Randomized Controlled Trial

. 2018 May 19;391(10134):1997-2007.

doi: 10.1016/S0140-6736(18)30801-8. Epub 2018 May 11.

Drug-eluting stents versus bare-metal stents in saphenous vein grafts: a double-blind, randomised trial

Emmanouil S Brilakis¹, Robert Edson², Deepak L Bhatt³, Steven Goldman⁴, David R Holmes Jr⁵, Sunil V Rao⁶, Kendrick Shunk⁷, Bavana V Rangan⁸, Kreton Mavromatis⁹, Kodangudi Ramanathan¹⁰, Anthony A Bavry¹¹, Santiago Garcia¹², Faisal Latif¹³, Ehrin Armstrong¹⁴, Hani Jneid¹⁵, Todd A Conner¹⁶, Todd Wagner¹⁷, Judit Karacsonyi⁸, Lauren Uyeda², Beverly Ventura², Aaron Alsleben², Ying Lu¹⁸, Mei-Chiung Shih¹⁹, Subhash Banerjee⁸; DIVA Trial Investigators

Collaborators, Affiliations

Collaborators

DIVA Trial Investigators:
Bina Ahmed, D Michelle Ratliff, Mark Ricciardi, Mark Sheldon, Milton Icenogle, Richard Snider, Amer Ardati, Brahmajee Nallamothu, Claire Duvernoy, Daniel S Menees, Hitinder Gurm, Michael P Thomas, Paul Grossman, Kristine Owen, On Topaz, Gautam Kumar, Kreton Mavromatis, Peter Block, David A Zidar, Hiram Bezerra, Jonathan Goldberg, Jose Ortiz, Joseph Jozic, Mohammed Osman, Noah Rosenthal, Sahil A Parikh, Tom A Lassar, Albert Chan, Arun Kumar, Kul Aggarwal, Tillmann Cyrus, Emmanouil S Brilakis, Jerrold Grodin, Subhash Banerjee, Brack Hattler, Ehrin Armstrong, Ivan Casserly, John Messenger, Michael Kim, R Kevin Rogers, Stephen Waldo, Thomas Tsai, Kenneth Morris, Mitchell Krucoff, Sunil Rao, Thomas J Povsic, William S Jones, Anthony Bavry, Calvin Choi, Ki Park, Jayson Liu Md, Biswajit Kar, David Paniagua, Hani Jneid, Jeffrey Breall, Islam Bolad, Rita Mukerji, Roopa Subbarao, Ahmed Abdel-Latif, David C Booth, Khaled M Ziada, Lawrence Rajan, Abdul Hakeem, Barry F Uretsky, Mayank Agrawal, Rajesh Sachdeva, Zubair Ahmed, Jesse McGee, Kodangudi Ramanathan, Rahman Shah, Alok Sharma, Edward McFalls, Rizwan Siddiqui, Santiago Garcia, Selcuk Adabag, Stefan Bertog, Anand Irimpen, Drew Baldwin, Nidal Abi Rafeh, Owen Mogabgab, Patrice Delafontaine, Jeffrey Lorin, Steven Sedlis, Eliot Schechter, Faisal Latif, Mazen Abu-Fadel, Talla Rousan, Udho Thadani, Fady Malik, Jeffrey Zimmet, Kendrick Shunk, Tony Chou, Alexis Beatty, Kenneth Lehmann, Michael Stadius, Andrew Klein, Caroline Rowe, Megumi Taniuchi, Andrew J Klein, Michael Forsberg, Divya Kapoor, Elizabeth Juneman, Huu Tam Truong, Kapildeo Lotun, Ryan Tsuda, Sergio Thai, Steven Goldman, Hoang Thai, David Lu, Vasilios Papademetriou, David Faxon, Deepak L Bhatt, Kevin Croce, Sammy Elmariah, Scott Kinlay

Affiliations

¹ VA North Texas Health Care System, Dallas, TX, USA; Minneapolis Heart Institute, Minneapolis, MN, USA; University of Texas Southwestern Medical School, Dallas, TX, USA. Electronic address: esbrilakis@gmail.com.
² VA Cooperative Studies Program Coordinating Center, Mountain View, CA, USA.
³ VA Boston Healthcare System, Boston, MA, USA; Brigham and Women's Hospital Heart and Vascular Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
⁴ University of Arizona, Sarver Heart Center, Tucson, AZ, USA.
⁵ Mayo Clinic School of Graduate Medical Education, Rochester, MN, USA.
⁶ Durham VA Medical Center, Durham, NC, USA; Duke University, Durham, NC, USA.
⁷ San Francisco VA Medical Center, San Francisco, CA, USA; University of California San Francisco, San Francisco, CA, USA.
⁸ VA North Texas Health Care System, Dallas, TX, USA; University of Texas Southwestern Medical School, Dallas, TX, USA.
⁹ Atlanta VA Medical Center, Atlanta, GA, USA; Emory University, Atlanta, GA, USA.
¹⁰ Memphis VA Medical Center, Memphis, TN, USA; University of Tennessee, Memphis, TN, USA.
¹¹ North Florida/South Georgia Veterans Health System, Gainesville, FL, USA; University of Florida, Gainesville, FL, USA.
¹² Minneapolis VA Medical Center, Minneapolis, MN, USA; University of Minnesota, Minneapolis, MN, USA.
¹³ Oklahoma VA Medical Center, Oklahoma City, OK, USA; University of Oklahoma, Oklahoma City, OK, USA.
¹⁴ Denver VA Medical Center, Denver, CO, USA; University of Colorado, Denver, CO, USA.
¹⁵ Michael E DeBakey VA Medical Center, Houston, TX, USA; Baylor College of Medicine, Houston, TX, USA.
¹⁶ VA Cooperative Studies Program Clinical Research Pharmacy Coordinating Center, Albuquerque, NM, USA.
¹⁷ VA Health Economics Resource Center, Menlo Park, CA, USA; Department of Surgery, Stanford University, CA, USA.
¹⁸ Department of Health Research and Policy, Stanford University, Stanford, CA, USA.
¹⁹ VA Cooperative Studies Program Coordinating Center, Mountain View, CA, USA; Department of Health Research and Policy, Stanford University, Stanford, CA, USA.

PMID: 29759512
PMCID: PMC6402785
DOI: 10.1016/S0140-6736(18)30801-8

Randomized Controlled Trial

Drug-eluting stents versus bare-metal stents in saphenous vein grafts: a double-blind, randomised trial

Emmanouil S Brilakis et al. Lancet. 2018.

. 2018 May 19;391(10134):1997-2007.

doi: 10.1016/S0140-6736(18)30801-8. Epub 2018 May 11.

Authors

Collaborators

DIVA Trial Investigators:
Bina Ahmed, D Michelle Ratliff, Mark Ricciardi, Mark Sheldon, Milton Icenogle, Richard Snider, Amer Ardati, Brahmajee Nallamothu, Claire Duvernoy, Daniel S Menees, Hitinder Gurm, Michael P Thomas, Paul Grossman, Kristine Owen, On Topaz, Gautam Kumar, Kreton Mavromatis, Peter Block, David A Zidar, Hiram Bezerra, Jonathan Goldberg, Jose Ortiz, Joseph Jozic, Mohammed Osman, Noah Rosenthal, Sahil A Parikh, Tom A Lassar, Albert Chan, Arun Kumar, Kul Aggarwal, Tillmann Cyrus, Emmanouil S Brilakis, Jerrold Grodin, Subhash Banerjee, Brack Hattler, Ehrin Armstrong, Ivan Casserly, John Messenger, Michael Kim, R Kevin Rogers, Stephen Waldo, Thomas Tsai, Kenneth Morris, Mitchell Krucoff, Sunil Rao, Thomas J Povsic, William S Jones, Anthony Bavry, Calvin Choi, Ki Park, Jayson Liu Md, Biswajit Kar, David Paniagua, Hani Jneid, Jeffrey Breall, Islam Bolad, Rita Mukerji, Roopa Subbarao, Ahmed Abdel-Latif, David C Booth, Khaled M Ziada, Lawrence Rajan, Abdul Hakeem, Barry F Uretsky, Mayank Agrawal, Rajesh Sachdeva, Zubair Ahmed, Jesse McGee, Kodangudi Ramanathan, Rahman Shah, Alok Sharma, Edward McFalls, Rizwan Siddiqui, Santiago Garcia, Selcuk Adabag, Stefan Bertog, Anand Irimpen, Drew Baldwin, Nidal Abi Rafeh, Owen Mogabgab, Patrice Delafontaine, Jeffrey Lorin, Steven Sedlis, Eliot Schechter, Faisal Latif, Mazen Abu-Fadel, Talla Rousan, Udho Thadani, Fady Malik, Jeffrey Zimmet, Kendrick Shunk, Tony Chou, Alexis Beatty, Kenneth Lehmann, Michael Stadius, Andrew Klein, Caroline Rowe, Megumi Taniuchi, Andrew J Klein, Michael Forsberg, Divya Kapoor, Elizabeth Juneman, Huu Tam Truong, Kapildeo Lotun, Ryan Tsuda, Sergio Thai, Steven Goldman, Hoang Thai, David Lu, Vasilios Papademetriou, David Faxon, Deepak L Bhatt, Kevin Croce, Sammy Elmariah, Scott Kinlay

Affiliations

¹ VA North Texas Health Care System, Dallas, TX, USA; Minneapolis Heart Institute, Minneapolis, MN, USA; University of Texas Southwestern Medical School, Dallas, TX, USA. Electronic address: esbrilakis@gmail.com.
² VA Cooperative Studies Program Coordinating Center, Mountain View, CA, USA.
³ VA Boston Healthcare System, Boston, MA, USA; Brigham and Women's Hospital Heart and Vascular Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
⁴ University of Arizona, Sarver Heart Center, Tucson, AZ, USA.
⁵ Mayo Clinic School of Graduate Medical Education, Rochester, MN, USA.
⁶ Durham VA Medical Center, Durham, NC, USA; Duke University, Durham, NC, USA.
⁷ San Francisco VA Medical Center, San Francisco, CA, USA; University of California San Francisco, San Francisco, CA, USA.
⁸ VA North Texas Health Care System, Dallas, TX, USA; University of Texas Southwestern Medical School, Dallas, TX, USA.
⁹ Atlanta VA Medical Center, Atlanta, GA, USA; Emory University, Atlanta, GA, USA.
¹⁰ Memphis VA Medical Center, Memphis, TN, USA; University of Tennessee, Memphis, TN, USA.
¹¹ North Florida/South Georgia Veterans Health System, Gainesville, FL, USA; University of Florida, Gainesville, FL, USA.
¹² Minneapolis VA Medical Center, Minneapolis, MN, USA; University of Minnesota, Minneapolis, MN, USA.
¹³ Oklahoma VA Medical Center, Oklahoma City, OK, USA; University of Oklahoma, Oklahoma City, OK, USA.
¹⁴ Denver VA Medical Center, Denver, CO, USA; University of Colorado, Denver, CO, USA.
¹⁵ Michael E DeBakey VA Medical Center, Houston, TX, USA; Baylor College of Medicine, Houston, TX, USA.
¹⁶ VA Cooperative Studies Program Clinical Research Pharmacy Coordinating Center, Albuquerque, NM, USA.
¹⁷ VA Health Economics Resource Center, Menlo Park, CA, USA; Department of Surgery, Stanford University, CA, USA.
¹⁸ Department of Health Research and Policy, Stanford University, Stanford, CA, USA.
¹⁹ VA Cooperative Studies Program Coordinating Center, Mountain View, CA, USA; Department of Health Research and Policy, Stanford University, Stanford, CA, USA.

PMID: 29759512
PMCID: PMC6402785
DOI: 10.1016/S0140-6736(18)30801-8

Abstract

Background: Few studies have examined the efficacy of drug-eluting stents (DES) for reducing aortocoronary saphenous vein bypass graft (SVG) failure compared with bare-metal stents (BMS) in patients undergoing stenting of de-novo SVG lesions. We assessed the risks and benefits of the use of DES versus BMS in de-novo SVG lesions.

Methods: Patients were recruited to our double-blind, randomised controlled trial from 25 US Department of Veterans Affairs centres. Eligible participants were aged at least 18 years and had at least one significant de-novo SVG lesion (50-99% stenosis of a 2·25-4·5 mm diameter SVG) requiring percutaneous coronary intervention with intent to use embolic protection devices. Enrolled patients were randomly assigned, in a 1:1 ratio, by phone randomisation system to receive a DES or BMS. Randomisation was stratified by presence or absence of diabetes and number of target SVG lesions requiring percutaneous coronary intervention (one or two or more) within each participating site by use of an adaptive scheme intended to balance the two stent type groups on marginal totals for the stratification factors. Patients, referring physicians, study coordinators, and outcome assessors were masked to group allocation. The primary endpoint was the 12-month incidence of target vessel failure, defined as the composite of cardiac death, target vessel myocardial infarction, or target vessel revascularisation. The DIVA trial is registered with ClinicalTrials.gov, number NCT01121224.

Findings: Between Jan 1, 2012, and Dec 31, 2015, 599 patients were randomly assigned to the stent groups, and the data for 597 patients were used. The patients' mean age was 68·6 (SD 7·6) years, and 595 (>99%) patients were men. The two stent groups were similar for most baseline characteristics. At 12 months, the incidence of target vessel failure was 17% (51 of 292) in the DES group versus 19% (58 of 305) in the BMS group (adjusted hazard ratio 0·92, 95% CI 0·63-1·34, p=0·70). Between-group differences in the components of the primary endpoint, serious adverse events, or stent thrombosis were not significant. Enrolment was stopped before the revised target sample size of 762 patients was reached.

Interpretation: In patients undergoing stenting of de-novo SVG lesions, no significant differences in outcomes between those receiving DES and BMS during 12 months of follow-up were found. The study results have important economic implications in countries with high DES prices such as the USA, because they suggest that the lower-cost BMS can be used in SVG lesions without compromising either safety or efficacy.

Funding: US Department of Veterans Affairs Cooperative Studies Program.

PubMed Disclaimer

Conflict of interest statement

Declaration of interests

ESB consults for and receives speaker honoraria from Abbott Vascular, Amgen, Asahi, Boston Scientific, Cardinal Health, CSI, Elsevier, GE Healthcare, Medicure, Medtronic, and Nitiloop, and receives research support from Boston Scientific, InfraRedx and Osprey. ESB’s spouse was an employee of Medtronic. DLB is an advisory board member of Cardax, Elsevier Practice Update Cardiology, Medscape Cardiology, and Regado Biosciences; is on the board of directors of Boston VA Research Institute and Society of Cardiovascular Patient Care; is chair of the American Heart Association Quality Oversight Committee; is on the data monitoring committees of Cleveland Clinic, Duke Clinical Research Institute, Harvard Clinical Research Institute, Mayo Clinic, Mount Sinai School of Medicine, and Population Health Research Institute; receives honoraria from the American College of Cardiology, Belvoir Publications, Duke Clinical Research Institute, Harvard Clinical Research Institute, HMP Communications, Journal of the American College of Cardiology, Population Health Research Institute, Slack Publications, Society of Cardiovascular Patient Care, and WebMD; is deputy editor of Clinical Cardiology, and chair of the NCDR-ACTION registry steering committee and VA CART research and publications committee; receives research funding from Abbott, Amarin, Amgen, AstraZeneca, Bristol-Myers Squibb, Chiesi, Eisai, Ethicon, Forest Laboratories, Ironwood, Ischemix, Lilly, Medtronic, Pfizer, Roche, Sanofi Aventis, and The Medicines Company; receives royalties from Elsevier; is a site co-investigator for Biotronik, Boston Scientific, and St Jude Medical (now Abbott); is a trustee of the American College of Cardiology; and does unfunded research for FlowCo, Merck, PLx Pharma, and Takeda. SG receives research support from the National Institutes of Health, the VA Cooperative Studies Program, the Arizona Biomedical Research Commission, and Merck Pharmaceuticals, and is the co-founder of Avery Therapeutic. SVR consults for Medtronic. KS consults for Medeon Bio Inc, TransAortic Medical, and Terumo, and receives research support from Siemens Medical Systems and Medinol. AAB consults for the American College of Cardiology. SG receives research grants from Edwards Lifesciences and VA Office of Research and Development, and consults for Medtronic, Boston Scientific, Osprey Medical, and Surmodics. FL is a speaker for Abbott Vascular, and consults for Medicure. EA consults for Abbott Vascular, Boston Scientific, Cardiovascular Systems, Medtronic, and Spectranetics. BVR receives a research grant from InfraRedx and the Spectranetics Corporation, and salary support from the VA Cooperative Studies Program. YL consults for PTC Therapeutics and PaxVax. SB receives speaker honoraria from AstraZeneca, CSI, Gore, and Medtronic, and institutional research grants from Boston Scientific Corporation, and Merck. All other authors declare no competing interests.

Figures

**Figure 1:. Enrolment, randomisation, and follow-up**
The number of patients who were eligible is lower than the number randomly assigned, because some ineligible patients were randomly assigned. SVG=saphenous vein aortocoronary bypass graft. PCI=percutaneous coronary intervention. *Two patients who were screened and randomly assigned without proper consent are not included. †Criteria are not mutually exclusive.

**Figure 2:. Clinical outcomes at 12 months**
Kaplan-Meier plot of cumulative incidence curves for patients who received drug-eluting stents (DES) or bare-metal stents (BMS) for the primary outcome of target vessel failure (composite outcome of cardiac death, target vessel myocardial infarction, or target vessel revascularisation), cardiac death, target vessel myocardial infarction, and target vessel revascularisation. HR=hazard ratio.

See this image and copyright information in PMC

Comment in

Stents in saphenous vein grafts.
Jeger RV, Möbius-Winkler S. Jeger RV, et al. Lancet. 2018 May 19;391(10134):1967-1968. doi: 10.1016/S0140-6736(18)30937-1. Epub 2018 May 11. Lancet. 2018. PMID: 29759511 No abstract available.
Drug-eluting stents versus bare-metal stents for vein-graft PCI.
Le Bras A. Le Bras A. Nat Rev Cardiol. 2018 Aug;15(8):442. doi: 10.1038/s41569-018-0042-8. Nat Rev Cardiol. 2018. PMID: 29867189 No abstract available.
Taking care of the soldiers.
Wan S, Cheng ZY. Wan S, et al. J Thorac Dis. 2018 Nov;10(Suppl 33):S4002-S4005. doi: 10.21037/jtd.2018.09.25. J Thorac Dis. 2018. PMID: 30631539 Free PMC article. No abstract available.
Second-generation drug-eluting stents versus bare-metal stents in saphenous vein grafts: is the choice more complicated than before?
Pellicano M, Azzano A, Barbato E. Pellicano M, et al. J Thorac Dis. 2019 Mar;11(Suppl 3):S385-S389. doi: 10.21037/jtd.2018.12.23. J Thorac Dis. 2019. PMID: 30997227 Free PMC article. No abstract available.
Drug eluting stents versus bare metal stents for the treatment of saphenous vein grafts failure: learnings from the DIVA trial.
Sayah N, Lefèvre G, Picard F. Sayah N, et al. J Thorac Dis. 2019 Mar;11(Suppl 3):S399-S403. doi: 10.21037/jtd.2018.11.123. J Thorac Dis. 2019. PMID: 30997231 Free PMC article. No abstract available.
Drug-eluting stents versus bare-metal stents for saphenous vein graft interventions.
Shah R, Hesterberg K. Shah R, et al. J Thorac Dis. 2019 May;11(Suppl 9):S1257-S1260. doi: 10.21037/jtd.2019.02.50. J Thorac Dis. 2019. PMID: 31245102 Free PMC article. No abstract available.
Trial Sequential Analysis of Drug-Eluting Stents Versus Bare-Metal Stents in Saphenous Vein Graft Intervention.
Kheiri B, Osman M, Bachuwa G, Cigarroa JE. Kheiri B, et al. Am J Cardiol. 2019 Sep 1;124(5):823-824. doi: 10.1016/j.amjcard.2019.05.043. Epub 2019 Jun 6. Am J Cardiol. 2019. PMID: 31272706 No abstract available.

Cited by

Percutaneous Coronary Intervention of Native Artery Versus Bypass Graft in Patients with Prior Coronary Artery Bypass Graft Surgery.
Farag M, Brilakis ES, Gasparini GL, Spratt JC, Egred M. Farag M, et al. Rev Cardiovasc Med. 2022 Jun 24;23(7):232. doi: 10.31083/j.rcm2307232. eCollection 2022 Jul. Rev Cardiovasc Med. 2022. PMID: 39076928 Free PMC article.
Defining Key Features of Complex Coronary Lesions: An Evidence Based Review of Clinical Practice. Part II: Chronic Total Occlusions, Graft Interventions, In-Stent Restenosis, and Antithrombotic Strategies.
Feldman D, Beerkens F, Nicolas J, Satish M, Jones D, Demirhan M, Dangas G. Feldman D, et al. Rev Cardiovasc Med. 2022 Jun 8;23(6):209. doi: 10.31083/j.rcm2306209. eCollection 2022 Jun. Rev Cardiovasc Med. 2022. PMID: 39077193 Free PMC article. Review.
One-year outcomes of percutaneous coronary intervention in native coronary arteries versus saphenous vein grafts in patients with prior coronary artery bypass graft surgery.
Abdelrahman A, Dębski M, More R, Abdelaziz HK, Choudhury T, Eichhofer J, Patel B. Abdelrahman A, et al. Cardiol J. 2022;29(3):396-404. doi: 10.5603/CJ.a2020.0131. Epub 2020 Oct 1. Cardiol J. 2022. PMID: 33001421 Free PMC article.
Saphenous Vein Graft Failure: Current Challenges and a Review of the Contemporary Percutaneous Options for Management.
Back L, Ladwiniec A. Back L, et al. J Clin Med. 2023 Nov 15;12(22):7118. doi: 10.3390/jcm12227118. J Clin Med. 2023. PMID: 38002729 Free PMC article. Review.
Drug eluting stents versus bare metal stents for the treatment of saphenous vein grafts failure: learnings from the DIVA trial.
Sayah N, Lefèvre G, Picard F. Sayah N, et al. J Thorac Dis. 2019 Mar;11(Suppl 3):S399-S403. doi: 10.21037/jtd.2018.11.123. J Thorac Dis. 2019. PMID: 30997231 Free PMC article. No abstract available.

See all "Cited by" articles

References

1. Hall MJ, Levant S, DeFrances CJ. Trends in inpatient hospital deaths: National Hospital Discharge Survey, 2000–2010. NCHS Data Brief 2013; 2013: 1–8. - PubMed
1. Widimsky P, Straka Z, Stros P, et al. One-year coronary bypass graft patency: a randomized comparison between off-pump and on-pump surgery angiographic results of the PRAGUE-4 trial. Circulation 2004; 110: 3418–23. - PubMed
1. Alexander JH, Hafley G, Harrington RA, et al. Efficacy and safety of edifoligide, an E2F transcription factor decoy, for prevention of vein graft failure following coronary artery bypass graft surgery: PREVENT IV: a randomized controlled trial. JAMA 2005; 294: 2446–54. - PubMed
1. Brilakis ES, Rao SV, Banerjee S, et al. Percutaneous coronary intervention in native arteries versus bypass grafts in prior coronary artery bypass grafting patients a report from the national cardiovascular data registry. JACC Cardiovasc Interv 2011; 4: 844–50. - PubMed
1. Goldman S, Zadina K, Moritz T, et al. Long-term patency of saphenous vein and left internal mammary artery grafts after coronary artery bypass surgery results from a Department of Veterans Affairs cooperative study. J Am Coll Cardiol 2004; 44: 2149–56. - PubMed

Publication types

Actions
Actions
Actions
Actions

MeSH terms

Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions

Associated data

Actions
- Search in PubMed
- Search in ClinicalTrials.gov

Grants and funding

P30 CA124435/CA/NCI NIH HHS/United States

LinkOut - more resources

Full Text Sources
Other Literature Sources
- scite Smart Citations
Medical
- ClinicalTrials.gov
- MedlinePlus Health Information
Research Materials
- NCI CPTC Antibody Characterization Program

Save citation to file

Email citation

Add to Collections

Add to My Bibliography

Your saved search

Create a file for external citation management software

Your RSS Feed

Drug-eluting stents versus bare-metal stents in saphenous vein grafts: a double-blind, randomised trial

Collaborators

Affiliations

Drug-eluting stents versus bare-metal stents in saphenous vein grafts: a double-blind, randomised trial

Authors

Collaborators

Affiliations

Abstract

Conflict of interest statement

Figures

Comment in

Similar articles

Cited by

References

Publication types

MeSH terms

Associated data

Grants and funding

LinkOut - more resources

Full Text Sources

Other Literature Sources

Medical

Research Materials

Abstract

Conflict of interest statement

Figures

Comment in

Similar articles

Cited by

References

Publication types

MeSH terms

Associated data

Related information

Grants and funding

LinkOut - more resources

Full Text Sources

Other Literature Sources

Medical

Research Materials