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  • 1. Björck, M.
    et al.
    Bergqvist, D.
    Eliasson, K.
    Jansson, I.
    Karlström, L.
    Kragsterman, B.
    Lundell, A.
    Malmstedt, J.
    Nordanstig, J.
    Norgren, Lars
    Örebro University, School of Health and Medical Sciences.
    Troëng, T.
    Twenty years with the Swedvasc Registry2008In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 35, no 2, p. 129-130Article in journal (Refereed)
  • 2. Block, Tomas
    et al.
    Isaksson, Helena S.
    Örebro University, School of Health and Medical Sciences.
    Acosta, Stefan
    Björck, Martin
    Brodin, David
    Nilsson, Torbjörn K.
    Örebro University, School of Health and Medical Sciences.
    Altered mRNA Expression due to Acute Mesenteric Ischaemia in a Porcine Model2011In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 41, no 2, p. 281-287Article in journal (Refereed)
    Abstract [en]

    Introduction: Messenger RNA (mRNA) changes in the small intestine in response to acute mesenteric ischaemia (AMI) could offer novel diagnostic possibilities, but have not been described. The aim was to characterize the mRNA response to experimental AMI. Materials and methods: Twelve pigs underwent catheterisation of the superior mesenteric artery with injection of polivinylalcohol embolisation particles or sodium chloride. Laparotomy and intestinal tissue sampling were performed. Microarray analysis was performed using the GeneChip (R) whole porcine genome array. Results: Seven down-regulated cellular pathways were associated with protein, lipid and carbohydrate metabolism. Seventeen up-regulated pathways were associated with inflammatory and immunological activity, regulation of extracellular matrix and decreased cellular proliferation. Thrombospondin (THS), monocyte chemoattractant protein 1(MCP-1) and gap junction alpha 1(GJA-1) were consistently up-regulated in all embolised pigs. Genes encoding earlier proposed biomarkers for AMI were up-regulated, such as lactate dehydrogenase and creatine kinase, or down-regulated, such as intestinal fatty acid binding protein and glutathione S-transferase. Conclusion: This study describes the intestinal tissue response on a gene expression level to AMI. THS, MCP-1 and GJA-1 were consistently up-regulated by ischaemia, whereas earlier proposed biomarkers for AMI were not. Gene expression may not be directly linked to the use of the corresponding proteins as potential clinical biomarkers. (C) 2010 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

  • 3.
    Brunkwall, J.
    et al.
    Univ Cologne, Dept Vasc & Endovasc Surg, Univ Clin, D-50931 Cologne, Germany..
    Kasprzak, P.
    Univ Regensburg, Dept Surg, Sect Vasc Surg, Klinikum Nurnberg,Dept Vasc Surg, Nurnberg, Germany..
    Verhoeven, E.
    Antonius Hosp, Dept Cardiovasc Surg, Nieuwegein, Netherlands..
    Heijmen, R.
    St Guys Hosp, Dept Vasc Surg, London, England..
    Taylor, P.
    St Guys Hosp, Dept Vasc Surg, London, England..
    Alric, P.
    CHU Arnaud de Villeneuve, Montpellier, France..
    Canaud, L.
    CHU Arnaud de Villeneuve, Montpellier, France..
    Janotta, M.
    Univ Regensburg, Dept Surg, Vasc Surg Sect, D-93053 Regensburg, Germany..
    Raithel, D.
    Klinikum Nuernberg, Nurnberg, Germany..
    Malina, M.
    Univ Hosp, Dept Vasc Dis, Malmo, Sweden..
    Resch, Ti
    Univ Hosp, Dept Vasc Dis, Malmo, Sweden..
    Eckstein, H. -H
    Ockert, S.
    TUM Munich, Dept Vasc Surg, Munich, Germany..
    Larzon, Thomas
    Örebro University Hospital. Vasc Surg Sect.
    Carlsson, F.
    Orebro Univ Hosp, Dept Cardiol, Orebro, Sweden..
    Schumacher, H.
    Dept Vasc Surg, Hanau, Germany..
    Classen, S.
    Dept Vasc Surg, Hanau, Germany..
    Schaub, P.
    Dept Vasc Surg, Hanau, Germany..
    Lammer, J.
    Wiener Neustadt Gen Hosp, Dept Radiol, Vienna, Austria..
    Lonn, L.
    Rigshosp, Dept Vasc Surg & Radiol, DK-2100 Copenhagen, Denmark..
    Clough, R. E.
    St Guys Hosp, Dept Vasc Surg, London, England..
    Rampoldi, V.
    Policlin San Donato, Milan, Italy..
    Trimarchi, S.
    Policlin San Donato, Milan, Italy..
    Fabiani, J. -N
    Boeckler, D.
    Univ Clin, Dept Vasc Surg, Heidelberg, Germany..
    Kotelis, D.
    Univ Clin, Dept Vasc Surg, Heidelberg, Germany..
    von Tenng-Kobligk, H.
    Univ Clin, Dept Radiol, Heidelberg, Germany..
    Mangialardi, N.
    Azienda Osped S Filippo Neri, Rome, Italy..
    Ronchey, S.
    Azienda Osped S Filippo Neri, Rome, Italy..
    Dialetto, G.
    V Monaldi Hosp, Naples, Italy..
    Matoussevitch, V.
    Univ Cologne, Dept Vasc & Endovasc Surg, Univ Clin, D-50931 Cologne, Germany..
    Endovascular Repair of Acute Uncomplicated Aortic Type B Dissection Promotes Aortic Remodelling: 1 Year Results of the ADSORB Trial2014In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 48, no 3, p. 285-291Article in journal (Refereed)
    Abstract [en]

    Objectives: Uncomplicated acute type B aortic dissection (AD) treated conservatively has a 10% 30-day mortality and up to 25% need intervention within 4 years. In complicated AD, stent grafts have been encouraging. The aim of the present prospective randomised trial was to compare best medical treatment (BMT) with BMT and Gore TAG stent graft in patients with uncomplicated AD. The primary endpoint was a combination of incomplete/no false lumen thrombosis, aortic dilatation, or aortic rupture at 1 year.

    Methods: The AD history had to be less than 14 days, and exclusion criteria were rupture, impending rupture, malperfusion. Of the 61 patients randomised, 80% were DeBakey type IIIB.

    Results: Thirty-one patients were randomised to the BMT group and 30 to the BMT+TAG group. Mean age was 63 years for both groups. The left subclavian artery was completely covered in 47% and in part in 17% of the cases. During the first 30 days, no deaths occurred in either group, but there were three crossovers from the BMT to the BMT TAG group, all due to progression of disease within 1 week. There were two withdrawals from the BMT+TAG group. At the 1-year follow up there had been another two failures in the BMT group: one malperfusion and one aneurysm formation (p = .056 for all). One death occurred in the BMT TAG group. For the overall endpoint BMT+TAG was significantly different from BMT only (p < .001). Incomplete false lumen thrombosis, was found in 13 (43%) of the TAG+BMT group and 30 (97%) of the BMT group (p < .001). The false lumen reduced in size in the BMT+TAG group (p < .001) whereas in the BMT group it increased. The true lumen increased in the BMT TAG (p < .001) whereas in the BMT group it remained unchanged. The overall transverse diameter was the same at the beginning and after 1 year in the BMT group (42.1 mm), but in the BMT+TAG it decreased (38.8 mm; p = .062).

    Conclusions: Uncomplicated AD can be safely treated with the Gore TAG device. Remodelling with thrombosis of the false lumen and reduction of its diameter is induced by the stent graft, but long term results are needed. (C) 2014 European Society for Vascular Surgery.

  • 4.
    Hörer, Tal
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Örebro University Hospital.
    Skoog, Per
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Örebro University Hospital.
    Norgren, Lars
    Örebro University, School of Health and Medical Sciences. Örebro University Hospital.
    Magnuson, A.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Örebro University Hospital.
    Berggren, Lars
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Örebro University Hospital.
    Jansson, Karl
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Örebro University Hospital.
    Larzon, Thomas
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Örebro University Hospital.
    Intra-peritoneal microdialysis and intra-abdominal pressure after endovascular repair of ruptured aortic aneurysms2013In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 45, no 6, p. 596-606Article in journal (Refereed)
    Abstract [en]

    Objectives: This study aims to evaluate intra-peritoneal (ip) microdialysis after endovascular aortic repair (EVAR) of ruptured abdominal aortic aneurysm (rAAA) in patients developing intra-abdominal hypertension (IAH), requiring abdominal decompression.

    Design: Prospective study.

    Material and methods: A total of 16 patients with rAAA treated with an emergency EVAR were followed up hourly for intra-abdominal pressure (IAP), urine production and ip lactate, pyruvate, glycerol and glucose by microdialysis, analysed only at the end of the study. Abdominal decompression was performed on clinical criteria, and decompressed (D) and non-decompressed (ND) patients were compared.

    Results: The ip lactate/pyruvate (l/p) ratio was higher in the D group than in the ND group during the first five postoperative hours (mean 20 vs. 12), p = 0.005 and at 1 h prior to decompression compared to the fifth hour in the ND group (24 vs. 13), p = 0.016. Glycerol levels were higher in the D group during the first postoperative hours (mean 274.6 vs. 121.7 mu M), p = 0.022. The IAP was higher only at 1 h prior to decompression in the D group compared to the ND group at the fifth hour (mean 19 vs. 14 mmHg).

    Conclusions: lp l/p ratio and glycerol levels are elevated immediately postoperatively in patients developing IAH leading to organ failure and subsequent abdominal decompression.

  • 5.
    Larzon, Thomas
    et al.
    Örebro University Hospital. Department of Cardiothoracic and Vascular Surgery.
    Roos, H.
    Department of Vascular Surgery, Sahlgrenska University Hospital, Göteborg, Sweden .
    Gruber, G.
    Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Henrikson, O.
    Department of Radiology, Sahlgrenska University Hospital, Göteborg, Sweden .
    Magnuson, A.
    Clinical Epidemiology and Biostatistics, Faculty of Medicine and Health, Örebro University, Sweden .
    Falkenberg, M.
    Department of Radiology, Sahlgrenska University Hospital, Göteborg, Sweden.
    Lönn, L.
    Department of Vascular Surgery and Radiology, National Hospital Copenhagen University, Copenhagen, Denmark .
    Norgren, L.
    Department of Surgery, Faculty of Medicine and Vascular Surgery, Örebro, Sweden .
    Editor's choice: a randomized controlled trial of the fascia suture technique compared with a suture-mediated closure device for femoral arterial closure after endovascular aortic repair2015In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 49, no 2, p. 166-173Article in journal (Refereed)
    Abstract [en]

    Objectives: The aim was to investigate whether the fascia suture technique (FST) can reduce access closure time and procedural costs compared with the Prostar technique (Prostar) in patients undergoing endovascular aortic repair and to evaluate the short- and mid-term outcomes of both techniques.

    Methods: In this two center trial, 100 patients were randomized to access closure by either FST or Prostar between June 2006 and December 2009. The primary endpoint was access closure time. Secondary outcome measures included access related costs and evaluation of the short- and mid-term complications. Evaluation was performed pen- and post-operatively, at discharge, at 30 days and at 6 months follow up.

    Results: The median access closure time was 12.4 minutes for FST and 19.9 minutes for Prostar (p < .001). Prostar required a 54% greater procedure time than FST, mean ratio 1.54 (95% Cl 1.25-1.90, p < .001) according to regression analysis. Adjusted for operator experience the mean ratio was 1.30 (95% Cl 1.09-1.55, p = .005) and for patient body mass index 1.59 (95% Cl 1.28-1.96, p < .001). The technical failure rate for operators at proficiency level was 5% (2/40) compared with 28% (17/59) for those at the basic level (p = .003). The proficiency level group had a technical failure rate of 4% (1/26) for FST and 7% (1/14) for Prostar, p = 1.00, while corresponding rates for the basic level group were 27% (6/22) for FST and 30% (11/37) for Prostar (p = .84). There was a significant difference in cost in favor. of FST, with a median difference of (sic)800 (95% Cl 710-927, p < .001).

    Conclusions: In aortic endovascular repair FST is a faster and cheaper technique than the Prostar technique.

  • 6. Liapis, C. D.
    et al.
    Bell, P. R. F.
    Mikhailidis, D.
    Sivenius, J.
    Nicolaides, A.
    Fernandes e Fernandes, J.
    Biasi, G.
    Norgren, Lars
    Örebro University, School of Health and Medical Sciences.
    ESVS guidelines: Invasive treatment for carotid stenosis: indications, techniques2009In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 37, no 4, Suppl 1, p. S1-S19Article in journal (Refereed)
    Abstract [en]

    The European Society for Vascular Surgery brought together a group of experts in the field of carotid artery disease to produce updated guidelines for the invasive treatment of carotid disease. The recommendations were rated according to the level of evidence. Carotid endarterectomy (CEA) is recommended in symptomatic patients with >50% stenosis if the perioperative stroke/death rate is <6% [A], preferably within 2 weeks of the patient's last symptoms [A]. CEA is also recommended in asymptomatic men <75 years old with 70-99% stenosis if the perioperative stroke/death risk is <3% [A]. The benefit from CEA in asymptomatic women is significantly less than in men [A]. CEA should therefore be considered only in younger, fit women [A]. Carotid patch angioplasty is preferable to primary closure [A]. Aspirin at a dose of 75-325 mg daily and statins should be given before, during and following CEA. [A] Carotid artery stenting (CAS) should be performed only in high-risk for CEA patients, in high-volume centres with documented low peri-operative stroke and death rates or inside a randomized controlled trial [C]. CAS should be performed under dual antiplatelet treatment with aspirin and clopidogrel [A]. Carotid protection devices are probably of benefit [C].

  • 7.
    Ljungberg, Liza U.
    et al.
    Department of Medical and Health Sciences, Faculty of Health Sciences, Linköping University, Linköping.
    De Basso, R.
    Department of Medical and Health Sciences, Faculty of Health Sciences, Linköping University, Linköping.
    Alehagen, U.
    Department of Medical and Health Sciences, Faculty of Health Sciences, Linköping University, Linköping.
    Björck, H. M.
    Department of Medical and Health Sciences, Faculty of Health Sciences, Linköping University, Linköping.
    Persson, K.
    Department of Medical and Health Sciences, Faculty of Health Sciences, Linköping University, Linköping.
    Dahlström, U.
    Department of Medical and Health Sciences, Faculty of Health Sciences, Linköping University, Linköping.
    Länne, T.
    Department of Medical and Health Sciences, Faculty of Health Sciences, Linköping University, Linköping.
    Impaired abdominal aortic wall integrity in elderly men carrying the angiotensin-converting enzyme D allele2011In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 42, no 3, p. 309-16Article in journal (Refereed)
    Abstract [en]

    Objective: A polymorphism in the angiotensin-converting-enzyme gene (ACE I/D) has been associated with abdominal aortic aneurysm and a link between aortic aneurysm and aortic stiffness has been suggested. This study aimed to explore the links between ACE I/D polymorphism, circulating ACE and abdominal aortic wall integrity as reflected by abdominal aortic wall stiffness.

    Material: A total of 212 men and 194 women, aged 70-88 years, were studied.

    Methods: Mechanical properties of the abdominal aorta were determined using the Wall Track System, ACE genotype using the polymerase chain reaction (PCR) and circulating ACE level by enzyme-linked immunosorbent assay (ELISA).

    Results: In men, pulsatile diameter change differed between genotypes (II 0.70, ID 0.55 and DD 0.60 mm, P = 0.048), whereas a tendency was seen for distensibility coefficient (DC) (II 10.38, ID 7.68 and ID 8.79, P = 0.058). Using a dominant model (II vs. ID/DD), men carrying the ACE D allele had lower pulsatile diameter change (P = 0.014) and DC (P = 0.017) than II carriers. Multiple regression analyses showed additional associations between the D allele and increased stiffness β, and reduced compliance coefficient.

    Conclusion: Men carrying the ACE D allele have stiffer abdominal aortas compared with II carriers. Deranged abdominal aortic stiffness indicates impaired vessel wall integrity, which, along with other local predisposing factors, may be important in aneurysmal disease.

  • 8.
    Norgren, Lars
    et al.
    Örebro University, School of Health and Medical Sciences.
    Hiatt, W. .R
    Dormandy, J. A.
    Nehler, M. .R
    Harris, K. A.
    Fowkes, F. G. R.
    Bell, Kevin
    Caporusso, Joseph
    Durand-Zaleski, Isabelle
    Komori, Kimihiro
    Lammer, Johannes
    Liapis, Christos
    Novo, Salvatore
    Razavi, Mahmood
    Robbs, Johns
    Schaper, Nicholaas
    Shigematsu, Hiroshi
    Sapoval, Marc
    White, Christopher
    White, John
    Clement, Denis
    Creager, Mark
    Jaff, Michael
    Mohler, Emile
    Rutherford, Robert B.
    Sheehan, Peter
    Sillesen, Henrik
    Rosenfield, Kenneth
    Inter-society consensus for the management of peripheral arterial disease (TASC II)2007In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 33 Suppl 1, p. S1-S75Article in journal (Refereed)
  • 9.
    Skoog, P.
    et al.
    Department of Cardio-Thoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Hörer, Tal M.
    Örebro University Hospital. Department of Cardio-Thoracic and Vascular Surgery.
    Nilsson, Kristofer F.
    Örebro University Hospital. Department of Cardio-Thoracic and Vascular Surgery.
    Norgren, L.
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Larzon, Thomas
    Örebro University Hospital. Department of Cardio-Thoracic and Vascular Surgery.
    Jansson, Kjell
    Örebro University Hospital. Department of Surgery.
    Abdominal Hypertension and Decompression: The Effect on Peritoneal Metabolism in an Experimental Porcine Study2014In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 47, no 4, p. 402-410Article in journal (Refereed)
    Abstract [en]

    Objective: The aim of this study was to investigate the abdominal metabolic response and circulatory changes after decompression of intra-abdominal hypertension in a porcine model.

    Methods: This was an experimental study with controls. Three-month-old domestic pigs of both sexes were anesthetized and ventilated. Nine animals had a pneumoperitoneum-induced IAH of 30 mmHg for 6 hours. Twelve animals had the same IAN for 4 hours followed by decompression, and were monitored for another 2 hours. Hemodynamics, including laser Doppler-measured mucosal blood flow, urine output, and arterial blood samples were analyzed every hour along with glucose, glycerol, lactate and pyruvate concentrations, and lactate-pyruvate (l/p) ratio, measured by microdialysis.

    Results: Laser Doppler-measured mucosal blood flow and urine output decreased with the induction of IAH and showed a statistically significant resolution after decompression. Both groups developed distinct metabolic changes intraperitoneally on induction of IAH, including an increased l/p ratio, as signs of organ hypoperfusion. In the decompression group the intraperitoneal l/p ratio normalized during the second decompression hour, indicating partially restored perfusion.

    Conclusion: Decompression after 4 hours of IAH results in an improved intestinal blood flow and a normalized intraperitoneal lip ratio.

  • 10.
    Verhoeven, E. L. G.
    et al.
    Paracelsus Med Univ, Dept Vasc & Endovasc Surg, Nurnberg, Germany..
    Katsargyris, A.
    Paracelsus Med Univ, Dept Vasc & Endovasc Surg, Nurnberg, Germany..
    Bachoo, P.
    Aberdeen Royal Infirm, Dept Vasc Surg, Aberdeen, Scotland..
    Larzon, Thomas
    Örebro University Hospital. Dept Cardiothorac & Vasc Surg.
    Fisher, R.
    Royal Liverpool Univ Hosp, Liverpool Vasc & Endovasc Serv, Liverpool, Merseyside, England..
    Ettles, D.
    Hull Royal Infirm, Dept Radiol, Kingston Upon Hull HU3 2JZ, N Humberside, England..
    Boyle, J. R.
    Cambridge Univ Hosp NHS Fdn Trust, Dept Vasc Surg, Cambridge, England..
    Brunkwall, J.
    Univ Cologne, Univ Clin, Dept Vasc & Endovasc Surg, D-50931 Cologne, Germany..
    Boeckler, D.
    Univ Heidelberg Hosp, Dept Vasc & Endovasc Surg, Heidelberg, Germany..
    Florek, H-J
    Weisseritztal Kliniken, Dept Vasc & Endovasc Surg, Freital, Germany..
    Stella, A.
    Univ Bologna, Policlin S Orsola Malpighi, Dept Vasc Surg, Bologna, Italy..
    Kasprzak, P.
    Univ Regensburg, Univ Hosp, Dept Surg Vasc Surg & Endovasc Surg, D-93053 Regensburg, Germany..
    Verhagen, H.
    Erasmus Univ, Med Ctr, Dept Vasc Surg, Rotterdam, Netherlands..
    Riambau, V.
    Univ Barcelona, Hosp Clin, Thorax Inst, Vasc Surg Div,Dept Cardiovasc Surg, E-08007 Barcelona, Spain..
    Real-world Performance of the New C3 Gore Excluder Stent-Graft: 1-year Results from the European C3 Module of the Global Registry for Endovascular Aortic Treatment (GREAT)2014In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 48, no 2, p. 131-137Article in journal (Refereed)
    Abstract [en]

    Objectives: The European C3 module of the Global Registry for Endovascular Aortic Treatment (GREAT) provides "real-world" outcomes for the new C3 Gore Excluder stent-graft, and evaluates the new deployment mechanism. This report presents the 1-year results from 400 patients enrolled in this registry. Methods: Between August 2010 and December 2012, 400 patients (86.8% male, mean age 73.9 +/- 7.8 years) from 13 European sites were enrolled in this registry. Patient demographics, treatment indication, case planning, operative details including repositioning and technical results, and clinical outcome were analyzed. Results: Technical success was achieved in 396/400 (99%) patients. Two patients needed intraoperative open conversion, one for iliac rupture, the second because the stent-graft was pulled down during a cross-over catheterization in an angulated anatomy. Two patients required an unplanned chimney renal stent to treat partial coverage of the left renal artery because of upward displacement of the stent-graft. Graft repositioning occurred in 192/399 (48.1%) patients, most frequently for level readjustment with regard to the renal arteries, and less commonly for contralateral gate reorientation. Final intended position of the stent-graft below the renal arteries was achieved in 96.2% of patients. Thirty-day mortality was two (0.5%) patients. Early reintervention (<= 30 days) was required in two (0.5%) patients. Mean follow-up duration was 15.9 +/- 8.8 months (range 0-37 months). Late reintervention (>30 days) was required in 26 (6.5%) patients. Estimated freedom from reintervention at 1 year was 95.2% (95% CI 92.3-97%), and at 2 years 91.5% (95% CI 86.8-94.5%). Estimated patient survival at 1 year was 96% (95% CI 93.3-97.6%) and at 2 years 90.6% (95% CI 85.6-93.9%). Conclusions: Early real-world experience shows that the new C3 delivery system offers advantages in terms of device repositioning resulting in high deployment accuracy. Longer follow-up is required to confirm that this high deployment accuracy results in improved long-term durability.

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