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Glotzer OS, Rieth G, Kistler A, Hnath J, Gifford E, Darling RC. Use of the right retroperitoneum as an alternative approach to the abdominal aorta. J Vasc Surg 2023; 78:71-76. [PMID: 36889607 DOI: 10.1016/j.jvs.2023.02.013] [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: 01/01/2022] [Revised: 02/15/2023] [Accepted: 02/17/2023] [Indexed: 03/08/2023]
Abstract
OBJECTIVE The left retroperitoneal approach to the aorta is a well-established technique for aortic exposure. The right retroperitoneal approach to the aorta is performed less commonly, and the outcomes remain unknown. This study aimed to evaluate the outcomes of right retroperitoneal aortic-based procedures and to determine its utility in aortic reconstruction when faced with hostile anatomy or infection in the abdomen or left flank. METHODS A retrospective query of a vascular surgery database from a tertiary referral center was performed for all retroperitoneal aortic procedures. Individual patient charts were reviewed, and data were collected. Demographics, indications, intraoperative details, and outcomes were tabulated. RESULTS From 1984 through 2020, there have been 7454 open aortic procedures; 6076 were retroperitoneal-based, and 219 of which were performed from the right retroperitoneal approach (Rrp). Aneurysmal disease was the most common indication (48.9%), and graft occlusion was the most common postoperative complication (11.4%). The average aneurysm size was 5.5 cm, and the most common reconstruction was with a bifurcated graft (77.6%). Average intraoperative blood loss was 923.8 mL (range, 50-6800 mL; median, 600 mL). Perioperative complications occurred in 56 patients (25.6%) for a total of 70 complications. Perioperative mortality occurred in two patients (0.91%). The 219 patients treated with Rrp required 66 subsequent procedures in 31 patients. These included 29 extra-anatomic bypasses, 19 thrombectomies/embolectomies, 10 bypass revisions, 5 infected graft excisions, and 3 aneurysm revisions. Eight Rrp eventually underwent a left retroperitoneal approach for aortic reconstruction. Fourteen patients with a left-sided aortic procedure required a Rrp. CONCLUSIONS The right retroperitoneal approach to the aorta is a useful technique in the setting of prior surgery, anatomic abnormality, or infection that complicates the use of other more frequently employed approaches. This review demonstrates comparable outcomes and the technical feasibility of this approach. The right retroperitoneal approach to aortic surgery should be considered a viable alternative to left retroperitoneal and transperitoneal access in patients with complex anatomy or prohibitive pathology for more traditional exposure.
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Affiliation(s)
- Owen S Glotzer
- Division of Vascular and Endovascular Surgery, Hartford Healthcare Medical Group, Hartford Hospital, Hartford, CT.
| | - Gabrielle Rieth
- Department of Vascular Surgery, Albany Medical College, Albany Medical Center Hospital, Albany, NY
| | - Amanda Kistler
- Department of Vascular Surgery, Albany Medical College, Albany Medical Center Hospital, Albany, NY
| | - Jeffrey Hnath
- Department of Vascular Surgery, Albany Medical College, Albany Medical Center Hospital, Albany, NY
| | - Edward Gifford
- Division of Vascular and Endovascular Surgery, Hartford Healthcare Medical Group, Hartford Hospital, Hartford, CT
| | - R Clement Darling
- Department of Vascular Surgery, Albany Medical College, Albany Medical Center Hospital, Albany, NY
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Stavres J, Wang J, Sica CT, Blaha C, Herr M, Pai S, Cauffman A, Vesek J, Yang QX, Sinoway LI. Diffusion tensor imaging indices of acute muscle damage are augmented after exercise in peripheral arterial disease. Eur J Appl Physiol 2021; 121:2595-2606. [PMID: 34106324 PMCID: PMC10445221 DOI: 10.1007/s00421-021-04711-7] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 05/05/2021] [Indexed: 12/20/2022]
Abstract
PURPOSE Although it is known that peripheral arterial disease (PAD) is associated with chronic myopathies, the acute muscular responses to exercise in this population are less clear. This study used diffusion tensor imaging (DTI) to compare acute exercise-related muscle damage between PAD patients and healthy controls. METHODS Eight PAD patients and seven healthy controls performed graded plantar flexion in the bore of a 3T MRI scanner. Exercise began at 2 kg and increased by 2 kg every 2 min until failure, or completion of 10 min of exercise. DTI images were acquired from the lower leg pre- and post-exercise, and were analyzed for mean diffusivity, fractional anisotropy (FA), and eigenvalues 1-3 (λ1-3) of the medial gastrocnemius (MG) and tibialis anterior (TA). RESULTS Results indicated a significant leg by time interaction for mean diffusivity, explained by a significantly greater increase in diffusivity of the MG in the most affected legs of PAD patients (11.1 × 10-4 ± 0.5 × 10-4 mm2/s vs. 12.7 × 10-4 ± 1.2 × 10-4 mm2/s at pre and post, respectively, P = 0.02) compared to healthy control subjects (10.8 × 10-4 ± 0.3 × 10-4 mm2/s vs. 11.2 × 10-4 ± 0.5 × 10-4 mm2/s at pre and post, respectively, P = 1.0). No significant differences were observed for the TA, or λ1-3 (all P ≥ 0.06). Moreover, no reciprocal changes were observed for FA in either group (all P ≥ 0.29). CONCLUSION These data suggest that calf muscle diffusivity increases more in PAD patients compared to controls after exercise. These findings are consistent with the notion that acute exercise results in increased muscle damage in PAD.
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Affiliation(s)
- Jon Stavres
- Penn State Heart and Vascular Institute, Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, PA, USA.
| | - Jianli Wang
- Department of Radiology, Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Christopher T Sica
- Department of Radiology, Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Cheryl Blaha
- Penn State Heart and Vascular Institute, Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Michael Herr
- Penn State Heart and Vascular Institute, Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Samuel Pai
- Penn State Heart and Vascular Institute, Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Aimee Cauffman
- Penn State Heart and Vascular Institute, Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Jeffrey Vesek
- Department of Molecular Biology, Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Qing X Yang
- Department of Radiology, Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, PA, USA
- Department of Neurosurgery, Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Lawrence I Sinoway
- Penn State Heart and Vascular Institute, Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, PA, USA
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Girault A, Pellenc Q, Roussel A, Senemaud J, Cerceau P, Maggiori L, Huguet A, Corcos O, Ben Abdallah I, Castier Y. Midterm results after covered stenting of the superior mesenteric artery. J Vasc Surg 2021; 74:902-909.e3. [PMID: 33684478 DOI: 10.1016/j.jvs.2021.02.038] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [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: 08/20/2020] [Accepted: 02/19/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Despite the continuing controversy of covered stents (CS) vs bare metal stents, the use of CS in mesenteric occlusive disease (MOD) has been recommended by expert centers. The aim of this study was to report midterm results with CS of the superior mesenteric artery. METHODS Between January 2014 and October 2019, patients with MOD with a severe atheromatous stenosis or occlusion of the superior mesenteric artery treated by mesenteric CS were included. Clinical presentation included both acute mesenteric ischemia (AMI), chronic mesenteric ischemia, and asymptomatic patients planned for major surgery. Demographics, procedure details, and follow-up data were prospectively collected and retrospectively reviewed. Study end points included primary patency, primary assisted patency, and secondary patency. RESULTS During the study period, 86 patients (mean age, 70 ± 9 years; 57% males) were included. Clinical presentation was AMI (n = 42 [49%]), chronic mesenteric ischemia (n = 31 [36%]), and asymptomatic (n = 13 [15%]). The technical success rate was 97%. A total of 96 stents were implanted, including 86 proximal CS (Advanta V12, n = 73; Lifestream, n = 13). The mean length and mean diameter of the CS were 31.5 ± 6.3 mm and 6.9 ± 0.5 mm, respectively. Additional distal bare metal stents were used in 10 patients (12%) to overcome a kinking (n = 9) or a dissection (n = 1) downstream of the CS. All postoperative deaths occurred in patients with AMI (n = 11, 13%). During a median follow-up of 15.6 months (95% confidence interval [CI], 15.6 ± 3.6 months), 12 patients (14%) underwent reinterventions for either stent misplacement (n = 3), stent recoil (n = 3), stent thrombosis (n = 2), de novo stenosis at the distal edge of the CS (n = 2), or gastric ischemia (n = 1). At 1 year, overall the primary patency, primary assisted patency, and secondary patency rates were 83% (95% CI, 83% ± 9%), 99% (95% CI, 99% ± 3%), and 99% (95% CI, 99% ± 3%), respectively. At 2 years, the overall primary patency, primary assisted patency, and secondary patency rates were 76% (95% CI, 76% ± 13%), 95% (95% CI, 95% ± 8%) and 95% (95% CI, 95% ± 8%), respectively. CONCLUSIONS Mesenteric CS provide very satisfactory midterm results in patients with MOD, with an excellent primary assisted patency rate at 2 years, at the price of a significant reintervention rate.
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Affiliation(s)
- Antoine Girault
- Service de chirurgie Vasculaire et Thoracique, Hôpital Bichat, Hôpital Beaujon, AP-HP, Université de Paris, Paris, France; Structure d'Urgences Vasculaire Intestinale (SURVI), Hôpital Beaujon, AP-HP, Université de Paris, Paris, France.
| | - Quentin Pellenc
- Service de chirurgie Vasculaire et Thoracique, Hôpital Bichat, Hôpital Beaujon, AP-HP, Université de Paris, Paris, France; Structure d'Urgences Vasculaire Intestinale (SURVI), Hôpital Beaujon, AP-HP, Université de Paris, Paris, France
| | - Arnaud Roussel
- Service de chirurgie Vasculaire et Thoracique, Hôpital Bichat, Hôpital Beaujon, AP-HP, Université de Paris, Paris, France; Structure d'Urgences Vasculaire Intestinale (SURVI), Hôpital Beaujon, AP-HP, Université de Paris, Paris, France
| | - Jean Senemaud
- Service de chirurgie Vasculaire et Thoracique, Hôpital Bichat, Hôpital Beaujon, AP-HP, Université de Paris, Paris, France; Structure d'Urgences Vasculaire Intestinale (SURVI), Hôpital Beaujon, AP-HP, Université de Paris, Paris, France
| | - Pierre Cerceau
- Service de chirurgie Vasculaire et Thoracique, Hôpital Bichat, Hôpital Beaujon, AP-HP, Université de Paris, Paris, France; Structure d'Urgences Vasculaire Intestinale (SURVI), Hôpital Beaujon, AP-HP, Université de Paris, Paris, France
| | - Léon Maggiori
- Structure d'Urgences Vasculaire Intestinale (SURVI), Hôpital Beaujon, AP-HP, Université de Paris, Paris, France; Service de chirurgie viscérale, Hôpital Beaujon, AP-HP, Université de Paris, Paris, France
| | - Audrey Huguet
- Structure d'Urgences Vasculaire Intestinale (SURVI), Hôpital Beaujon, AP-HP, Université de Paris, Paris, France; Service de gastro-entérologie et assistance nutritive, Hôpital Beaujon, AP-HP, Université de Paris, Paris, France
| | - Olivier Corcos
- Structure d'Urgences Vasculaire Intestinale (SURVI), Hôpital Beaujon, AP-HP, Université de Paris, Paris, France; Service de gastro-entérologie et assistance nutritive, Hôpital Beaujon, AP-HP, Université de Paris, Paris, France
| | - Iannis Ben Abdallah
- Service de chirurgie Vasculaire et Thoracique, Hôpital Bichat, Hôpital Beaujon, AP-HP, Université de Paris, Paris, France; Structure d'Urgences Vasculaire Intestinale (SURVI), Hôpital Beaujon, AP-HP, Université de Paris, Paris, France
| | - Yves Castier
- Service de chirurgie Vasculaire et Thoracique, Hôpital Bichat, Hôpital Beaujon, AP-HP, Université de Paris, Paris, France; Structure d'Urgences Vasculaire Intestinale (SURVI), Hôpital Beaujon, AP-HP, Université de Paris, Paris, France
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Lotto CE, Sharma G, Walsh JP, Shah SK, Nguyen LL, Ozaki CK, Menard MT, Belkin M. The impact of combined iliac occlusive disease and aortic aneurysm on open surgical repair. J Vasc Surg 2019; 71:2021-2028.e1. [PMID: 31727458 DOI: 10.1016/j.jvs.2019.08.249] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 08/11/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Severe aortoiliac occlusive disease is a relative contraindication for endovascular aneurysm repair, owing to an association with high stent graft-related complication and reintervention rates in this population. Open AAA repair requiring aortofemoral bypass (AFB), however, may represent a unique population with differing outcomes from standard open repair. We sought to compare the demographic and procedural characteristics, as well as outcomes of patients undergoing standard intra-abdominal repairs (STD) versus those requiring AFB. METHODS Using a prospectively maintained database, we retrospectively identified patients who underwent open AAA repair from 1994 to 2017. A total of 1087 consecutive cases were performed consisting of 981 STD (681 tube graft, 300 aortoiliac) and 106 AFB cases. Demographics, procedural data, postoperative complications, and long-term survival were analyzed. RESULTS The AFB cohort had more women (39.0 vs 22.8%; P = .001) and higher rates of hypertension (81.1 vs 69.8%; P = .015), chronic obstructive pulmonary disease (28.3 vs 17.4%; P = .006), and smoking (50.9 vs 36%; P = .002). The AFB group had smaller mean aortic (5.22 vs 5.77 cm; P = .001) and graft (17.08 vs 18.2 mm; P = .001) diameters. Proximal clamp position and blood loss were equivalent, although total anesthesia time was longer (295 vs 234 minutes; P = .001) in the AFB cohort. Overall 30-day postoperative morbidity (38.7 vs 24.8%; P = .002) was higher in the AFB group. Specifically, postoperative renal insufficiency (8.2 vs 3.4%; P = .032), wound infection (5.7 vs 1.2%; P = .005), and hematoma/seroma (5.7 vs 1.2%; P = .003) were more likely. Hospital length of stay was longer for AFB (11.9 vs 9.9 days; P = .007). The 30-day mortality (0.9% AFB vs 1.8% STD; P = .50) and major morbidity (17 vs 11.5%; P = .10) did not differ. Reintervention rate within 30 days of the initial surgery (12.3 vs 4.6; P = .001) and overall (33 vs 18.9%; P = .001) was higher in the AFB group. Long-term survival was lower in the AFB group (5-year survival: 63.1% AFB vs 71.9% STD; hazard ratio 0.76, log-rank P = .047). Multivariate regression analysis identified age, comorbid conditions, and aneurysm characteristics-rather than repair type-as independent predictors of 30-day reintervention and mortality at 5 years. CONCLUSIONS Patients requiring AFB for AAA owing to associated iliac occlusive disease have more preoperative comorbidities, postoperative complications, a longer length of stay, reintervention rates and shorter 5-year survival. Patient and aneurysm characteristics rather than surgical repair type appear to be responsible for these differences. Nevertheless, 30-day mortality and major morbidity were comparable, making AFB an attractive alternative to endovascular aneurysm repair in patients with advanced iliac occlusive disease.
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Affiliation(s)
- Christine E Lotto
- Division of Vascular and Endovascular Surgery, Brigham and Women's Heart and Vascular Center/Harvard Medical School, Boston, Mass
| | - Gaurav Sharma
- Division of Vascular and Endovascular Surgery, Brigham and Women's Heart and Vascular Center/Harvard Medical School, Boston, Mass
| | - Jillian P Walsh
- Division of Vascular and Endovascular Surgery, Brigham and Women's Heart and Vascular Center/Harvard Medical School, Boston, Mass
| | - Samir K Shah
- Division of Vascular and Endovascular Surgery, Brigham and Women's Heart and Vascular Center/Harvard Medical School, Boston, Mass
| | - Louis L Nguyen
- Division of Vascular and Endovascular Surgery, Brigham and Women's Heart and Vascular Center/Harvard Medical School, Boston, Mass
| | - C Keith Ozaki
- Division of Vascular and Endovascular Surgery, Brigham and Women's Heart and Vascular Center/Harvard Medical School, Boston, Mass
| | - Matthew T Menard
- Division of Vascular and Endovascular Surgery, Brigham and Women's Heart and Vascular Center/Harvard Medical School, Boston, Mass
| | - Michael Belkin
- Division of Vascular and Endovascular Surgery, Brigham and Women's Heart and Vascular Center/Harvard Medical School, Boston, Mass.
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Illuminati G, Pizzardi G, Calio FG, Masci F, Pasqua R, Frezzotti F, Peschillo S. Results of subclavian to carotid artery bypass for occlusive disease of the common carotid artery: A retrospective cohort study. Int J Surg 2018; 53:111-6. [PMID: 29581047 DOI: 10.1016/j.ijsu.2018.03.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 03/19/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Optimal treatment of significant atherosclerosis of the common carotid artery (CCA) is not well-defined. The purpose of this study was to evaluate the long-term results of prosthetic subclavian to carotid bypass for occlusive disease of the CCA. MATERIAL AND METHODS From January 1994 to December 2015, 45 patients, mean age 67 years, underwent an ipsilateral subclavian to carotid bypass for occlusive disease of the CCA. Thirty-eight patients (84%) presented with neurologic symptoms, including transitory ischemic attacks in 29 cases and minor strokes in 9 cases. The graft material consisted of a 7 mm polytetrafluoroethylene conduit, and the distal anastomosis was done on the carotid bulb in 21 patients, on the internal carotid artery in 19 cases, and on the distal CCA in 5 cases. Median length of follow-up was 58 months. Study endpoints were the combined postoperative stroke/mortality rate, graft infection, overall late survival, freedom from ipsilateral stroke, and graft patency. RESULTS Postoperative stroke/mortality rate was 2%. No graft infection was observed throughout follow-up. At 60 months, overall survival, freedom from stroke, and graft patency were 71% (standard error [SE] = 0.07), 98% (SE = 0.02), and 95.5% (SE = 0.06), respectively. CONCLUSIONS Subclavian to carotid bypass allows very good patency rates and excellent protection from postoperative and late stroke, remaining a benchmark for any other treatment method.
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Hinojosa CA, Anaya-Ayala JE, Gomez-Arcive Z, Laparra-Escareno H, Torres-Machorro A, Lizola R. Factors Associated With Need for Revascularisation in Non-coronary Arterial Occlusive Lesions Secondary to Takayasu's Arteritis. Eur J Vasc Endovasc Surg 2017; 54:397-404. [PMID: 28709561 DOI: 10.1016/j.ejvs.2017.05.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [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: 10/13/2016] [Accepted: 05/31/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVE/BACKGROUND Takayasu's arteritis (TA) is rare inflammatory large vessel form of vasculitis. The objective of this study was to evaluate experience in the management of TA patients and to identify the influence of inflammatory markers and clinical variables associated with disease progression, worsening ischaemic symptoms, and the need for interventions. METHODS Demographics, and laboratory and clinical variables in patients that required revascularisation procedures were compared with those who had adequate symptomatic control with medical management. Categorical data were analysed with Fisher's exact test, continuous variables with two-sample t test, and a life table analysis was used to study the recurrence of symptoms in intervened patients. RESULTS From January 1995 to May 2016, 47 patients (mean age 30 years; range 14-59 years) were managed; 44 (94%) were female. During the mean follow-up period of 120 months, 21 (45%) underwent 23 procedures (17 of these [74%] open, six [26%] endovascular). From the intervened group, eight (38%) patients presented with transient ischaemic attacks, five (24%) with renovascular hypertension, and four (19%) with upper extremity and four (19%) lower extremity claudication. Comparative analysis demonstrated that elevation of erythrocyte sedimentation rate (ESR) at the time of the diagnosis (revascularisation group: median value 28 mm/hour; medical management group: median value 15 mm/hour) was associated with progression of the disease, worsening symptoms, and subsequent need for intervention (p = .04). Active smoking was a factor connected with the need for revascularisation (p = .05). Immediate symptomatic improvement occurred in 19 (90%) patients that underwent surgical or endovascular revascularisation. CONCLUSION Patients with TA who underwent interventions had higher ESR at the time of diagnosis; this factor and active smoking were associated with progression of the disease and worsening ischaemic symptoms despite medical therapy. Revascularisation procedures are effective at relieving symptoms; lifelong surveillance is necessary.
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Affiliation(s)
- C A Hinojosa
- Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Mexico City, Mexico.
| | - J E Anaya-Ayala
- Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Mexico City, Mexico
| | - Z Gomez-Arcive
- Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Mexico City, Mexico
| | - H Laparra-Escareno
- Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Mexico City, Mexico
| | - A Torres-Machorro
- Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Mexico City, Mexico
| | - R Lizola
- Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Mexico City, Mexico
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