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Falcon AK, Caballero LM, Filiberto DM, Lenart EK, Easterday TS, Bhatt MN, Mitchell EL, Byerly S. Risk Factors for Venous Thromboembolism and Eventual Amputation in Traumatic Femoral and Iliac Vein Injuries: A Trauma Quality Improvement Program Analysis. Am Surg 2024; 90:1879-1885. [PMID: 38527489 DOI: 10.1177/00031348241241645] [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] [Indexed: 03/27/2024]
Abstract
BACKGROUND Iliac and femoral venous injuries represent a challenging dilemma in trauma surgery with mixed results. Venous restoration of outflow (via repair or bypass) has been previously identified as having higher rates of VTE (venous thromboembolism) compared to ligation. We hypothesized that rates of VTE and eventual amputation were similar whether restoration of venous outflow vs ligation was performed at initial operation. METHODS Patients in the 2019-2021 National Trauma Data Bank with iliac and femoral vein injuries were abstracted and analyzed. The primary outcomes of interest were in-hospital lower extremity amputation and VTE. RESULTS A total of 2642 patients with operatively managed iliac and femoral vein injuries were identified VTE was found in 10.8% of patients. Multivariable logistic regression was performed and identified bowel injury, higher ISS, older age, open repair, and longer time to VTE prophylaxis initiation as independent predictors of VTE. Amputation was required in 4.2% of patients. Multivariable logistic regression identified arterial or nerve injury, femur or tibia fracture, venous ligation, percutaneous intervention, fasciotomy, bowel injury, and higher ISS as independent factors of amputation. CONCLUSION Venous restoration was not an independent predictor of VTE. Venous ligation on index operation was the only modifiable independent predictor of amputation identified on regression analysis.
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Affiliation(s)
- Allison K Falcon
- Department of Surgery, University of Tennessee Health Science Campus, Memphis, TN, USA
| | - Ladd M Caballero
- Department of Surgery, University of Tennessee Health Science Campus, Memphis, TN, USA
| | - Dina M Filiberto
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Tennessee Health Science Campus, Memphis, TN, USA
| | - Emily K Lenart
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Tennessee Health Science Campus, Memphis, TN, USA
| | - Thomas S Easterday
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Tennessee Health Science Campus, Memphis, TN, USA
| | - Maunil N Bhatt
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Tennessee Health Science Campus, Memphis, TN, USA
| | - Erica L Mitchell
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Tennessee Health Science Campus, Memphis, TN, USA
| | - Saskya Byerly
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Tennessee Health Science Campus, Memphis, TN, USA
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Ribeiro R, Kondo W, Erzinger FL. Management of vascular injuries in gynecologic oncology surgery. Int J Gynecol Cancer 2023; 33:1477-1478. [PMID: 37666536 DOI: 10.1136/ijgc-2023-004682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2023] Open
Affiliation(s)
- Reitan Ribeiro
- Department of Gynecology Oncology, Erasto Gaertner Hospital, Curitiba, Brazil
| | - William Kondo
- Department of Gynecology, Vital Batel Hospital, Curitiba, Brazil
| | - Fabiano L Erzinger
- Department of Vascular Surgery, Erasto Gaertner Hospital, Curitiba, Brazil
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O'Shea AE, Lee C, Kauvar DS. Analysis of Concomitant and Isolated Venous Injury in Military Lower Extremity Trauma. Ann Vasc Surg 2022; 87:147-154. [PMID: 35460859 DOI: 10.1016/j.avsg.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 04/11/2022] [Accepted: 04/11/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVES The implications of major venous injury to the lower extremity are not well established. We aimed to determine the significance of concomitant and isolated femoropopliteal venous injury and assess the impact of surgical management strategies on limb outcomes. METHODS The Fasciotomy and Vascular Injury Outcomes Database was queried for limbs sustaining femoropopliteal arterial, venous, or concomitant injuries in Iraq or Afghanistan between 2004-2012. Demographics, injury patterns and severity, interventions, and outcomes were compared between patients sustaining isolated arterial injuries (IAI) and concomitant arteriovenous injuries (AVI). In limbs with any venous injury, outcomes were compared between those undergoing venous (VR) and ligation (VL). RESULTS 330 patients (133 IAI, 135 AVI, 62 isolated venous injuries (IVI)) were included. AVI was associated with greater limb injury severity: median extremity Abbreviated Injury Scale (AVI 4 vs. IAI 3, p=0.01), Mangled Extremity Severity Score >7 (25.9% vs. 13.5%, p= 0.01), multi-level vascular injury (6.7% vs. 0.8%, p=0.01) and with greater fasciotomy use (83.0% vs. 69.2%, p=0.01). No differences were present in tourniquet use/time, shunting, or nature of arterial repair. No differences in vascular or limb complications (71.1% vs. 63.9%, p=0.21) or amputation rate (25.9% vs. 18.8%, p=0.16) were present, though limb DVT rate was 12.6% in AVI vs. 7.5% in IAI (p=0.17). Limbs with IVI had a 12.9% amputation and a 74.2% complication rate. Repair (n=103) versus ligation (n=94) of venous injuries was not associated with a difference in amputation (18.4% vs. 25.5%, p=0.23) or limb complication rates (71.8% vs. 72.3%, p=0.94). CONCLUSION Despite higher extremity injury severity and more frequent fasciotomies, concomitant venous injury was not associated with poorer limb salvage or complications. With nontrivial amputation and complication rates, IVI is indicative of severe limb trauma. Repair of femoropopliteal venous injuries does not appear to influence limb outcomes.
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Affiliation(s)
- Anne E O'Shea
- Department of Surgery, Brooke Army Medical Center, Ft. Sam Houston, TX, USA
| | - Christina Lee
- Department of Surgery, Brooke Army Medical Center, Ft. Sam Houston, TX, USA
| | - David S Kauvar
- Vascular Surgery Service, Brooke Army Medical Center, Ft. Sam Houston, TX, USA; Department of Surgery, Uniformed Services University, Bethesda, MD, USA.
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Góes Junior AMDO, Silva KTBD, Furlaneto IP, Abib SDCV. Lessons Learned From Treating 114 Inferior Vena Cava Injuries at a Limited Resources Environment - A Single Center Experience. Ann Vasc Surg 2021; 80:158-169. [PMID: 34752854 DOI: 10.1016/j.avsg.2021.08.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 08/16/2021] [Accepted: 08/24/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND The inferior vena cava is the most frequently injured vascular structure in penetrating abdominal trauma. We aimed to review inferior vena cava injury cases treated at a limited resources facility and to discuss the surgical management for such injures. METHODS This was a retrospective study of patients with inferior vena cava injuries who were treated at a single center between January 2011 and January 2020. Data pertaining to the following were assessed: demographic parameters, hypovolemic shock at admission, the distance that the patient had to be transported to reach the hospital, affected anatomical segment, treatment, concomitant injuries, complications, and mortality. Non-parametric data were analyzed using Fisher's exact, Chi-square, Mann-Whitney, or Kruskal-Wallis test, as applicable. The Student's t-test was used to assess parametric data. Moreover, multiple logistic regression analyses (including data of possible death-related variables) were performed. Statistical significance was set at P <0.05. RESULTS Among 114 patients with inferior vena cava injuries, 90.4% were male, and the majority were aged 20-29 years. Penetrating injuries accounted for 98.2% of the injuries, and the infrarenal segment was affected in 52.7% of the patients. Suturing was perfomed in 69.5% and cava ligation in 29.5% of the patients, and 1 patient with retrohepatic vena cava injury was managed non-operatively. The overall mortality was 52.6% with no case of compartment syndrome in the limbs. A total of 7.9% of the patients died during surgery. CONCLUSION The inferior vena cava is often injured by penetrating mechanisms, and the most frequently affected segment was the infrarenal segment. A higher probability of death was not associated with injury to a specific anatomical segment. Additionally, cava ligation was not related to an increased probability of compartment syndrome in the leg; therefore, prophylactic fasciotomy was not supported.
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Abstract
ABSTRACT This is a literature review on the history of venous trauma since the 1800s, especially that to the common femoral, femoral and popliteal veins, with focus on the early 1900s, World War I, World War II, Korean War, Vietnam War, and then civilian and military reviews (1960-2020). In the latter two groups, tables were used to summarize the following: incidence of venous repair versus ligation, management of popliteal venous injuries, patency of venous repairs when assessed <30 days from operation, patency of venous repairs when assessed >30 days from operation, clinical assessment (edema or not) after ligation versus repair, incidence of deep venous thrombosis after ligation versus repair, and incidence of pulmonary embolism after ligation versus repair.There is a lack of the following in the literature on the management of venous injuries over the past 80 years: standard definition of magnitude of venous injury in operative reports, accepted indications for venous repair, standard postoperative management, and timing and mode of early and later postoperative assessment.Multiple factors have entered into the decision on venous ligation versus repair after trauma for the past 60 years, but a surgeon's training and local management protocols have the most influence in both civilian and military centers. Ligation of venous injuries, particularly those in the lower extremities, is well tolerated in civilian trauma, although there is the usual lack of short- and long-term follow-up as noted in many of the articles reviewed. LEVEL OF EVIDENCE Review article, levels IV and V.
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Affiliation(s)
- David V Feliciano
- From the Department of Surgery (D.V.F.), Shock Trauma Center, University of Maryland Medical Center, University of Maryland, Baltimore, Maryland; Division of Acute Care Surgery, Department of Surgery (M.P.K.), University of Florida Health Jacksonville Medical Center, Jacksonville, Florida; and Division of Acute Care Surgery, Department of Surgery (G.F.R.), John Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Kochuba M, Rozycki GF, Feliciano D. Outcome after ligation of major veins for trauma. J Trauma Acute Care Surg 2021; 90:e40-e49. [PMID: 33502152 DOI: 10.1097/ta.0000000000003014] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Matthew Kochuba
- From the Division of Acute Care Surgery, Department of Surgery, UF Health Jacksonville Medical Center (M.K.), University of Florida-Jacksonville, Jacksonville, Florida; Division of Acute Care and Adult Trauma Surgery, Department of Surgery, Johns Hopkins University School of Medicine (G.F.R.), Johns Hopkins University; and Division of Surgical Critical Care, Department of Shock Trauma Center, Shock Trauma Center (D.F.), University of Maryland Medical Center, University of Maryland, Baltimore, Maryland
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Shaban Y, Elkbuli A, McKenney M, Boneva D. Traumatic femoral arteriovenous fistula following gunshot injury: Case report and review of literature. Ann Med Surg (Lond) 2020; 55:223-226. [PMID: 32518646 PMCID: PMC7272506 DOI: 10.1016/j.amsu.2020.05.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 05/08/2020] [Accepted: 05/12/2020] [Indexed: 11/19/2022] Open
Abstract
Introduction Vascular injuries account for approximately 2–4% of trauma admissions with only 2.5% of these being traumatic arteriovenous fistulas (AVFs). We offer a case report of a traumatic AVF and review of the literature. Presentation of case A 40-year-old male presented following 4 gunshot wounds, 2 in the forearm and 2 in the left upper thigh. The patient had decreased range of motion and paresthesia of the left lower extremity with palpable pulses and adequate capillary refill in all extremities. A CT angiogram demonstrated a left traumatic AVF involving the left deep femoral artery and left common femoral vein with an adjacent bullet fragment. The patient was taken to the operating room and underwent an exploration of the left groin, repair of the traumatic AVF, and removal of bullet fragment. The venous aspect had a grade IV injury and was ligated. The arterial defect was debrided to healthy tissue and repaired primarily. The patient recovered from his injuries with adequate ambulation and resolution of lower extremity edema. He was discharged home on postoperative day 4 on aspirin and a compression stocking. Discussion Traumatic AVFs are rare, with up to 70% diagnosed in a delayed fashion. Clinicians must maintain a high index of suspicion to correctly diagnose and manage this injury to avoid potential morbidity and mortality. Conclusion Despite literature accounts of surgeons’ experience, this pathology is lacking level one evidence-based standardized surgical management algorithms. Controversy exists regarding venous repair methods. Early diagnosis and management of traumatic AVFs help avoid potential long-term morbidity and mortality. Traumatic AVFs with Grade IV venous injuries can be safely ligated with minimal morbidity while reducing operative time and potential blood loss. Patients with traumatic AVFs should be placed on a strict DVT surveillance and management regimen along with compression stockings postoperatively.
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Affiliation(s)
- Youssef Shaban
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA
- Corresponding author. Department of Surgery, Kendall Regional Medical Center, 11750 Bird Road. Miami, FL, 33175, USA.
| | - Mark McKenney
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA
- University of South Florida, Tampa, FL, USA
| | - Dessy Boneva
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA
- University of South Florida, Tampa, FL, USA
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Toth S, Flohr TR, Schubart J, Knehans A, Castello MC, Aziz F. A meta-analysis and systematic review of venous thromboembolism prophylaxis in patients undergoing vascular surgery procedures. J Vasc Surg Venous Lymphat Disord 2020; 8:869-881.e2. [PMID: 32330639 DOI: 10.1016/j.jvsv.2020.03.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 03/06/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Perioperative venous thromboembolism (VTE) is generally considered preventable. Whereas the non-vascular surgery literature is rich in providing data about the impact of VTE prophylaxis on VTE outcomes, vascular surgery data are relatively sparse on this topic. This study sought to evaluate the evidence for VTE prophylaxis specifically for the population of vascular surgery patients. METHODS A systematic search was conducted in MEDLINE, Cochrane, and Embase databases in December 2018. Included were studies reporting primary and secondary outcomes for common vascular surgery procedures (open aortic operation, endovascular aneurysm repair [EVAR], peripheral artery bypass, amputation, venous reflux operation). A meta-analysis was performed comparing the patients who did not receive VTE prophylaxis and had VTE complications with patients who developed VTE despite receiving prophylaxis. RESULTS From 3757 uniquely identified articles, 42 publications met the criteria for inclusion in this review (1 for the category of all vascular operations, 5 for open aortic reconstructions, 2 for EVAR, 1 for open aortic surgery or EVAR, 3 for abdominal or bypass surgery, 2 for peripheral bypass surgery, 2 for amputations, 1 for vascular trauma, and 25 for surgical treatment of superficial venous disease). Five studies met the criteria for inclusion in the meta-analysis. The results demonstrated slightly lower relative risk for development of VTE among patients receiving VTE prophylaxis (relative risk, 0.70; 95% confidence interval, 0.26-1.87). After open aortic reconstruction, the risk of VTE is 13% to 18% and is not reduced by VTE prophylaxis. For EVAR patients, the risk of VTE without prophylaxis is 6%. For patients undergoing peripheral bypass surgery and not receiving therapeutic or prophylactic anticoagulation, the risk of VTE is <2%. For patients undergoing amputations, VTE prophylaxis reduces the risk of VTE. For patients undergoing surgical treatment of superficial venous disease, there is an abundance of literature exploring the utility of VTE prophylaxis, but the evidence is conflicting; some studies demonstrated a benefit, whereas others showed no reduction of VTE with prophylaxis. CONCLUSIONS Overall, there is a paucity of literature that addresses the effectiveness of VTE prophylaxis specifically in the population of vascular surgery patients. Our meta-analysis of the literature does not demonstrate a statistically significant benefit of VTE prophylaxis among the vascular surgery patients evaluated; however, it does suggest a low incidence of VTE among patients who receive VTE prophylaxis. Clinicians should identify the patients at high risk for development of postoperative VTE as the risk-benefit ratio may favor VTE prophylaxis in a selected group of patients. Clinicians should use their judgment and established VTE risk prediction models to assess VTE risk for patients. Vascular surgeons should consider reporting VTE incidence as a secondary outcome in publications.
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Affiliation(s)
- Sandra Toth
- Division of Vascular Surgery, Penn State Heart and Vascular Institute, Pennsylvania State University College of Medicine, Hershey, Pa
| | - Tanya R Flohr
- Division of Vascular Surgery, Penn State Heart and Vascular Institute, Pennsylvania State University College of Medicine, Hershey, Pa
| | - Jane Schubart
- Division of Outcomes Research and Quality, Department of Surgery, Pennsylvania State University College of Medicine, Hershey, Pa
| | - Amy Knehans
- Harrell Health Sciences Library Research and Learning Commons, Pennsylvania State University College of Medicine, Hershey, Pa
| | - Maria C Castello
- Division of Vascular Surgery, Penn State Heart and Vascular Institute, Pennsylvania State University College of Medicine, Hershey, Pa
| | - Faisal Aziz
- Division of Vascular Surgery, Penn State Heart and Vascular Institute, Pennsylvania State University College of Medicine, Hershey, Pa.
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Guice JL, Gifford SM, Hata K, Shi X, Propper BW, Kauvar DS. Analysis of Limb Outcomes by Management of Concomitant Vein Injury in Military Popliteal Artery Trauma. Ann Vasc Surg 2020; 62:51-56. [DOI: 10.1016/j.avsg.2019.05.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 04/15/2019] [Accepted: 05/25/2019] [Indexed: 11/15/2022]
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A Rare Case of Vascular Leiomyosarcoma Originating from a Branch Vessel of the External Iliac Vein. Case Rep Med 2018; 2018:5160591. [PMID: 30123281 PMCID: PMC6079617 DOI: 10.1155/2018/5160591] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 06/24/2018] [Indexed: 11/17/2022] Open
Abstract
Leiomyosarcoma arising from the external iliac vein is uncommon. This is a report of a 51-year-old Japanese man with venous leiomyosarcoma originating from a branch vessel of the left external iliac vein. The tumor was found during a medical examination, and the patient had no symptoms. Computed tomography showed a 72 × 49 mm mass adjacent to the left external iliac vein. The tumor was resected en-block along with ligation of the external iliac vein due to strong adhesion with the tumor. Histological examination showed venous leiomyosarcoma, and its origin was thought to be a branch vessel of the left external iliac vein. The patient has remained free from recurrence at 30 months after surgery.
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Manley NR, Magnotti LJ, Fabian TC, Cutshall MB, Croce MA, Sharpe JP. Factors Contributing to Morbidity after Combined Arterial and Venous Lower Extremity Trauma. Am Surg 2018. [DOI: 10.1177/000313481808400742] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The purpose of this study was to evaluate the impact of management of venous injury on clinical outcomes in patients with combined lower extremity arterial and venous trauma. Patients with common and external iliac, common and superficial femoral, and popliteal artery injuries were identified. Patients who underwent vein repair and those who received vein ligation were compared. The analysis was repeated for those patients who required secondary intervention for their arterial injury and those who did not require secondary intervention. Seventy patients were identified with both arterial and venous injuries: 40 underwent vein ligation and 30 received vein repair. There was no difference in ischemic time between patients undergoing vein repair compared with ligation. Vein ligation did not produce a higher incidence of muscle debridement (10% vs 15%, P = 0.72), necessity for secondary intervention (10% vs 7.5%, P = 0.99), or amputation (3.3% vs 7.5%, P = 0.63). Patients who required secondary intervention had a greater degree of shock on presentation (packed red blood cells (PRBC), 13 units vs 6 units, P = 0.02) and were more likely to require muscle debridement (50% vs 9%, P = 0.02) and amputation (33% vs 3%, P = 0.03). Vein ligation did not impact muscle ischemia or success of arterial repair in patients with combined venous and arterial trauma in the lower extremities. Patient morbidity after extremity vascular trauma is most related to degree of shock.
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Affiliation(s)
- Nathan R. Manley
- From the University of Tennessee Health Science Center, Memphis, Tennessee
| | - Louis J. Magnotti
- From the University of Tennessee Health Science Center, Memphis, Tennessee
| | - Timothy C. Fabian
- From the University of Tennessee Health Science Center, Memphis, Tennessee
| | | | - Martin A. Croce
- From the University of Tennessee Health Science Center, Memphis, Tennessee
| | - John P. Sharpe
- From the University of Tennessee Health Science Center, Memphis, Tennessee
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Affiliation(s)
- Gregory A Magee
- Department of Surgery, University of Southern California, Los Angeles, Calif
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