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Omran S, Gröger S, Bruder L, Bürger M, Kapahnke S, Haidar H, Konietschke F, Greiner A. Neoaortoiliac system and cryopreserved human allograft for the treatment of aortic graft infections. Vascular 2023; 31:850-857. [PMID: 35549485 PMCID: PMC10563369 DOI: 10.1177/17085381221091372] [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: 11/15/2022]
Abstract
OBJECTIVE To report and compare neoaortoiliac system reconstruction and cryopreserved human allograft in treating aortic graft infections. METHODS We retrospectively analysed the data of the patients treated for aorto graft infections between January 2015 and May 2021 in our hospital. The clinical data, diagnostic procedures, and surgical options were evaluated. The primary endpoint of this study was the 30-day and 1-year mortality; secondary endpoints were major postoperative complications. RESULTS We retrospectively reviewed a series of 31 consecutive patients (28 males; median age 72 years, range, 50-87 years) with aortic graft infection treated with NAIS (n = 20, 65%) or cryopreserved allograft (n = 11, 36%). The clinical presentation included fever attacks in 18 (58%) patients, abdominal pain in 15 (48%) patients, haemodynamic instability in 6 (19%) patients, and haematemesis in 2 (7%) patients. The median operative time of the NAIS was longer than CHA without a statistically significant difference (458 min vs. 359 min, p = .505). The postoperative morbidity for all patients was 81%, with no significant difference between NAIS and CHA groups (85% vs. 73%, p = .638). There was no limb thrombosis of the new reconstructions. Limb loss occurred in 4 (13%) patients, including 2 (10%) NAIS patients and 2 (18%) CHA patients. One NAIS patient developed complications in the form of a distal (femoral) disruption of the vein 15 days after surgery. There were no significant differences between NAIS and CHA groups in ICU stay (12 vs 8 days, .984) but in hospitalization (22 vs 33, p = .033). The most common bacteria isolated were staphylococci strains in 15 (48%). In 13 (36%) patients, candida was positive. The in-hospital 30-day and 1-year mortality for all patients was 16% (5/31) and 29% (9/31), with no significant differences between NAIS and CHA at 30 days (25% vs. 0, p = .133) or 1 year (35% vs. 18%, .429). Five NAIS patients died during the hospital stay; three of them had end-of-life decisions. After a median follow-up of 16 months (1-66 months), 12 (39%) patients died, including 9 patients with NAIS and 3 with CHA reconstructions. The causes of death included overwhelming sepsis in 5 (42%) patients, graft disruption in one (8%) NAIS patient, non-small cell lung cancer in one (8%) patient, COVID-19 in one (8%) patient and unknown causes (8%) in one. CONCLUSIONS Non-staged neoaortoiliac system reconstruction and cryopreserved human allografts show comparable short- and midterm results for treating aortic graft infections. However, both procedures remain challenging with high morbidity and mortality rates.
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Affiliation(s)
- Safwan Omran
- Department of Vascular Surgery, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Germany
| | - Steffen Gröger
- Department of Vascular Surgery, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Germany
| | - Leon Bruder
- Department of Vascular Surgery, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Germany
| | - Matthias Bürger
- Department of Vascular Surgery, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Germany
| | - Sebastian Kapahnke
- Department of Vascular Surgery, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Germany
| | - Haidar Haidar
- Department of Vascular Surgery, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Germany
| | - Frank Konietschke
- Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Institute of Medical Biometrics and Clinical Epidemiology and Berlin Institute of Health (BIH), Charité – Universitätsmedizin Berlin, Germany
| | - Andreas Greiner
- Department of Vascular Surgery, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Germany
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Newman JS, Pupovac SS, Scheinerman SJ, Tseng JC, Hemli JM, Brinster DR. Who needs their descending thoracic aorta anyway? Extra-anatomic bypass for aorto-bronchial fistula after TEVAR. J Cardiothorac Surg 2023; 18:243. [PMID: 37580735 PMCID: PMC10424404 DOI: 10.1186/s13019-023-02326-x] [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: 12/09/2022] [Accepted: 06/29/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND Aortobronchial fistula after TEVAR remains a vexing clinical problem associated with high mortality. Although a combination of endovascular and open surgical strategies have been reported in managing this pathology, there is as yet no definitive treatment algorithm that can be used for all patients. We discuss our approach to an aortobronchial fistula associated with an overtly infected aortic endograft. CASE PRESENTATION A 49-year-old female sustained a traumatic aortic transection 14 years prior, managed by an endovascular stent-graft. Due to persistent endoleak, she underwent open replacement of her descending thoracic aorta 4 years later. Ten years after her open aortic surgery, the patient presented with hemoptysis, and a pseudoaneurysm at her distal aortic suture line was identified on computed tomography, whereupon she underwent placement of an endograft. Eight weeks later, she presented with dyspnea, recurrent hemoptysis, malaise and fever, with clinical and radiographic evidence of an aortobronchial communication and an infected aortic stent-graft. The patient underwent management via a two-stage open surgical approach, constituting an extra-anatomic bypass from her ascending aorta to distal descending aorta and subsequent radical excision of her descending aorta with all associated infected prosthetic material and repair of the airway. CONCLUSION Aortobronchial fistula after TEVAR represents a challenging complex clinical scenario. Extra-anatomic aortic bypass followed by radical debridement of all contaminated tissue may provide the best option for durable longer-term outcomes.
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Affiliation(s)
- Joshua S Newman
- Department of Cardiovascular and Thoracic Surgery, North Shore University Hospital, Northwell Health, 300 Community Drive, Manhasset, NY, USA.
| | - Stevan S Pupovac
- Department of Cardiovascular and Thoracic Surgery, North Shore University Hospital, Northwell Health, 300 Community Drive, Manhasset, NY, USA
| | - S Jacob Scheinerman
- Department of Cardiovascular and Thoracic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - Jui-Chuan Tseng
- Department of Cardiovascular and Thoracic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - Jonathan M Hemli
- Department of Cardiovascular and Thoracic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - Derek R Brinster
- Department of Cardiovascular and Thoracic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY, USA
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Rebelo A, Partsakhashvili J, Ronellenfitsch U, John E, Kleeff J, Ukkat J. Single-Center Retrospective Subgroup Analysis of "Primary Aortic" (Aneurysm, Aortic Dissection, PAU) and "Secondary Aortic" (Iatrogenic, Trauma, Aortoesophageal Fistula) Indications for Emergency TEVAR. J Clin Med 2023; 12:4037. [PMID: 37373731 DOI: 10.3390/jcm12124037] [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: 04/22/2023] [Revised: 05/22/2023] [Accepted: 06/12/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND The aim of this study was to analyze the outcome of emergency thoracic endovascular aortic repair (TEVAR) in the treatment of "primary aortic" (aneurysm, aortic dissection, penetrating aortic ulcer (PAU)) and "secondary aortic" (iatrogenic, trauma, and aortoesophageal fistula) pathologies. METHODS Retrospective review of a cohort of patients treated at a single tertiary referral center from 2015 to 2021. The primary end point was postoperative in-hospital mortality. Secondary end points were the duration of the procedure, duration of postoperative intensive care treatment, length of hospital stay, and the nature and severity of postoperative complications according to the Dindo-Clavien classification. RESULTS A total of 34 patients underwent TEVAR for emergency indications. Twenty-two patients were treated for primary and twelve patients for secondary aortic pathologies. Concerning in-hospital mortality, no statistically significant difference could be observed between the primary and secondary aortic groups (27.3% vs. 33.3%, p = 0.711). Patients with an aortoesophageal fistula had a mortality rate of 66.7%. Postoperative morbidity (Dindo-Clavien > 3) was also not statistically significantly different between the primary and secondary aortic groups (36.4% vs. 33.3%, p = 0.86). Preoperative hemoglobin level (p < 0.001 for mortality, p = 0.002 for morbidity), hemoglobin level difference (p = 0.022, p = 0.032), postoperative creatinine level (p = 0.009, p = 0.035), and pre- and postoperative lactate levels (p < 0.001 for both mortality and morbidity) were found to be independent factors associated with postoperative mortality and morbidity (Dindo-Clavien > 3), respectively. The preoperative creatinine level was found to be associated with mortality (p = 0.024) but not morbidity. CONCLUSIONS Morbidity and in-hospital mortality are still considerable after emergency TEVAR for both primary and secondary aortic indications. Pre- and postoperative levels of hemoglobin, creatinine, and lactate may be valuable to predict patient outcomes.
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Affiliation(s)
- Artur Rebelo
- Department of General, Abdominal, Vascular and Endocrine Surgery, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, 06120 Halle, Germany
| | - Jumber Partsakhashvili
- Department of General, Abdominal, Vascular and Endocrine Surgery, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, 06120 Halle, Germany
| | - Ulrich Ronellenfitsch
- Department of General, Abdominal, Vascular and Endocrine Surgery, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, 06120 Halle, Germany
| | - Endres John
- Department of General, Abdominal, Vascular and Endocrine Surgery, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, 06120 Halle, Germany
| | - Jörg Kleeff
- Department of General, Abdominal, Vascular and Endocrine Surgery, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, 06120 Halle, Germany
| | - Jörg Ukkat
- Department of General, Abdominal, Vascular and Endocrine Surgery, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, 06120 Halle, Germany
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Omran S, Gröger S, Shafei B, Schawe L, Bruder L, Haidar H, Greiner A. Outcomes of Candida and Non-Candida Aortic Graft Infection. Vasc Endovascular Surg 2023; 57:97-105. [PMID: 36148827 PMCID: PMC9846377 DOI: 10.1177/15385744221129236] [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] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To evaluate and compare the outcomes of Candida- and non-Candida-associated aortic graft infections. METHODS We retrospectively analyzed the data from patients treated for aortic graft infection from 2015 to 2021 in our hospital. RESULTS A total of 66 patients (56 men; median age, 69 years; range, 50-87 years) were admitted with aortic graft infection, including 21 (32%) patients in the Candida group and 45 (68%) in the non-Candida group. The average time between initial operation and presentation of aortic graft infection was 50 months (range, 1-332 months). Graft-enteric fistulas (GEFs) were more often in the Candida group (57% vs 27%, P = .017). The most proven causative fungal specimen was C. albicans in 16 (76%) patients. Non-albicans Candida was found in 9% of all patients and 29% of the Candida patients. The median ICU length of stay was longer in the Candida group than non-Candida (10 vs 9 days, P = .012). Additionally, the median hospital length of stay was longer in the Candida group (33 vs 22 days, P = .048). There were no statistically significant differences between Candida and non-Candida groups according to the in-hospital mortality (24% vs 24%, P = .955), and 1-year mortality (38% vs 38%, P = .980). CONCLUSIONS Patients with bacterial and fungal aortic graft infections have high rates of morbidity and mortality. We found no significant differences in postoperative morbidity and mortality between Candida and non-Candida patients. However, the ICU and hospital length of stay were longer in the Candida group.
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Affiliation(s)
- Safwan Omran
- Department of Vascular Surgery,
Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin,
and Berlin Institute of Health, Charité––Universitätsmedizin
Berlin, Berlin, Germany,Safwan Omran, Department of Vascular
Surgery, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu
Berlin, and Berlin Institute of Health, Charité––Universitätsmedizin Berlin,
Hindenburgdamm 30, Berlin 12203, Germany.
| | - Steffen Gröger
- Department of Vascular Surgery,
Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin,
and Berlin Institute of Health, Charité––Universitätsmedizin
Berlin, Berlin, Germany
| | - Bashaer Shafei
- Department of Vascular Surgery,
Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin,
and Berlin Institute of Health, Charité––Universitätsmedizin
Berlin, Berlin, Germany
| | - Larissa Schawe
- Department of Vascular Surgery,
Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin,
and Berlin Institute of Health, Charité––Universitätsmedizin
Berlin, Berlin, Germany
| | - Leon Bruder
- Department of Vascular Surgery,
Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin,
and Berlin Institute of Health, Charité––Universitätsmedizin
Berlin, Berlin, Germany
| | - Haidar Haidar
- Department of Vascular Surgery,
Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin,
and Berlin Institute of Health, Charité––Universitätsmedizin
Berlin, Berlin, Germany
| | - Andreas Greiner
- Department of Vascular Surgery,
Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin,
and Berlin Institute of Health, Charité––Universitätsmedizin
Berlin, Berlin, Germany
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Omran S, Raude B, Schawe L, Carstens JC, Angermair S, Berger C, Konietschke F, Treskatsch S, Greiner A. Isolated Ruptured Paravisceral Penetrating Aortic Ulcers. Ann Vasc Surg 2021; 81:138-147. [PMID: 34780950 DOI: 10.1016/j.avsg.2021.09.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 09/11/2021] [Accepted: 09/19/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND The goal of this study is to investigate the clinical presentation, treatment options, and outcomes of the patients with isolated ruptured paravisceral penetrating aortic ulcers (PV-PAU). METHODS All patients presenting with acute aortic syndrome from 2015 to 2020 were screened, of which patients with isolated ruptured PV-PAU were included in this retrospective study. Study endpoints were the assessment of treatment options, technical success, and clinical outcome. Outcome measures included major perioperative complications and mortality. RESULTS Sixteen patients (11 men; median age 68; IQR 60 - 75 years) presented with isolated ruptured PV-PAU were included in this study. The median follow-up was 25 months (range 1 - 51). Ruptured PV-PAUs represented 12.3% of the ruptured aortic aneurysms in all locations. PV-PAUs were found in segment A (n = 8, 50%), segment B (n = 5, 31%), and segment C (n = 3, 19%). PV-PAUs showed a mean protrusion distance of 27±10 mm, a mean neck diameter of 21 ± 7 mm, and maximal aortic diameter of 50 ± 11 mm. Five patients (31%) showed hemodynamic instability on admission and needed intense fluid resuscitation. Of those, 2 patients needed urgent laparotomy with a fast transabdominal supraceliac aortic clamping, one needed an aortic balloon occlusion to obtain rapid aortic control. The open aortic repair was the most frequently performed surgery (11/16, 69%), followed by hybrid procedures (3/16) and parallel graft chimney technique (2/16). Two patients died during the follow-up, calculating for in-hospital and 1-year mortality rates of 6 - 12%, respectively. The postoperative morbidity rate was 31%. Postoperative complications included acute renal failure (31%), pneumonia (25%), and 1case of ischemic colitis (6%). No spinal cord ischemia was reported. CONCLUSIONS Ruptured PV-PAU is a rare and challenging diagnostic and therapeutic entity. Open aortic repair seems to be a reliable option in treating patients with isolated ruptured PV-PAUs. Hybrid procedures and parallel stent-graft techniques can only be used in selected patients.
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Affiliation(s)
- Safwan Omran
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of vascular surgery, Berlin, Germany.
| | - Ben Raude
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of vascular surgery, Berlin, Germany
| | - Larissa Schawe
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of vascular surgery, Berlin, Germany
| | - Jan Christoph Carstens
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of vascular surgery, Berlin, Germany
| | - Stefan Angermair
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Charité Campus Benjamin Franklin, Berlin, Germany
| | - Christian Berger
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Charité Campus Benjamin Franklin, Berlin, Germany
| | - Frank Konietschke
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Institute of Medical Biometrics and Clinical Epidemiology and Berlin Institute of Health (BIH), Berlin, Germany
| | - Sascha Treskatsch
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Charité Campus Benjamin Franklin, Berlin, Germany
| | - Andreas Greiner
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of vascular surgery, Berlin, Germany
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Omran S, Gröger S, Schawe L, Berger C, Konietschke F, Treskatsch S, Greiner A, Angermair S. Preoperative and ICU Scoring Models for Predicting the In-Hospital Mortality of Patients With Ruptured Abdominal Aortic Aneurysms. J Cardiothorac Vasc Anesth 2021; 35:3700-3707. [PMID: 34493435 DOI: 10.1053/j.jvca.2021.08.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 08/06/2021] [Accepted: 08/09/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVES This study's objective was to compare several preoperative and intensive care unit (ICU) prognostic scoring systems for predicting the in-hospital mortality of ruptured abdominal aortic aneurysms (RAAAs). DESIGN Retrospective cohort study. SETTING Single tertiary university center. PARTICIPANTS The study comprised 157 patients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 157 patients (82% male) presented with RAAA at Charité University Hospital from January 2011 to December 2020. The mean age was 74 years (standard deviation ten years). In-hospital mortality was 29% (n = 45), of whom nine patients (6%) died en route to the operating room, 13 (8%) on the operating table, and 23 (15%) in the ICU. A total of 135 patients (86%) were admitted to the ICU. All six models demonstrated good discriminating performance between survivors and nonsurvivors. Overall, the area under the curve (AUC) for RAAA preoperative scores was greater than those for ICU scores. The largest AUC was achieved with the Vascular Study Group of New England (VSGNE) RAAA risk score (AUC = 0.87 for all patients, AUC = 0.84 for patients admitted to the ICU), followed by Hardman Index (AUC = 0.83 for all patients, AUC = 0.81 for patients admitted to the ICU), and Glasgow Aneurysm Score (AUC = 0.74 for all patients, AUC = 0.83 for patients admitted to the ICU). The largest AUC for ICU scores (only patients admitted to the ICU) was achieved with Simplified Acute Physiology Score II (0.75), followed by Sepsis-related Organ Failure Assessment (0.73), and Acute Physiology and Chronic Health Evaluation II (0.71). CONCLUSIONS Preoperative and ICU scores can predict the mortality of patients presenting with RAAA. In addition, the discriminatory ability of preoperative scores between survivors and nonsurvivors was larger than that for ICU scores.
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Affiliation(s)
- Safwan Omran
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Berlin, Germany.
| | - Steffen Gröger
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Berlin, Germany
| | - Larissa Schawe
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Berlin, Germany
| | - Christian Berger
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Charité Campus Benjamin Franklin, Berlin, Germany
| | - Frank Konietschke
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Institute of Medical Biometrics and Clinical Epidemiology and Berlin Institute of Health (BIH), Berlin, Germany
| | - Sascha Treskatsch
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Charité Campus Benjamin Franklin, Berlin, Germany
| | - Andreas Greiner
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Vascular Surgery, Berlin, Germany
| | - Stefan Angermair
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Charité Campus Benjamin Franklin, Berlin, Germany
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