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Liang F, Su JQ. Central nervous injury risk factors after endovascular repair of a thoracic aortic aneurysm with type B aortic dissection. World J Clin Cases 2024; 12:4873-4880. [DOI: 10.12998/wjcc.v12.i22.4873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 06/10/2024] [Accepted: 06/14/2024] [Indexed: 06/30/2024] Open
Abstract
BACKGROUND Aortic dissection is the deadliest disease of the cardiovascular system. Type B aortic dissection accounts for 30%-60% of aortic dissections and is mainly treated by endovascular repair of thoracic endovascular aneurysm repair (TEVAR). However, patients are prone to various complications after surgery, with central nervous system injury being the most common, which seriously affects their prognosis and increases the risk of disability and death. Therefore, exploring the risk factors of central nervous system injury after TEVAR can provide a basis for its prevention and control.
AIM To investigate the risk factors for central nervous system injury after the repair of a thoracic endovascular aneurysm with type B aortic dissection.
METHODS We enrolled 306 patients with type B aortic dissection who underwent TEVAR at our hospital between December 2019 and October 2022. The patients were categorized into injury (n = 159) and non-injury (n = 147) groups based on central nervous system injury following surgery. The risk factors for central nervous system injury after TEVAR for type B aortic dissection were screened by comparing the two groups. Multivariate logistic regression analysis was performed.
RESULTS The Association between age, history of hypertension, blood pH value, surgery, mechanical ventilation, intensive care unit stay, postoperative recovery times on the first day after surgery, and arterial partial pressure of oxygen on the first day after surgery differed substantially (P < 0.05). Multivariate logistic regression analysis indicated that age, surgery time, history of hypertension, duration of mechanical ventilation, and intensive care unit stay were independent risk factors for central nervous system injury after TEVAR of type B aortic dissection (P < 0.05).
CONCLUSION For high-risk patients with central nervous system injury after TEVAR of type B aortic dissection, early intervention measures should be implemented to lower the risk of neurological discomfort following surgery in high-risk patients with central nervous system injury after TEVAR for type B aortic dissection.
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Affiliation(s)
- Feng Liang
- Department of Vascular Surgery, Qinghai Province Cardiovascular and Cerebrovascular Disease Specialist Hospital, Xining 810012, Qinghai Province, China
| | - Jie-Qiong Su
- Department of Neurology, Qinghai Province Cardiovascular and Cerebrovascular Disease Specialist Hospital, Xining 810012, Qinghai Province, China
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Firwana M, Hasan B, Saadi S, Abd-Rabu R, Alabdallah K, Al-Zu'bi H, Shalhub S, Black JH, Prokop LJ, Murad MH. A systematic review supporting the Society for Vascular Surgery guidelines on the management of heritable aortopathies. J Vasc Surg 2023; 78:1077-1082.e12. [PMID: 37327953 DOI: 10.1016/j.jvs.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 05/29/2023] [Accepted: 06/03/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND To support the development of clinical practice guidelines on the management of patients with genetic aortopathies and arteriopathies, a writing committee from the Society for Vascular Surgery has commissioned this systematic review. METHODS We conducted a systematic review and searched multiple databases for studies addressing six questions identified by the Society for Vascular Surgery guideline committee about evaluating and managing patients with genetic aortopathies and arteriopathies. Studies were selected and appraised by pairs of independent reviewers. RESULTS We included 12 studies in this systematic review. We did not identify studies about the long-term outcomes of endovascular repair for aortic aneurysm in patients with heritable aortopathy or about new aortic events in pregnant women with a history of aortic dissection (AD) or aneurysm. A small case series demonstrated a 100% survival rate and 100% aortic intervention-free survival at 15 months (range, 7-28 months) after endograft repair for type B AD. A positive genetic diagnosis was discovered in 36% of patients with aortic aneurysms and dissections who had no risk factors for hereditary aortopathies, and these patients had a mortality rate of 11% at a median follow-up duration of 5 months. Black patients had lower 30-day mortality than White patients (5.6% vs 9.0%, respectively), but they had a higher overall aortic reintervention rate at 30 days after AD repair (47% vs 27%, respectively). Aortic reinterventions owing to aneurysmal expansion and endoleak at 30 days were higher in Black patients than White patients. The certainty of evidence was judged to be very low across all the outcomes evaluated in this systematic review. CONCLUSIONS The available evidence suggests high survival after thoracic endovascular aortic repair for type B AD in young patients with heritable aortopathies, but with limited long-term follow-up. Genetic testing in patients with acute aortic aneurysms and dissections had a high yield. It was positive for most patients with risk factors for hereditary aortopathies and in more than one-third for all other patients, and was associated with new aortic events within 15 years.
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Affiliation(s)
- Mohammed Firwana
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Bashar Hasan
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Samer Saadi
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Rami Abd-Rabu
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Khaled Alabdallah
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Hossam Al-Zu'bi
- Division of Cardiology, Mount Sinai Medical Center, Miami Beach, FL
| | - Sherene Shalhub
- Division of Vascular Surgery, Oregon Health & Science University, Portland, OR
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - M Hassan Murad
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.
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Körfer D, Erhart P, Wortmann M, Dihlmann S, Grond-Ginsbach C, Kilian S, Asatryan A, Jung G, Schmitz-Rixen T, Böckler D, Hakimi M. Characteristics of patients with multiple arterial aneurysms. VASA 2023; 52:119-123. [PMID: 36601699 DOI: 10.1024/0301-1526/a001050] [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: 01/06/2023]
Abstract
Background: The aim of this retrospective cross-sectional observational study was to determine differences of patients with multiple arterial aneurysms to patients with single arterial aneurysms. Patients and methods: Patients with the diagnosis of an arterial aneurysm from January 2006 to January 2016 in the department of vascular surgery Heidelberg were investigated. Excluded were patients with hereditary disorders of connective tissue or systemic inflammatory disease, as well as other arterial pathologies than true aneurysms. Patients with multiple aneurysms (defined by at least four aneurysms) were compared to patients with single aneurysms concerning age at initial diagnosis, sex and affected arterial site. To verify the findings, a replication of the study was performed at a comparable institution. Results: Of 3107 patients with arterial aneurysms, 918 were excluded. Of the resulting 2189 patients, 1238 (56.6%) patients had a single, 808 (36.9%) two or three, and 143 (6.5%) at least four aneurysms (group mult-AA). Nine hundred seventy-two patients (44.4%) had a single abdominal aortic aneurysm (group sing-AAA). Age at initial diagnosis differed between mult-AA (66.7±9.5 y) and sing-AAA (69.1±8.6 y) (p=0.0338). Within mult-AA, 138 patients (96.5%) were male, compared with 865 patients (89.0%) in sing-AAA (p=0.0041). The most frequent aneurysm localization shifted from the abdominal aorta and its branches in patients with a single aneurysm (n=1029; 83.1%) to pelvic and leg arteries in patients with at least four aneurysms (n=318; 63.2%). The replication of the study at the department of vascular surgery Frankfurt confirmed the younger age at initial diagnosis in mult-AA (67.3±12.5 y) compared to sing-AAA (70.9±9.6 y) (p=0.0259) and the distribution shift toward the arteries below the aortic bifurcation in mult-AA. Conclusions: Patients with multiple aneurysms are younger at initial diagnosis and differ concerning aneurysm localization compared to patients with a single aneurysm.
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Affiliation(s)
- Daniel Körfer
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Germany
| | - Philipp Erhart
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Germany
| | - Markus Wortmann
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Germany.,Department of Vascular Surgery, Endovascular Surgery and Transplant Surgery, Klinikum Stuttgart - Katharinenhospital, Germany
| | - Susanne Dihlmann
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Germany
| | - Caspar Grond-Ginsbach
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Germany
| | - Samuel Kilian
- Institute for Medical Biometry and Informatics, University of Heidelberg, Germany
| | - Ara Asatryan
- Department of Vascular and Endovascular Surgery, University Hospital Frankfurt, Germany
| | - Georg Jung
- Department of Vascular and Endovascular Surgery, University Hospital Frankfurt, Germany.,Department of Vascular Surgery, Lucerne Cantonal Hospital, Switzerland
| | - Thomas Schmitz-Rixen
- Department of Vascular and Endovascular Surgery, University Hospital Frankfurt, Germany
| | - Dittmar Böckler
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Germany
| | - Maani Hakimi
- Department of Vascular Surgery, Lucerne Cantonal Hospital, Switzerland
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Hao X, Cheng S, Jiang B, Xin S. Applying multi-omics techniques to the discovery of biomarkers for acute aortic dissection. Front Cardiovasc Med 2022; 9:961991. [PMID: 36588568 PMCID: PMC9797526 DOI: 10.3389/fcvm.2022.961991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022] Open
Abstract
Acute aortic dissection (AAD) is a cardiovascular disease that manifests suddenly and fatally. Due to the lack of specific early symptoms, many patients with AAD are often overlooked or misdiagnosed, which is undoubtedly catastrophic for patients. The particular pathogenic mechanism of AAD is yet unknown, which makes clinical pharmacological therapy extremely difficult. Therefore, it is necessary and crucial to find and employ unique biomarkers for Acute aortic dissection (AAD) as soon as possible in clinical practice and research. This will aid in the early detection of AAD and give clear guidelines for the creation of focused treatment agents. This goal has been made attainable over the past 20 years by the quick advancement of omics technologies and the development of high-throughput tissue specimen biomarker screening. The primary histology data support and add to one another to create a more thorough and three-dimensional picture of the disease. Based on the introduction of the main histology technologies, in this review, we summarize the current situation and most recent developments in the application of multi-omics technologies to AAD biomarker discovery and emphasize the significance of concentrating on integration concepts for integrating multi-omics data. In this context, we seek to offer fresh concepts and recommendations for fundamental investigation, perspective innovation, and therapeutic development in AAD.
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Affiliation(s)
- Xinyu Hao
- Department of Vascular Surgery, The First Affiliated Hospital of China Medical University, China Medical University, Shenyang, China,Key Laboratory of Pathogenesis, Prevention and Therapeutics of Aortic Aneurysm, Shenyang, Liaoning, China
| | - Shuai Cheng
- Department of Vascular Surgery, The First Affiliated Hospital of China Medical University, China Medical University, Shenyang, China,Key Laboratory of Pathogenesis, Prevention and Therapeutics of Aortic Aneurysm, Shenyang, Liaoning, China
| | - Bo Jiang
- Department of Vascular Surgery, The First Affiliated Hospital of China Medical University, China Medical University, Shenyang, China,Key Laboratory of Pathogenesis, Prevention and Therapeutics of Aortic Aneurysm, Shenyang, Liaoning, China
| | - Shijie Xin
- Department of Vascular Surgery, The First Affiliated Hospital of China Medical University, China Medical University, Shenyang, China,Key Laboratory of Pathogenesis, Prevention and Therapeutics of Aortic Aneurysm, Shenyang, Liaoning, China,*Correspondence: Shijie Xin,
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HTAD patient pathway: Strategy for diagnostic work-up of patients and families with (suspected) heritable thoracic aortic diseases (HTAD). A statement from the HTAD working group of VASCERN. Eur J Med Genet 2022; 66:104673. [PMID: 36460281 DOI: 10.1016/j.ejmg.2022.104673] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/06/2022] [Accepted: 11/27/2022] [Indexed: 11/30/2022]
Abstract
Heritable thoracic aortic diseases (HTAD) are rare pathologies associated with thoracic aortic aneurysms and dissection, which can be syndromic or non-syndromic. They may result from genetic defects. Associated genes identified to date are classified into those encoding components of the (a) extracellular matrix (b) TGFβ pathway and (c) smooth muscle contractile mechanism. Timely diagnosis allows for prompt aortic surveillance and prophylactic surgery, hence improving life expectancy and reducing maternal complications as well as providing reassurance to family members when a diagnosis is ruled out. This document is an expert opinion reflecting strategies put forward by medical experts and patient representatives involved in the HTAD Rare Disease Working Group of VASCERN. It aims to provide a patient pathway that improves patient care by diminishing time to diagnosis, facilitating the establishment of a correct diagnosis using molecular genetics when possible, excluding the diagnosis in unaffected persons through appropriate family screening and avoiding overuse of resources. It is being recommended that patients are referred to an expert centre for further evaluation if they meet at least one of the following criteria: (1) thoracic aortic dissection (<70 years if hypertensive; all ages if non-hypertensive), (2) thoracic aortic aneurysm (all adults with Z score >3.5 or 2.5-3.5 if non-hypertensive or hypertensive and <60 years; all children with Z score >3), (3) family history of HTAD with/without a pathogenic variant in a gene linked to HTAD, (4) ectopia lentis without other obvious explanation and (5) a systemic score of >5 in adults and >3 in children. Aortic imaging primarily relies on transthoracic echocardiography with magnetic resonance imaging or computed tomography as needed. Genetic testing should be considered in those with a high suspicion of underlying genetic aortopathy. Though panels vary among centers, for patients with thoracic aortic aneurysm or dissection or systemic features these should include genes with a definitive or strong association to HTAD. Genetic cascade screening and serial aortic imaging should be considered for family screening and follow-up. In conclusion, the implementation of these strategies should help standardise the diagnostic work-up and follow-up of patients with suspected HTAD and the screening of their relatives.
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Huang L, Tang J, Lin L, Wang R, Chen F, Wei Y, Si Y, Fu W. Association of genetic variants in ULK4 with the age of first onset of type B aortic dissection. Front Genet 2022; 13:956866. [PMID: 36118886 PMCID: PMC9478570 DOI: 10.3389/fgene.2022.956866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 07/28/2022] [Indexed: 11/30/2022] Open
Abstract
Background: The association between autophagy, structural alterations of the aortic wall, and endothelial dysfunction in humans has yet to be fully elucidated. The family of ULK (UNC51-like) enzymes plays critical roles in autophagy and development. This study aimed to evaluate the association between ULK gene family members and patient age of first type B aortic dissection (TBAD) onset. Methods: The genotype data in a TBAD cohort from China and the related summary-level datasets were analyzed. We applied the sequence kernel association test (SKAT) to test the association between single-nucleotide polymorphisms (SNPs) and age of first onset of TBAD controlling for gender, hypertension, and renal function. Next, we performed a 2-sample Mendelian randomization (MR) to explore the potential causal relationship between ULK4 and early onset of TBAD at the level of gene expression coupled with DNA methylation with genetic variants as instrumental variables. Results: A total of 159 TBAD patients with 1,180,097 SNPs were included. Concerning the association between the ULK gene family and the age of first onset of the TBAD, only ULK4 was found to be significant according to SKAT analysis (q-FDR = 0.0088). From 2-sample MR, the high level of ULK4 gene expression was related to a later age of first onset of TBAD (β = 4.58, p = 0.0214). Conclusion: This is the first study of the ULK gene family in TBAD, regarding the association with the first onset age. We demonstrated that the ULK4 gene is associated with the time of onset of TBAD based on both the SKAT and 2-sample MR analyses.
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Affiliation(s)
- Lihong Huang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Department of Biostatistics, Zhongshan Hospital, Fudan University, Shanghai, China
- Clinical Research Unit, Institute of Clinical Science, Zhongshan Hospital of Fudan University, Shanghai, China
| | - Jiaqi Tang
- Department of Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Lijuan Lin
- Department of Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Ruihan Wang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Feng Chen
- Department of Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Yongyue Wei
- Department of Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Yi Si
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- *Correspondence: Yi Si, ; Weiguo Fu,
| | - Weiguo Fu
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- *Correspondence: Yi Si, ; Weiguo Fu,
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Sun L, Chang Y, Jiang P, Ma Y, Yuan Q, Ma X. Association of gene polymorphisms in FBN1 and TGF-β signaling with the susceptibility and prognostic outcomes of Stanford type B aortic dissection. BMC Med Genomics 2022; 15:65. [PMID: 35307021 PMCID: PMC8935688 DOI: 10.1186/s12920-022-01213-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 02/28/2022] [Indexed: 11/13/2022] Open
Abstract
Background This study is aimed at investigating the association of Fibrillin-1 (FBN1) and transforming growth factor β (TGF-β) signaling-related gene polymorphisms with the susceptibility of Stanford type B aortic dissection (AD) and its clinical prognostic outcomes. Methods Five single-nucleotide polymorphism (SNPs) (FBN1rs 145233125, rs201170905, rs11070646, TGFB1rs1800469, and TGFB2rs900) were analyzed in patients with Stanford type B AD (164) and healthy controls (317). Gene–gene and gene–environment interactions were assessed by generalized multifactor dimensionality reduction. A 4-year follow-up was performed for all AD patients. Results G carriers of FBN1 rs201170905 and TGFB1 rs1800469 have an increased risk of Stanford type B AD. The interaction of FBN1, TGFB1, TGFB2 and environmental promoted to the increased risk of type B AD (cross-validation consistency = 10/10, P = 0.001). Dominant models of FBN1rs145233125 TC + CC genotype (P = 0.028), FBN1 rs201170905 AG + GG (P = 0.047) and TGFB1 rs1800469 AG + GG (P = 0.052) were associated with an increased risk of death of Stanford type B AD. The recessive model of FBN1 rs145233125 CC genotype (P < 0.001), FBN1rs201170905 GG (P < 0.001), TGFB1 rs1800469 AG + GG genotype (P = 0.011) was associated with an increased risk of recurrence of chest pain in Stanford type B AD. Conclusions The interactions of gene–gene and gene–environment are related with the risk of Stanford type B AD. C carriers of rs145233125, G carriers of rs201170905 and G carriers of rs1800469 may be the poor clinical outcome indicators of mortality and recurrent chest pain in Stanford type B AD. Supplementary Information The online version contains supplementary material available at 10.1186/s12920-022-01213-z.
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Erhart P, Körfer D, Grond-Ginsbach C, Qiao JL, Bischoff MS, Hempel M, Schaaf CP, Grau A, Böckler D. Genetic Variation in LRP1 Associates with Stanford Type B Aortic Dissection Risk and Clinical Outcome. J Cardiovasc Dev Dis 2022; 9:jcdd9010014. [PMID: 35050224 PMCID: PMC8780592 DOI: 10.3390/jcdd9010014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 12/29/2021] [Accepted: 01/04/2022] [Indexed: 02/04/2023] Open
Abstract
Genetic variation in LRP1 (low-density lipoprotein receptor-related protein 1) was reported to be associated with thoracic aortic dissections and aneurysms. The aims of this study were to confirm this association in a prospective single-center patient cohort of patients with acute Stanford type B aortic dissections (STBAD) and to assess the impact of LRP1 variation on clinical outcome. The single nucleotide variation (SNV) rs11172113 within the LRP1 gene was genotyped in 113 STBAD patients and 768 healthy control subjects from the same population. The T-allele of rs11172113 was more common in STBAD patients as compared to the reference group (72.6% vs. 59.6%) and confirmed to be an independent risk factor for STBAD (p = 0.002) after sex and age adjustment in a logistic regression model analyzing diabetes, smoking and hypertension as additional risk factors. Analysis of clinical follow-up (median follow-up 2.0 years) revealed that patients with the T-allele were more likely to suffer aorta-related complications (T-allele 75.6% vs. 63.8%; p = 0.022). In this study sample of STBAD patients, variation in LRP1 was an independent risk factor for STBAD and affected clinical outcome.
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Affiliation(s)
- Philipp Erhart
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany; (D.K.); (C.G.-G.); (J.-L.Q.); (M.S.B.); (D.B.)
- Correspondence: ; Tel.: +49-6221-56-6249
| | - Daniel Körfer
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany; (D.K.); (C.G.-G.); (J.-L.Q.); (M.S.B.); (D.B.)
| | - Caspar Grond-Ginsbach
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany; (D.K.); (C.G.-G.); (J.-L.Q.); (M.S.B.); (D.B.)
| | - Jia-Lu Qiao
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany; (D.K.); (C.G.-G.); (J.-L.Q.); (M.S.B.); (D.B.)
| | - Moritz S. Bischoff
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany; (D.K.); (C.G.-G.); (J.-L.Q.); (M.S.B.); (D.B.)
| | - Maja Hempel
- Institute of Human Genetics, Heidelberg University, 69120 Heidelberg, Germany; (M.H.); (C.P.S.)
| | - Christian P. Schaaf
- Institute of Human Genetics, Heidelberg University, 69120 Heidelberg, Germany; (M.H.); (C.P.S.)
| | - Armin Grau
- Department of Neurology, Community Hospital Klinikum der Stadt Ludwigshafen am Rhein, 67063 Ludwigshafen, Germany;
| | - Dittmar Böckler
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany; (D.K.); (C.G.-G.); (J.-L.Q.); (M.S.B.); (D.B.)
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