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22 • Lower Extremity Vascular Trauma 285
saphenous v.
Anterior tibial a.
P
eroneal n.
https://t.me/medicina_free
(Fig. 22.11). In these cases, the operative focus should be on
restoration of inline tibial ow to the foot via a single vessel.
This usually involves a bypass, often using the below-knee
popliteal artery for inow. When planning vascular reconstruction with a tibial target in severe limb trauma, the eventual perfusion result must be considered carefully. These are
often cases of high-energy, transtibial trauma with a zone
of severe bony and soft tissue injury between the inow and
outow vessels. Revascularization of a single tibial vessel
and restoring ow to the foot may not result in satisfactory
perfusion to these injured tissues to support eventual limb
salvage.31 These cases require careful consideration and discussion between the vascular, orthopedic, and reconstructive
surgical teams to ensure that early vascular reconstruction
Fig. 22.11 Gustillo grade IIIC tibial fracture with massive soft tissue disruption and transection of all tibial arteries. Due to the severity of the
soft and bony tissue injuries, the limb was deemed not salvageable.
is not undertaken in vain. Of critical importance is the fact
that there must be adequate perfused tissue at the conclusion
of the vascular reconstruction to completely cover the graft.
FASCIOTOMY
Following major lower extremity arterial reconstruction for
trauma, a four-compartment calf fasciotomy should be considered and typically performed to prevent the development
of compartment syndrome with limb reperfusion. The rare
exceptions to this are in cases with extremely short ischemic
(including operative) times of 2 hours or less or in cases
where the acute reconstruction was performed in the setting
of underlying chronic arterial occlusive disease in which collateral circulation is present during ischemia. We generally
perform fasciotomy in cases of trauma regardless of these
situations, however, unless the clinical status of the limb can
be frequently and closely monitored following revascularization. This is a very rare situation in the trauma setting.
The calf fasciotomy can be performed early during the
surgical procedure or following revascularization. Early fasciotomy allows for more accurate assessment of ow during and immediately following reperfusion with shunting
or reconstruction, but can often lead to additional blood
loss during the procedure. The below-knee arterial exposures give a “head start” on decompressing the anterior
compartment (ATA) and deep posterior compartment (TPT
and PTA), but it is critical to decompress the entire length
of each of the four calf compartments. The most frequently
missed compartment is the lateral, so care should be taken
to properly identify the intermuscular septum laterally and
divide both the anterior and lateral compartments’ investing fascia completely (Fig. 22.12).
If a fasciotomy is performed and the surgeon feels that
the patient is at low risk for developing compartment syndrome in the perioperative period, the fascia can be kept
Saphenous nerve
Great saphenous v.
Medial incision
Tibial n.
osterior tibial a.
and v.
Tibia
Small
and v.
Lateral incision
P
Fibula
Fibular a.
and v.
Fig. 22.12 Surgical exposure for two-incision, fourcompartment lower extremity fasciotomy.
286 SECTION 4 • The Management of Vascular Trauma
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open and the overlying skin incisions closed with staples
if skin aps can be mobilized. This technique preserves the
option for rapid decompression via bedside staple removal
if it becomes necessary and avoids the potential morbidity of open wounds postoperatively. For the majority of
limbs, a full compartment release should be completed and
the supercial and fascial layers left open. We favor using
negative pressure therapy dressings over the skin and subcutaneous tissues to temporarily dress the wound. We use
interlaced vessel loops in a “Jacobs ladder” conguration
to pull the skin edges together. This technique minimizes
the extent of open wound but accommodates edema of the
underlying tissues and prevents skin retraction facilitating
early primary closure.
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Surgical Damage Control and
Temporary Vascular Shunts
DANIEL J. SCOTT and SHAUN M. GIFFORD
Introduction
Since the turn of the century, there have been major changes in
the management of the severely injured patient. Perhaps
most notable is the adoption of damage control or staged
procedures. Stone and colleagues provided the landmark
description of a staged operation in 1983.1 With intent
to limit the physiologic burden on an already threatened
patient, they demonstrated a survival advantage in a series
of 17 patients. Later coined by Rotondo et al. as “damage control surgery,” this concept of limiting the “bloody
vicious cycle” of hypothermia, acidosis, and coagulopathy
has been embraced in nearly every major trauma center
with reproducible results.
laparotomy as described by Stone and colleagues was the
attention to control and repair of blood vessel injuries.
Hemorrhage (and subsequently, hemorrhagic shock) is perhaps the most signicant factor contributing to the triad of
coagulopathic bleeding. Incidentally, the management of
injured blood vessels in a severely injured patient is often
arduous, technically demanding, and time-consuming, all
of which can force vessel ligation out of desperation. This
chapter provides a review of a technique that offers a viable
alternative to ligation and adheres to the mantra of damage
control, namely the use of temporary intravascular shunts.
Temporary shunts have many benets in the multip ly
injured patient. Not only do they allow for reperfusion
and/or venous decompression across the injured vessel, but
they also afford time to transport a patient to a higher level
of care or to manage concomitant life-threatening injuries.
In this context, “extra time” means that ow is restored
across the injured artery and/or vein through the shunt
while resuscitation, orthopedic xation, cranial decompression or other lifesaving procedures are performed. In addition to gaining time to treat the patient, temporary shunts
also limit the ischemic insult that results from vascular ligation, which can also negatively impact the physiology of the
patient.
2–4
One of the tenets of staged
Historical Use of Intravascular
Shunts
The concept of an implantable prosthetic conduit has a
long history, with rst descriptions in World War I by Tufer
and Makins.
posed for the perceived advantages of sutureless technique
and initially meant for permanent placement. The general
goal was not long-term patency of the conduit, but rather
5,6
These parafn-lined silver tubes were pro-
a temporary means of perfusion that would promote collateral formation as the tube slowly occluded. In 1932,
Blakemore and Lord introduced use of a new composite
alloy called Vitallium (composed of cobalt, chromium, and
molybdenum). Initially, the Vitallium tube was internally
lined with vein graft but was soon followed by a two-tube
method with interposed vein, again as a sutureless technique (Fig. 23.1). Despite theoretical advantages and widespread dissemination in World War II, the use of such tubes
was limited by logistics and prolonged medical evacuation
times of the wounded to surgical facilities.
Experimental use of intravascular shunts as a means
of temporary restoration of blood ow has roots to both
the French-Algerian war (1954–62) and the Soviet war
in Afghanistan (1981–85).
the use of temporary shunts to maintain blood ow to
allow time for either onward transport, or to “administer
antishock therapy.” Among the rst modern descriptions
of temporary shunts is that from Eger et al., who in 1971
used a temporary vascular shunt prior to orthopedic xation. This practice ultimately demonstrated a decreased frequency of extremity amputation in the setting of complex
popliteal artery injury.
10,12
10,11
Both accounts described
7–9
Modern Use of Intravascular
Shunts
MILITARY AND COMBAT EXPERIENCE
Despite advances in civilian damage control, use of temporary vascular shunts in trauma had been limited to a few
case series prior to the events of September 11, 2001.
One bittersweet effect of war is the renaissance of surgical experience, technology, and technique. In a report
from Operation Iraqi Freedom, Rasmussen et al. described
a 1-year experience of 126 extremity vascular injuries,
in which 30 temporary vascular shunts were utilized in
the management of vascular injury. In this report, shunts
were used as a damage control adjunct to either facilitate
casualty evacuation, or to allow perfusion while other lifethreatening injuries were managed. In this series, 57% of
patients had patent shunts on arrival to a higher level of
care (typically <2 hours after initial surgery). The authors
noted that patency of the shunts hours after placement
was higher (86%) when they had been used in larger, more
proximal vessel injuries.21 The favorable experience with
the use of vascular shunts in this initial report was corroborated by subsequent series provided by other combat
13–20
288
23 • Surgical Damage Control and Temporary Vascular Shunts 289
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Vein
Vitallium
Silk Tie
Artery
Vein
Vitallium
Fig. 23.1 Illustration of the experimental and clinical application of the Vitallium tube techniques used by Blakemore and Lord.
surgical teams.
which a mid-subclavian artery injury was initially treated
at a forward surgical location with the insertion of an intraluminal shunt and subsequently repaired with interposition graft at a higher level of care.
Gifford and colleagues provided one of the only studies
22–24
Fig. 23.2 details a case example in
94% and a secondary amputation rate of 3.5%. In distinction, shunts were used primarily in the extremities but were
also successfully implemented in aortic, iliac, and visceral
vessels.26 Table 23.1 details both the military and civilian
experience with peripheral vascular shunting in the setting
of trauma.
21–25,27
to characterize longer-term extremity outcomes following
the use of temporary vascular shunts. In their study, the
authors used case-controlled methodology to show that
Indications
the use of temporary shunts had no adverse outcome in the
years following vascular repair and likely extended the window for limb salvage, especially in the most severely injured
extremities.
25
Damage control, that is, physiologic instability or presence
of higher operative priorities precluding denitive reconstruction of the vascular injury, is the primary indication
for the use of a temporary shunt. The rapid placement of a
CIVILIAN TRAUMA EXPERIENCE
Following the normalization of vascular shunts in wartime trauma, civilian trauma centers have embraced and
published a favorable experience as well. In 2008, a large
10-year review of the civilian experience from Dr. Feliciano’s
group at Grady Memorial, Subramanian et al. conrmed
the utility of shunts in certain patterns of vascular injury.
This study demonstrated a 95% patency rate and an overall
survival rate of 88% following major vascular injury. In this
series of 101 vascular shunts, the authors documented a
secondary amputation rate of 18%. The safety prole and
total body implementation was reinforced in a subsequent
multicenter review of 213 injuries over a 9-year period.
Dr. Inaba et al. demonstrated a favorable patency rate of
shunt is useful to reduce the time to reperfusion (i.e., oxygen delivery) beyond the disrupted vessel when there are
other higher-priority management steps required. With the
shunt in place, stabilization of associated fractures or performance of a laparotomy, craniotomy, or thoracotomy can be
completed with the extremity or other end-organ perfused
instead of having continued and compounding ischemic
injury. Finally, expedited placement of a shunt may be useful
if a surgeon desires to curtail the intervention due to lack of
training in or comfort with performing the vascular reconstruction. Placement of a shunt in the setting of prolonged
ischemia provides end-organ perfusion and may allow the
infusion of medications designed to limit thrombosis or ischemia-reperfusion injury (e.g., heparin or mannitol). Use of
a temporary shunt in an axial vessel of a severely mangled
Artery
290 SECTION 4 • The Management of Vascular Trauma
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A
B
C
Fig. 23.2 (A) The distal aspect of a Javid shunt inserted into the right
axillary artery is shown in this image. The proximal aspect of the shunt
had been placed in the proximal most right subclavian artery and
routed in an extra-anatomic fashion above the clavicle, underneath the
pectoralis major muscle, and out of the zone of injury, which was the
mid-right subclavian artery. (B) A wider image of the same case showing the proximal aspect of the exposure which was median sternotomy. The proximal Javid shunt has been removed and is secured with
a hemostatic clamp in the upper portion of the photograph. The proximal anastomosis of a 6-mm expanded polytetrafluo roethylene (ePTFE)
graft has been created to the origin of the right subclavian artery with
the graft routed in an anatomic fashion in preparation for the distal
anastomosis to the right axillary artery. (C) A completion image following successful reconstruction using 6-mm ePTFE from the proximal
most right subclavian artery to the right axillary artery. The subclavian
artery injury in this case was over sewn just proximal to the clavicle.
(Courtesy Rasmussen, TE.)
upon early reports of successful use of vascular shunting
in theater, the Department of Defense Joint Trauma System
created a clinical practice guideline for extremity vascular
injury that provided guidance on the use of vascular shunts.29
In its guidance to deploying surgeons, shunts should be
considered for all extremity vascular injuries including
proximal venous injuries.
Most situations of vascular injury afford the option of
shunt placement, making rare contraindications for their use.
Control of hemorrhage requires exposure where the decision
to ligate or place a shunt can be made. Clearly, the patient
would need to be in a stable enough condition to allow exploration of the vascular injury to commence with anticipated
blood loss during that operation. With adequate exposure of
the vascular injury, placing and securing a shunt can be done
in the same amount of time as is needed to ligate both ends
of a damaged blood vessel. Access to adequate shunt material
(see subsequent section) is needed to successfully temporize
the injury. In the extremity with multiple injuries and the
possibility for vascular disruption in multiple segments, the
surgeon must ensure re-establishment of ow does not lead
to worsening hemorrhage. The tenant of damage control vascular surgery is the control of hemorrhage, with limitation
of ischemic insult being a close second. Placement of a shunt
to establish ow leading to continued hemorrhage from the
limb would not be prudent. Additionally, reports demonstrate
few ill effects from placement of shunts.30 Theoretically, further damage to the uninjured vessel after shunt placement,
embolization of the shunt, occlusion, and/or dislodgment of
the shunt could occur. These are of limited likelihood and one
could argue that ligation leads to a worse outcome. Ligation
after shunt placement is always a consideration; however, the
reverse is unlikely to be an option due to distal thrombosis
and loss of outow.
extremity allows for the limb to be stabilized, débrided, and
reassessed at a second-look operation if needed. This strategy
allows for a more organized mobilization of requisite surgical
disciplines to assess the limb at a scheduled time after the
initial operation has been performed. The indications for the
use of temporary shunts are provided in Box 23.1.
12,28
Based
Shunt Materials
Many hollow tubular devices have been described to function
as temporary vascular shunts including large bore angiocatheters, sterile intravenous tubing, endotracheal tubes,
feeding tubes, and small caliber chest tubes. Although these
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Table 23.1 Combat Versus Civilian Use of Temporary Vascular Shunts
Review Year
Rasmussen
et al. (combat)
Taller et al.
(combat)
Chambers et al.
(combat)
Borut et al.
(combat)
Subramanian
et al.
(civilian)
Inaba et al.
(civilian)
a
Proximal = brachial artery and proximal in upper extremity or popliteal artery and proximal in lower extremity
b
Parentheses = secondary amputations attributable to shunt thrombosis
c
Shunt-related complications = shunt displacement, bleeding, or thromboembolism
d, Day; Fr, French; ga, gauge; h, hour; NL, not listed.
2004–05 30 arterial Javid 16 Arterial Proximal 86%
2006–07 14 arterial Javid NL Arterial Proximal 100%
2004–05 18 arterial Javid NL Arterial Proximal 86%
2003–07 42 arterial Argyle NL NL NL
1997–
2005–13 202
Shunt
Location
4 venous Argyle 12 Distal 12% <2 h 2 0
9 venous Argyle NL Venous 89% ~ 5 h 0 0
11 venous Sundt NL Venous 82%
8 venous Javid NL
72 arterial Argyle 61 Arterial 91%
2007
29 venous Pruitt-Inahara 20
arterial
11 venous Pruitt-Inahara 20 Trunk 99%
Shunt Type and
Number % Patency
Sundt 2 Venous Proximal 100%
Unknown NL
Sundt NL NL 4 (0) NL
12-Fr feeding
tube
Chest tube 16 23.5 h 10 (1) 0
5-Fr feeding
tube
16-ga.
Angiocath
Argyle 173 Arterial Extremity 95%
Chest tube 16 <24 h 7 (0) 0
Nasogastric/
feeding
tube
NL
1 Venous 100%
1
4 Venous 100%
21–24,26,27
Average
a
Distal 50% ~ 1.5 h 3 (1) 0
Shunt
Time
Early (<30 days)
Secondary
Amputations
b
Shunt-Related
Complications
c
Box 23.1 Indications for Temporary Vascular
Shunts
Damage control surgery for patients in extremis
Complex skeletal injury requiring fixation (e.g., Gustilo IIIc)
Temporary restoration of flow during vein harvest
Management of other injuries
Multiple vascular injuries
Prolonged ischemia (>6 hours)
Re-plantation of avulsed limbs
Temporary flow for delayed re-evaluation in mangled extremity or
prior to limb replantation
Need for perfusion during complex vascular reconstruction
Truncal vascular control
Complex repair of zone III neck injuries
Adapted from Eger M, Golcman L, Goldstein A. The use of a temporary
shunt in the management of arterial vascular injuries. Surg Gynecol Obstet.
1971;132(1):67–70; Abou Ali AN, Salem KM, Alarcon LH, et al. Vascular shunts
in civilian trauma. Front Surg. 2017;4(July):2–7.
improvised “shunts” may provide temporary ow, they are
not designed for this purpose and are predisposed to causing vessel injury and/or thrombosis due to a number of
physical characteristics. Currently, there are no Food and
Drug Administration–approved shunts for trauma and
surgeons must rely on off-label use of devices designed for
use for carotid endarterectomy and other cardiovascular
operations. Examples include the Javid (Bard PV, Tempe,
AZ), Argyle (Cardinal Health, Dublin, OH), Sundt (Integra,
Plainsboro, NJ), and Pruitt-Inahara (LeMaitre Vascular,
Burlington, MA) shunts. There are no studies that have
compared the effectiveness of these shunts to one another
in the setting of trauma and any one or more may be used
for vascular trauma even at the same institution.27 Nevertheless, extrapolation from translational hemodynamic and
hydrodynamic studies of commonly used shunts seems to
favor larger diameter, in-line (shorter) shunts as they tend to
produce higher ow rates and distal perfusion pressures.31
Auero et al. also recommends the use of tapered shunts
when smaller diameter shunts (<12 Fr) are required.
32
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Several physical characteristics must be weighed when
selecting the type of shunt to use and a list of features of
commonly used devices is provided in Table 23.2. In-line
shunts are shorter and useful when operative space is limited and the gap in or injury to the vessel is short. In-line
shunts lie inside of the injured vessel and once in place
are not likely to become entangled with wound dressing
material, surgical retractors, orthopedic xator devices, or
monitor wires which often surround the injured extremity
(Figs. 23.3 and 23.4). Looped shunts are longer with a signicant portion outside of the vessel and therefore more
prone to becoming entangled. However, looped shunts are
more effective at bridging longer injuries or segments of
missing vessel and this design may be preferable when the
vascular injury crosses a joint or unstable fracture prone
to signicant motion. In these instances, the longer, looped
shunt allows for motion across this defect with a lower likelihood of the device being dislodged. Finally, looped shunts
allow visualization of arterial or venous ow and are readily
assessed by continuous wave Doppler (Fig. 23.5).
Some shunts, such as the Bard Brener and Pruitt F3, have
a designed side-port that provides the opportunity for additional management considerations. Invasive monitoring of
blood pressure via tubing attached to the port can be utilized to support ongoing resuscitation efforts. Blood draws
for point-of-care testing can be obtained if no other access
is available or if arterial blood is needed. In addition, the
port can be used for infusion of drugs or for use in diagnostic angiography of distal structures. A unique design, the
Pruitt F3 shunt has a side-arm port that may prove useful.
Secured by proximal and distal balloons, placement of the
Pruitt F3 may be made easier and avoids the need for excessive proximal and distal vessel dissection (Fig. 23.6).
Insertion Technique
Inserting a vascular shunt, although seemingly straightforward, has the potential to cause injury if tissues are
not respected. Suggested sequential steps are outlined in
Fig. 23.3 12-Fr Argyle shunt within a left external iliac artery injury just
above the inguinal ligament. This shunt is truly in the “in-line” configuration placed within the short segment arterial defect and out of
the way of retractors, packs, or other operative apparatus. This shunt,
which is seen secured with silk ties, was patent approximately 6 hours
after placement. (Courtesy Rasmussen, TE.)
Table 23.2 Shunt Types
Manufacturer Type Features Composition Sizes
Bard Straight ± bevel tip; ± side holes;
± balloon tip
Brener Tapered w/ side arm
Burbank Tapered; depth
markings
Cardinal Argyle ± loop; kit with all 4
sizes
Integra Sundt ± loop; steel
reinforcement ± nonreinforced segment;
cone-shaped ends
LeMaitre Pruitt F3 ± T-port; color coding;
depth marks; balloon
with safety sheath; kit
with 4 sizes
cm, Centimeter; Fr, French; in, inch; mm, millimeter.
Data from manufacturer websites:
www.bard.pv.com/_vascular/product.php=37.
www.kendall-ltp.com/Kendall-LTP/pageBuilder.aspx?topicID=67419&breadcrumbs=81035:0,67418:0.
integalive.com/Neurosurgeon/Neurosurgeon-Product-Detail.asp.
www.lemaitre.com/medical_shunts.asp.
Polyvinyl chloride (± latex
balloon)
Polyvinyl chloride Diameter: 8 Fr, 10 Fr, 12 Fr,
Silicone elastomer Diameter: 3 × 4 mm,
Polyurethane (latex balloon) Diameter: 8 Fr, 9 Fr, 10 Fr,
Diameter: 9 Fr (balloon),
10 Fr, 12 Fr, 14 Fr, 16 Fr
Length: 13 cmJavid Tapered ± loop
14 Fr
Length: 11 in (loop), 6 in
(straight)
3 × 5 mm, 4 × 5 mm
Length: 30 cm (loop), 10 cm
(straight)
12 Fr, 14 Fr
Length: 31 cm (outlying),
15 cm (inlying), 13 cm
(inlying)
23 • Surgical Damage Control and Temporary Vascular Shunts 293
A
C
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B
Fig. 23.4 12-Fr Argyle shunt within a left proximal superficial femoral
artery injury just distal to the origin of the left profunda femorus artery.
Difficult to observe in this photograph, deep to the arterial shunt is a
shunt in the proximal superficial femoral vein. Also observed in this
image is the left greater saphenous vein which was exposed and used as
interposition conduit for reconstruction of this injury pattern. Although
the arterial shunt in this case was patent 5 hours after placement, the
venous shunt had thrombosed. Both artery and vein were successfully
reconstructed in this case after shunt removal. (Courtesy Rasmussen, TE.)
Fig. 23.6 Modern (carotid) shunt types. (A) Looped (Sundt) shunt.
(B) In-line (Sundt) shunt. (C) Looped Pruitt-Inahara shunt.
vessel may be subjected to balloon-catheter thrombectomy.
Several passes with the thromboembolectomy catheter can
be performed until no additional clot is retrieved and good
fore and back bleeding is achieved. Instillation of a heparinized saline solution into the proximal and distal ends of the
injured vessel (i.e., local heparinization) should be considered
followed by re-clamping of the vessel. The vessel ends should
be inspected, carefully trimmed to healthy or normal appearing segments (securing the shunt to questionable vessel wall
may lead to inadvertent disruption and hemorrhage). It is not
uncommon for vasospasm to be present. To ease insertion
and decrease risk of injury, gentle dilation of the vessel may
be necessary.
Following selection of a size-matched shunt, the distal/
smaller end (if tapered) is gently inserted into the distal vessel, allowed to back-bleed to clear any platelet aggregates
or bubbles, and is secured with thick (size 0) silk tie. It is
important to avoid the tendency to over-tighten the
suture as this may cause unintended narrowing and even
occlusion of the shunt. The proximal end of the shunt is
then inserted, and also secured with a silk tie or similar
material. Handheld Doppler evaluation is next performed
to conrm patency and marking of distal arterial signals as
able, thus facilitating future/serial Doppler examinations.
If the shunt traverses a noninjured joint, splinting of
the joint is performed to avoid dislodgement. Ideally, the
wound should be stapled closed and soft-tissue coverage
of the shunted vessel secured. If left open, wound-vacuum
Fig. 23.5 Looped (30 cm) Sundt shunt placed to bridge a defect in the
right superficial femoral artery. Although difficult to observe anatomic
context, this injury is exposed through an above-knee popliteal artery
exposure. Note that this shunt is able to be elevated out of the wound
and has ample length should the arterial injury or defect be over a
long length or an unstable fracture prone to movement. (Courtesy
Rasmussen, TE.)
dressings should not be applied directly to the vessel. The
need for fasciotomy should be considered (see later) and
time of shunt placement marked on both the patient and
on the chart.
REMOVAL TECHNIQUE
After patient transport and/or completion of other dam-
Fig. 23.7. The injured blood vessel should be carefully dis-
sected to allow vascular clamp application. This step may be
circumvented by endovascular balloon occlusion if proximal
control is likely to be lengthy or technically c hallenging (i.e.,
proximal subclavian injuries). Once controlled and opened, the
age control procedures, the surgical team should prepare
to remove the shunt and perform a more denitive vascular
reconstruction. Exposure of the shunted vessel is carried
out in a similar fashion as to when the device was placed.
Additional exposure of the proximal and distal vessel may
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Fig. 23.7 Sequential steps in placement of a temporary vascular shunt (TVS). (A) Proximal and distal control of the artery. (B) Clean transection of the
artery in an uninjured area and systematic Fogarty catheter thrombectomy. (C) Placement of a TVS with a diameter close to that of the artery, inserted
to a depth of 15 to 20 mm. (D) Water-tight fixation of the shunt with two heavy-gauge ligatures. (From Hornez E, Boddaert G, Ngabou UD, et al. Temporary
vascular shunt for damage control of extremity vascular injury: a toolbox for trauma surgeons. J Vasc Surg. 2015;152:363–368.)
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