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Madhavan P, Sultan S, McDonnell CO, Cowman JP, Colgan MP, McEniff N, Molloy M, Moore DJ, Shanik G. Low Dose Intraarterial Thrombolysis with Tissue Plasminogen Activator: Does It Deliver as Promised? Vasc Endovascular Surg 2016; 36:351-6. [PMID: 12244423 DOI: 10.1177/153857440203600504] [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: 11/16/2022]
Abstract
The widespread use of intraarterial thrombolytic therapy has been based on perceived benefits over operative treatment and the downgrading of the magnitude of subsequent surgery. Thirty-three patients who had thrombolysis for peripheral artery occlusion were retrospectively analyzed at St. James's Hospital from 1991 to 1997. One patient received streptokinase unsuccessfully. Five other patient's records were inadequate for analysis. Twenty-seven patient's notes were analyzed for risk, duration of occlusion, duration of treatment, dosage of tissue plasminogen activator (tPA) and conduits thrombolysed. There were 15 males and 12 females. The mean age was 62 years (range, 20-87). Fourteen were current or reformed smokers. Five were diabetic. Indications for treatment included acute graft occlusion (n = 13), embolus (n = 6), and primary and secondary arterial thrombosis (n = 8). Duration of occlusion was less than 24 hours in seven, 1 to 7 days in ten, and more than 7 days in ten patients. Twelve (44.44%) patients had complete clot lysis, four (14.81%) had partial clearance, and 1 1 (40.74%) remained occluded. Eight (29.63%) had serious complications including one death. Eighteen (66.66%) patients needed further surgical intervention to maintain graft patency. Data were analyzed using the chi-square and pooled t test. No significant difference was observed in results from thrombolysis from different conduits, gender, etiology, or smoking history. Increased duration of tPA administration was associated with an increased risk of failure. Administration of total dosages greater than 60 mg was associated with a higher risk of failure. Diabetics had a poor outcome (p=0.0520). Only 44% of patients successfully underwent lysis. A primary surgical option may be a more sensible course than lysis, given that the vast majority of patients ended up having surgery anyway.
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Affiliation(s)
- P Madhavan
- Department of Vascular and Endovascular Surgery, St. James's Hospital, Dublin.
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Sebastian AJ, Robinson GJ, Dyet JF, Ettles DF. Long-term Outcomes of Low-dose Catheter-directed Thrombolytic Therapy: A 5-year Single-center Experience. J Vasc Interv Radiol 2010; 21:1004-10. [DOI: 10.1016/j.jvir.2010.03.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2008] [Revised: 03/04/2010] [Accepted: 03/30/2010] [Indexed: 11/29/2022] Open
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Abstract
Acute limb ischemia is a potentially life-threatening clinical event. Thrombosis in situ, bypass graft thrombosis, and embolic occlusion are the three major precipitating events leading to acute limb ischemia. Management of acute ischemia depends on the clinical status of the affected limb and patient comorbidities. Catheter-directed thrombolysis (CDT) is the treatment of choice for patients with relatively mild acute limb ischemia (Rutherford categories I and IIa) with no contraindications to thrombolytic therapy. Patients with severe acute limb ischemia (Rutherford category IIb) need emergent revascularization. CDT should be considered, nonetheless, if the relative risks compared with primary operation are favorable. CDT is a life- and limb-saving treatment for many patients despite limitations of efficacy and associated complications. This article is a review of the etiology of acute arterial occlusion; clinical triage of patients presenting with acute limb ischemia; catheter guide wire techniques, pharmacological agents, and devices in current use for CDT; as well as the outcomes of CDT.
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Affiliation(s)
- Harry L Morrison
- Interventional Radiology Section, Department of Diagnostic Imaging, Santa Clara Valley Medical Center, San Jose, California
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Allie DE, Hebert CJ, Lirtzman MD, Wyatt CH, Keller VA, Khan MH, Barker EA, McElderry MW, Khan MA, Fail PS, Stagg SJ, Mitran EV, Chaisson G, Allie SD, Allie AA, Walker CM. Novel simultaneous combination chemical thrombolysis/rheolytic thrombectomy therapy for acute critical limb ischemia: The power-pulse spray technique. Catheter Cardiovasc Interv 2004; 63:512-22. [PMID: 15558768 DOI: 10.1002/ccd.20216] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The novel power-pulse spray (P-PS) technique maximizes and combines the advantages and minimizes the disadvantages of both chemical thrombolysis (CT) and rheolytic thrombectomy (RT). Forty-nine consecutive patients with iliofemoral thrombotic occlusion were treated via P-PS technique. Using a 6 Fr RT catheter, saline prime was exchanged for thrombolytic solution [group 1, 10-20 mg tenecteplase (TNK)/50 cc saline, n = 25; group 2, 1,000,000 urokinase (UK)/50 cc saline, n = 24]. The outflow port was closed, then the catheter was advanced at 1 mm increments while pulsing lytic agent. After 30-min lysis time, RT and definitive treatment of the underlying stenosis were performed. Procedure success was 23/25 (92%) and 22/24 (91.6%) for group 1 and 2, respectively. The mean total procedure time was 72 and 75 min in group 1 and 2, respectively. Thirty-day limb salvage was 91% in both groups. There were no major surgical complications. The P-PS technique is safe and effective using either UK or TNK, offering several potential advantages over monotherapy, including more rapid revascularization, decreases systemic lytic exposure and bleeding complications while facilitating both CT and RT capacity and efficacy.
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Affiliation(s)
- David E Allie
- Cardiovascular Institute of the South-Opelousas, 2730 Ambassador Caffery Parkway, Lafayette, LA 70506, USA.
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Razavi MK, Lee DS, Hofmann LV. Catheter-directed Thrombolytic Therapy for Limb Ischemia: Current Status and Controversies. J Vasc Interv Radiol 2004; 15:13-23. [PMID: 14709682 DOI: 10.1097/01.rvi.0000112621.22203.12] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Absence of urokinase from the United States market for the past 4 years has resulted in increasing experience with other plasminogen activators in catheter-directed thrombolytic therapy. The differences in the pharmacologic properties and biologic behavior of these agents may translate into clinical outcomes that are distinct. Some of these manifestations can be predicted based on the existing large clinical trials in the acute myocardial infarction literature. However, because of the fundamental differences in techniques and thrombolytic regimens, extrapolation of the coronary data may not always predict the performance of these agents in peripheral catheter-directed fibrinolysis. In this article, the current status of the available lytic agents in the treatment of limb ischemia is reviewed.
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Affiliation(s)
- Mahmood K Razavi
- Department of Vascular and Interventional Radiology, Stanford University Hospital, H3651 Vascular Center, 300 Pasteur Drive, Stanford, California 94305, USA.
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Razavi MK, Lee DS, Hofmann LV. Catheter-directed Thrombolytic Therapy for Limb Ischemia: Current Status and Controversies. J Vasc Interv Radiol 2003; 14:1491-501. [PMID: 14654482 DOI: 10.1097/01.rvi.0000099531.29957.94] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Absence of urokinase from the United States market for the past 4 years has resulted in increasing experience with other plasminogen activators in catheter-directed thrombolytic therapy. The differences in the pharmacologic properties and biologic behavior of these agents may translate into clinical outcomes that are distinct. Some of these manifestations can be predicted based on the existing large clinical trials in the acute myocardial infarction literature. However, because of the fundamental differences in techniques and thrombolytic regimens, extrapolation of the coronary data may not always predict the performance of these agents in peripheral catheter-directed fibrinolysis. In this article, the current status of the available lytic agents in the treatment of limb ischemia is reviewed.
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Affiliation(s)
- Mahmood K Razavi
- Department of Vascular and Interventional Radiology, Stanford University Hospital, H3651 Vascular Center, 300 Pasteur Drive, Stanford, CA 94305, USA.
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Tanabe Y, Itoh E, Nakagawa I, Suzuki K. Pulse-spray thrombolysis in acute myocardial infarction caused by thrombotic occlusion of an ectatic coronary artery. Circ J 2002; 66:207-10. [PMID: 11999650 DOI: 10.1253/circj.66.207] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Pulse-spray thrombolysis was performed in 2 patients with acute myocardial infarction (AMI) caused by thrombotic occlusion of coronary artery ectasia. Case 1, a 66-year-old woman with an inferior AMI underwent emergency coronary arteriography, which revealed occlusion of an ectatic right coronary artery. Primary balloon angioplasty failed to reestablish distal flow. Urokinase was administered through the pulse-spray infusion catheter (UltraFuse) and intravenous recombinant tissue plasminogen activator was also administered. Angiographic disappearance of the thrombus was observed within 30 min of starting the infusion, and there was only mild irregularity in the ectatic coronary artery. Case 2, a 45-year-old man with an inferior AMI underwent emergency coronary arteriography, which revealed occlusion of an ectatic right coronary artery. TIMI-3 flow was soon obtained after administration of 480,000 units of urokinase through the pulse-spray infusion catheter. There was diffuse right coronary ectasia without angiographic evidence of coronary stenosis. Coronary ectasia sometimes develops into AMI without the coexistence of coronary stenosis. Because a massive thrombus plays a major role, pulse-spray thrombolysis is a possible treatment in coronary artery ectasia with thrombotic occlusion.
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Affiliation(s)
- Yasuhiko Tanabe
- Department of Cardiology, Niigata Prefectural Shibata Hospital, Shibata, Japan
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Semba CP, Murphy TP, Bakal CW, Calis KA, Matalon TA. Thrombolytic therapy with use of alteplase (rt-PA) in peripheral arterial occlusive disease: review of the clinical literature. The Advisory Panel. J Vasc Interv Radiol 2000; 11:149-61. [PMID: 10716384 DOI: 10.1016/s1051-0443(07)61459-6] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
PURPOSE The clinical literature describing the use of alteplase in the treatment of peripheral arterial occlusive (PAO) disease is reviewed. MATERIALS AND METHODS The literature database was acquired by a MEDLINE search using the Boolean keyword string: tissue plasminogen activator and/or rt-PA and peripheral not animal. A review was performed to identify the dose range of alteplase, technique of infusion, use of anticoagulation, clinical success rates, and risk of complications. RESULTS Forty-six clinical studies were identified. There are few prospective, randomized clinical trials and a lack of standardized protocols and endpoints. Use of catheter-directed infusions of recombinant tissue plasminogen activator (rt-PA) may be beneficial versus surgery in the initial management of acute limb ischemia (< 14 days) and in reducing the magnitude of subsequent surgical or percutaneous revascularization. For patients with chronic limb ischemia (> 14 days), irreversible acute limb ischemia, or advanced diabetic arteriopathy, catheter-directed infusion of rt-PA or other plasminogen activators may be unsuitable. The risk of adverse bleeding appears related to the overall dose and duration of infusion. These risks appear similar to those of urokinase. The role of heparin in increasing adverse bleeding during rt-PA therapy is unclear. CONCLUSIONS There is no generally accepted dose or technique for administering catheter-directed thrombolysis using alteplase; however, several studies have demonstrated its clinical safety and efficacy. Formal studies will be required to determine the optimal dose, technique of infusion, the role of anticoagulation, and complication rates when alteplase is used for PAO disease.
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Affiliation(s)
- C P Semba
- Interventional Radiology, H-3646, Stanford University Medical Center, CA 94305, USA.
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Lambert AW, Trkulja D, Fox AD, Budd JS, Chalmers AH, Horrocks M. Age-related outcome for peripheral thrombolysis. Eur J Vasc Endovasc Surg 1999; 17:144-8. [PMID: 10063410 DOI: 10.1053/ejvs.1998.0722] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To investigate the age-related outcome of peripheral thrombolysis and determine for which patient group this treatment is worthwhile. DESIGN AND METHODS A combined retrospective and prospective analysis of consecutive patients undergoing thrombolysis for acute lower-limb ischaemia was made with respect to age-related outcome and other risk factors. RESULTS One hundred and two patients underwent thrombolysis for acute limb ischaemia. In the under 60 age group there was a 40% amputation rate. Seventy-three per cent of this group smoked. In the over 80 age group, the amputation rate was 15% and only 8% were smokers. CONCLUSION Advancing age is not an adverse risk factor for thrombolysis which appears to be safe and effective in this patient group. There is a high incidence of smoking in the younger age group (< 60 years), in whom failed thrombolysis frequently leads to amputation.
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Affiliation(s)
- A W Lambert
- University Department of Surgery, Royal United Hospital, Bath, U.K
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Silva JA, Ramee SR, Collins TJ, Jenkins JS, Lansky AJ, Ansel GM, Dolmatch BL, Glickman MH, Stainken B, Ramee E, White CJ. Rheolytic thrombectomy in the treatment of acute limb-threatening ischemia: immediate results and six-month follow-up of the multicenter AngioJet registry. Possis Peripheral AngioJet Study AngioJet Investigators. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1998; 45:386-93. [PMID: 9863742 DOI: 10.1002/(sici)1097-0304(199812)45:4<386::aid-ccd7>3.0.co;2-q] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
We tested the efficacy of rheolytic thrombectomy in treating 21 patients (mean age 68+/-12 years; 66% male) and 22 vessels (limbs) who presented to the hospital within 2 weeks of the development of limb-threatening ischemia. Fifty-two percent had contraindications to use thrombolytics, and 57% had severe comorbidities. All of the vessels were occluded with thrombus on the initial angiogram. Procedural success was achieved in 20 limbs (91%). Three patients expired in the hospital, and one expired at follow-up due to nonvascular causes. Acute limb salvage was achieved in 18 of 19 limbs (95%) in the 18 survivors, and 6-month limb salvage was achieved in 16 of 18 limbs (89%) in the 17 survivors. Rheolytic thrombectomy is effective in restoring immediate blood flow in acute limb-threatening ischemia, especially in high-risk surgical patients or patients with contraindications to thrombolytic therapy.
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Affiliation(s)
- J A Silva
- Department of Cardiology, Ochsner Clinic, New Orleans, Louisiana 70121, USA
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Nobuyoshi M, Nakagawa Y. AngioJet thrombectomy catheter for the thrombus-laden lesions. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1998; 45:394-5. [PMID: 9863743 DOI: 10.1002/(sici)1097-0304(199812)45:4<394::aid-ccd8>3.0.co;2-s] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Armon MP, Yusuf SW, Whitaker SC, Gregson RHS, Wenham PW, Hopkinson BR. Results of 100 cases of pulse-spray thrombolysis for acute and subacute leg ischaemia. Br J Surg 1997. [DOI: 10.1002/bjs.1800840118] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Armon MP, Yusuf SW, Whitaker SC, Gregson RHS, Wenham PW, Hopkinson BR. Results of 100 cases of pulse-spray thrombolysis for acute and subacute leg ischaemia. Br J Surg 1997. [DOI: 10.1046/j.1365-2168.1997.02442.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Saito T, Taniguchi I, Nakamura S, Oka H, Mizuno Y, Noda K, Yamashita S, Oshima S. Pulse-spray thrombolysis in acutely obstructed coronary artery in critical situations. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1997; 40:101-8. [PMID: 8993826 DOI: 10.1002/(sici)1097-0304(199701)40:1<101::aid-ccd20>3.0.co;2-u] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Pulse-spray thrombolysis (PST) was performed to treat large coronary thrombus in 3 patients in critical situations. The originally developed pump system and a custom infusion catheter (SciMed/Boston Scientific, Maple Grove, MN) were used in combination. Case 1, a 48-yr-old male with extensive anterior myocardial infarction, failed to be recanalized by systemic thrombolysis. He underwent emergent coronary angiography, which revealed proximal occlusion of a large left anterior descending artery (LAD). TIMI 3 flow was achieved after 20 min with 200,000 units of urokinese by PST, followed by balloon angioplasty. In case 2, a 57-yr-old male, subacute stent thrombosis occurred 4 days after two and a half Palmatz-Schatz stents were implanted in mid-LAD. TIMI 3 flow was recovered at 20 min with 240,000 units of urokinese and an additional 72,000 units of rt-PA, followed by redilatation with a quarter-size larger balloon than that used in stent deployment. In case 3, a 70-yr-old male, during ultrasound study for unstable angina, a massive thrombotic complication occurred which occluded the left main trunk. PST was immediately performed under cardiac resuscitation, and the patient recovered from shock after 15 min. TIMI 3 flow was restored after 25 min. Two Palmatz-Schatz stents were implanted after thrombus completely disappeared. There were no complications, including distal embolization, intimal dissection, or bleeding. There was also no recurrence of the ischemic event. PST may be considered a potential treatment modality for coronary artery disease where large thrombus plays a major role.
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Affiliation(s)
- T Saito
- Cardiovascular Division, Kumamoto Central Hospital, Japan
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Valji K. Thrombolysis for Peripheral Vascular Disease. J Vasc Interv Radiol 1996. [DOI: 10.1016/s1051-0443(96)70111-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Yusuf SW, Whitaker SC, Gregson RH, Wenham PW, Hopkinson BR, Makin GS. Prospective randomised comparative study of pulse spray and conventional local thrombolysis. Eur J Vasc Endovasc Surg 1995; 10:136-41. [PMID: 7655964 DOI: 10.1016/s1078-5884(05)80104-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES To compare the time required to achieve lysis with the pulse spray technique and the conventional slow continuous infusion technique. DESIGN Prospective randomised open Study. METHODS Eighteen patients suitable for intra-arterial thrombolytic therapy with conventional and pulse spray technique were randomised 1:1 to receive either pulse spray thrombolysis with 0.33 mg/ml rt-PA injected as a bolus of 0.2 ml or conventional thrombolysis with 0.05 mg/ml rt-PA infused at a rate of 10 ml/h. RESULTS The age, duration of symptoms, length of occlusion and prethrombolysis ankle brachial pressure index were comparable in the two groups. The median duration of thrombolytic therapy in the pulse spray group was 195 min (range 90-1260) compared to 1390 min (range 300-2400) in the Conventional group. The difference between the two groups was significant, p < 0.002 (Mann-Whitney test). CONCLUSIONS Significantly shorter time is required to achieve local thrombolysis with pulse spray compared to the conventional infusion method.
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Affiliation(s)
- S W Yusuf
- Department of Vascular Surgery, University Hospital, Nottingham, U.K
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Yusuf SW, Wenham PW, Hopkinson BR. Advances in thrombolytic therapy. Br J Surg 1995; 82:281-2. [PMID: 7749716 DOI: 10.1002/bjs.1800820253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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