Skip to main content
SpringerLink
Log in

Lower Extremity Intervention

  • Chapter
  • First Online:
Peripheral and Cerebrovascular Intervention

Part of the book series: Contemporary Cardiology ((CONCARD))

  • 1118 Accesses

Abstract

Angioplasty with or without stenting remains the mainstay of interventional therapy for arterial occlusive disease of the aortoiliac and femoropopliteal systems. Mortality in patients with peripheral arterial disease, however, derives primarily from systemic cardiovascular events. As such, all patients should have aggressive control of relevant risk factors (e.g., hypertension, diabetes, hyperlipidemia). Decisions regarding revascularization for patients with claudication must be individualized in contrast to patients with critical limb ischemia, who should routinely undergo revascularization. Noncomplex lesions of the iliac arteries may be treated with angioplasty alone; stenting should be reserved for special cases. Stent placement should be more liberal in complex aortoiliac lesions. Stent placement for femoropopliteal disease is more controversial. Techniques for conventional and subintimal angioplasty of both aortoiliac and femoropopliteal segments along with stent placement are described along with outcomes and postprocedural care.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 89.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 119.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 169.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Dotter CT, Judkins MP. Transluminal treatment of arteriosclerotic obstruction. Description of a new technique and a preliminary report of its application. Circulation. 1964;30:654–670.

    PubMed  CAS  Google Scholar 

  2. Gruntzig A, Kumpe DA. Technique of percutaneous transluminal angioplasty with the Gruntzig ­balloon catheter. AJR 1979;132:547–552.

    PubMed  CAS  Google Scholar 

  3. Sigwart U, Puel J, Mirkovitch V, Joffre F, Kappenberger L. Intravascular stents to prevent occlusion and restenosis after transluminal angioplasty. N Engl J Med. 1987;316:701–706.

    Article  PubMed  CAS  Google Scholar 

  4. Palmaz JC, Sibbitt RR, Reuter SR, Tio FO, Rice WJ. Expandable intraluminal graft: a preliminary study: work in progress. Radiology. 1985;156:73–77.

    PubMed  CAS  Google Scholar 

  5. Schatz RA, Palmaz JC, Tio FO, Garcia F, Garcia O, Reuter SR. Balloon-expandable intracoronary stents in the adult dog. Circulation. 1987;76:450–457.

    Article  PubMed  CAS  Google Scholar 

  6. Taute BM, Thommes S, Taute R, Rapmund I, Lindner K, Podhaisky H. Long-term outcome of patients with mild intermittent claudication under secondary prevention. Vasa. 2009; 38(5):346–355.

    Article  PubMed  Google Scholar 

  7. Aquino R, Johnnides C, Makaroun M, et al. Natural history of claudication: Long-term serial ­follow-up study of 1244 claudicants. J Vasc Surg. 2001; 34:962–970.

    Article  PubMed  CAS  Google Scholar 

  8. Olin JW, Sealove BA. Peripheral artery disease: current insight into the disease and its diagnosis and management. Mayo Clin Proc. 2010;85(7):678–692.

    Article  PubMed  Google Scholar 

  9. Kannel WB, Shurtleff D. The Framingham Study: cigarettes and the development of intermittent claudication. Geriatrics. 1973;28(2):61–68.

    PubMed  CAS  Google Scholar 

  10. Jonason T, Bergstrom R. Cessation of smoking in patients with intermittent claudication: effects on the risk of peripheral vascular complications, myocardial infarction and mortality. Acta Med Scand. 1987;221(3):253–260.

    Article  PubMed  CAS  Google Scholar 

  11. Kumakura G, Kanai H, Aizaki M, et al. The influence of the obesity paradox and chronic kidney disease on long-term survival in a Japanese cohort with peripheral arterial disease. J Vasc Surg. 2010;52(1):110–117.

    Article  PubMed  Google Scholar 

  12. Lavie CJ, Milani RV, Ventura HO. Obesity and cardiovascular disease: risk factor, paradox, and impact of weight loss. J Am Coll Cardiol. 2009;53:1925–1932.

    Article  PubMed  Google Scholar 

  13. Gardner AW, Poehlman ET. Exercise rehabilitation programs for the treatment of claudication pain. A meta-analysis. JAMA. 1995;274:975–980.

    CAS  Google Scholar 

  14. Regensteiner JG, Gardner A, Hiatt WR. Exercise testing and exercise rehabilitation for patients with peripheral arterial disease: status in 1997. Vasc Med. 1997;2:147–155.

    PubMed  CAS  Google Scholar 

  15. Izquierdo-Porrera AM, Gardner AW, Powell CC, Katzel LI. Effects of exercise rehabailitation on cardiovascular risk factors in older patients with peripheral arterial occlusive disease. J Vasc Surg. 2000;31:670–677.

    Article  PubMed  CAS  Google Scholar 

  16. Antithrombotic Trialist Collaboration. Collaborative meta-analysis of randomized trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ. 2002;324(7329):71–86.

    Article  Google Scholar 

  17. Berger JS, Krantz MJ, Kittelson JM, Hiatt WR. Aspirin for the prevention of cardiovascular events in patients with peripheral artery disease: a meta-analysis of randomized trials. JAMA. 2009;301(18):1909–1919.

    Article  PubMed  CAS  Google Scholar 

  18. CAPRIE Steering Committee. A randomized, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet. 1996;348(9038):1329–1339.

    Article  Google Scholar 

  19. Murabito JM, D’Agostino RB, Silbershatz H, Wilson WF. Intermittent claudication. A risk profile from The Gramingham Heart Study. Circulation. 1997;96:44–49.

    PubMed  CAS  Google Scholar 

  20. Kannel WB, McGee DL. Update on some epidemiologic features of intermittent claudication: The Framingham Study. J Am Geriatr Soc. 1985;33:13–18.

    PubMed  CAS  Google Scholar 

  21. Kannel WB, McGee D. Diabetes and cardiovascular disease. The Framingham Study. JAMA. 1979;241:2035–2038.

    Article  PubMed  CAS  Google Scholar 

  22. Kannel WB, D’Agostino RB, Wilson PW, et al. Diabetes, fibrinogen, and risk of cardiovascular disease: The Framingham experience. Am Heart J. 1990;120:672–676.

    Article  PubMed  CAS  Google Scholar 

  23. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet. 1998;352:837–853.

    Article  Google Scholar 

  24. Sixth report of the Joint National Committee on detection, evaluation, and treatment of high blood pressure (JNC-VI). Arch Intern Med. 1997;157:2413–2446.

    Article  Google Scholar 

  25. Vogt MT, Cauley JA, Kuller LH, Hulley SB. Prevalence and correlates of lower extremity arterial disease in elderly women. Am J Epidemiol. 1993;137:559–568.

    PubMed  CAS  Google Scholar 

  26. Safar ME, Laurent S, Asmar RE, et al. Systolic hypertension in patients with arteriosclerosis obliterans of the lower limbs. Angiology. 1987;38:287–295.

    Article  PubMed  CAS  Google Scholar 

  27. Hirsch AT, Haskal ZJ, Hertzer NR, et al. ADD/AHA 2005 Practice guidelines for the management of patients with peripheral arterial disease(lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular Pulmonary Rehabilitation: National Heart, Lung, and Blood Institute; Society for Vascular ; Transatlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation. 2006;113(11):e463–e654.

    Article  PubMed  Google Scholar 

  28. Radack K, Deck C. Beta-adrenergic blocker therapy does not worsen intermittent claudication in ­subjects with peripheral arterial disease: a meta-analysis of randomized controlled trials. Arch Intern Med. 1991;151(9):1769–1776.

    Article  PubMed  CAS  Google Scholar 

  29. Lonn E, Yusuf S, Dzavik V, et al. Effects of ramipril and vitamin E on atherosclerosis  : the study to evaluate carotid ultrasound changes in patients treated with ramipril and vitamin E (SECURE). Circulation. 2001;103(7):919-925.

    PubMed  CAS  Google Scholar 

  30. Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G; Heart Outcomes Prevention Evaluation Study Investgators. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. N Engl J Med. 2000; 342(3):145–153.

    Article  PubMed  CAS  Google Scholar 

  31. Fox KM. Efficacy of perindopril in reduction of cardiovascular events among patients with stable coronary artery disease: randomized, double-blind, placebo-controlled, multicentre trial (the EUROPA study). Lancet. 2003;262(9386):782–788.

    Google Scholar 

  32. Heart Protection Study Collaborative Group. MRC/BHF heart protection study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomized placebo-controlled trial. Lancet. 2002;360(9326):7–22.

    Article  Google Scholar 

  33. Randomized trial of cholesterol lowering in 4444 patients with coronary heart disease: The Scandinavian Simvastatin Survival Study (4S). Lancet. 1994;344(8934):1383–1389.

    Google Scholar 

  34. Olsson AG, Ruhn G, Erikson U. The effect of serum lipid regulation on the development of femoral atherosclerosis in hyperlipidaemia: a non-randomized controlled study. J Intern Med. 1990;227:381–390.

    Article  PubMed  CAS  Google Scholar 

  35. McDermott MM, Guralnik JM, Greenland P, et al. Statin use and leg functioning in patients with and without lower-extremity peripheral arterial disease. Circulation. 2003;107(5):757–761.

    Article  PubMed  CAS  Google Scholar 

  36. Giri J, McDermott MM, Greenland P, et al. Statin use and functional decline in patients with and without peripheral arterial disease. J Am Coll Cardiol. 2006;47(5):998–1004.

    Article  PubMed  CAS  Google Scholar 

  37. Leng GC, Fowler B, Ernst E. Exercise for intermittent claudication. Cochrane Database Syst Rev. 2000; (2):CD000990.

    Google Scholar 

  38. Hood SC, Moher D, Barber GG. Management of intermittent claudication with pentoxifylline: meta-analysis of randomized controlled trials. Can Med Assoc J. 1996;155:1053–1059.

    CAS  Google Scholar 

  39. Girolami B, Bernardi E, Prins MH, et al. Treatment of intermittent claudication with physical training, smoking cessation, pentoxifylline, or nafronyl: a meta-analysis. Arch Intern Med. 1999;150:337–345.

    Article  Google Scholar 

  40. Regensteiner JG, Hiatt WR. Improvements in quality of life in cilostazol-treated patients with intermittent claudication. Vasc Med. 2000;5:198.

    Google Scholar 

  41. Beebe HG, Dawson GL, Cutler BS, et al. A new pharmacological treatment for intermittent claudication: results of a randomized, multicenter trial. Arch Intern Med. 1999;150:2041–2049.

    Article  Google Scholar 

  42. Money SR, Herd JA, Isaacsohn JL, et al. Effect of cilostazol on walking distances in patients with intermittent claudication caused by peripheral vascular disease. J Vasc Surg. 1998;27:267–274.

    Article  PubMed  CAS  Google Scholar 

  43. Strandness DE Jr. Two doses of cilostazol versus placebo in the treatment of claudication: results of a randomized multicenter trial. Circulation. 1998;95:I–12.

    Google Scholar 

  44. Dawson D, Cutler BS, Hiatt WR, et al. A comparison of cilostazol and pentoxifylline for treating intermittent claudication. Am J Med. 2000;109:523–530.

    Article  PubMed  CAS  Google Scholar 

  45. Whyman MR, Ruckley CV. Should claudicants receive angioplasty or just exercise training? Cardiovascular Surgery. 1998;6(3):226–231.

    Article  PubMed  CAS  Google Scholar 

  46. Spronk S, Bosch JL, Veen HF, den Hoed PT, Hunink MGM. Intermittent claudication: functional capacity and quality of life after exercise training or percutaneous transluminal angioplasty—systematic review. Radiology. 2005;235:833–842.

    Article  PubMed  Google Scholar 

  47. Wilson S, Gelfand D, Jimenez J, Gordon I. Comparison of the results of percutaneous transluminal angioplasty and stenting with medical treatment for claudicants who have superficial femoral artery occlusive disease. Vascular. 2006;14(2):81–87.

    Article  PubMed  Google Scholar 

  48. Nylaende M, Abdelnoor M, Stranden E, et al. The Oslo Ballon Angioplasty versus Conservative Treatment Study (OBACT)—The 2-years results of a single centre, prospective, randomized study in patients with intermittent claudication. Eur J Vasc Endovas Surg. 2007;33:3–12.

    Article  CAS  Google Scholar 

  49. The MIMIC Trial Participants. The adjuvant benefit of angioplasty in patients with mild to moderate intermittent claudication (MIMIC) managed by supervised exercise, smoking cessation advice and best medical therapy: results from tow randomized trials for stenotic femoropopliteal and aortoiliac arterial disease. Eur J Vasc Endovas Surg. 2008;36:680–688.

    Article  Google Scholar 

  50. Mazari JAK, Gulati S, Rahman MNA, et al. Early outcomes from a randomized, controlled trial of supervised exercise, angioplasty, and combined therapy in intermittent claudication. Ann Vasc Surg. 2010;24:69–79.

    Article  PubMed  CAS  Google Scholar 

  51. Management of peripheral arterial disease(PAD). TransAtlantic Inter-Society Consensus (TASC). J Vasc Surg. 2000;31:S1–S206.

    Google Scholar 

  52. Novo S, Coppola G, Milio G. Critical limb ischemia: definition and natural history. Current Drug Targets. Cardiovascular & Haematological Disorders. 2004;4:219–225.

    Article  CAS  Google Scholar 

  53. Slovut DP, Sullivan TM. Critical limb ischemia: medical and surgical management. Vascular Med. 2008;13:281–291.

    Article  Google Scholar 

  54. Varu VN, Hogg ME, Kibbe MR. Critical limb ischemia J Vasc Surg. 2010;51:230–241.

    Article  PubMed  Google Scholar 

  55. Adam DJ, Beard JD, Cleveland T, et al. Bypass versus angioplasty in severe ischaemia of the leg (BASIL): multicentre, randomized controlled trial. Lancet. 2005;366:1925–1934.

    Article  PubMed  CAS  Google Scholar 

  56. Walsh JJ Jr, Cofelice M, Limpkin D, Kerstein MD. Is screening for vascular disease a valuable proposition? J Cardiovasc Surg 1988;29:306–309.

    Google Scholar 

  57. U.S. Preventive Services Task Force. Screening for Peripheral Arterial Disease: Recommendation Statement. AHRQ Publication No. 05-0583-A-EF. Rockville, MD: Agency for Healthcare Research and Quality. 2005. http://www.ahrq.gov/clinic/uspstf05/pad/padrs.htm

  58. Hirsch AT, Criqui MH, Treat-Jacobson D, et al. Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA. 2001;286:1317–1324.

    Article  PubMed  CAS  Google Scholar 

  59. Hirsch AT, Halverson SL, Treat-Jacobson D, et al. The Minnesota regional peripheral arterial disease screening program: toward a definition of community standards of care. Vascular Med. 201;6:87–96.

    Google Scholar 

  60. Bolia A, Fishwick G. Recanalization of iliac artery occlusions by subintimal dissection using the ipsilateral and the contralateral approach. Clin Radiol. 1997;52(9):684–687.

    Article  PubMed  CAS  Google Scholar 

  61. Leville CD, Kashyap VS, Clair DG, et al. Endovascular management of iliac artery occlusions: extending treatment to TransAtlantic Inter-Society Consensus class C and D patients. J Vasc Surg. 2006;43:32–39.

    Article  PubMed  Google Scholar 

  62. Gandini R, Gabiano S, Chiocchi M, Chiappa R, Simonetti G. Percutaneous treatment in iliac artery occlusion: long-term results. Cardiovasc Intervent Radiol. 2008;31:1069–1076.

    Article  PubMed  Google Scholar 

  63. Motarjeme A, Gordon GI, Bodenhagen K. Thrombolysis and angioplasty of chronic iliac artery occlusions. JVIR. 1995; 6:66S–72S.

    Article  PubMed  CAS  Google Scholar 

  64. Taddei G, Tamellini P, Niccolo F, Antonio I. Thrombolysis during the endovascular treatment of iliac artery occlusions. Diagn Interv Radiol. 2010;16:84–89.

    PubMed  Google Scholar 

  65. Klein W, van der Graaf Y, Seeger J, et al. Dutch iliac stent trial; long-term results in patients randomized for primary or selective stent placement. Radiology. 2005;238 (2): 734–744.

    Article  PubMed  Google Scholar 

  66. AbuRahma AF, Hayes JD, Flaherty SK, Peery W. Primary iliac stenting versus transluminal angioplasty with selective stenting. J Vasc Surg. 2007;46(5):965–970.

    Article  PubMed  Google Scholar 

  67. Krajcer Z, Sioco G, Reynolds T. Comparison of Wallfraft and Wallstent for treatment of complex iliac artery stenosis and occlusion. Tex Heart Inst J. 1997;24(3):193–199.

    PubMed  CAS  Google Scholar 

  68. Rzucidlo EM, Powell RJ, Zwolak RM, et al. Early results of stent-grafting to treat diffuse aortoiliac occlusive disease. J Vasc Surg. 2003;37:1175–1180.

    Article  PubMed  Google Scholar 

  69. Reekers JA, Bolia A. Percutaneous intentional extraluminal (subintimal) recanalization: how to do it yourself. Eur J Radiol. 1998;28:192–198.

    Article  PubMed  CAS  Google Scholar 

  70. Schillinger M, Sabeti S, Loewe C, et al. Galloon angioplasty versus implantation of nitinol stents in the superficial femoral artery. N Engl J Med. 2006;254(18):1879–1888.

    Article  Google Scholar 

  71. Laird JR, Katzen BT, Scheinert D, et al. RESILIENT investigators. Nitinol stent implantation versus balloon angioplasty for lesions in the superficial femoral artery and proximal popliteal artery: twelve-month results from the RESILIENT randomized trial. Circ Cardiovasc Interv. 2010;3(3):267–276.

    Article  PubMed  Google Scholar 

  72. Park KB, Do YS, Kim DI, et al. The TransAtlantic InterSociety Consensus (TASC) classification system in iliac arterial stent placement: long-term patency and clinical limitations. J Vasc Interv Radiol. 2007;18:193–201

    Article  PubMed  Google Scholar 

  73. Galaria II, Davies MG. Percutaneous transluminal revascularization for iliac occlusive disease: long-term outcomes in TransAtlantic Inter-Society Consensus A and B lesions. Ann Vasc Surg. 2005;19:352–360

    Article  PubMed  Google Scholar 

  74. Powell RJ, Fillinger M, Bettmann M, et al. The durability of endovascular treatment of multisegment iliac occlusive disease. J Vasc Surg. 2000;31:1178–1184

    PubMed  CAS  Google Scholar 

  75. Tetteroo E, van der Graaf Y, Bosch JL, et al. Randomised comparison of primary stent placement versus primary angioplasty followed by selective stent placement in patients with iliac-artery occlusive disease. Dutch Iliac Stent Trial Study Group. Lancet. 1998;351:1153–1159

    Article  PubMed  CAS  Google Scholar 

  76. Conrad MF, Cambria RP, Stone DH, et al. Intermediate results of percutaneous endovascular therapy of femoropopliteal occlusive disease: a contemporary series. J Vasc Surg. 2006;44:762–769

    Article  PubMed  Google Scholar 

  77. Dearing DD, Patel KR, Compoginis JM, Kamel MA, Weaver FA, Katz SG. Primary stenting of the superficial femoral and popliteal artery. J Vasc Surg. 2009;50:542–547.

    Article  PubMed  Google Scholar 

  78. Krankenberg H, Schluter M, Steinkamp HJ, et al. Nitinol stent implantation versus percutaneous transluminal angioplasty in superficial femoral artery lesions up to 10 cm in length: the femoral artery stenting trial (FAST). Circulation. 2007;116:285–292.

    Article  PubMed  CAS  Google Scholar 

  79. Gonzalo B, Solanich T, Bellmunt S, et al. Cryoplasty as endovascular treatment in the femoropopliteal region: hemodynamic results and follow-up at one year. Ann Vasc Surg. 2010;24:680–685.

    Article  PubMed  Google Scholar 

  80. Laird J, Jaff MR, Biamino G, et al. Cryoplasty for the treatment of femoropopliteal arterial disease: results of a prospective, multicenter registry. J Vasc Interv Radiol. 2005;16:1067–1073.

    Article  PubMed  Google Scholar 

  81. McKinsey JF, Goldstein L, Khan HU, et al. Novel treatment of patients with lower extremity ischemia: use of percutaneous atherectomy in 579 lesions. Ann Surg. 2008;248:519–528.

    PubMed  Google Scholar 

  82. Zeller T, Rastan A, Sixt S, et al. Long-term results after directional atherectomy of femoro-popliteal lesions. J Am Coll Cardiol. 2006;48:1573–1578.

    Article  PubMed  Google Scholar 

  83. Laird JR, Zeller T, Gray BH, et al. LACI Investigators. Limb salvage following laser-assisted angioplasty for critical limb ischemia: results of the LACI multicenter trial. J Endovasc Ther. 2006;13:1–11

    Article  PubMed  Google Scholar 

  84. Wissgott C, Scheinert D, Rademaker J, Werk M, Schedel H, Steinkamp HJ. Treatment of long superficial femoral artery occlusions with excimer laser angioplasty: long-term results after 48 months. Acta Radiol. 2004;45:23–29.

    Article  PubMed  CAS  Google Scholar 

  85. Norgren L, Hiatt WR, Dormandy JA, et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg. 2007;45:S5–S67.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Cleveland Clinic, Cleveland, OH, USA

    Samir K. Shah MD

  2. Department of Vascular Surgery, The Cleveland Clinic, Cleveland, OH, USA

    Daniel G. Clair MD

  3. CWRU Lerner College of Medicine, Cleveland, OH, USA

    Daniel G. Clair MD

Authors
  1. Samir K. Shah MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Daniel G. Clair MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Samir K. Shah MD .

Editor information

Editors and Affiliations

  1. and Women’s Hospital, and Harvard Medica, Department of Cardiovascular Medicine, VA Boston Healthcare System, Brigham, Francis Street 75, Boston, 02115, Massachusetts, USA

    Deepak L. Bhatt

Rights and permissions

Reprints and permissions

Copyright information

© 2012 Springer Science+Business Media, LLC

About this chapter

Cite this chapter

Shah, S.K., Clair, D.G. (2012). Lower Extremity Intervention. In: Bhatt, D. (eds) Peripheral and Cerebrovascular Intervention. Contemporary Cardiology. Humana Press. https://doi.org/10.1007/978-1-60327-965-9_2

Download citation

  • DOI: https://doi.org/10.1007/978-1-60327-965-9_2

  • Published:

  • Publisher Name: Humana Press

  • Print ISBN: 978-1-60327-964-2

  • Online ISBN: 978-1-60327-965-9

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation