Allscripts EPSi. Moreover, vascular complications such as RAO[21] and radial artery spasm[22] are not uncommon and very recently concerns have been raised that patients undergoing TRA PCI may encounter hand dysfunction[23]. During your drive home, stop every hour and walk for five to 10 minutes. Angioplasty is performed by a heart specialist (cardiologist) and a team of specialized cardiovascular nurses and technicians in a special operating room called a cardiac catheterization laboratory. TRA: Transradial access; TFA: Transfemoral access; PCI: Percutaneous coronary intervention; UED: Upper Extremity dysfunction. Ask when you can resume physical activity . An official website of the United States government. Before Chelation therapy for heart disease: Does it work? The clinical significance of neurological and motor injuries leading to hand dysfunction must be considered. Complex regional pain syndrome (CRPS) is a disease with unclear pathophysiology. You can watch your cardiac cath on the monitors, but you must keep your head down so that you dont bump into the camera accidentally. Mayo Clinic offers appointments in Arizona, Florida and Minnesota and at Mayo Clinic Health System locations. Jolly SS, Yusuf S, Cairns J, Niemel K, Xavier D, Widimsky P, Budaj A, Niemel M, Valentin V, Lewis BS, et al. For advice and further information, contact us at telephone: +972-9-959-4888, or leave your details and we will get back to you promptly. If you have more than a two-hour drive home, you should stay overnight in a hotel for your comfort. The procedure can be performed from either wrist, and . 9500 Euclid Avenue, Cleveland, Ohio 44195 |, Important Updates + Notice of Vendor Data Event, (https://medlineplus.gov/ency/article/003419.htm), (https://www.nhlbi.nih.gov/health-topics/cardiac-catheterization). Your provider wont discharge you unless you have someone available to drive you home. 7th ed. You will need to keep your wrist straight for 2 to 4 hours. NSAIDs: Do they increase my risk of heart attack and stroke? Theyll observe you for a few hours to monitor any symptoms or side effects of the procedure. Elsevier; 2020. https://www.clinicalkey.com. In view of the limited published data we conducted a systematic review to evaluate the hand dysfunction post TRA. Cardiac catheterization. Click here for an email preview. A nurse or technician may shave the hair from the site where the catheter will be inserted. Discuss all of your allergies with your provider, especially these: Discuss your medications with your provider, who may want to stop or adjust the doses several days before or on the day of the procedure, especially these: Ask your provider if youve completed or scheduled all of the required tests before your cardiac catheterization procedure. The source for pain after a cath procedure can be the skin, nerves, muscles, tendons or blood vessel walls. and transmitted securely. You can watch your cardiac cath on the monitors, but you must keep your head down so that you dont bump into the camera accidentally. A total of 3815 participants with mean age of 62.5 years were included in the studies. Rashid M, Sperrin M, Ludman PF, ONeill D, Nicholas O, de Belder MA, Mamas MA. You can usually drive 24 hours after leaving the hospital. 1-ranked heart program in the United States. Table Table11 provides the description of studies, year of study, percentage of males and number of participants. Higher quality studies with clinically relevant endpoints are needed to better understand the incidence and clinical significance of the hand dysfunction following TRA. A Mayo Clinic cardiologist explains. Mankad SV, et al. Analysis of safety outcomes for radial versus femoral access for percutaneous coronary intervention from a large clinical registry. BCTQ questionnaire comprises of a symptom severity scale and a functional status scale (Table (Table6).6). Sticky patches (electrodes) will be placed on your chest to monitor your heartbeat before, during and after the procedure. hand and wrist specialist, for the appropriate treatment. Like an operating room, the cardiac catheterization lab is a sterile area. Endothelial dysfunction, intimal hyperplasia and medial dissections resulting in radial artery stenosis and occlusion are well known complications associated with TRA[45,46]. Of course everyone makes their own health decisions in life. This is normal. Posts: 149. Severe wrist pain after heart cath done. Sometimes perhaps the real problem is the fact that people get dehydrated or eat so much sugar their blood gets thick and syrupy in my opinion. A contrast dye visible in X-rays is injected through the catheter. These may include some of the following: Wear comfortable, easy-to-fold clothing on the day of your procedure and bring: The cardiac catheterization room is cool and dimly lit. 7 Do you have weakness in your hand or wrist? The majority of studies that reported cases of neurological deficits following TRA were underpowered[26,29,37]. Complex regional pain syndrome and acute carpal tunnel syndrome following radial artery cannulation: a neurological perspective and review of the literature. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Access and non-access site bleeding after percutaneous coronary intervention and risk of subsequent mortality and major adverse cardiovascular events: systematic review and meta-analysis. You may need to hold your breath while your provider takes the X-rays. Thirty of these patients had symptoms, and they were treated with 4 weeks of anticoagulation. The sheath has to be removed very carefully because pulling it out incorrectly can cause you to bleed. Bethesda, MD 20894, Web Policies The symptom severity scale has 11 questions scored from 1 point (mildest) to 5 points (most severe). Your provider will tell you if youre able to return home or will need to stay overnight. Possible risks associated with cardiac cath include: Bleeding or bruising where the catheter is put into the body (the groin, arm, neck, or wrist) Pain where the catheter is put into the body; Blood clot or damage to the blood . Ask your healthcare provider when you can resume driving and exercising. In: Kern's Cardiac Catheterization Handbook. When you meet with your provider, ask questions to make sure you understand all of the potential risks and why they recommend the procedure. Take BP on side opposite a/v fistula in general. You may not notice it until days or weeks after the procedure. Your provider will place electrodes (small, flat, sticky patches) on your chest. ku.ca.eleek@dihsar.m, Telephone: +44-1782-671652 Fax: +44-1782-674467. It can show blockages in the heart arteries. Specialty type: Cardiac and cardiovascular systems, P- Reviewer: Falconi M, Gong KZ, Said SAM S- Editor: Ji FF L- Editor: A E- Editor: Wu HL, National Library of Medicine After Your Heart Catheterization with Transradial (Wrist) Approach: Self-care after your test - 07/2020, Click on your preferred language below to access/print your document. A responsible driver must drive you home. CISS: Cold intolerance symptom severity; EMG: Electromyography. Advertising revenue supports our not-for-profit mission. Because there is significantly less chance of bleeding when done this way, I didn't have to go off my blood thinners. Once it is in place, several diagnostic and treatment procedures can be done using catheterization. Youll need to keep your arm straight for at least an hour, but youll be able to walk around. Take a tiny bit of muscle from your heart to examine . Cardiac catheterization is generally a safe procedure. 2018; doi:10.1093/europace/eux274. The search results were reviewed by two independent judicators for studies that met the inclusion criteria and relevant reviews. Get useful, helpful and relevant health + wellness information. Arm pain was assessed by . Check your pulmonary arteries for issues. When the catheter is in place, your provider will dim the lights and inject a small amount of contrast material through the catheters into your arteries and heart chambers. Cardiac Catheterization Risks and Complications. Connect with a U.S. board-certified doctor by text or video anytime, anywhere. I'll try the heat instead of ice. It's guided to the heart. An allergic reaction (itching, tightness in the throat, shortness of breath). Can i check my blood pressure with the same hand that was held with cardiac catheterization?if i can't .how long time?i've l hand hd av fistula. The .gov means its official. Complex regional pain syndrome after hand surgery. Feb. 5, 2021. Recovery time for a cardiac catheterization is quick, and there's a low risk of complications. http://creativecommons.org/licenses/by-nc/4.0/, https://www.pcronline.com/eurointervention/AbstractsEuroPCR2016_issue/abstracts-europcr-2016/Euro16A-POS1035/upper-extremity-function-after-transradial-pci-preliminary-results.html, Participants had transradial coronary angioplasty with 6-Fr catheters and Palmaz-Schatz stent, Participants had transradial coronary angiogram with 5-Fr, 6-Fr and 7-Fr sheath, Participants had transradial diagnostic and interventional cardiac procedures with 4-Fr, 5-Fr or 6-Fr introducer sheath and guide catheters with RadiStop radial compression system, Participants had transradial coronary angiography and intervention and severe peripheral vascular disease with 5-Fr or 6-Fr sheath and 6-Fr guide catheter, Participants had transradial coronary angiography with 6-Fr introducer and 6-Fr-guide catheters, Participants had transradial coronary angiography and angioplasty with 6-Fr introducer and 6-Fr guide catheters, Participants had transradial diagnostic cardiac catheterization with 5-Fr or 6-Fr sheath or transradial coronary intervention with 7-Fr sheath, Participants had transradial coronary angiography and angioplasty with 6-Fr introducer sheath, Retrospective case control study; United Kingdom; 2005-2006, Participants had transradial coronary angiography and angioplasty, Prospective cohort study; The Netherlands, Italy; 2014, Prospective cohort study; The Netherlands; 2015, Participants underwent 6-Fr and 8-Fr transradial procedure, Participants had transradial coronary angiography and angioplasty with 5- and 6-Fr introducer, 4-, 5- and 6-Fr catheters, Local complications assessed in clinic by history and EMG, Nerve damage documented by EMG: 0/50 Local pain: 0/50, Patients were re-examined or questioned over telephone about local complications, Physicians assessed for any clinical events, Paraesthesia of right thumb during exercise: 1/159, Haematoma and paraethesia post procedure: 1/75 Hand sensation and function at 4-6 wk: 0/75, Examination and ultrasound study performed if radial artery pulsations or flow were absent, Small hematoma in wrist: 3/100 Small pseudoaneurysm: 2/100 Numbness of the thumb and index finger: 1/100 No flow on Doppler: 2/100, Vascular complication: 9/93 Motor skills, coordination or force reduction of hand after procedure: 0/93 No pseudoaneurysm: 0/93, Radial artery occlusion by ultrasound test. Last reviewed by a Cleveland Clinic medical professional on 04/29/2022. 251 0 obj <>stream There is a need of internationally agreed, sensitive method of assessing hand function amongst the radial community to evaluate and monitor for such complications. and transmitted securely. Barbash IM, Minha S, Gallino R, Lager R, Badr S, Loh JP, Kitabata H, Pendyala LK, Torguson R, Satler LF, et al. Moretti A, Gimigliano F, Paoletta M, Bertone M, Liguori S, Toro G, Iolascon G. Diagnostics (Basel). Table Table22 describes the various methods of assessment employed to assess hand dysfunction, follow up time and results. Complications of diagnostic cardiac catheterization. As with most procedures done on the heart and blood vessels, cardiac catheterization has some risks. Cruden NL, Teh CH, Starkey IR, Newby DE. National Library of Medicine government site. The catheter is guided to the narrowed artery. Ice makes it hurt worse. American Heart Association. Your provider may do this as a scheduled procedure or shortly after a heart attack. Depending on where the catheter was put into your body, youll need to avoid strenuous activities (including sports and lifting) for two to five days. Another important point how minor changes in hand function may impact on a patients life. This is normal and will go away in a few seconds. Cardiac catheterization (also called cardiac cath or coronary angiogram) is an invasive imaging procedure that allows your healthcare provider to evaluate your heart function. A plug is a material that works with your body's natural healing processes to form a clot in your artery. Lotan C, Hasin Y, Mosseri M, Rozenman Y, Admon D, Nassar H, Gotsman MS. Transradial approach for coronary angiography and angioplasty. Cardiac catheterization (also called cardiac cath or coronary angiogram) is an invasive imaging procedure that allows your healthcare provider to evaluate your heart function. A list of your medications (including over-the-counter drugs) and dosages. A responsible driver must drive you home. After Your Cardiac Catheterization. 200 0 obj <> endobj Numbness or weakness of your face, arm or leg specifically on one side of your body. The site is secure. We observe a very low incidence of hand dysfunction in limited literature and importantly, we observe significant heterogeneity in the definition and method of assessment of hand dysfunction amongst the studies, with no internationally accepted measure of hand dysfunction that can be used as the gold standard for such studies. Your healthcare provider has to keep the air cool to prevent damage to the X-ray machinery they use during the procedure. Some hospitals have a medical concierge to help you make arrangements. Complex regional pain syndrome-like symptoms during herpes zoster. It is unclear what factors are associated with hand dysfunction after TRA. This can be done in your arm, in the neck, or in your leg. Finally ARCUS (Effects of transradial percutaneous coronary intervention on upper extremity function) is an ongoing trial assessing the effects of TRA on hand function by taking various measurement such as Echo Doppler for radial artery occlusion, Questionnaires testing including Quick DASH (Table (Table4),4), Boston Carpal Tunnel Questionnaire (BCTQ, Table Table6)6) and Visual Analogue Scale (VAS), volumetry of hand and forearm, sensibility of fingertips, key and palmar grips and isometric strength of wrist and elbow[40]. Keep all of your follow-up appointments with your provider and make sure you keep taking your medicines. A list of your medications (including over-the-counter drugs) and dosages. National Heart, Lung, and Blood Institute. You may need other treatments if the pseudoaneurysm is wider than 2 centimeters (about 3/4 inch) or if you take certain medicines, such as blood thinners. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). I had a cardiac cath done 10 days ago via radial artery in my wrist. Jameson JL, et al., eds. Finally, current literature does not provide an insight around the prevalence and significance of lower limb function in patients undergoing transfemoral access. Evaluate or confirm the presence of coronary artery disease. This is normal. To help position the catheter, your provider may ask you to turn your head or take a deep breath and hold it for a few seconds. Once it is in place, several diagnostic and treatment procedures can be done using catheterization. Mamas MA, Fraser DG, Ratib K, Fath-Ordoubadi F, El-Omar M, Nolan J, Neyses L. Minimising radial injury: prevention is better than cure. For something that takes more time, like a lab analysis of a tissue sample, it might take a few days to get results. These complications appear to be rare and of uncertain clinical impact in most cases. AuntNanc. Careers. What is coronary artery disease? Complex Regional Pain Syndrome Type I Following Non-Orthopedic Surgery: Case Report and Narrative Review. Accessibility Transradial cardiac catheterization is a procedure used to treat and diagnose certain heart conditions. Created for people with ongoing healthcare needs but benefits everyone. Access site practice has changed in a number of European and Asian countries from mainly being transfemoral (TFA) to transradial (TRA)[3,4] in view of less access site related bleeding complications, mortality and shorter hospital stay associated with TRA[5-11]. The condition is characterized by pain, soft tissue change, vasomotor change, and even psychosocial disturbance. Federal government websites often end in .gov or .mil. To sythesize the available literature on hand dysfunction after transradial catheterization. 11th ed. 2023 MH Sub I, LLC dba Internet Brands. You should not submerge the puncture site in water for a week. Angina treatment: Stents, drugs, lifestyle changes What's best? A plastic sheath is passed into this opening to allow your doctor to insert the catheter. In cardiac catheterization (often called cardiac cath), a very small hollow tube, or catheter, is advanced from a blood vessel in the groin, arm, or neck through the aorta into the heart. Table Table33 presents pooled results of various form of limb dysfunction described by the studies. The electrodes attach to an electrocardiograph monitor (ECG), which monitors your heart rate and rhythm. Allergic reaction to the medication or contrast material you received during the procedure. Haematoma or pseudoaneurysm is another relatively rare complications encountered after TRA. Cardiac catheterization. Learn how we can help. You may need to hold your breath while your provider takes the X-rays. One million cardiac catheterizations take place in the U.S. each year, but the chances of a major complication during a heart catheterization for diagnostic reasons is less than 1%. Youll need to lie flat and keep your leg straight for two to six hours to prevent bleeding (less time if they used a plug). CRPS was first diagnosed due to hand swelling, allodynia, paresthesia, and the limited range of motion of interphalangeal, metacarpophalangeal, and wrist joints, with the preceding factor of transradial cardiac catheterization, and was then confirmed by a three-phase bone scan. If you look above you, youll see a large X-ray camera and several TV monitors. Your provider will close your puncture site with applied pressure, and sometimes a suture device or a "plug." Finally, we find no evidence of widespread clinically significant hand dysfunction post TRA and the potential benefits of TRA in reducing major bleeding, access site related complications and mortality outweigh such rare events. Data was extracted, these results were narratively synthesized. Sign up for free, and stay up to date on research advancements, health tips and current health topics, like COVID-19, plus expertise on managing health. According to the American Heart Association (AHA), cardiac catheterization is typically very safe. 2010 May;26(2):281-9. doi: 10.1016/j.hcl.2009.11.001. Many of these studies are poorly conducted and subjective reports of sensory/hand dysfunction with only few studies quantifying any changes in a robust manner. Thanks much! Evaluate or confirm the presence of coronary artery disease, valve disease or disease of the aorta. Complex regional pain syndrome (CRPS) is a disease with unclear pathophysiology. Sterile drapes will cover the site and help prevent infection. McGraw Hill; 2019. https://accessmedicine.mhmedical.com. It is also known as transradial cardiac cath. Bonow RO, et al., eds. You may feel the need to pee more frequently. After you leave the recovery room, you'll usually be moved to a regular hospital or outpatient room. Impact of Center Experience on Patient Radiation Exposure During Transradial Coronary Angiography and Percutaneous Intervention: A Patient-Level, International, Collaborative, Multi-Center Analysis. 24/7 visits - just $44! In either case, theyll monitor you for several hours after the procedure. When you arrive for your appointment, tell your provider if youre taking. During the test . If the health professional does not have a good reason why it cannot be done I might try moist heat for 20 minutes 3 times a day instead of cold. Characterization of operator learning curve for transradial coronary interventions. The cardiac catheterization procedure itself generally takes 30 minutes, but the preparation and recovery time add several hours to your appointment time (five to nine hours or longer). Before you go home, theyll talk with you about your treatment, including medications, diet and future procedures. 230 0 obj <>/Filter/FlateDecode/ID[<9BDEE4775A01C144986E4A11C883DAFB>]/Index[200 52]/Info 199 0 R/Length 132/Prev 161135/Root 201 0 R/Size 252/Type/XRef/W[1 3 1]>>stream Place a stent to open a blockage in an artery. Threading the catheter shouldn't be painful, and you shouldn't feel it moving through your body. Sudden confusion, trouble speaking or understanding. 13th ed. An Analysis From the British Cardiovascular Intervention Society. (Please score 0-10), Holding a frozen package from the freezer, When you get out of a hot bath/shower with air room temperature, Please state how each of the following activities have been affected as a consequence of cold induced symptoms in your injured hand and score each (please score 0-4). 10 days after my angioplasty and my bruised arm/wrist is blue instead of the black it was after the procedure. Then theyll insert a catheter through the sheath and thread it to your hearts arteries. Angioplasty is performed through an artery in your groin, arm or wrist area. During a cardiac catheterization, your healthcare provider puts a long, narrow tube (catheter) into a blood vessel in your leg or arm and moves it to your coronary arteries. Painful wrist after cardiac cath. Your family member can retrieve these items from your car when you need them. HealthTap uses cookies to enhance your site experience and for analytics and advertising purposes. Although radial artery occlusion was not our primary end point for this review, it was observed in 2.41% of the participants in total of five studies included. van Leeuwen MA, van Mieghem NM, Lenzen MJ, Selles RW, Hoefkens MF, Zijlstra F, van Royen N. The effect of transradial coronary catheterization on upper limb function. 50% off with $19/month membership. There are 2 arteries that supply blood to the hand (the radial artery and ulnar artery), and if both are working it is safe to proceed. For instance, in the United Kingdom use of radial access has increased from 14% to 80% between 2005 and 2014 in patients undergoing percutaneous coronary intervention (PCI) and it is estimated that this practice change has saved an estimated 450 lives nationally[12]. For some cases which are very short, you may not receive a sedative, especially if your provider wants to take certain kinds of measurements such as pressure inside your heart chambers. Coronary angiography is the current gold standard in providing anatomical information regarding the extent and severity of coronary artery disease[1,2].Access site practice has changed in a number of European and Asian countries from mainly being transfemoral (TFA) to transradial (TRA)[3,4] in view of less access site related bleeding complications, mortality and shorter hospital . When the contrast material goes into your heart, you may feel hot or flushed for several seconds. A 29-year-old male asked: . official website and that any information you provide is encrypted Your provider will clean (and possibly shave) your skin at the site (arm or groin) where theyll insert the catheter (narrow plastic tube). Cardiac catheterization is usually done in the hospital in a room with special X-ray and imaging machines. The incidence of hand dysfunction defined as disability, grip strength change, power loss or any other hand complication was incredibly low at 0.26%[24,30,32,33,37,39]. Any one or a combination of these structures could give rise to pain after a cath. The risks are mainly bruising in the skin entry sit Cardiac caths are used to identify blockages in the arteries that supply blood to the heart. A tear in the wall of a major non-coronary artery leading to the collection of blood within the layers of arterial wall is a rare complication of transradial cardiac catheterization with an incidence of 0.02-0.4%. August 10, 2021. In addition, you'll only need to wear a pressure bracelet over the access point for a few hours, Dr. Ellis says. Arm movements can cause serious bleeding. On the day of your procedure, call (734) 936-7375 Monday through Friday from 8:00 am to 4:30 pm. There was no restriction based on language of study. A 93-year-old female with a medical history significant for severe aortic stenosis (EF 60-65%) and scheduled for transcatheter aortic valve replacement, presented to the ED complaining about pain and swelling in her right wrist after a transradial cardiac catheterization performed as part of transcatheter aortic valve replacement evaluation. doi: 10.1097/MD.0000000000004388. The interim results were published recently suggesting that 143 of 191 (74.9%) patients had some form of upper limb dysfunction defined as a complied binary score of various measurements taken[38]. Upper-extremity dysfunction following transradial percutaneous procedures: an overlooked and disregarded complication? 11th ed. Senior Member. Sudden onset of severe headache. Your provider can perform an interventional procedure during a diagnostic cardiac catheterization when they find a blockage, or they may schedule it after a catheterization confirms the presence of coronary artery disease (narrowing or blockage of your hearts arteries). Your doctor should go over this with you. Cardiac catheterization is not considered a surgical procedure because your provider wont make a large incision. I am scheduled to have a cardiac cath two days from today. Theyll check your bandage regularly, but call your provider if you think youre bleeding (have a wet, warm sensation) or if your toes begin to tingle or feel numb. Office of Patient Education. Other rare potential risks include a perforated blood vessel, blood clots, and an irregular heartbeat. Advertising on our site helps support our mission. Trouble breathing. Handgrip strength by Jamar Plus dynamometer. For some cases which are very short, you may not receive a sedative, especially if your provider wants to take certain kinds of measurements such as pressure inside your heart chambers. Stein G, Skouras E, Faymonville C, Thelen U, Schiffer G. Unfallchirurg. You may be asked to remove dentures and any jewelry, especially necklaces that could interfere with pictures of the heart. Recently, concerns have been raised around hand dysfunction following transradial procedures. The .gov means its official. The catheterization laboratory. Your provider will tell you if youre able to return home or will need to stay overnight. sharing sensitive information, make sure youre on a federal 3. The secondary endpoints of interest were thumb and forefinger pinch measured using key pinch and electronic pinch gauge respectively. Would you like email updates of new search results? Aug. 19, 2022. Kiemeneij F, Laarman GJ. Evaluate or confirm the presence of coronary artery disease. Wu SS, Galani RJ, Bahro A, Moore JA, Burket MW, Cooper CJ. the unsubscribe link in the e-mail. Theyll check your bandage regularly, but call your provider if you think youre bleeding (have a wet, warm sensation) or if your toes begin to tingle or feel numb. For instance, van Leeuwen et al[24] reported that almost 20% patients developed subjective neurological complications in the form of numbness, tingling, stiffness and less power, more importantly nearly 50% resolved by 30 d at follow up. Since then, however, I wage a constant battle to keep my dose stable and am always encountering foods or supplements that can send my PT/INR levels shooting up or down the scale. Visual analogue scale is measure of pain intensity on a continuous scale anchored by pain descriptor ranging from no pain (0 score) to worst pain (score 10)[41]. Also, the recovery time is much shorter than that of surgery. To learn more, please visit our. (https://www.ncbi.nlm.nih.gov/books/NBK531461/), caring for your wound site, activity and follow-up care, Heart, Vascular & Thoracic Institute (Miller Family), Find out why youre having chest pain or an, Take a tiny bit of muscle from your heart to examine (. Thumb and forefinger pinch test by Jamar Plus electronic pinch gauge, Day of procedure and at least 30 d follow up, Radial artery occlusion: 9/99 Hand grip strength change at follow up: 0/99 Thumb and forefinger pinch test change at follow up: 0/99, Questionnaire posted to address and clinical notes for significant clinical events, Problem with radial access site: 166/1283 (12.9%) Pain at puncture site: 95/1283 (7.4%) Swelling: 46/1283 (3.6%) Bruising: 30/1283 (2.3%) Non-specific sensory abnormalities either pain or paraesthesia in hand: 22/1283 (1.71%), Radial artery occlusion by duplex echocardiographic examination.
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