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   Table of Contents - Current issue
April-June 2021
Volume 8 | Issue 2
Page Nos. 115-193

Online since Tuesday, April 13, 2021

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March of the vaccines Highly accessed article p. 115
Kalkunte R Suresh
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What they forgot to teach us at M school… Highly accessed article p. 117
Ilayakumar Paramasivam
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Management of vasculitis in pregnancy Highly accessed article p. 119
Nabnita Patnaik, Nihar Ranjan Pradhan
Vasculitis in pregnancy is a rare disease-modifying effect on autoimmune connective tissue diseases such as vasculitis and that connective tissue disease can have an adverse effect on pregnancy. It is essential that pregnant women with vasculitis are managed to the highest standards of care in order to prevent negative outcomes not only for the mother but also for the child. Vasculitis in pregnancy is probably underdiagnosed and under-reported; cases of vasculitis are rare and so disease flares may not always be recognized by a general clinician. Preconceptual counseling is critical, and assessment of disease activity, major organ involvement, and risk factors, such as hypertension and renal impairment, will help to guide both the woman and her clinicians as to the risks entailed in embarking on a pregnancy. Such patients are best catered for in multidisciplinary settings where there is access to specialized care from nephrologists, rheumatologists and respiratory medicine physicians, as well as obstetricians and pediatricians skilled in caring for complex pregnancies. This article aims to provide an approach to managing these patients with the best current evidence-based practice.
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Compliance with the use of compression stockings, experience from a tertiary center in Oman p. 122
Rahma AlHarthi, Edwin Stephen, Ibrahim Abdelhedy, Hanan AlMaawali, Khalifa AlWahaibi
Objectives: Compression stockings (CSs) are effective in the treatment of chronic venous and lymphatic diseases. Noncompliance with wearing them remains a hindrance to good results. This study aims to quantify the issue of noncompliance and to identify the reasons behind it. Methods: Over a period of 6 months, a set of questionnaire to assess the compliance to CSs was conducted on patients seen during their follow-up visits and of whom CSs were prescribed previously. Results: A total of 50 patients were recruited in this study. Females formed the majority of participants (76%), with a mean age of 42 years. The body mass index of our participants ranged between normal (18%), overweight (52%), and obese (30%). Most (78%) of our patients used CSs, while 22% did not. Duration of use ranged as follows: 40% of the patients used them for <2 weeks, 26% used them for 2–8 weeks, while 30% used them for >8 weeks. 71% of our patients encountered difficulty in finding appropriate CSs. Conclusions: Noncompliance with CSs is a true challenge. The reasons behind it start from difficulty in finding appropriate size/quality, to patient-related characteristics. These need to be frequently assessed by the prescribing doctor and addressed.
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Management of deep-vein thrombosis in pregnancy p. 125
Nabnita Patnaik, Nihar Ranjan Pradhan
Introduction: Pregnancy and puerperium are well-established risk factors for deep-vein thrombosis (DVT) and pulmonary embolism (PE), which are collectively referred to as venous thromboembolism (VTE). Objectives: Treatment of VTE in pregnant patients is unique in several ways. A subset of pregnant patients requires anticoagulation during pregnancy and/or in the postpartum period, including women at high risk of DVT and some women with fetal loss. Materials and Methods: It was a retrospective study of all DVT patients with pregnancy, referred to the vascular surgery department of a tertiary care hospital from December 2015 to November 2019. Results: A total of 56 DVT patients with pregnancy were admitted in the vascular surgery department during the above period. Sixteen of them had a past history of DVT in previous pregnancy. Thirty-two patients presented in the first trimester, 14 in the second trimester, and 10 in the third trimester of pregnancy. Eight of them had associated PE and managed with intensive care unit care. All patients were managed with long-term anticoagulant with low-molecular-weight heparin. Conclusion: Use of anticoagulants during pregnancy is challenging due to the potential teratogenic effects and dosing complexities of the various agents and the management of anticoagulation during the time of labor. The need for thromboprophylaxis should be assessed antepartum, postpartum, and at any time the patient transitions from the outpatient to the inpatient setting. When it is determined that thromboprophylaxis is warranted, an appropriate strategy should be selected and prescribed.
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Management of lower limb vascular injuries in a tertiary care centre: An Indian scenario p. 129
Ramneesh Garg, Rajinder K Mittal, Sheerin Shah Kathpal, Devika Rakesh
Context: Lower limb vascular trauma accounts for majority of peripheral vascular injuries. Delay in diagnosis and referral to higher centers in developing countries like India poses a major challenge with regard to optimum management of these vascular injuries. Aims: The aim was to study the time gap between injury and revascularization and the incidence of reperfusion injuries in patients presenting late to the hospital. Materials and Methods: This descriptive prospective study involved 51 patients who presented with clinical signs of vascular injury confirmed by handheld Doppler. In cases presenting late (more than 6 h), decision to proceed with revascularization versus primary amputation was based on distal muscle viability tested intraoperatively. All anastomosis were done under microscopic magnification with the use of venous graft wherever needed. Results: All 51 patients in the study were males with a mean age group of 32.6 years. Six patients underwent primary amputation. Road traffic accidents were the most common cause of injury with popliteal artery involvement in most cases. Of the total 45 patients who underwent revascularization, 25 patients (55.5%) presented within the golden period of 6 h and only five patients (11.1%) underwent revascularization within 6 h of injury despite which we had a limb salvage rate of 88.8%. Reperfusion injury was seen in 14 patients, vascular thrombosis in three patients and two deaths were reported. Conclusions: We thus recommend that decision to reperfuse the involved limb should not be solely based on the time elapsed but also on factors such as muscle viability and neurological status, especially in a country like India.
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Outcome of prosthetic arteriovenous graft in lower limb for hemodialysis: A series of 10 patients p. 134
Mohd Azam Haseen, Mayank Yadav, Sumit Pratap Singh, Renu Yadav
Background: The burden of chronic kidney disease and the incidence of end-stage renal disease in India are continuously increasing. For each of these patients, adequate vascular access for dialysis is essential for survival. Access to patients' blood can come in the form of a catheter, native arteriovenous fistula (AVF), or prosthetic graft. It is apparent that the number of new “incident” patients and “prevalent” patients will continue to increase, requiring stable forms of vascular access. An alternative to autologous AVF is placement of a synthetic vascular graft prosthesis. Methods: This is a retrospective study which aims to evaluate the outcome of 10 consecutive patients with arteriovenous grafts (AVGs) made for hemodialysis in patients with exhaustive veins/failed AVFs with central venous catheters (CVCs) in situ. Results: The mean age of patients in our study was 54 years. The primary patency rate of AVGs was 50% and 30%, whereas the secondary patency rate was found to be 80% and 60% at 6 months and 1 year, respectively. Conclusion: AVGs can be used as an alternative to AVFs with acceptable results.
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Retrograde mesenteric bypass with saphenous vein graft in chronic mesenteric ischemia in a resource-challenged setting p. 139
Anil Sharma, Sunil Dixit, Sourabh Mittal, Dhruva Sharma
Introduction: Chronic mesenteric ischemia is a pathophysiologic condition arising due to demand–supply mismatch of blood supply to bowel postprandially, resulting in chronic abdominal pain, food fear, and weight loss. The most common cause is atherosclerosis. Timely intervention in the form of mesenteric revascularization is the key to successful outcome. There are limited contemporary data on in-hospital outcomes of mesenteric revascularization via open versus endovascular therapy in a resource-challenged setting. Materials and Methods: This retrospective-prospective observational study included eight patients of chronic mesenteric ischemia who underwent open revascularization and were followed for a mean duration of 15 months. All patients were evaluated as per the institutional protocol, and retrograde mesenteric bypass with reverse saphenous vein graft was done in all cases. Outcomes were evaluated in terms of resolution of symptoms and confirmation of graft patency with duplex scan after 1 month and every 6 months thereafter. Results: Out of 8 patients, six patients were males. Predisposing factors for atheromatous diseases were present in all. All patients presented with postprandial abdominal pain and weight loss. Majority of patients ( n = 5) had involvement of all three mesenteric vessels (superior mesenteric artery, inferior mesenteric artery, and celiac axis). One patient was re-explored for bleeding in immediate postoperative period. One patient was admitted for small bowel obstruction in 1st month of follow-up after surgery and was managed conservatively. Two patients were lost to follow-up and six patients are symptom free and doing well on a close follow-up of 15 months. Conclusion: Open mesenteric revascularization, by reverse saphenous vein graft as conduit for bypass, performed by experienced surgeon gives promising results in terms of symptom-free duration and graft patency and can be preferred over endoscopic revascularization as a viable option in resource-challenged settings in developing nations.
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Factors affecting contralateral extremity following lower-extremity major amputation p. 144
B Nishan, K Sivakrishna, V Vishal Hudgi, VP Ahsan, Vivekanand
Objective: Lower-extremity amputation is performed in patients who are at risk due to acute limb ischemia (ALI), chronic limb-threatening ischemia (CLTI), and diabetic foot infections, yet the proportion of patients who progress to amputation of their contralateral extremity following major amputation is not well defined. This study determines the rate of subsequent minor or major amputation of a contralateral extremity. Methods: We conducted a retrospective review of patients undergoing lower-extremity major amputation at JIVAS from 2011 to 2015. Outcomes included the proportion of patients who underwent minor or major amputation of contralateral extremity for a follow-up of 3 years. Results: From 2011 to 2015 period, 113 patients underwent major lower-extremity amputation. The mean age of patients was 59.5 years. Seventy-five percent were male, 88% were diabetic, 69% were hypertensive, 19% had renal insufficiency, 35% had coronary artery disease, 15% were smokers, 31% presented with diabetic foot infections, 20% presented with ALI (four patients underwent contralateral major amputation within the same admission), and 48% presented with CLTI who underwent an initial major amputation. After ipsilateral major amputation, 54% had normal contralateral extremity (four patients had ALI and six patients had CLTI and underwent revascularization), 14% underwent contralateral minor amputation (toe/transmetatarsal), 4% underwent contralateral major amputation (below/above the knee), 6% lost to follow-up, and 19% were dead at follow-up for 3 years. In this study, there is no significant difference between factors (gender and comorbidities) affecting contralateral limb amputation in patients who underwent major amputation. Conclusions: Preexisting comorbidities and gender might not affect contralateral limb amputations in patients with major amputation. Good control of comorbidities in the follow-up and diligent foot care probably play a role in predicting contralateral limb amputations. Vascular surgeons should be alert, and close surveillance and counseling of patients should be followed to prevent subsequent amputation in their contralateral lower extremity.
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Randomized control trial to assess the efficacy of superoxide solution on wound healing p. 148
Ajith John George, Cecil T Thomas, Vasanth Mark Samuel, Pranay Gaikwad, Srujan Lam Sharma, Emmanuel Lazarus, Vimalin Samuel
Introduction: Chronic wounds are the bane of any healthy population, with widespread economic and mental repercussions. Various techniques have been described to improve wound healing which includes the debridement of unhealthy tissue, saline, sodium hypochlorite (Daikin's) solution dressings. Newer techniques described include silver-based solutions and superoxide gel solutions. Methods: The study was a double-blinded randomized control trial. Randomization was done on the same limb of each donor site. The sample size was 16 in each arm. All patients undergoing STSG were randomized into two groups, one receiving the superoxide gel solution to one random half of the wound and the other group receiving only regular dressings. The donor site was analyzed on Day 5, 7, and 9. The assessor was blinded from the solution used. The difference in the rate of healing, with time to epithelialization and granulation, was assessed. Results: The mean time to epithelialization in the superoxide gel group was 6.75 days and in the non-gel group was 8.35 days. The mean difference was 1.60 days, which was statistically significant. The mean time to granulation in the superoxide gel group was 5.89 days and in the non-gel group was 6.60 days. The mean difference was 0.71 days, which was not statistically significant. The intraclass correlation coefficient (ICC) was 0.699. Conclusion: There was a significant and faster rate of epithelialization in the superoxide gel group. A superoxide gel solution is a cheaper method to improve the rate of healing.
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Influence of body mass index on developing ulceration in patients with venous disease: A case–control study p. 151
Pearl Lal, Edwin Stephen, Prabhu Premkumar, Albert Abhinay Kota, Vimalin Samuel, Sunil Agarwal, Dheepak Selvaraj
Aim: The aim of this study was to assess the influence of body mass index (BMI) on the development of ulceration in patients with venous disease. We also analyzed other risk factors that might lead to the progression of disease to ulceration. Design: A prospective case–control study from January 2016 to June 2017. Materials and Methods: This study was conducted at the vascular surgery outpatient department of a tertiary care hospital in India. One hundred and thirty cases with an active or healed venous ulcer were compared with 130 controls with no ulceration. A questionnaire was administered to look at the factors that influence the risk of developing ulceration. The patients underwent a clinical examination and the clinical class of venous disease was documented using the Clinical, Etiological, Anatomical and Pathophysiological classification. The patient's height and weight were measured, and the BMI was calculated. Results: The mean BMI of the study population was 29.04. Nearly 38.8% of the 260 patients recruited were obese and another 38.8% were overweight. Nearly 35.4% of the cases and 42.3% of the controls were obese. About 45.5% of the obese patients had an active or healed ulcer. About 77.8% of the patients with recurrent ulcers were either overweight or obese. However, on comparing the BMI between the cases and controls, there was no statistically significant difference. On multivariate analysis, we found older age, male gender, deep-vein thrombosis, and prolonged periods of standing, to have a significant association with ulceration in venous disease. Conclusion: Our study suggests that there is no association between BMI and ulceration in patients with venous disease. Older age, male gender, deep-vein thrombosis, and periods of prolonged standing have a higher association with venous ulceration.
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Outcomes of infrapopliteal angioplasty in advanced diabetic ischemic foot ulcers p. 155
Jithin Jagan Sebastian, MK Ayyappan, Naveen Rajendra, Kapil Mathur, Arun Kumar, Athirath Reddy, Radhakrishnan Raju
Aims: Diabetic patients in India present late in advanced stages of tissue loss and isolated occlusive infrapopliteal disease. We aim to determine the outcomes of angioplasty in these patients with SINBAD score >3 and infrapopliteal disease presenting with critical limb-threatening ischemia (CLTI) and tissue loss. Materials and Methods: A prospective, observational, single-center study was carried out of diabetic patients with infrapopliteal occlusive disease who underwent angioplasty for CLTI and tissue loss. Transatlantic society consensus (TASC) - classification was used for staging. Ischemia and Peripheral Artery Calcium Scoring was used to assess peripheral calcium. The patients were followed up till their ulcer healed and then every six months. Results: A total of 73 diabetic patients underwent angioplasty for CLTI. 21.8% (16/73) all-cause mortality was seen during the study. The average age was 68.9 years with 78.9% males. The average time to presentation was 55 days. 61.3% of patients had TASC C or D lesions. Technical success was achieved in 94.5% of patients. 27.4% of patients underwent angioplasty of multiple tibial vessels. The mean duration of follow-up was 2 years. 62.5% of patients had their ulcers completely heal in 6 months. Six patients went on to have major amputation. The amputation-free period was 500 days in this patient group. Ulcer healing was found to be dependent on successful revascularization. Conclusion: Mortality is seen in 1 in 10 and morbidity in 1 in 5 patients. It is difficult to accurately prognosticate healing in these patients. Successful revascularization is the only factor affecting healing in these patients.
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Know the man who demystified the deep venous system p. 161
Albert A Kota
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Beyond the arch: Ocular manifestation in middle aortic syndrome p. 163
Ritu Bhatia
Middle aortic syndrome is a rare vascular disorder threatening life beyond the age of 40 years. We describe a rare case of atypical presentation of middle aortic syndrome in a 35-year-old female, diagnosed in the third decade of life. The patient was successfully treated with stent implantation; however, she developed vision disturbance in her right eye.
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Air in the aortic wall: A rare case of Clostridium septicum aortitis p. 167
Aniket Pradhan, Giordano Perin
An 81-year-old male presented to the emergency department with a 48-h history of central chest pain radiating to the back. Observations revealed hypoxia, tachycardia, and hypotension. Biochemistry revealed raised inflammatory markers (white cell count: 18.5 × 109/L and C-reactive protein: 62.5 mg/L) and reduced renal function (creatinine: 157 μmol/L and urea 10.2 mmol/L). Computed tomographic (CT) scan (CT aortogram) revealed the presence of air in a diseased thoracic and abdominal aorta wall with no evidence of aneurysm (A, B, and C). Wall thickening at the cecal pole was noted as well (D). A diagnosis of acute aortitis was made, and the patient was started on intravenous antibiotics. Blood cultures isolated Clostridium septicum. Follow-up CT aortogram performed at 2 weeks revealed a resolution of the pockets of air. Colonoscopy revealed the presence of a fungating cecal mass (adenocarcinoma) as a source of bacteremia leading to aortitis; further, staging identified the disease as nonresectable.
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Suprarenal inferior vena cava ligation: All is not lost p. 169
Vignesh Kumar, Vijayan Purushothaman, Dinesh Bagaria, Harshit Agarwal
Inferior vena cava (IVC) injuries account for about 25%–40% of abdominal vascular injuries. Blunt vena cava injury has a lower survival rate than penetrating injury. They may present with torrential bleed. In extreme cases, ligation of the IVC may have to be done as a damage control procedure. However, it is associated with significant morbidity and mortality, especially when the suprarenal IVC is ligated. It can lead to acute kidney injury and lower limb compartment syndrome. Suprarenal IVC ligation has been done in oncological resections, as it is a chronic disease that allows collateral vessel formation. However, there is a paucity of data on the ligation of the suprarenal IVC in acute trauma. We present a case of penetrating injury to the IVC which was managed initially by suprarenal IVC ligation, followed by synthetic interposition graft placement once the patient stabilized hemodynamically. The case highlights that this approach can be viable as a damage control procedure in exsanguinating patients.
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A peculiar case of iliac vein aneurysm p. 173
Rajeev Thilak Chellasamy, Hemachandren Munuswamy, BV Saichandran, Durga Prasad Rath
Venous abdominal aneurysm is a rare entity, especially at the iliac vein. This condition is very rare and is usually grave when the aneurysm ruptures. It requires immediate treatment, surgically or by endovascular technique, to prevent such complications. Most of the iliac vein aneurysm cases are associated with arteriovenous fistula (AVF). We report the case of a 33-year-old male who presented with iliac vein aneurysm secondary to AVF. He was treated surgically after a failed endovascular procedure. The venous aneurysm had numerous feeder vessels which were difficult to manage intraoperatively. It prompted us to ligate the common iliac artery and do grafting between the common iliac artery and the common femoral artery. Iliac vein aneurysm diagnosis requires precise clinical suspicion, and the treatment is based on patients' clinical presentation and radiological features. Use of appropriate imaging modalities facilitates a correct preoperative diagnosis which consequently improves the surgical outcome.
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Long-standing traumatic femoro-femoral arteriovenous fistula presenting with congestive cardiac failure after 35 years p. 176
Olugbenga Olalekan Ojo, Uvie Ufuoma Onakpoya, Anthony Olubunmi Akintomide, Anthony Taiwo Adenekan
Acquired arteriovenous fistulas (AVFs) could either be traumatic or iatrogenic, though a spontaneous etiology was described by Syme in 1831. Penetrating injuries from stab wounds account for a large proportion of civilian cases of traumatic AVFs. Chronic or long-standing AVFs are characterized by significant shunting of blood from the arterial to the venous system. We report a case of a large traumatic femoral AVF, presenting with features of congestive cardiac failure (CCF), in a 54-year-old male after a remote stab injury to the right groin. The patient had also developed signs of unilateral chronic venous insufficiency in the involved limb. Following clinical examination, duplex ultrasound, and computed tomography angiography, the diagnosis of chronic AVF was confirmed. He successfully underwent open surgical repair with a dramatic resolution of symptoms of CCF.
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Complex aortic aneurysm associated with multiple splanchnic arterial aneurysms and a giant coronary artery aneurysm: An endovascular nightmare p. 179
Nikhil Vilas Chaudhari, Varinder Singh Bedi, Sandeep Agarwal, Ajay Yadav, Ambarish Satwik, Apurva Srivastava
A 50-year-old male diabetic, hypertensive and chronic smoker presented with complex aortic, splanchnic aneurysms with impending rupture of iliac artery aneurysm, underwent coiling of celiac artery, internal iliac artery, and fenestrated/chimney endovascular aortic repair. One month later, the patient landed in an emergency due to bleeding complications of common hepatic artery and gastroduodenal artery aneurysms, which were managed successfully using endovascular techniques. The mayhem of progressive nature of the disease in the patient continued as he had left lower limb ischemia due to occlusion of the iliac artery and iliac limb of the aortic graft device as he continued to smoke. All of the above sequences of events occurred over a period of 5 years. He also developed a giant aneurysm of left anterior descending of 6.8 cm diameter, which had to be repaired by open surgical technique. The patient has been followed up for 6 years since his first presentation, and he was managed successfully from all the catastrophe of events using endovascular techniques. Giant coronary artery aneurysm with previous aneurysms at multiple sites is quite unusual and rare. Currently, there is no consensus regarding the clinical characteristics, diagnostic method, and the treatment of these cases.
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Parkes–weber syndrome: Rare but not uncommon – An experience from Oman p. 184
Ibrahim Al Kindi, Edwin Stephen, Ibrahim Abdelhady, Hanan Al-Mawaali, Rashid Al Sukaiti, Khalifa Al-Wahaibi
We present three cases that were seen at our tertiary care hospital in Oman over the past 18 months. The paucity of knowledge of Parkes–Weber syndrome had these three patients visit several centers nationally and internationally. Through this case series, the reader will be better informed about the presentation, diagnosis, and management of a not so uncommon disorder.
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Angiosarcoma secondary to primary upper limb lymphedema p. 187
Husam Bashir, Hussam alzaarir, Rizziki Abdellah, Adnane Benzirar, Omar El Mahi
Stewart–Treves syndrome (STS) is a rare entity with a poor prognosis defined as an angiosarcoma appearing in a specific clinical setting, in 90% of cases in a context of breast neoplasia. Herein, we report a rare case of STS of the upper limb as a complication of primary lymphedema. A 55-year-old male was referred for a large, reddish, necrotic multinodular tumor of rapid extension on the anterior aspect of the right forearm. A biopsy of the lesions was performed, confirming the diagnosis of angiosarcoma. The evaluation of tumor extension showed no distant metastasis. An amputation of the arm was performed. Angiosarcoma as a complication of primary lymphedema is a very rare entity with very poor prognosis.
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Iatrogenic subclavian artery cannulation: Implications and management p. 190
Joshi Thomas, Deepak Dwivedi, Debarshi Guha, Jagdeep Singh Bhatia
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Anthologies in vascular surgery-Part 5 p. 192

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