the state of endothelium. CONCLUSIONS For the first time, we developed a comprehensive understanding of the coagulopathic profile of VM and the role of endothelial dysfunction in its pathogenesis. These findings will enable the implementation of targeted therapies based on the individual coagulation profiles.
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Affiliation(s)
| | - Elena Monzon Manzano
- Department of Haematology, Hospital Universitario La Paz, Madrid, Spain
- IdiPAZ, Madrid, Spain
| | - Vanesa Viana-Huete
- Department of Health Sciences, Universidad Europea de Madrid, Madrid, Spain
| | - Paloma Triana Junco
- Department of Paediatric Surgery, Hospital Universitario La Paz, Madrid, Spain
| | | | - Elena G Arias-Salgado
- Department of Haematology, Hospital Universitario La Paz, Madrid, Spain
- IdiPAZ, Madrid, Spain
| | - Nora Butta
- Department of Haematology, Hospital Universitario La Paz, Madrid, Spain
- IdiPAZ, Madrid, Spain
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Bouwman FCM, Verhaak C, de Blaauw I, Kool LJS, Loo DMWMT, van Rooij IALM, van der Vleuten CJM, Botden SMBI, Verhoeven BH. Health-related quality of life in children with congenital vascular malformations. Eur J Pediatr 2023; 182:5067-5077. [PMID: 37665335 PMCID: PMC10640403 DOI: 10.1007/s00431-023-05166-y] [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: 07/17/2023] [Revised: 08/16/2023] [Accepted: 08/16/2023] [Indexed: 09/05/2023]
Abstract
A cross-sectional study was performed to evaluate health-related quality of life (HRQOL) in children with congenital vascular malformations (CVM) and to investigate factors associated with an impaired HRQOL. Children (2-17 years) with CVMs who visited the HECOVAN expertise center between 2016-2018 were included. The PedsQL 4.0 Generic Core Scales were used and a score ≥ 1.0 SD below the normative mean was defined as an impaired HRQOL. Factors associated with impairment were investigated using univariate and multivariate logistic regression analysis. The median overall HRQOL was 84.8/100 (n = 207; 41% boys, 59% girls; self-reported IQR 73.9-92.4 and parent-reported IQR 71.4-92.4). Patients aged 13-17 years reported significantly worse physical functioning than those aged 8-12 years (median 84.4, IQR 71.1-93.8 versus median 90.6, IQR 81.3-96.9; p = 0.02). Parents reported a significantly lower overall HRQOL than their children (median 80.4, IQR 70.7-90.8 versus median 85.9, IQR 76.1-92.4; p = 0.001). HRQOL was impaired in 25% of patients. Impairment occurred significantly more often in lower extremity CVMs (38%, p = 0.01) and multifocal CVMs (47%, p = 0.01) compared to CVMs in the head/neck region (13%). Other associated factors included invasive management (31% versus 14%; p = 0.01), age at first treatment ≤ 5 years (48% versus 25%; p = 0.02) and ongoing treatment (38% versus 18%; p = 0.004). After correction for other factors, significance remained for lower extremity CVMs and ongoing invasive treatment. CONCLUSIONS Overall median HRQOL was reasonable and not significantly different from the norm sample. Parental ratings were significantly lower than their children's ratings. A quarter of the patients had an impaired HRQOL, which seemed to worsen with age. Independently associated factors included a lower extremity CVM and invasive management. WHAT IS KNOWN • Congenital vascular malformations could affect health-related quality of life (HRQOL). • Studies on pediatric patients are limited and either very small or in combination with adult patient series. WHAT IS NEW • This study raises awareness of an impaired HRQOL in 25% of pediatric patients with congenital vascular malformations. • Associated factors included a lower extremity CVM and invasive management.
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Affiliation(s)
- Frédérique C M Bouwman
- Department of Pediatric Surgery, Radboudumc-Amalia Children's Hospital, P.O. Box 9101, 6500 HB, Nijmegen, the Netherlands.
- Department of Radiology and Nuclear Medicine, Radboudumc, P.O. Box 9101, 6500 HB, Nijmegen, the Netherlands.
- Radboudumc Center of Expertise for Vascular Anomalies Hecovan, VASCERN VASCA European Reference Center, P.O. Box 9101, 6500 HB, Nijmegen, the Netherlands.
| | - Chris Verhaak
- Department of Medical Psychology, Radboudumc, Nijmegen, the Netherlands
| | - Ivo de Blaauw
- Department of Pediatric Surgery, Radboudumc-Amalia Children's Hospital, P.O. Box 9101, 6500 HB, Nijmegen, the Netherlands
| | - Leo J Schultze Kool
- Department of Radiology and Nuclear Medicine, Radboudumc, P.O. Box 9101, 6500 HB, Nijmegen, the Netherlands
- Radboudumc Center of Expertise for Vascular Anomalies Hecovan, VASCERN VASCA European Reference Center, P.O. Box 9101, 6500 HB, Nijmegen, the Netherlands
| | - D Maroeska W M Te Loo
- Radboudumc Center of Expertise for Vascular Anomalies Hecovan, VASCERN VASCA European Reference Center, P.O. Box 9101, 6500 HB, Nijmegen, the Netherlands
- Department of Pediatric Hematology, Radboudumc-Amalia Children's Hospital, Nijmegen, the Netherlands
| | | | - Carine J M van der Vleuten
- Radboudumc Center of Expertise for Vascular Anomalies Hecovan, VASCERN VASCA European Reference Center, P.O. Box 9101, 6500 HB, Nijmegen, the Netherlands
- Department of Dermatology, Radboudumc, Nijmegen, the Netherlands
| | - Sanne M B I Botden
- Department of Pediatric Surgery, Radboudumc-Amalia Children's Hospital, P.O. Box 9101, 6500 HB, Nijmegen, the Netherlands
- Radboudumc Center of Expertise for Vascular Anomalies Hecovan, VASCERN VASCA European Reference Center, P.O. Box 9101, 6500 HB, Nijmegen, the Netherlands
| | - Bas H Verhoeven
- Department of Pediatric Surgery, Radboudumc-Amalia Children's Hospital, P.O. Box 9101, 6500 HB, Nijmegen, the Netherlands
- Radboudumc Center of Expertise for Vascular Anomalies Hecovan, VASCERN VASCA European Reference Center, P.O. Box 9101, 6500 HB, Nijmegen, the Netherlands
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Responsiveness of the Patient-Reported Outcome Measure for Vascular Malformation Questionnaire in Patients with Low-Flow Vascular Malformations. J Vasc Interv Radiol 2023; 34:840-848.e5. [PMID: 36758741 DOI: 10.1016/j.jvir.2023.01.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 12/27/2022] [Accepted: 01/30/2023] [Indexed: 02/10/2023] Open
Abstract
PURPOSE To assess the responsiveness, defined as the ability to detect change in a patient's health or function, of the Patient-Reported Outcome Measure for Vascular Malformation (PROVAM) questionnaire in a cohort of patients with low-flow vascular malformations (VMs). MATERIALS AND METHODS PROVAM was previously developed to assess symptoms, functional limitations, and social/emotional effects experienced by patients with VMs. This is a prospective cohort study of 56 patients with venous and lymphatic VMs who completed at least 2 PROVAM questionnaires, of whom 43 had undergone treatment with sclerotherapy in the interim between questionnaires. External responsiveness was assessed using a receiver operating characteristic (ROC) curve to ascertain whether a change in the total PROVAM score predicts whether patients reported symptom improvement and by correlating the change in the total PROVAM score and change in symptoms reported during clinic visit. Internal responsiveness was evaluated using Wilcoxon signed rank test, Cohen d effect size (ESp), and standard response mean difference (SRM). RESULTS The total PROVAM score demonstrated excellent discrimination for symptom improvement with an area under the ROC curve of 0.856. There was a statistically significant, moderate positive correlation between the change in the total PROVAM score and the change in patient symptoms as determined from clinical visits (Spearman correlation coefficient [rs] = 0.67, P < .001). The total PROVAM score and all subdomain scores improved significantly after treatment (all P < .05). ESp and SRM were 0.80 and 0.83, respectively. CONCLUSIONS PROVAM is responsive to improvement after treatment and may be useful to assess health-related quality of life in patients treated for VMs.
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Berger S, Andersen R, Smaastuen MC, Rosseland LA, Dorenberg E. Long-term changes of health-related quality of life in patients with peripheral vascular malformations - a prospective observational study. J Plast Reconstr Aesthet Surg 2023; 77:46-53. [PMID: 36549122 DOI: 10.1016/j.bjps.2022.10.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 08/30/2022] [Accepted: 10/11/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE The aim of this observational study was to assess health-related quality of life (HRQOL) changes in patients with vascular malformations, over a period of almost eight years, and to assess clinical and demographic characteristics possibly associated with HRQOL changes. METHODS Eighty out of 111 patients who were included in a previously published comparative HRQOL study accepted inclusion in this follow-up study. HRQOL at baseline and follow-up was assessed with the Short-Form 36-item questionnaire (SF-36). Median observation time was 7.9 years. Linear mixed models and linear regression models were applied to assess HRQOL change and possible associations with demographic and clinical variables. RESULTS The median age of the patient cohort at baseline evaluation (n = 111) was 27.0 years. Ninety-six out of 111 (86.5%) patients were diagnosed with venous malformations. Significantly higher SF-36 scores at follow-up were found for the physical domains Role limitations due to (RLDT) physical problems (difference=13.5; 95% CI [1.6, 25.3]) and Bodily pain (difference=11.3; 95% CI [3.8, 18.8]). No deterioration of HRQOL was found in any domain. In multivariate analyses, female gender, muscle/bone involvement, and higher age were associated with a positive relative change in SF-36 in the domains Physical functioning, RLDT physical problems, and RLDT emotional problems, respectively. Invasive treatment was not associated with long-term HRQOL change. CONCLUSIONS Over a period of almost eight years, significant improvement of SF-36 scores was observed in the physical domains RLDT physical problems and bodily pain. Female gender, muscle/bone involvement, and higher age were associated with HRQOL improvement in certain domains.
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Affiliation(s)
- Sigurd Berger
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Norway; Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Norway.
| | - Rune Andersen
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Norway
| | - Milada Cvancarova Smaastuen
- Faculty of Health Sciences, Department of Nursing and Health Promotion, Oslo Metropolitan University, Norway; Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Norway
| | - Leiv Arne Rosseland
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Norway; Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Norway
| | - Eric Dorenberg
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Norway; Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Norway
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Appearance-related concerns and their impact on health-related quality of life in patients with peripheral vascular malformations. J Plast Reconstr Aesthet Surg 2022; 75:4202-4211. [DOI: 10.1016/j.bjps.2022.08.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 06/21/2022] [Accepted: 08/18/2022] [Indexed: 11/18/2022]
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Kerr AM, Sisk BA. Unanswered questions and unmet needs: A call for communication research in vascular anomalies. PATIENT EDUCATION AND COUNSELING 2021; 104:2839-2842. [PMID: 33858723 DOI: 10.1016/j.pec.2021.03.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 03/03/2021] [Accepted: 03/28/2021] [Indexed: 06/12/2023]
Affiliation(s)
- Anna M Kerr
- Department of Primary Care, Heritage College of Osteopathic Medicine, Ohio University, Athens, OH, USA.
| | - Bryan A Sisk
- Division of Hematology/Oncology, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
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Clinical characteristics associated with pain in patients with peripheral vascular malformations. J Vasc Surg 2021; 75:1054-1062.e1. [PMID: 34606955 DOI: 10.1016/j.jvs.2021.08.101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 08/29/2021] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Vascular malformations (VM) can negatively impact the patient's quality of life (QoL). Pain is a common problem in these patients. The aim of this study was to investigate risk factors associated with pain and to assess how pain affects QoL. METHODS This prospective cross-sectional study was conducted in a tertiary vascular anomaly expertise center. Between June and December 2020, all patients from our local database (334 adults and 189 children) with peripheral VMs were invited to complete the Outcome Measures for VAscular MAlformations questionnaire to evaluate the presence, frequency, and intensity of pain. Additionally, patients were asked to complete several Patient-Reported Outcome Measurement Information System scales to evaluate their QoL. Risk factors associated with pain were identified in bivariate analysis and multivariable logistic regression. QoL domains were compared between patients who experienced pain and patients who did not. RESULTS A total of 164 patients completed the questionnaire about pain and 133 patients completed all QoL questionnaires. Approximately one-half of the patients (52%) reported pain in the past four weeks and 57% of these patients reported pain daily or several times a week. Female sex (P = .009), lesions located in the upper extremity (P < .001) or lower extremity (P < .001), and intramuscular/intraosseous lesions (P = .004) were independently associated with the presence of pain. The following QoL domains were diminished in patients who experienced pain in comparison with patients who did not: pain interference (P < .001), physical functioning (P < .001), and social participation (P < .001) in adults, and pain interference (P = .001), mobility (P = .001), and anxiety (P = .024) in children. CONCLUSIONS Pain is a frequently reported complaint in patients with VMs and is present in approximately one-half of the patients. Patients with lesions located in the upper or lower extremity, intramuscular/intraosseous lesions, and female patients are more likely to experience pain. The presence of pain negatively impacted patients' QoL. Although VM are a benign condition and expectative management is frequently applied, our study shows that pain is a serious concern and needs to be actively assessed. Pain is a sign of various etiologies and should be examined to properly treat the pain.
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Pang C, Gibson M, Nisbet R, Evans N, Khalifa M, Papadopoulou A, Tsui J, Hamilton G, Brookes J, Lim CS. Quality of life and mental health of patients with vascular malformations in a single specialist center in the United Kingdom. J Vasc Surg Venous Lymphat Disord 2021; 10:159-169. [PMID: 33872818 DOI: 10.1016/j.jvsv.2021.03.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 03/31/2021] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Patients with vascular malformations suffer from chronic debilitating symptoms that have been shown to contribute negatively to their quality of life (QoL) and mental health. Despite this, the current literature evaluating the QoL and mental health of patients with vascular malformations remains scarce. Our aim was to evaluate the QoL and mental health of patients with vascular malformations. METHODS We prospectively analyzed the validated health-related QoL (HRQoL) questionnaires: the RAND Health Care 36-Item Short Form Survey (SF-36), Hospital Anxiety and Depression Scale (HADS), and visual analogue score for pain reported by 253 patients with vascular malformations in a specialist center of vascular anomalies in the UK over two years. RESULTS Patients with vascular malformations reported significantly poorer SF-36 scores in all domains compared with the UK general population. Patients with low-flow vascular malformations and arteriovenous malformations reported little variations in SF-36, HADS, and visual analogue score for pain scores. No significant association was found between age and any of the health-related QoL scores, other than the physical functioning in SF-36. Female patients reported significantly lower physical and social functioning of SF-36 and worse HADS-Depression than their male counterparts. Patients with syndromic vascular malformations reported significantly lower SF-36 scores in role-physical, role-emotional and bodily pain than nonsyndromic vascular malformations. CONCLUSIONS This study concluded that patients with vascular malformations reported worse QoL than the UK general population. Therefore, the assessment and management of QoL and mental health should be incorporated into the overall treatment strategies of patients with vascular malformations.
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Affiliation(s)
- Calver Pang
- Department of Vascular Surgery, Royal Free London NHS Foundation Trust, London, UK; Division of Surgery & Interventional Science, Department of Surgical Biotechnology, Faculty of Medical Sciences, University College London, London, UK
| | - Michael Gibson
- Department of Vascular Surgery, Royal Free London NHS Foundation Trust, London, UK
| | - Rebecca Nisbet
- Department of Vascular Surgery, Royal Free London NHS Foundation Trust, London, UK
| | - Nicholas Evans
- Department of Vascular Surgery, Royal Free London NHS Foundation Trust, London, UK
| | - Mohamed Khalifa
- Department of Interventional Radiology, Royal Free London NHS Foundation Trust, London, UK
| | - Anthie Papadopoulou
- Department of Interventional Radiology, Royal Free London NHS Foundation Trust, London, UK
| | - Janice Tsui
- Department of Vascular Surgery, Royal Free London NHS Foundation Trust, London, UK; Division of Surgery & Interventional Science, Department of Surgical Biotechnology, Faculty of Medical Sciences, University College London, London, UK
| | - George Hamilton
- Department of Vascular Surgery, Royal Free London NHS Foundation Trust, London, UK; Division of Surgery & Interventional Science, Department of Surgical Biotechnology, Faculty of Medical Sciences, University College London, London, UK
| | - Jocelyn Brookes
- Department of Vascular Surgery, Royal Free London NHS Foundation Trust, London, UK; Department of Interventional Radiology, Royal Free London NHS Foundation Trust, London, UK
| | - Chung Sim Lim
- Department of Vascular Surgery, Royal Free London NHS Foundation Trust, London, UK; Division of Surgery & Interventional Science, Department of Surgical Biotechnology, Faculty of Medical Sciences, University College London, London, UK.
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