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Pan Afr Med J 2018 30;30:296. Epub 2018 Aug 30.

Service d'ORL et de Chirurgie Cervico-faciale, Hôpital Militaire d'Instruction Mohamed V, Faculté de Médecine, Université Mohamed V, Rabat, Maroc.

Thoracic Outlet Syndrome (NTOS) encloses the whole set of clinical manifestations associated with the compression of the trunks of the brachial plexus and/or of the subclavian vessels as they cross the thoracic outlet (cervico-thoraco-brachial junction). It rarely affects children. We here report the case of a young girl treated for neurologic NTOS caused by supernumerary cervical rib. Read More

JBJS Case Connect 2018 Oct-Dec;8(4):e85

Mercy Health-Cincinnati Sports Medicine and Orthopaedic Center, Cincinnati, Ohio.

Case: Brachial plexopathy is a rare complication of nonoperatively treated clavicular fractures. We describe a 68-year-old man who presented with fracture-callus-induced acute brachial plexopathy and dynamic thoracic outlet syndrome after 9 weeks of nonoperative management for a clavicular fracture. He underwent fracture fixation with brachial plexus decompression via callus excision; intraoperative neuromonitoring was used to evaluate brachial plexus function. Read More

Thromb Res 2019 Feb 8;174:34-39. Epub 2018 Dec 8.

Department of Medicine, Division of Hematology, Western University, London, ON, Canada; Department of Epidemiology and Biostatistics, Western University, London, ON, Canada. Electronic address:

Introduction: There is limited data on the occurrence of complications in patients with upper extremity deep vein thrombosis (UEDVT).

Aims: We aimed to determine the frequency of post-thrombotic syndrome (PTS), thrombosis recurrence and major bleeding (MB) in patients with UEDVT.

Material And Methods: We conducted a systematic review of the literature including studies from 1970 onwards. Read More

JACC Cardiovasc Interv 2018 Dec 28;11(24):2537-2539. Epub 2018 Nov 28.

Department of Cardiology, Elias Emergency University Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.

Cureus 2018 Jun 25;10(6):e2875. Epub 2018 Jun 25.

Neurosurgery, Seattle Science Foundation, Seattle, USA.

Axillary arch muscles are often found. In their course through this area, they might interfere with regional neurovascular structures. This case report will examine the presence of the axillary arch muscle and its implication in brachial plexus compression. Read More

J Belg Soc Radiol 2017 Dec 16;101(Suppl 2):20. Epub 2017 Dec 16.

Reine Fabiola Children's University Hospital, Université Libre de Bruxelles, BE.

Ultrasound (US) allows a reliable examination of the brachial plexus except for the spinal nerve roots, located deep in the neuro-foramina, beyond the shadowing of the transverse processes of the vertebral bodies. All the other fascicles of the brachial plexus can be mapped by US from the roots of the spinal cervical nerves, from C5 to T1 to the branches at level of the axillary region. US can be considered as an alternative to Magnetic Resonance Imaging (MRI) when MRI is contraindicated, not readily available or in case of claustrophobia. Read More

J Neurosurg 2018 Nov 1:1-11. Epub 2018 Nov 1.

OBJECTIVEBoth clinical and radiological reports have suggested that the subclavius, a muscle in the costoclavicular space of the thoracic outlet, participates in neurogenic thoracic outlet syndrome (NTOS) in some instances, especially during movements narrowing the costoclavicular space. Magnetic resonance imaging can identify subclavius muscles with signs of nerve impingement, yet the impact of the subclavius in such situations remains unclear. Therefore, the authors investigated whether dividing or sparing the subclavius characterized by nerve impingement on MRI would affect surgical outcomes. Read More

Zhonghua Wai Ke Za Zhi 2018 Dec;56(12):916-921

Department of Cardiac Surgery, Guangdong General Hospital, Guangdong Cardiocvascular Diseases Institute, Guangdong Academy of Medical Sciences, Guangzhou 510080, China.

To analyze the early and midterm results of surgical treatment of interrupted aortic arch (IAA) with double-ventricular procedure. The data of the 68 cases with the main diagnosis of IAA with biventricular structure from June 2009 to June 2017 at Department of Cardiac Surgery, Guangdong General Hospital was collected, including 46 cases of type A, 22 cases of type B. There was no type C case. Read More

Ann Vasc Surg 2018 Nov 27. Epub 2018 Nov 27.

Department of Cardiovascular Surgery, Manisa Celal Bayar University, Manisa, Turkey.

Aneurysms of the upper extremity mostly originate from trauma, mycotic lesions, thoracic outlet syndrome, previous arteriovenous fistulae, and atherosclerosis. True aneurysms of the brachial and axillary artery are encountered rarely. They can be diagnosed by simple physical examination as a pulsatile mass. Read More

Ann Vasc Surg 2018 Nov 23. Epub 2018 Nov 23.

Vascular Surgery Department, University Hospital Grenoble, Grenoble, France.

Background: The aim of this study is to report long-term functional results following cervical rib (CR) resection for thoracic outlet syndrome (TOS).

Methods: This monocentric study included all cases of resection of CR for TOS performed between January 2004 and December 2016. Data were retrospectively collected from the hospital electronic database including preoperative symptoms and the evaluation of occupational well-being, intraoperative data, and early clinical evaluation and occupational well-being during the postoperative period. Read More

Ann Vasc Surg 2018 Nov 23. Epub 2018 Nov 23.

Vascular Surgery Division, UCLA David Geffen School of Medicine, Los Angeles, CA. Electronic address:

Background: Subclavian artery aneurysms associated with thoracic outlet syndrome (TOS) have traditionally been managed by open surgical reconstruction. Endovascular subclavian artery reconstruction is novel in the setting of arterial TOS (aTOS). Our objective is to report our results with endovascular subclavian artery reconstruction in aTOS patients over a 10-year period with attention to surgical approach and late results. Read More

J Vasc Surg Venous Lymphat Disord 2019 Jan 12;7(1):106-112.e3. Epub 2018 Nov 12.

Division of Vascular and Endovascular Surgery, USF Health Morsani College of Medicine, Tampa, Fla.

Background: Subclavian vein stenosis or occlusion at the thoracic outlet is a problem associated with certain anatomic and environmental stresses (venous thoracic outlet syndrome [VTOS]), the presence of central venous catheters, and the high flows associated with arteriovenous (AV) access in the limb. We describe our experience with open and endovascular techniques for restoring patency in highly symptomatic patients.

Methods: A prospectively collected database of patients was queried for patients treated for central venous obstructive disease in the setting of highly symptomatic VTOS and ipsilateral AV access from October 2011 to August 2016. Read More

Rev Pneumol Clin 2018 Dec 10;74(6):492-496. Epub 2018 Nov 10.

Département de chirurgie thoracique, hôpital Militaire d'instruction Mohammed V, faculté de médecine et de pharmacie, université Mohamed V, 10100 Rabat, Maroc.

Implantable catheter systems are the most common procedure used for patients requiring chemotherapy or long-term drug administration. Several procedures are used for the installation of these systems. Patients with long-term subclavian venous catheters described a progressive rupture of the catheter which is a rare complication. Read More

J Thorac Imaging 2019 Jan;34(1):W10-W12

Departments of Cardiothoracic Surgery.

Hibernomas are rare benign soft tissue tumors derived from brown fat. This case report describes an axillary hibernoma with intrathoracic extension, presenting as a thoracic outlet syndrome. A multimodality imaging series illustrates the classic radiologic features of hibernoma as well as its highly unusual pattern of growth. Read More

Phys Sportsmed 2018 Nov 5:1-7. Epub 2018 Nov 5.

f Department of Neurological Surgery , Stanford University , Stanford , CA , USA.

Introduction: Sports surveillance databases provide valuable information regarding common ailments, yet fewer studies have focused on more rare peripheral nerve injuries. Our objective was to characterize peripheral nerve injuries in high school athletics with respect to incidence, time loss, mechanism, and diagnoses.

Methods: Sport-related nerve injury data on high school athletes were collected during the 2005/2006 through 2015/2016 academic years via the High School Reporting Information Online (RIO) database. Read More

J Anaesthesiol Clin Pharmacol 2018 Jul-Sep;34(3):419-420

Department of Anesthesiology, Mount Sinai Medical Center of Florida, Miami Beach, Florida, USA.

J Vasc Bras 2018 Apr-Jun;17(2):174-177

Hospital Nossa Senhora das Graças - HNSG, Serviço de Cirurgia Vascular e Endovascular Elias Abrão, Curitiba, PR, Brasil.

Compression of the subclavian artery in the thoracic outlet is a well-known phenomenon. In rare cases, bone abnormalities, such as pseudarthrosis of the clavicle, can cause arterial compression at this level. Pseudarthrosis may develop as a result of trauma, which is the more common form, or it may be congenital. Read More

J Clin Neurosci 2018 Dec 16;58:75-78. Epub 2018 Oct 16.

Department of Neurological Surgery and Neuroscience, University of Virginia Health System, Charlottesville, VA, USA.

In total, 665 of 680 (97%) patients with neurogenic thoracic outlet syndrome (NTOS) improved with conservative treatment. The remaining (3%) patients (15 of 680 patients) did not benefit after 3 months of conservative treatment and were referred for transaxillary first rib resection. We retrospectively compared the preoperative and postoperative (3 months) electromyelography and Quick Disability of Arm, Shoulder and Hands results of operated NTOS patients. Read More

Rinsho Shinkeigaku 2018 Oct 29;58(10):631-635. Epub 2018 Sep 29.

Department of Neurology, Kyoto Second Red Cross Hospital.

A 61-year-old man, with a history of right clavicular fracture 35 years prior, visited our hospital due to the sudden onset of vertigo and tinnitus following weakness and numbness in his left arm and leg. He also had a 6-month history of right arm pain with overuse. Brain MRI showed acute brain infarcts in the right posterior cerebral artery territory. Read More

Acta Chir Orthop Traumatol Cech 2018 ;85(4):291-293

I. chirurgická klinika Lékařské fakulty Masarykovy Univerzity a Fakultní nemocnice U sv. Anny v Brně.

The purpose of the case report is to present the case of a 42-year-old woman with thoracic outlet syndrome caused by fibrous dysplasia of the first rib treated by surgical therapy through cervicothoracic approach by Grunenwald with complete vascular and partial brachial plexus preparation. Key words:thoracic outlet syndrome, fibrous dysplasia, cervicothoracic approach. Read More

J Vasc Surg 2018 10;68(4):939-940

Department of Surgery, University of South Florida College of Medicine, Tampa, Fla. Electronic address:

A A Pract 2018 Sep 18. Epub 2018 Sep 18.

From the Department of Anesthesiology, John H. Stroger Cook County Hospital, Chicago, Illinois.

Thoracic outlet compression syndrome is a complex syndrome of neurovascular compression at the superior thoracic aperture, thought to occur at 1 of 3 anatomical compartments: the interscalene triangle, the costoclavicular space, and the retropectoralis minor space. Injection into the middle interscalene muscle (ISM) and/or pectoralis muscle plane (PECS I and II) is gaining popularity because it provides significant symptomatic relief. A 44-year-old woman was diagnosed with thoracic outlet compression syndrome, with failed conservative therapy, including physical therapy. Read More

Ann Vasc Surg 2019 Jan 11;54:118-122. Epub 2018 Sep 11.

Yale University, Division of Vascular Surgery, Department of General Surgery, New Haven, CT.

Background: Venous thoracic outlet syndrome (vTOS) is a rare disease with no defined guidelines regarding treatment. Patients with first rib resection with anterior scalenectomy (FRRS) often have residual subclavian vein stenosis. The aim of this study was to evaluate the use of intravascular ultrasound (IVUS) in the treatment of vTOS patients who have been surgically decompressed with FRRS. Read More

ANZ J Surg 2018 Sep 11. Epub 2018 Sep 11.

Department of Surgery, Zuyderland Medical Centre, Heerlen, the Netherlands.

Medicine (Baltimore) 2018 Sep;97(36):e11846

Department of Thoracic Surgery, PLA Army General Hospital, Beijing, China.

Rationale: The Nuss procedure has become a major alternative operation for patients with pectus excavatum (PE).

Patient Concerns: We report a case of 27-year-old man with PE who developed thoracic outlet syndrome (TOS) after the Nuss procedure. The patient showed clinical symptoms of brachial plexus compression. Read More

Hand (N Y) 2018 Sep 5:1558944718798834. Epub 2018 Sep 5.

2 Toronto Western Hospital Hand Program, Division of Plastic & Reconstructive Surgery, Department of Surgery, University of Toronto, ON, Canada.

Background: Surgical thoracic outlet syndrome (TOS) management involves decompression of the neurovascular structures by releasing the anterior and/or middle scalene muscles, resection of the first and/or cervical ribs, or a combination. Various surgical approaches (transaxillary, supraclavicular, infraclavicular, and transthoracic) have been used with varying rates of complications. The purpose of this study was to evaluate early postoperative outcomes following surgical decompression for TOS. Read More

J Orthop Case Rep 2018 Mar-Apr;8(2):78-80

Department of Orthopaedics, National Orthopaedic Hospital Enugu, Nigeria.

Introduction: Cervical rib is a mesenchymal or cartilaginous elongation of the transverse process of usually the seventh, rarely the sixth, and very rarely the fifth cervical vertebrae. It is an important cause of thoracic outlet syndrome as it has been reported in 5-% of patients with thoracic outlet syndrome. Bilateral cervical rib is a rare anomaly with a prevalence of 0. Read More

Trans Am Clin Climatol Assoc 2018 ;129:88-94

WINSTON-SALEM, NORTH CAROLINA.

This review describes the outcomes for patients who underwent first rib resection for all three forms of thoracic outlet syndrome during a period of 10 years. The data were previously published in 2014 and the ACCA presentation, and this manuscript are derived largely from this work (1). Patients treated with first rib section from August 2003 through July 2013 were retrospectively reviewed using a prospectively maintained database. Read More

Clin Case Rep 2018 Aug 5;6(8):1631-1632. Epub 2018 Jun 5.

Department of Thoracic Surgery "Attikon" Hospital National and Kapodistrian University of Athens Athens Greece.

Transaxillary partial excision of the first rib is associated with minimal morbidity and excellent relief of symptoms of thoracic outlet syndrome due to instant and permanent obviation of the external arterial compression. Three-dimensional imaging offers incremental value of the surgical outcome, highlighting the role of minimally invasive partial resection. Read More

J Orthop 2018 Sep 16;15(3):832-836. Epub 2018 Aug 16.

Department of Orthopaedic Surgery, University of Toledo College of Medicine and Life Sciences, 3000 Arlington Ave., Toledo, OH, 43614, USA.

Cubital tunnel syndrome is the second most common peripheral nerve compression seen by hand surgeons. A thorough understanding of the ulnar nerve anatomy and common sites of compression are required to determine the cause of the neuropathy and proper treatment. Recognizing the various clinical presentations of ulnar nerve compression can guide the surgeon to choose examination tests that aid in localizing the site of compression. Read More

J Hand Surg Am 2018 Aug 16. Epub 2018 Aug 16.

Department of Hand Surgery, Tianjin Hospital, Tianjin, China.

Purpose: To provide a summary of the relevant evidence on outcomes of transaxillary first rib excision (TAFRE), supraclavicular first rib excision with scalenectomy (SCFRE), and supraclavicular release leaving the first rib intact (SCR) for patients with neurogenic thoracic outlet syndrome (TOS), and interpret the treatment effects from a Bayesian perspective.

Methods: A systematic literature search and review were performed. Random-effects meta-analyses were conducted to estimate success rate and complete relief rate of each procedure. Read More

Vasc Endovascular Surg 2018 Aug 14:1538574418794081. Epub 2018 Aug 14.

1 Department of Neurosurgery, Augusta Health, Augusta, GA, USA.

Thoracic outlet syndrome (TOS) is an infrequent entity encountered by medical practitioners attributed to compression of the neurovascular structures passing through the thoracic outlet. Here, we report the presentation of a young adult who was referred for workup of cervical radiculopathy and was planned to undergo an anterior cervical discectomy and fusion. A dynamic cerebral angiogram was performed and confirmed the diagnosis of arteriogenic TOS. Read More

Ann Vasc Surg 2019 Jan 4;54:269-275. Epub 2018 Aug 4.

Division of Vascular Surgery, Baylor Heart and Vascular Hospital, Dallas, TX.

Background: Neurogenic thoracic outlet syndrome (NTOS) is the most common form of thoracic outlet syndrome (TOS) and may occur from injury, occupational stress, or athletic endeavors. Although most patients with NTOS will improve after first-rib resection and scalenectomy (FRRS), the prognostic risk factors for success remain unclear. Athletes are a very motivated and disciplined demographic and therefore should be a group more likely to respond to FRRS for NTOS than nonathletes. Read More

Childs Nerv Syst 2018 Dec 17;34(12):2503-2507. Epub 2018 Jul 17.

Department of Pediatric Neurology, Medical University of Warsaw, Warsaw, Poland.

Arterial type of thoracic outlet syndrome belongs to the most unusual mechanisms of stroke in children in the first decade of life. We present a case diagnosed for bilateral and symmetric changes due to retrograde thromboembolic phenomenon. Regarding the age of the patient, the appropriate diagnostics and management are still a matter of debate in pediatric and neurological literature. Read More

Folia Morphol (Warsz) 2018 Jul 16. Epub 2018 Jul 16.

Faculty of Medicine, University of Montenegro, Ljubljanska 1, 20000 Podgorica, Serbia and Montenegro.

The brachial plexus represents a field of many anatomical variations with important clinical implications, especially in the diagnosis and treatment of the thoracic outlet syndrome (TOS). The case described in this paper presented a novel bilateral variation in the relation of the upper trunk of the brachial plexus to the anterior scalene muscle. The ventral rami of the C5 and C6 spinal nerves perforated the anterior scalene muscle simultaneously through a common opening, and joined to form the upper trunk. Read More

Surg Radiol Anat 2018 Oct 4;40(10):1141-1145. Epub 2018 Jul 4.

Department of Radiology, American Hospital, 34580, Istanbul, Turkey.

Purpose: The subclavius posticus muscle (SPM) is an aberrant muscle, and the presence of the SPM has a clinical significance, since the SPM might lead to thoracic outlet syndrome (TOS). To date, no radiological study has been evaluated the prevalence of the SPM in the adult population. In this study, we aimed to assess the prevalence of the SPM using magnetic resonance imaging (MRI). Read More

Int J Surg Case Rep 2018 20;49:81-86. Epub 2018 Jun 20.

Department of Orthopaedics, Sengkang General Hospital, Singapore. Electronic address:

Background: Paget-Schrotter Syndrome (PSS) also known as "effort thrombosis" is a form of primary thrombosis in the subclavian vein at the costoclavicular junction is usually seen in younger patients after repeated strenuous activity of the shoulders and arms. When occurring in younger patients, PSS presents itself with predisposing factors such as unilateral dull, aching pain in the shoulder or axilla and swelling of the arm and hand.

Case Presentation: We report a rare case of unusual left axillo-subclavian vein thrombosis following narrowing of thoracic outlet due to stress injury of rib fracture likely during gym activity in absence of other clear risk factors and a negative hypercoagulable workup in a 27-year-old man who was admitted as left deltoid rupture 5 days after his usual gym. Read More

J Vasc Surg Cases Innov Tech 2018 Jun 30;4(2):163-165. Epub 2018 Apr 30.

Presbyterian/St. Lukes Hospital and St. Joseph Hospital, Denver, Colorado.

A patient with neurogenic thoracic outlet syndrome was initially treated with scalenectomy, first rib resection, and wrapping of the brachial plexus (BP) with amnion membrane (AM) to prevent postoperative adhesions. Twelve months later, at reoperation for recurrent symptoms, the AM was observed to be intact. The BP had no scar tissue around it. Read More

Int J Surg Case Rep 2018 7;48:139-141. Epub 2018 Jun 7.

ENT Department, Al- Farwaniya Institute, Kuwait.

Introduction: A fibrolipoma of the left subclavicular region, a neoplasm rarely encountered in this region, was compromising the branchial plexus and thoracic duct, causing thoracic outlet syndrome in a symptomatic patient.

Case Presentation: A 41-year-old Asian woman was brought to our ENT (ear-nose-throat) clinic because of slowly progressive swelling of the left subclavicular region since 10 years before, which became painful with time, associated with increasing subpectoral and shoulder pains, left arm swelling, and left forearm paresthesias.

Discussion: The exact etiology of fibrolipomas remains disputed, and endocrine, dysmetabolic, genetic, and traumatic factors have been often considered. Read More

QJM 2018 11;111(11):831-832

Department of Neurology, Hiroshima City Hiroshima Citizens Hospital, 7-33 Motomachi, Naka-ku, Hiroshima-shi, Hiroshima, Japan.

Healthcare (Basel) 2018 Jun 19;6(2). Epub 2018 Jun 19.

Biomechanics and Motor Behavior Laboratory, Department of Kinesiology, Texas Woman's University, Denton, TX 76207, USA.

Thoracic outlet syndrome (TOS) describes a group of disorders that are due to a dynamic compression of blood vessels or nerves, between the clavicle and first rib or cervical vertebral nerve roots. Individuals with TOS typically experience upper limb pain, numbness, tingling, or weakness that is exacerbated by shoulder or neck movement. The causes of TOS vary, and can include abrupt movements, hypertrophy of the neck musculature, and anatomical variations in which the brachial plexus roots pass through this musculature, edema, pregnancy, repeated overhead motions, the blockage of an artery or vein, or abnormal posture. Read More

Surgeon 2019 Feb 22;17(1):43-51. Epub 2018 May 22.

International Evidence-Based Anatomy Working Group, Kraków, Poland; Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland.

Purpose: The following research aimed to investigate the prevalence and anatomical features of the axillary arch (AA) - a muscular, tendinous or musculotendinous slip arising from the latissimus dorsi and that terminates in various structures around the shoulder girdle. The AA may complicate axillary lymph node biopsy or breast reconstruction surgery and may cause thoracic outlet syndrome.

Methods: Major electronic databases were thoroughly searched for studies on the AA and its variations. Read More

J Vasc Access 2019 Jan 24;20(1):105-106. Epub 2018 May 24.

AMC Heart Center and Department of Cardiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.

Semin Musculoskelet Radiol 2018 Jul 23;22(3):323-333. Epub 2018 May 23.

Department of Imaging and Interventional Radiology, The Chinese University of Hong Kong, Hong Kong.

Examination of the brachial plexus with ultrasound is efficient because it allows many parts of the brachial plexus as well as the surrounding soft tissues to be assessed with high spatial resolution. The key to performing good ultrasound of the brachial plexus is being familiar with the anatomy and the common variants. That makes it possible to concentrate solely on the ultrasound appearances free of simultaneously wondering about the anatomy. Read More

Diagnostics (Basel) 2018 May 19;8(2). Epub 2018 May 19.

Wake Forest Baptist Medical Center, Wake Forest School of Medicine, Winston-Salem, 27157 NC, USA.

Those who diagnose and treat patients with thoracic outlet syndrome, especially those patientswith neurogenic thoracic outlet syndrome, have a practice, which needs to include many modalities todiagnose, treat, and intervene to improve their quality of life for the present and for the future.[.. Read More

Ann Vasc Surg 2018 Aug 15;51:147-149. Epub 2018 May 15.

Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN.

Background: Cervical rib can often be symptomatic causing neurogenic thoracic outlet syndrome (nTOS). Surgical treatment involves rib resection through a supraclavicular, transaxillary or combined approach. We review outcomes of different approaches and describe our technique of transaxillary resection through a video. Read More

Ann Vasc Surg 2018 Aug 11;51:25-29. Epub 2018 Jun 11.

Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Bronx, NY.

Background: The objective of the study was to analyze causes and outcomes of malpractice claims against vascular surgeons in the United States.

Methods: Cases entered into the Westlaw database from January 1, 1999 to December 31, 2014 were reviewed. Search terms "vascular" and "surgeon" were used. Read More

Ann Thorac Surg 2018 Nov 9;106(5):e253-e255. Epub 2018 May 9.

Department of Cardiovascular and Thoracic Surgery, Onze-Lieve-Vrouwziekenhuis Aalst, Aalst, Belgium. Electronic address:

Several different approaches to surgical decompression of the thoracic outlet have been described. This report describes a unique case of robotically assisted transthoracic cervical rib resection for neurogenic thoracic outlet syndrome. This minimally invasive technique offers delicate tissue manipulation under optimal visualization of the thoracic outlet structures. Read More

Asian Cardiovasc Thorac Ann 2018 Jun 7;26(5):422. Epub 2018 May 7.

Department of Cardiovascular and Thoracic Surgery, Government Medical College, Kottayam, India.