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Ogino H, Iida O, Akutsu K, Chiba Y, Hayashi H, Ishibashi-Ueda H, Kaji S, Kato M, Komori K, Matsuda H, Minatoya K, Morisaki H, Ohki T, Saiki Y, Shigematsu K, Shiiya N, Shimizu H, Azuma N, Higami H, Ichihashi S, Iwahashi T, Kamiya K, Katsumata T, Kawaharada N, Kinoshita Y, Matsumoto T, Miyamoto S, Morisaki T, Morota T, Nanto K, Nishibe T, Okada K, Orihashi K, Tazaki J, Toma M, Tsukube T, Uchida K, Ueda T, Usui A, Yamanaka K, Yamauchi H, Yoshioka K, Kimura T, Miyata T, Okita Y, Ono M, Ueda Y. JCS/JSCVS/JATS/JSVS 2020 Guideline on Diagnosis and Treatment of Aortic Aneurysm and Aortic Dissection. Circ J 2023; 87:1410-1621. [PMID: 37661428 DOI: 10.1253/circj.cj-22-0794] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Affiliation(s)
- Hitoshi Ogino
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital
| | - Koichi Akutsu
- Cardiovascular Medicine, Nippon Medical School Hospital
| | - Yoshiro Chiba
- Department of Cardiology, Mito Saiseikai General Hospital
| | | | | | - Shuichiro Kaji
- Department of Cardiovascular Medicine, Kansai Electric Power Hospital
| | - Masaaki Kato
- Department of Cardiovascular Surgery, Morinomiya Hospital
| | - Kimihiro Komori
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University
| | | | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine
| | - Yoshikatsu Saiki
- Division of Cardiovascular Surgery, Graduate School of Medicine, Tohoku University
| | - Kunihiro Shigematsu
- Department of Vascular Surgery, International University of Health and Welfare Mita Hospital
| | - Norihiko Shiiya
- First Department of Surgery, Hamamatsu University School of Medicine
| | | | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University
| | - Hirooki Higami
- Department of Cardiology, Japanese Red Cross Otsu Hospital
| | | | - Toru Iwahashi
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kentaro Kamiya
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Takahiro Katsumata
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
| | - Nobuyoshi Kawaharada
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine
| | | | - Takuya Matsumoto
- Department of Vascular Surgery, International University of Health and Welfare
| | | | - Takayuki Morisaki
- Department of General Medicine, IMSUT Hospital, the Institute of Medical Science, the University of Tokyo
| | - Tetsuro Morota
- Department of Cardiovascular Surgery, Nippon Medical School Hospital
| | | | - Toshiya Nishibe
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kenji Okada
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | | | - Junichi Tazaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Masanao Toma
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Takuro Tsukube
- Department of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital
| | - Keiji Uchida
- Cardiovascular Center, Yokohama City University Medical Center
| | - Tatsuo Ueda
- Department of Radiology, Nippon Medical School
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Kazuo Yamanaka
- Cardiovascular Center, Nara Prefecture General Medical Center
| | - Haruo Yamauchi
- Department of Cardiac Surgery, The University of Tokyo Hospital
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | - Yutaka Okita
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo
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Mansukhani NA, Brown KR, Zheng X, Mao J, Goodney PP, Hoel AW. High incidence of type 2 endoleak and low associated adverse events in the Vascular Quality Initiative linked to Medicare claims. J Vasc Surg 2023; 78:351-361. [PMID: 37086823 PMCID: PMC10524631 DOI: 10.1016/j.jvs.2023.04.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/18/2023] [Accepted: 04/10/2023] [Indexed: 04/24/2023]
Abstract
INTRODUCTION Type 2 endoleak (T2EL) is the most common adverse finding on postoperative surveillance after endovascular aortic aneurysm repair (EVAR). A low rate of aneurysm-related mortality with T2EL has been established. However, the optimal management strategy and the efficacy of reintervention remain controversial. This study used data from the Vascular Quality Initiative linked to Medicare claims (VQI-Medicare) to evaluate T2LE in a real-world cohort. METHODS This retrospective review of EVAR procedures in VQI-Medicare included patients undergoing their first EVAR procedure between 2015 and 2017. Patients with an endoleak other than T2EL on completion angiogram and those without VQI imaging follow-up were excluded. Patients without Medicare part A or part B enrollment at the time of the procedure or without 1-year complete Medicare follow-up data were also excluded. The exposure variable was T2EL, defined as any branch vessel flow detected within the first postoperative year. Outcomes of interest were mortality, reintervention, T2EL-related reintervention, post-EVAR imaging, and T2EL behavior including spontaneous resolution, aneurysm sac regression, and resolution after reintervention. The association of prophylactic branch vessel embolization (PBE) with T2EL resolution and aneurysm sac regression was also evaluated. RESULTS In a final cohort of 5534 patients, 1372 (24.7%) had an identified T2EL and 4162 (75.2%) did not. The median age of patients with and without T2EL was 77 and 75 years, respectively. There were no differences in mortality, imaging, reintervention, or T2EL-related reintervention at 3 years after the procedure for patients with T2EL. The aneurysm sac diameter decreased by 4 mm (range: 9-0 mm decrease) in the total cohort. Patients with inferior mesenteric artery-based T2EL had the smallest decrease in aneurysm diameter (median 1 mm decrease compared with 1.5 mm for accessory renal artery-based T2EL, 2 mm for multiple feeding vessel-based T2EL, and 4 mm for lumbar artery-based T2EL; P < .001). Spontaneous resolution occurred in 73.7% of patients (n = 809). T2ELs with evidence of multiple feeding vessels were associated with the lowest rate of spontaneous resolution (n = 51, 54.9%), compared with those with a single identified feeding vessel of inferior mesenteric artery (n = 99, 60.0%), lumbar artery (n = 655, 77.7%), or accessory renal artery (n = 31, 79.5%) (P < .001). PBE was performed in 84 patients. Patients who underwent PBE and were without detectable T2EL after EVAR had the greatest rate of sac regression at follow-up (7 mm decrease) compared with baseline. CONCLUSIONS T2EL after EVAR is associated with high rates of spontaneous resolution, low rates of aneurysm sac growth, and no evidence of increased early mortality or reintervention. PBE in conjunction with EVAR may be indicated in some circumstances.
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Affiliation(s)
- Neel A Mansukhani
- Division of Vascular and Endovascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI; Division of Vascular Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL.
| | - Kellie R Brown
- Division of Vascular and Endovascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Xinyan Zheng
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY
| | - Jialin Mao
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY
| | - Philip P Goodney
- Section of Vascular Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Andrew W Hoel
- Division of Vascular Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
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Hanna L, Gibbs RGJ. Type II Endoleaks and Culprit Vessels: Will 4D MRI Change the Paradigm? Eur J Vasc Endovasc Surg 2023; 66:148. [PMID: 37062332 DOI: 10.1016/j.ejvs.2023.03.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 03/06/2023] [Indexed: 04/18/2023]
Affiliation(s)
- Lydia Hanna
- Department of Surgery and Cancer, Imperial College London, London, UK; Imperial Vascular Unit, Imperial Healthcare NHS Trust, London, UK
| | - Richard G J Gibbs
- Department of Surgery and Cancer, Imperial College London, London, UK; Imperial Vascular Unit, Imperial Healthcare NHS Trust, London, UK
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Wu Y, Yin J, Hongpeng Z, Wei G. Systematic review and network meta-analysis of pre-emptive embolization of the aneurysm sac side branches and aneurysm sac coil embolization to improve the outcomes of endovascular aneurysm repair. Front Cardiovasc Med 2022; 9:947809. [PMID: 35935638 PMCID: PMC9354492 DOI: 10.3389/fcvm.2022.947809] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 06/29/2022] [Indexed: 01/02/2023] Open
Abstract
Objective Previous reports have revealed a high incidence of type II endoleak (T2EL) after endovascular aneurysm repair (EVAR). The incidence of T2EL after EVAR is reduced by pre-emptive embolization of aneurysm sac side branches (ASSB) and aneurysm sac coil embolization (ASCE). This study aimed to investigate whether different preventive interventions for T2EL were correlated with suppression of aneurysm sac expansion and reduction of the re-intervention rate. Methods The PubMed, Web of Science, MEDLINE and Embase databases, and conference proceedings were searched to identify articles on EVAR with or without embolization. The study was developed in line with the Participants, Interventions, Comparisons, Outcomes, and Study design principles and was conducted and reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. We used network meta-analysis based on multivariate random-effects meta-analysis to indirectly compare outcomes of different strategies for embolization during EVAR. Results A total of 31 studies met all inclusion criteria and were included in the qualitative and quantitative syntheses. The included studies were published between 2001 and 2022 and analyzed a total of 18,542 patients, including 1,882 patients who received prophylactic embolization treatment during EVAR (experimental group) and 16,660 who did not receive prophylactic embolization during EVAR (control group). The effect of pre-emptive embolization of the inferior mesenteric artery (IMA) (IMA-ASSB) in preventing T2EL was similar (relative risk [RR] 1.01, 95% confidence interval [CI] 0.38–2.63) to the effects of non-selective embolization of ASSB (NS-ASSB) and ASCE (RR 0.88, 95% CI 0.40–1.96). IMA-ASSB showed a better clinical effect in suppressing the aneurysm sac expansion (RR 0.27, 95% CI 0.09–2.25 compared with NS-ASSB; RR 0.93, 95% CI 0.16–5.56 compared with ASCE) and reducing the re-intervention rate (RR 0.34, 95% CI 0.08–1.53 compared with NS-ASSB; RR 0.66, 95% CI 0.19–2.22 compared with ASCE). All prophylactic embolization strategies improved the clinical outcomes of EVAR. Conclusion Prophylactic embolization during EVAR effectively prevents T2EL, suppresses the aneurysm sac expansion, and reduces the re-intervention rate. IMA embolization demonstrated benefits in achieving long-term aneurysm sac stability and lowering the risk of secondary surgery. NS-ASSB more effectively reduces the incidence of T2EL, while IMA embolization alone or in combination with ASCE enhances the clinical benefits of EVAR. In addition, as network meta-analysis is still an indirect method based on a refinement of existing data, more studies and evidence are still needed in the future to establish more credible conclusions.
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Affiliation(s)
- Ye Wu
- Department of Vascular Surgery, First Medical Center, Chinese PLA General Hospital, Beijing, China.,Medical College of Chinese PLA, Beijing, China
| | - Jianhan Yin
- Department of Vascular Surgery, First Medical Center, Chinese PLA General Hospital, Beijing, China.,Nankai University, Tianjin, China
| | - Zhang Hongpeng
- Department of Vascular Surgery, First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Guo Wei
- Department of Vascular Surgery, First Medical Center, Chinese PLA General Hospital, Beijing, China
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Menges AL, Meuli L, Dueppers P, Stoklasa K, Kopp R, Reutersberg B, Zimmermann A. Relevance of Type II Endoleak After Endovascular Repair of Ruptured Abdominal Aortic Aneurysms: A Retrospective Single-Center Cohort Study. J Endovasc Ther 2022:15266028221086476. [PMID: 35352969 DOI: 10.1177/15266028221086476] [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: 01/09/2023]
Abstract
INTRODUCTION Endovascular aortic repair (EVAR) is widely used as an alternative to open repair in elective and even in emergent cases of ruptured abdominal aortic aneurysm (rAAA). One of the most frequent complications after EVAR is type II endoleak (T2EL). In elective therapy, evidence-based therapeutic recommendations for T2EL are limited. Completely unclear is the role of T2EL after EVAR for rAAA (rEVAR). This study aims to investigate the significance of T2ELs after rEVAR. PATIENTS AND METHODS This is a retrospective single-center data analysis of all patients who underwent rEVAR between January 2010 and December 2020 with primary T2EL. The outcome criteria were overall and T2EL-related mortality and reintervention rate as well as development of aneurysm diameter over follow-up (FU). RESULTS During the study period between January 2010 and December 2020, 35 (25%) out of 138 patients with rEVAR presented a primary postoperative T2EL (age 74±11 years, 34 males). At rupture, mean aneurysm diameter was 73±12 mm. Follow-up was 26 (0-172) months. The reintervention-free survival was 69% (95% confidence interval [CI]: 55%-86%) at 30 days, 58% (95% CI: 43%-78%) at 1 year, and 52% (95% CI: 36%-75%) at 3 years. In 40% (n=14), T2ELs resolved spontaneously within a median time of 3.4 (0.03-85.6) months. The overall and T2EL reintervention rates were 43% (n=15) and 9% (n=3), respectively. Within 30 days, 11 patients (31%) required reintervention, of which 2 were T2EL related. Aneurysm sac growth by ≥5 mm was seen in 3 patients (9%), and aneurysm shrinkage rate was significantly higher in sealed T2EL group (86% vs 5%, p<0.0001). The overall survival was 85% (95% CI: 74%-98%) at 30 days, 75% (95% CI: 61%-92%) at 1 year, and 67% (95% CI: 51%-87%) at 3 years. Six deaths were aneurysm related, while 1 was T2EL related within the first 30 days due to persistent hemorrhage. During FU, one more patient died due to a T2EL-related secondary rupture (T2EL-related mortality, 5.7%, n=2). Multivariable analysis revealed that arterial hypertension was associated with an increased risk for reintervention (hazard ratio [HR]: 27.8, 95% CI: 1.48-521, p=0.026) and age was associated with an increased risk for mortality (HR 1.14, 95% CI: 1.04-1.26, p=0.005). CONCLUSION T2ELs after rEVAR showed a benign course in most cases. In the short term, the possibility of persistent bleeding should be considered. In the mid term, a consequent FU protocol is required to detect known late complications after EVAR at an early stage and to prevent secondary rupture and death.
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Affiliation(s)
- Anna-Leonie Menges
- Department of Vascular Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Lorenz Meuli
- Department of Vascular Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Philip Dueppers
- Department of Vascular Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Kerstin Stoklasa
- Department of Vascular Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Reinhard Kopp
- Department of Vascular Surgery, University Hospital Zurich, Zurich, Switzerland
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Scallan O, Kribs S, Power AH, DeRose G, Duncan A, Dubois L. Onyx versus coil embolization for the treatment of type II endoleaks. J Vasc Surg 2020; 73:1966-1972. [PMID: 33249208 DOI: 10.1016/j.jvs.2020.10.069] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 10/15/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Little evidence is available supporting the optimal treatment of type II endoleaks associated with aortic sac growth. Previous studies have lacked comparisons between treatment methods and long-term follow-up. The purpose of the present study was to review our center's experience with the treatment of type II endoleaks comparing Onyx (a liquid embolization agent consisting of ethylene vinyl alcohol; Medtronic, Minneapolis, Minn) embolization and coil embolization. METHODS A retrospective review of prospectively collected data from a vascular surgery database was performed to identify all patients who had undergone embolization of a type II endoleak for aortic sac growth after endovascular aneurysm repair from 2005 to 2018. The Onyx and coil embolization groups were compared using univariate statistics. RESULTS A total of 58 patients had undergone 77 embolization procedures for type II endoleaks with either Onyx (27 patients; 37 procedures) or coils (31 patients; 40 procedures). The average aneurysm size at embolization was larger in the Onyx group (77.9 ± 15.1 mm) compared with coil embolization (73.4 ± 11.9 mm). The mean follow-up was 57 months for the Onyx group and 74 months for the coil embolization group. Of the 27 patients who had undergone Onyx embolization, 2 (7.4%) had required graft explantation compared with 5 of the 31 patients (16.1%) who had undergone coil embolization (P = .33). The results of the per-patient analysis showed that the coil embolization group had a significantly greater rate of the need for further reintervention compared with the Onyx group (55% vs 19%; P < .01). Clinical success was observed in 13 patients (48%) in the Onyx embolization group compared with 10 patients (32%) in the coil embolization group (P = .04). Two patients in each group had presented with secondary rupture of the aneurysm sac after attempted embolization. CONCLUSIONS Type II endoleaks associated with sac growth treated with Onyx were less likely to require further reinterventions than were those treated with coil embolization. A trend was found toward a greater need for endovascular aneurysm repair explant after coil embolization. With a high rate of further reintervention and potential for sac rupture, diligent follow-up is required after attempted type II embolization, regardless of the technique used.
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Affiliation(s)
- Oonagh Scallan
- Department of Vascular Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Stewart Kribs
- Department of Interventional Radiology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Adam H Power
- Department of Vascular Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Guy DeRose
- Department of Vascular Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Audra Duncan
- Department of Vascular Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Luc Dubois
- Department of Vascular Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
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Natural history of isolated type II endoleaks in patients treated by fenestrated-branched endovascular repair for pararenal and thoracoabdominal aortic aneurysms. J Vasc Surg 2020; 72:44-54. [DOI: 10.1016/j.jvs.2019.09.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 09/13/2019] [Indexed: 11/21/2022]
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Katada Y. Recent Update of Endovascular Type 2 Endoleak Management. INTERVENTIONAL RADIOLOGY 2020; 5:114-119. [PMID: 36284754 PMCID: PMC9550397 DOI: 10.22575/interventionalradiology.2020-0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 07/08/2020] [Indexed: 12/01/2022]
Abstract
EVAR has been used clinically for almost three decades, and it has been widely applied in clinical practice and has been applied to difficult cases as devices and techniques have evolved. Although the major advantage of EVAR is its lower perioperative mortality, compared with open surgery, late-onset complications such as endoleaks have become major issues, requiring lifelong follow-up after EVAR. The clinical guidelines have been updated, and many systematic reviews/meta-analyses and multi-center registries have been published; surgeons must keep up-to-date regarding these changes. In this review, the author reviews evidence on the recent update of the type 2 endoleak management.
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Affiliation(s)
- Yoshiaki Katada
- Department of Radiology, Tokyo Women's Medical University Medical Center East, Tokyo
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D'Oria M, Mastrorilli D, Ziani B. Natural History, Diagnosis, and Management of Type II Endoleaks after Endovascular Aortic Repair: Review and Update. Ann Vasc Surg 2020; 62:420-431. [PMID: 31376537 DOI: 10.1016/j.avsg.2019.04.048] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 03/02/2019] [Accepted: 04/28/2019] [Indexed: 12/20/2022]
Affiliation(s)
- Mario D'Oria
- Division of Vascular and Endovascular Surgery, Mayo Clinic Gonda Vascular Center, Rochester, MN; Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUITs, Trieste, Italy.
| | - Davide Mastrorilli
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUITs, Trieste, Italy
| | - Barbara Ziani
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUITs, Trieste, Italy
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