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Borghese O, Pisani A, Funaru DA, Di Marzo L, Di Centa I. Late onset infection of covered and bare metal arterial stents. Vascular 2021; 30:960-968. [PMID: 34348520 DOI: 10.1177/17085381211036548] [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: 11/17/2022]
Abstract
OBJECTIVE The objective was to present the case of a late covered iliac stent late infection and report a comprehensive literature review on diagnosis and outcomes in this setting. METHODS A comprehensive review of the literature was performed through MedLine by two independent reviewers from 1990 to 2020 on reported cases of arterial stent late onset infection over arterial stents. The data about on the risk factors, clinical presentation, treatment and outcomes were collected. RESULTS Twenty-two studies were selected as pertinent for the analysis, totalling 24 patients including the indexed case. Infection occurred at a median of 22 months postoperatively (range 2-120 months) over a bare metal stent in 66.7% (n 16) of cases versus 33.3% (n 8) over a covered stent. Clinical presentation included local symptoms (local pain, oedema, petechiae or skin rash) in 21 (87.5%) cases and non-specific systemic symptoms (fever, sepsis, chills and leucocytosis) in 8 cases (33.3%). In 4 cases (16.7%), patients presented with haemorrhagic shock upon arterial rupture. The bacteria most frequently encountered were S. aureus (54.2% of cases). Several factors were supposed to be responsible for the infection including among which procedure-related (non-aseptic technique, lack of prophylactic antibiotics and repetitive punctures at the access site) or related to pre-existing patient's clinical conditions (immunosuppression, diabetes and concurrent infection) have been considered responsible for the infection. Treatment consisted in antibiotics alone (2 patients, 8.3%) or in association with surgical explant, both with or and without revascularization (n 21, 87.5%). In one case, an endovascular coiling was performed. Complications occurred in 29.2% (n 7) of cases and included the need for amputation, bowel resection, endocarditis, pulmonary failure or pneumonia. Overall, three patients (12.5%) died from a septic shock or multi-organ failure. CONCLUSIONS Intravascular stent infection is a rare but fearsome condition associated with high morbidity and mortality.
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Affiliation(s)
- Ottavia Borghese
- Department of Vascular and Endovascular Surgery, Foch Hospital, Suresnes, France.,Sapienza University, Rome, Italy
| | - Angelo Pisani
- Departement of Cardiac Surgery, 55183Pineta Grande Hospital, Castel Volturno, Italy
| | - Dan Andrei Funaru
- Department of Vascular and Endovascular Surgery, Foch Hospital, Suresnes, France
| | | | - Isabelle Di Centa
- Department of Vascular and Endovascular Surgery, Foch Hospital, Suresnes, France
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Whitcher GH, Bertges DJ, Shukla M. Peripheral Vascular Stent Infection: Case Report and Review of Literature. Ann Vasc Surg 2018; 51:326.e9-326.e15. [DOI: 10.1016/j.avsg.2018.02.047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 02/12/2018] [Indexed: 12/12/2022]
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Li HL, Chan YC, Cheng SW. Current Evidence on Management of Aortic Stent-graft Infection: A Systematic Review and Meta-Analysis. Ann Vasc Surg 2018; 51:306-313. [PMID: 29772328 DOI: 10.1016/j.avsg.2018.02.038] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Revised: 08/26/2017] [Accepted: 02/19/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Aortic stent-graft infection (SGI) is rare but remains one of the most challenging and threatening complications. This systematic review aimed to identify the clinical features, treatment, and outcomes of endograft infection after abdominal endovascular aortic repair (EVAR) and thoracic endovascular aortic repair (TEVAR). METHODS A systematic literature review of all published literature from January 1991 to September 2016 on SGI was performed under the instruction of Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Aorta, aneurysm, endovascular, stent-graft, endograft and infection were the keywords used in our comprehensive search in PubMed and MEDLINE databases. Data analysis was performed using SPSS, V 22.0. RESULTS A total of 185 potential relevant articles were identified, but only 11 studies with 402 patients met the inclusion criteria. Majority of the patients were male (308/402, 77%), with a mean age ranging from 65 to 73 years. Most of the endografts were implanted for EVAR (351/402, 87%), while the other 51 (13%) endografts were infected following TEVAR. Among the 402 patients, 39 (9.7%) patients presented with aortic rupture. Ninety-two of 380 (24.2%) patients with available data had aortoenteric fistula (AEF). Sixty-nine patients (17%) died in hospital or within 30 days after operation. One hundred fourteen patients (28%) died during follow-up. The most commonly used stent grafts were Zenith (Cook Inc, Bloomington, IN) (22%) and Excluder (W.L. Gore, Flagstaff, AZ) (20%). Of the 402 patients in this series, 108 patients (27%) had negative culture, and multiple microorganisms were identified in 103 patients (26%). The most frequently isolated microorganisms were Staphylcoccus species (30.1%), Streptococcus (14.8%), and fungus (9.2%). Forty-two patients (42/401, 10%) received conservative treatment, whereas 359 (90%) patients underwent surgical treatment, including stent graft removal with in situ reconstruction or extra-anatomical bypass, and secondary endovascular procedure. Patients in the surgical group had a higher survival rate compared with conservative group (58% vs. 33%, P = 0.002). The survival rate was higher in the patients with infected EVAR than TEVAR (58% vs. 27%, P = 0.000). Patient with AEF had a worse prognosis (survival rate 72% vs. 33%, P = 0.002). CONCLUSIONS Current evidence suggests that surgical treatment is a better option compared with conservative management in selected patients with aortic endograft infection. The outcome was worse in patients with infected TEVAR and AEF.
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Affiliation(s)
- Hai Lei Li
- Division of Vascular Surgery, Department of Surgery, University of Hong Kong Shenzhen hospital, Guangdong, China
| | - Yiu Che Chan
- Division of Vascular & Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, South Wing, 14th Floor K Block, Queen Mary Hospital, Hong Kong, China.
| | - Stephen W Cheng
- Division of Vascular & Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, South Wing, 14th Floor K Block, Queen Mary Hospital, Hong Kong, China
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Villaescusa J, Pontón A, Fernández-Sampedro M. Infección de endoprótesis tras angioplastia ilíaca: ¿es necesaria una profilaxis antibiótica? ANGIOLOGIA 2018. [DOI: 10.1016/j.angio.2017.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Hertz JA, Valentino J, Kwolek CJ, Endean ED. Carotid Blowout with Infection: Management with Endovascular and Open Vascular Approaches. Vasc Endovascular Surg 2016; 38:477-81. [PMID: 15490049 DOI: 10.1177/153857440403800515] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The management of patients with head and neck cancer can be complicated by massive carotid artery hemorrhage, often requiring ligation owing to the emergent conditions and scarring from previous surgery and radiation. A case of emergent endovascular management of carotid artery hemorrhage in a patient treated for pharyngeal carcinoma is described. Hemorrhage was controlled, but on follow-up the patient developed a carotid-cutaneous fistula with exposure of the coils. Further management required the use of autogenous vein to replace the involved vessels. This case demonstrates that endovascular control of carotid hemorrhage can be successful, but close follow-up is necessary to identify potential subsequent complications.
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Affiliation(s)
- Jeffrey A Hertz
- Division of Vascular Surgery, University of Kentucky School of Medicine, Lexington, KY 40536, USA
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Affiliation(s)
- Albert C W Ting
- Division of Vascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong.
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Fiorani P, Speziale F, Calisti A, Misuraca M, Zaccagnini D, Rizzo L, Giannoni MF. Endovascular Graft Infection: Preliminary Results of an International Enquiry. J Endovasc Ther 2016; 10:919-27. [PMID: 14656181 DOI: 10.1177/152660280301000512] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: To investigate the frequency of aortoiliac endovascular graft infections and seek the main factors influencing their development. Methods: To augment personal experience (1 case), a questionnaire was sent to 40 international centers of vascular and endovascular surgery. The literature was also reviewed to collect data on infections developing in endovascular grafts. Results: The survey (85% response rate) and literature review identified 62 cases of infected endovascular grafts (0.4% frequency of endograft infection). In 22 (35%) patients, the infection manifested initially with vague symptoms only, but 41 (65%) patients eventually presented with abdominal abscess, groin fistula, and septic embolization. Common bacteria, such as Staphylococcus aureus, were identified as the cause of most infections (54.5%). The majority (49, 79%) of the 62 patients were treated surgically; 11 (17.7%) patients received conservative therapy (no therapeutic data in 2 patients). Overall mortality was 27.4% (17/62), and operative mortality was 16.3% (8/49). Conservative treatment led to a mortality rate of 36.4% (4/11). The mean follow-up for all patients was 47.8 weeks. Possible factors influencing the development of an infection were secondary adjunctive procedures, immunosuppression, treatment of false aneurysms, and infected central lines. Conclusions: Infected endovascular grafts are an urgent problem that has been heretofore underestimated and will probably increase as follow-up lengthens. New techniques should be sought to expedite the diagnosis, and an international registry should be set up to provide validated data.
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Affiliation(s)
- Paolo Fiorani
- Department of Vascular Surgery, Policlinico Umberto I, Rome, Italy
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Bosman WMPF, Borger van der Burg BLS, Schuttevaer HM, Thoma S, Hedeman Joosten PP. Infections of intravascular bare metal stents: a case report and review of literature. Eur J Vasc Endovasc Surg 2013; 47:87-99. [PMID: 24239103 DOI: 10.1016/j.ejvs.2013.10.006] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Accepted: 10/06/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of the paper is to present a case of an infected bare metal stent in the left common iliac artery that was removed by an urgent operation, and to review the literature on diagnosis and outcome of infected coronary and non-coronary metal stents. METHODS A systematic search of the Medline database was performed with the purpose of identifying risk factors, signs and symptoms, imaging strategies, and treatment modalities of bare metal stent infections, both coronary and peripheral. RESULTS In total, 76 additional studies/case reports (48 non-coronary; 29 coronary) were included and analyzed. Intravascular bare metal stent infections are a rare but serious complication, often leading to emergency surgery (overall: 75.3%; non-coronary cases: 83.3%; coronary cases: 62.1%). In 25.0% of the non-coronary cases, infection led to amputation of an extremity or removal of viscera. Reported mortality was up to 32.5% of the cases (non-coronary: 22.9%; coronary 48.3%). Physicians should always be suspicious of a stent infection when patients present with aspecific symptoms such as fever and chills after stent placement. Additional imaging can be used to detect the presence of a pseudoaneurysm. A PET-CT is an ideal medium for identification of a stent infection. CONCLUSIONS Intravascular stent infection is associated with a high risk of morbidity and mortality. Surgery is the preferred treatment option, but not always possible, especially in patients with a coronary stent. In selected cases, bare metal stent infections may be prevented by the use of prophylactic antibiotics at stent placement.
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Affiliation(s)
- W M P F Bosman
- Department of Surgery, Rijnland Hospital Leiderdorp, The Netherlands.
| | | | - H M Schuttevaer
- Department of Radiology, Rijnland Hospital Leiderdorp, The Netherlands
| | - S Thoma
- Department of Radiology, Rijnland Hospital Leiderdorp, The Netherlands
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Abstract
A infecção envolvendo endopróteses é uma complicação pouco frequente, associada a elevadas taxas de mortalidade. A apresentação clínica é geralmente tardia, podendo variar de sintomas inespecíficos até complicações graves como pseudoaneurisma e fístula aortoentérica. O diagnóstico envolve alto índice de suspeição e investigação com exames de imagem e laboratoriais. O tratamento segue os preceitos da infecção de prótese em cirurgia convencional, indicando-se, para a maioria dos pacientes, a excisão cirúrgica acompanhada da revascularização in situ ou extra-anatômica. O tratamento conservador fica reservado para casos selecionados.
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Abstract
INTRODUCTION Infection of transjugular intrahepatic portosystemic stent shunt (TIPSS) called 'Tipsitis' has been reported but appears unusual. We report here our experience of patients who were diagnosed to have Tipsitis at our centre. METHODS Retrospective single centre study. Patients identified from a dedicated data base. Patients with TIPSS with otherwise unexplained sustained bacteraemia were included. RESULTS Over 14 years of age, of 785 patients with TIPSS, eight (1%) had Tipsitis. Indication for TIPSS: variceal bleed, seven; refractory ascites, one. Child-Pugh score: 8.3 (1.4). Seven patients had overlapping stents in situ. Duration to Tipsitis: 21.6 (7.1) months. At diagnosis, TIPSS was occluded in four and patent in three. Tipsitis developed within 2 weeks of shunt interventions in two patients and was owing to development of bilio-venous fistula in one. The organisms identified were: Lactobacillus rhamnosus, Escherichia coli, Enterobacter cloacae, Enterococcusfaecium and Staphylococcus aureus. Median duration of antibiotic therapy: 3 (0.3-3) months. Symptoms initially resolved in all but one. Symptoms recurred in three and this was related to premature cessation of antibiotics in two. Five patients died at a median 1.3 (0.3 to 33) months after Tipsitis with Tipsitis contributing to death in three. CONCLUSION Tipsitis is a rare but serious problem. It should be suspected in patients with TIPSS and unexplained sustained bacteraemia. Shunt interventions, where TIPSS is inserted for variceal bleed, and use of overlapping shunts at TIPSS insertion may be risk factors for its development. Prolonged antibiotics are usually required but Tipsitis may recur despite apparently successful treatment.
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Zimmerman PM, Cherr GS, Angelos GC, Gona J, Dosluoglu HH. Is F 18 Fluorodeoxyglucose Positron Emission Tomography Too Sensitive for the Diagnosis of Vascular Endograft Infection? Vascular 2008; 16:346-9. [DOI: 10.2310/6670.2008.00049] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We report a case of a false positive fluorodeoxyglucose positron emission tomography (FDG-PET) scan in a patient who presented with abdominal pain, and gastrointestinal bleeding accompanied by elevation of inflammatory markers, seven weeks after a proximal type I endoleak repair with a cuff extension. Aortoenteric fistula and endograft infection was ruled out by laparotomy. FDG-PET image may have a role in diagnosis of infection, but false positive results are possible and caution is necessary if other data are non-confirmatory.
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Affiliation(s)
- Pamela M. Zimmerman
- *Division of Vascular and Endovascular Surgery, West Virginia University, Morgantown, WV; †Division of Vascular Surgery, Department of Surgery, ‡School of Medicine, and §Department of Nuclear Medicine, State University of New York at Buffalo, Buffalo, NY; ‖VA Western New York Healthcare System, Buffalo, NY
| | - Gregory S. Cherr
- *Division of Vascular and Endovascular Surgery, West Virginia University, Morgantown, WV; †Division of Vascular Surgery, Department of Surgery, ‡School of Medicine, and §Department of Nuclear Medicine, State University of New York at Buffalo, Buffalo, NY; ‖VA Western New York Healthcare System, Buffalo, NY
| | - George C. Angelos
- *Division of Vascular and Endovascular Surgery, West Virginia University, Morgantown, WV; †Division of Vascular Surgery, Department of Surgery, ‡School of Medicine, and §Department of Nuclear Medicine, State University of New York at Buffalo, Buffalo, NY; ‖VA Western New York Healthcare System, Buffalo, NY
| | - Jayakumari Gona
- *Division of Vascular and Endovascular Surgery, West Virginia University, Morgantown, WV; †Division of Vascular Surgery, Department of Surgery, ‡School of Medicine, and §Department of Nuclear Medicine, State University of New York at Buffalo, Buffalo, NY; ‖VA Western New York Healthcare System, Buffalo, NY
| | - Hasan H. Dosluoglu
- *Division of Vascular and Endovascular Surgery, West Virginia University, Morgantown, WV; †Division of Vascular Surgery, Department of Surgery, ‡School of Medicine, and §Department of Nuclear Medicine, State University of New York at Buffalo, Buffalo, NY; ‖VA Western New York Healthcare System, Buffalo, NY
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12
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Hogg ME, Peterson BG, Pearce WH, Morasch MD, Kibbe MR. Bare metal stent infections: Case report and review of the literature. J Vasc Surg 2007; 46:813-20. [PMID: 17903662 DOI: 10.1016/j.jvs.2007.05.043] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2007] [Accepted: 05/21/2007] [Indexed: 10/22/2022]
Abstract
Infection of bare metal stents in the vasculature is rare, but associated with significant morbidity and mortality. We report two cases of bare metal stent infections and review the literature regarding infected bare metal stents with respect to risk factors, pathophysiology, diagnosis, treatment, and prevention. Overall, this article highlights the need to have a high index of suspicion of bare metal stent infection, since prompt diagnosis and treatment can ultimately decrease the morbidity and mortality associated with this devastating problem.
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Affiliation(s)
- Melissa E Hogg
- Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
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14
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Ducasse E, Calisti A, Speziale F, Rizzo L, Misuraca M, Fiorani P. Aortoiliac stent graft infection: current problems and management. Ann Vasc Surg 2004; 18:521-6. [PMID: 15534730 DOI: 10.1007/s10016-004-0075-9] [Citation(s) in RCA: 137] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Aortic stent graft infection is uncommon. Most cases have been described anecdotaly in single-case reports. After observing one case in our experience, we decided to review the literature and contact centers performing endovascular aortic repair to determine the frequency, risk factors, and current treatment of stent graft infection. The literature was reviewed and the authors of identified articles were contacted for further information. In addition, 40 centers specializing in endovascular treatment were contacted by means a dedicated questionnaire. A total of 65 aortic stent graft infections were identified, including 43 reported cases and 22 previously unpublished cases that were observed at specialized centers. Stent grafts were implanted in the aorta in 50 cases and in the iliac artery in 15 cases. The frequency of infection was 0.43%. The gender ratio was 4:1 (M:F). Twenty-three percent of patients had immunodeficiency factors. Placement was performed in an interventional radiology suite in 62.5% of cases and in a sterile operating theater in 37.5%. Also, 35.5% of patients underwent other vascular procedures during the course of study and 29.2% stent grafts benefited from adjuvant endovascular procedures. Infection was classified as low grade in 35.4% of patients and high grade in 64.6%. Thirty-one percent of infections were associated with aortoenteric fistula. The offending microorganism was Staphylococcus aureus in 54.5% of cases. Treatment was conservative in 18% of cases and surgical in 82%. Surgical treatment consisted of stent graft removal followed by either extraanatomical bypass (59.5%) or in situ prosthetic reconstruction (40.5%). Mortality was 18% overall, 36.4% after conservative treatment and 14% after surgical treatment ( p = 0.083). Mortality was 16% after surgical treatment with extraanatomical bypass vs. 5.8% surgical treatment with in situ reconstruction. From these results we conclude that stent graft infection is an uncommon occurrence associated with poorly defined risk factors. Surgical treatment with complete excision of the infected stent graft followed by in situ reconstruction provides the best outcome. Establishment of a multicenter register to record such complications is needed to confirm the findings of this study.
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Affiliation(s)
- Eric Ducasse
- Department of Vascular Surgery, Tripode-Pellegin Hospital, Bordeaux, France.
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Abstract
As an increasing number and variety of prosthetic devices are used in cardiovascular medicine, novel infectious complications have been described. Infection of intra-arterial devices, including arterial closure devices, prosthetic carotid patches, coronary artery stents and endovascular stents, and stent-grafts, is now being reported. Prosthetic vascular graft infection is an older, more common, and better-characterized entity, but recent developments in the surgical management of these infections have prompted a re-examination of the syndrome. Staphylococcal species account for most intra-arterial device infections, and often, morbidity and mortality rates are high. An update on intra-arterial device infections is warranted.
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Baddour LM, Bettmann MA, Bolger AF, Epstein AE, Ferrieri P, Gerber MA, Gewitz MH, Jacobs AK, Levison ME, Newburger JW, Pallasch TJ, Wilson WR, Baltimore RS, Falace DA, Shulman ST, Tani LY, Taubert KA. Nonvalvular Cardiovascular Device–Related Infections. Circulation 2003; 108:2015-31. [PMID: 14568887 DOI: 10.1161/01.cir.0000093201.57771.47] [Citation(s) in RCA: 363] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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