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van de Voort JC, Stark PW, van Dongen TT, Borger van der Burg BL, Hoencamp R. Ultrasound guided arterial access for combat medics: A blinded proof-of-concept study using echogenic needles. J Vasc Access 2024:11297298241256171. [PMID: 38825786 DOI: 10.1177/11297298241256171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2024] Open
Abstract
BACKGROUND Obtaining percutaneous vascular access in hemodynamically unstable patients with constricted vessels can be challenging. Training combat medics in this procedure is necessary for administration of fluid and blood products and introducing endovascular bleeding control tools in pre-hospital settings. Echogenic coated needles might provide better ultrasound visibility in invasive procedures and hereby lower complications. The primary aim was to evaluate the efficacy of a microteaching program for obtaining ultrasound-guided femoral artery access for ultrasound inexperienced combat medics. The secondary aim was to assess the additional value of innovative echogenic coated needles in ultrasound-guided vascular access. METHODS Combat medics participated in a four-step microteaching program. The program consisted of a theoretical and step-by-step practical part with three different models including live and dead tissue & a REBOA Access Task Trainer. During the final test, all participants had to obtain femoral artery access on a pressurized post-mortem human specimen model with both echogenic coated and conventional needles. Self-perceived and observed performance as well as procedure times were scored. RESULTS All nine participants succeeded in blood vessel visualization and obtaining vascular access in the two models within 3 minutes and were significantly faster during the second attempt on the pressurized post-mortem human specimen model. Scoring comparison and usability preference by ultrasound inexperienced personnel showed a significant difference in favor of the echogenic coated needles. CONCLUSION Microteaching may be an effective approach to train combat medics in obtaining ultrasound-guided percutaneous femoral artery access. The use of echogenic coatings on needles could be a valuable adjunct and provide advantage in obtaining vascular access. Future research should focus on realistic simulation of austere situations and further evaluation of the use of echogenic coated instruments for vascular access in these pre-hospital settings.
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Affiliation(s)
- Jan C van de Voort
- Department of Surgery, Alrijne Hospital, Leiderdorp, The Netherlands
- Trauma Research Unit, Department of Trauma Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Pieter W Stark
- Department of Surgery, Alrijne Hospital, Leiderdorp, The Netherlands
- Trauma Research Unit, Department of Trauma Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | | | - Rigo Hoencamp
- Department of Surgery, Alrijne Hospital, Leiderdorp, The Netherlands
- Trauma Research Unit, Department of Trauma Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
- Defense Healthcare Organisation, Ministry of Defense, Utrecht, The Netherlands
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Wanhainen A, Van Herzeele I, Bastos Goncalves F, Bellmunt Montoya S, Berard X, Boyle JR, D'Oria M, Prendes CF, Karkos CD, Kazimierczak A, Koelemay MJW, Kölbel T, Mani K, Melissano G, Powell JT, Trimarchi S, Tsilimparis N, Antoniou GA, Björck M, Coscas R, Dias NV, Kolh P, Lepidi S, Mees BME, Resch TA, Ricco JB, Tulamo R, Twine CP, Branzan D, Cheng SWK, Dalman RL, Dick F, Golledge J, Haulon S, van Herwaarden JA, Ilic NS, Jawien A, Mastracci TM, Oderich GS, Verzini F, Yeung KK. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2024; 67:192-331. [PMID: 38307694 DOI: 10.1016/j.ejvs.2023.11.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 02/04/2024]
Abstract
OBJECTIVE The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy. METHODS The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence. RESULTS A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed. CONCLUSION The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.
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d'Entremont MA, Alrashidi S, Seto AH, Nguyen P, Marquis-Gravel G, Abu-Fadel MS, Juergens C, Tessier P, Lemaire-Paquette S, Heenan L, Skuriat E, Tyrwhitt J, Couture ÉL, Bérubé S, Jolly SS. Ultrasound guidance for transfemoral access in coronary procedures: an individual participant-level data metaanalysis from the femoral ultrasound trialist collaboration. EUROINTERVENTION 2024; 20:66-74. [PMID: 37800723 PMCID: PMC10758987 DOI: 10.4244/eij-d-22-00809] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 09/01/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND Randomised controlled trials of ultrasound (US)-guided transfemoral access (TFA) for coronary procedures have shown mixed results. AIMS We aimed to compare US-guided versus non-US-guided TFA from randomised data in an individual participant-level data (IPD) meta-analysis. METHODS We completed a systematic review and an IPD meta-analysis of all randomised controlled trials comparing US-guided versus non-US-guided TFA for coronary procedures. We performed a one-stage mixed-model meta-analysis using the intention-to-treat population from included trials. The primary outcome was a composite of major vascular complications or major bleeding within 30 days. RESULTS A total of 2,441 participants (1,208 US-guided, 1,233 non-US-guided) from 4 randomised clinical trials were included. The mean age was 65.5 years, 27.0% were female, and 34.5% underwent a percutaneous coronary intervention. The incidence of major vascular complications or major bleeding (34/1,208 [2.8%] vs 55/1,233 [4.5%]; odds ratio [OR] 0.61, 95% confidence interval [CI]: 0.39-0.94; p=0.026) was lower in the US-guided TFA group. In the prespecified subgroup of participants who received a vascular closure device, those randomised to US-guided TFA experienced a reduction in the primary outcome (2.1% vs 5.6%; OR 0.36, 95% CI: 0.19-0.69), while no benefit for US guidance was observed in the subgroup without vascular closure devices (4.1% vs 3.3%; OR 1.21, 95% CI: 0.65-2.26; interaction p=0.009). CONCLUSIONS In participants undergoing coronary procedures by TFA, US guidance decreased the composite outcome of major vascular complications or bleeding and may be especially helpful when using vascular closure devices.
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Affiliation(s)
- Marc-André d'Entremont
- Population Health Research Institute, Hamilton, ON, Canada
- Centre Hospitalier Universitaire de Sherbrooke (CHUS), Sherbrooke, QC, Canada
- McMaster University, Hamilton, ON, Canada
| | | | | | - Phong Nguyen
- Western Sydney University, Campbelltown, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
| | | | - Mazen S Abu-Fadel
- Oklahoma Heart Hospital, Oklahoma City, OK, USA and University of Oklahoma, Norman, OK, USA
| | - Craig Juergens
- University of New South Wales, Sydney, NSW, Australia
- Liverpool Hospital, Liverpool, NSW, Australia
| | - Pierre Tessier
- Hôpital du Sacré-Coeur-de-Montréal, Montreal, QC, Canada
| | | | - Laura Heenan
- Population Health Research Institute, Hamilton, ON, Canada
| | | | | | - Étienne L Couture
- Centre Hospitalier Universitaire de Sherbrooke (CHUS), Sherbrooke, QC, Canada
| | - Simon Bérubé
- Centre Hospitalier Universitaire de Sherbrooke (CHUS), Sherbrooke, QC, Canada
| | - Sanjit S Jolly
- Population Health Research Institute, Hamilton, ON, Canada
- McMaster University, Hamilton, ON, Canada
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Foley MP, Walsh SR, Doolan N, Vulliamy P, McMonagle M, Aylwin C. Editor's Choice - Systematic Review and Meta-Analysis of Lower Extremity Vascular Complications after Arterial Access for Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): An Inevitable Concern? Eur J Vasc Endovasc Surg 2023; 66:103-118. [PMID: 36796674 DOI: 10.1016/j.ejvs.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 01/24/2023] [Accepted: 02/10/2023] [Indexed: 02/16/2023]
Abstract
OBJECTIVE Resuscitative endovascular balloon occlusion of the aorta (REBOA) is used to temporise non-compressible torso haemorrhage. Recent data have suggested that vascular access complications secondary to REBOA placement are higher than initially anticipated. This updated systematic review and meta-analysis aimed to determine the pooled incidence rate of lower extremity arterial complications after REBOA. DATA SOURCES PubMed, Scopus, Embase, conference abstract listings, and clinical trial registries. REVIEW METHODS Studies including more than five adults undergoing emergency REBOA for exsanguinating haemorrhage that reported access site complications were eligible for inclusion. A pooled meta-analysis of vascular complications was performed using the DerSimonian-Laird weights for the random effects model, presented as a Forest plot. Further meta-analyses compared the relative risk of access complications between different sheath sizes, percutaneous access techniques, and indications for REBOA. Risk of bias was assessed using the Methodological Index for Non-Randomised Studies (MINORS) tool. RESULTS No randomised controlled trials were identified, and the overall study quality was poor. Twenty-eight studies including 887 adults were identified. REBOA was performed for trauma in 713 cases. The pooled proportion rate of vascular access complications was 8.6% (95% confidence interval 4.97 - 12.97), with substantial heterogeneity (I2 = 67.6%). There was no significant difference in the relative risk of access complications between 7 and > 10 F sheaths (p = .54), or between ultrasound guided and landmark guided access (p = .081). However, traumatic haemorrhage was associated with a significantly higher risk of complications compared with non-traumatic haemorrhage (p = .034). CONCLUSION This updated meta-analysis aimed to be as comprehensive as possible considering the poor quality of source data and high risk of bias. It suggested that lower extremity vascular complications were higher than originally suspected after REBOA. While the technical aspects did not appear to impact the safety profile, a cautious association could be drawn between REBOA use for traumatic haemorrhage and a higher risk of arterial complications.
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Affiliation(s)
- Megan Power Foley
- Department of Vascular Surgery, University College Hospital Galway, Galway, Ireland; Blizard Institute for Trauma Sciences, Queen Mary University of London, London, UK.
| | - Stewart R Walsh
- Lambe Institution for Translational Research, National University of Ireland Galway, Galway, Ireland; National Surgical Research Support Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Nathalie Doolan
- Department of Vascular Surgery, University College Hospital Galway, Galway, Ireland
| | - Paul Vulliamy
- Blizard Institute for Trauma Sciences, Queen Mary University of London, London, UK
| | | | - Christopher Aylwin
- Blizard Institute for Trauma Sciences, Queen Mary University of London, London, UK; Department of Trauma Surgery, Imperial College London, London, UK
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Hamed M, Thakker R, Elkheshen A, Saleh M, Dang AT, Jneid H, Khalife W, Kumbhani D, Rahman F, Elbadawi A. Meta-Analysis on Ultrasound Guidance for Femoral Vascular Access. Am J Cardiol 2023; 192:98-100. [PMID: 36758270 DOI: 10.1016/j.amjcard.2023.01.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 01/14/2023] [Accepted: 01/14/2023] [Indexed: 02/10/2023]
Affiliation(s)
- Mohamed Hamed
- Department of Internal Medicine, Florida Atlantic University, Boca Raton, Florida
| | - Ravi Thakker
- Division of Cardiology, University of Texas Medical Branch, Galveston, Texas
| | - Ahmed Elkheshen
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Mohammed Saleh
- Division of Cardiology, University of Texas Medical Branch, Galveston, Texas
| | - Alexander T Dang
- Division of Cardiology, University of Texas Medical Branch, Galveston, Texas
| | - Hani Jneid
- Division of Cardiology, University of Texas Medical Branch, Galveston, Texas
| | - Wissam Khalife
- Division of Cardiology, University of Texas Medical Branch, Galveston, Texas
| | - Dharam Kumbhani
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Faisal Rahman
- Division of Cardiology, John Hopkins University, Baltimore, Maryland
| | - Ayman Elbadawi
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas.
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Tokuda T, Takahara M, Iida O, Kohsaka S, Soga Y, Oba Y, Hirano K, Shinke T, Amano T, Ikari Y. Institutional Volume and Initial Results for Endovascular Treatment for Chronic Occlusive Lower-Extremity Artery Disease: A Report From the Japanese Nationwide Registry. J Endovasc Ther 2023:15266028231161242. [PMID: 36935577 DOI: 10.1177/15266028231161242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
PURPOSE Chronic total occlusion (CTO) remains as a major target for endovascular treatment (EVT) in improving symptomatic lower-extremity artery disease (LEAD). However, despite the technical demand and learning curve for the procedure, volume-outcome relationship of EVT targeted for CTO in symptomatic LEAD remains unclear. MATERIALS AND METHODS Data were obtained from a nationwide registry for EVT procedures limited to the Japanese Association of Cardiovascular Intervention and Therapeutics between January 2018 and December 2020 from 660 cardiovascular centers in Japan. In total, 96 099 patients underwent EVT for symptomatic LEAD, and 41 900 (43.6%) underwent CTO-targeted EVTs during the study period. Institutional volume was classified into quartiles. The association of institutional volumes with short-term outcomes was explored using the generalized linear mixed model using a logit link function, in which, interinstitution variability was used as a random effect. RESULTS The median institutional volume for all EVT cases per quartile was 29, 68, 125, and 299 cases/year for the first, second, third, and fourth quartiles, respectively. With each model analysis, the adjusted odds ratios (ORs) for technical success were significantly lower in patients who underwent EVT in institutions within the first quartile (<52 cases/year) than in the other quartiles (P < .01, respectively). On the contrary, the adjusted ORs for procedural complications were significantly higher in the first and second quartiles than in the third and fourth quartiles (P < .01, respectively). CONCLUSION In contemporary Japanese EVT practice, a higher institutional volume but not operator volume was associated with a higher technical success rate and a lower procedural complication rate in patients with symptomatic LEAD involving CTO lesions. CLINICAL IMPACT EVT for CTO lesions is still challenging for clinicians because of difficulties of wire/devise crossing or high procedural complications rate. Our study demonstrated that a higher institutional volume but not operator volume was associated with a higher technical success rate and a lower procedural complication rate in patients with symptomatic LEAD involving CTO lesions. In contemporary Japanese practice, a higher institutional experience has better impacts on short-term clinical outcomes. Future research should determine the relationship between institutional volume and long-term clinical outcomes.
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Affiliation(s)
- Takahiro Tokuda
- Department of Cardiology, Nagoya Heart Center, Nagoya, Japan
| | - Mitsuyoshi Takahara
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan.,Department of Diabetes Care Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
| | - Shun Kohsaka
- Department of Cardiology, School of Medicine, Keio University, Tokyo, Japan
| | - Yoshimitsu Soga
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Yasuhiro Oba
- Department of Cardiology, Nagoya Heart Center, Nagoya, Japan
| | - Keisuke Hirano
- Department of Cardiology, Toyohashi Heart Center, Toyohashi, Japan
| | - Toshiro Shinke
- Department of Cardiology, School of Medicine, Showa University, Tokyo, Japan
| | - Tetsuya Amano
- Department of Cardiology, Aichi Medical University, Nagakute, Japan
| | - Yuji Ikari
- Division of Cardiovascular Medicine, Tokai University Hospital, Isehara, Japan
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Modarai B, Haulon S, Ainsbury E, Böckler D, Vano-Carruana E, Dawson J, Farber M, Van Herzeele I, Hertault A, van Herwaarden J, Patel A, Wanhainen A, Weiss S, Esvs Guidelines Committee, Bastos Gonçalves F, Björck M, Chakfé N, de Borst GJ, Coscas R, Dias NV, Dick F, Hinchliffe RJ, Kakkos SK, Koncar IB, Kolh P, Lindholt JS, Trimarchi S, Tulamo R, Twine CP, Vermassen F, Document Reviewers, Bacher K, Brountzos E, Fanelli F, Fidalgo Domingos LA, Gargiulo M, Mani K, Mastracci TM, Maurel B, Morgan RA, Schneider P. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on Radiation Safety. Eur J Vasc Endovasc Surg 2023; 65:171-222. [PMID: 36130680 DOI: 10.1016/j.ejvs.2022.09.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 09/15/2022] [Indexed: 01/24/2023]
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Salık F, Bıçak M. Comparison of ultrasound-guided femoral artery cannulation versus palpation technique in neonates undergoing cardiac surgery. J Vasc Access 2023; 24:27-34. [PMID: 34082593 DOI: 10.1177/11297298211023307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVES Palpation technique for femoral artery cannulation can be very difficult, especially in neonates. In this study, we evaluated whether ultrasound-guided cannulation of the femoral artery is superior to palpation technique in neonates undergoing cardiac surgery. METHODS Forty neonates undergoing cardiac surgery were prospectively randomized into two groups (Ultrasound group and Palpation group). Access time, number of attempts, number of successful cannulations on first attempt, success rate, number of cannulas used, inadvertent access, and complications were compared between the two groups. Cost analyses of the cannulation were performed in two groups. RESULTS In the ultrasound group, access time for femoral artery cannulation was shorter (6.4 ± 3.0 and 10.2 ± 4.4, p = 0.003) and the number of attempts (1.4 ± 0.6 and 2.3 ± 0.8, p < 0.001) was lower compared to the palpation group. The number of successful cannulations on first-attempt (15 (75%) and 5 (25%), p = 0.002) and the success rate (95% (19) and 60% (12), p = 0.008) were higher in the ultrasound group. The number of cannulas used in the ultrasound group was less than the palpation group (p = 0.001). The cost of intervention was higher in the palpation group compared to the ultrasound group (p = 0.048). CONCLUSIONS The ultrasound-guided cannulation of the femoral artery in neonates is superior to the palpation technique based on the increased of the number of successful first-attempt cannulation and success rate, and the reducing of the access time, number of attempts, number of cannulas used, and cost of cannulation.
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Affiliation(s)
- Fikret Salık
- Department of Anesthesiology and Reanimation, Diyarbakır Gazi Yaşargil Training and Research Hospital, Diyarbakır, Turkey
| | - Mustafa Bıçak
- Department of Anesthesiology and Reanimation, Diyarbakır Gazi Yaşargil Training and Research Hospital, Diyarbakır, Turkey
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Jolly SS, AlRashidi S, d’Entremont MA, Alansari O, Brochu B, Heenan L, Skuriat E, Tyrwhitt J, Raco M, Tsang M, Valettas N, Velianou JL, Sheth T, Sibbald M, Mehta SR, Pinilla-Echeverri N, Schwalm JD, Natarajan MK, Kelly A, Akl E, Tawadros S, Camargo M, Faidi W, Bauer J, Moxham R, Nkurunziza J, Dutra G, Winter J. Routine Ultrasonography Guidance for Femoral Vascular Access for Cardiac Procedures: The UNIVERSAL Randomized Clinical Trial. JAMA Cardiol 2022; 7:1110-1118. [PMID: 36116089 PMCID: PMC9483833 DOI: 10.1001/jamacardio.2022.3399] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 08/19/2022] [Indexed: 12/15/2022]
Abstract
Importance A significant limitation of femoral artery access for cardiac interventions is the increased risk of vascular complications and bleeding compared with radial access. Strategies to make femoral access safer are needed. Objective To determine whether routinely using ultrasonography guidance for femoral arterial access for coronary angiography/intervention reduces bleeding or vascular complications. Design, Setting, and Participants The Routine Ultrasound Guidance for Vascular Access for Cardiac Procedures (UNIVERSAL) randomized clinical trial is a multicenter, prospective, open-label trial of ultrasonography-guided femoral access vs no ultrasonography for coronary angiography or intervention with planned femoral access. Patients were randomized from June 26, 2018, to April 26, 2022. Patients with ST-elevation myocardial infarction were not eligible. Interventions Ultrasonography guidance vs no ultrasonography guidance for femoral arterial access on a background of fluoroscopic landmarking. Main Outcomes and Measures The primary composite outcome is the composite of major bleeding based on the Bleeding Academic Research Consortium 2, 3, or 5 criteria or major vascular complications within 30 days. Results A total of 621 patients were randomized at 2 centers in Canada (mean [SD] age, 71 [10.24] years; 158 [25.4%] female). The primary outcome occurred in 40 of 311 patients (12.9%) in the ultrasonography group vs 50 of 310 patients (16.1%) without ultrasonography (odds ratio, 0.77 [95% CI, 0.49-1.20]; P = .25). The rates of Bleeding Academic Research Consortium 2, 3, or 5 bleeding were 10.0% (31 of 311) vs 10.7% (33 of 310) (odds ratio, 0.93 [95% CI, 0.55-1.56]; P = .78). The rates of major vascular complications were 6.4% (20 of 311) vs 9.4% (29 of 310) (odds ratio, 0.67 [95% CI, 0.37-1.20]; P = .18). Ultrasonography improved first-pass success (277 of 311 [86.6%] vs 222 of 310 [70.0%]; odds ratio, 2.76 [95% CI, 1.85-4.12]; P < .001) and reduced the number of arterial puncture attempts (mean [SD], 1.2 [0.5] vs 1.4 [0.8]; mean difference, -0.26 [95% CI, -0.37 to -0.16]; P < .001) and venipuncture (10 of 311 [3.1%] vs 37 of 310 [11.7%]; odds ratio, 0.24 [95% CI, 0.12-0.50]; P < .001) with similar times to access (mean [SD], 114 [185] vs 129 [206] seconds; mean difference, -15.1 [95% CI, -45.9 to 15.8]; P = .34). All prerandomization prespecified subgroups were consistent with the overall finding. Conclusions and Relevance In this randomized clinical trial, use of ultrasonography for femoral access did not reduce bleeding or vascular complications. However, ultrasonography did reduce the risk of venipuncture and number of attempts. Larger trials may be required to demonstrate additional potential benefits of ultrasonography-guided access. Trial Registration ClinicalTrials.gov Identifier: NCT03537118.
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Affiliation(s)
- Sanjit S. Jolly
- Population Health Research Institute, Hamilton, Ontario, Canada
- McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
- Niagara Health, St Catherines, Ontario, Canada
| | - Sulaiman AlRashidi
- McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
- Niagara Health, St Catherines, Ontario, Canada
| | - Marc-André d’Entremont
- Population Health Research Institute, Hamilton, Ontario, Canada
- Centre Hospitalier Universitaire de Sherbrooke (CHUS), Sherbrooke, Quebec, Canada
| | - Omar Alansari
- McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
- Niagara Health, St Catherines, Ontario, Canada
| | - Bradley Brochu
- CK Hui Heart Centre, Royal Alexandra Hospital Edmonton, Edmonton, Alberta, Canada
| | - Laura Heenan
- Population Health Research Institute, Hamilton, Ontario, Canada
| | | | | | - Michael Raco
- McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
- Niagara Health, St Catherines, Ontario, Canada
| | - Michael Tsang
- McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
- Niagara Health, St Catherines, Ontario, Canada
| | - Nicholas Valettas
- McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
- Niagara Health, St Catherines, Ontario, Canada
| | - James L. Velianou
- McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
- Niagara Health, St Catherines, Ontario, Canada
| | - Tej Sheth
- Population Health Research Institute, Hamilton, Ontario, Canada
- McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
- Niagara Health, St Catherines, Ontario, Canada
| | - Matthew Sibbald
- McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
- Niagara Health, St Catherines, Ontario, Canada
| | - Shamir R. Mehta
- Population Health Research Institute, Hamilton, Ontario, Canada
- McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
- Niagara Health, St Catherines, Ontario, Canada
| | - Natalia Pinilla-Echeverri
- Population Health Research Institute, Hamilton, Ontario, Canada
- McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
- Niagara Health, St Catherines, Ontario, Canada
| | - Jon David Schwalm
- Population Health Research Institute, Hamilton, Ontario, Canada
- McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
- Niagara Health, St Catherines, Ontario, Canada
| | - Madhu K. Natarajan
- Population Health Research Institute, Hamilton, Ontario, Canada
- McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
- Niagara Health, St Catherines, Ontario, Canada
| | - Andrew Kelly
- McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
- Niagara Health, St Catherines, Ontario, Canada
| | - Elie Akl
- McGill University Faculty of Medicine and Health Sciences, Montreal, Quebec, Canada
| | | | | | - Walaa Faidi
- Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - John Bauer
- Hamilton Health Sciences, Hamilton, Ontario, Canada
| | | | - James Nkurunziza
- McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
- Niagara Health, St Catherines, Ontario, Canada
| | - Gustavo Dutra
- McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Jose Winter
- Departamento de enfermedades cardiovasculares, Clínica Alemana De Santiago, Universidad del Desarrollo, Chile
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Alrashidi S, d’Entremont MA, Alansari O, Winter J, Brochu B, Heenan L, Skuriat E, Tyrwhitt J, Raco M, Tsang MB, Valettas N, Velianou J, Sheth T, Sibbald M, Mehta SR, Pinilla-Echeverri N, Schwalm JD, Natarajan MK, Kelly A, Akl E, Tawadros S, Camargo M, Faidi W, Dutra G, Jolly SS. Design and Rationale of Routine Ultrasou Nd Gu Idance for Vascular Acc Ess fo R Cardiac Procedure s: A Randomized Tria L (UNIVERSAL). CJC Open 2022; 4:1074-1080. [PMID: 36562014 PMCID: PMC9764117 DOI: 10.1016/j.cjco.2022.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 08/22/2022] [Indexed: 12/25/2022] Open
Abstract
Background A significant limitation of femoral artery access for cardiac interventions is the increased risk of vascular complications and bleeding compared to radial access. Ultrasound (US)-guided femoral access may reduce major vascular complications and bleeding. We aim to determine whether routinely using US guidance for femoral arterial access for coronary angiography or intervention will reduce Bleeding Academic Research Consortium (BARC) 2, 3, or 5 bleeding or major vascular complications. Methods The Ultrasound Guidance for Vascular Access for Cardiac Procedures: A Randomized Trial (UNIVERSAL) is a multicentre, prospective, open-label, randomized trial with blinded outcomes assessment. Patients undergoing coronary angiography with or without intervention via a femoral approach with fluoroscopic guidance will be randomized 1:1 to US-guided femoral access, compared to no US. The primary outcome is the composite of major bleeding based on the BARC 2, 3, or 5 criteria or major vascular complications within 30 days. The trial is designed to have 80% power and a 2-sided alpha level of 5% to detect a 50% relative risk reduction for the primary outcome based on a control event rate of 14%. Results We completed enrollment on April 29, 2022, with 621 randomized patients. The patients had a mean age of 71 years (25.4% female), with a high rate of comorbidities, as follows: 45% had a prior percutaneous coronary intervention; 57% had previous coronary artery bypass surgery; and 18% had peripheral vascular disease. Conclusions The UNIVERSAL trial will be one of the largest randomized trials of US-guided femoral access and has the potential to change guidelines and increase US uptake for coronary procedures worldwide.
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Affiliation(s)
- Sulaiman Alrashidi
- McMaster University, Hamilton, Ontario, Canada,Hamilton Health Sciences, Hamilton, Ontario, Canada,Niagara Health, St. Catharines, Ontario, Canada
| | - Marc-André d’Entremont
- Population Health Research Institute, Hamilton, Ontario, Canada,Centre Hospitalier Universitaire de Sherbrooke (CHUS), Sherbrooke, Quebec, Canada
| | - Omar Alansari
- McMaster University, Hamilton, Ontario, Canada,Hamilton Health Sciences, Hamilton, Ontario, Canada,Niagara Health, St. Catharines, Ontario, Canada
| | - Jose Winter
- Clinica Alemana de Santiago, Santiago, Chile
| | - Bradley Brochu
- CK Hui Heart Centre, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Laura Heenan
- Population Health Research Institute, Hamilton, Ontario, Canada
| | | | | | - Michael Raco
- McMaster University, Hamilton, Ontario, Canada,Hamilton Health Sciences, Hamilton, Ontario, Canada,Niagara Health, St. Catharines, Ontario, Canada
| | - Michael B. Tsang
- McMaster University, Hamilton, Ontario, Canada,Hamilton Health Sciences, Hamilton, Ontario, Canada,Niagara Health, St. Catharines, Ontario, Canada
| | - Nicholas Valettas
- McMaster University, Hamilton, Ontario, Canada,Hamilton Health Sciences, Hamilton, Ontario, Canada,Niagara Health, St. Catharines, Ontario, Canada
| | - James Velianou
- McMaster University, Hamilton, Ontario, Canada,Hamilton Health Sciences, Hamilton, Ontario, Canada,Niagara Health, St. Catharines, Ontario, Canada
| | - Tej Sheth
- McMaster University, Hamilton, Ontario, Canada,Hamilton Health Sciences, Hamilton, Ontario, Canada,Niagara Health, St. Catharines, Ontario, Canada,Population Health Research Institute, Hamilton, Ontario, Canada
| | - Matthew Sibbald
- McMaster University, Hamilton, Ontario, Canada,Hamilton Health Sciences, Hamilton, Ontario, Canada,Niagara Health, St. Catharines, Ontario, Canada
| | - Shamir R. Mehta
- McMaster University, Hamilton, Ontario, Canada,Hamilton Health Sciences, Hamilton, Ontario, Canada,Niagara Health, St. Catharines, Ontario, Canada,Population Health Research Institute, Hamilton, Ontario, Canada
| | - Natalia Pinilla-Echeverri
- McMaster University, Hamilton, Ontario, Canada,Hamilton Health Sciences, Hamilton, Ontario, Canada,Niagara Health, St. Catharines, Ontario, Canada,Population Health Research Institute, Hamilton, Ontario, Canada
| | - Jon David Schwalm
- McMaster University, Hamilton, Ontario, Canada,Hamilton Health Sciences, Hamilton, Ontario, Canada,Niagara Health, St. Catharines, Ontario, Canada,Population Health Research Institute, Hamilton, Ontario, Canada
| | - Madhu K. Natarajan
- McMaster University, Hamilton, Ontario, Canada,Hamilton Health Sciences, Hamilton, Ontario, Canada,Niagara Health, St. Catharines, Ontario, Canada,Population Health Research Institute, Hamilton, Ontario, Canada
| | - Andrew Kelly
- McMaster University, Hamilton, Ontario, Canada,Hamilton Health Sciences, Hamilton, Ontario, Canada,Niagara Health, St. Catharines, Ontario, Canada
| | - Elie Akl
- McGill University Health Centre, Montreal, Quebec, Canada
| | | | | | - Walaa Faidi
- Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Gustavo Dutra
- McMaster University, Hamilton, Ontario, Canada,Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Sanjit S. Jolly
- McMaster University, Hamilton, Ontario, Canada,Hamilton Health Sciences, Hamilton, Ontario, Canada,Niagara Health, St. Catharines, Ontario, Canada,Population Health Research Institute, Hamilton, Ontario, Canada,Corresponding author: Dr Sanjit S. Jolly, Population Health Research Institute, Hamilton General Hospital, 237 Barton St. East, Hamilton, Ontario L8L 2X2, Canada. Tel.: +1-905-521-2100 ext. 40309.
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11
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Weir A, Kennedy P, Joyce S, Ryan D, Spence L, McEntee M, Maher M, O'Connor O. Endovascular management of pelvic trauma. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1196. [PMID: 34430637 PMCID: PMC8350659 DOI: 10.21037/atm-20-4591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 12/18/2020] [Indexed: 11/06/2022]
Abstract
Traumatic pelvic injuries are an important group of acquired pathologies given their frequent association with significant vascular compromise. Potentially fatal as a consequence of rapid hemorrhage, achievement of early hemostasis is a priority; endovascular management of traumatic pelvic arterial injuries is an important potential option for treatment. Precipitated by any number of mechanisms of trauma, pelvic vascular injury necessitates timely patient assessment. Variable patterns of arterial injury may result from blunt, penetrating or iatrogenic trauma. Selection of the most appropriate imaging modality is a priority, ensuring streamlined access to treatment. In the case of CT, this is complemented by acquisition of the most appropriate phase of imaging; review of both arterial and delayed phase imaging improves the accuracy of detection of low-flow hemorrhage. In cases where surgical intervention is not deemed appropriate, endovascular treatment provides an alternative means for cessation of hemorrhage associated with pelvic injuries. This may be achieved in a selective or nonselective manner depending on the patient's clinical status and time constraints. Consequently, a detailed understanding of vascular anatomy is essential, including an appreciation of the normal variant anatomy between males and females. Additional consideration must be given to variant anatomy which may co-exist in both sexes. This review article aims to provide a synopsis of endovascular management of pelvic vascular injury. Through case examples, available treatment options will be discussed, including thrombin injection and transcatheter arterial embolization. Furthermore, potential adverse complications of pelvic arterial embolization will be highlighted. Finally, in view of the potential severity of these injuries, a brief overview of initial management of the hemodynamically unstable patient is provided.
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Affiliation(s)
- Arlene Weir
- Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland.,Department of Radiology, Mercy University Hospital, Grenville Place, Cork, Ireland
| | - Padraic Kennedy
- Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland.,Department of Radiology, Mercy University Hospital, Grenville Place, Cork, Ireland
| | - Stella Joyce
- Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland.,Department of Radiology, Mercy University Hospital, Grenville Place, Cork, Ireland.,School of Medicine, University College Cork, Cork, Ireland
| | - David Ryan
- School of Medicine, University College Cork, Cork, Ireland
| | - Liam Spence
- Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland
| | - Mark McEntee
- School of Medicine, University College Cork, Cork, Ireland
| | - Michael Maher
- Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland.,Department of Radiology, Mercy University Hospital, Grenville Place, Cork, Ireland.,School of Medicine, University College Cork, Cork, Ireland
| | - Owen O'Connor
- Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland.,Department of Radiology, Mercy University Hospital, Grenville Place, Cork, Ireland.,School of Medicine, University College Cork, Cork, Ireland
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12
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Asbeutah AAA, Asbeutah AM, Ibebuogu UN, Khouzam RN. Meta-Analysis of Outcomes in Ultrasound Guided Versus Traditional Guided Vascular Access for Interventional Cardiac and Peripheral Vascular Procedures. Am J Cardiol 2021; 148:176-178. [PMID: 33689697 DOI: 10.1016/j.amjcard.2021.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 03/02/2021] [Indexed: 11/25/2022]
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13
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Shin JH. Recent Radiation Reduction Strategies for Neurointerventionists. Neurointervention 2020; 15:167-170. [PMID: 33080665 PMCID: PMC7608495 DOI: 10.5469/neuroint.2020.00346] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 10/06/2020] [Indexed: 01/10/2023] Open
Affiliation(s)
- Jae Ho Shin
- Department of Radiology, St. Vincent's Hospital, The Catholic University of Korea, Suwon, Korea
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14
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Balceniuk MD, Sebastian A, Schroeder AC, Ayers BC, Raman K, Ellis JL, Doyle AJ, Glocker RJ, Stoner MC. Regional Variation in Usage of Ultrasound-Guided Femoral Access in the Vascular Quality Initiative. Ann Vasc Surg 2020; 72:544-551. [PMID: 32949742 DOI: 10.1016/j.avsg.2020.08.156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 08/31/2020] [Accepted: 08/31/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Access site complications are among the most common complications following peripheral vascular interventions. Previous studies have demonstrated a reduced rate of complications with ultrasound-guided vascular access (UGVA). The objective of this study is to evaluate the regional use of UGVA within the Vascular Quality Initiative (VQI). METHODS The VQI peripheral intervention module between 2010 and 2018 was evaluated. Regional ID was used to compare distribution of ultrasound usage. Regions were grouped into terciles based on the rate of ultrasound use. Patients were categorized based on type of access. Primary outcome was use of ultrasound across regions. Secondary outcomes were access site complications. RESULTS Over 43,000 cases across the 18 VQI regions were evaluated. The average rate of ultrasound usage was 71% across the regions with a wide variation (range 38-97%). There is a significant difference in utilization among the top third (87%), middle third (79%), and bottom third (58%) (P < 0.001). Average sheath size was similar across all 3 groups. A higher use of ultrasound-guided access was associated with significantly fewer access site complications (top third 1.96% vs. bottom third 3.04%, P < 0.001), the most significant of which was a decreased rate of access site hematoma (top third 1.37% vs. bottom third 2.35%, P < 0.001). CONCLUSIONS This is the first study to evaluate ultrasound-guided access across VQI regions. Our results demonstrate that despite strong evidence supporting the utilization of UGVA, there remains a wide variation in ultrasound usage across VQI regions. This is also the first study to show that the prevalence of ultrasound use in peripheral vascular interventions (PVI) is inversely related to access site complications. Given all of the data supporting the usage of UGVA across numerous specialties, our findings encourage the consideration of an ultrasound-first approach for vascular access in PVI and the implementation of targeted strategies and evidence-based guidelines to enhance UGVA utilization in PVI.
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Affiliation(s)
- Mark D Balceniuk
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Armand Sebastian
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Andrew C Schroeder
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Brian C Ayers
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Kathleen Raman
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Jennifer L Ellis
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Adam J Doyle
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Roan J Glocker
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Michael C Stoner
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY.
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15
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Keohane C, Walsh S, Tawfick W. Regarding "On-Site-Modified Sheath to Overcome the Undesirable Catheterization of the Profunda Femoris Artery During Antegrade Femoral Access". J Endovasc Ther 2020; 28:173. [PMID: 32907450 DOI: 10.1177/1526602820954267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Colum Keohane
- Vascular Surgery, National University of Ireland Galway, Lambe Institute National University of Ireland, Galway, Ireland
| | - Stewart Walsh
- Vascular Surgery, National University of Ireland Galway, Lambe Institute National University of Ireland, Galway, Ireland
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