Peripheral Artery Stenosis Research Articles

Abstract P431: Renal Artery Stenosis Caused by a Bcr-Abl Tyrosine Kinase Inhibitor: Blood Pressure Response to Revascularization

Introduction: Bcr-Abl tyrosine kinase inhibitors (TKI) are first line agents for management of chronic myelogenous leukemia (CML). Amongst the second generation TKIs, which have less resistance and improved side effect profile, nilotinib and ponatinib have also been reported to be associated with vascular adverse events (VAEs), including systemic and peripheral arterial stenosis. We report on a patient with CML treated with ponatinib, who developed bilateral renal artery stenoses, difficult to control hypertension, and responded to revascularization. Case: A 55 year old man, with CML due to a Bcr-Abl truncating mutation diagnosed in 2007, was treated with ponatinib 45 mg daily starting in 2011, which induced a complete remission. He subsequently developed hypertension. Hypertension appeared angiotensin II-dependent as BP normalized on combination of candesartan 32 mg once daily and hydrochlorothiazide 25 mg once daily. This treatment was however associated with an increase in serum creatinine from 1.4 to 2.6 mg/dL. Consistent with our clinical suspicion, a computed tomography angiogram revealed bilateral renal artery stenosis. He eventually required bilateral renal artery angioplasty and stenting as the BP could not be controlled without renin-angiotensin system blockers despite using up 5 classes of BP lowering drugs. Furthermore, follow up imaging of renal arteries showed progressive renal artery stenosis bilaterally. He underwent angioplasty and stenting in the left renal artery and angioplasty of both the branches of the right main renal artery, which could not be stented because of the early branching. After 6 months, BP is within target with 8 mg candesartan, amlodipine 10 mg and bisoprolol 2.5 mg daily, and the renal function is stable (creatinine 1.1 mg/dL). Overall, in this case, renal artery angioplasty and stenting stabilized renal function and improved control of hypertension. Discussion: Second generation TKIs are associated with VAEs, including renal artery stenosis. Renal artery angioplasty and stenting stabilized renal function and improved control of hypertension in this case. Future research should clarify the mechanisms of VAEs with TKIs, natural history, and long term response to revascularization in this setting.

Standardized incidence ratio of peripheral arterial disease and aortic stenosis in genotyped familial hypercholesterolemia in Norway during 2001-2009

Standardized incidence ratio of peripheral arterial disease and aortic stenosis in genotyped familial hypercholesterolemia in Norway during 2001-2009

The Diagnosis and Treatment of Peripheral Arterial Vascular Disease.

In peripheral arterial occlusive disease (PAOD), arterial stenosis or occlusion impairs perfusion in the territory of the distal portion of the aorta and the iliac and leg arteries. In Germany, the prevalence of PAOD rises with age, reaching 20% among persons over age 70. This guideline was prepared by a collaboration of 22 medical specialty societies and two patient self-help organizations on the basis of pertinent publications that were retrieved by a systematic search in PubMed for articles that appeared from 2008 to April 2014, with a subsequent update to May 2015. 294 articles were assessed, including 34 systematic reviews and 98 randomized controlled trials (RCTs). The diagnostic assessment of PAOD is based on physical examination, blood pressure at the ankles, and color-coded duplex ultrasonography (grade A recommendation). Other tomographic imaging methods can be used for suitable indications. The main elements of the treatment of PAOD are the control of cardiovascular risk factors and structured vascular exercise (grade A recommendation). Acetylsalicylic acid and statins are the main drugs for symptomatic PAOD (grade A recommendation). Patients with claudication and correlated structural findings can undergo an endo - vascular or open surgical procedure. Critical ischemia is an indication for arterial revascularization as soon as possible (grade A recommendation); this may be performed either by open surgery or by an endovascular procedure of one of the types that are now undergoing rapid development, or one of the crural treatment options. There is inadequate evidence concerning the optimal drug regimen after revascularization procedures. The diagnostic assessment of PAOD is based on physical examination, measurement of the ankle-brachial index (ABI), and duplex ultrasonography. Acetylsalicylic acid and statins are indicated for patients with symptomatic PAOD. Endovascular procedures should be used if indicated. Randomized studies are needed to provide better evidence on many open questions in the treatment of PAOD.

Non-contrast-enhanced MR angiography in critical limb ischemia: performance of quiescent-interval single-shot (QISS) and TSE-based subtraction techniques.

The aim of this study was to evaluate diagnostic performance of non-contrast-enhanced 2D quiescent-interval single-shot (QISS) and 3D turbo spin-echo (TSE)-based subtraction magnetic resonance angiography (MRA) in the assessment of peripheral arteries in patients with critical limb ischemia (CLI). Nineteen consecutive patients (74% male, 72.8 ± 9.9years) with CLI underwent 2D QISS and 3D TSE-based subtraction MRA at 1.5T. Axial-overlapping QISS MRA (3mm/2mm; 1 × 1mm2) covered from the toes to the aortic bifurcation while coronal 3D TSE-based subtraction MRA (1.3 × 1.2 × 1.3mm3) was restricted to the calf only. MRA data sets (two readers) were evaluated for stenosis (≥50%) and image quality. Results were compared with digital subtraction angiography (DSA). Two hundred and sixty-seven (267) segments were available for MRA-DSA comparison, with a prevalence of stenosis ≥50% of 41.9%. QISS MRA was rated as good to excellent in 79.5-96.0% of segments without any nondiagnostic segments; 89.8-96.1% of segments in 3D TSE-based subtraction MRA were rated as nondiagnostic or poor. QISS MRA sensitivities and specificities (segmental) were 92% and 95%, respectively, for reader one and 81-97% for reader two. Due to poor image quality of 3D TSE-based subtraction MRA, diagnostic performance measures were not calculated. QISS MRA demonstrates excellent diagnostic performance and higher robustness than 3D TSE-based subtraction MRA in the challenging patient population with CLI. • QISS MRA allows reliable diagnosis of peripheral artery stenosis in critical limb ischemia. • Robustness of TSE-based subtraction MRA is limited in critical limb ischemia. • QISS MRA allows robust therapy planning in PAD patients with resting leg pain.

DIABETES MELLITUS IS A CARDIOVASCULAR DISEASE (CVD) RISK EQUIVALENT FOR PERIPHERAL ARTERIAL DISEASE AND CAROTID ARTERY STENOSIS

Diabetes Mellitus (DM) is associated with significantly increased risk of peripheral arterial disease (PAD) and carotid artery stenosis (CAS). Guidelines have classified DM as a coronary artery disease (CAD) risk equivalent. Whether DM is a CVD risk equivalent for vascular disease phenotypes such as

Bilateral Photoplethysmography Analysis for Peripheral Arterial Stenosis Screening With a Fractional-Order Integrator and Info-Gap Decision-Making

Peripheral arterial disease and atherosclerosis are common complications in patients with type 2 diabetes or with both diabetes and end-stage renal disease. Lower-limb peripheral arterial disease and hemodialysis (HD) vascular access stenosis are highly prevalent in HD patients; in particular, progressively narrowed vascular access and suboptimal dialysis blood flows are the major issues. In this paper, we propose a fractional-order integrator (FOI) for indicating the differences in the rise-timing and amplitudes of bilateral photoplethysmography (PPG) signals with the aim of improving HD healthcare. The area under the systolic peak ratio was used as an index to separate the patients without arterial stenosis from those with arterial stenosis; subsequently, info-gap decision making was conducted to evaluate risk levels in reference to the patients’ health records and the degrees of stenosis. The experimental results indicated that in comparison with 1) the resistive index; 2) bilateral timing parameters; and 3) the hybrid intelligent method, our proposed screening model was more efficient in preventing complications of peripheral arterial stenosis and was easily implemented in an embedded system.

Numerical modeling of compensation mechanisms for peripheral arterial stenoses

The goal of this paper is to develop a numerical model for physiological mechanisms that help to compensate reduced blood flow caused by a peripheral arterial stenosis. Thereby we restrict ourselves to the following compensation mechanisms: Metabolic regulation and arteriogenesis, i.e., growth of pre-existing collateral arteries. Our model is based on dimensionally reduced differential equations to simulate large time periods with low computational cost. As a test scenario, we consider a stenosis located in the right posterior tibial artery of a human. We study its impact on blood supply for different narrowing degrees by the help of numerical simulations. Moreover, the efficiency of the above compensation mechanisms is examined. Our results reveal that even a complete occlusion of this artery exhibiting a cross-section area of 0.442cm2 can be compensated at rest, if metabolic regulation is combined with collateral arteries whose total cross-section area accounts for 8.14% of the occluded artery.

National characteristics and predictors of neurologic 30-day readmissions.

To examine national 30-day readmission rates for patients hospitalized with neurologic disorders. Using the University HealthSystem Consortium (UHC) database, we identified 554,399 index neurologic admissions from October 2011 through January 2015. We collected information regarding age, race, insurance payer, Medicare severity diagnosis-related group, and severity of illness. We examined readmission by diagnosis and performed multivariable logistic regression to determine predictors of readmission. The unplanned readmission rate was 11.0%. Rates of unplanned readmission were highest for patients with peripheral nerve disorders (21.9%), CNS neoplasms (21.0%), nonhypertensive encephalopathy (15.5%), arterial stenosis (15.4%), and bacterial CNS infections (14.5%). In multivariable analysis, higher severity of illness and public health insurance coverage predicted higher rates of 30-day readmission. We found significant variation in readmission rates for different neurologic disorders. These data provide insight into management of neurologic disease nationally, offering policymakers realistic goals for standards of care and challenging health care providers to develop systems-based solutions that will improve transitions of care for those at highest risk of readmission with neurologic disease.

Whole-Body MR Imaging Including Angiography: Predicting Recurrent Events in Diabetics.

Whether whole-body MRI can predict occurrence of recurrent events in patients with diabetes mellitus. Whole-body MRI was prospectively applied to 61 diabetics and assessed for arteriosclerosis and ischemic cerebral/myocardial changes. Occurrence of cardiocerebral events and diabetic comorbidites was determined. Patients were stratified whether no, a single or recurrent events arose. As a secondary endpoint, events were stratified into organ system-specific groups. During a median follow-up of 70 months, 26 diabetics developed a total of 39 events; 18 (30%) developed one, 8 (13%) recurrent events. Between diabetics with no, a single and recurrent events, a stepwise higher burden was observed for presence of left ventricular (LV) hypo-/akinesia (3/28/75%, p < 0.0001), myocardial delayed-contrast-enhancement (17/33/63%, p = 0.001), carotid artery stenosis (11/17/63%, p = 0.005), peripheral artery stenosis (26/56/88%, p = 0.0006) and vessel score (1.00/1.30/1.76, p < 0.0001). After adjusting for clinical characteristics, LV hypo-/akinesia (hazard rate ratio = 6.57, p < 0.0001) and vessel score (hazard rate ratio = 12.29, p < 0.0001) remained independently associated. Assessing organ system risk, cardiac and cerebral MR findings predicted more strongly events in their respective organ system. Vessel-score predicted both cardiac and cerebral, but not non-cardiocerebral, events. Whole-body MR findings predict occurrence of recurrent events in diabetics independent of clinical characteristics, and may concurrently provide organ system-specific risk. • Patients with long-standing diabetes mellitus are at high risk for recurrent events. • Whole-body MRI predicts occurrence of recurrent events independently of clinical characteristics. • The vessel score derived from whole-body angiography is a good general risk-marker. • Whole-body MRI may also provide organ-specific risk assessment. • Current findings may indicate benefits of whole-body MRI for risk stratification.

Serum biomarkers VEGF-C and IL-6 are associated with severe human Peripheral Artery Stenosis.

BackgroundEmerging reports propose possible biomarkers that are related to inflammation, nutrition and lipid parameters for detection of the progression of atherosclerotic plaques, peripheral artery disease (PAD) and particularly peripheral artery stenosis (PAS). However, it remains unclear which biomarkers in serum are associated with the severity of PAS.FindingsIn this study, we measured serum levels of inflammatory biomarkers along with lipid and nutritional parameters in 53 patients who suffered different degrees of PAS. Serum concentrations of vascular endothelial growth factor-c (VEGF-C) and IL-6 (Interleukin 6) were significantly increased in patients showing moderate or severe PAS. Furthermore, the number of blood monocytes from PAS patients was significantly increased, which showed elevated adhesion to plate-coated fibrinogen. Compared to healthy subjects, freshly isolated or LPS (lipopolysaccharide)-stimulated blood monocytes from PAS patients could produce VEGF-C and IL-6 at higher levels.ConclusionsOur study suggests that the increased number of blood monocytes might play key roles during the development of severe PAS, which enhance adhesion at the local narrowed peripheral artery and secret high levels of VEGF-C and IL-6. We suggest that serum concentrations of VEGF-C and IL-6 might be used as biomarkers for diagnosis severe PAS in combination with clinical imaging examination.Electronic supplementary materialThe online version of this article (doi:10.1186/s12950-015-0095-y) contains supplementary material, which is available to authorized users.

Reliability and Accuracy of Simple Visual Estimation in Assessment of Peripheral Arterial Stenosis

PurposeTo evaluate reliability, accuracy, and agreement of simple visual estimation (SVE) in determining the degree of peripheral arterial stenosis compared with calibrated measurements. Materials and MethodsIn 2 sessions, 23 interventionists with a wide range of experience and subspecialty training reviewed 42 angiographic images of lower extremity and carotid arteries (21 iliofemoral arteries and 21 carotid arteries). An independent physician measured all lesions using manual calipers. Intrarater and interrater reliability were assessed by intraclass correlation. A ± 5% error was considered the threshold for accuracy, and weighted κ statistics were computed to assess agreement with respect to the degree of stenosis (< 50%, nonsignificant; 50%–80%, significant; > 80%, severe). ResultsIntrarater reliability of SVE was 0.99, and interrater reliability was 0.83. Accuracy varied from 52.8% for images of severe stenosis to 26.5% and 18.1% for significant and nonsignificant stenosis, respectively (P < .001). Agreement between SVE and caliper with regard to degree of stenosis was good (weighted κ 0.56) overall with correct classification ranging from 92.6% for severe stenosis to 53.4% and 68.2% for significant and nonsignificant stenosis, respectively (P < .001). Misclassification of nonsignificant and significant stenosis was more frequent for carotid arteries than for lower extremities. ConclusionsDespite high reliability, SVE of peripheral arterial stenosis has limited accuracy in determining the exact degree of stenosis. Although severe stenosis is readily identified by SVE, arterial stenosis of < 80% is frequently overestimated, especially for carotid arteries, and should be confirmed by caliper assessment.

Carotid artery stenosis and coronary artery disease coincidence

Cerebrovascular event is one of the important causes of death in the world. Carotid artery stenosis is one of main risk factors of cerebrovascular events. Risk factors for atherosclerosis are found in carotid artery stenosis. Thus, coincidence of coronary artery disease and carotid artery stenosis were observed. In an individual with high risk of coronary artery plaque formation, peripheral artery stenosis is imaginable. Histological morphology and plaque formation in coronary artery disease and carotid artery stenosis are similar and they occur together most of the time. Although many similar findings were shown in coronary artery disease and carotid artery stenosis, carotid artery stenosis is associated with more severe stenosis compare with coronary artery disease. Carotid artery stenosis does not have exact similar biological activity with coronary artery disease.Some invasive and non-invasive diagnostic methods are established for carotid artery stenosis detection.Same medical and surgical treatment techniques could be used for carotid artery stenosis management that vary due to patient-to-patient specific conditions.

Diagnostic accuracy of dual energy CT angiography in patients with diabetes mellitus

Peripheral arterial disease (PAD) represents a major and highly prevalent complication in patients with diabetes mellitus. The diagnostic, non-invasive work-up by computed tomography angiography (CTA) is limited in the presence of extensive calcification. The aim of the study was to determine the diagnostic accuracy of dual energy CTA (DE-CTA) for the detection and characterization of PAD in patients with diabetes mellitus. In this study 30 diabetic patients with suspected or known PAD were retrospectively included in the analysis. All subjects underwent DE-CTA (Somatom Definition Flash, Siemens Healthcare, Erlangen, Germany) prior to invasive angiography, which served as the reference standard. Blinded analysis included assessment of the presence and degree of peripheral stenosis on curved multiplanar reformatting (MPR) and maximum intensity projections (MIP). Conventional measures of diagnostic accuracy were derived. Among the 30 subjects included in the analysis (83% male, mean age 70.0 ± 10.5 years, 83% diabetes type 2), the prevalence of critical stenosis in 331 evaluated vessel segments was high (30%). Dual energy CT identified critical stenoses with a high sensitivity and good specificity using curved MPR (100% and 93.1%, respectively) and MIP images (99% and 91.8%, respectively). In stratified analysis, the diagnostic accuracy was higher for stenosis pertaining to the pelvic and thigh vessels as compared with the lower extremities (curved MPR accuracy 97.1% vs. 99.2 vs. 90.9%; respectively, p < 0.001). The use of DE-CTA allows reliable detection and characterization of peripheral arterial stenosis in patients with diabetes mellitus with higher accuracy in vessels in the pelvic and thigh regions compared with the vessels in the lower legs.

New hybrid reformations of peripheral CT angiography: do we still need axial images?

PurposeTo quantify the detectability of peripheral artery stenosis on hybrid CT angiography (CTA) reformations. MethodsHybrid reformations were developed by combining multipath curved planar reformations (mpCPR) and maximum intensity projections (MIP). Fifty peripheral CTAs were evaluated twice: either with MIP, mpCPR and axial images or with hybrid reformations only. Digital subtraction angiography served as gold standard. ResultsUsing hybrid reformations, two independent readers detected 88.0% and 81.3% of significant stenosis, respectively. However, CTA including axial images detected statistically significant more lesions (98%). ConclusionPeripheral CTA reading including axial images is still recommended. Further improvement of these hybrid reformations is necessary.

Extracardiac manifestation of elevated lipoprotein(a) levels--cumulative incidence of peripheral arterial disease and stenosis of the carotid artery

Elevated lipoprotein(a) (Lp(a)) levels are an accepted risk factor for coronary heart disease. The role of Lp(a) in the development of extracardiac arteriosclerosis like peripheral arterial disease (PAD) and stenosis of the arteria carotis (ACIS) has hardly been documented so far. We aimed to investigate the incidence of extracardiac arteriosclerosis in individuals with elevated Lp(a) values. In our center, we measured Lp(a) levels in 31,734 consecutive patients over 5 years. Of these, 1411 patients were selected retrospectively for the presented analysis. Patients were matched according to age, sex, and other accepted cardiovascular risk factors and were assigned to 6 groups according to their Lp(a) values. Retrospectively, we analysed the incidence of PAD and ACIS. In the group with Lp(a) values <2mg/dl the incidence of PAD was 1.9% (ACIS 2.8%), in the group with Lp(a) 23-29mg/dl 7.3% (6.1%), 30-60mg/dl 9.0% (8.3%), 60-91mg/dl 11.4% (7.9%), 91-110mg/dl 8.6% (6.0%) and >110mg/dl 12.7% (10.9%). None of the patients had LDL levels >130mg/dl or HbA1c 6.1%. Elevated Lp(a) levels seem to be associated with an increased incidence of PAD and ACIS. Even Lp(a) concentrations between 23 and 29mg/dl show a threefold increased risk of PAD when compared to patients with Lp(a) <2mg/dl. However, these findings have to be verified in large prospective studies. In this context cut-off values have to be reevaluated as well.

Peripheral arterial stenosis and coronary artery disease coincidence

Atherosclerosis is a chronic slow-developing condition affecting medium-size and large blood vessels. It is the principal underlying pathology of coronary heart disease and stroke. In some countries, coronary artery disease (CAD) is the cause of nearly half (48%) of the deaths and, loss of productivity life. Peripheral arterial disease (PAD) is defined as atherosclerosis in peripheral arteries instead of coronary arteries. CAD and PAD have same risk factors and underlying pathophysiological processes. Therefore, patient with CAD should be considered for PAD. Ankle brachial index (ABI), duplex sonography, and some other non-invasive techniques are recommended for PAD diagnosis in patients with the history of CAD. Pharmacotherapy, endovascular interventions, and surgical management could be chosen according to the patient’s situation. Cardiologists and general practitioners should consider PAD in a patient with CAD or DM as a strong correlated disease.

Site-specific association between distal aortic pulse wave velocity and peripheral arterial stenosis severity: a prospective cardiovascular magnetic resonance study.

BackgroundVascular disease expression in one location may not be representative for disease severity in other vascular territories, however, strong correlation between disease expression and severity within the same vascular segment may be expected. Therefore, we hypothesized that aortic stiffening is more strongly associated with disease expression in a vascular territory directly linked to that aortic segment rather than in a more remote segment. We prospectively compared the association between aortic wall stiffness, expressed by pulse wave velocity (PWV), sampled in the distal aorta, with the severity of peripheral arterial occlusive disease (PAOD) as compared to atherosclerotic markers sampled in remote vascular territories such as PWV in the proximal aorta and the normalized wall index (NWI), representing the vessel wall thickness, of the left common carotid artery.MethodsForty-two patients (23 men; mean age 64±10 years) underwent velocity-encoded cardiovascular magnetic resonance (CMR) in the proximal and distal aorta, whole-body contrast-enhanced MR angiography (CE-MRA) and carotid vessel wall imaging with black-blood CMR in the work-up for PAOD. Strength of associations between aortic stiffness, carotid NWI and peripheral vascular stenosis grade were assessed and evaluated with multiple linear regression.ResultsStenosis severity correlated well with PWV in the distal aorta (Pearson rP=0.64, p<0.001, Spearman rS=0.65, p<0.001) but to a lesser extent with PWV in the proximal aorta (rP=0.48, p=0.002, rS=0.22, p=0.18). Carotid NWI was not associated with peripheral stenosis severity (rP=0.17, p=0.28, rS=0.14, p=0.37) nor with PWV in the proximal aorta (rP=0.22, p=0.17) nor in the distal aorta (rP=0.21, p=0.18). Correlation between stenosis severity and distal aortic PWV remained statistically significant after correction for age and gender.ConclusionsDistal aortic wall stiffness is more directly related to peripheral arterial stenosis severity than markers from more remote vascular territories such as proximal aortic wall stiffness or carotid arterial wall thickness. Site-specific evaluation of vascular disease may be required for full vascular risk estimation.

Standards of the Polish Ultrasound Society - update. Ultrasound examination of the aorta and arteries of the lower extremities.

A Doppler ultrasound examination has an advantage over other vessel imaging methods as it can be carried out by the patient's bedside and allows to make a diagnosis without exposing the patient to the inconveniency of transportation or an X-ray scan. The purpose of testing the lower extremities and the aorta is to objectively confirm a preliminary clinical diagnosis, localize lesions responsible for the symptoms of the disease, determine their severity and nature (e.g., if they are calcifications or soft lesions), and finally evaluate the hemodynamic criteria. In assessment of the aorta attention is paid not only to aortic diameter measurements, but also to the vascular lumen (dissections with the formation of two flow channels, detachments, balloting of atherosclerotic plaques, etc.) and the presence of atherosclerotic plaques with influx into them (PAU – penetrating ulcer in the plaque or lesions surrounding the aorta, such as retroperitoneal fibrosis or mycotic aneurysm). A correct diagnosis of an abdominal aortic aneurysm requires repeated measurements of the abdominal aorta diameter, and in particular its transverse dimension. When assessing the degree of peripheral arterial stenosis on the basis of hemodynamic parameters, degree of morphological stenosis must be taken into consideration. Collateral circulation may reduce the flow through the main vessel, and thus, the achieved systolic velocities are lower and may understate the degree of the assessed stenosis. Calf vessels are difficult to detect, which results both from the thickness of the muscle and the presence of calcifications. This article has been prepared on the basis of Standards of the Polish Ultrasound Society (2011) and updated on the basis of the latest reports from relevant literature.

Application of artificial palpation in vascular surgeries for detection of peripheral arterial stenosis

Palpation is one of the applied methods that surgeons usually use during surgery in order to verify the health condition of a tissue/organ. In fact, most of surgical assessments are based on analysis of the force feedback received from tissue/organ via palpation. Although palpation has a key role in efficient progress of surgery operations, it depends very much on the experience and skill of the surgeons. This limits the application of this technique in some cases to a large extent. In this regard, an artificial tactile sensing approach is an innovative technology that tries to make tactile data more available for surgeons, especially in situations where doing the palpation is not possible or is too difficult. In this paper, having considered the present problems of artery bypass surgery in peripheral arterial occlusive disease (PAOD), applicability of a new tactile sensory system capable of detecting arterial stenosis during surgery was evaluated. Presenting the modelling and numerical solution of the problem, it was demonstrated that the artificial tactile sensing approach is not only capable of detecting the presence of an arterial stenosis in an artery, but also its type. Furthermore, it was shown that the new tactile sensory system (previously designed, fabricated and tested in laboratory) is efficiently capable of detecting the simulated artery in the simulated biological tissue as well as diagnosis of the stenosis occurred inside it.

Abstract No. 418 - Accuracy of simple visual estimation in grading peripheral arterial stenosis- is eyeballing enough?

Abstract No. 418 - Accuracy of simple visual estimation in grading peripheral arterial stenosis- is eyeballing enough?