The patient population treated by vascular medicine is becoming older, which goes along with an increasing number of patients presenting with frailty syndrome. The level of frailty determines the outcomes after vascular surgery or interventions. This position paper written by the German Society for Vascular Surgery and Vascular Medicine, the German Society for Geriatrics, and the German Society for Angiology - Society for Vascular Medicine summarizes the current evidence on the impact of frailty on the outcome after treatment for vascular diseases, and calls for a closer collaboration between geriatrics and vascular medicine and an integration of geriatric assessment in the preoperative or preinterventional evaluation of patients. Concrete and practical demands and tasks are formulated aiming at increasing awareness of geriatrization of the patient population, promoting research on the impact of frailty on the treatment of vascular patients and improving patients' safety, reducing complications and enhancing quality of care of older vascular patients.
Background: To assess the mid-term outcome of endovascular treatment for popliteal artery restenosis. Patients and methods: This retrospective study included patients with peripheral artery disease (Rutherford class (RC) 2-5) and popliteal artery restenosis treated between January 2007 and December 2017. Patients were classified into four groups based on lesion extent: isolated popliteal lesions and lesions extending to femoral and/or below-the-knee arteries (BTK). The primary endpoint was target lesion revascularization (TLR) at 12 months. Secondary endpoints included TLR at 24 months, changes in RC, ankle-brachial index (ABI), amputation and mortality rates. Results: A total of 332 patients were analyzed. Ninety-two patients received popliteal treatment only (group I), in 81 patients lesion extended into the femoral artery (group II), 112 lesions extended into the BTK arteries (group III), and 47 lesions involved both, femoral and BTK arteries (group IV). At 12 months, the overall TLR rate was 34.6%, with no significant differences between subgroups. Drug-coated balloon (DCB) angioplasty showed a significant benefit during the first 12 months (p = .035), but this advantage was not sustained thereafter (p = .798). TLR rates did not differ significantly between patients treated with stent angioplasty and those without stenting (p = .087). Significant improvements in ABI and RC were observed in all groups. Major amputation rates were 0.9% at 12 months and 1.8% at 24 months. Mortality rates were 1.5% and 7.5%, respectively. Conclusions: Reintervention rate after endovascular treatment of popliteal artery restenosis is high. The potential benefits of drug-coated balloon angioplasty and stent angioplasty require further clarification through prospective studies.
Background: Arterio-venous malformations (AVMs) may lead to vessel aneurysms and thus to life-threatening bleeding or malperfusion of the extremities, causing recurrent ulceration. Possible therapies are embolisation and/or resection. This study investigates treatment options for patients with AVM Schobinger stage III and IV for whom embolisation and resection are no longer possible and medical treatment with trametinib, a mitogen-activated protein kinase inhibitor (MEK) was performed. Patients and methods: As part of the German guideline development process for the diagnosis and treatment of vascular malformations (AWMF register number 003-007), a systematic literature search was performed using a professional service provider, followed by a retrospective, exploratory analysis based on a consecutive local registry at an interdisciplinary tertiary care center for vascular anomalies. All patients with AVM Schobinger stage IIII-IV were included. Results: Of the 559 reports on specific medications for vascular malformations, only 4 (0.7%) included treatment with trametinib, and only 2 (0.4%) of them addressed its use in AVMs showing reduced blood inflow in the malformation or volume reduction. In our case series of 99 consecutive patients with AVM Schobinger stage III-IV, nine were treated with trametinib. Out of them, 6/9 (66%) had ulceration. 1/6 (20% of the patients with ulceration died, one patient required major amputation, and 4(60%) were healed without recurrence through treatment. Three patients with chronic pain showed reduced symptoms without requiring additional analgesics. Conclusions: The single cases found in the literature and our small case series suggest that MEK1-inhibitors, such as trametinib, are an option for treating AVM Schobinger stage III-IV. Further large-scale studies are required to confirm these initial observations and to fully explore the potential of MEK1-inhibitors.
Background: Endovenous ablation methods are commonly used to treat great saphenous vein (GSV) insufficiency. However, great saphenous vein is also a valuable resource in vascular surgery. Therefore, it is important to perform minimal saphenous ablation. The aim of the study was to determine the optimal length of saphenous ablation in treatment. Patients and methods: This retrospective study was performed by measuring preoperative and postoperative venous haemodynamic parameters using plethysmography in 614 patients who required endovenous ablation. Only the segment of great saphenous vein was ablated, where the diameter was superior to 5.5 mm in standing position, starting 1 cm below the saphenofemoral junction. Patients were divided into four groups based on the length of the ablated saphenous vein at the end of 12- month. The study aimed to investigate the optimum length of ablation in dilated and insufficient GSV to preserve the GSV and improve venous haemodynamics. Results: The Mage of 614 patients included in the study was 55.78 ± 15.27 years, of which 379 (61.7%) were female and 235 (38.3%) were male. A statistically significant improvement was observed in the haemodynamic values measured by plethysmography after Endo Venous Laser Ablation (p < .001). However, no statistically significant difference was found between the groups of different lengths in terms of these variables. Conclusions: Endo Venous Laser Ablation effectively treats great saphenous vein insufficiency. To protect the saphenous vein, ablation of only 10 cm from the junction of the saphenous vein may improve venous haemodynamics and reduce patient complaints. Strain gauge-venous occlusion plethysmography and similar methods can be used in conjunction with Doppler ultrasonography to assess venous haemodynamics and determine the optimal treatment.
Background: To evaluate the outcomes of occluded lower limb bypass grafts treated by surgical thrombectomy and heparin-bonded covered stent graft deployment for distal anastomotic stenosis. Materials and methods: This was a single-centre, retrospective, single-arm study including consecutive patients with occluded infrainguinal bypass grafts treated between January 2020 and December 2024 with surgical thrombectomy followed by endovascular reconstruction of the distal anastomosis using a heparin-bonded covered stent graft. The primary endpoint was primary patency. Secondary endpoints were secondary patency, freedom from target lesion revascularization (TLR), mortality, and major amputation. Results: Thirty-two patients were included. Most patients presented with acute limb ischaemia (59.4%), followed by chronic limb-threatening ischaemia and claudication. Twenty-nine patients (90.6%) had a previously placed prosthetic bypass. Median hospital stay was 11 days (9-21). Intensive care unit treatment was required in 31%, while in-hospital morbidity and mortality were 34% and 9%, respectively. Primary patency at 3, 6, and 12 months was 55%, 49%, and 33%. Secondary patency at 12 months was 42%, freedom from TLR 43%, survival 80%, and freedom from major amputation 89%. Conclusions: In this high-risk cohort, surgical thrombectomy followed by covered stent graft reconstruction of distal anastomotic stenosis was associated with limited primary patency and frequent reintervention. These findings should be interpreted as descriptive outcomes of a complex hybrid bypass salvage strategy rather than isolated covered stent graft performance.
Background: In routine clinical practice, patient's management may differ from scientific organizations' guidelines and compromise patient's safety. This discrepancy indicates either an educational gap to fill or a need to adapt the guidelines to better reflect the real-world practice. Aims: Describe the management of venous thromboembolism (VTE): deep vein thrombosis (DVT) and pulmonary embolism (PE) among Vascular Medicine Specialists (VMS) practicing in France between 2020 and 2023 and compare it to national and international VTE guidelines. Materials and methods: A random selection of VMS from the national VMS directory were asked to 1) complete a questionnaire on their own management of patients with VTE (VMS survey) and 2) report their personal management of five consecutive patients with acute VTE (VTE case series). The study period partly overlapped with the COVID-19 pandemic, during which outpatient management strategies were increasingly promoted. Results: Among the 163 VMS contacted, 85 agreed to participate. We found that a direct oral anticoagulant (DOAC) was preferentially prescribed as first line anticoagulant in VTE: 65% in the VTE case series and 80% in the VMS survey. Low molecular weight heparins (LMWH) was preferred in case of high-risk PE (60%) or ilio-femoral DVT (35%) and in cancer-associated thrombosis (91%) in the VMS survey. After the first 6 months therapy, 30% of the VMS taper to a reduced-dose DOAC. This management was consistent with the VTE case series. Conclusions: DOAC is the standard of care to treat most VTE conditions in routine clinical practice, in line with VTE guidelines. LMWH is still preferred in case of high risk-PE and cancer-associated thrombosis. ECS use to prevent post-thrombotic syndrome remains frequent after DVT. Outpatient management of PE was common during the study period, reflecting evolving care models that were reinforced during the COVID-19 pandemic.
Background: Arterio-venous malformations (AVMs) may lead to vessel aneurysms and thus to life-threatening bleeding or malperfusion of the extremities, causing recurrent ulceration. Possible therapies are embolisation and/or resection. This study investigates treatment options for patients with AVM Schobinger stage III and IV for whom embolisation and resection are no longer possible and medical treatment with trametinib, a mitogen-activated protein kinase inhibitor (MEK) was performed. Patients and methods: As part of the German guideline development process for the diagnosis and treatment of vascular malformations (AWMF register number 003-007), a systematic literature search was performed using a professional service provider, followed by a retrospective, exploratory analysis based on a consecutive local registry at an interdisciplinary tertiary care center for vascular anomalies. All patients with AVM Schobinger stage IIII - IV were included. Results: Of the 559 reports on specific medications for vascular malformations, only 4 (0.7%) included treatment with trametinib, and only 2 (0.4%) of them addressed its use in AVMs showing reduced blood inflow in the malformation or volume reduction. In our case series of 99 consecutive patients with AVM Schobinger stage III-IV, nine were treated with trametinib. Out of them, 6/9 (66%) had ulceration. 1/6 (20% of the patients with ulceration died, one patient required major amputation, and 4 (60%) were healed without recurrence through treatment. Three patients with chronic pain showed reduced symptoms without requiring additional analgesics. Conclusions: The single cases found in the literature and our small case series suggest that MEK1-inhibitors, such as trametinib, are an option for treating AVM Schobinger stage III - IV. Further large-scale studies are required to confirm these initial observations and to fully explore the potential of MEK1-inhibitors.
Background: Pseudoxanthoma elasticum (PXE) is a rare, genetic disorder characterised by progressive vision loss, skin changes, and early-onset arteriosclerosis. The latter makes PXE a risk factor not only for peripheral artery disease (PAD) but may also promote coronary artery disease. In this context, patients with PXE have repeatedly reported problems with the radial access during coronary angiography. Therefore, the aim of this study was to prospectively investigate the prevalence of upper extremity (UE) arterial occlusion in patients with PXE and to identify possible associated risk factors. Patients and methods: Between November 2022 and February 2024, 93 consecutive patients with PXE were examined. 65 eligible patients with PXE were retained for further analysis and compared with 57 in-hospital controls. All patients underwent extensive screening for UE arterial disease using colour-coded duplex sonography (CCDS). Results: UE artery occlusion was significantly more common in patients with PXE than in the control group (58.5% vs. 3.5%; p < .001). The radial arteries were most commonly affected, predominantly bilaterally (50.8% of all PXE patients). Age was significantly associated with the presence of UE artery occlusion with an odds ratio (OR) of 1.06 (confidence interval [CI]: 1.01-1.10; p = .013). Conclusions: Peripheral occlusion of the UE arteries is a common finding in patients with PXE. In clinical practice, these findings suggest that patients with PXE may require a screening for PAD and occlusion of the arteries of the UE using CCDS after the age of 40 years. This is particularly recommended prior to coronary angiography or percutaneous coronary intervention.
Background: Peripheral artery disease (PAD) constitutes a major global burden of disease. Regarding patient-cases of patients with PAD, it is of outstanding interest to identify patients with a high risk for adverse in-hospital events. Thus, risk stratification tools including scores are of key interest for prognosis prediction. Materials and methods: The German nationwide inpatient statistics 2005-2018 was used for this analysis. Patient-cases of PAD patients were stratified according to a modified Mansoor's Self-Report Tool for Cardiovascular Risk Assessment class and compared. The predictive performance of this score was evaluated to predict adverse in-hospital events with the help of unadjusted and adjusted logistic regressions. Results: Overall, 2,462,085 patient-cases (36.8% females; 57.4% ≥ 70 years) of patients hospitalised due PAD were included in Germany 2005-2018. According to the Mansoor's self-report tool for cardiovascular risk assessment, 1,101,123 (44.7%) of the PAD patient-cases were classified as low-risk and 1,360,962 (55.3%) as high-risk. High-risk class was predictive for major adverse cardiovascular and cerebrovascular events (MACCE; odds ratio [OR] 1.09 [95% confidence interval [CI] 1.07-1.10], p < .001), acute kidney injury (OR 1.33 [95% CI 1.30-1.36], p < .001) and amputations (OR 1.46 [95% CI 1.44-1.47], p < .001). In contrast, high risk class was not associated with increased rate of arterial and venous embolism/thrombosis and in-hospital death (OR 0.97 [95% CI 0.96-0.99], p < .001). High risk class was associated with coronary revascularization treatments. Conclusions: The modified Mansoor's Self-Report Tool for Cardiovascular Risk Assessment score is a new and effective risk stratification tool to predict individual risk regarding MACCE, acute kidney injury and amputations in PAD patients during their hospitalisation, but the score failed to predict for in-hospital mortality.
Background: Complex decongestive therapy (CDT) is the standard conservative treatment for lymphedema. This study aims to provide insights into the maintenance phase of CDT, its impact on health and quality of life over six months, and identify factors influencing these outcomes in individuals with leg lymphedema. Patients and methods: This prospective cohort study assessed health and quality of life by Short-Form-36, Freiburg Quality of Life Assessment for lymphatic disorders (FLQA-lk), Knee Outcome Survey Activities of Daily Living Scale, Symptom Checklist-90 Revised, and Coping Strategies Questionnaire. Health status was expressed by means (±SD) and standardised response means (SRMs). Multivariate linear regression explored the score change of FLQA-lk. Results: Participants were on average aged 53.9 years, female (75.9%), and had two comorbidities (n = 87). On 22/26 dimensions, average improvements ranged from 8.7 to 0.7 (scores) respectively from -0.05 to 0.51 (SRMs). Most participants (89.7%) continued with manual lymphatic drainage and wore stockings regularly (95%) at baseline. Formal education, exercise and compression showed the highest, in trend statistically significant partial correlations. Conclusions: Health and quality of life in individuals with leg lymphedema can be stabilised and slightly improved during the maintenance phase of the CDT with regular use of compression stockings and manual lymphatic drainage.
: Background: Supervised Exercise Therapy (SET) improves walking performance in patients with peripheral arterial disease (PAD) and intermittent claudication, yet implementation and adherence remain inconsistent. This study evaluated functional outcomes, ankle-brachial index (ABI), quality of life (QoL), and adherence to SET in a real-world clinical setting. Materials and methods: This monocentric retrospective cohort study included 190 patients with PAD Fontaine stage II treated at a university vascular outpatient clinic between 01.01.2018 and 31.12.2022. Exposure was participation in SET compared with standard care without SET. Claudication onset distance (COD), peak walking distance (PWD), and ABI were assessed at baseline and after 3, 6, 12, and 24 months. Health-related QoL was evaluated using the SF-36 questionnaire. Adherence and reasons for dropout or non-participation were extracted from medical records. Results: Of the 190 patients (mean age 71.4 years; 60.5% male), 32 (16.8%) completed 12 months of SET, while 158 (83.2%) served as the comparison group. SET participants were older and predominantly male. COD and PWD improved significantly after 6 months (p = .0001 and p = .041) and continued to rise through 24 months, whereas ABI showed no significant changes. Adherence to SET was low. Dropout was mainly related to clinical deterioration, comorbidities, or hospitalisation, with additional sociodemographic and motivational barriers contributing to non-participation. SF-36 scores did not differ significantly, although trends toward reduced pain and improved physical functioning were observed. Conclusions: In this single-centre cohort, SET was associated with improved walking performance but low adherence and no significant changes in ABI or overall QoL.
Background: Atherectomy devices have become a widely used tool to treat peripheral vessels in a variety of clinical situations. This trial assesses the efficacy, safety and clinical success of the Rotarex Catheter, a rotational athero-thrombectomy system, for the treatment of acute, subacute and chronic occlusions in peripheral arteries including native arteries, bypasses and in-stent restenosis, used alone or as an adjunctive tool. Patients and methods: 220 patients were enrolled in this prospective, multicentre, single-arm study in Europe. Procedural success was measured after the index procedure. Freedom from major adverse events (MAEs), was collected through 30 days. Primary patency was collected at 1, 6, 12, and 24 months. Secondary outcomes included safety events, freedom from target lesion and vessel revascularization (TLR and TVR) and quality of life improvement. Results: Procedural success of Rotarex with an adjunctive treatment was 94.1%. Primary patency was 87.2%, 68.1%, 57.8% and 49.1% at 1, 6, 12 and 24 months, respectively. Freedom from MAEs through 30 days was 96.3%. The MAE rate was 21.0%, 31.0% and 41.1% at 6, 12 and 24 months. Freedom from TLR was 97.7%, 81.0%, 72.0% and 64.3% at 1, 6, 12 and 24 months. Freedom from TVR was 95.8%, 79.0%, 69.9% and 62.3% at 1, 6, 12 and 24 months. Most subjects showed improvement in Rutherford Class and in the quality-of-life measures. Conclusions: These results show that Rotarex performs effectively and safely when it is being used as an adjunctive treatment in acute, subacute and chronic occlusions of native arteries, ISR and bypass.
Background: Whether current real-world treatment of critical limb ischemia with lower extremity bypass (LEB) or infrainguinal endovascular intervention (IEI) meets the Society for Vascular Surgery objective performance goals (OPG) was investigated. Materials and methods: Literature search in PubMed, studies from 2010 to March 2021. A total of 35,981 endovascular interventions were reported in 82 publications and 26,707 open procedures in 49 publications. Results: Perioperative major adverse limb events was 8% (OPG) versus 9% for IEI and 10% for LEB (no significant differences). Perioperative major adverse cardiovascular events was significantly better with IEI (4%; p < .001) and LEB (6%; p = .018) than the OPG (8%). After 1 year, amputation-free survival (AFS) was 76.5% (OPG), compared to 71% with IEI (p = .932) and 77% with LEB (p = .006) and patient survival was 85.7% (OPG) compared to 84% (LEB; p = .006) and 78% (IEI; p = .102). 5-year survival was 51% with LEB and 45% with IEI (p = .320), and AFS was 44% with LEB and 46% with IEI (p = .802). 5-year OPGs were not reported. Conclusions: In the studies analysed, the results after IEI and LEB largely corresponded to the OPGs. 5-year outcomes after LEB and IEI did not differ significantly.
: Background: Acute abdominal aortic occlusion is a rare vascular emergency associated with high morbidity and mortality. To date, the topic has hardly been addressed scientifically. Most case series are afflicted with small cohort numbers. The aim of this study was to identify risk factors after invasive treatment of acute abdominal aortic occlusion and changes over time. Patients and methods: Using case-based nationwide hospital statistics (diagnosis-related group [DRG] statistics) from 2009 to 2020, all cases with ICD-10 codes for embolism and thrombosis of the abdominal aorta in conjunction with acute limb ischaemia and consecutive invasive treatment (endovascular or open surgery) were included. The analysis included patient characteristics, treatment, mortality, amputation, and complications. The primary outcome was in-hospital death. A multivariable regression model was applied to detect risk factors. Results: A total of 1160 cases (66% male) with acute abdominal aortic occlusion were identified (941 open; 219 endovascular). Between 2009 and 2020, the rate of endovascular treatments (2010: 6%; 2020: 29%; p<.001) increased significantly over the years. Older patients (odds ratio [OR] 0.76; 95% confidence interval [CI] 0.64-0.9, p=.002) and women (OR 0.65; 95% CI 0.48-0.88, p=.006) were more likely to receive endovascular care. In-hospital mortality was 13% after open surgery and 14% after endovascular treatment, with no significant change in open surgery, but high variability in endovascular treatment during the observation period (2009-2011: open 14%; endovascular 25%; 2018-2020: 10%; 11%). In-hospital mortality increased significantly with higher age (OR 2.19 per 10-year increase; 95% CI 1.79-2.7, p<.001) and comorbidities (OR 1.1 per Elixhauser point; 95% 1.07-1.11, p<.001). Conclusions: Acute aortic occlusion remains a rare but life-threatening emergency. Use of endovascular revascularization techniques is increasing, while in-hospital mortality rates remain high, specifically for older and morbid patients.
Background: Data on volume changes after complex decongestive therapy (CDT) for leg lymphedema are sparse. This naturalistic prospective cohort study aimed to quantify the intraindividual changes of leg volume after comprehensive inpatient rehabilitation, focusing on intensive CDT, and to relate these changes to health-related quality of life (HRQOL). Patients and methods: Limb volume of patients with leg lymphedema (n = 101; 75 women) were measured between entry and discharge (3 weeks later) by the 4 cm measurement method according to Kuhnke and the Perometer® method. Changes were also expressed as standardised response means (SRM). The change on the Freiburg Quality of Life Assessment for lymphatic disorders, short version (FLQA-lk) total score was predicted using multivariate linear regression analysis with volume data adjusted for various confounders. Results: The overall mean volume decrease on the 4 cm/Perometer® method for both legs combined was 1.94/1.31 l for all patients, corresponding to SRMs of 1.04/0.86. In the lymphedema-affected limbs, the decreases ranged between 1.03 and 1.40 l/0.77 and 0.99 l (SRMs 0.70-1.72/0.67-1.28). The total volume loss (4 cm) of both legs of all n = 101 patients correlated by 0.240 (bivariate, p = .010) and by 0.216 (multivariate, adjusted, p = .045). Conclusions: After multidisciplinary rehabilitation focusing on intensive CDT, moderate to large effects on reducing limb volume were observed. Volume reduction was positively associated with improvement in HRQOL.
Background: This proof-of-concept study aims to determine whether the haemodynamic effect of saphenous treatment can be predicted using the saphenous occlusion test (SOT). Materials and methods: Fifteen legs (11 patients) with chronic venous disease and 12 legs of healthy controls were assessed using air plethysmography (APG) on a manually operated tilt table transitioning from near-standing to a -40° head-down position and back to control leg filling via APG. Measurements were taken: (i) preoperatively, (ii) during ultrasound-guided compression of the saphenous vein at the thigh (SOT), and (iii) after treatment of the GSV with proximal short-segment endovenous laser ablation (EVLA, not the controls). Clinical CEAP classification: C2 = 2, C3 = 4, C4a = 10, and C6 = 1, median Venous Clinical Severity Score (VCSS) of 5 [2-14]. Median follow 73 [30-89] days. Results: Both, the venous filling index (VFI, mL/s) and venous filling time (VFT90, in seconds) improved significantly with GSV probe compression and EVLA (p < .0005): VFI from baseline 2.6[2-3.3] and predicted 1.2 [1.1-1.6] to postoperative 1.3 [1.1-1.7], VFT90 from baseline 34.7 [23.8-40.1] and predicted 71.4 [46-89.9] to 70.7 [47.9-76]. No significant difference was found between the predicted and actual post-treatment values for VFI (p = .601) or VFT90 (p = 1). Significant difference between controls and patients (VFT90 p < .01, VFI p < .001) was lost after treatment (VFT90 p = .751, VFI p = .826). Conclusions: The haemodynamic effect of saphenous reflux correction can be accurately predicted using the saphenous occlusion test with APG together with orthostatic manoeuvres. This method may serve as a standardised, objective tool to evaluate the need for GSV intervention in patients with visible varicose veins.
Background: Spot-stent grafting (SSG) for acute/subacute Stanford type B aortic dissection (ADB) and intramural hematoma (IMHB) entails selective coverage of the primary tear in the distal thoracic aorta (zones 4 or 5), with the stent graft fully deployed within the dissected segment-an intentional use beyond the Instructions for Use (IFU) aimed at minimising aortic coverage and preserving spinal cord perfusion. While early outcomes were favourable, long-term data on durability and reintervention remain limited. Materials and methods: In a single-centre retrospective analysis, all patients with acute/subacute ADB or IMHB treated with SSG between 03/1997 and 08/2024 were evaluated. The primary endpoint was the cumulative incidence of reintervention using a competing risk model over a median follow-up of 6.9 years (range 1.7 months-16.9 years). Secondary endpoints included technical success, aortic remodeling (AR), and false lumen thrombosis (FLT). Results: Of 270 TEVAR-treated patients with ADB or IMHB, 30 (16 ADB, 14 IMHB) underwent SSG. The cumulative incidence of reintervention at 30 days, one year, and three years was 6.7%, 16.7%, and 20%, respectively. Technical success was 100% with no 30-day mortality, stroke, or spinal ischaemia. Limited FLT occurred in 29/30, complete AR in 22/30. Reinterventions (7/30-23.3%) were distal (4) or proximal (3) extensions. Six-year survival was 66.7%. Conclusions: SSG demonstrated perioperative safety and mid-term efficacy beyond the IFU. However, higher reintervention rates - mainly proximal or distal extensions - may be expected, reflecting a trade-off for enhanced spinal cord protection in distal thoracic lesions when applied in carefully selected patients.
