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Kalmykov EL, Suchkov IA, Kalinin RE, Dammrau R. Experience in Treatment of Patients with First Type Secondary Endoleaks. I.P. PAVLOV RUSSIAN MEDICAL BIOLOGICAL HERALD 2023; 31:459-466. [DOI: 10.17816/pavlovj569332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2024]
Abstract
INTRODUCTION: First type secondary endoleaks (EL) require quickest elimination, primarily using the endovascular methods. Despite the existence of a sufficiently large number of methods of their elimination, the results of treatment remain ambiguous.
AIM: Analysis of our own experience of elimination of the first type ELs in patients after endoprosthetics of infrarenal abdominal aortic aneurysm.
MATERIALS AND METHODS: The study is retrospective with prospective observation. All patients underwent computed tomography (CT) for identification of the type of EL and choosing a method of its elimination. The term first type secondary EL was understood as EL which developed in the long-term period after the primarily negative CT-angiography after endoprosthetic repair of the aorta.
RESULTS: ELs of Ia type were diagnosed in 14 cases, in one case EL of Ib type was identified. On average, first type secondary ELs were identified in 34 months after the primary operation for endograft implantation. In 2 of 15 patients, EL were symptomatic. The elimination of the first type EL required an individualized approach in all cases. The main methods of elimination of the first type EL were: elongation using Jotec E-iliac (n = 1); coiling with implantation of Gore cuff and Chimney-stenting of the left renal artery (LRA; n = 2); implantation of Gore cuff (n = 4); reinforcement with Aptus EndoAnchors (n = 2); Cuff Gore implantation and LRA stenting by Chimney-technique (n = 1); implantation of Cuff Jotec and reinforcement with Aptus EndoAnchors (n = 1); aneurysmal sac coiling (n = 2); Gore cuff implantation with fixation with EndoAnchors and LRA stenting using Chimney-technique (n = 1). The technical success of EL elimination was 100% (in all cases, the success was confirmed by intraoperative angiography, as well as by CT angiography or ultrasound duplex scanning with contrast enhancement after surgery), there were no deaths. In the long-term period (from 6 to 60 months), re-interventions were performed in two cases, fatal outcome happened in one case, after a late open conversion for elimination of EL.
CONCLUSION: In 13% of cases, first type ELs were symptomatic, and their elimination required individual approach with taking into account anatomical factors and the implanted graft. The medium-term results of the elimination of the first type EL are good, no fatal cases have been reported, and the number of reinterventions has reached 20%, which requires monitoring in the postoperative period.
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Waldeck S, Overhoff D, Brockmann MA, Becker BV. Detection of Endoleaks Following Thoracic and Abdominal Aortic Endovascular Aortic Repair-: A Comparison of Standard and Dynamic 4D-Computed Tomography Angiography. J Endovasc Ther 2023; 30:739-745. [PMID: 35582987 DOI: 10.1177/15266028221095390] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Endoleaks are a common complication after endovascular aortic repair (EVAR) and thoracic endovascular aortic repair (TEVAR). The detection and correct classification of endoleaks is essential for the further treatment of affected patients. However, standard computed tomography angiography (CTA) provides no hemodynamic information on endoleaks, which can result in misclassification in complex cases. The aim of this study was to compare standard CTA (sCTA) with dynamic, dual-energy CTA (dCTA) for detection and classification of endoleaks following EVAR or TEVAR. MATERIALS AND METHODS This retrospective evaluation compared 69 sCTA diagnostic examinations performed on 50 different patients with 89 dCTA diagnostic examinations performed on 69 different patients. RESULTS In total, 15.9% of sCTA examinations and 49.4% of dCTA examinations led to the detection of endoleaks. With sCTA, 20.0% of patients were diagnosed with endoleaks, while with dCTA, 37.7% of patients were diagnosed with endoleaks. With sCTA, mainly Type 1 endoleaks were detected, whereas, with dCTA, the types of detected endoleaks were more evenly distributed. In comparison with the literature, the frequencies of endoleak types detected with dCTA better reflect the natural distribution than the frequencies detected with standard CTA. CONCLUSION Based on the retrospective comparative evaluation, dCTA could pose a valuable supplementary diagnostic tool resulting in a more accurate and realistic detection and classification of suspected endoleaks.
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Affiliation(s)
- Stephan Waldeck
- Department of Diagnostic and Interventional Radiology and Neuroradiology, Bundeswehr Central Hospital Koblenz, Koblenz, Germany
- Institute of Neuroradiology, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Daniel Overhoff
- Department of Diagnostic and Interventional Radiology and Neuroradiology, Bundeswehr Central Hospital Koblenz, Koblenz, Germany
- Department of Radiology and Nuclear Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Marc A Brockmann
- Institute of Neuroradiology, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Benjamin V Becker
- Department of Diagnostic and Interventional Radiology and Neuroradiology, Bundeswehr Central Hospital Koblenz, Koblenz, Germany
- Institute of Neuroradiology, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
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Spinal cord ischemia following simultaneous EVAR and TEVAR for concomitant thoracic and abdominal aortic aneurysms. Ann Vasc Surg 2022; 87:343-350. [PMID: 35926790 DOI: 10.1016/j.avsg.2022.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 06/21/2022] [Accepted: 06/23/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVES In patients with abdominal aortic aneurysms, 10-20% have concomitant thoracic aortic pathologies. These are typically managed with staged endovascular aneurysm repair (EVAR) and thoracic endovascular aortic repair (TEVAR) due to a perceived higher risk of spinal cord ischemia from a simultaneous intervention. We aimed to determine the outcomes of patients undergoing simultaneous EVAR and TEVAR for concomitant aneurysms. METHODS A retrospective cohort study was performed using the Vascular Quality Initiative registry from December 2003 to January 2021. Patients undergoing same-day EVAR and TEVAR were included and analyzed in accordance with the Society for Vascular Surgery reporting standards. Primary outcomes were technical success and spinal cord ischemia. RESULTS Simultaneous EVAR and TEVAR was performed in 25 patients. Median age was 75.0 (IQR 63.0-79.0) years and 20 (80.0%) patients were male. Two (4.0%) patients were symptomatic and four (16.0%) presented with rupture. Median maximum infrarenal and thoracic aortic diameter was 57.0 (IQR 52.0-65.0). Infrarenal aortic neck length was 15.0mm (IQR 10.0-25.0), and diameter was 27.0mm (IQR 24.5-30.0). Median procedure time was 185.0 minutes (IQR, 117.8-251.3), fluoroscopy time 32.7 minutes (IQR, 21.8-63.1), and contrast volume 165 ml (IQR 115.0-207.0). There were three (12.0%) Type Ia endoleaks and three (12.0%) Type II endoleaks in EVAR's, with one (4.0%) Type Ia and one (4.0%) Type II endoleak in TEVARs. In-hospital mortality occurred in three (12.0%) patients (one elective, two ruptures). Spinal cord ischemia occurred in one (4.0%) patient. This patient had a symptomatic aneurysm. Thoracic coverage extended from Zone 4 to Zone 5 and an emergent spinal drain was placed postoperatively. Symptoms were present on discharge. There was one (4.0%) conversion to open repair which occurred in a ruptured aneurysm. Technical success was achieved in 19 (76.0%) patients, however when excluding ruptured aneurysms, was achieved in 17 (81.0%) patients. Follow-up data was available for 19 (76.0%) patients at a median of 426.0 (IQR 329.0-592.5) days postoperatively. A total of 3 (12.0%) patients died during the late mortality period, at a mean of 509.0 (±503.7) days. Median change in abdominal and thoracic aortic sac diameter was -1.35mm (IQR -11.5-2.5) and 8.0 (IQR -10.5-12.0) respectively. CONCLUSIONS Simultaneous EVAR and TEVAR for concomitant abdominal and thoracic aortic aneurysms can be performed with low rates of spinal cord ischemia. Short- and mid-term outcomes are acceptable.
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Kalmykov EL, Suchkov IA, Kalinin RE, Damrau R. [Endoleaks in endovacular treatment of infrareneral abdominal aortic aneurysm (part I)]. Khirurgiia (Mosk) 2022:77-84. [PMID: 35775848 DOI: 10.17116/hirurgia202207177] [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: 06/15/2023]
Abstract
We analyzed the PubMed, Scopus databases and the eLIBRARY electronic library regarding appropriate literature data. In the first part, modern classifications of endoleaks type 1 and 2 after stenting of infrarenal aortic aneurysm are considered. We described causes, risk factors and effectiveness of various treatment options.
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Affiliation(s)
| | - I A Suchkov
- Pavlov Ryazan State Medical University, Ryazan, Russia
| | - R E Kalinin
- Pavlov Ryazan State Medical University, Ryazan, Russia
| | - R Damrau
- St. Katharinen Hospital, Frechen, Germany
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Abbott E, Dhara S, Khabaz K, Sankary S, Cao K, Nguyen N, Babrowski T, Pocivavsek L, Milner R. Computational analysis of endovascular aortic repair proximal seal zone preservation with endoanchors: A case study in cylindrical neck anatomy. JVS Vasc Sci 2021; 2:170-178. [PMID: 34617067 PMCID: PMC8489211 DOI: 10.1016/j.jvssci.2021.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 06/11/2021] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Endovascular aortic repair is the common approach for abdominal aortic aneurysms, but endoleaks remain a significant problem with long-term success. Endoanchors have been found to reduce the incidence of type 1A endoleaks and can treat intraoperative type 1a endoleaks. However, little is known about the optimal number and position of endoanchors to achieve the best outcome. METHODS Using image segmentation and a computational model derived from a reconstructed native patient abdominal aortic aneurysm geometry, the stability of the proximal seal zone was examined through finite element analysis in Abaqus (Dassault Systèmes, Providence, RI). The biomechanical parameter of contact area was compared for varying numbers (0, 2, 4, 8) and positions (proximal, medial, distal) of endoanchors under different adhesion strengths and physiologic pressure conditions. RESULTS In every simulation, an increase in adhesion strength is associated with maintenance of proximal seal. For biologically plausible adhesion strengths, under conditions of normal blood pressure (120 mm Hg), the addition of any number of endoanchors increases the stability of the endograft-wall interface at the proximal seal zone by approximately 10% compared with no endoanchors. At hypertensive pressures (200 mm Hg), endoanchors increase the stability of the interface by 20% to 60% compared with no endoanchors. The positioning of endoanchors within the proximal seal zone has a greater effect at hypertensive pressures, with proximal positioning increasing stability by 15% compared with medial and distal positioning and 30% compared with no endoanchors. CONCLUSIONS Endoanchors improve fixation within the proximal seal zone particularly under conditions of high peak systolic pressure. Seal zone stabilization provides a mechanism through which endoanchor addition may translate into lower rates of type 1a endoleaks for patients.
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Affiliation(s)
- Erin Abbott
- The College, University of Chicago, Chicago, Ill
| | - Sanjeev Dhara
- Pritzker School of Medicine, University of Chicago, Chicago, Ill
| | | | - Seth Sankary
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Chicago, Chicago, Ill
| | - Kathleen Cao
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Chicago, Chicago, Ill
| | - Nhung Nguyen
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Chicago, Chicago, Ill
| | - Trissa Babrowski
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Chicago, Chicago, Ill
| | - Luka Pocivavsek
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Chicago, Chicago, Ill
| | - Ross Milner
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Chicago, Chicago, Ill
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Mazzaccaro D, Mazzeo G, Zuccon G, Modafferi A, Malacrida G, Righini PC, Marrocco-Trischitta MM, Nano G. Factors affecting the occurrence of proximal endoleak after endovascular abdominal aortic repair for abdominal aneurysms. J Int Med Res 2020; 48:300060520971515. [PMID: 33256478 PMCID: PMC7711229 DOI: 10.1177/0300060520971515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective This retrospective study was performed to assess the clinical and
radiological variables associated with proximal type IA endoleak (EL) in
patients treated with elective endovascular repair for abdominal aortic
aneurysms. Methods The chi-square test, t-test, and logistic regression analysis were performed
as appropriate. A P value of <0.05 was considered statistically
significant. Results The data of 79 patients were analyzed. No mortality occurred. During
follow-up (median, 28.5 months; interquartile range, 12.8–43.0 months), 10
patients developed type IA EL. In the logistic regression analysis,
undersizing of the endograft diameter by <10% significantly affected the
occurrence of type IA EL. When the diameter was used for measurements, less
oversizing was significantly associated with a higher risk of type IA EL.
When the area was used for measurements, oversizing of >20% significantly
affected the occurrence of type IA EL. Conclusion When sizing endografts, a discrepancy was noted between the measurements of
the diameter and area of the proximal neck. The area might represent a more
accurate measurement than the axial diameter to optimize the proximal
sealing and lower the risk of developing type IA EL.
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Affiliation(s)
- Daniela Mazzaccaro
- Operative Unit of Vascular Surgery, 27288IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Girolomina Mazzeo
- Operative Unit of Vascular Surgery, 27288IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Gianmarco Zuccon
- Operative Unit of Vascular Surgery, 27288IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Alfredo Modafferi
- Operative Unit of Vascular Surgery, 27288IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Giovanni Malacrida
- Operative Unit of Vascular Surgery, 27288IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Paolo C Righini
- Operative Unit of Vascular Surgery, 27288IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | | | - Giovanni Nano
- Operative Unit of Vascular Surgery, 27288IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy.,Department of Biomedical Sciences for Health, 9304University of Milan, Milan, Italy
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Hori D, Kusadokoro S, Shimizu T, Kimura N, Yamaguchi A. Prosthetic Graft Dilation at the Aortic Arch in the Era of Hybrid Aortic Surgery. Ann Vasc Dis 2020; 13:163-169. [PMID: 32595793 PMCID: PMC7315240 DOI: 10.3400/avd.oa.20-00005] [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] [Indexed: 11/13/2022] Open
Abstract
Objective: This study aims to evaluate the chronological size changes of the prosthetic graft in the aortic arch, which is used as a landing zone for a subsequent stent grafting in hybrid aortic surgery. Materials and Methods: Eighty-five patients who underwent total aortic arch replacement followed by computed tomography follow-up for at least 30 months after the surgery were included in the study. Results: Prosthetic grafts used were Hemashield (Maquet, Rastatt, Germany), J-Graft (Japan Lifeline Inc., Tokyo, Japan) and Triplex (Terumo, Tokyo, Japan). There was an initial increase in diameter compared to package size after implantation (Hemashield, 1.04±0.035 vs. J-Graft, 1.06±0.027 vs. Triplex, 1.04±0.023, p=0.13). Significant difference in graft dilation ratio was observed in Triplex (1.18±0.062) at long-term compared to Hemashield (1.07±0.052, p<0.001) and J-Graft (1.10±0.071, p<0.001). Multivariate analysis showed that age (r=0.002; 95% confidence interval [CI], 0.0001–0.0037; p=0.035), knitted-type prosthesis (r=0.089; 95% CI, 0.0610–0.1163; p<0.0001), and prevalence of cerebral vascular disease (r=0.038; 95% CI, 0.0030–0.0732; p=0.034) were independently associated with graft dilation after surgery. Conclusion: Prosthetic graft selection and appropriate sizing of the stent graft should be considered for each individual undergoing hybrid aortic surgery to maintain sufficient oversizing of the stent graft.
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Affiliation(s)
- Daijiro Hori
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Saitama, Japan
| | - Sho Kusadokoro
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Saitama, Japan
| | - Toshikazu Shimizu
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Saitama, Japan
| | - Naoyuki Kimura
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Saitama, Japan
| | - Atsushi Yamaguchi
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Saitama, Japan
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Long-term outcome of sac filling with fibrin sealant after endovascular aneurysm repair of abdominal aortic aneurysm with challenging aortic neck anatomy. J Vasc Surg 2019; 70:471-477. [DOI: 10.1016/j.jvs.2018.10.113] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 10/22/2018] [Indexed: 11/18/2022]
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Belczak SQ, Pedroso GD, Ogawa LC, Campos PT, Padula AL, Machado GP, Dos Santos MZS, Abrão BM. Treatment of type 1A endoleak using coil embolization: a case report. J Vasc Bras 2019; 18:e20180130. [PMID: 31360155 PMCID: PMC6636908 DOI: 10.1590/1677-5449.180130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
In a type 1A endoleak, the endograft is unable to fully seal the proximal aneurysm neck and blood flow leaks between the wall of the aortic neck and the graft material. This article reports a case in which coil embolization was used and presents a literature review (PubMed, LILACS, and SciELO). Searches were run for articles published in the past 5 years using the descriptors “endoleak 1A”, “coil embolization,” and “treatment”. Type 1A endoleak occurs in 1.1% of patients within 30 days of graft placement. Treatment of an endoleak is obligatory and usually consists of sealing the proximal graft neck using stents and balloons to expand the landing zone or to increase the radial force of the graft. Some studies have suggested using embolization techniques with cyanoacrylate, fibrin glue, and Onyx, demonstrating success rates that exceed 97%. However, correction of type 1A endoleak using coil embolization has seldom been described.
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Affiliation(s)
- Sergio Quilici Belczak
- Centro Universitário São Camilo - CUSC, São Paulo, SP, Brasil.,Instituto de Aprimoramento e Pesquisa em Angiorradiologia e Cirurgia Endovascular - IAPACE, São Paulo, SP, Brasil
| | | | - Lara Cote Ogawa
- Centro Universitário São Camilo - CUSC, São Paulo, SP, Brasil
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Hsu HL, Huang CY, Chen PL, Chen YY, Hsu CP, Chen IM, Shih CC. Efficacy of ascending aortic banding technique concomitant with type I hybrid aortic arch repair in high-risk patients. Heart Vessels 2019; 34:1524-1532. [PMID: 30911784 DOI: 10.1007/s00380-019-01384-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 03/15/2019] [Indexed: 11/26/2022]
Abstract
Banding of the ascending aorta has been introduced as a less complex procedure to optimize the proximal landing zone of the stent graft in hybrid aortic arch surgery. However, data about the long-term results and effects of this technique are still limited. We aimed to study the efficacy of banding of the ascending aorta in hybrid aortic arch repair. The study included 11 high-risk patients with dilated ascending aorta (wider than 38 mm in diameter) undergoing ascending aortic banding for hybrid arch repair. Clinical outcomes, including technical success, endoleaks, perioperative mortality and morbidity, and sequential remodeling of the ascending aorta were investigated. The average diameter of the ascending aorta had been reduced (p = 0.02) from 42.1 mm (range = 39.0-46.4) to 37.2 mm (range = 35.6-38.6) after banding procedure. The technical success rate was 100.0%. No type I endoleak occurred, but 2 cases of distal stent graft-induced new entry required re-interventions. The 5-year survival and freedom from aortic events rates both were 81.8%. The ascending aortic diameter remained stable and no proximal migration of the stent graft was observed during the study period. The 5-year results validated the durability of this therapeutic modality, especially in high-risk patients.
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Affiliation(s)
- Hung-Lung Hsu
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Cardiovascular Surgery, Far Eastern Memorial Hospital, New Taipei City, Taiwan
- Department of Surgery, Taiwan Adventist Hospital, Taipei, Taiwan
| | - Chun-Yang Huang
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Division of Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital, #201, Section 2, Shipai Road, Taipei, Taiwan
| | - Po-Lin Chen
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Division of Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital, #201, Section 2, Shipai Road, Taipei, Taiwan
| | - Yin-Yin Chen
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Surgery, Taiwan Adventist Hospital, Taipei, Taiwan
| | - Chiao-Po Hsu
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Division of Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital, #201, Section 2, Shipai Road, Taipei, Taiwan
| | - I-Ming Chen
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Division of Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital, #201, Section 2, Shipai Road, Taipei, Taiwan
| | - Chun-Che Shih
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.
- Division of Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital, #201, Section 2, Shipai Road, Taipei, Taiwan.
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