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Giuliani A, Romano L, Necozione S, Cofini V, Di Donato G, Schietroma M, Carlei F. Excisional Hemorrhoidectomy Versus Dearterialization With Mucopexy for the Treatment of Grade III Hemorrhoidal Disease: The EMODART3 Multicenter Study. Dis Colon Rectum 2023; 66:e1254-e1263. [PMID: 37616177 DOI: 10.1097/dcr.0000000000002885] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
BACKGROUND Over the past few decades, several surgical approaches have been proposed to treat hemorrhoids. OBJECTIVE This multicenter study aimed to compare transanal hemorrhoidal artery ligation and conventional excisional hemorrhoidectomy for grade III hemorrhoidal disease. DESIGN Multicenter retrospective study. SETTINGS Any center belonging to the Italian Society of Colorectal Surgery in which at least 30 surgical procedures per year for hemorrhoidal disease were performed was able to join the study. PATIENTS Clinical data from patients with Goligher's grade III hemorrhoidal disease who underwent excisional hemorrhoidectomy or hemorrhoidal artery ligation were retrospectively analyzed after a 24-month follow-up period. MAIN OUTCOME MEASURES The primary aims were to evaluate the adoption of 2 different surgical techniques and to compare them in terms of symptoms, postoperative adverse events, and recurrences at a 24-month follow-up. RESULTS Data from 1681 patients were analyzed. The results of both groups were comparable in terms of postoperative clinical score by multiple regression analysis and matched case-control analysis. Patients who underwent excisional hemorrhoidectomy had a significantly higher risk of postoperative complication (adjusted OR = 1.58; p = 0.006). A secondary analysis highlighted that excisional hemorrhoidectomy performed with new devices and hemorrhoidal artery ligation reported a significantly lower risk for complications than excisional hemorrhoidectomy performed with traditional monopolar diathermy. At the 24-month follow-up assessment, recurrence was significantly higher in the hemorrhoidal artery ligation group (adjusted OR = 0.50; p = 0.001). A secondary analysis did not show a higher risk of recurrences based on the type of device. LIMITATIONS The retrospective design and the self-reported nature of data from different centers. CONCLUSIONS Hemorrhoidal artery ligation is an effective option for grade III hemorrhoidal disease; however, it is burdened by a high risk of recurrences. Excisional hemorrhoidectomy performed with newer devices is competitive in terms of postoperative complications.HEMORROIDECTOMÍA POR ESCISIÓN VERSUS DESARTERIALIZACIÓN CON MUCOPEXIA PARA EL TRATAMIENTO DE LA ENFERMEDAD HEMORROIDAL DE GRADO 3: EL ESTUDIO MULTICÉNTRICO EMODART3ANTECEDENTES:En las últimas décadas se han propuesto varios abordajes quirúrgicos para el tratamiento de las hemorroides.OBJETIVO:Este estudio multicéntrico tiene como objetivo comparar la ligadura de la arteria hemorroidal transanal y la hemorroidectomía por escisión convencional para la enfermedad hemorroidal de grado III.DISEÑO:Estudio retrospectivo multicéntrico.ÁMBITO:Cualquier centro perteneciente a la Sociedad Italiana de Cirugía Colorrectal en el que se realizaron al menos 30 procedimientos quirúrgicos por año para la enfermedad hemorroidal pudo participar en el estudio.PACIENTES:Los datos clínicos de pacientes con enfermedad hemorroidal de grado III de Goligher que se sometieron a hemorroidectomía por escisión o ligadura de arterias hemorroidales se analizaron retrospectivamente después de un período de seguimiento de 24 meses.PRINCIPALES MEDIDAS DE RESULTADO:Los objetivos primarios fueron evaluar la adopción de dos técnicas quirúrgicas diferentes y compararlas en términos de síntomas, eventos adversos posoperatorios y recurrencias a los 24 meses de seguimiento.RESULTADOS:Se analizaron datos de 1681 pacientes. Los 2 grupos resultaron ser comparables en términos de puntuación clínica posoperatoria mediante análisis de regresión múltiple y análisis de casos y controles emparejados. Los pacientes sometidos a hemorroidectomía excisional tuvieron un riesgo significativamente mayor de complicaciones posoperatorias (odds ratio ajustado = 1,58; p = 0,006). Un análisis secundario destacó que la hemorroidectomía por escisión realizada con nuevos dispositivos y la ligadura de la arteria hemorroidal informaron un riesgo significativamente menor de complicaciones que la hemorroidectomía por escisión realizada con diatermia monopolar tradicional. En la evaluación de seguimiento de 24 meses, la recurrencia fue significativamente mayor en el grupo de ligadura de la arteria hemorroidal (razón de probabilidad ajustada = 0,50; p = 0,001). Un análisis secundario no mostró un mayor riesgo de recurrencias según el tipo de dispositivo.LIMITACIONES:El diseño retrospectivo y el carácter autoinformado de los datos de diferentes centros.CONCLUSIÓN:HAL es una opción efectiva para la enfermedad hemorroidal grado III; sin embargo, se ve afectado por un alto riesgo de recurrencias. La hemorroidectomía por escisión realizada con dispositivos más nuevos es competitiva en términos de complicaciones posoperatorias. (Traducción-Dr Yolanda Colorado ).
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Affiliation(s)
- Antonio Giuliani
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
- Department of General Surgery, San Salvatore Hospital, L'Aquila, Italy
| | - Lucia Romano
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Stefano Necozione
- Biostatistics and Epidemiology Unit, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Vincenza Cofini
- Biostatistics and Epidemiology Unit, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Giada Di Donato
- Department of General Surgery, San Salvatore Hospital, L'Aquila, Italy
| | - Mario Schietroma
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
- Department of General Surgery, San Salvatore Hospital, L'Aquila, Italy
| | - Francesco Carlei
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
- Department of General Surgery, San Salvatore Hospital, L'Aquila, Italy
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Verre L, Gallo G, Grassi G, Bussolin E, Carbone L, Poto GE, Carpineto Samorani O, Marano L, Marrelli D, Roviello F. Transanal hemorrhoidal dearterialization (THD) for hemorrhoidal disease: An Italian single-institution 5-year experience analysis and updated literature review. Front Surg 2022; 9:1088546. [PMID: 36620384 PMCID: PMC9811001 DOI: 10.3389/fsurg.2022.1088546] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022] Open
Abstract
Background Hemorrhoidal disease is a highly prevalent, chronic disorder that usually compromise patients' quality of life. Despite recent advances in pharmacologic and surgical therapeutic options, a clear treatment "gold standard" is lacking. Our aim is to analyze the outcomes following Transanal Hemorrhoidal Dearterialization (THD) procedure. Methods Patients who failed conservative treatment and underwent THD Doppler between 2017 and 2021 were enrolled. Follow-up interviews (consisting of clinical examination, Visual Analog Scale for pain-VAS, Vaizey incontinence score, Hemorrhoid Severity Score) were administered 1 week, 2 weeks, 1 month and 6 months after surgery. Results Forty-seven out of 75 patients were male, and the mean age was 50 (± 17.9) years. Hemorrhoids were classified as Goligher's degree II in 25 cases, III in 40 and IV, simple irreducible without ischemic changes, in 10. The mean operative time was 35 (28-60) minutes, and most procedures were performed with epidural anesthesia (80%). No intraoperative complications occurred, and 73 patients (97.3%) were discharged within post-operative day 1. Early post-operative pain and bleeding occurred in 37.3% and 8% of patients, respectively. No patients experienced anal incontinence and severe symptoms at 6 months after surgery. The overall success rate was 97.3%. Conclusions THD is safe and effective in hemorrhoidal disease at degree II if bleeding, III, and IV without ischemic changes, both as a first intervention and on recurrence. Physician and patient need to understand each other's expectations, weight the risks and benefits, and customize the treatment.
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Affiliation(s)
- Luigi Verre
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, Siena, Italy,Correspondence: Luigi Verre
| | - Gaetano Gallo
- Department of Surgical Sciences, La Sapienza University of Roma, Roma, Italy
| | - Giulia Grassi
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, Siena, Italy
| | - Edoardo Bussolin
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, Siena, Italy
| | - Ludovico Carbone
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, Siena, Italy
| | - Gianmario Edoardo Poto
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, Siena, Italy
| | - Osvaldo Carpineto Samorani
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, Siena, Italy
| | - Luigi Marano
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, Siena, Italy
| | - Daniele Marrelli
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, Siena, Italy
| | - Franco Roviello
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, Siena, Italy
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SOBRADO CW, SOBRADO LF, OBREGON CA, VILLELA HM, HORA JAB. STAPLED HEMORRHOIDOPEXY: RESULTS, LATE COMPLICATIONS, AND DEGREE OF SATISFACTION AFTER 16 YEARS OF FOLLOW-UP. ABCD. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA (SÃO PAULO) 2022; 35:e1689. [PMID: 36134815 PMCID: PMC9484825 DOI: 10.1590/0102-672020220002e1689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 07/07/2022] [Indexed: 11/22/2022]
Abstract
Stapled hemorrhoidopexy has been widely used for the treatment of hemorrhoids,
but concerns about complications and recurrences after prolonged follow-up are
still under debate.
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Huang H, Gu Y, Ji L, Li Y, Xu S, Guo T, Xu M. A NEW MIXED SURGICAL TREATMENT FOR GRADES III AND IV HEMORRHOIDS: MODIFIED SELECTIVE HEMORRHOIDECTOMY COMBINED WITH COMPLETE ANAL EPITHELIAL RETENTION. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2021; 34:e1594. [PMID: 34669884 PMCID: PMC8521818 DOI: 10.1590/0102-672020210002e1594] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 12/17/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Varicose veins appear above and below the dentate line in mixed hemorrhoids, which seriously affects anal function and quality of life. AIM To propose an improvement in tissue-selecting therapy repair of anal pad combined with complete anal canal epithelial retention comparing with Milligan-Morgan surgery. METHODS A prospective randomized controlled study was designed enrolling 200 patients with grade III and IV hemorrhoids. They were divided into control and observation groups. The control received Milligan-Morgan surgery, and the observation the modified tissue-selecting therapy stapler combined with complete anal canal preservation surgery. All patients were followed for six months to evaluate the treatment differences. RESULTS In final, control group included 82 and observation 87. The average operation time of the control group was significantly lower than that of the observation, while the bleeding volume was significantly lower in control group. The control group VAS score was 3 (1, 4), and observation 4 (2, 5). There was no significant difference in the incidence of urinary retention, bleeding and wound margin edema after surgery at one month postoperatively. Digital incidence of anal stenosis in the observation group was significantly lower than in control; the same occurred with residual anal margins. The postoperative anal canal diameter was significantly larger than the control group. Wexner anal incontinence score showed that no anal incontinence occurred in both groups, and the control group scored was significantly higher than observation. In final six months follow-up, the observation group did not experience any relapse and four cases were found among controls. The treatment satisfaction of the observation group was better. CONCLUSIONS In grades III and IV hemorrhoids, modified tissue-selecting therapy combined with complete anal canal preservation had better prognosis and treatment satisfaction than Milligan-Morgan procedure, and it is a new surgical method for patients with advanced mixed hemorrhoids.
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Affiliation(s)
- Hua Huang
- Department of Anorectal, Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, Changshu 215500, China
| | - Yunfei Gu
- Department of Anorectal, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210000, China
| | - Lijiang Ji
- Department of Anorectal, Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, Changshu 215500, China
| | - Youran Li
- Department of Anorectal, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210000, China
| | - Shanshan Xu
- Nanjing University of Chinese Medicine, Nanjing 210000, China
| | - Tianwei Guo
- Department of Anorectal, Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, Changshu 215500, China
| | - Minmin Xu
- Department of Anorectal, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210000, China
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Pinto RA, Correa-Neto IJF, Bustamante-Lopez LA, Nahas CSR, Marques CFS, Sobrado-Junior CW, Cecconello I, Nahas SC. ANORECTAL MANOMETRY STANDARD OF A BRAZILIAN POPULATION AT PRODUCTIVE AGE WITHOUT PELVIC FLOOR DISORDERS: A PROSPECTIVE VOLUNTEERED STUDY. ACTA ACUST UNITED AC 2021; 34:e1580. [PMID: 34133527 PMCID: PMC8195462 DOI: 10.1590/0102-672020210001e1580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 10/29/2020] [Indexed: 11/22/2022]
Abstract
Background: Due to the lack of normal standards of anorectal manometry in Brazil, data used are subject to normality patterns described at different nationalities.
Aim: To determine the values and range of the parameters evaluated at anorectal manometry in people, at productive age, without pelvic floor disorders comparing the parameters obtained between male and female.
Methods: Prospective analysis of clinical data, such as gender, age, race, body mass index (BMI) and anorectal manometry, of volunteers from a Brazilian university reference in pelvic floor disorders.
Results: Forty patients were included, with a mean age of 45.5 years in males and 37.2 females (p=0.43). According to male and female, respectively in mmHg, resting pressures were similar (78.28 vs. 63.51, p=0.40); squeeze pressures (153.89 vs. 79.78, p=0.007) and total squeeze pressures (231.27 vs. 145.63, p=0.002). Men presented significantly higher values of anorectal squeeze pressures, as well as the average length of the functional anal canal (2.85 cm in male vs. 2.45 cm in female, p=0.003).
Conclusions: Normal sphincter pressure levels in Brazilians differ from those used until now as normal literature standards. Male gender has higher external anal sphincter tonus as compared to female, in addition a greater extension of the functional anal canal
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Affiliation(s)
- Rodrigo Ambar Pinto
- Hospital das Clínicas, Discipline of Coloproctology, Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil
| | - Isaac José Felippe Correa-Neto
- Hospital das Clínicas, Discipline of Coloproctology, Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil
| | | | - Caio Sergio R Nahas
- Hospital das Clínicas, Discipline of Coloproctology, Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil
| | - Carlos Frederico S Marques
- Hospital das Clínicas, Discipline of Coloproctology, Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil
| | - Carlos Walter Sobrado-Junior
- Hospital das Clínicas, Discipline of Coloproctology, Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil
| | - Ivan Cecconello
- Hospital das Clínicas, Discipline of Coloproctology, Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil
| | - Sergio Carlos Nahas
- Hospital das Clínicas, Discipline of Coloproctology, Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil
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Santos CHMD, Guimarães FDS, Barros FHR, Leme GAL, Silva LDMD, Santos SEDO. EFFICACY OF LOW-LEVEL LASER THERAPY ON FISTULA-IN-ANO TREATMENT. ACTA ACUST UNITED AC 2021; 34:e1572. [PMID: 34008713 PMCID: PMC8121061 DOI: 10.1590/0102-672020210001e1572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 09/18/2020] [Indexed: 11/25/2022]
Abstract
Background: Treating anal fistulae is still a great challenge due to the possibility of fecal incontinence after surgery and that the use of laser has been gaining space in medicine, including as an inducing method of healing.
Aim:
To evaluate the efficacy of low-level laser therapy on fistula-in-ano treatment in rats.
Methods: Fifteen male Wistar rats weighing approximately 250-300g were used, which were subjected to the anal fistula induction procedure and after 30 days were distributed into two groups: control group (CG, n=5) and laser group (LG, n=10) observed for another 30 days. In the CG no treatment was performed and, in the LG, low-level laser therapy was applied in fistulous tracts daily. The closure of the fistulous tract, the area of the remaining tract, the inflammatory infiltrate and vascular congestion were evaluated.
Results:
There was no complete closure of the tract in any of the animals. The mean area of the remaining tract was 847.2 µm2 in the CG and 248.5 µm2 in the LG (p=0.001). The mean inflammatory infiltrate score was 2.4 in the CG and 1.3 in the LG (p=0.0285), while in the evaluation of vascular congestion, 1.6 was observed in the CG and 0.6 in the LG (p=0.031).
Conclusions: Low-level laser therapy was able to reduce the area of the fistulous tracts as well as decrease the inflammatory process and local vascular congestion.
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Affiliation(s)
- Carlos Henrique Marques Dos Santos
- Coloproctology Department, University Hospital Maria Aparecida Pedrossian, Federal University of Mato Grosso do Sul, Campo Grande, MS, Brazil.,Anhanguera-Uniderp University, Campo Grande, MS, Brazil
| | | | | | - Guilherme Apolinário Laureano Leme
- Coloproctology Department, University Hospital Maria Aparecida Pedrossian, Federal University of Mato Grosso do Sul, Campo Grande, MS, Brazil
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Sobrado CW, Sobrado LF, Nahas SC, Cecconello I. A NEW APPROACH FOR HEMORRHOID DISEASE: SELECTIVE DEARTERIALIZATION AND MUCOPEXY WITHOUT DOPPLER GUIDANCE. ACTA ACUST UNITED AC 2021; 34:e1560. [PMID: 34008704 PMCID: PMC8121048 DOI: 10.1590/0102-672020210001e1560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 10/20/2020] [Indexed: 12/05/2022]
Abstract
Background:
Transanal hemorrhoidal dearterialization (THD) is safe and effective minimally invasive treatment for hemorrhoidal disease, but reports regarding recurrence and postoperative complications (pain and tenesmus) vary significantly.
Aim:
To evaluate if selective dearterialization and mucopexy at the symptomatic hemorrhoid only, without Doppler guidance, achieves adequate control of the prolapse and bleeding and if postoperative morbidity is reduced with this technique.
Methods:
Twenty consecutive patients with grade II and III hemorrhoids were treated with this new approach and were evaluated for postoperative complications and recurrence.
Results:
Control of prolapse and bleeding was achieved in all patients (n=20). Postoperative complications were tenesmus (n=2), external hemorrhoidal thrombosis (n=2) and urinary retention (n=2). After a mean follow-up of 13 months no recurrences were diagnosed.
Conclusion:
Selective dearterialization and mucopexy is safe and achieves adequate control of prolapse and bleeding and, by minimizing sutures in the anal canal, postoperative morbidity is diminished. Doppler probe is unnecessary for this procedure, which makes it also more interesting from an economic perspective.
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Affiliation(s)
- Carlos Walter Sobrado
- Digestive and Colorectal Surgery Division, Department of Gastroenterology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Lucas Faraco Sobrado
- Digestive and Colorectal Surgery Division, Department of Gastroenterology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Sergio Carlos Nahas
- Digestive and Colorectal Surgery Division, Department of Gastroenterology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Ivan Cecconello
- Digestive and Colorectal Surgery Division, Department of Gastroenterology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
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Alonso-Burgos A. Interventional Radiology Should be Competitive-If Haemorrhoids are Arteriovenous Connections, It is Now the Time for Liquids? Commentary on "Superior Rectal Artery Embolisation for Haemorrhoids: What do We Know so Far?". Cardiovasc Intervent Radiol 2021; 44:686-688. [PMID: 33629136 DOI: 10.1007/s00270-021-02788-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 01/23/2021] [Indexed: 01/17/2023]
Affiliation(s)
- Alberto Alonso-Burgos
- Radiology Department, Unit of Vascular Surgery and Interventional Radiology, Clínica Universidad de Navarra, Marquesado de Santa Marta 1, 28022, Madrid, Spain.
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