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ABSTRACT: OBJECTIVE: To compare arterial elasticity in children, adolescents, and young adults with and without metabolic syndrome (MetS), and to assess which MetS components, demographic measures, and body composition measures are associated with arterial elasticity. MATERIALS/METHODS: Two-hundred six subjects (107 females and 99 males) between the ages of 10 and 20years were recruited by local newspaper advertisements, university email advertisements, and informational flyers. Subjects were assessed on MetS components, demographic measures, body composition measures, and arterial elasticity via radial tonometry. Forty-five subjects (22%) had MetS, as defined by the International Diabetes Federation, and 161 subjects (78%) did not. RESULTS: The primary novel finding was that group differences were not observed for large artery elasticity index (LAEI) (MetS=16.1±4.4 (ml×mmHg(-1))×10 (mean±SD), control=15.4±4.9, (ml×mmHg(-1))×10, p=0.349), and small artery elasticity index (SAEI) (MetS=9.2±2.7 (ml×mmHg(-1))×100, control=8.4±2.9, (ml×mmHg(-1))×100, p=0.063). In the MetS group, fat free mass was positively associated with arterial elasticity, and was the strongest multivariate predictor of LAEI (partial R(2)=0.41) and SAEI (partial R(2)=0.29). CONCLUSIONS: Youth with MetS did not exhibit differences in LAEI and SAEI compared to controls. Furthermore, fat free mass of youth with MetS was positively associated with arterial elasticity, and was the strongest predictor of both LAEI and SAEI. The clinical implication is that exercise intervention designed to increase fat free mass might increase arterial elasticity in youth, particularly in youth with MetS.
Metabolism: clinical and experimental 11/2012; · 2.59 Impact Factor
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ABSTRACT: PURPOSES: To compare daily ambulatory measures in children, adolescents, and young adults with and without metabolic syndrome, and to assess which metabolic syndrome components, demographic measures, and body composition measures are associated with daily ambulatory measures. METHODS: Two-hundred fifty subjects between the ages of 10 and 30 years were assessed on metabolic syndrome components, demographic and clinical measures, body fat percentage, and daily ambulatory strides, durations, and cadences during seven consecutive days. Forty-five of the 250 subjects had metabolic syndrome, as defined by the International Diabetes Federation. RESULTS: Subjects with metabolic syndrome ambulated at a slower daily average cadence than those without metabolic syndrome (13.6 ± 2.2 strides/min vs. 14.9 ± 3.2 strides/min; p=0.012), and they had slower cadences for continuous durations of 60 minutes (p=0.006), 30 minutes (p=0.005), 20 minutes (p=0.003), 5 minutes (p=0.002), and 1 minute (p=0.001). However, the total amount of time spent ambulating each day was not different (p=0.077). After adjustment for metabolic syndrome status, average cadence is linearly associated with body fat percentage (p<0.001) and fat mass (p<0.01). Group difference in average cadence was no longer significant after adjusting for body fat percentage (p=0.683) and fat mass (p=0.973). CONCLUSION: Children, adolescents, and young adults with metabolic syndrome ambulate more slowly and take fewer strides throughout the day than those without metabolic syndrome, even though the total amount of time spent ambulating is not different. Furthermore, the detrimental influence of metabolic syndrome on ambulatory cadence is primarily a function of body fatness.
Medicine and science in sports and exercise 07/2012; · 3.71 Impact Factor
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ABSTRACT: Cardiovascular disease is seen at a younger age and at a higher prevalence in patients with type 1 diabetes than in the general population. It is well described that women with type 1 diabetes have a higher relative risk of cardiovascular disease than men with type 1 diabetes, unlike that seen in the general population. The pathophysiology behind this is unknown.
We performed a cross-sectional study to examine sex differences in cardiovascular disease risk factors in adolescents with type 1 diabetes between ages 13 and 20 years, compared with children of a similar age without type 1 diabetes.
All patients underwent a dual energy x-ray absorptiometry scan to measure body composition and a pulse wave test measure of arterial elasticity. Fasting serum lipid levels, apolipoprotein B, and apolipoprotein C-III levels were measured in each patient. Twenty-nine children with type 1 diabetes (10 girls, 19 boys) and 37 healthy children (18 girls, 19 boys) participated.
Although no sex differences for body mass index (P = 0.91) and glycosylated hemoglobin (P = 0.69) were seen, girls with type 1 diabetes had a significantly higher percent trunk fat compared with boys (P = 0.004). No sex differences were found (P > 0.05) for percent trunk fat in adolescents without diabetes. There was no sex difference among any other cardiovascular risk factors in either children with or without diabetes.
Female adolescents with type 1 diabetes have more centrally distributed fat, which may contribute to their relatively higher cardiovascular disease risk. Attenuation of the central distribution of fat through exercise and dietary modifications may help ameliorate their subsequent cardiovascular disease burden.
Gender Medicine 07/2012; 9(4):251-8. · 2.10 Impact Factor
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ABSTRACT: Our primary objective assessed whether a decline in ankle systolic blood pressure (SBP) to less than 50 mm Hg after treadmill exercise is associated with lower extremity ischemia, as measured by calf muscle hemoglobin oxygen saturation (StO(2)). Eighty-four patients with peripheral artery disease (PAD) completed a treadmill test. Ankle SBP <50 mm Hg following exercise was observed in only 49% (group 1), whereas 51% had ankle SBP ≥50 mm Hg (group 2). No group differences were observed for the decline in calf muscle StO(2) to a minimum value (group 1: 18 ± 21%, group 2: 20 ± 20%; P = .60) and for the time to reach minimum StO(2) (group 1: 224 ± 251 seconds, group 2: 284 ± 283 seconds; P = .30). Requirement of ankle SBP to decrease below 50 mm Hg after exercise has little clinical significance for assessing ischemia in calf muscle of patients with PAD limited by intermittent claudication.
Angiology 05/2012; · 1.51 Impact Factor
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ABSTRACT: This prospective, randomized controlled clinical trial determined whether an optimal exercise program length exists to efficaciously change claudication onset time (COT) and peak walking time (PWT) in patients with peripheral artery disease and claudication.
The study randomized 142 patients to supervised exercise (n = 106) or a usual care control group (n = 36), with 80 completing the exercise program and 27 completing the control intervention. The exercise program consisted of intermittent walking to nearly maximal claudication pain 3 days per week. COT and PWT were the primary outcomes obtained from a treadmill exercise test at baseline and bimonthly during the study.
After exercise, changes in COT (P < .001) and PWT (P < .001) were consistently greater than changes after the control intervention. In the exercise program, COT and PWT increased from baseline to month 2 (P < .05) and from months 2 to 4 (P < .05) but did not significantly change from months 4 to 6 (P > .05). When changes were expressed per mile walked during the first 2 months, middle 2 months, and final 2 months of exercise, COT and PWT only increased during the first 2 months (P < .05).
Exercise-mediated gains in COT and PWT occur rapidly within the first 2 months of exercise rehabilitation and are maintained with further training. The clinical significance is that a relatively short 2-month exercise program may be preferred to a longer program to treat claudication because adherence is higher, costs associated with personnel and use of facilities are lower per patient, and more patients can be trained for a given amount of personnel time and resource utilization.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 03/2012; 55(5):1346-54. · 3.52 Impact Factor
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ABSTRACT: This study compared calf muscle hemoglobin oxygen saturation (Sto(2)) and exercise performance during standardized treadmill exercise in patients with peripheral artery disease (PAD) who describe different types of exertional leg pain and compared secondary outcomes consisting of daily ambulatory activity and exercise performance during a 6-minute walk test (6MWT).
Leg pain symptoms were evaluated in 114 patients with PAD using the San Diego Claudication Questionnaire, by which atypical exertional leg pain was defined in 31, claudication in 37, and leg pain on exertion and rest in 46. Patients were evaluated on a standardized, graded treadmill test during which calf muscle Sto(2) was continuously monitored. The 6MWT distance, Walking Impairment Questionnaire (WIQ), and ambulatory activity were monitored during 1 week.
All patients experienced symptoms during the treadmill test consistent with claudication. The groups were not significantly different on the primary outcomes of time to reach the minimum calf muscle Sto(2) (P = .350) or peak walking time (P = .238) during treadmill exercise. Patients with atypical leg pain had the highest daily ambulatory activity for total strides per day (P = .032), average daily cadence (P = .010), maximum cadences for durations between 5 minutes (P = .035) and 60 minutes (P = .029), speed score on the WIQ (P = .006), and lowest rating of perceived exertion at the end of the 6MWT (P = .017).
PAD patients with atypical leg pain have vascular-mediated limitations in exercise performance during standardized treadmill testing similar to patients with claudication and patients with leg pain on exertion and rest but have higher levels of daily ambulatory activity in the community setting and higher perceived ambulatory function.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 02/2012; 55(6):1654-61. · 3.52 Impact Factor
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ABSTRACT: This study compared oxygen uptake before and after the onset of claudication in individuals with peripheral artery disease (PAD) during a 6-minute walk test, and identified predictors of the change in oxygen uptake after the onset of claudication pain.
The study included 50 individuals with PAD. During a 6-minute walk test, 33 experienced claudication (pain group), and 17 were pain-free (pain-free group). Oxygen uptake and ambulatory cadence were the primary outcomes evaluated during the 6-minute walk test.
The pain group experienced onset of claudication pain at a mean (standard deviation) of 179 (45) meters and continued to walk to achieve a 6-minute walk distance of 393 (74) meters, which was similar to the 401 (76) meters walked in the pain-free group (P = .74). Oxygen uptake increased (P < .0001) after the onset of pain in the pain group, and this change was greater (P = .025) than the increase in oxygen uptake from the second to fifth minutes of walking in the pain-free group. Ambulatory cadence decreased after the onset of pain in the pain group (P = .0003). The change in oxygen uptake was associated with metabolic syndrome (P = .0023), 6-minute walk distance (P = .0037), age (P = .0041), and oxygen uptake during the second minute of the test (P = .012).
Claudication increases oxygen uptake of self-paced, over-the-ground ambulation, despite a decrease in cadence. The pain-mediated increase in oxygen uptake was blunted in individuals with metabolic syndrome, suggesting that the ability to increase oxygen uptake during ambulation is impaired. The clinical significance is that claudication increases the metabolic cost of ambulation, thereby increasing the relative intensity of exercise and reducing the tolerance to sustain ambulation.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 09/2011; 54(5):1366-73. · 3.52 Impact Factor
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ABSTRACT: We compared arterial elasticity in American Indian and Caucasian children, adolescents, and young adults, and we assessed whether demographic, body composition, and ambulatory activity measures were predictive of arterial elasticity within each group. Fifty-one American Indians and 66 Caucasians between the ages of 8 and 30 years were assessed on large artery elasticity index, small artery elasticity index, body fat percentage, and daily ambulatory activity during 7 consecutive days. American Indians had a higher percentage of body fat than Caucasians (p = 0.002), whereas daily ambulatory activity measures were similar (p > 0.05). American Indians had a 16% lower large artery elasticity index (p = 0.007) and a 19% lower small artery elasticity index (p < 0.001) than Caucasians. The regression model for large artery elasticity index included average cadence (p = 0.001), fat-free mass (p < 0.001), age component (Caucasian only) (p < 0.001), and sex (p = 0.025). The regression model for small artery elasticity index included fat-free mass (p < 0.001), maximum cadence for 30 continuous minutes (p = 0.009), race (p = 0.005), and average cadence (p = 0.049). Between 8 and 30 years of age, elasticity means for the large and small arteries is lower in American Indians than in Caucasians. A smaller difference was observed in children, with a trend to a much larger difference in young adults. Furthermore, greater fat-free mass and higher daily ambulatory cadence are associated with higher arterial elasticity in both American Indians and Caucasians.
Vascular Medicine 08/2011; 16(4):275-83. · 1.46 Impact Factor
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ABSTRACT: We assessed the reliability of the Baltimore Activity Scale for Intermittent Claudication (BASIC) for the evaluation of physical activity levels in individuals with intermittent claudication. We also identify the characteristics of the patients that influence the reliability of this questionnaire. A total of 38 men and women with peripheral artery disease and symptoms of intermittent claudication participated in the study. BASIC was administered to patients by the same evaluator at 2 different visits, separated by 7 days. The concordance coefficient ranged from .43 (How often do you walk at a fast pace?) to .85 (What happens when you feel pain while you walk?). The concordance coefficient of BASIC total score was .60. Higher concordance coefficients were observed in women (.66 vs .55), in younger patients (.63 vs .56), and in patients with lower ankle-brachial index (.64 vs .55). The reliability of BASIC questionnaire ranged from moderate to good in patients with claudication.
Angiology 07/2011; 63(4):254-8. · 1.51 Impact Factor
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ABSTRACT: Type 1 diabetes (T1D) is a risk factor for cardiovascular disease. However, it is unclear whether increased body weight amplifies that risk in T1D patients. This is a cross-sectional study examining the presence of cardiovascular risk factors in normal and overweight children, both with and without T1D. Sixty-six children (aged 16±2.2 years) were included in one of the following groups: (T1D and normal weight, T1D and overweight, healthy and normal weight, and healthy and overweight). A fasting blood sample was analyzed for lipid profile (triglyceride, cholesterol, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol), apolipoprotein B (apoB), and apolipoprotein C-III (apoC-III) levels. Body composition was determined by dual energy x-ray absorptiometry and vascular elasticity by HDI/Pulsewave CR-2000 (Hypertension Diagnostics, Eagan, MN). Statistical analyses examined the effect of T1D and body weight status and their interactions on cardiovascular risk parameters. In this study, the authors were unable to demonstrate an additive effect of body weight status and T1D on cardiovascular risk profile. However, subgroup analysis of patients with T1D revealed higher apoC-III levels in overweight patients with T1D (P=.0453) compared with normal-weight diabetic children. Most notably, there was a direct relationship of small artery elasticity to body weight status. This seemingly paradoxical observation supports recent data and warrants further investigation.
Journal of Clinical Hypertension 05/2011; 13(5):351-6. · 1.83 Impact Factor
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ABSTRACT: We compared the prevalence and management of metabolic syndrome (MetS) and its components in men and women with peripheral artery disease (PAD). A total of 70 men and 70 women with PAD were evaluated for presence of MetS. There was no significant gender difference in presence of MetS (P = .399) and the number of MetS components (P = .411). Among PAD patients with each MetS component, there was no significant gender difference in the use (P = .617) and number (P = .716) of blood pressure medications, the use (P = .593) and number (P = .591) of lipid-lowering medications, and the number (P = .155) of diabetic medications. Significantly more women were treated with diabetic medications compared with men (85 vs 57%, P = .026). The prevalence and management of MetS and its components was similar between men and women with PAD, except that more women were treated for diabetes. Patients with PAD having MetS did not receive optimal medical management.
Angiology 04/2011; 62(8):657-61. · 1.51 Impact Factor
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ABSTRACT: The study's purposes were to assess the cardiovascular responses during constant-load walking and to identify predictors of this response in peripheral artery disease (PAD) patients.
Seventy-nine patients with PAD performed a constant-load treadmill test (2 mph, 0% grade). During the test, systolic blood pressure (BP), diastolic BP, and HR were obtained at the fourth minute to the last minute of exercise. Patients were also characterized by demographic measures, cardiovascular risk factors, baseline exercise performance, and vascular measures.
During constant-load walking, there was a significant increase (P < 0.01) in systolic BP (+12 ± 10 mm Hg), diastolic BP (+6 ± 9 mm Hg), and HR (+5 ± 5 bpm). The HR responses were negatively correlated with the ischemic window (r = -0.23, P < 0.05), expressed as an area under the curve of the resting ankle systolic BP and its recovery from a maximal graded treadmill test, and positively correlated with the HR during the first minute of recovery from the maximal graded treadmill test (r = 0.27, P < 0.05). The increase in cardiovascular variables during constant-load walking was greater in subjects with a higher body mass index and in men (P < 0.05).
Patients with PAD had an increased cardiovascular response during constant-load walking, and these responses were greater in obese patients and in men. The clinical implication is that PAD patients engaged in walking training programs, particularly men and those with obesity, require frequent assessment of cardiovascular parameters to avoid exaggerated increases in BP and HR during constant-load walking.
Medicine and science in sports and exercise 04/2011; 43(11):2017-23. · 3.71 Impact Factor
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Andrew W Gardner
Evidence-based medicine 04/2011; 16(2):43-4.
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ABSTRACT: We compared the dietary intake of participants with peripheral artery disease (PAD) and claudication with diet recommendations of the National Cholesterol Education Program (NCEP) and dietary reference intake values recommended by the Institute of Medicine (IOM) of the National Academy of Sciences. Forty-six participants consumed a mean macronutrient composition of 17% protein, 51% carbohydrate, and 30% fat. Compared to the NCEP and IOM recommendations, few participants met the recommended daily intake for sodium (0%), vitamin E (0%), folate (13%), saturated fat (20%), fiber (26%), and cholesterol (39%). Participants with PAD and claudication have poor nutrition, with diets particularly high in saturated fat, sodium, and cholesterol, and low in fiber, vitamin E, and folate intakes. Participants should be encouraged to reduce consumption of dietary fat, saturated fat, cholesterol, and sodium and to increase fiber and vitamin intakes to meet recommendations of the NCEP and IOM.
Angiology 04/2011; 62(3):270-5. · 1.51 Impact Factor
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ABSTRACT: We determined whether arterial compliance measured by pulse wave analysis is impaired in obese pubertal children compared to normal weight controls, and assessed whether arterial compliance is associated with ambulatory activity. Body fat percentage was significantly different between the normal (n = 33) and obese (n = 34) participants (P < .001). Large (P = .012) and small (P < .001) arterial compliance were lower in the normal-weight group. After adjusting for height, systolic and diastolic blood pressure, race, sex, and Tanner stage, large arterial compliance was no longer different between groups (P = .066), whereas small arterial compliance remained higher in the obese group (P < .001). Obese pubertal children have paradoxically increased small arterial compliance compared to that of normal weight children, even after adjusting for height, blood pressure, race, sex, and Tanner stage. Thus, obesity in adolescence is not associated with impairments in small arterial compliance.
Angiology 03/2011; 62(7):565-70. · 1.51 Impact Factor
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ABSTRACT: We compared exercise performance, daily physical activity, and health-related quality of life in 115 participants with stable angina and 441 controls without coronary artery disease or stable angina. Participants with stable angina had shorter 6-min walk distance (P = .003), and lower total leisure-time physical activity (P = .003) than the controls. Group differences in these measures remained (P < .05) after adjusting for age, race, current smoking, diabetes, hypertension, and obesity. Participants with stable angina also had lower health-related quality of life for physical function (P < .001), general health (P = .002), and vitality (P < .001), but group differences did not remain (P > .05) after adjustment for comorbid conditions. Participants with stable angina have impaired exercise performance and reduced daily physical activity. Thus, they are prime candidates for exercise interventions designed to improve daily physical activity and exercise performance.
Angiology 03/2011; 62(6):461-6. · 1.51 Impact Factor
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ABSTRACT: This prospective, randomized, controlled clinical trial compared changes in exercise performance and daily ambulatory activity in peripheral artery disease patients with intermittent claudication after a home-based exercise program, a supervised exercise program, and usual-care control.
Of the 119 patients randomized, 29 completed home-based exercise, 33 completed supervised exercise, and 30 completed usual-care control. Both exercise programs consisted of intermittent walking to nearly maximal claudication pain for 12 weeks. Patients wore a step activity monitor during each exercise session. Primary outcome measures included claudication onset time and peak walking time obtained from a treadmill exercise test; secondary outcome measures included daily ambulatory cadences measured during a 7-day monitoring period. Adherence to home-based and supervised exercise was similar (P=0.712) and exceeded 80%. Both exercise programs increased claudication onset time (P<0.001) and peak walking time (P<0.01), whereas only home-based exercise increased daily average cadence (P<0.01). No changes were seen in the control group (P>0.05). The changes in claudication onset time and peak walking time were similar between the 2 exercise groups (P>0.05), whereas the change in daily average cadence was greater with home-based exercise (P<0.05).
A home-based exercise program, quantified with a step activity monitor, has high adherence and is efficacious in improving claudication measures similar to a standard supervised exercise program. Furthermore, home-based exercise appears more efficacious in increasing daily ambulatory activity in the community setting than supervised exercise.
Circulation 02/2011; 123(5):491-8. · 14.74 Impact Factor
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ABSTRACT: We identified demographic variables, cardiovascular risk factors, and ambulatory activity measures that predict large and small artery elasticity in apparently healthy subjects between 9 and 89 years of age.
A total of 480 subjects were assessed on large artery elasticity index (LAEI), small artery elasticity index (SAEI), demographic measures, cardiovascular risk factors, and daily ambulation during 7 consecutive days. All possible regression and Mallow's C(p) were used to select multivariate models for prediction of LAEI and SAEI.
In subjects 20 years of age and younger, LAEI model (R(2) = 0.25, P < 0.001) included age, average ambulatory cadence, and obesity. SAEI model (R(2) = 0.39, P < 0.001) contained body mass index (BMI), maximum daily ambulatory cadence for 30 continuous min, age, and total ambulatory strides. In subjects between 21 and 50 years, LAEI model (R(2) = 0.41, P < 0.001) included systolic blood pressure (SBP), gender, race, and diastolic blood pressure (DBP). SAEI model (R(2) = 0.42, P < 0.001) contained gender, BMI, DBP, race, dyslipidemia, and SBP. In subjects older than 50 years, LAEI model (R(2) = 0.54, P < 0.001) included SBP, gender, age, and BMI. SAEI model (R(2) = 0.45, P < 0.001) contained gender, age, BMI, DBP, current smoking, and SBP.
Daily ambulatory activity, particularly cadence of 30 continuous min of ambulation, is positively associated with arterial elasticity in children and adolescents. In contrast, the predominant factors related to the decline in arterial elasticity in adults are blood pressure and age.
American Journal of Hypertension 02/2011; 24(5):599-605. · 3.18 Impact Factor
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ABSTRACT: The effects of acute exercise on arterial compliance in older adults are unknown. Large and small arterial compliance were assessed during and 24 hours following a 30-minute bicycle ergometer test and on a nonexercise, control condition. The change in large artery compliance was similar between the exercise and nonexercise conditions (P = 0.876). Small artery compliance during the exercise day was higher than the nonexercise day at 45, 60, and 75 minutes following exercise (P < .001), was 17% higher 30 minutes postexercise than at rest (P < .001), and decreased by 20% between 30 minutes (4.5 ± 0.4 mL/mm Hg × 100) and 120 minutes (3.6 ± 0.3 mL/mm Hg × 100) after exercise (P = .027). The current study shows 30 minutes of moderate-intensity exercise transiently increases small arterial compliance 30 minutes after exercise but does not elicit more sustained increases in either large or small arterial compliance.
Angiology 01/2011; 62(1):33-7. · 1.51 Impact Factor
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ABSTRACT: To compare the pattern of daily ambulatory activity in men and women with intermittent claudication, and to determine whether calf muscle hemoglobin oxygen saturation (StO2) is associated with daily ambulatory activity.
Forty men and 41 women with peripheral arterial disease limited by intermittent claudication were assessed on their community-based ambulatory activity patterns for 1 week with an ankle-mounted step activity monitor and on calf muscle StO2 during a treadmill test.
Women had lower adjusted daily maximal cadence (mean±SE) for 5 continuous minutes of ambulation (26.2±1.2 strides/min vs 31.0±1.2 strides/min; P=.009), for 1 minute of ambulation (43.1±0.9 strides/min vs 47.2±0.9 strides/min; P=.004), and for intermittent ambulation determined by the peak activity index (26.3±1.2 strides/min vs 31.0±1.2 strides/min; P=.009). Women also had lower adjusted time to minimum calf muscle StO2 during exercise (P=.048), which was positively associated with maximal cadence for 5 continuous minutes (r=0.51; P<.01), maximal cadence for 1 minute (r=0.42; P<.05), and peak activity index (r=0.44; P<.05). These associations were not significant in men.
Women with intermittent claudication ambulate slower in the community setting than men, particularly for short continuous durations of up to 5 minutes and during intermittent ambulation at peak cadences. Furthermore, the daily ambulatory cadences of women are correlated with their calf muscle StO2 during exercise, as women who walk slower in the community setting reach their minimum calf muscle StO2 sooner than those who walk at faster paces. Women with intermittent claudication should be encouraged to not only walk more on a daily basis, but to do so at a pace that is faster than their preferred speed.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 11/2010; 52(5):1204-10. · 3.52 Impact Factor
