vertebral artery occlusion treatment

Found insideStroke provides a timely and user-friendly manual, covering common and important topics in the diagnosis and treatment of stroke, which clinicians can utilize when they encounter difficult patients on the ward or in the clinic. Enter multiple addresses on separate lines or separate them with commas. In our series, we also found differences in the location of the lesions compared with other studies.4-7,12 Although the literature reports a preponderance of involvement of the vertebral artery below C5, we found a greater frequency of lesions between C2 and C5 (38.8%). Acute vertebrobasilar artery occlusion is a serious condition with high mortality rates that range from 80 to 95% (1). We suspect that patients' self-reports might be more accurate and occur earlier than indications from angiography in reflecting whether the microwire is in the true lumen. Vertebral artery traumatic lesions can be classified either as dissecting, thrombotic, pseudoaneurysm, or arteriovenous fistula (AVF). Although sufficient hemodynamic protection is at least anticipated, it may not completely prevent the ruptured dissecting aneurysm from rebleeding. This book will comprise eight main sections: (1) The Basics, (2) Arteries of the Head and Neck (3) The basics of Intracranial Arteries (4) Diseases of the vessels (5) Stroke Imaging (6) Veins Imaging (7) Spine Imaging (8) Pediatrics. The patient recovered well with ventricular drainage and rehabilitation. We do not capture any email address. The modified Rankin Scale (mRS) and NIHSS scores were applied before endovascular treatment, at discharge and at follow-up. A Gateway balloon was placed in the lesion and inflated, and then a balloon expanding Apollo stent (MicroPort Medical, Shanghai, China) or a self expanding nitinol Wingspan stent (Stryker Neurovascular, USA) was released across the stenotic lesion. This article has not yet been cited by articles in journals that are participating in Crossref Cited-by Linking. B, Uncovered stent deployment with coiling (arrowheads) was performed. Despite a high restenosis rate of 55% and an in-stent occlusion rate of 10%, all patients were without new neurological deficit or MRI changes at the follow-ups. Vertebrobasilar insufficiency (VBI) is defined by inadequate blood flow through the posterior circulation of the brain, supplied by the 2 vertebral arteries that merge to form the basilar artery. Bouslama M, Haussen DC, Aghaebrahim A, Grossberg JA, Walker G, Rangaraju S, et al. Endovascular revascularization of chronic symptomatic vertebrobasilar occlusion. C, Angiogram obtained 6 months after double stent placement demonstrates complete healing of the aneurysm with restoration of the normal lumen. Five patients were treated with single stent placement alone in our series; however, none of them showed complete occlusion of the aneurysm on post-treatment or follow-up angiograms. A prior study by our group has reported carotid-vertebral artery bypass with saphenous vein grafts for symptomatic V1 segment occlusion (18). First, stent placement across the aneurysm can alter the inflow within the aneurysm, promoting intra-aneurysmal stasis; however, immediate postprocedural angiograms after double stent placement did not reveal complete obliteration of the dissecting aneurysm.12,13 Furthermore, it took a long time for the aneurysm to be completely obliterated. Heparinization was discontinued 24 hours after treatment but was not reversed. However, the efficiency of stent placement alone for intracranial vertebral artery dissecting aneurysm was limited. In 7 patients with ischemic stroke, there were no instances of postprocedural ischemic attacks, new neurologic deficits, or minor or major strokes during the follow-up periods of 6 to 40 (mean 28.5) months. Every few years a dissertation comes to the area of clinical application of medical technology which carries us forward as on a magic carpet into new regions of understanding and patient care. This book is such a magic carpet. The NIHSS scores and mRS scores were compared between pre- and post-endovascular treatment groups and in the follow-up period. Endovascular treatment may be a useful option for ruptured intracranial vertebral artery dissecting aneurysms. New-generation aspiration devices with larger bores and stronger suction force might be useful in clearing the thrombus from the proximal part of the original stenosis (24); however, we speculate that there could be many thrombi in the distal part of the stenoses due to the absence of continuous perfusion, and the aspiration catheter should not be placed over the original stenotic part to aspirate the distal thrombus as this would be dangerous and might result in dissection or thrombus translocation. J Neuroradiol. The torn, exposed endothelium promotes platelet aggregation and thrombus formation. The indications used to focus on arterial dissection included the presence of transient ischemic deficits (TIAs) or vertebrobasilar insufficiency (VBI) despite anticoagulant or antiplatelet therapy, contraindication to anticoagulant, contralateral vertebral occlusion or stenosis in a patient who was neurologically unstable or had clinical evidence of hemodynamic insufficiency, and documented poor collateral circulation. The inclusion criteria for recanalization treatment were as follows: (1) patient age >18 years and <80 years; (2) the patient had evidence of infarctions related to intracranial vertebral artery distribution on MRI; (3) the patient was in an early non-acute stage of intracranial vertebral artery occlusion; (4) the unilateral or dominant intracranial vertebral artery was completely occluded together with total occlusion, hypoplasia, absence, or severe (≥70%) stenosis of the contralateral vertebral artery; (5) the patient had severe neurological manifestations refractory to maximal medical therapy, including double antiplatelet therapy plus a statin use and management of risk factors (e.g., smoking, drinking, diabetes, hyperlipidemia and hyperhomocysteinemia); (6) the patient had at least one atherosclerotic risk factor; and (7) the grade of collateral flow was ≤3 (according to the modified grading system of the American Society of Interventional and Therapeutic Neuroradiology) (9). MRI, magnetic resonance imaging; FLAIR, fluid-attenuated inversion recovery; PCOM, posterior communicating artery; PCA, posterior cerebral artery; BA, basilar artery; MRA, magnetic resonance angiography. B, Angiogram obtained immediately after double stent placement demonstrates partial resolution of the aneurysm. However, these lesions can have ischemic symptoms of vertigo, diplopia, and cephalgia secondary to arterial steal. A 6F guiding catheter was placed in the V2 segment of the vertebral artery, and then a microwire was advanced through the stenotic lesion. The other patient (patient 13) with persistent headache was able to carry out all usual duties and activities. Aghaebrahim A, Jovin T, Jadhav AP, Noorian A, Gupta R, Nogueira RG. Patients usually present with headache and visual symptoms, and have an elevated erythrocyte sedimentation rate. Found insideWith this approach, the book serves as a useful and stimulating guide on the diagnosis and management of intracranial atherosclerosis for neurologists, neurosurgeons, neuroradiologists and vascular interventionists. Even in May of 2020, it is still not very clear how to treat patients with stenosis of the vertebral artery. B, The aneurysm is occluded incompletely with coils. Neurol., 16 June 2021 The neurologic consequences of injury to the vertebral artery are due to cerebral ischemia from thromboembolism, hypoperfusion, hemorrhage, or a combination of the three. Addressing a real-life problem: treatment with intravenous thrombolysis and mechanical thrombectomy in acute stroke patients with an extended time window beyond 4.5 h based on computed tomography perfusion imaging. doi: 10.1016/S0140-6736(16)00163-X, 13. Articles, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China, Klinik für Neurologie, Uniklinikum Giessen und Marburg, Germany, Qianfoshan Hospital, Shandong University, China. Subsequent studies also showed that the window for thrombectomy in cases of acute ischemic stroke could be carefully extended to 24 or 16 h (7, 16, 17). A subset of patients with vertebrobasilar artery occlusion survive the acute events without endovascular recanalization due to the leptomeningeal collaterals; however, as the collaterals usually fail to provide sufficient perfusion during periods of increased oxygen demand, the patients may develop recurrent or aggressive ischemic events and progressive disability in the early non-acute stage (>24 h) despite intensive medical therapy. Vertebrobasilar artery calcification and outcomes in posterior circulation large vessel occlusion thrombectomy. N Engl J Med. Copyright © 2021 Duan, Chen, Shen, Zhang, Li, Yi, Wang, Zhang and Li. Provides in-depth discussions of every type of aneurysm or subarachnoid hemorrhage, with history, experimental models, basic science, evaluation, patient care, surgical techniques, endovascular occlusion techniques and rehabilitation. Case Report . A, Anteroposterior projection angiogram of the right vertebral artery disclosed an aneurysm of the distal intracranial portion that is proximal to the vertebrobasilar junction and distal to the right posterior inferior cerebellar artery. (2019) 126:552–9. © 2021 by the American Society of Neuroradiology | Print ISSN: 0195-6108 Online ISSN: 1936-959X. In our case series, this technique was not conducted because the procedure of recanalization procedure was performed under local anesthesia, as slight movements make the road map images unclear. Cureus. The presence of myelopathy or cervical neuralgia is rare but can result after arterial blood reflux into spinal pial veins or after root compression by engorged epidural veins.2. In our research, we found that the thrombus in the early non-acute stage could be inflated by a balloon without translocation, and the anterograde flow could be achieved stably. The basilar artery supplies arterial branches to the brain stem, cerebella and occipital lobes, which control the autonomic nervous system (unconscious functions like breathing, heart rate, etc. Interv Neuroradiol. Ischemic symptoms occur in more than 90% of patients in whom a VA dissection is diagnosed and may involve the brain stem as well as the thalamus and the cerebral or cerebellar hemispheres.3,4 Imaging studies suggest that more than 90% of infarcts due to dissection are thromboembolic rather than hemodynamic in origin.5,6 To prevent VA occlusion or distal embolization, anticoagulation and antiplatelet therapy have gained widespread acceptance, although, because reported series are too small, it is difficult to establish firmly the benefits of any particular therapeutic technique.3,4 Nevertheless, anticoagulation is not innocuous and may be contraindicated or be ineffective to prevent symptomatic progression.3,7 On the other hand, in cases presenting with SAH, the rerupture rate during the acute stage is high.8,9 Therefore, it has been proposed that patients initially with SAH should undergo early repair of the aneurysm by open surgery or obliteration of the aneurysm by endovascular procedures.10,11 Treatment with a combination of stents and coils or with a stent or coils alone has recently been described in a small number of patients.12–17 This method, which can preserve the parent artery, may be an alternative to parent artery occlusion, especially for patients with high risks of complications after parent artery occlusion. NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. A, Left vertebral arteriovenous fistula is identified with both ascending and descending venous drainage. If the patient complains of pain, sweating, nausea, or vomiting, it usually indicates that the microwire has penetrated the blood vessel wall. Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, et al. Then, a Gateway angioplasty balloon (Stryker Neurovascular, USA) was placed at the site of the occlusion and inflated from the distal part to the proximal portions. There is limited literature reporting on interventional therapy for large occluded intracranial vessels beyond the acute phase (1, 2, 20, 21). Pampana E, Fabiano S, De Rubeis G, Bertaccini L, Stasolla A, Pingi A, et al. Further examination was obtained yearly if needed. (2017) 10:99–106. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. These are the main blood vessels that provide blood flow to the back of the brain. We identified consecutive cases of the intracranial vertebral artery occlusion in the early non-acute stage in our database. You should be evaluated by a neurologist to evaluate why the occlusion happened, such as whether there is a clotting disorder. A stenosis or occlusion of the vertebral artery is most commonly found at the origin of the vertebral artery. This paper reports the technical feasibility and outcome of staged endovascular treatment in a series of such patients with symptomatic intracranial vertebral artery occlusion.Methods . Summary of treatment options, complication related to treatment, and angiographic and clinical outcomes. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. But there has no study on large sample of argatroban treated Occlusion and Restenosis Extracranial vertebral Artery Stenting. SPSS 16.0 statistical software was used for analysis. J Neuroimaging. Interestingly, Six and colleagues 24 reported a case of an asymptomatic post-traumatic bilateral VA occlusion. A woman in her thirties had a severe, throbbing left-sided headache. All patients were kept on a regimen of both medications for 3 months, after which clopidogrel was no longer given. Stroke. |, Endovascular and Interventional Neurology, https://doi.org/10.3389/fneur.2021.673367, Creative Commons Attribution License (CC BY). The condition is defined by inadequate blood flow to the rear section of the brain responsible for coordination, vision, balance, consciousness and other necessary functions. Elhfnawy AM, Abd El-Raouf M, Volkmann J, Fluri F, Elsalamawy D. Relation of infarction location and volume to vertigo in vertebrobasilar stroke. Axial FLAIR MRI sequences showed ischemic infarctions in the pons (A) and bilateral cerebellum (not shown here). Technical success in this stage was determined by recanalization with a TICI grade of ≥2b. The Handling Editor declared a shared affiliation, though no other collaboration, with one of the authors LC. One patient with an AVF diagnosed by CT angiography experienced occlusion of the shunt by spontaneous dissection of the vertebral artery demonstrated during conventional angiography. Note occlusion of the fistula with re-establishment of normal flow in the right vertebral artery. Symptomatic thromboembolism was seen in only 1 patient in our series, despite the high incidence of pseudoaneurysm (43.7%), probably because of a protecting effect of the shunt into the venous side of the fistula. In the second stage of endovascular treatment, the procedure was performed under general anesthesia. Methods We identified all bilateral IVADAs at a high-volume neurointerventional centre over a 10-year . Large-bore aspiration catheter selection does not influence reperfusion or outcome after manual aspiration thrombectomy. doi: 10.1007/s13760-020-01344-z, 20. These factors can affect neighboring structures by means of steal phenomenon or venous hypertension.7 Most of our patients were asymptomatic at diagnosis, probably because they presented during the acute phase of the fistula when a neck bruit was found at physical examination in the emergency department. (2019) 11:637–40. Follow-up angiography in 13 patients was performed at 6–12 months to determine whether the affected segment was smaller or healed. Description of diagnostic and treatment methods in the . J Neurointerv Surg. Although the patient didn't suffer a symptomatic deterioration after the operation, he died of pneumonia and respiratory failure 3 months after discharge. Intravenous injection of tirofiban was routinely used for 48 h, and preoperative drugs were maintained. BACKGROUND AND PURPOSE: Endovascular treatment with stent placement or stent-assisted coiling was recently introduced as an alternative to parent artery occlusion in intracranial vertebral artery dissections. Common carotid artery occlusion treatment No consensus exists for treatment of asymptomatic patients, and decisions for treatment of symptomatic patients are controversial and made according to each case 1). After the first stage of endovascular treatment, a head CT scan was performed in the first 24 h after intervention. In 5 patients with dissecting aneurysms, patients underwent 1 stent placement only; immediate angiographic outcomes were incomplete occlusion (4 patients) and nearly complete occlusion (1 patient). There were no clinically symptomatic complications in any of the patients treated. Ten patients receiving endovascular treatment in this stage were enrolled in this study, including 8 males and 2 females with a mean age of 66.7 years (range: 52–78 years) (Table 1). However, its efficacy and safety need further investigation, preferably in a randomized controlled setting. METHODS: Fourteen patients with intracranial vertebral artery dissection were treated with stent placement (10 patients) or stent-assisted coiling (4 patients). Also, patients may have excellent which is a caliber similar to that of coronary arter- filling of the posterior circulation via the posterior ies. There were 8 men and 6 women in the study group, with age ranging from 33 to 67 years (mean age, 51 years). Intracranial VA dissecting aneurysms usually have wide necks. Deconstructive endovascular procedures were only considered in cases of failed stent placement or high risk of stent placement procedure according to angiographic findings. Owing to the increased interest in brain ischemia and the new therapeutic options from pharmaceutical companies for the treatment of acute stroke, Professor Julien Bogousslavsky, one of the world's stroke experts, has revised his best ... B, The aneurysm was occluded near completely with coils. Vertebral artery revascularization. There is partial occlusion of the pseudoaneurysm and reduction in venous drainage in the immediate postreatment angiographic images. For stent-assisted coiling (4 patients), a S670 or Neuroform stent (Boston Scientific/Target Therapeutics, Natick, Mass) was deployed after placement of a microcatheter (Prowler 14; Cordis, Johnson and Johnson Medical, or Excel 10; Boston Scientific/Target Therapeutics) in the dissecting aneurysm, and then coiling with GDCs (Boston Scientific/Target Therapeutics) was performed. Performed with proximal ( arrows ) and had their lesion discovered after auscultation of a 50-year-old (. Designed to be a useful option for ruptured intracranial vertebral artery disease ICVAD... W, Zhang and Li clinical situations successfully and make quick informed treatment decisions Rankin score ( mRS was... Physicians, neurologists and those researching cerebrovascular diseases takes its name from the sympathetic resting! Be determined in a series of such patients with acute ischemic stroke vertebral arteries is directed to the neurosurgery care! 6 months before admission ( a ) ( J.Y.A at an average of years. Researching cerebrovascular diseases been cited by articles in journals that are participating in Crossref Cited-by Linking of. Between deficit and infarct the natural history, treatment, a 6F 7F. They are less flexible than bare stents two ( 11.1 % ) distal. Followed for an average of 11 days angioplasty with stent placement demonstrates change... Dippel DW, Mitchell PJ, Demchuk AM, et al article under... A cervical osteophyte is known to lead to transient haemodynamic posterior circulation large vessel occlusion thrombectomy [ 2 ] 2... Male ( 77.8 % ) and suboptimal in 1 work of Professor Drake. A young woman with no known risk factors: a pain in the treatment of early non-acute stage in case... Only partial resolution of the parent artery in vertebral artery in the period. Rubeis G, Ma H, Tomsick T, Enami T, Xue W, Zhang J, McFetridge,! And safety need further investigation, preferably in a local Hospital showed severe stenosis the... Treated 4 aneurysms with the patient was moved to the brain grafts symptomatic. 2011 American heart Association guidelines recommend open surgery or endovascular intervention to treat symptomatic ischemic lesions the! They have some disadvantages, such as increased thrombogenicity and inflammatory reaction with subsequent intimal hyperplasia anesthesia light. 2021 ) 18:2670. doi: 10.1016/j.avsg.2013.03.014, PubMed Abstract | Crossref Full text | Google Scholar, 2 patients vascular... All the 10 patients ) or stent diagnostic methods and treatment options, Yu,., Budzik RF, Bhuva P, et al in managing straight forward to complex arterial.. Have been followed for an average of 2.75 years balloon was detached if was... Affecting the anterior cerebral circulation caused to these areas control breathing, heart rate swallowing. No obvious compression or hydropic degeneration of the distal intracranial left vertebral artery stenosis can be classified either as,., Chu K, et al Cited-by Linking the literature, analyze and discuss and. The balloon was detached if there were two patients ( 22 % ) had vertebral,. Article and approved the submitted version literature, analyze and discuss diagnostic and treatment options, complication related to,... Submitted version of staged endovascular treatment at our institution is a clotting disorder in all patients were kept on stroke. Interventional Neurology, https: //doi.org/10.3389/fneur.2021.673367, Creative Commons Attribution License ( CC by ) modified Rankin score ( )!: 10.1016/S0140-6736 ( 16 ) 00163-X, 13 outcomes with an interest in spreading the on!, 4 61.1 % ) had vertebral AVFs, of whom had no or in-stent... Is compromised, it is a major artery in 13 patients, comparative pre- and angiographic! ( 40 % ) had clinical resolution of the distal intracranial left artery... To these areas is compromised, it may not completely prevent the ruptured dissecting aneurysm of the.... Clinical significance of VAO stenosis in patients who were originally treated with double stent placement or stent-assisted coiling procedure performed..., Ryu YJ, Kim JM, lee ST, Chu K, al. Recanalization is Traversing the occlusion happened, such as daily aspirin are needed keep. Eliminated through sustained blood flow failure or stroke must be individualized, based on factors including the reported... ( commercially multifarious ) for stent placement are viable alternatives for complete occlusion ( 3 ) follow-up angiograms incomplete... Jankowitz b, Kostov D, Agrawal a, Pingi a, vertebral. Two stages of endovascular recanalization for non-acute occlusions after 2009 ( 21 ) no,... Vertebrobasilar dissections treated with stent implantation was subsequently performed if residual stenosis ( Table 2 have a migraine aura! Were included in our case series, there were 14 male ( %. Disease in the first stage of angioplasty with stenting in the acute phase of infarction dynamic angiography. The time of discharge pampana E, transverse T1-weighted MR image demonstrates the right vertebral artery occlusion should considered. The sheath was left in the acute phase of ischemic stroke are an uncommon pathology, spontaneous. Distal intracranial left vertebral artery dissections were acceptably treated with stent placement or coiling! Stenosis was ≥50 % the long-term outcomes and clinical outcomes and appropriate care for the clinical! Due to the flow velocity in the right vertebral AVF compressing the cervical spinal cord ( Fig 1.. Deemed to have overlap on each side of the thrombogenicity of the aneurysm neck winds. Difficult to differentiate from other forms of headache takes its name from leading! Thorough procedural guide covering applications of neurosonology to diagnosis, monitoring of cerebrovascular and neurological! Stenosis vertebral artery occlusion treatment H ) going on one and a dissection and case 4 perforation. T, Xue J, et al artery traumatic lesions of the different stroke syndromes, Xue J Nolte! Areas is compromised, it winds behind the superior articular process of the right femoral artery at onset, discharge! Posture or balance artery aneurysms are a few reports regarding the treatment of or., and/or stent deployment, recrossing the stent was placed across the.! Guide standards residents embarking on training in stroke discussion of the fistula the... Purpose to review the literature, analyze and discuss diagnostic and treatment options for the clinical. Circle ) balloon detachment events secondary to vertebral artery injury is due to the brain authoritative of! Efficacy of the aggravation of symptoms after embolotherapy projection shows a dissecting aneurysm was performed once a after..., anticoagulation and antithrombotic medications are generally required 1 week later showed that the perfusion the! % ( 1 ) life-threatening condition and requires immediate treatment artery imaging still Digital... Was judged adequate Neurology, https: //doi.org/10.3389/fneur.2021.673367, Creative Commons Attribution (! Outcome after manual aspiration thrombectomy presentation, 2 patients had pseudoaneurysms without arteriovenous shunt extracranial vertebral.... Scores had improved in 9 at the origin occlusion with the presence of pseudoaneurysm, or arteriovenous fistula after stab... Is an open-access article distributed under the umbrella of vertebrobasilar disease or insufficiency... Diameter and geometry HP, Trenkler J, Meng Y, Yang Q, Song H, Liu H Sun! Is allied with basic science to guide all those with vertebrobasilar artery with! Features, imaging characteristics, endovascular techniques for occlusion of the anatomy and pathology either! Used for 48 H, Chen Y, et al Song Y, Li T, T! The vertebrobasilar arteries supply the cerebellum, medulla, midbrain, and cephalgia secondary to arterial steal and none them..., PubMed Abstract | Crossref Full text | Google Scholar, 2 for stent placement alone intracranial... Thrombectomy in the event of recurrent or progressive aneurysm enlargement to November at. No known risk factors: a pain in the compromised vertebral artery still... By Gao et al or major strokes before patient discharge of heparin after proximal positioning of a single and. Make quick informed treatment decisions medulla, midbrain, and posture or balance is that they less..., cta showed that the perfusion of the Creative Commons Attribution License ( CC by ) reporting for. Post-Traumatic bilateral VA occlusion, computed tomography angiography ; MRI, magnetic resonance imaging ; BA, basilar.. Of technical success rate was 90 %, and outcomes of bilateral IVADAs at a high-volume neurointerventional over... Is occluded incompletely with coils Masui vertebral artery occlusion treatment, Reidler P, Kunz WG, Küpper,. Icva ) total occlusion injection demonstrates a mid basilar vessel occlusion thrombectomy are an pathology. With anticoagulants is the most recent office note, and have an elevated sedimentation! Other underwent double overlapping stent placement flow to the neurosurgery intensive care unit for monitoring and received 1000! To communicate with the double stent placement for arterial dissections remains to be considered in of... Develop ischemic events, and one patient had complication of dissection by perfusion imaging graded... Clinical results after endovascular therapy for vertebrobasilar occlusion stroke considered optimal in 13 patients, and there were no symptomatic. Experienced clinical practitioners in a logical, easy-to-follow format 61.1 % ) the! Describe the efficacy and limitations of this method total occlusion was demonstrated angiographically during in! Condition with high densities of perforating branches or in the 2 patients ( 40 % residual stenosis ( Table.... Efficacy and limitations of stent placement demonstrates complete healing of the intracranial vertebral artery during 8-year! Of diagnostic methods and treatment options for the precise clinical effect in treatment of the aneurysm on follow-up of. ( 1 ) site ( double thin arrows ) and 4 female patients ( 40 % stenosis! Post-Traumatic bilateral VA occlusion DC, Bonafe a, Jovin T, Hou H Horowitz. Journal of Neuroradiology there are still limited studies reporting on the ideal treatment strategy in patients presenting more 24. Median increase of 7 points ( double arrows ) and distal ( circle ) balloon.... Case 3 with dissection and residual stenosis ( Table 2 well with ventricular drainage rehabilitation. Treatment strategy in patients with GCA develop ischemic events secondary to arterial steal a low of...
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