經(jīng)皮椎體成形術治療新鮮骨質疏松性椎體壓縮骨折

·臨床研究·

經(jīng)皮椎體成形術治療新鮮骨質疏松性椎體壓縮骨折

孟祥玉,吐爾洪江·阿布都熱西提,謝江,田惠中,馬原

作者單位:830002新疆維吾爾自治區(qū),新疆醫(yī)科大學第六附屬醫(yī)院微創(chuàng)脊柱外科

【摘要】目的探討經(jīng)皮椎體成形術(percutaneous vertebroplasty,PVP)治療新鮮骨質疏松性椎體壓縮骨折的療效。方法2011年1月～2012年12月共治療骨質疏松性單椎體壓縮骨折38例,其中男7例,女31例；年齡55～80歲(平均65.1歲)。患者取俯臥位局麻下行單側穿刺PVP。測量椎體高度的恢復情況和后凸角改善情況,視覺模擬量表(visual analogue scale, VAS)評分評價疼痛緩解程度,活動能力評分檢測活動改善情況,并對并發(fā)癥進行分析。結果所有手術均順利完成,每個椎體平均填充骨水泥3.5 mL。隨訪時間均>12個月。椎體前壁高度由術前(19.2±5.7) mm改善至術后(20.0±5.7) mm,椎體中間高度由術前(19.2±5.1) mm改善至術后(20.2±5.0) mm,差異有統(tǒng)計學意義(P<0.05)；椎體后壁高度和Cobb角術前與術后相比,差異無統(tǒng)計學意義(P>0.05)；VAS評分術前8.3±1.1,術后12個月時為1.1±0.6,術前、術后差異有統(tǒng)計學意義(P<0.05)。活動能力評分術前3.1±0.9，術后12個月時為1.1±0.3,術前、術后差異有統(tǒng)計學意義(P<0.05)。骨水泥滲漏9例。結論PVP可有效治療新鮮骨質疏松性椎體壓縮骨折,創(chuàng)傷小,減輕疼痛,改善功能,無重大并發(fā)癥。

【關鍵詞】老年人; 胸椎; 腰椎; 骨質疏松; 脊柱骨折; 骨折,壓縮性; 經(jīng)皮椎體后凸成形術

作者簡介:孟祥玉(1976—), 碩士,副主任醫(yī)師

【中圖分類號】R 683.2

DOI【】

收稿日期：(2014-07-22)

Percutaneous vertebroplasty for treatment of acute osteoporotic vertebral compression fracturesMENGXiang-yu,Turghunjan·Abdurxit,XIEJiang,TIANHui-zhong,MAYuan.DepartmentofMinimallyInvasiveSpinalSurgery,SixthAffiliatedHospitalofXinjiangMedicalUniversity, 830002Urumqi,XinjiangUygurAutonomousRegion,China

Abstract【】ObjectiveTo analyze the therapeutic effect of percutaneous vertebroplasty (PVP) for the treatment of acute osteoporotic vertebral compression fractures. MethodsFrom January 2011 to December 2012, 38 cases were treated with PVP for one-level osteoporotic compression fracture, which included 7 males and 31 females in the age range of 55-80 years with a mean age of 65.1 years old. All operations were finished successfully under local anesthesia on the surgical area with 1% lidocaine at prone position. Body height and kyphotic Cobb’s angle of vertebral bodies were measured before and after operation, pain levels and activity was evaluated by visual analogue scale(VAS) score and locomotor activity score at preoperative, postoperative 1 d, postoperative 1 week,postoperative 3 months and postoperative 12 months. Complications were also recorded. ResultsThe average operation time was 32 min(ranging 25-50 min). An average of 3.5 mL Polymethylmethacrylate(PMMA)were injected. Follow-up period was more than 12 months. Respective preoperative and postoperative, the anterior height of the vertebral body were (19.2±5.7) mm and (20.0±5.7) mm; the medium height of the vertebral body were (19.2±5.1) mm and (20.2±5.0) mm; the difference was statistically significant(P<0.05). There was no difference in the posterior vertebral height and the kyphotic Cobb’s angle correction rate at preoperative and postoperative. Pain relief and mobility improvement were observed after the operation. VAS score revealed a decrease from 8.3±1.1 to 1.1±0.6. Locomotor activity score decreased from 3.1±0.9 to 1.1±0.3. Cement leakage happened in 9 patients without neurological complications. ConclusionPVP can achieve satisfactory clinical outcomes in treating acute osteoporotic compression fractures.

【Key words】Aged; Thoracic vertebrae; Lumbar vertebrae; Osteoporosis; Spinal fractures; Fractures, compression; Percutaneous kyphoplasty

J Spinal Surg, 2015,13(3):135-139

隨著社會的老齡化,骨質疏松的發(fā)生率逐漸增加,由于骨質疏松所導致的老年椎體壓縮性骨折不斷增多[1]。老年骨質疏松性椎體壓縮性骨折常伴有較高的死亡率和致殘率,引起慢性疼痛,身體功能受損,降低生活質量[2]。既往的非手術治療包括臥床休息、藥物、理療和支具,治療時間長、并發(fā)癥多,患者較痛苦[3]。近年來,經(jīng)皮椎體成形術(percutaneous vertebroplasty,PVP)廣泛開展,取得了良好的治療效果[4-5],但多用于非手術治療無效的老年骨質疏松性壓縮骨折[6],由于該手術的微創(chuàng)性和療效,已有文獻報道新鮮骨折患者療效滿意[7],本研究對本科治療的患者資料進行回顧性分析,以明確該手術是否適合老年新鮮骨質疏松性壓縮骨折。

1資料與方法

1.1一般資料

本組患者共38例,男7例,女31例；年齡55～80歲,平均65.1歲。均為影像學檢查所證實。骨折原因：走路滑倒跌傷27例,墜落傷3例,其他原因8例。均為單椎體骨折。受傷至手術時間均<2周。傷椎部位：T81例,T101例,T114例,T1213例,L111例,L25例,L32例,L41例。采用Genant等[8]的方法對椎體骨折的類型和壓縮程度進行分級。楔形骨折Ⅰ度12例,Ⅱ度7例,Ⅲ度3例;雙凹型骨折Ⅰ度10例,Ⅱ度4例 ;粉碎性骨折Ⅰ度1例,Ⅱ度1例。

1.2手術方法

患者取俯臥位,常規(guī)心電監(jiān)護,建立靜脈通道,腰背部穿刺區(qū)域行常規(guī)皮膚消毒鋪巾,在正位透視下選擇穿刺點,穿刺點位于棘突旁2～3 cm處,穿刺針與人體矢狀面成角15°～20°。術中正側位雙向透視證實穿刺方向,當側位見穿刺針抵達椎體后緣骨皮質但未超過椎弓根前緣時,正位像針尖應位于椎弓根投影之內,然后將穿刺針穿刺至椎體前部的1/3處。透視證實穿刺針位置后開始調配骨水泥,于透視監(jiān)控下將骨水泥于黏稠狀態(tài)下注入,注射時間2～3 min,術中如發(fā)現(xiàn)有骨水泥滲漏便立即停止注射,注射結束后插入針芯,待骨水泥固化后拔出穿刺針。

1.3評價方法

止痛效果采用疼痛視覺模擬量表(visual analogue scale, VAS)評價[9],VAS評分卡范圍：0(完全無痛) ～10(患者所經(jīng)歷的最嚴重的疼痛)。活動能力評分：①行動無明顯困難,②行走困難(需幫助),③需使用輪椅或只能坐立,④被迫臥床。椎體高度壓縮率和恢復率計算參照Lee 等[10]的方法,測量側位X 線片上壓縮骨折椎體前壁高度a0、中間高度m0和后壁高度p0,同時測量側位X線片相應骨折椎體上、下前壁高度a1、a2、中間高度m1、m2和后壁高度p1、p2。壓縮骨折椎體原始前壁高度A =(a1+a2)/2,中間高度M =(m1+m2)/2,后壁高度P =(p1+p2)/2。椎體前壁壓縮率=(A-a0)/A×100%,中間壓縮率=(M-m0)/M×100%,后壁壓縮率=(P-p0)/P×100%,椎體高度恢復率= (術前壓縮率-術后壓縮率)/ 術前壓縮率×100%。椎體后凸角度和恢復率參照脊柱Cobb角測量方法,側位X線片上壓縮骨折椎體上、下終板垂線交角即為椎體后凸角度,后凸角度恢復率=(術前后凸角度-術后后凸角度)/術前后凸角度×100%

1.4統(tǒng)計學處理

2結果

本組38例患者均順利完成手術,手術時間25～50 min,平均32 min。每個椎體平均填充骨水泥3.5 mL。

患者術后VAS評分明顯改善,從術后1 d至術后3個月疼痛呈逐漸減輕的趨勢,3個月以后疼痛維持在一個比較穩(wěn)定的狀態(tài)。患者活動功能的改善以術后1 d最明顯,此后穩(wěn)定在一個較好的水平(見表1)。

比較患者術前及術后X線片,發(fā)現(xiàn)患者椎體前壁高度和椎體中間高度均較術前改善明顯；椎體后壁高度和后凸Cobb角度術前與術后比較無明顯變化(見表2)。

9例患者出現(xiàn)骨水泥滲漏,其中4例滲漏至脊柱旁軟組織,2例滲漏至椎旁靜脈,2例滲漏至椎管內硬膜外,1例滲漏至鄰近椎間隙。但均未出現(xiàn)神經(jīng)癥狀,有3例患者出現(xiàn)鄰椎骨折均再次行椎體成形術,未出現(xiàn)感染及硬膜外血腫等其他并發(fā)癥。典型病例影像學資料見圖1。

表1術前和術后隨訪VAS評分及活動能力評分

Tab.1VAS score and locomotor activity score at operation and follow-up

項目Items術前Preoperative術后1dPostoperative1d術后1周Postoperative1week術后3個月Postoperative3months術后12個月Postoperative12monthsVAS評分VASscore8.3±1.13.1±1.8*2.2±1.7*1.6±1.2*1.1±0.6*活動能力評分Locomotoractivityscore3.1±0.91.5±0.8*1.1±0.5*1.1±0.3*1.1±0.3*

注：*與術前比較P<0.05

Note:*Compared with preoperativeP<0.05

表2術前和術后椎體高度和后凸角度

Tab.2Height of the vertebral body and Cobb’s angle at preoperative and postoperative

項目Items術前Preoperative術后Postoperative恢復率Recoveryrate椎體前壁高度Anteriorvertebralheight(19.2±5.7)mm(20.0±5.7)mm*(12.5±15.9)%椎體中間高度Mediumvertebralheight(19.2±5.1)mm(20.2±5.0)mm*(25.9±17.3)%椎體后壁高度Posteriorvertebralheight(26.4±5.6)mm(26.5±5.6)mm(6.3±5.7)%后凸角度Cobb‘sangle5.6°±5.4°5.8°±4.7°(4.9±5.2)%

注：*與術前比較P<0.05

Note:*Compared with preoperativeP<0.05

a:術前腰椎側位X線片示L1椎體楔形壓縮性骨折b:術前CT三維重建示L1椎體粉碎性骨折c:術前MRI示L1椎體T2加權像信號異常d:術中X線示穿刺針位置好,骨水泥充填好,椎體高度部分恢復e:術后CT三維重建示骨水泥充填好,無滲漏

a: Preoperative roentgenograph shows L1wedge type compression fractureb: Preoperative 3D-CT reconstruction shows L1crush type compression fracturec: Preoperative T2WI MRI shows L1fresh compression fractured: Intraoperative roentgenograph shows puncture needle position is good, bone cement is well filled and vertebral body height is recoveried partiallye: Postoperative 3D-CT reconstruction shows bone cement is well filled and no cement leakage happen

圖1典型病例影像學資料

Fig.1Radiologic data of typical case

3討論

自20世紀90年代中期以來,PVP逐漸成為骨質疏松性椎體壓縮骨折的首選治療方法,其適應證為頸椎、胸椎和腰椎>2周的骨質疏松性椎體壓縮性骨折引起中至重度的疼痛并非手術治療無效,其絕對禁忌證：①已愈合的骨質疏松性椎體壓縮性骨折或骨折非手術治療有效；②存在未治療的凝血疾病；③存在椎間盤炎、骨髓炎或敗血癥。相對禁忌證：①骨折椎體后緣有骨塊突入椎管；②骨折時間>1年；③骨折椎體壓縮>80%[6]。臨床上通常認為對于椎體壓縮性骨折所導致的疼痛、活動受限以及降低生活質量有一定的自限行,隨著時間的推移骨折逐漸愈合,在幾周至幾個月的時間內患者的癥狀會減輕,生活質量會隨之改善。但Hasserius等[11]的研究顯示椎體骨折后健康狀況的惡化持續(xù)許多年,結局比其他類型的脆性骨折要差。Suzuki 等[12]報道1組病例,107例患者因骨質疏松性壓縮性骨折就診,給予患者藥物治療及制動和康復,觀察患者疼痛、活動能力和生活質量等在3周,3、6、12個月的改善情況,發(fā)現(xiàn)骨折后1年患者的狀況與腰椎椎間盤突出、中央型腰椎椎管狹窄及因腰頸部問題而完全不能工作的患者情況相同,與通常大多數(shù)人所認為的骨折后預后較好所不同,急性椎體骨折是骨折患者健康狀況長期持續(xù)嚴重惡化的開始。

目前對于新鮮與陳舊性骨質疏松性壓縮骨折尚無統(tǒng)一的定義。本研究采用較為通用的分期方法[13],將骨質疏松椎體骨折后2周內定義為新鮮骨折(急性期),>3個月為陳舊骨折,2周～3個月的骨折為亞急性骨折。本組38例患者均為新鮮骨折,發(fā)病至手術時間均<2周,未經(jīng)過正規(guī)的非手術治療而采取手術治療,基于以下幾點考慮：①急診就診的患者疼痛非常明顯,活動受限,患者對早期藥物治療的滿意度較低,迫切希望能較快的緩解疼痛,恢復活動。②患者均為老年人,長期臥床會導致一系列的相關并發(fā)癥。③對既往非手術治療效果欠佳患者手術治療后效果比較肯定。④經(jīng)濟生活水平的提高使患者要求有更高的生活質量。⑤有文獻報道對急性骨折行PVP的有效性[7]。

既往有研究證明單側穿刺與雙側穿刺臨床療效無明顯差異[14],注入骨水泥的量與臨床療效無明顯差異[15],且一項關于骨水泥的生物力學研究證實3.5 mL的骨水泥就可以使骨折椎體及領近椎體達到正常的應力分布[16],單側穿刺與雙側穿刺相比能明顯減少手術操作的時間,患者的耐受性更好,故本組病例均采用單側穿刺入路,注射的骨水泥量為3～4 mL。根據(jù)術前X線及CT影像,從壓縮較重的一側穿刺,如果壓縮程度相同則從癥狀較重的一側穿刺,如果壓縮程度相同癥狀無明顯區(qū)別則可根據(jù)醫(yī)生的操作習慣選擇。術中既要保證椎體有較好的充盈,又要減少骨水泥的滲漏。

Omidi-Kashani等[17]報道了對單一椎體的壓縮性骨折行PVP與椎體后凸成形術(percutaneous kyphoplasty, PKP)的療效對比, PVP組28例,PKP組29例,觀察患者的疼痛評分以及SF-36評分,隨訪6個月發(fā)現(xiàn)2組患者的臨床療效相同,而且并發(fā)癥無顯著差異,相比PKP比較昂貴的價格,作者推薦行PVP治療。本組病例選擇PVP而非PKP考慮以下因素：對于新鮮椎體骨質疏松性壓縮性骨折,PVP的骨水泥能很好的填充至骨折的裂隙,在椎體內形成較好的骨水泥分布,而PKP需要用球囊對椎體進行撐開造成椎體骨小梁的壓縮,雖然能較好地恢復椎體的高度,但骨水泥的分布較差,不能與椎體骨質很好的結合,由于PKP較高的費用及臨床療效與PVP相比并無明顯優(yōu)勢故選擇后者。

PVP治療骨質疏松性椎體壓縮性骨折的并發(fā)癥發(fā)生率為1%～10%[6]。大多數(shù)都是一過性的和輕微的。包括：出血,肋骨或椎體后方結構骨折,由于骨水泥聚合反應產(chǎn)生的術后幾小時一過性發(fā)熱和疼痛加重,神經(jīng)根的刺激,骨水泥通過椎旁靜脈叢引起的肺栓塞,氣胸和感染,需要減壓手術去除滲漏的骨水泥和修復骨折的椎弓根的發(fā)生率<1%。本組共9例發(fā)生骨水泥滲漏,發(fā)生率為23.7%,考慮與新鮮骨折有關,但未出現(xiàn)血腫、肺栓塞、氣胸和感染等其他并發(fā)癥,可能與手術病例較少有關,但應密切防范,有3例病患者分別于術后1個月、5個月及10個月出現(xiàn)再骨折,均行椎體成形術后恢復,有1例患者術后1年死于其他疾病。

本組病例的臨床結果說明PVP可以有效治療新鮮的老年骨質疏松性壓縮骨折,患者的疼痛明顯緩解,活動能力改善,但椎體高度恢復不明顯,后凸角度改善不明顯,并發(fā)癥的發(fā)生率沒有明顯的提高[18-19]。但本研究病例數(shù)較少,沒有對照組且為回顧性研究,有一定的研究缺陷,需要隨機對照試驗來證實結論的可靠性。

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[3] Tamayo-Orozco J, Arzac-Palumbo P, Peón-Vidales H, et al.Vertebral fractures associated with osteoporosis: patient management[J].Am J Med, 1997, 103(2A):44S-48S.

[4] 郝定均, 劉鵬, 賀寶榮, 等.陳舊性與新鮮性壓縮骨折行椎體成形術的臨床對比研究[J].脊柱外科雜志, 2012, 10(2):83-86.

[5] Anselmetti GC, Corrao G, Monica PD, et al.Pain relief following percutaneous vertebroplasty: results of a series of 283 consecutive patients treated in a single institution[J].Cardiovasc Intervent Radiol, 2007, 30(3):441-447.

[6] Hulme PA, Krebs J, Ferguson SJ, et al.Vertebroplasty and kyphoplasty: a systematic review of 69 clinical studies[J].Spine (Phila Pa 1976), 2006, 31(17):1983-2001.

[7] Klazen CA, Lohle PN, de Vries J, et al.Vertebroplasty versus conservative treatment in acute osteoporotic vertebral compression fractures (Vertos II): an open-label randomised trial[J].Lancet, 2010, 376(9746):1085-1092.

[8] Genant HK, Wu CY, van Kuijk C, et al.Vertebral fracture assessment using a semiquantitative technique[J].J Bone Miner Res, 1993, 8(9):1137-1148.

[9] Huskisson EC.Measurement of pain[J].Lancet, 1974, 2(7889):1127-1131. JT, Lane JM.Osteoporosis: a review[J].Clin Orthop Relat Res, 2004, 425:126-134.

[2] Gold DT.The nonskeletal consequences of osteoporotic fractures. Psychologic and social outcomes[J].Rheum Dis Clin North Am, 2001, 27(1):255-262.

[3] Tamayo-Orozco J, Arzac-Palumbo P, Peón-Vidales H, et al.Vertebral fractures associated with osteoporosis: patient management[J].Am J Med, 1997, 103(2A):44S-48S.

[4] 郝定均, 劉鵬, 賀寶榮, 等.陳舊性與新鮮性壓縮骨折行椎體成形術的臨床對比研究[J].脊柱外科雜志, 2012, 10(2):83-86.

[5] Anselmetti GC, Corrao G, Monica PD, et al.Pain relief following percutaneous vertebroplasty: results of a series of 283 consecutive patients treated in a single institution[J].Cardiovasc Intervent Radiol, 2007, 30(3):441-447.

[6] Hulme PA, Krebs J, Ferguson SJ, et al.Vertebroplasty and kyphoplasty: a systematic review of 69 clinical studies[J].Spine (Phila Pa 1976), 2006, 31(17):1983-2001.

[7] Klazen CA, Lohle PN, de Vries J, et al.Vertebroplasty versus conservative treatment in acute osteoporotic vertebral compression fractures (Vertos II): an open-label randomised trial[J].Lancet, 2010, 376(9746):1085-1092.

[8] Genant HK, Wu CY, van Kuijk C, et al.Vertebral fracture assessment using a semiquantitative technique[J].J Bone Miner Res, 1993, 8(9):1137-1148.

[9] Huskisson EC.Measurement of pain[J].Lancet, 1974, 2(7889):1127-1131.

[10]Lee ST, Chen JF.Closed reduction vertebroplasty for the treatment of osteoporotic vertebral compression fractures. Technical note[J].J Neurosurg, 2004, 100(4 Suppl Spine):392-396.

[11]Hasserius R, Karlsson MK, Jónsson B, et al.Long-term morbidity and mortality after a clinically diagnosed vertebral fracture in the elderly-a 12-and 22-year follow-up of 257 patients[J].Calcif Tissue Int, 2005, 76(4):235-242.

[12]Suzuki N, Ogikubo O, Hansson T.The course of the acute vertebral body fragility fracture: its effect on pain, disability and quality of life during 12 months[J].Eur Spine J, 2008, 17(10):1380-1390.

[13]Yu CW, Hsieh MK, Chen LH, et al.Percutaneous balloon kyphoplasty for the treatment of vertebral compression fractures[J].BMC Surg, 2014, 14:3.

[14]Song BK, Eun JP, Oh YM.Clinical and radiological comparison of unipedicular versus bipedicular balloon kyphoplasty for the treatment of vertebral compression fractures[J].Osteoporos Int, 2009, 20(10):1717-1723.

[15]Chen JF, Lee ST, Lui TN, et al.Percutaneous vertebroplasty for the treatment of osteoporotic vertebral compression fractures: a preliminary report[J].Chang Gung Med J, 2002, 25(5):306-314.

[16]Luo J, Daines L, Charalambous A, et al. Vertebroplasty: only small cement volumes are required to normalize stress distributions on the vertebral bodies[J].Spine (Phila Pa 1976), 2009, 34(26):2865-2873.

[17]Omidi-Kashani F, Samini F, Hasankhani EG, et al.Does percutaneous kyphoplasty have better functional outcome than vertebroplasty in single level osteoporotic compression fractures? A comparative prospective study[J].J Osteoporos, 2013:690329.

[18]胡英江, 馬永東, 常琴.不同時限行經(jīng)皮椎體成形術的臨床分析[J].脊柱外科雜志, 2013, 11(4):230-232.

[19]Nussbaum DA, Gailloud P, Murphy K.A review of complications associated with vertebroplasty and kyphoplasty as reported to the Food and Drug Administration medical device related web site[J].J Vasc Interv Radiol, 2004, 15(11):1185-1192. ST, Chen JF.Closed reduction vertebroplasty for the treatment of osteoporotic vertebral compression fractures. Technical note[J].J Neurosurg, 2004, 100(4 Suppl Spine):392-396.

[11]Hasserius R, Karlsson MK, Jónsson B, et al.Long-term morbidity and mortality after a clinically diagnosed vertebral fracture in the elderly-a 12-and 22-year follow-up of 257 patients[J].Calcif Tissue Int, 2005, 76(4):235-242.

[12]Suzuki N, Ogikubo O, Hansson T.The course of the acute vertebral body fragility fracture: its effect on pain, disability and quality of life during 12 months[J].Eur Spine J, 2008, 17(10):1380-1390.

[13]Yu CW, Hsieh MK, Chen LH, et al.Percutaneous balloon kyphoplasty for the treatment of vertebral compression fractures[J].BMC Surg, 2014, 14:3.

[14]Song BK, Eun JP, Oh YM.Clinical and radiological comparison of unipedicular versus bipedicular balloon kyphoplasty for the treatment of vertebral compression fractures[J].Osteoporos Int, 2009, 20(10):1717-1723.

[15]Chen JF, Lee ST, Lui TN, et al.Percutaneous vertebroplasty for the treatment of osteoporotic vertebral compression fractures: a preliminary report[J].Chang Gung Med J, 2002, 25(5):306-314.

[16]Luo J, Daines L, Charalambous A, et al. Vertebroplasty: only small cement volumes are required to normalize stress distributions on the vertebral bodies[J].Spine (Phila Pa 1976), 2009, 34(26):2865-2873.

[17]Omidi-Kashani F, Samini F, Hasankhani EG, et al.Does percutaneous kyphoplasty have better functional outcome than vertebroplasty in single level osteoporotic compression fractures? A comparative prospective study[J].J Osteoporos, 2013:690329.

[18]胡英江, 馬永東, 常琴.不同時限行經(jīng)皮椎體成形術的臨床分析[J].脊柱外科雜志, 2013, 11(4):230-232.

[19]Nussbaum DA, Gailloud P, Murphy K.A review of complications associated with vertebroplasty and kyphoplasty as reported to the Food and Drug Administration medical device related web site[J].J Vasc Interv Radiol, 2004, 15(11):1185-1192.

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