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Khoury MK, Thornton MA, Dua A. Systematic review of intermediate and long-term results of thoracic outlet decompression. Semin Vasc Surg 2024; 37:90-97. [PMID: 38704189 DOI: 10.1053/j.semvascsurg.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 12/06/2023] [Accepted: 01/19/2024] [Indexed: 05/06/2024]
Abstract
Thoracic outlet syndrome (TOS) consists of a group of disorders resulting from compression of the neurovascular bundle exiting through the thoracic outlet. TOS can be classified as follows based on the etiology of the pathophysiology: neurogenic TOS, venous TOS, arterial TOS, and mixed TOS. The constellation of symptoms a patient may experience varies, depending on the structures involved. Due to the wide range of etiologies and presenting symptoms, treatments for TOS also differ. Furthermore, most studies focus on the perioperative and short-term outcomes after surgical decompression for TOS. This systematic review aimed to provide a pooled analysis of studies to better understand the intermediate and long-term outcomes of surgical decompression for TOS. We conducted a systematic literature search in the Ovid MEDLINE, Embase, and Google Scholar databases for studies that analyzed long-term outcomes after surgical decompression for TOS. The inclusion period was from January 2015 to May 2023. The primary outcome was postoperative QuickDASH Outcome Measure scores. A total of 16 studies were included in the final analysis. The differences between postoperative and preoperative QuickDASH Outcome Measure scores were calculated, when possible, and there was a mean overall difference of 33.5 points (95% CI, 25.2-41.8; P = .001) after surgical decompression. There was a higher proportion of excellent outcomes reported for patients undergoing intervention for arterial and mixed TOS etiologies, whereas those with venous and neurogenic etiologies had the lowest proportion of excellent outcomes reported. Patients with neurogenic TOS had the highest proportion of poor outcomes reported. In conclusion, surgical decompression for TOS has favorable long-term outcomes, especially in patients with arterial and mixed etiologies.
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Affiliation(s)
- Mitri K Khoury
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, 55 Fruit Street, Boston, MA, 02114
| | - Micah A Thornton
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, 55 Fruit Street, Boston, MA, 02114
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, 55 Fruit Street, Boston, MA, 02114.
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Mansilha A. A new cycle for the International Angiology Journal. INT ANGIOL 2022; 41:455-456. [PMID: 36719298 DOI: 10.23736/s0392-9590.23.05025-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Weiss K, Grünert J, Knechtle B. [Please Don't Forget the Neurogenic Thoracic Outlet Syndrome]. Praxis (Bern 1994) 2022; 111:632-638. [PMID: 35975409 DOI: 10.1024/1661-8157/a003870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Please Don't Forget the Neurogenic Thoracic Outlet Syndrome Abstract. We report the case of a 52-year-old patient who was treated for years for headaches, pain in the neck and arms, and sweating. Despite various therapeutic approaches there was no improvement in the symptoms. Further investigations showed a bilateral thoracic outlet syndrome in the status after multiple bilateral rib fractures after a fall from a window at the age of 18. After the operation of a bilateral thoracic outlet syndrome, the headache disappeared almost completely and there was no more sweating.
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Affiliation(s)
- Katja Weiss
- Medbase St. Gallen am Vadianplatz, St. Gallen, Schweiz
| | - Jörg Grünert
- Klinik für Hand-, Plastische und Wiederherstellungschirurgie, Kantonsspital St. Gallen, St. Gallen, Schweiz
| | - Beat Knechtle
- Medbase St. Gallen am Vadianplatz, St. Gallen, Schweiz
- Institut für Hausarztmedizin, Universität Zürich, Zürich, Schweiz
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Arnold MT, Hart CM, Greig DE, Trikha R, Gelabert HA, Jones KJ. Thoracic Outlet Syndrome in Major League Baseball Pitchers: Return to Sport and Performance Metrics After Rib Resection. Orthop J Sports Med 2022; 10:23259671221079835. [PMID: 35494495 PMCID: PMC9047814 DOI: 10.1177/23259671221079835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 11/30/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Thoracic outlet syndrome (TOS) is a rare injury that affects Major League
Baseball (MLB) pitchers and is often corrected with surgical resection of
the first rib. There are limited return-to-play (RTP) data for this surgery
in MLB pitchers. Hypothesis: It was hypothesized that MLB pitchers who undergo first rib resection for TOS
will show (1) a high rate of RTP, (2) no difference in postoperative career
length compared with controls, (3) no difference in pre- and postoperative
performance, and (4) no difference in postoperative performance compared
with controls. Study Design: Cohort study; Level of evidence, 3. Methods: This retrospective cohort study evaluated MLB pitchers with neurogenic or
vascular TOS who underwent rib resection surgery between January 1, 2001,
and December 31, 2019. Players were identified through public injury reports
from press releases, the MLB website, MLB team injury reports, and blogs. A
demographics- and performance-matched control group was generated for
comparison. Each player in the control group was given an index year that
corresponded to the surgery year of the case group. Performance data
included innings pitched (IP), games played (GP), earned run average (ERA),
complete GP, shutouts, saves, hits, runs, home runs (HR), walks, strikeouts
(K), walks plus hits per IP (WHIP), and earned runs (ER). Results: We identified 26 MLB pitchers who underwent rib resection for neurogenic or
vascular TOS; 21 players (81%) had a successful RTP. Pitchers were 30 ± 3.6
years old at the time of surgery and had played 6.2 ± 3.5 seasons before
undergoing surgery. Average postoperative career length was 3.1 ± 2.0
seasons, with an average time from surgery to RTP being 10 ± 4.7 months.
Pitchers who RTP showed no significant differences in performance metrics
compared with controls. Players pitch 0.94 (P < .05)
more IP/GP in the season directly following RTP compared with the season
before surgical intervention. Conclusion: MLB pitchers undergoing rib resection for TOS demonstrated (1) high RTP rates
following rib resection, (2) no difference in postoperative career length
compared with controls, (3) improvement in postoperative performance, and
(4) no difference in postoperative performance compared with controls.
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Affiliation(s)
- Michael T. Arnold
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Christopher M. Hart
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Danielle E. Greig
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Rishi Trikha
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Hugh A. Gelabert
- Department of Vascular Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Kristofer J. Jones
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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Camporese G, Bernardi E, Venturin A, Pellizzaro A, Schiavon A, Caneva F, Strullato A, Toninato D, Forcato B, Zuin A, Squizzato F, Piazza M, Stramare R, Tonello C, Di Micco P, Masiero S, Rea F, Grego F, Simioni P. Diagnostic and Therapeutic Management of the Thoracic Outlet Syndrome. Review of the Literature and Report of an Italian Experience. Front Cardiovasc Med 2022; 9:802183. [PMID: 35391849 PMCID: PMC8983020 DOI: 10.3389/fcvm.2022.802183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 02/28/2022] [Indexed: 11/18/2022] Open
Abstract
The Thoracic Outlet Syndrome is a clinical potentially disabling condition characterized by a group of upper extremity signs and symptoms due to the compression of the neurovascular bundle passing through the thoracic outlet region. Because of the non-specific nature of signs and symptoms, to the lack of a consensus for the objective diagnosis, and to the wide range of etiologies, the actual figure is still a matter of debate among experts. We aimed to summarize the current evidence about the pathophysiology, the diagnosis and the treatment of the thoracic outlet syndrome, and to report a retrospective analysis on 324 patients followed for 5 years at the Padua University Hospital and at the Naples Fatebenefratelli Hospital in Italy, to verify the effectiveness of a specific rehabilitation program for the syndrome and to evaluate if physical therapy could relieve symptoms in these patients.
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Affiliation(s)
- Giuseppe Camporese
- Angiology Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, Padua University Hospital, Padua, Italy
| | - Enrico Bernardi
- Department of Emergency and Accident Medicine, Hospital of Treviso, Treviso, Italy
| | - Andrea Venturin
- Physical Medicine and Rehabilitation Unit, Department of Neurosciences, Padua University Hospital, Padua, Italy
| | - Alice Pellizzaro
- Physical Medicine and Rehabilitation Unit, Department of Neurosciences, Padua University Hospital, Padua, Italy
| | - Alessandra Schiavon
- Physical Medicine and Rehabilitation Unit, Department of Neurosciences, Padua University Hospital, Padua, Italy
| | - Francesca Caneva
- Physical Medicine and Rehabilitation Unit, Department of Neurosciences, Padua University Hospital, Padua, Italy
| | - Alessandro Strullato
- Physical Medicine and Rehabilitation Unit, Department of Neurosciences, Padua University Hospital, Padua, Italy
| | - Daniele Toninato
- Physical Medicine and Rehabilitation Unit, Department of Neurosciences, Padua University Hospital, Padua, Italy
| | - Beatrice Forcato
- Physical Medicine and Rehabilitation Unit, Department of Neurosciences, Padua University Hospital, Padua, Italy
| | - Andrea Zuin
- Thoracic Surgery, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, Padua University Hospital, Padua, Italy
| | - Francesco Squizzato
- Vascular Surgery, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, Padua University Hospital, Padua, Italy
- Department of Medicine DIMED, Institute of Radiology, Padua University Hospital, Padua, Italy
| | - Michele Piazza
- Vascular Surgery, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, Padua University Hospital, Padua, Italy
- Department of Medicine DIMED, Institute of Radiology, Padua University Hospital, Padua, Italy
| | - Roberto Stramare
- Unit of Advanced Clinical and Translational Imaging, Department of Medicine, University Hospital of Padua, Padua, Italy
| | - Chiara Tonello
- Angiology Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, Padua University Hospital, Padua, Italy
| | - Pierpaolo Di Micco
- Department of Internal Medicine and Emergency Room, Naples Buon Consiglio Fatebenefratelli Hospital, Naples, Italy
| | - Stefano Masiero
- Physical Medicine and Rehabilitation Unit, Department of Neurosciences, Padua University Hospital, Padua, Italy
| | - Federico Rea
- Thoracic Surgery, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, Padua University Hospital, Padua, Italy
| | - Franco Grego
- Vascular Surgery, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, Padua University Hospital, Padua, Italy
- Department of Medicine DIMED, Institute of Radiology, Padua University Hospital, Padua, Italy
| | - Paolo Simioni
- Department of Internal Medicine, General Medicine Unit, Thrombotic and Haemorrhagic Disorders Unit, University Hospital of Padua, Padua, Italy
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Yamada T, Kudo T, Kawabata A, Yoshii T. Upper limb gangrene due to a subclavian arterial thrombosis associated with thoracic outlet syndrome following cervical spondylotic amyotrophy. J Surg Case Rep 2021; 2021:rjab495. [PMID: 34804481 PMCID: PMC8599054 DOI: 10.1093/jscr/rjab495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 10/11/2021] [Accepted: 10/14/2021] [Indexed: 11/14/2022] Open
Abstract
Thoracic outlet syndrome (TOS) refers to an abnormal compression of the subclavian vessels and the brachial plexus at the base of the neck or thoracic outlet. The authors described a novel case of a 66-year-old male with arterial TOS and unilateral upper rib dysplasia following cervical spine disease. Owing to the comorbidity of cervical spondylotic amyotrophy and a history of sloping shoulder due to rib dysplasia, TOS occurred, which subsequently led to subclavian arterial thrombosis and eventually resulted in the gangrene of the hand. Thrombectomy and surgical resection of the first and second ribs avoided the progression of further neurovascular disorder. When treating a cervical spondylotic patient, concurrent TOS can be obscured by symptoms caused by cervical lesions, leading to difficulty in identifying the origin of these neurovascular findings. The possibility of subsequent thromboembolic events based on TOS should be considered, especially in cases with dysplasia of the upper ribs.
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Affiliation(s)
- Tsuyoshi Yamada
- Department of Orthopaedic Surgery, Kudanzaka Hospital, Tokyo, Japan
| | - Toshifumi Kudo
- Department of Specialized Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Atsuyuki Kawabata
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toshitaka Yoshii
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
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Li W, Dissanaike S. Jury verdicts, outcomes, and tort reform features of malpractice cases involving thoracic outlet syndrome. J Vasc Surg 2021; 75:962-967. [PMID: 34601048 DOI: 10.1016/j.jvs.2021.08.098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 08/22/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE/BACKGROUND Thoracic outlet syndrome (TOS) is most often referred to vascular surgeons. However, there is a lack of understanding of the malpractice cases involving TOS. The goal of this study is to better understand the medicolegal landscape related to the care of TOS. METHODS The Westlaw Edge AI-powered proprietary system was retrospectively reviewed for malpractice cases involving TOS. A Boolean search strategy was used to identify target cases under the case category of "Jury Verdicts & Settlements" for all state and federal jurisdictions from 1970 to September 2020. The settled case was described but not included in the statistical analysis. Descriptive statistics were used to report our findings, and when appropriate. The P ≤ .05 decision rule was established a priori as the null hypothesis rejection criterion to determine associations between jury verdicts outcomes and state's tort reform status. RESULTS In this study, 39 cases were identified and met the study's inclusion criteria from the entire Westlaw Edge database. Among plaintiffs who disclosed age and/or gender, median age was 35.0 years with a female majority (67.6%). Cases involving TOS were noted to be steadily decreasing since the mid-1990s. The cases were unevenly spread across 18 states, with the highest number of cases (14, 35.9%) from California and the second highest (4, 10.3%) from Pennsylvania. A similar uneven distribution was seen among U.S. census regions, in which the West had the highest cases (39.5%). The study revealed that more cases were brought to trials in tort reform states (26, 68.4%) than in non-tort reform states (12, 31.6%). A total of 24 of 39 (61.5%) plaintiffs had one specific claim, which resulted in their economic and noneconomic damages. Negligent operation and treatment complication represented an overwhelming majority of claims brought by 38 of 39 plaintiffs (97.4%). Misdiagnosis and lack of informed consent were both brought nine times (23.1%) by the group. Intraoperative nerve injury (20 patients, 51.3%) was the most commonly reported complication. Excluding one case with a settlement of $965,000, 30 of 38 (78.9%) cases went to trials and received defense verdicts. Eight cases (20.5%) were found in favor of plaintiffs with a median payout of $725,581. CONCLUSIONS This study highlighted higher than average payouts to plaintiffs and risk factors that may result in malpractice lawsuits for surgeons undertaking TOS treatment. Future studies are needed to further clarify the relationships between tort reform and outcomes of malpractice cases involving TOS.
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Affiliation(s)
- Wei Li
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Tex; Loyola University Chicago School of Law, Chicago, Ill.
| | - Sharmila Dissanaike
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Tex
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Li N, Dierks G, Vervaeke HE, Jumonville A, Kaye AD, Myrcik D, Paladini A, Varrassi G, Viswanath O, Urits I. Thoracic Outlet Syndrome: A Narrative Review. J Clin Med 2021; 10:jcm10050962. [PMID: 33804565 PMCID: PMC7957681 DOI: 10.3390/jcm10050962] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 02/16/2021] [Accepted: 02/25/2021] [Indexed: 01/08/2023] Open
Abstract
Thoracic outlet syndrome comprises a group of disorders that result in compression of the brachial plexus and subclavian vessels exiting the thoracic outlet. Symptoms include pain, paresthesia, pallor, and weakness depending upon the compromised structures. While consensus in diagnostic criteria has not yet been established, a thorough patient history, physical exam, and appropriate imaging studies are helpful in diagnosis. General first-line therapy for thoracic outlet syndrome is a conservative treatment, and may include physical therapy, lifestyle modifications, NSAIDs, and injection therapy of botulinum toxin A or steroids. Patients who have failed conservative therapy are considered for surgical decompression. This article aims to review the epidemiology, etiology, relevant anatomy, clinical presentations, diagnosis, and management of thoracic outlet syndrome.
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Affiliation(s)
- Nathan Li
- Medical College of Wisconsin–Milwaukee, Milwaukee, WI 53233, USA;
| | - Gregor Dierks
- Louisiana State University Health Sciences Center–Shreveport, Shreveport, LA 71106, USA; (G.D.); (H.E.V.); (A.J.)
| | - Hayley E. Vervaeke
- Louisiana State University Health Sciences Center–Shreveport, Shreveport, LA 71106, USA; (G.D.); (H.E.V.); (A.J.)
| | - Allison Jumonville
- Louisiana State University Health Sciences Center–Shreveport, Shreveport, LA 71106, USA; (G.D.); (H.E.V.); (A.J.)
| | - Alan D. Kaye
- Department of Anesthesiology, Louisiana State University Shreveport, Shreveport, LA 71106, USA; (A.D.K.); (O.V.); (I.U.)
| | - Dariusz Myrcik
- Department of Internal Medicine, Medical University of Silesia, Katowice, 42-600 Bytom, Poland;
| | | | - Giustino Varrassi
- Paolo Procacci Foundation, Via Tacito 7, 00193 Roma, Italy
- Correspondence: ; Tel.: +39-348-606-8472
| | - Omar Viswanath
- Department of Anesthesiology, Louisiana State University Shreveport, Shreveport, LA 71106, USA; (A.D.K.); (O.V.); (I.U.)
- Valley Anesthesiology and Pain Consultants–Envision Physician Services, Phoenix, AZ 85004, USA
- Department of Anesthesiology, University of Arizona, Phoenix, AZ 85004, USA
- Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE 68114, USA
| | - Ivan Urits
- Department of Anesthesiology, Louisiana State University Shreveport, Shreveport, LA 71106, USA; (A.D.K.); (O.V.); (I.U.)
- Southcoast Health, Southcoast Physicians Group Pain Medicine, Wareham, MA 02571, USA
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ASLANER O. TORASİK OUTLET SENDROMUNDA CERRAHİ TEDAVİNİN ETKİNLİĞİ. Acta Medica Alanya 2020. [DOI: 10.30565/medalanya.792279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Vigliotti RC, Montelione N, Franceschi F, Franceschini E, Zardi E, Spinelli F, Stilo F. Externally Supported Extra-anatomical Venous Bypass to Treat Upper Limb Ischemia with Shoulder Prosthetic Infection. Ann Vasc Surg 2020; 69:453.e5-453.e10. [PMID: 32653615 DOI: 10.1016/j.avsg.2020.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 06/01/2020] [Accepted: 07/03/2020] [Indexed: 10/23/2022]
Abstract
To report a case of acute arm ischemia and prosthetic shoulder infection treated by extra-anatomical great saphenous vein graft with external vascular scaffolding. A 65 year-old man with multiple surgical interventions for soft tissue sarcoma of the right shoulder, local radiotherapy with residual brachial plexus neuropraxia, was referred to our attention for signs of arm ischemia. Two weeks before, the patient was submitted to prosthetic shoulder replacement complicated with prosthetic infection. Considering the mechanism of vascular injury, an open surgical revascularization was planned with a deliberate avoidance of the natural anatomic pathway to reduce the risk of graft infection. Consequently, after the complete removal of infected shoulder prosthesis and placement of antibiotic spacer, an axillarbrachial artery bypass using great saphenous vein was performed using a new braided cobalt chrome kink resistant external vascular support to prevent compression, also considering the extra-anatomical position of the graft. At 12 months' follow-up, patient was in good clinical condition with complete resolution of arm ischemia; computed tomographic angiography and duplex scan revealed patency of the graft with excellent distal perfusion. The new external vascular support seems to be useful and feasible for preventing compression of extra-anatomical venous bypass.
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Affiliation(s)
- Rossella C Vigliotti
- Vascular Surgery Division, University Campus Bio-Medico, Rome, Italy; Division of Vascular Surgery, Department of Medical, Surgical, and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Nunzio Montelione
- Vascular Surgery Division, University Campus Bio-Medico, Rome, Italy.
| | | | | | - Enrico Zardi
- Vascular Surgery Division, University Campus Bio-Medico, Rome, Italy; Upper and Lower Limb Surgery Unit, University Campus Bio-Medico, Rome, Italy
| | | | - Francesco Stilo
- Vascular Surgery Division, University Campus Bio-Medico, Rome, Italy
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