Papers by Mårten Falkenberg
European Journal of Vascular and Endovascular Surgery, Dec 1, 2019
European Journal of Vascular and Endovascular Surgery, Jun 1, 2021
OBJECTIVE To identify factors affecting the outcome after open surgical (OSR) and endovascular (E... more OBJECTIVE To identify factors affecting the outcome after open surgical (OSR) and endovascular (ER) repair of popliteal artery aneurysm (PA) in comparable cohorts. METHODS A matched comparison in a national, population based cohort of 592 legs treated for PA (2008 - 2012), with long term follow up. Registry data from 899 PA patients treated in 2014 - 2018 were analysed for time trends. The 77 legs treated by ER were matched, by indication, with 154 legs treated with OSR. Medical records and imaging were collected. Analysed risk factors were anatomy, comorbidities, and medication. Elongation and angulations were examined in a core lab. The main outcome was occlusion. RESULTS Patients in the ER group were older (73 vs. 68 years, p = .001), had more lung disease (p = .012), and were treated with dual antiplatelet therapy or anticoagulants more often (p < .001). The hazard ratio (HR with 95% confidence intervals) for occlusion was 2.69 (1.60 - 4.55, p < .001) for ER, but 3.03 (1.26 - 7.27, p = .013) for poor outflow. For permanent occlusion, the HR after ER was 2.47 (1.35 - 4.50, p = .003), but 4.68 (1.89 - 11.62, p < .001) for poor outflow. In the ER subgroup, occlusion was more common after acute ischaemia (HR 2.94 [1.45 - 5.97], p = .003; and poor outflow HR 14.39 [3.46 - 59.92], p < .001). Larger stent graft diameter reduced the risk (HR 0.71 [0.54 - 0.93], p = .014). In Cox regression analysis adjusted for indication and stent graft diameter, elongation increased the risk (HR 1.020 per degree [1.002 - 1.033], p = .030). PAs treated for acute ischaemia had a median stent graft diameter of 6.5 mm, with those for elective procedures being 8 mm (p < .001). Indications and outcomes were similar during both time periods (2008 - 2012 and 2014 - 2018). CONCLUSION In comparable groups, ER had a 2.7 fold increased risk of any occlusion, and 2.4 fold increased risk of permanent occlusion, despite more aggressive medical therapy. Risk factors associated with occlusion in ER were poor outflow, smaller stent graft diameter, acute ischaemia, and angulation/elongation. An association between indication, acute ischaemia, and small stent graft diameter was identified.
Acta Radiologica, Jul 20, 2016
Background Renal artery duplex ultrasound (RADUS) is an established method for diagnosis of renal... more Background Renal artery duplex ultrasound (RADUS) is an established method for diagnosis of renal artery stenosis (RAS), but there is no consensus regarding optimal RADUS criteria. Purpose To define optimal cutoff values for RADUS parameters when screening for RAS using intra-arterial trans-stenotic pressure gradient measurement (PGM) as reference. Material and Methods The renal arteries of 58 consecutive patients evaluated for renovascular hypertension were examined by RADUS and PGM. Conclusive measurements with both methods were obtained in 76 arteries. Hemodynamically significant RAS was defined as PGM ≥15 mmHg and was found in 43 of the 76 arteries. RADUS parameters included renal artery peak systolic velocity (PSV) and the renal–aortic ratio (RAR) of flow velocities. Receiver operating characteristic curves (ROCs) and Youden’s index were used to calculate optimal RADUS criteria for RAS. Results When traditional RADUS criteria for RAS were used, with a combination of PSV ≥180 cm/s and RAR ≥3.5, the sensitivity was 62% and the specificity was 91%. When RADUS criteria were optimized for sensitivity, then RAR ≥2.6 alone resulted in a sensitivity of 89% and a specificity of 69%. Conclusion The RAR ≥2.6 is a more sensitive criterion than traditional RADUS criteria when screening patients with clinical suspicion of RAS.
European Journal of Vascular and Endovascular Surgery, Aug 1, 2014
WHAT THIS PAPER ADDS Severe ischemiaereperfusion injury to the lower limb is a feared complicatio... more WHAT THIS PAPER ADDS Severe ischemiaereperfusion injury to the lower limb is a feared complication of prolonged vascular procedures and of acute conditions caused by sudden obstruction of arterial blood flow. This paper describes a novel and simple technique for arterial shunting to prevent intraoperative ischemia. The method is applicable in both endovascular and open surgical procedures. Objectives: The use of an intraoperative shunt is an established technique used to reduce the ischemic time after acute arterial obstruction or in the prevention of hypoperfusion due to complex open vascular or endovascular operative procedures. To date, described methods of temporary extremity blood perfusion have required open surgical techniques. Methods: An endovascular shunt (ES) was formed by connecting two introducer sheaths to each other, one positioned proximal and one distal to an arterial obstruction. The ES method was used in patients considered to be at high risk for prolonged lower limb ischemia in conjunction with a vascular procedure and where shunt creation by open surgical technique was not considered to be a practical alternative. The flow capacity of the ES was defined in a desktop model. Results: The ES method was used clinically in 15 vascular interventions including eight complex endovascular aortic procedures, three open aortic operations, and four procedures for acute limb ischemia.The shunts were functional in all patients and there were no shunt occlusions. Postoperatively, there were no evident clinical reperfusion injuries. Flow analysis revealed that the ES had a flow capacity of 73% flow capacity compared to a Pruitt-Inahara shunt. Conclusion: A new method of temporary blood shunting in connection to vascular procedures has been demonstrated.
Journal of Endovascular Therapy, Sep 17, 2015
Purpose: To present a new combination of imaging techniques that helps reduce the use of iodinate... more Purpose: To present a new combination of imaging techniques that helps reduce the use of iodinated contrast during endovascular aneurysm repair (EVAR) procedures in patients with renal insufficiency. Technique: Relevant anatomical structures are marked in the preprocedure computed tomography (CT) angiogram. A 3D-3D image fusion between the preprocedure CT and an intraprocedure cone-beam CT is performed in order to overlay anatomical information on live fluoroscopy. Verification of the correct overlay matching (or adjustment if necessary) is based on carbon dioxide (CO2) digital subtraction angiograms (DSA) instead of iodine DSA. The stent-graft is placed and deployed based on the overlaid information. Correct device placement is finally verified with conventional contrast angiography. Conclusion: The combination of 3D image fusion of a preoperative CT with live fluoroscopy and CO2 DSA verification is feasible and sufficient for guidance of abdominal EVAR. This method minimizes the use of iodinated contrast media, protecting residual function in the setting of preexisting renal insufficiency.
Thrombosis and Haemostasis, 1996
SummaryLocal fibrinolytic changes in atherosclerotic arteries have been suggested to influence pl... more SummaryLocal fibrinolytic changes in atherosclerotic arteries have been suggested to influence plaque growth and promote mural thrombosis on ruptured or ulcerated plaques. Increased levels of plasminogen activator inhibitor (PAI-1) have been found in atherosclerotic arteries. In this study tissue plasminogen activator (t-PA), urokinase-type plasminogen activator (u-PA) and PAI-1 were localized in arterial biopsies of healthy and atherosclerotic vessels by immunohistochemis-try. The expression of fibrinolytic regulators was related to the distribution of endothelial cells (EC) and macrophages. Results: t-PA was expressed in vasa vasorum. PAI-1 was positive in endothelial cells, in the media and in the adventitia. Increased expression of t-PA, u-PA and PAI-1 was found in atherosclerotic vessels. t-PA, u-PA, PAI-1 and macrophages were co-localized in plaques. These results support the concept that macrophages can be important in the local regulation of fibrinolysis in atherosclerotic vessels.
Proceedings of the National Academy of Sciences of the United States of America, Jul 29, 2002
Overexpression of urokinase plasminogen activator (uPA) in endothelial cells can decrease intrava... more Overexpression of urokinase plasminogen activator (uPA) in endothelial cells can decrease intravascular thrombosis. However, expression of uPA is increased in atherosclerotic human arteries, which suggests that uPA might accelerate atherogenesis. To investigate whether elevated uPA expression accelerates atherogenesis, we cloned a rabbit uPA cDNA and expressed it in carotid arteries of cholesterol-fed rabbits. uPA gene transfer increased artery-wall uPA activity for at least 1 week, with a return to baseline by 2 weeks. One week after gene transfer, uPA-transduced arteries were constricted, with significantly smaller lumens and thicker walls, but no difference in intimal or medial mass. Two weeks after gene transfer, uPA-and control-transduced arteries were morphologically indistinguishable. By 4 weeks, however, uPA-transduced arteries had 70% larger intimas than control-transduced arteries (P < 0.01) and smaller lumens (P < 0.05). Intimal lesions appeared to be of similar composition in uPA-and control-transduced arteries, except that degradation of elastic laminae was evident in uPA-transduced arteries. These data suggest that elevated uPA expression in atherosclerotic arteries contributes to intimal growth and constrictive remodeling leading to lumen loss. Antagonists of uPA activity might, therefore, be useful in limiting intimal growth and preventing constrictive remodeling. Overexpression of uPA in endothelial cells to prevent intravascular thrombosis must be reconsidered, because this intervention could worsen underlying vascular disease.
European Journal of Vascular and Endovascular Surgery, Oct 1, 2007
Background: Stent grafts are used to treat aortic aneurysms, as a minimal invasive alternative to... more Background: Stent grafts are used to treat aortic aneurysms, as a minimal invasive alternative to open surgery. The aorta is accessed via percutaneous punctures in the groins and insertion of guide wires. A stent graft is advanced over the guide wire and deployed in the desired position, using x-ray fluoroscopic guidance. The procedure significantly reduces short-term morbidity and mortality compared to open repair, but has a higher rate of late complications and re-interventions. Two possible complications are: release of air bubbles during thoracic stent graft deployment may lead to cerebral embolization and immediate stroke, and long-term migration due to flow-induced forces may lead to leakage into the aneurysm sack and remaining risk of aortic rupture.
Atherosclerosis is a major cause of morbidity and mortality. The fibrinolytic system may be invol... more Atherosclerosis is a major cause of morbidity and mortality. The fibrinolytic system may be involved with several aspects of human atherosclerotic disease by regulating cellular migration, matrix remodelling and local thrombogenicity. The aim of the present investigation was to test the hypotheses: -Local expression of fibrinolytic factors is determined by inflammatory activity.-Macrophages and fibrinolytic factors are heterogeneously distributed in human atherosclerotic vessels.-Fibrinolytic factors are altered in aneurysmatic arteries. Immunohistochemistry was used to characterise the distribution of tissue plasminogen activator (t-PA), urokinase plasminogen activator (u-PA), plasminogen activator inhibitors type 1 and 2 (PAI-1 and PAI-2), tumour necrosis factor alpha (TNF), tissue factor (TF) and macrophages in vascular sections from patients with peripheral atherosclerotic disease. Co-localisation of fibrinolytic factors with macrophages was calculated using computer assisted image analysis of circumferential serial sections. Heterogeneity was evaluated by calculating the representativity of random samples concerning the expression of antigens as a function of sample size. Tissue extraction and immunosorbant assay was used to compare antigen and activity levels of fibrinolytic factors in aneurysmatic versus normal aortic tissue. The expression of fibrinolytic factors, especially u-PA and PAI-2, was different in atherosclerotic vessels compared to healthy controls and clearly related to the presence of macrophages. u-PA co-localised with an activated subpopulation of macrophages. Macrophages, fibrinolytic factors, TNF and TF were heterogeneously distributed in atherosclerotic vessels and the representativity of small vascular samples was poor. u-PA antigen concentration was increased and t-PA activity was decreased in aneurysmatic aortas. The results of the present study indicate that inflammatory reactions in human atherosclerotic vessels may be modulated by the fibrinolytic system, in particular by u-PA and PAI-2. Inflammatory activation and proteolytic activation may be interrelated via the u-PA-plasmin pathway. Atherosclerotic vessels are heterogeneous with respect to various important factors and results based on small vascular samples should be carefully evaluated. Furthermore, the value of small vascular samples in a clinical situation is likely to be low. Increased u-PA concentration in aortic aneurysms may promote proteolytic degradation of the vessel wall and decreased t-PA activity may contribute to mural thrombosis in the aneurysmal sac
European Journal of Vascular and Endovascular Surgery, Sep 1, 2017
This paper explores the minimum important difference of the VascuQoL-6 (VQ-6), a disease specific... more This paper explores the minimum important difference of the VascuQoL-6 (VQ-6), a disease specific health related quality of life instrument, following revascularisation for PAD. Numerical VQ-6 thresholds for a minimum important change and a substantial clinical benefit after revascularisation in intermittent claudication and critical limb ischaemia are presented, which could be used when evaluating outcomes following different interventions in PAD and in the design of clinical trials. Objectives: Patient reported outcomes are increasingly used to assess outcomes after peripheral arterial disease (PAD) interventions. VascuQoL-6 (VQ-6) is a PAD specific health-related quality of life (HRQoL) instrument for routine clinical practice and clinical research. This study assessed the minimum important difference for the VQ-6 and determined thresholds for the minimum important difference and substantial clinical benefit following PAD revascularisation. Materials and methods: This was a population-based observational cohort study. VQ-6 data from the Swedvasc Registry (January 2014 to September 2016) was analysed for revascularised PAD patients. The minimum important difference was determined using a combination of a distribution based and an anchor-based method, while receiver operating characteristic curve analysis (ROC) was used to determine optimal thresholds for a substantial clinical benefit following revascularisation. Results: A total of 3194 revascularised PAD patients with complete VQ-6 baseline recordings (intermittent claudication (IC) n ¼ 1622 and critical limb ischaemia (CLI) n ¼ 1572) were studied, of which 2996 had complete VQ-6 recordings 30 days and 1092 a year after the vascular intervention. The minimum important difference 1 year after revascularisation for IC patients ranged from 1.7 to 2.2 scale steps, depending on the method of analysis. Among CLI patients, the minimum important difference after 1 year was 1.9 scale steps. ROC analyses demonstrated that the VQ-6 discriminative properties for a substantial clinical benefit was excellent for IC patients (area under curve (AUC) 0.87, sensitivity 0.81, specificity 0.76) and acceptable in CLI (AUC 0.736, sensitivity 0.63, specificity 0.72). An optimal VQ-6 threshold for a substantial clinical benefit was determined at 3.5 scale steps among IC patients and 4.5 in CLI patients. Conclusions: The suggested thresholds for minimum important difference and substantial clinical benefit could be used when evaluating VQ-6 outcomes following different interventions in PAD and in the design of clinical trials.
European Journal of Vascular and Endovascular Surgery, Feb 1, 2015
WHAT THIS PAPER ADDS This is the first randomized trial including two centers comparing the fasci... more WHAT THIS PAPER ADDS This is the first randomized trial including two centers comparing the fascia suture technique with a suturemediated closure device in patients having endovascular treatment of aortic aneurysms and dissections. The study brings information about access closure time and cost and also the complication rate for both techniques and independent risk factors for failure. 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 peri-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% CI 1.25e1.90, p < .001) according to regression analysis. Adjusted for operator experience the mean ratio was 1.30 (95% CI 1.09e1.55, p ¼ .005) and for patient body mass index 1.59 (95% CI 1.28e1.96, 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 ¼ .003). The proficiency level group had a technical failure rate of 4% (1/26) for FST and 7% (1/14) for Prostar, p ¼ 1.00, while corresponding rates for the basic level group were 27% (6/22) for FST and 30% (11/37) for Prostar (p ¼ .84). There was a significant difference in cost in favor of FST, with a median difference of V800 (95% CI 710e927, p < .001). Conclusions: In aortic endovascular repair FST is a faster and cheaper technique than the Prostar technique.
European Journal of Trauma and Emergency Surgery, Aug 11, 2017
variables, REBOA-specific data, complications and 30-days mortality were reported. Results Ninety... more variables, REBOA-specific data, complications and 30-days mortality were reported. Results Ninety-six cases from 6 different countries were reported between 2011 and 2016. Mean age was 52 ± 22 years and 88% of the cases were blunt trauma with a median injury severity score (ISS) of 41 (IQR 29-50). In the majority of the cases, Zone I REBOA was used. Median systolic blood pressure before balloon inflation was 60 mmHg (IQR 40-80), which increased to 100 mmHg (IQR 80-128) after inflation. Continuous occlusion was applied in 52% of the patients, and 48% received non-continuous occlusion. Occlusion time longer than 60 min was reported as 38 and 14% in the non-continuous and continuous groups, respectively. Complications, such as extremity compartment Abstract Purpose Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a technique for temporary stabilization of patients with non-compressible torso hemorrhage. This technique has been increasingly used worldwide during the past decade. Despite the good outcomes of translational studies, clinical studies are divided. The aim of this multicenter-international study was to capture REBOA-specific data and outcomes. Methods REBOA practicing centers were invited to join this online register, which was established in September 2014. REBOA cases were reported, both retrospective and prospective. Demographics, injury patterns, hemodynamic
Apmis, 1997
Serosal trauma elicits an inflammatory response which leads to the deposition of fibrin at injure... more Serosal trauma elicits an inflammatory response which leads to the deposition of fibrin at injured sites, the residuals of which appear to be essential in excessive tissue repair and formation of intraabdominal adhesions. Local plasminogen activity may modulate this early phase of tissue repair. The present study was undertaken to investigate the distribution and cellular expression of plasminogen activators and their inhibitors in human peritoneal normal and inflamed tissue. Tissue-type plasminogen activator (t-PA) was expressed in subserosal capillary walls, and in normal mesothelium, but not in inflammation. Immunoreactivity for the plasminogen activator inhibitor type 1 (PAI-1) was present in normal mesothelium, and substantially increased in inflammation, where, in addition, immunoreactivity was found throughout the submesothelial tissue. This PAI-1 was partly co-localized with macrophages, as was the urokinase plasminogen activator (u-PA), suggesting an involvement of these cells in peritoneal tissue fibrinolysis. Inflammation or abrasion of the mesothelium during surgery is likely to cause a depletion of the local t-PA source and expose the potentially PAI-1-containing submesothelial tissue, thus promoting persistence of fibrin and formation of adhesions.
Interactive Cardiovascular and Thoracic Surgery, Jul 25, 2022
Can aneurysmal expansion of chronic aortic dissection be prevented by sealing the proximal entry ... more Can aneurysmal expansion of chronic aortic dissection be prevented by sealing the proximal entry with an endovascular plug? Key Findings Endovascular occlusion of proximal entries can stop and reverse aortic expansion in patients not eligible for conventional treatment. Take-home message Endovascular occlusion of the proximal entries reduces the aortic diameter in selected patients with expanding chronic aortic dissection.
Journal of Endovascular Therapy, Jun 25, 2018
Radiation Protection Dosimetry, May 25, 2021
Imaging optimisation can benefit from combining structured data with qualitative data in the form... more Imaging optimisation can benefit from combining structured data with qualitative data in the form of audio and video recordings. Since video is complex to work with, there is a need to find a workable solution that minimises the additional time investment. The purpose of the paper is to outline a general workflow that can begin to address this issue. What is described is a data management process comprising the three steps of collection, mining and contextualisation. This process offers a way to work systematically and at a large scale without succumbing to the context loss of statistical methods. The proposed workflow effectively combines the video and structured data to enable a new level of insights in the optimisation process.
European Journal of Vascular and Endovascular Surgery, Oct 1, 2021
OBJECTIVE Invasive treatment of intermittent claudication (IC) is commonly performed, despite lim... more OBJECTIVE Invasive treatment of intermittent claudication (IC) is commonly performed, despite limited evidence of its cost effectiveness. IC symptoms are mainly caused by atherosclerotic lesions in the superficial femoral artery (SFA), and endovascular treatment is performed frequently. The aim of this study was to investigate its cost effectiveness vs. non-invasive treatment. METHODS One hundred patients with IC due to lesions in the SFA were randomised to treatment with primary stenting, best medical treatment (BMT) and exercise advice (stent group), or to BMT and exercise advice alone (control group). Patients were recruited at seven hospitals in Sweden. For this analysis of cost effectiveness after 24 months, 84 patients with data on quality adjusted life years (QALY; based on the EuroQol Five Dimensions EQ-5D 3L™ questionnaire) were analysed. Patient registry and imputed cost data were used for accumulated costs regarding hospitalisation and outpatient visits. RESULTS The mean cost per patient was €11 060 in the stent group and €4 787 in the control group, resulting in a difference of €6 273 per patient between the groups. The difference in mean QALYs between the groups was 0.26, in favour of the stent group, which resulted in an incremental cost effectiveness ratio (ICER) of € 23 785 per QALY. CONCLUSION The costs associated with primary stenting in the SFA for the treatment of IC were higher than for exercise advice and BMT alone. With concurrent improvement in health related quality of life, primary stenting was a cost effective treatment option according to the Swedish national guidelines (ICER < €50 000 - €70 000) and approaching the UK's National Institute for Health and Care Excellence threshold for willingness to pay (ICER < £20 000 - £30 000). From a cost effectiveness standpoint, primary stenting of the SFA can, in many countries, be used as an adjunct to exercise training advice, but it must be considered that successful implementation of structured exercise programmes and longer follow up may alter these findings.
European Journal of Surgery, Sep 17, 1999
Objective: To investigate the effect of hyperbaric oxygen treatment (HBO) on the thrombolytic pro... more Objective: To investigate the effect of hyperbaric oxygen treatment (HBO) on the thrombolytic properties of endothelial cells. Setting: University hospital, Sweden. Interventions: Human endothelial cells were derived from saphenous veins, and exposed to oxygen in a compression chamber at 2.5 atmospheres absolute (ATA, =250kPa). Cells exposed to 2.5 ATA with a gas mixture similar to air (HB Air), and unpressurised air-exposed cells served as controls. Main outcome measures: Tissue-type plasminogen activator (t-PA) and plasminogen activator inhibitor type-1 (PAI-1). Results: Immediately after treatment there was a significant increase in t-PA protein in the medium in cultures treated with HBO compared with HB Air (p = 0.015, n = 6), and untreated controls (p = 0.015, n = 6). The PAI-1 concentration in media was also higher in the HBO-treated group compared with HB Air (p = 0.004, n = 6) and untreated controls (p = 0.004, n = 6). Six hours after treatment there was still a significant increase in PAI-1 in the HBO-treated group compared with untreated controls (p = 0.007, n = 6), but not with the pressure control. t-PA concentrations were similar. Specific mRNA for t-PA and PAI-1 was detectable immediately after treatment and six hours later in all experimental groups as assessed by reverse transcriptase polymerase chain reaction (RT-PCR). HBO increased the gene expression for both t-PA and PAI-1. Conclusions: HBO affects endothelial cell function and its fibrinolytic response. These findings may have clinical relevance in hyperbaric medicine and trauma care.
European Journal of Surgery, 2001
Objective: To measure the concentrations and activities of plasminogen activators and plasminogen... more Objective: To measure the concentrations and activities of plasminogen activators and plasminogen activator inhibitors in human abdominal aneurysms. Design: Laboratory study. Setting: University hospital, Sweden. Material: Biopsy specimens from 12 abdominal aortic aneurysms and 8 normal aortas (controls). Intrerventions: Tissues were homogenised and eluted. The supernatants were assayed for antigens of tissue and urokinase plasminogen activator and plasminogen activator inhibitor 1 and 2. The activities of tissue plasminogen activator and plasminogen activator inhibitor-1 were assayed by ELISA. Frozen sections were immunostained for tissue and urokinase plasminogen activators and for plasminogen activator inhibitor-1. Main outcome measures: Concentrations and activities of these activators and inhibitors. Results: The concentration of urokinase plasminogen activator antigen was higher in aneurysmal walls than in normal aortas; it was detected immunohistochemically in aneurysmal but not in normal aortas. The concentration (and the detection immunohistochemically) of tissue plasminogen activator was equal in aneurysmal and normal aortas, but its activity was reduced in the aneurysmal wall. Plasminogen activator inhibitor-1 did not differ signi cantly between the groups. Conclusions: Urokinase plasminogen activator may be responsible for the digestion of the media of the aorta and the development of an aneurysm. Reduced activity of tissue plasminogen activator may be responsible for thrombosis in the aneurysm.
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Papers by Mårten Falkenberg