BackTable Vascular & Interventional

In this episode of the Back Table MSK podcast, Dr. Jacob Fleming and Dr. Douglas Beall dive into the intricacies of sacroplasty, including considerations for selecting cement volume, efficacy of small versus large needles, and biomechanics of the pelvis.

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Stryker Interventional Spine

https://www.strykerivs.com

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SYNPOSIS

The doctors review evidence from the SAKOS trial on pain relief and highlight the complexities of billing. They also emphasize proactive treatments for aging populations suffering from fractures and the need for more training and propagation of sacroplasty techniques. Listeners are encouraged to stay informed about new educational opportunities and advancements in sacroplasty through ongoing updates and courses.

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TIMESTAMPS

00:00 - Introduction

02:33 - Expanding Sacroplasty Training and Curriculum

04:50 - Walkthrough of Sacroplasty Technique

10:36 - Mechanical Stabilization and Cement Volume

21:41 - Choosing Hardware and Needle Size

27:37 - Industry-Sponsored Trials and Bias

32:47 - Navigating Billing and Reimbursement

38:05 - Closing Thoughts on Sacroplasty and Osteoporotic Fractures

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RESOURCES

BackTable VI Ep. 51- Sacroplasty: Principles & New Data in the Treatment of Sacral Insufficiency Fractures:

https://www.backtable.com/shows/msk/podcasts/51/sacroplasty-i-principles-new-data-in-the-treatment-of-sacral-insufficiency-fractures

Seattle Science Foundation Annual Image Guided Interventional Spine Procedures Course:

https://ssf.cloud-cme.com/course/courseoverview?P=5&EID=1149

Dr. Doug Beall’s Twitter: @dougbeall

Vertebral Augmentation: The Comprehensive Guide to Vertebroplasty, Kyphoplasty, and Implant Augmentation:

https://www.amazon.com/Vertebral-Augmentation-Comprehensive-Vertebroplasty-Kyphoplasty/dp/1684200156

An Interim Analysis of the First 102 Patients Treated in the Prospective Vertebral Augmentation Sacroplasty Fracture Registry (Beall, 2023):

https://www.jvir.org/article/S1051-0443(23)00356-1/fulltext

Dr. Jacob Fleming and Dr. Douglas Beall discuss the challenges and advancements in treating sacral insufficiency fractures (SIF), the importance of real-world data in evaluating treatment efficacy, and the need to increase awareness of sacral fractures and sacroplasty.

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Stryker Interventional Spine

https://www.strykerivs.com

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SYNPOSIS

Dr. Beall emphasizes the underrecognition and undertreatment of sacral insufficiency fractures, pointing out the high mortality and chronic pain rates associated with non-treatment. He urges providers to consider this diagnosis, especially if the patient is describing symptoms of pain with position changes with standing, sitting, and laying, has pubic rami fractures, or reports a history of pelvic radiation. Even with imaging, the diagnosis can remain elusive, since it is not commonly recognized on x-ray and may not show obvious cortical disruption on CT or MRI.

We also review the current literature on sacroplasty efficacy in lowering patient-reported pain scores and adverse events associated with treatment versus conservative management. Dr. Beall speaks about the importance of real-world data collection in the form of patient registries and the insight that these resulting studies have on applications of sacroplasty in specific patient populations.

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TIMESTAMPS

00:00 - Introduction

03:01 - Sacral Fractures and Sacroplasty

15:17 - Treatment Options for Sacral Fractures

17:34 - Consequences of Untreated Sacral Fractures

28:32 - Sacroplasty Registry and Current Research

38:08 - Imaging Modalities: CT vs. Fluoroscopy

40:49 - Complications of Sacroplasty: Extravasation

43:21 - Bone Quality and Fracture Healing

45:42 - Growing Awareness of Sacral Fractures and Treatment Options

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RESOURCES

Spontaneous osteoporotic fracture of the sacrum. An unrecognized syndrome of the elderly (Lourie, 1982):

https://pubmed.ncbi.nlm.nih.gov/7097924/

Percutaneous cementoplasty for pelvic bone metastasis (Marcy, 2000):

https://pubmed.ncbi.nlm.nih.gov/11094996/

Safety and Efficacy of Sacroplasty for Sacral Fractures: A Systematic Review and Meta-Analysis (Chandra et al, 2019):

https://pubmed.ncbi.nlm.nih.gov/31587952/

Percutaneous sacroplasty for osteoporotic sacral insufficiency fractures: a prospective, multicenter, observational pilot study (Frey et al, 2008):

https://pubmed.ncbi.nlm.nih.gov/17981097/

Sacroplasty: A Ten-Year Analysis of Prospective Patients Treated with Percutaneous Sacroplasty: Literature Review and Technical Considerations (Frey et al, 2017):

https://pubmed.ncbi.nlm.nih.gov/29149151/

Vertebral Augmentation: The Comprehensive Guide to Vertebroplasty, Kyphoplasty, and Implant Augmentation (Beall, 2020):

https://www.thieme-connect.de/products/ebooks/book/10.1055/b000000226

An Interim Analysis of the First 102 Patients Treated in the Prospective Vertebral Augmentation Sacroplasty Fracture Registry (Beall et al, 2023):

https://pubmed.ncbi.nlm.nih.gov/37207812/

Clinical Effect of Balloon Kyphoplasty in Elderly Patients with Multiple Osteoporotic Vertebral Fracture (Liu et al, 2019):

​https://journals.lww.com/njcp/fulltext/2019/22030/clinical_effect_of_balloon_kyphoplasty_in_elderly.1.aspx

Dr. Dylan Suttle and Dr. Harris Chengazi delve into recent advancements in transjugular intrahepatic portosystemic shunt (TIPS) procedures, highlighting the significant reduction in procedural time and improvements in outcomes due to the introduction of Intracardiac Echo (ICE) and the Scorpion Portal Vein Access Series.

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Argon Medical

http://www.argonmedical.com/

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SYNPOSIS

The doctors share their experiences, techniques, and the evolution of their approaches. They emphasize benefits such as high-resolution imaging, cost-effectiveness, and new technologies that make TIPS cases more approachable.

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TIMESTAMPS

00:00 - Introduction

06:17 - Portal Hypertension Clinics

13:17 - Technical Aspects of TIPS Procedures

35:17 - Challenges in Selecting the Right Hepatic Vein

38:48 - Pre-Procedure Planning

39:36 - Puncture Techniques

50:04 - Stent Deployment and Placement

55:35 - Learning Curve of ICE & Advantages

01:07:58 - The Future of TIPS Procedures

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RESOURCES

BackTable VI Episode #123 - TIPS University Freshman Year: Referrals and Pre-op Workup with Dr. Emmett Lynskey:

https://www.backtable.com/shows/vi/podcasts/123/tips-university-freshman-year-referrals-pre-op-workup

BackTable VI Episode #124 - TIPS University Sophomore Year: Basic Procedure Technique

with Dr. Emmett Lynskey:

https://www.backtable.com/shows/vi/podcasts/124/tips-university-sophomore-year-basic-procedure-technique

BackTable VI Episode #125 - TIPS University Junior Year: Advanced Techniques, ICE, and Splenic Access with Dr. Emmett Lynskey:

https://www.backtable.com/shows/vi/podcasts/125/tips-university-junior-year-advanced-techniques-ice-splenic-access

BackTable VI Episode #126 - TIPS University Senior Year: Gunsight Technique & Splenic Closure with Dr. Emmett Lynskey:

https://www.backtable.com/shows/vi/podcasts/126/tips-university-senior-year-gunsight-technique-splenic-closure

Dr. Suttle TIPS Technique Video:

https://www.youtube.com/watch?v=jYfr_rWe5Ck

TIPS prevents further decompensation and improves survival in patients with cirrhosis and portal hypertension in an individual patient data meta-analysis:

https://www.journal-of-hepatology.eu/article/S0168-8278(23)00314-8/abstract

Intracardiac Echocardiography–Guided TIPS: A Primer for New Operators:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7540636/

In this episode of the BackTable Podcast, host Dr. Ally Baheti discusses the concept of moral injury with Dr. Mina Makary from Ohio State University and Dr. Jeff Chick from the University of Washington. The conversation focuses on their recent study published in Academic Radiology, which employed a survey to analyze prevalence of moral injury, factors contributing to its occurrence, and strategies to address it.

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RADPAD® Radiation Protection

https://www.radpad.com/

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SYNPOSIS

It is important to distinguish burnout from moral injury, with the former concept more focused on personal resilience, and the latter defined as extrinsic circumstances that lead to disconnection with one’s career. A key finding from the study was the negative correlation between degree of moral injury and quality of life. Respondents’ free text answers identified a variety of factors contributing to moral injury. The doctors also speak about strategies for addressing moral injury such as psychotherapy, spiritual care, and physical exercise. Most importantly, they believe it is crucial to target systemic factors with efforts to increase physician leadership, administrative support, and research in physician wellness.

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TIMESTAMPS

00:00 - Introduction

02:14 - Defining Moral Injury

05:31 - Survey Methodology and Respondent Demographics

07:52 - Key Survey Findings

11:07 - Causes of Moral Injury

12:11 - Personal and Systemic Strategies for Addressing Moral Injury

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RESOURCES

Moral Injury Among Interventional Radiologists (Woerner, 2024):

https://pubmed.ncbi.nlm.nih.gov/37926643/

Identifying Moral Injury in Healthcare Professionals: The Moral Injury Symptom Scale-HP (Mantri, 2020):

https://pubmed.ncbi.nlm.nih.gov/32681398/

In this episode, Dr. Paul Lewis discusses best practices for thoracentesis. He shares insights on using image guidance, managing complex effusions, and managing complications such as pneumothorax and hemothorax. Dr. Lewis is an interventional radiologist at the University of Pittsburgh Medical Center.

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Laborie RenovaRP Centesis System

https://www.laborie.com/product/renovarp-products/

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SYNPOSIS

Dr. Lewis also speaks on patient selection, procedural techniques, equipment choices, and other troubleshooting tips. Additionally, the doctors cover procedural nuances such as bilateral thoracentesis and patient positioning and highlight the efficiency of the RenovaRP Centesis System.

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TIMESTAMPS

00:00 - Introduction

06:07 - Thoracentesis Procedure Walkthrough

16:49 - Equipment Used

22:14 - Troubleshooting

30:56 - Post-Procedural Care

36:12 - Complications

48:07 - Helpful Resources

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RESOURCES

Prospective comparison between a peristaltic pump and vacuum containers for paracentesis: Time, resources and safety:

https://pubmed.ncbi.nlm.nih.gov/38042055/

Paracentesis: Faster and easier using the RenovaRP® pump:

https://pubmed.ncbi.nlm.nih.gov/35548901/

Society of Interventional Radiology Consensus Guidelines for the Periprocedural Management of Thrombotic and Bleeding Risk in Patients Undergoing Percutaneous Image-Guided Interventions—Part II: Recommendations:

https://www.jvir.org/article/S1051-0443(19)30407-5/fulltext

The Impact of Gravity vs Suction-driven Therapeutic Thoracentesis on Pressure-related Complications: The GRAVITAS Multicenter Randomized Controlled Trial:

https://pubmed.ncbi.nlm.nih.gov/31711990/

In this episode, Dr. Ally Baheti interviews interventional radiologist Dr. Lorenzo Patrone about his recent multidisciplinary editorial entitled "The 'Woundosome' Concept and Its Impact on Procedural Outcomes in Patients With Chronic Limb-Threatening Ischemia.”

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Reflow Medical

https://www.reflowmedical.com/

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SYNPOSIS

Dr. Patrone explains his interest in critical limb ischemia (CLI) and describes how he reached out to colleagues around the world with the intention of drafting a paper that summarizes research in below-the-ankle interventions and increases awareness of the woundosome concept.

He explains the woundosome concept, which aims to understand how each patient’s foot vasculature influences the effectiveness of below-the-ankle interventions and tissue healing. Understanding each patient’s anatomy, having adequate imaging of the foot, obtaining pedal acceleration times, and using micro-oxygen sensors are strategies to assess wound perfusion, which is integral for treatment planning and prognosis. He illustrates these techniques in a case study of a non-healing wound.

Finally, Dr. Patrone shares some technical tips for below-the-ankle interventions, including the benefits of ipsilateral antegrade access, sheath selection, and strategic contrast administration.

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TIMESTAMPS

00:00 - Introduction

02:25 - Multidisciplinary and Global Collaboration

05:59 - Explaining the Woundosome Concept

07:51 - Understanding Wound Perfusion

10:20 - Assessing the Effectiveness of Revascularization

20:09 - Case Example with Pictures

28:07 - Technical Tips for CLI Interventions

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RESOURCES

Find Your Algorithm (FYA):

https://fya-congress.com/

The "Woundosome" Concept and Its Impact on Procedural Outcomes in Patients With Chronic Limb-Threatening Ischemia:

https://journals.sagepub.com/doi/10.1177/15266028241231745?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed

Vascular imaging of the foot: the first step toward endovascular recanalization (Manzi):

https://pubmed.ncbi.nlm.nih.gov/21997985/

BASIL-2 Trial:

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)00462-2/fulltext

BackTable VI Ep. 90- Pedal Acceleration Time for Limb Salvage with Jill Sommerset and Dr. Mary Constantino:

https://www.backtable.com/shows/vi/podcasts/90/pedal-acceleration-time-for-limb-salvage

The First-in-Man "Si Se Puede" Study for the use of micro-oxygen sensors (Montero-Baker):

https://pubmed.ncbi.nlm.nih.gov/26004327/

PEDRA Perfusion Monitoring:

https://www.pedratech.com/

Armada XT Balloon:

https://www.cardiovascular.abbott/us/en/hcp/products/peripheral-intervention/peripheral-dilatation-catheters/armada-14.html

In this episode of the BackTable Podcast, vascular surgeon Dr. Nicolas Mouawad and interventional radiologist Dr. Raja Ramaswamy share their insights on the changing landscape of deep vein thrombosis (DVT) management, steps of mechanical thrombectomy, and current research on DVT interventions.

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Inari Medical

https://www.inarimedical.com/

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SYNPOSIS

The guests start by describing their typical referral patterns, noting that most cases come through the emergency department. In terms of workup, it is important to distinguish between acute and chronic DVTs and classify the thrombosis location as either proximal (femoral vein or higher) or distal. Anticoagulation, usually with direct oral anticoagulants, is always started, with efficacy largely determined by patient compliance.

Regarding endovascular intervention, thrombolysis may be an effective adjunctive treatment if the clot occurred within a two-week timespan, but it carries a bleeding risk and requires ICU monitoring. On the other hand, mechanical thrombectomy is an option for both acute and chronic clots, allows for intervention in patients with high bleeding risk, and does not require post-procedural hospitalization. Both physicians emphasize that interventions should be employed if there are long-term benefits of avoiding post-thrombotic syndrome and pulmonary embolism.

The physicians walk through a typical mechanical thrombectomy procedure, which involves the thrombectomy device, venogram, intravascular ultrasound, and possible stent placement. Finally, they discuss recent data, including the ATTRACT Trial for thrombolytics and the CLOUT Registry and Trial for ClotTriever use. Notably, they mention the DEFIANCE Trial as a current prospective randomized clinical trial for ClotTriever use in the iliofemoral region.

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TIMESTAMPS

00:00 - Introduction

03:48 - DVT Referral Patterns and Treatment Algorithms

08:55 - Choosing an Anticoagulation Regimen

11:01 - DVT Interventions

13:54 - Patient Scenarios and Treatment Decisions

22:29 - Post-Thrombotic Syndrome

26:16 - Mechanical Thrombectomy Technique

35:45 - Postoperative Care

39:09 - The Evolution of Mechanical Thrombectomy

43:38 - ATTRACT Trial

46:20 - CLOUT Trial

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RESOURCES

Inari ClotTriever System:

https://www.inarimedical.com/clottriever-system

ATTRACT Trial:

https://www.nejm.org/doi/full/10.1056/NEJMoa1615066

CLOUT Trial:

https://pubmed.ncbi.nlm.nih.gov/35218955/

DEFIANCE Trial:

https://evtoday.com/news/inari-medical-begins-defiance-randomized-clinical-trial-of-clottriever-system-in-dvt

Trigger warning: This episode contains discussions about suicide.

In this episode of the BackTable podcast, interventional radiologist Dr. Jenanan Vairavamurthy shares about the tragic loss of his physician brother to suicide and discusses his own mental health journey. He highlights the immense pressures and challenges that medical training and practice impose on providers.

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SYNPOSIS

The discussion emphasizes the need for mental health awareness and the importance of creating supportive environments within the medical community. He advocates for open conversations about mental health struggles and urges those in leadership positions to prioritize the well-being of colleagues and trainees. This powerful conversation aims to destigmatize mental health issues in the medical field and encourages medical providers to seek and provide support for each other.

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TIMESTAMPS

00:00 Introduction

04:11 Assessing Personal Mental Health

06:31 Personal Tragedy and Mindset Shift

11:49 The Realities of Wellness in Medicine

21:59 Creating Supportive Environments Within Medicine

25:58 Navigating Personal and Professional Challenges

35:15 Building and Leading Supportive Networks

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RESOURCES

Physician Supp​​ort Line:

https://www.physiciansupportline.com/

In this episode, interventional cardiologist Dr. Peter Soukas joins us to discuss percutaneous transmural arterial bypass (PTAB) using the DETOUR system, a novel percutaneous treatment for extensive and complex blockages in the superficial femoral artery (SFA).

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Endologix

https://endologix.com/

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SYNPOSIS

Dr. Soukas shares his extensive experience and insights into PTAB development, benefits, patient selection, and procedural details. The idea behind PTAB is to create an SFA-to-popliteal artery bypass through endovascular means, using a system of overlapping stent grafts within the femoral vein as a conduit. When planning the procedure, it is important to consider the location of reentry into the popliteal artery, avoid calcified zones, and meet femoral vein size criteria. Additionally, we explore the advantages of PTAB over other endovascular options and traditional open surgical bypass, which carry a higher likelihood of restenosis and longer recovery times, respectively.

We also discuss the types of training and support available for physicians interested in adopting this technique, cost and reimbursement aspects, and the future direction of PTAB, including ongoing post-market studies.

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TIMESTAMPS

00:00 Introduction

02:38 Dr. Soukas’ Career in Vascular Medicine

05:19 Introduction to PTAB

13:00 Landing Zones

19:37 Stent Graft Sizing

23:14 Patient Selection and Adjunctive Medical Therapy

28:04 Procedural Risks

29:18 Navigating PTAB Implementation

32:20 Opportunities for Learning PTAB

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RESOURCES

PTAB with the DETOUR System:

https://endologix.com/ptab/detour/

Brown Vascular and Endovascular Fellowship:

https://brownmedicine.org/3/cardiology-vascular-endovascular-fellowship/

COMPASS Trial:

https://www.nejm.org/doi/full/10.1056/NEJMoa1709118

VOYAGER Trial:

https://www.nejm.org/doi/full/10.1056/NEJMoa2000052

DETOUR 2 Trial:

https://www.jvascsurg.org/article/S0741-5214(22)01274-5/fulltext

In this episode, Dr. Marta Lobato explores advanced endovascular techniques in below the knee (BTK) and below the ankle (BTA) interventions for critical limb ischemia (CLI). She introduces various skills that were developed and used by her team, such as the telescopic needle, buddy needle, balloon-assisted puncture, and vasodilation to prevent artery spasm. Dr. Lobato is a vascular surgeon at Hospital de Cruces in Barakaldo, Spain.

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Reflow Medical

https://www.reflowmedical.com/

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SYNPOSIS

The discussion covers the importance of visualizing the fifth metatarsal for effective lateral views in X-rays, the intricacies of accessing the lateral and medial plantar arteries, and the significance of starting with easier procedures before attempting more complex interventions. Additionally, Dr. Lobato highlights the role of social media in learning about innovative medical practices.

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TIMESTAMPS

00:00 - Introduction

05:54 - Below the Knee and Ankle Interventions

15:35 - Complexities of Zone 2 and 3 Access

23:12 - Buddy Needle Technique for Calcified Arteries

30:12 - Advanced Techniques for Supporting the Wire

34:13 - Vasodilator Use

37:12 - Balloon-Assisted Techniques

41:02 - Advancing Your Endovascular Skills

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RESOURCES

Tips and Tricks for Simple and Complex Below-the-Ankle Punctures:

https://pubmed.ncbi.nlm.nih.gov/38441118/

Buddy Needle Technique to Facilitate Retrograde Puncture of Heavily Calcified Tibial Vessels:

https://pubmed.ncbi.nlm.nih.gov/28587566/

Balloon-Assisted Retrograde Puncture of Distal Vessels in Patients Unsuitable for a Conventional Transpedal Approach:

https://pubmed.ncbi.nlm.nih.gov/34989276/

Retrograde Balloon-Assisted Approach to Prevent Distal Embolization During Complex Recanalization Procedures:

https://pubmed.ncbi.nlm.nih.gov/36415934/

The "Woundosome" Concept and Its Impact on Procedural Outcomes in Patients With Chronic Limb-Threatening Ischemia:

https://pubmed.ncbi.nlm.nih.gov/38523459/

New antioxidant therapy for hard-to-heal neuroischaemic diabetic foot ulcers with deep exposure:

https://pubmed.ncbi.nlm.nih.gov/37029973/

Percutaneous endovascular arteriovenous fistula creation for hemodialysis access using "off-the-shelf" conventional devices:

https://pubmed.ncbi.nlm.nih.gov/33251393/