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Sanders AP, Swerdlow NJ, Yadavalli SD, Marcaccio CL, Stangenberg L, Schermerhorn ML. Reinterventions and sac dynamics after fenestrated endovascular aortic repair with physician-modified endografts for index aneurysm repair and following proximal failure of prior endovascular aortic repair. J Vasc Surg 2024; 79:1287-1294.e1. [PMID: 38185213 DOI: 10.1016/j.jvs.2024.01.002] [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: 11/14/2023] [Revised: 12/29/2023] [Accepted: 01/03/2024] [Indexed: 01/09/2024]
Abstract
OBJECTIVE The high frequency of reinterventions after fenestrated endovascular aortic repair (FEVAR) with physician-modified endografts (PMEGs) has been well-studied. However, the impact of prior EVAR on reinterventions and sac behavior following these procedures remains unknown. We analyzed 3-year rates of reinterventions and sac dynamics following PMEG for index aneurysm repair compared with PMEG for prior EVAR with loss of proximal seal. METHODS We performed a retrospective analysis of 122 consecutive FEVARs with PMEGs at a tertiary care center submitted to the United States Food and Drug Administration in support of an investigational device exemption trial. We excluded patients with aortic dissection (n = 5), type I to III thoracoabdominal aneurysms (n = 13), non-elective procedures (n = 4), and prior aortic surgery other than EVAR (n = 8), for a final cohort of 92 patients. Patients were divided into those who underwent PMEG for index aneurysm repair (primary FEVAR) and those who underwent PMEG for rescue of prior EVAR with loss of proximal seal (secondary FEVAR). The primary outcomes were freedom from reintervention and sac dynamics (regression as ≥5 mm decrease, expansion as ≥5 mm increase, and stability as <5 mm increase or decrease) at 3 years. Secondary outcomes were perioperative mortality and 3-year survival. RESULTS Of the 92 patients included, 56 (61%) underwent primary FEVAR and 36 (39%) underwent secondary FEVAR. Secondary FEVAR patients were older (78 years [interquartile range (IQR), 74.5-83.5 years] vs 73 years [IQR, 69-78.5 years]; P < .001), more frequently male (86% vs 68%; P = .048), and had larger aneurysms (72.5 mm [IQR, 65.5-81 mm] vs 59 mm [IQR, 55-65 mm]; P < .001). Perioperative mortality was 1.8% for primary FEVAR and 2.7% for secondary FEVAR (P = .75). At 3 years, overall survival was 84% for primary FEVAR and 71% for secondary FEVAR (P = .086). Freedom-from reintervention was significantly higher for primary FEVAR than secondary FEVAR, specifically 82% vs 38% at 3 years (P < .001). Primary FEVAR also had more desirable sac dynamics relative to secondary FEVAR at 3 years (primary: 54% stable, 46% regressed, 0% expanded vs secondary: 33% stable, 28% regressed, and 39% expanded; P = .038). CONCLUSIONS FEVAR for primary aortic repair and FEVAR for rescue of prior EVAR with loss of proximal seal are two distinct entities. Following primary FEVAR, less than a quarter of patients have undergone reintervention at 3 years, and sac expansion was not seen in our cohort. Comparatively, 3 years after secondary FEVAR, over one-half of patients have undergone reintervention and over one-third have had ongoing sac expansion. Vigilant surveillance and a low threshold for further interventions are crucial following secondary FEVAR.
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Affiliation(s)
- Andrew P Sanders
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Nicholas J Swerdlow
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sai Divya Yadavalli
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Christina L Marcaccio
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Lars Stangenberg
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Sulzer TAL, de Bruin JL, Rastogi V, Boer GJ, Mesnard T, Fioole B, Rijn MJV, Schermerhorn ML, Oderich GS, Verhagen HJM. Midterm Outcomes and Aneurysm Sac Dynamics Following Fenestrated Endovascular Aneurysm Repair after Previous Endovascular Aneurysm Repair. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00097-2. [PMID: 38301871 DOI: 10.1016/j.ejvs.2024.01.070] [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: 07/14/2023] [Revised: 12/19/2023] [Accepted: 01/23/2024] [Indexed: 02/03/2024]
Abstract
OBJECTIVE Fenestrated endovascular aneurysm repair (FEVAR) is a feasible option for aortic repair after endovascular aneurysm repair (EVAR), due to improved peri-operative outcomes compared with open conversion. However, little is known regarding the durability of FEVAR as a treatment for failed EVAR. Since aneurysm sac evolution is an important marker for success after aneurysm repair, the aim of the study was to examine midterm outcomes and aneurysm sac dynamics of FEVAR after prior EVAR. METHODS Patients undergoing FEVAR for complex abdominal aortic aneurysms from 2008 to 2021 at two hospitals in The Netherlands were included. Patients were categorised into primary FEVAR and FEVAR after EVAR. Outcomes included five year mortality rate, one year aneurysm sac dynamics (regression, stable, expansion), sac dynamics over time, and five year aortic related procedures. Analyses were done using Kaplan-Meier methods, multivariable Cox regression analysis, chi square tests, and linear mixed effect models. RESULTS One hundred and ninety-six patients with FEVAR were identified, of whom 27% (n = 53) had had a prior EVAR. Patients with prior EVAR were significantly older (78 ± 6.7 years vs. 73 ± 5.9 years, p < .001). There were no significant differences in mortality rate. FEVAR after EVAR was associated with a higher risk of aortic related procedures within five years (hazard ratio [HR] 2.6; 95% confidence interval [CI] 1.1 - 6.5, p = .037). Sac dynamics were assessed in 154 patients with available imaging. Patients with a prior EVAR showed lower rates of sac regression and higher rates of sac expansion at one year compared with primary FEVAR (sac expansion 48%, n = 21/44, vs. 8%, n = 9/110, p < .001). Sac dynamics over time showed similar results, sac growth for FEVAR after EVAR, and sac shrinkage for primary FEVAR (p < .001). CONCLUSION There were high rates of sac expansion and a need for more secondary procedures in FEVAR after EVAR than primary FEVAR patients, although this did not affect midterm survival. Future studies will have to assess whether FEVAR after EVAR is a valid intervention, and the underlying process that drives aneurysm sac growth following successful FEVAR after EVAR.
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Affiliation(s)
- Titia A L Sulzer
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands; The University of Texas Health Science Centre at Houston, McGovern Medical School, Houston, TX, USA.
| | - Jorg L de Bruin
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Vinamr Rastogi
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Gert Jan Boer
- Department of Vascular Surgery, Maasstad Hospital Rotterdam, The Netherlands
| | - Thomas Mesnard
- The University of Texas Health Science Centre at Houston, McGovern Medical School, Houston, TX, USA
| | - Bram Fioole
- Department of Vascular Surgery, Maasstad Hospital Rotterdam, The Netherlands
| | - Marie Josee van Rijn
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Marc L Schermerhorn
- Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | - Gustavo S Oderich
- The University of Texas Health Science Centre at Houston, McGovern Medical School, Houston, TX, USA
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Asirwatham M, Konanki V, Lucas SJ, Grundy S, Zwiebel B, Shames M, Arnaoutakis DJ. Comparative outcomes of physician-modified fenestrated/branched endovascular aortic aneurysm repair in the setting of prior failed endovascular aneurysm repair. J Vasc Surg 2023; 78:1153-1161. [PMID: 37451371 DOI: 10.1016/j.jvs.2023.07.002] [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: 03/26/2023] [Revised: 06/29/2023] [Accepted: 07/04/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE Endovascular treatment of aortic aneurysms involving renal-mesenteric arteries, especially in the setting of prior failed endovascular aneurysm repair (EVAR) typically requires fenestrated/branched endovascular aneurysm repair (F/BEVAR) with a custom-made device (CMD). CMDs are limited to select centers, and physician-modified endografts are an alternative treatment platform. Currently, there is no data on the outcomes of physician-modified F/BEVAR (PM-F/BEVAR) in the setting of failed prior EVAR. The purpose of this study was to evaluate the use of PM-F/BEVAR in patients with prior failed EVAR. METHODS A prospective database of consecutive patients treated at a single center with PM-F/BEVAR between March 2021 and November 2022 was retrospectively reviewed. The cohort was stratified by presence of a failed EVAR (type Ia endoleak or aneurysm development proximal to a prior EVAR) prior to PM-F/BEVAR. Demographics, operative details, and postoperative complications were compared between the groups using univariate analysis. One-year survival and freedom from reintervention were compared using the Kaplan-Meier method. RESULTS A total of 103 patients underwent PM-F/BEVAR during the study period; 27 (26%) were in the setting of prior EVAR. Patients with prior failed EVAR had similar age (75.2 ± 7.7 vs 71.5 ± 8.8 years; P = .058), male gender (n = 24 ; 89% vs n = 57 ; 75%; P = .130), and comorbid conditions except higher incidence of moderate-to-severe chronic obstructive pulmonary disease (n = 7 ; 26% vs n = 7 ; 9%; P = .047). Overall, aneurysm diameter was 65.5 ± 13.9 mm with aneurysms categorized as juxta-/pararenal in 43% and thoracoabdominal in 57%, with no differences between the groups. Twelve patients (14%) presented with symptomatic/ruptured aneurysms. The average number of target arteries incorporated per patient was 3.8. Four different aortic devices were modified with a greater proportion of Terumo TREO devices used in the failed EVAR group (P = .03). There was no difference in procedure time, radiation dose, or iodinated contrast use between groups. Overall technical success was 99%. Rates of 30-day mortality (n = 0 ; 0% vs n = 3 ; 4%; P = .565) and major adverse events (n = 6 ; 22% vs n = 16 ; 21%; P = 1.0) were similar between groups. For the overall cohort, rates of type 1 or 3 endoleak, branch vessel stenosis/occlusion, and reintervention were 2%, 1%, and 8%, respectively, with no difference between groups. One-year survival (failed EVAR 94% vs no EVAR 82%; P = .756) was similar between groups. CONCLUSIONS PM-F/BEVAR is a safe and effective treatment for patients with aneurysms involving the renal-mesenteric arteries in the setting of prior failed EVAR where additional technical challenges may be present. Additional follow-up is warranted to demonstrate long-term efficacy, but early results are encouraging and similar to those using CMDs.
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Affiliation(s)
- Mark Asirwatham
- Division of Vascular Surgery, University of South Florida College of Medicine, Tampa, FL
| | - Varun Konanki
- Division of Vascular Surgery, University of South Florida College of Medicine, Tampa, FL
| | - Spencer J Lucas
- Department of Surgery, University of South Dakota, Sioux Falls, SD
| | - Shane Grundy
- Department of Radiology, Tampa General Hospital, Tampa, FL
| | - Bruce Zwiebel
- Department of Radiology, Tampa General Hospital, Tampa, FL
| | - Murray Shames
- Division of Vascular Surgery, University of South Florida College of Medicine, Tampa, FL
| | - Dean J Arnaoutakis
- Division of Vascular Surgery, University of South Florida College of Medicine, Tampa, FL.
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Yazar O, Pilz da Cunha G, de Haan MW, Mees BM, Schurink GW. Impact of stent-graft complexity on mid-term results in fenestrated endovascular aortic repair of juxtarenal and suprarenal abdominal aortic aneurysms. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:268-278. [PMID: 36106397 DOI: 10.23736/s0021-9509.22.12311-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND The impact of stent-graft complexity on clinical outcome after fenestrated endovascular aortic aneurysm repair (FEVAR) has been conflicting in the literature. The objective of this study was to compare mid-term results of stent-grafts with renal fenestrations alone with more complex stent-grafts including mesenteric fenestrations. METHODS A single center retrospective study was conducted on 154 patients, who underwent FEVAR from 2006 to 2020 at our institution. RESULTS There were 54 (35.1%) patients in the renal FEVAR group and 100 (64.9%) patients in the complex FEVAR group. Median follow-up of the total group was 25 months (IQR 7-45). There were no significant differences in technical success and perioperative mortality. Intraoperative complications (4% vs. 18%, P=0.001), operative time (145 min vs. 191 min, P=0.001), radiation dose (119372 mGy*cm2 vs. 159573 mGy*cm2, P=0.004) and fluoroscopy time (39 min vs. 54 min, P=0.007) were significantly lower in the renal FEVAR group. During follow-up target vessel instability, endoleaks and reinterventions were not significantly different between the two groups. CONCLUSIONS In this single center retrospective study, renal FEVAR was a safe and effective treatment for patients with juxtarenal AAA demonstrating fewer intraoperative complications and similar mid-term outcomes as complex FEVAR. If the anatomy is compatible for renal FEVAR, it might be unnecessary to expose patients to potentially more complications by choosing a complex FEVAR strategy.
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Affiliation(s)
- Ozan Yazar
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
- Department of Vascular Surgery, Zuyderland Medical Center, Heerlen, the Netherlands
| | - Gabriela Pilz da Cunha
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Michiel W de Haan
- Department of Radiology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Barend M Mees
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Geert W Schurink
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, the Netherlands -
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Jessula S, Eagleton MJ. Conversion of failed endovascular infrarenal aortic aneurysm repair with fenestrated/branched stent grafts. Semin Vasc Surg 2022; 35:341-349. [DOI: 10.1053/j.semvascsurg.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/23/2022] [Accepted: 06/27/2022] [Indexed: 11/11/2022]
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Juszczak M, Vezzosi M, Nasr H, Claridge M, Adam DJ. Fenestrated-Branch Endovascular Repair After Prior Abdominal Aortic Aneurysm Repair. Eur J Vasc Endovasc Surg 2021; 62:728-737. [PMID: 34474963 DOI: 10.1016/j.ejvs.2021.07.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 06/03/2021] [Accepted: 07/05/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To report the outcome of fenestrated and branch endovascular aortic repair (FEVAR-BEVAR) for asymptomatic and acute symptomatic proximal aortic pathology in patients with prior open (OSR) or endovascular (EVAR) abdominal aortic aneurysm (AAA) repair. METHODS This was a single centre retrospective study of consecutive patients with non-ruptured (asymptomatic and acute symptomatic) proximal aortic pathology after prior OSR or EVAR treated between December 2007 and February 2020. The primary endpoint was 30 day/in hospital mortality. Secondary endpoints were technical success, primary clinical success, and Kaplan-Meier estimates of medium term survival and freedom from re-intervention. Data are presented as median (interquartile range [IQR]). The effect of covariates on medium term survival was estimated using multivariable (Cox proportional hazards model) analysis. A p value < .05 was considered to be statistically significant. RESULTS Ninety-two patients (83 men; median age 75 years [IQR 71 - 80 years]; median diameter 73 mm [IQR 64 - 89 mm]; 82 elective, 10 acute) underwent FEVAR-BEVAR after prior OSR (n = 47) or EVAR (n = 45). Indications for intervention were aneurysmal degeneration with or without type 1a endoleak (n = 57; four juxtarenal [JR] AAA, 21 extent II/III, 32 extent IV thoraco-abdominal aortic aneurysms); type 1a endoleak alone (n = 27) and to create a more durable repair after acute infrarenal EVAR (n = 8; JRAAA). In total, 348 renovisceral vessels were targeted for preservation and 324 were stent grafted. Twenty-four unstented vessels comprised one bypass, 11 scallops and six fenestrations intentionally not stent grafted, two vessels occluded before graft implantation, and four vessels occluded intra-operatively. Primary technical success was 95.6%. The thirty day mortality rate was 1.1% and one patient each (1.1%) required permanent dialysis or developed temporary spinal cord ischaemia. Early primary clinical success was 94.6%. Median follow up was 36 months (IQR 23 - 64 months). Estimated overall survival (± standard error) at one, two, and three years was 86% ± 4%, 85% ± 4%, and 70% ± 5%, respectively. Multivariable analysis did not demonstrate any independent predictors of survival. Four target vessels occluded during follow up. Nineteen patients underwent 28 late re-interventions, with almost half performed for issues arising distal to the FEVAR-BEVAR. Patients treated with a cuff were statistically significantly more likely to require distal re-intervention compared with those treated by relining (9/49 vs. 1/43, p = .018 [odds ratio 9.3, 95% confidence interval 1.2 - 423]). In patients with prior EVAR alone, this did not reach statistical significance (cuff 7/25 vs. relining 1/20, p = .059 [odds ratio 7.1, 95% confidence interval 0.8 - 350]). Estimated freedom from re-intervention at one, two, and three years was 88% ± 3%, 81% ± 4%, and 81% ± 4%, respectively. CONCLUSION FEVAR-BEVAR after prior OSR or EVAR is associated with low peri-operative morbidity and mortality, and acceptable medium term survival and freedom from re-intervention. Treatment with a FEVAR-BEVAR cuff is associated with a higher requirement for distal re-intervention than relining of the original repair.
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Affiliation(s)
- Maciej Juszczak
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Massimo Vezzosi
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Hosaam Nasr
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Martin Claridge
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Donald J Adam
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
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Marques de Marino P, Malgor RD, Verhoeven EL, Katsargyris A. Rescue of proximal failure of endovascular abdominal aortic aneurysm repair with standard and fenestrated grafts. THE JOURNAL OF CARDIOVASCULAR SURGERY 2019; 60:159-166. [PMID: 30665286 DOI: 10.23736/s0021-9509.19.10872-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND This study aimed to assess the outcomes of standard and fenestrated grafts to treat proximal failure of previous endovascular aneurysm repair (EVAR) in a tertiary referral center. METHODS All patients undergoing elective implantation of a standard or fenestrated graft after proximal failure of a previous EVAR between April 2010-November 2018 were included. Data were collected prospectively. RESULTS Fifty procedures were performed in 49 patients (45 male; mean age 74.6±7 years). A fenestrated proximal cuff was used in 24 (48%) cases, a composite bifurcated configuration in 21 (42%) cases, and EVAR in 5 (10%) cases. Technical success was achieved in all 5 EVAR cases and 41 of 45 FEVAR cases (91.1%). Iliac artery access problems due to the presence of the previous graft were encountered in eight (16%) procedures and renal artery catheterization difficulties in grafts with suprarenal fixation in seven (15.6%) procedures. There was one (2%) early death due to retroperitoneal bleeding. Early major complications occurred in three (6%) patients. Median follow-up was 26 months (range 1-77). Late occlusion occurred in two (1.3%) of the 151 targeted vessels. One patient needed permanent dialysis. Nine patients died during follow-up, one (2%) of them aneurysm-related. Ten (20.4%) patients presented with major complications during follow-up of which nine (18.4%) needed reintervention. Estimated freedom from reintervention at 1 and 3 years was 89.3±5.1% and 78.8±7.3%, respectively. CONCLUSIONS Repair with fenestrated grafts represents a safe and effective treatment option. Increased technical challenges are to be expected due to the previous graft.
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Affiliation(s)
- Pablo Marques de Marino
- Department of Vascular and Endovascular Surgery, General Hospital Nuremberg, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Rafael D Malgor
- Department of Vascular and Endovascular Surgery, General Hospital Nuremberg, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Eric L Verhoeven
- Department of Vascular and Endovascular Surgery, General Hospital Nuremberg, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Athanasios Katsargyris
- Department of Vascular and Endovascular Surgery, General Hospital Nuremberg, Paracelsus Medical University Nuremberg, Nuremberg, Germany -
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Spanos K, Rohlffs F, Panuccio G, Eleshra A, Tsilimparis N, Kölbel T. Outcomes of endovascular treatment of endoleak type Ia after EVAR: a systematic review of the literature. THE JOURNAL OF CARDIOVASCULAR SURGERY 2019; 60:175-185. [PMID: 30650961 DOI: 10.23736/s0021-9509.19.10854-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Endovascular repair of infra-renal aortic aneurysm (EVAR) has become treatment of choice. However, individuals undergoing EVAR have a high re-intervention rate. The aim of this study is to evaluate the current endovascular treatment modalities of endoleak type Ia (ET Ia) treatment after EVAR and their outcome. EVIDENCE ACQUISITION A systematic review and meta-analysis was performed. MEDLINE, EMBASE and Cochrane databases were searched with PRISMA methodology for studies reporting on endovascular treatment of ET Ia after EVAR. Studies presenting treatment of intra-operative ET Ia were excluded. EVIDENCE SYNTHESIS Two international registries, fourteen non-randomized retrospective and twelve case-report studies were included reporting on 356 patients. Reported endovascular techniques included fenestrated-, branched-, chimney EVAR, endovascular sealing (EVAS), endoanchors, embolization techniques, cuff and/or "giant" Palmaz stents. Technical success rate ranged from 90% to 100%, with intra-operative mortality rate of 0%. During early period, persistence of ET Ia was 3.4% (9/262) and the re-intervention rate was 3.5% (8/227). The 30-day mortality rate was 2% (7/356). Mean follow-up was 22.4 months±18. Presence of ET Ia was 5.9% (21/356), and the reintervention rate was 5.1% (18/349). The mortality rate was 13% (26/203), while the primary patency rate of TVs ranged from 94.3% to 100%. CONCLUSIONS A multitude of techniques for endovascular repair for ET Ia exists. No strong evidence supports one specific technique. The early and mid-term outcomes are encouraging in terms of ET Ia resolution, mortality and morbidity rates.
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Affiliation(s)
- Konstantinos Spanos
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, Hamburg, Germany -
| | - Fiona Rohlffs
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, Hamburg, Germany
| | - Giuseppe Panuccio
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, Hamburg, Germany
| | - Ahmed Eleshra
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, Hamburg, Germany
| | - Nikolaos Tsilimparis
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, Hamburg, Germany
| | - Tilo Kölbel
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, Hamburg, Germany
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Sakalihasan N, Michel JB, Katsargyris A, Kuivaniemi H, Defraigne JO, Nchimi A, Powell JT, Yoshimura K, Hultgren R. Abdominal aortic aneurysms. Nat Rev Dis Primers 2018; 4:34. [PMID: 30337540 DOI: 10.1038/s41572-018-0030-7] [Citation(s) in RCA: 276] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
An abdominal aortic aneurysm (AAA) is a localized dilatation of the infrarenal aorta. AAA is a multifactorial disease, and genetic and environmental factors play a part; smoking, male sex and a positive family history are the most important risk factors, and AAA is most common in men >65 years of age. AAA results from changes in the aortic wall structure, including thinning of the media and adventitia due to the loss of vascular smooth muscle cells and degradation of the extracellular matrix. If the mechanical stress of the blood pressure acting on the wall exceeds the wall strength, the AAA ruptures, causing life-threatening intra-abdominal haemorrhage - the mortality for patients with ruptured AAA is 65-85%. Although AAAs of any size can rupture, the risk of rupture increases with diameter. Intact AAAs are typically asymptomatic, and in settings where screening programmes with ultrasonography are not implemented, most cases are diagnosed incidentally. Modern functional imaging techniques (PET, CT and MRI) may help to assess rupture risk. Elective repair of AAA with open surgery or endovascular aortic repair (EVAR) should be considered to prevent AAA rupture, although the morbidity and mortality associated with both techniques remain non-negligible.
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Affiliation(s)
- Natzi Sakalihasan
- Department of Cardiovascular and Thoracic Surgery, CHU Liège, University of Liège, Liège, Belgium. .,Surgical Research Center, GIGA-Cardiovascular Science Unit, University of Liège, Liège, Belgium.
| | - Jean-Baptiste Michel
- UMR 1148, INSERM Paris 7, Denis Diderot University, Xavier Bichat Hospital, Paris, France
| | - Athanasios Katsargyris
- Department of Vascular and Endovascular Surgery, Paracelsus Medical University, Nuremberg, Germany
| | - Helena Kuivaniemi
- Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Jean-Olivier Defraigne
- Department of Cardiovascular and Thoracic Surgery, CHU Liège, University of Liège, Liège, Belgium.,Surgical Research Center, GIGA-Cardiovascular Science Unit, University of Liège, Liège, Belgium
| | - Alain Nchimi
- Surgical Research Center, GIGA-Cardiovascular Science Unit, University of Liège, Liège, Belgium.,Department of Medical Imaging, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
| | - Janet T Powell
- Vascular Surgery Research Group, Imperial College London, London, UK
| | - Koichi Yoshimura
- Graduate School of Health and Welfare, Yamaguchi Prefectural University, Yamaguchi, Japan.,Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Rebecka Hultgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
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Vourliotakis GD, Tzilalis VD, Theodoridis PG, Stoumpos CS, Kamvysis DG, Kantounakis IG. Fenestrated and Branched Stent Grafting in Complex Aneurysmatic Aortic Disease: A Single-Center Early Experience. Ann Vasc Surg 2016; 40:154-161. [PMID: 27890847 DOI: 10.1016/j.avsg.2016.07.078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 07/01/2016] [Accepted: 07/06/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND The aim of this study is to present our early experience and highlight the technical difficulties associated with the use of fenestrated and branched stent grafts to treat patients with juxtarenal abdominal aortic aneurysm (AAA), pararenal AAA, and thoracoabdominal aortic aneurysms (TAAAs). METHODS A prospectively held database maintained at our department was queried for patients who have undergone branched and fenestrated stent grafting for AAA or TAAA treatment. Indication for repair, comorbidity precluding open repair, technical challenges associated with the repair, as well as operative mortality, morbidity, and reintervention rate were evaluated. RESULTS A total of 8 patients underwent repair with a fenestrated or branched stent graft. All patients had aneurysmal degeneration of the juxtarenal aorta, pararenal aorta, and thoracoabdominal aorta not suitable to standard endovascular techniques. Two patients had a prior aortic repair, a failed migrated stent graft, and an old surgical tube graft after an open repair. One patient had a type III TAAA and 1 patient had a postdissection TAAA type I. For all patients, target vessel success rate was 96.4% (27/28) and mean hospital stay was 6.0 days (range 3-21). Thirty-day and 1-year mortality were 0%. Mean follow-up was 23 months (range 7-45). Two endoleaks occurred, 1 type III and 1 type II, which were treated endovascularly. No death or major complication occurred during follow-up. CONCLUSIONS Fenestrated and branched endovascular stent grafts can be used to repair juxtarenal AAA, pararenal AAA, and TAAA in patients with significant comorbidities. However, several technical challenges have to be overcome due to the unique complex aortic pathology of each patient.
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Affiliation(s)
- Georgios D Vourliotakis
- Department of Surgery, Division of Vascular Surgery, 401 General Military Hospital of Athens, Athens, Greece
| | - Vasileios D Tzilalis
- Department of Surgery, Division of Vascular Surgery, 401 General Military Hospital of Athens, Athens, Greece
| | - Panagiotis G Theodoridis
- Department of Surgery, Division of Vascular Surgery, 401 General Military Hospital of Athens, Athens, Greece.
| | - Charalampos S Stoumpos
- Radiology Department, Division of Digital Subtraction Angiography, 401 General Military Hospital of Athens, Athens, Greece
| | - Dimitrios G Kamvysis
- Radiology Department, Ultrasound Division, 401 General Military Hospital of Athens, Athens, Greece
| | - Ioannis G Kantounakis
- Radiology Department, Division of Digital Subtraction Angiography, 401 General Military Hospital of Athens, Athens, Greece
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11
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Massara M, Barillà D, Franco G, Volpe A, Serra R, De Caridi G, Alberti A, Volpe P. An Uncommon Case of Type III Endoleak Treated with a Custom-made Thoracic Stent Graft. Ann Vasc Surg 2016; 35:206.e1-3. [PMID: 27263819 DOI: 10.1016/j.avsg.2016.02.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Revised: 02/04/2016] [Accepted: 02/05/2016] [Indexed: 11/29/2022]
Abstract
Endovascular aortic repair (EVAR) has been shown to be a valid and minimally invasive alternative to open abdominal aortic aneurysm repair. A major shortcoming for EVAR is the need to submit patients to regular follow-up to detect potential complications such as endoleak, limb occlusion, aneurysm expansion, aneurysm rupture, infection, structural failure, and migration. In this case report, we describe an uncommon case of late type III endoleak due to complete detachment of the stent-graft main body segment from its suprarenal uncovered fixation stent. It was treated with a custom-made Relay(®) NBS Plus (Bolton Medical, Barcelona, Spain) thoracic stent graft which also provided extra suprarenal fixation of the thoracic stent graft in the proximal neck. The postoperative period was uneventful and a computed tomography scan 1 year later revealed proper positioning of the stent graft and no signs of endoleak. The successful strategy chosen to correct this complication was at the same time original and infrequent, and also avoided potential complications related to open surgical repair and general anesthesia.
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Affiliation(s)
- Mafalda Massara
- Unit of Vascular Surgery, Bianchi-Melacrino-Morelli Hospital, Reggio Calabria, Italy
| | - David Barillà
- Unit of Vascular Surgery, Bianchi-Melacrino-Morelli Hospital, Reggio Calabria, Italy
| | - Gaetana Franco
- Anesthesia Unit, Bianchi-Melacrino-Morelli Hospital, Reggio Calabria, Italy
| | - Alberto Volpe
- School of Medicine, University Campus Biomedico of Rome, Rome, Italy
| | - Raffaele Serra
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, University Magna Graecia of Catanzaro, Catanzaro, Italy; Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy.
| | - Giovanni De Caridi
- Cardiovascular and Thoracic Department, Policlinico G. Martino Hospital, University of Messina, Messina, Italy
| | - Antonino Alberti
- Unit of Vascular Surgery, Bianchi-Melacrino-Morelli Hospital, Reggio Calabria, Italy
| | - Pietro Volpe
- Unit of Vascular Surgery, Bianchi-Melacrino-Morelli Hospital, Reggio Calabria, Italy
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12
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Gallitto E, Gargiulo M, Freyrie A, Bianchini Massoni C, Mascoli C, Pini R, Faggioli GL, Ancetti S, Stella A. Fenestrated and Branched Endograft after Previous Aortic Repair. Ann Vasc Surg 2016; 32:119-27. [DOI: 10.1016/j.avsg.2015.10.018] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 10/10/2015] [Accepted: 10/15/2015] [Indexed: 10/22/2022]
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13
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Successful laparoscopic repair of refractory type Ia endoleak after endovascular abdominal aortic aneurysm repair. J Vasc Surg 2015; 61:275-9. [DOI: 10.1016/j.jvs.2014.08.065] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 08/09/2014] [Indexed: 11/18/2022]
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14
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Katsargyris A, Yazar O, Oikonomou K, Bekkema F, Tielliu I, Verhoeven ELG. Fenestrated Stent-Grafts for Salvage of Prior Endovascular Abdominal Aortic Aneurysm Repair. Eur J Vasc Endovasc Surg 2013; 46:49-56. [PMID: 23642523 DOI: 10.1016/j.ejvs.2013.03.028] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Accepted: 03/27/2013] [Indexed: 11/30/2022]
Affiliation(s)
- A Katsargyris
- Department of Vascular and Endovascular Surgery, Klinikum Nürnberg, Germany
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15
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Bown MJ, Harrison GJ, How TV, Brennan JA, Fisher RK, Vallabhaneni SR, McWilliams RG. Anchoring barbs and balloon expandable stents: what is the risk of perforation and failed stent deployment? Eur J Vasc Endovasc Surg 2012; 44:327-31. [PMID: 22819740 DOI: 10.1016/j.ejvs.2012.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2012] [Accepted: 06/11/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE Balloon expandable stents may on occasion be deployed in close proximity to the anchoring barbs of endovascular grafts. The aim of this study was to determine the risk and effect of balloon perforation by anchoring barbs and to assess whether these risks are different if the balloon is protected by a covered stent mounted upon it. METHODS A bench-top model was developed to mimic the penetration of anchoring barbs into the lumen of medium sized blood vessels. The model allowed variation of angle and depth of vessel penetration. Both bare balloons and those with covered stents mounted upon them were tested in the model to determine whether there was a risk of perforation and which factors increased or decreased this risk. RESULTS All combinations of barb angle and depth caused balloon perforation but this was most marked when the barb was placed perpendicular to the long axis of the balloon. When the deployment of covered stents was attempted balloon perforation occurred in some cases but full stent deployment was achieved in all cases where the perforation was in the portion of the balloon covered by the stent. The only situation in which stent deployment failed was where the barb was intentionally placed in the uncovered portion of the balloon. This resulted in only partial deployment of the stent. CONCLUSIONS Balloon rupture is a distinct possibility when deploying balloon-expandable stents in close proximity to anchoring barbs. Care should be taken in this circumstance to ensure that the barb is well away from the uncovered portion of the balloon.
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Affiliation(s)
- M J Bown
- Department of Cardiovascular Sciences, University of Leicester, UK
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16
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Abstract
Fenestrated stent grafts have been developed to offer an endovascular treatment option to those patients with abdominal aortic aneurysms whose infrarenal necks are anatomically unsuitable for endovascular repair with standard infrarenal devices. The ability to have customized fenestrations that will preserve flow to essential visceral arteries allows proximal seal and fixation to be achieved at and above the renal level. This article discusses patient selection, stent-graft design, and the importance of accurate planning. Deployment techniques along with complications and their avoidance are considered. The published midterm results are reviewed and appear to justify the continued use and evaluation of this technique as an alternative to open surgical repair in high-risk patients with infrarenal necks unsuitable for standard endovascular repair.
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Affiliation(s)
- James R H Scurr
- Royal Liverpool University Hospital, Liverpool, United Kingdom
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17
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Henrikson O, Roos H, Falkenberg M. Ethylene vinyl alcohol copolymer (Onyx) to seal type 1 endoleak. A new technique. Vascular 2011; 19:77-81. [DOI: 10.1258/vasc.2010.oa0257] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The aim of this study was to investigate whether the liquid embolic agent Onyx, an ethylene vinyl alcohol copolymer, can be used to seal type 1 endoleaks during endovascular aortic repair (EVAR). Six patients with large aortic aneurysms and remaining type 1 endoleaks during or after EVAR were treated with Onyx embolization through a microcatheter placed in the proximal neck in five cases and in the distal neck in one case. Four of the patients were treated using the chimney technique. The type 1 endoleak was primarily sealed by Onyx in all six patients. There was no distal embolization. Two patients had complications during follow-up. One patient had occlusions of chimney grafts to the renal arteries and to one leg extension. These occlusions were not anatomically related to Onyx embolization. One patient had late stentgraft migration of the Onyx-treated distal neck with aneurysm rupture 18 months after treatment. Early experience of Onyx embolization as a bailout solution of type 1 endoleaks after complicated EVAR is promising. However, effective seal with Onyx does not prevent late stentgraft migration. More reported patients and longer follow-up are necessary to evaluate this new technique.
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Affiliation(s)
| | - Håkan Roos
- Department of Vascular Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
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18
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Tapping CR, Ettles DF, Renwick PM, Robinson GJ. Three-year follow-up of fenestrated thoracoabdominal stent graft bridging an endovascular thoracic stent graft and a surgical abdominal aortic graft. J Vasc Interv Radiol 2011; 22:385-90. [PMID: 21353989 DOI: 10.1016/j.jvir.2010.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2010] [Revised: 10/17/2010] [Accepted: 11/02/2010] [Indexed: 11/19/2022] Open
Abstract
This case report describes repair of a type I endoleak at the distal landing zone of a thoracic aortic stent graft by endovascular placement of a thoracoabdominal fenestrated stent graft (Cook, Brisbane, Australia). The fenestrated stent graft was interposed between a previous abdominal aortic aneurysm (AAA) Gelsoft tube graft (Sulzer Vascutek Ltd, Inchinnan, United Kingdom) and two overlapping Zenith thoracic endografts (Cook Inc, Bloomington, Indiana). Placement was made more complex because the distal thoracic endograft had rotated into a horizontal position. At 3-year clinical and computed tomography (CT) follow-up, continued clinical and radiologic success was shown with no further intervention required.
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Affiliation(s)
- Charles Ross Tapping
- Department of Radiology, Hull Royal Infirmary, Anlaby Road, Hull and East Yorkshire NHS Trust, UK
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19
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Manning BJ, Agu O, Richards T, Ivancev K, Harris PL. Early Outcome Following Endovascular Repair of Pararenal Aortic Aneurysms: Triple- Versus Double- or Single-Fenestrated Stent-Grafts. J Endovasc Ther 2011; 18:98-105. [DOI: 10.1583/10-3122.1] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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20
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Verhoeven ELG, Adam DJ, Ferreira M, Zipfel B, Tielliu IFJ. Endovascular treatment of complex aortic aneurysms. Interv Cardiol 2010. [DOI: 10.2217/ica.10.45] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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21
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Manning BJ, Harris PL, Hartley DE, Ivancev K. Preloaded Fenestrated Stent-Grafts for the Treatment of Juxtarenal Aortic Aneurysms. J Endovasc Ther 2010; 17:449-55. [DOI: 10.1583/10-3024.1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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