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Kokkinidis DG, Armstrong EJ. Current developments in endovascular therapy of peripheral vascular disease. J Thorac Dis 2020; 12:1681-1694. [PMID: 32395311 PMCID: PMC7212127 DOI: 10.21037/jtd.2019.12.130] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
More than 200 million people worldwide have peripheral artery disease (PAD) or its most severe manifestation, critical limb ischemia (CLI). While endovascular treatment has become first line therapy in most cases, a number of challenges remain for optimal treatment of femoropopliteal (FP) or infrapopliteal (IP) disease, especially when these lesions are severely calcified, chronic total occlusions (CTOs) or in-stent restenosis (ISR). Continued evolution of technologies has significantly improved the outcomes for endovascular treatment. A number of new devices are in the pipeline right now, including new paclitaxel eluting stents and balloons, intravascular lithotripsy to treat severely calcified lesions, adventitial delivery of anti-restenotic agents to limit restenosis rates, and percutaneous femoro-popliteal bypass.
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Affiliation(s)
- Damianos G Kokkinidis
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Aurora, CO, USA
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Aurora, CO, USA
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2
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Vossen RJ, Vahl AC, Leijdekkers VJ, Montauban van Swijndregt AD, Balm R. Long-Term Clinical Outcomes of Percutaneous Transluminal Angioplasty with Optional Stenting in Patients with Superficial Femoral Artery Disease: A Retrospective, Observational Analysis. Eur J Vasc Endovasc Surg 2018; 56:690-698. [PMID: 30108029 DOI: 10.1016/j.ejvs.2018.06.063] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 06/23/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND OBJECTIVE The recent ESC guideline advises primary stent placement in superficial femoral arterial disease (SFAD). The aim of this study was to compare clinical outcomes of SFAD patients selected for stent placement with plain percutaneous transluminal angioplasty (PTA). MATERIALS AND METHODS A single centre retrospective, observational analysis was performed of all consecutive patients undergoing endovascular treatment for SFAD from 2004 to 2015. Primary endpoints were primary and secondary clinical patency rates in patients with or without stent placement. Secondary endpoints were recurrence rates and number of amputations. Kaplan-Meier curves were used to compare patency rates. Multivariable Cox regression analysis was performed to adjust for confounding variables and to identify variables associated with loss of patency. RESULTS A total of 389 patients were analysed with a median follow up of 42 months. Two hundred and fifty one patients (64.5%) were stented. Primary clinical patency rates at 1, 3, and 5 years were 82.8%, 71.0%, and 65.6% after PTA and 76.3%, 65.7%, and 58.1% after stent placement (PTA-S), respectively (p = .30). Secondary patency rates were also comparable for the PTA and PTA-S group resulting in 1, 3 and 5 year clinical secondary patency of 89.1%, 81.0%, and 76.3% in the PTA group versus 87.8%, 78.5%, and 71.9% in the PTA-S group (p = .58). Multivariable analysis revealed equal primary and secondary clinical patency between the treatment groups. The absolute re-intervention rate was 29.3%. The number of re-interventions and amputation rate did not significantly differ between the two groups (p = .41 and p = .75). CONCLUSIONS Selective stenting in patients with SFAD shows comparable results in long-term clinical outcomes in patients who were treated with plain PTA as well as patients who are selected for stent placement. An approach of selective stenting is justified.
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Affiliation(s)
- Rianne J Vossen
- Department of Vascular Surgery, OLVG, Amsterdam, The Netherlands.
| | - Anco C Vahl
- Department of Vascular Surgery, OLVG, Amsterdam, The Netherlands
| | | | | | - Ron Balm
- Department of Vascular Surgery, Amsterdam University Medical Centre, Amsterdam, The Netherlands
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Kokkinidis DG, Jeon-Slaughter H, Khalili H, Brilakis ES, Shammas NW, Banerjee S, Armstrong EJ. Adjunctive stent use during endovascular intervention to the femoropopliteal artery with drug coated balloons: Insights from the XLPAD registry. Vasc Med 2018; 23:358-364. [DOI: 10.1177/1358863x18775593] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
With growing use of drug-coated balloons (DCB) for femoropopliteal (FP) artery interventions, there is limited information on rates of real-world adjunctive stent use and its association with short and long-term outcomes. We report on 225 DCB treated FP lesions in 224 patients from the Excellence in Peripheral Artery Disease (XLPAD) registry (NCT01904851) between 2014 and 2016. Cochran–Mantel–Haenszel and Wilcoxon rank sum statistics were used to compare stented (planned or ‘bail-out’) versus non-stented DCB treated lesions. Stents were implanted in 31% of FP DCB interventions. Among the 70 stents implanted, 46% were for ‘bail-out’ indications and 54% were planned. Lesions treated with stents were longer (mean 150 mm vs 100 mm; p < 0.001) and less likely to be in-stent restenosis lesions (10% vs 28%; p=0.003). Stenting was significantly more frequent in complex FP lesions, including chronic total occlusions (66% vs 34%; p < 0.001). For bail-out stenting, interwoven nitinol stents were the most common type (50%) followed by drug-eluting stents (34%) and bare-metal stents (22%). There were no differences in peri-procedural complication rates or 12-month target limb revascularization rates (18.6% vs 11.6%; p=0.162) or 12-month amputation rates (11.4% vs 11%; p=0.92) between lesions where adjunctive stenting was used versus lesions without adjunctive stenting, respectively. In conclusion, in a contemporary ‘real-world’ adjudicated multicenter US registry, adjunctive stenting was necessary in nearly a third of the lesions, primarily for the treatment of more complex FP lesions, with similar short and intermediate-term clinical outcomes compared with non-stented lesions. ClinicalTrials.gov Identifier: NCT01904851
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Affiliation(s)
- Damianos G Kokkinidis
- Division of Cardiology, VA Eastern Colorado Health Care System and University of Colorado, Denver, CO, USA
| | - Haekyung Jeon-Slaughter
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center and VA North Texas Health Care System, Dallas, TX, USA
| | - Houman Khalili
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center and VA North Texas Health Care System, Dallas, TX, USA
| | | | | | - Subhash Banerjee
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center and VA North Texas Health Care System, Dallas, TX, USA
| | - Ehrin J Armstrong
- Division of Cardiology, VA Eastern Colorado Health Care System and University of Colorado, Denver, CO, USA
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4
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Kokkinidis DG, Armstrong EJ. Emerging and Future Therapeutic Options for Femoropopliteal and Infrapopliteal Endovascular Intervention. Interv Cardiol Clin 2017; 6:279-295. [PMID: 28257775 DOI: 10.1016/j.iccl.2016.12.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Despite recent advances in endovascular therapy for peripheral artery disease, current technologies remain limited by rates of long-term restenosis and application to complex lesion subsets. This article presents data on upcoming therapies, including novel drug-coated balloons, drug-eluting stents, bioresorbable scaffolds, novel drug delivery therapies to target arteries, techniques to limit postangioplasty dissection, and treatment of severely calcified lesions.
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Affiliation(s)
- Damianos G Kokkinidis
- Section of Cardiology, Denver VA Medical Center, University of Colorado School of Medicine, 1055 Clermont Street, Denver, CO 80220, USA
| | - Ehrin J Armstrong
- Section of Cardiology, Denver VA Medical Center, University of Colorado School of Medicine, 1055 Clermont Street, Denver, CO 80220, USA.
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Song XL, Zhu YQ, Lu HT, Liu F, Wei LM, Kang HK, Zhao JG. Predictors for Better Blood-Flow Restoration of Long-Segmental Below-the-Knee Chronic Total Occlusions after Endovascular Therapy in Diabetic Patients. Korean J Radiol 2016; 17:874-881. [PMID: 27833403 PMCID: PMC5102915 DOI: 10.3348/kjr.2016.17.6.874] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 06/26/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To prospectively investigate predictors for good restoration of blood flow of below-the-knee (BTK) chronic total occlusions (CTOs) after endovascular therapy in diabetes mellitus (DM) patients. MATERIALS AND METHODS A total of 120 long-segmental (≥ 5 cm) BTK, CTOs in 81 patients who underwent recanalization were included in this study. After angioplasty, blood-flow restoration was assessed using modified thrombolysis in myocardial ischemia grades and classified as good flow (grade 3) and poor flow (grade 1/2). One hundred and six CTOs with successful recanalization were divided into a good flow group (GFG; n = 68) and poor flow group (PFG; n = 38). Multivariate logistic regression analyses were undertaken to determine independent predictors of blood-flow restoration. Receiver operating characteristic curves were constructed to determine the best cutoff value. The prevalence of target-lesion restenosis during follow-up was compared between two groups. RESULTS Univariate analyses suggested that CTOs in GFG were characterized by lighter limb ischemia (p = 0.03), shorter course of ischemic symptoms (p < 0.01) and lesion length (p = 0.04), more frequent use of intraluminal angioplasty (p = 0.03), and higher runoff score (p < 0.01) than those in PFG. Multivariate regression analyses suggested that distal runoffs (p = 0.001; odds ratio [OR], 10.32; 95% confidence interval [CI]: 4.082-26.071) and lesion length (p < 0.001; OR, 1.26; 95% CI: 1.091-1.449) were independent predictors for good flow restoration. Kaplan-Meier analyses at 12 months showed a higher prevalence of non-restenosis in GFG (p < 0.01). CONCLUSION Distal runoffs and lesion length are independent predictors for good flow restoration for long-segmental BTK, CTOs in DM patients who receive endovascular therapy.
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Affiliation(s)
- Xiao-Li Song
- Department of Radiology, Chonnam National University Medical School, Gwangju 501757, Korea
| | - Yue-Qi Zhu
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Hai-Tao Lu
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Fang Liu
- Department of Endocrinology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Li-Ming Wei
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Heoung Keun Kang
- Department of Radiology, Chonnam National University Medical School, Gwangju 501757, Korea
| | - Jun-Gong Zhao
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
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Schneider PA, Giasolli R, Ebner A, Virmani R, Granada JF. Early experimental and clinical experience with a focal implant for lower extremity post-angioplasty dissection. JACC Cardiovasc Interv 2016; 8:347-354. [PMID: 25700758 DOI: 10.1016/j.jcin.2014.07.032] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 07/31/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVES This study provides preliminary data on the safety and feasibility of the use of a novel focal implant for managing post-percutaneous transluminal balloon angioplasty (post-PTA) dissection. BACKGROUND Post-PTA dissection of the lower extremity arteries is managed with stent placement. This provides an acceptable post-intervention result but has long-term disadvantages, such as in-stent restenosis. Focal treatment of post-PTA dissection and avoidance of stents are the objectives of the Tack-It (Intact Vascular, Inc., Wayne, Pennsylvania) device. METHODS A preclinical study and first-in-human data are presented. Seven swine underwent superficial femoral artery device placement, with a self-expanding nitinol stent on 1 side and a series of 4 Tack-It devices on the other side. Specimens were harvested at 28 days. The clinical study included 15 limbs that underwent revascularization for critical limb ischemia (n = 9) or claudication (n = 6). Twenty-five lesions were treated in the superficial femoral (n = 8), popliteal (n = 7), and tibial (n = 10) arteries. RESULTS The preclinical study demonstrated a reduction in stenosis with the Tack-It (16.8 ± 2.6%) compared with stents (46.4 ± 9.8%). Neointimal thickness and injury score decreased with the Tack-It. Clinically, Tack-It placement resulted in acute technical success with resolution of the post-PTA dissection in 100% of lesions. There were no device-related complications or major amputations. Eighteen of the 25 lesions were available for angiographic follow-up at 1-year, and patency was 83.3%. CONCLUSIONS Preclinical data suggest that the Tack-It device causes minimal vessel injury. Clinical use of the Tack-It to manage post-PTA dissection was safe and feasible in this early study and resulted in apposition of dissection flaps without stent placement.
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Affiliation(s)
| | | | | | | | - Juan F Granada
- Skirball Research Center, Cardiovascular Research Foundation, Orangeburg, New York
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Zhu YQ, Wang J, Tan HQ, Lu HT, Liu F, Cheng YS, Wei LM, Zhang PL, Zhao JG. Runoff Detected by Magnetic Resonance Angiography as an Indicator for Better Recanalization Outcomes in Below-the-Knee Chronic Total Occlusions in Diabetic Patients. J Endovasc Ther 2015; 22:243-51. [PMID: 25809370 DOI: 10.1177/1526602815573229] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To compare the feasibility and efficacy of recanalizing below-the-knee (BTK) chronic total occlusions (CTOs) between patients with good or poor distal runoff based on magnetic resonance angiography (MRA) scans. Methods: Two hundred long-segment BTK CTOs in 171 limbs of 113 diabetic patients (58 men; mean age 69.8±1.9 years) were divided into good distal runoff (GDR: 119 lesions, 98 limbs) or poor distal runoff groups (PDR: 81 lesions, 73 limbs) based on baseline MRA findings. After angioplasty, modified thrombolysis in myocardial ischemia (mTIMI) grades and ankle-brachial index (ABI) were used to assess immediate outcomes. Regularly scheduled duplex or MRA imaging was performed in follow-up. The restenosis and limb salvage rates were compared. Results: The success rates were 93.3% and 87.7% in the GDR and PDR groups, respectively (p=0.21); subintimal angioplasty was more common in the PDR group (93.0% vs. 63.1%, p<0.01). Completion angiography indicated an mTIMI grade 3 blood flow in 71.2% lesions in the GDR patients and in 52.1% in the PDR (p=0.01) group. Improvement in the ABI was greater in the GDR limbs (p<0.001 vs. PDR). Mean imaging follow-up was 10.8±6.9 months in the GDR group and 11.1±6.6 months in the PDR group. Kaplan-Meier analysis showed a better restenosis-free rate in the GDR group (80.6% vs. 61.7%; p=0.02) at 12 months and for lesions with mTIMI grade 3 flow (p<0.01). At 24 months, Kaplan-Meier analysis revealed a better limb salvage rate in the GDR group (84.2% vs. 54.6%; p=0.02). Conclusion: Distal runoff detected using MRA could be a predictor for successful intraluminal recanalization, better distal tissue perfusion, improved long-term patency, and better limb salvage for patients with BTK CTOs.
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Affiliation(s)
- Yue-Qi Zhu
- Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Jue Wang
- Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Hua-Qiao Tan
- Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Hai-Tao Lu
- Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Fang Liu
- Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Ying-Sheng Cheng
- Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Li-Ming Wei
- Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Pei-Lei Zhang
- Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Jun-Gong Zhao
- Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
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Jones DW, Graham A, Connolly PH, Schneider DB, Meltzer AJ. Restenosis and symptom recurrence after endovascular therapy for claudication: does duplex ultrasound correlate with recurrent claudication? Vascular 2014; 23:47-54. [PMID: 24788064 DOI: 10.1177/1708538114532083] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
After endovascular therapy, duplex ultrasound surveillance to detect restenosis guides clinical decisions and defines treatment failure. However, the correlation between duplex ultrasound and symptom recurrence remains unclear. We reviewed our institutional experience (2007-2010) to identify patients undergoing endovascular therapy for claudication. The association between post-intervention systolic velocity ratio and patient-reported symptom recurrence was determined. We analyzed 183 follow-up visits following treatment in 88 limbs (femoropopliteal (56%) or iliac (44%) arteries). After femoropopliteal intervention, median systolic velocity ratio was higher in patients with symptom recurrence (2.99 symptomatic vs. 1.69 asymptomatic; p<0.001). Elevated systolic velocity ratio or occlusion correlated with symptom recurrence (area under receiver operator characteristic curve=0.82 [95% CI 0.74-0.83]), and systolic velocity ratio>2.5 was 71% sensitive and 72% specific for symptom recurrence. After femoropopliteal endovascular therapy for claudication, duplex ultrasound-detected restenosis is highly associated with clinical deterioration. This validates objective criteria for treatment failure in claudicants and suggests that symptom status can serve as a primary indicator of anatomic restenosis.
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Affiliation(s)
- Douglas W Jones
- Vascular and Endovascular Surgery, New York Presbyterian Hospital - Weill-Cornell Medical Center, New York, NY, USA
| | - Ashley Graham
- Vascular and Endovascular Surgery, New York Presbyterian Hospital - Weill-Cornell Medical Center, New York, NY, USA
| | - Peter H Connolly
- Vascular and Endovascular Surgery, New York Presbyterian Hospital - Weill-Cornell Medical Center, New York, NY, USA
| | - Darren B Schneider
- Vascular and Endovascular Surgery, New York Presbyterian Hospital - Weill-Cornell Medical Center, New York, NY, USA
| | - Andrew J Meltzer
- Vascular and Endovascular Surgery, New York Presbyterian Hospital - Weill-Cornell Medical Center, New York, NY, USA
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Vernon SA, Murphy WRC, Murphy TW, Haan JM. Abdominal aortic rupture from an impaling osteophyte following blunt trauma. J Vasc Surg 2013; 59:1112-5. [PMID: 23810261 DOI: 10.1016/j.jvs.2013.04.062] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Revised: 04/29/2013] [Accepted: 04/29/2013] [Indexed: 11/17/2022]
Abstract
Blunt injury of the abdominal aorta is highly fatal. We present an unusual case of an osteophyte impaling the abdominal aorta treated by endovascular repair. A 77-year-old man sustained a thoracolumbar fracture-dislocation with posterior aortic rupture between his celiac and superior mesenteric artery origins. His aortic injury was treated with a stent graft, excluding the celiac origin. He was dismissed on postoperative day 6. At 6 months, he had returned to most preinjury activities, and at 2-year follow-up, he continues to have good functional outcome. Endovascular repair may be successfully employed in select aortic injuries in hemodynamically stable patients.
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MESH Headings
- Accidents, Traffic
- Aged
- Aneurysm, False/diagnosis
- Aneurysm, False/etiology
- Aneurysm, False/surgery
- Aorta, Abdominal/diagnostic imaging
- Aorta, Abdominal/injuries
- Aorta, Abdominal/surgery
- Aortic Aneurysm, Abdominal/diagnosis
- Aortic Aneurysm, Abdominal/etiology
- Aortic Aneurysm, Abdominal/surgery
- Aortic Rupture/diagnosis
- Aortic Rupture/etiology
- Aortic Rupture/surgery
- Aortography/methods
- Blood Vessel Prosthesis Implantation
- Endovascular Procedures
- Humans
- Male
- Osteophyte/complications
- Osteophyte/diagnosis
- Tomography, X-Ray Computed
- Treatment Outcome
- Vascular System Injuries/diagnosis
- Vascular System Injuries/etiology
- Vascular System Injuries/surgery
- Wounds, Nonpenetrating/diagnosis
- Wounds, Nonpenetrating/etiology
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Affiliation(s)
- Seth A Vernon
- Department of Surgery, The University of Kansas School of Medicine-Wichita, Wichita, Kan
| | - William R C Murphy
- Department of Surgery, The University of Kansas School of Medicine-Wichita, Wichita, Kan
| | - Todd W Murphy
- Department of Surgery, The University of Kansas School of Medicine-Wichita, Wichita, Kan; Department of Trauma Services, Via Christi Hospital, Saint Francis Campus, Wichita, Kan
| | - James M Haan
- Department of Surgery, The University of Kansas School of Medicine-Wichita, Wichita, Kan; Department of Trauma Services, Via Christi Hospital, Saint Francis Campus, Wichita, Kan.
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