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Aortoiliac Kissing Stents: Long-term Results and Analysis of Risk Factors Affecting Patency

Saim Yilmaz, MD; Timur Sindel, MD; Ilhan Golbasi, MD; Cengiz Turkay, MD; Atalay Mete, MD; and Ersin Lüleci, MD

Traditional treatment of aortoiliac stenoses or occlusions is surgery; for focal lesions not extending into the common iliac artery (CIA), the procedure of choice is aortoiliac endarterectomy, whereas more diffuse lesions are generally treated with aortobifemoral bypass.1 The durability of these procedures is excellent (85% to 90% at 5 years), particularly in claudicators.1–3 According to a meta-analysis, which used data back to 1975, the operative mortality rate was 3.3%, with an aggregated systemic perioperative morbidity of 8.3%.2

Despite the excellent patency rates, surgery has several disadvantages, including the need for general anesthesia, longer hospitalization and recovery from the required incision, loss of sexual function, and high cost.1,2 Kissing balloon angioplasty was proposed as an alternative to surgery; although the technique was found to be effective and durable, there was a significant incidence of dissection, thrombosis, and residual stenosis.4,5 The kissing stents technique, which involves simultaneous implantation of two stents at the aortic bifurcation, was presumed to overcome these drawbacks.6,7 Today, with the refinements in stent technology, the kissing stents technique has largely replaced kissing balloon dilation for the treatment of aortoiliac occlusive disease.

In the literature, there are a number of studies in which the results of kissing stents have been reported.6–14 In these series, the number of patients are relatively low, and there are no data regarding the factors affecting patency. In the present study, we present our early and long-term results of aortoiliac kissing stent implantation in 68 patients and analyze the variables affecting patency.

Methos

Study

Design In this retrospective cohort study, the data on all patients who underwent aortoiliac kissing stents implantation during the last 12 years were retrospectively reviewed. In our analysis, only lesions involving the aortic bifurcation that were scheduled for the kissing stents procedure were included; unilateral or bilateral iliac lesions that did not extend to the bifurcation were treated with “non-kissing stents” and thus excluded. Also excluded from endovascular treatment were patients with aneurysms of the distal aorta that required surgery, bilateral iliac occlusions, and diffuse disease that involved the common femoral artery (CFA). Before all procedures, potential risks and benefits were explained in detail, and an informed written consent was obtained from each patient. Throughout the study, the principles of the Helsinki Declaration were strictly followed.

Patient and Lesion Characteristics

In the 12-year period, 68 patients (64 men; mean age 55±11, range 32–77) with aortoiliac occlusive disease were treated with kissing stents (Table 1 ). According to the TASC (TransAtlantic Inter-Society Consensus) classification,15 24 (35%) patients had type A lesions, 39 (58%) type B, and 5 (7%) type C (Table 2 ). In our patients, the lesions were demonstrated either with catheter angiography (n=43, 63%) or with different combinations (n=25, 37%) of Doppler ultrasonography, magnetic resonance angiography, or computed tomographic angiography.

 

Table 1. Clinical Characteristics of 68 Patients Undergoing Aortoiliac Kissing Stents Implantation

Age, y 55.6 ± 11.1 53.0-58.2)
   <50 year 28 (41%)
Men 64 (94%)
Atherosclerotic risk factors  
   Past smoking 68(100%)
   Continued smoking 20(29%)
   Diabetes mellitus 14(21%)
   hypertension 26(38%)
   Hypercholesterolemia 32(47%)
   Coronary heart disease 32(47%)
Numbers of risk factors/patient  
   1 2(3%)
   2 18(26%)
   3 24(36%)
   4 18(26%)
   5 6(9%)
   >2 risk factors/patient 48(71%)
Clinical category*  
   1.Mild claudication  
   2.Moderate claudication 25(37%)
   3.Severe claudication 39(57%)
   4.Ischemic rest pain 4(6%)
   5.Minor tissue loos 0
   6.Major tissue loos 0
Ankle-brachial index  
   Right leg  
      Preprocedural 0.55±0.14(0.50-0.60)
      Postprocedural 0.91±0.19(0.86-0.96)
   Left leg  
      Preprocedural 0.48±0.13(0.44-0.51)
      Postprocedural 0.89±0.19(0.84-0.94)

Continuous data are presented as mean±standard deviation(95% confidence interval).Discrete data are
given as counts(percentages).
*Rutherford classification15

Procedure

In all patients, the intention was to treat iliac lesions via bilateral retrograde CFA catheterizations. After 5- to 7-F sheaths were placed into both CFAs, a 0.035-inch hydrophilic guidewire (Roadrunner; Cook, Bloomington, IN, USA) was inserted to cross the lesion, with or without the use of an angled 4- to 5-F diagnostic catheter. As soon as the guidewire was successfully advanced into the aorta, a 5-F flush catheter was placed proximal to the bifurcation, and a preprocedural angiogram was obtained. If a chronic iliac occlusion could not be crossed ipsilaterally, another guidewire and catheter were advanced contralaterally over the aortic bifurcation and across the lesion with a combined antegrade-retrograde approach using the wire-loop technique.16 When the lesions were crossed, 2 stents were advanced bilaterally over the guidewires, placed side by side in the aortic bifurcation, and implanted simultaneously (Fig. 1A,B ). Whenever possible, direct stenting was preferred over selective stenting. When necessary, however, predilation was performed with 4- to 5-mm balloon dilation catheters. The stent model and size were chosen based on lesion characteristics and availability; the same stent models were used on both sides. Self-expanding models included Wallstent (Boston Scientific, Natick, MA, USA; n=26), Memotherm (Bard Peripheral Vascular, Tempe, AZ, USA; n=23), and Smart (Cordis, a Johnson & Johnson company, Miami Lakes, FL, USA; n=3); the balloon-expandable stents used were AVE (Medtronic Vascular, Santa Rosa, CA, USA; n=10), Express LD (Boston Scientific; n=4), and Strecker (Boston Scientific; n=2). Postdilation was performed after implantation of all self-expanding stents.

In all patients, aspirin (300 mg/d) was started 1 week before the procedure and continued indefinitely. In patients with severe atherosclerosis of the abdominal aorta or distal runoff arteries, another antiaggregate agent (ticlopidine or clopidogrel) was also prescribed. During the procedure, 5000 units of unfractionated heparin were given intra-arterially, followed by a 500- to 1000-U/h intravenous infusion for 24 hours. If intra-arterial fibrinolysis was required during the recanalization, moderate intensity warfarin treatment (International Normalized Ratio 2 to 3) was given for 3 to 6 months.

Follow-up

The follow-up included clinical examination, measurement of ankle-brachial indices (ABI), and Doppler ultrasound imaging of the treated segments at 1, 3, 6, and 12 months after the procedure, and annually thereafter. Angiography was performed if the patient had recurrent symptoms, if the Doppler ultrasound revealed reobstruction, or if an endovascular intervention was indicated at other sites, such as in the carotid, renal, or femoral arteries. Restenoses and reocclusions were treated with balloon angioplasty and selective stenting. When soft thrombus was detected within a reocclusion, adjunctive intra-arterial fibrinolysis was performed.

Definitions

Technical success was defined as the absence of >30% residual stenosis on postprocedural angiography at the treated segment. Clinical success was defined as improvement by at least 1 category immediately after the intervention according to the Rutherford classification.15 Complications were defined as minor if no or only minor therapy with overnight observation was required or major when major therapy, prolonged hospitalization, or an unplanned increase in the level of care was necessary. “Greater than 50% stent crossing” indicated the overlap of the proximal ends of the kissing stents by >50% on anteroposterior control angiography.

Clinical, hemodynamic, and anatomical (angiographic) patencies were determined according to the definitions suggested by the TASC Working Group.15 In our study, although clinical examination and ABI measurement were routinely included in each follow-up control, patencies were based on angiography (if available) or Doppler ultrasound, since they are more specific to the lesion site.

Primary patency was defined as a patent stent without any reintervention. Primary assisted patency was defined as a patent stent after endovascular reintervention but without occlusion at any time. Secondary patency was defined as a patent stent after occlusion, with patency ending with an untreated or surgically treated occlusion.

Data Analysis

In our patients, primary, assisted primary, and secondary patency rates were determined on an intention-to-treat basis with a Kaplan-Meier analysis. In patients who died or were lost to follow-up, patency times were censured. A number of clinical and angiographic variables were assessed as potential risk factors for patency loss, including age, sex, smoking, diabetes, hypercholesterolemia, hypertension, coronary heart disease, >2 atherosclerotic risk factors, iliac occlusion, distal aortic diameter, crossing of kissing stents in the aorta, the amount of stent extension into the aorta, stent length, lesion length, self-expanding versus balloon-expandable stents, separate aortic stenoses, and runoff lesions. Whenever appropriate, continuous and categorical variables were stratified into 2 subgroups. These variables were then examined with univariate Cox proportional hazards model, and those with a significant effect on the primary, assisted primary, and secondary patency rates were later combined in a multivariate Cox model. The patency rates of the subgroups with and without statistically significant risk factors were determined with the Kaplan-Meier analysis and compared with the log-rank test. Calculations were done with SPSS/PC statistical software (version 11.5; SPSS, Chicago, IL, USA). For all analyses, p<0.05 was considered significant.

Results

Immediate Outcomes

Technical and clinical success was achieved in all patients. During the intervention, lesions were crossed ipsilaterally in 65 (96%) patients, while the wire-loop technique via crossover catheterization was required for chronic occlusions in 3 (4%). In most patients (64, 94%), direct stenting was performed, but 4 (6%) required predilation. Kissing stents were extended >2 cm into the aorta in 26 cases, while in 2, a separate stent was placed in the aorta, which was overlapped by the kissing stents (Table 2 ).

Table 2. Angiographic Characteristics in 68 Patients in Whom Aortoiliac Kissing Stents Were Implanted

Lesions  
   Bilateral stenoses 36(53%)
   unilateral stenosis 6(9%)
   Stenosis+oclussion 26(38%)
Lesion length,cm 2.3±1.3 (2.1-1.5; 1-6)
   >3-cm lesion length 28(41%)
Separate aortic stenoses 16(23%)
Narrow(<14-mm)distal aorta 22(32%)
Runoff lesions(total) 13(19%)
EIA stenosis 3(4%)
EIA occlusion 2(3%)
SFA stenosis 3(4%)
SFA occlusion 5(7%)
Stent legth,cm 4.9±2.4(4.5-5.3; 2-10)
   >5-stent legth 34(50%)
Stent type  
   Self-expanding Wallstent 26(38%)
   Self-expanding nitinol 26(38%)
   Balloon-expandable 16(24%)
>2cm stent extension into the aorta 26(38%)
>50% stent crossing in the aorta 28(41%)

Continuous data are presented as mean±standard deviation(95% confidence interval; range).Discrete data are
given as counts(percentages).
EIA: external iliac artery, SFA: superficial femoral artery.

Complications

Following the interventions, complications occurred in 8 (12%) patients; the 2 major complications were distal embolisms, which were treated with intra-arterial fibrinolysis, aspiration, and angioplasty via a separate antegrade access. Minor complications included 3 hematomas, 2 pseudoaneurysms, and 1 arteriovenous fistula. The hematomas were managed conservatively with prolonged manual compression, and the pseudoaneurysms and fistula were successfully treated with ultrasound-guided compression. No patient required surgery, and the 30-day mortality was zero.

Follow-up

Over a follow-up period of 35±31 months (range 3–132), 13 patients were lost to follow-up, and 7 patients died of cardiovascular or malignant disease with patent stents at 12 to 84 months. Restenoses were detected in 16 patients at 3 to 34 months and successfully treated with balloon angioplasty and selective stenting once (n=14) or twice (n=2). Occlusions were seen in 14 patients at 3 to 52 months (4 as a primary event, 10 after restenosis); in 3, the patients refused reintervention and underwent aortobifemoral bypass surgery. In the remaining 11 patients, reocclusions were successfully treated with balloon angioplasty and selective stenting once (n=9) or twice (n=2; Fig. 1C,D ). In 4 reocclusions, soft clot was seen during the recanalization and successfully treated with intra-arterial fibrinolysis. In all, 31 reinterventions of the aortoiliac region were performed in 20 patients during follow-up.

After kissing stents implantation, additional endovascular treatment was performed in 8 patients for stenoses in the internal carotid artery (n=3), renal artery (n=2), and superficial femoral artery (n=3). In these patients, control angiography of the aortoiliac region was also obtained in the same session. Thus, when all reinterventions and de novo interventions were considered, follow-up angiography was available in 35 (51%) patients.

Figure 1

In a 47-year-old patient with claudication at 100 m, the preprocedural angiogram (A) obtained by contrast injection through both sheaths shows a 3-cm right CIA occlusion (black arrows) and a 2-cm stenosis of the left CIA (open arrows). After simultaneous implantation of 2 balloon-expandable AVE stents, the postprocedural angiogram (B) shows good technical success. At 12 months, the patient complained of right-sided claudication, and the Doppler ultrasound revealed stent reocclusion on the right side. Angiography (C) was performed after the occlusion was crossed with a diagnostic catheter (open arrow); the stent on the right (black arrows) was occluded but the left stent was patent. In the same session, the reocclusion was successfully treated with another balloon-expandable Express LD stent (D). Both stents were patent on Doppler ultrasound at 24 months.

Patency Analysis

According to the Kaplan-Meier analysis (Fig. 2 ), the primary, assisted primary, and secondary patency rates were 76%, 90%, and 94%, respectively, at 1 year; 63%, 86%, and 92% at 3 years; and 63%, 64%, and 81% at 5 years.

With univariate Cox regression analysis (Table 3 ), a number of variables were demonstrated as risk factors for reduced primary, assisted primary, and secondary patency. Among them, female gender, age <50 years, and presence of iliac occlusion were identified as risk factors for all patency rates. In the multivariate Cox regression analysis, age <50 years, presence of iliac occlusion, and >50% stent crossing in the aorta were identified as significant risk factors for primary patency loss. For assisted primary patency loss, age <50 years and presence of an iliac occlusion were significant risk factors, whereas no variable was found statistically significant for reduced secondary patency.

In Kaplan-Meier analysis of patients below versus over 50 years of age, primary and assisted primary patency rates were 64% and 32%, respectively, at 1 year and 79% and 79% at 3 years in patients <50 versus 85% and 85%, respectively, at 1 year and 97% and 92% at 3 years in those >50, which were statistically significant (p=0.002 and p=0.0004 for primary and assisted primary patency rates, respectively). In the analysis of patients with iliac stenoses versus occlusion, primary and assisted primary patency rates at 1 and 3 years were 62% and 62% and 73% and 68%, respectively, in patients with occlusion versus 86% and 76% and 100% and 97%, respectively, in those with stenoses; again, these differences were statistically significant (p=0.0025 and p=0.0008 for primary and assisted primary patency rates, respectively).

Figure 2

Kaplan-Meier analyses of primary, assisted primary, and secondary patency rates after aortoiliac kissing stents implantation. SE: standard error, CI: confidence interval, Cum. events: cumulative events.

Table 3. Significant Risk Factors From Univariate and Multivariate Cox Regression Analyses for Reduced Primary, Assisted Primary, and Secondary Patency Rates Following Aortoiliac Kissing Stents Implantation

  Variables p β Exp(β) 95%
confidence
limit2
Primary Patency          
Univariate Age <50 years <0.00 -1.3 3.9 1.5-10.2
  Female gender <0.00 -1.7 5.6 1.8-17.6
  >2 atherosclerotic risk factors/patient <0.04 -1.4 0.2 0.1-0.9
  Iliac occlusion <0.00 -1.3 0.2 0.1-0.6
  ≥50% stent crossing in the aorta 0.01 -1.2 0.2 0.1-0.7
Multivariate Age <50 years <0.00 -1.4 0.2 0.1-0.6
  Iliac occlusion 0.03 -1.0 0.03 0.1-0.9
  ≥50% stent crossing in the aorta 0.01 -1.2 0.2 0.1-0.7
Assisted Primary Patency          
Univariate Age <50 years <0.00 -2.4 0.1 0.0-0.4
  Female gender 0.01 -2.0 0.1 0.0-0.7
  Continued smoking 0.04 -1.1 0.3 0.1-0.9
  Iliac occlusion <0.00 -1.8 0.1 0.0-0.5
Multivariate Age <50 years 0.02 -1.6 0.2 0.0-0.8
  Iliac occlusion 0.01 -1.8 0.1 0.0-0.7
Secondary Patency          
Univariate Age <50 years 0.01 -2.5 0.1 0.0-0.6
  Female gender <0.00 -2.7 0.1 0.0-0.4
  Iliac occlusion 0.04 -1.5 0.2 0.1-0.8
  >2-cm stent extension into aorta 0.04 -1.2 0.2 0.1-0.7
Multivariate no variable was found statistically significant        

β: regression coefficient, Exp(β): Exponential of β, 95%.

Discussion

Percutaneous transluminal angioplasty of the lesions located at the aortic bifurcation has long been considered as contraindicated because of the risk of occlusion and embolization to the contralateral side.4,7 With the initial utilization of double balloons4,5 and subsequent introduction of the kissing stents technique,6 such lesions can now be safely and effectively treated via the endovascular route.

The primary concern about kissing stents is the lack of contact between the vessel wall and the opposing stents, which may prevent endothelialization and cause thrombosis or hemolysis6 or induce intimal hyperplasia owing to variations in the wall shear stress.17 Despite these concerns, early results of aortoiliac kissing stents were quite promising.6–9 In the literature, we found 9 case series in which kissing stents were used for aortoiliac occlusive disease.6–14 There are, however, several problems with these studies, which makes it difficult to draw reliable conclusions regarding the outcome of kissing stents. First, the numbers of cases are relatively low; except for the series from Haulon et al.,14 which included 106 patients, the series typically involved 50 patients.6–13 Second, the follow-up period is relatively short; the mean/median follow-up period varies between 12 and 30 months. Third, the patency results are not uniformly reported; they are not applicable in 36,7,10 or not available beyond 3 years in 6.6–11 In only 1 study are the primary, assisted primary, and secondary patency rates presented.9

In the literature, the technical success of aortoiliac kissing stents implantation was reported to be 86% to 100%. Complications occurred in 0% to 16%, including hematoma, pseudoaneurysm, arteriovenous fistula, distal embolism, and aortoiliac dissection.6–14 In our series, the technical success (100%), complication rate (12%), and the type of complications were comparable to these studies. However, in our study, the follow-up period was longer, and all 3 patency rates are presented up to 5 years. Our primary patency rates vary between 76% and 63% at 1 to 5 years, which seem lower than those reported in previous series (79% to 92%).9,11–14 A number of factors may be responsible for this discrepancy, including the patency definition, patient selection, number of cases, and technical factors. Our assisted primary patency rates are 90% and 86% at 1 and 2 years, respectively, and are comparable to those of Mohamed et al.,9 who reported an assisted primary patency of 84% at 1 and 2 years. Our secondary patency rates vary between 94% and 81% over 5 years. Although these figures seem similar to those reported in previous series (84% to 100%), a reliable comparison is still difficult to make because of the differences in follow-up periods, patency definitions, and methods.9,11–14 Nonetheless, these results suggest that aortoiliac kissing stents implantation is associated with a low complication rate and an excellent immediate outcome. However, although earlier series reported patency rates comparable to surgery,11–13 our results show that the primary and assisted primary patency rates are inferior to those reported for surgery. In our study, the secondary patency rates are comparable to the primary patency rates of surgical treatment, but this has been achieved at the cost of 1 to 2 reinterventions performed in about 30% of the patients in our series.

In the literature, there are no data about the risk factors predicting patency loss after aortoiliac kissing stents implantation. In our study, patient age <50 years and presence of an iliac occlusion were found to be the most significant predictors of reduced primary and assisted primary patency. Patients <50 years have been reported to have lower patency rates after aortobifemoral bypass compared to older patients.18 In the study of Reed et al.,18 the 5-year primary patency rates were 66% in patients <50 years, 87% in those aged 50 to 59 years, and 96% in those >60 years. The authors indicated increased virulence of aortic disease, smaller aortic size, and more progressive infrainguinal disease as the responsible factors. Unlike its negative effect on surgery, younger age has not been found to be a significant risk factor for iliac artery stent placement in the study of Siskin et al.19 These authors reported that at 1, 2, and 3 years, the primary patency rates were 86%, 72%, and 65%, and the secondary patency rates were 90%, 88%, and 88%, respectively; these figures were found comparable to those reported for older patients. In contrast to the results of Siskin et al.,19 in our study, primary and secondary patency rates at 1 to 5 years were 64% to 32% and 86% to 43%, respectively, for kissing-stent patients who were <50 years of age; these figures were significantly lower than those for patients who were >50 (log rank 0.002 and 0.003, respectively). Further studies are required to clarify this controversy.

The presence of iliac occlusion was another significant predictor of primary and assisted primary patency loss in our study. In the literature, challenging technical success of iliac occlusions has long been a focus of interest, but the fate of iliac occlusions after successful endovascular treatment has not been well investigated. However, in a meta-analysis of aortoiliac angioplasty and stent placement in 1300 patients, Bosch and Hunink20 found that the primary patency rates were 77% for stenoses versus 61% for occlusions in claudicators and 67% for stenoses versus 53% for occlusions in patients with critical ischemia.

In our study, the primary and secondary patency rates at 1 to 5 years were 62% to 31% and 85% to 79%, respectively, for kissing-stent patients with occlusions; these figures were significantly lower than those for patients with stenoses (log rank=0.0025 and 0.04, respectively). Possible reasons for these differences in patency rates may be the increased atherosclerotic and thrombotic burden of occlusions, which necessitates higher dilating forces to obtain an optimal result and can induce more trauma to the vessel wall. In our study, the crossing of kissing stents over the aortic bifurcation has also been found to be a significant risk factor for reduced primary patency, although its significance was lost for the assisted primary and secondary patency rates. As reported by Saker et al.17 and Richter et al.,21 flow separation and wall shear stress variations caused by aortoiliac kissing stents may be associated with increased risk of thrombus and neointima formation. For this reason, it is generally recommended that whenever possible, the proximal ends of the stents should not extend more than 0.5 cm over the aortic bifurcation.17 These adverse effects of kissing stents on flow and wall shear stress may theoretically be augmented if they are placed in a crossing configuration in the distal aorta. In our experience, the degree of stent crossing seemed to be proportional to the length to which the kissing stents extended into the aorta, which is more likely to occur when the diameter of the distal aorta is tightly narrowed at the level of the bifurcation.

In the aortoiliac region, as elsewhere in the body, the type of stent is usually chosen based on lesion characteristics, location, vessel tortuosity, and the profile of the stent. Unavoidably, however, other factors, such as ease of deployment, familiarity of the physician, cost, and availability are also taken into consideration.22 In our patients, stent selection was primarily based on lesion characteristics; for long lesions, occlusions, or those located in tortuous vessels, we preferred self-expanding stents, while we used balloon-expandable stents for short, focal lesions or for eccentric, calcified lesions that are prone to recoil. For lesions that were suitable to either type of stent, other factors, such as cost and availability, influenced our decision. In the early years, we used the Wallstent more frequently because it was more popular at that time; the balloon-expandable stents were rigid and required a larger sheath, and the results of the nitinol stents were not yet available. Later, with the introduction of lower profile, more flexible balloon-expandable stents and increased worldwide experience with the nitinol stents, we used these stent models relatively more often. Covered stents have been proposed as a good alternative in complex iliac lesions because of their theoretical potential to decrease restenosis by excluding the plaque and endothelium, which may prevent migration and proliferation of cells through the stent struts.22,23 However, since this theoretical benefit has not yet been proved, and the device has a larger profile and higher cost compared to bare stents, we did not use covered stents in our patients.

Limitations

First of all, our series is not consecutive; only the patients who met the inclusion criteria underwent kissing stent implantation, which might bias the outcome. Second, because of its retrospective design, our study is subject to biases regarding the patients, lesions, and materials used. Third, although the patients were actively invited to follow-up examinations, there were still gaps in the surveillance of some patients, which may have affected our patency rates to a certain extent. Fourth, because of the relatively small number of patients, the value of our multivariate analysis may be limited. Therefore, our results should be regarded with caution.

Conclusion

The results of our study show that kissing stents implantation is a safe and effective alternative in the treatment of aortoiliac obstructions. The long-term patency is not significantly impaired in patients with distal runoff obstructions or in those with lesions up to 6 cm in length, as long as a favorable stent configuration is obtained. In patients >50 years and in those without iliac occlusions, the kissing stent technique should be preferred to surgery because the patency rates are comparable to surgery and the advantages of endovascular treatment are well known. In patients <50 years or in those with an iliac occlusion, the type of treatment should be chosen on an individual basis by weighing the relatively frequent need for reinterventions of kissing stents against the potential risks of surgery.

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Autor: Saim Yilmaz, MD; Timur Sindel, MD; Ilhan Golbasi, MD; Cengiz Turkay, MD; Atalay Mete, MD; and Ersin Lüleci, MD

Fuente: Journal of Endovascular Therapy

Ultima actualizacion: 5 DE JULIO DE 2006

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