Printer Friendly

TRANS-RADIAL CORONARY ANGIOGRAPHY--A STUDY OF CAUSES OF PROCEDURAL FAILURE IN A TERTIARY CARE HOSPITAL IN SOUTH BENGAL.

BACKGROUND

The trans-radial approach for performing coronary angiography was initially proposed by Campeau [1] in 1989. Several studies have shown that the trans-radial approach allows treatment of the same type of patients and lesions as the classic femoral approach, with some advantages. Because it involves a minimal vascular complication rate, eliminates the necessity for prolonged compression or closure devices and allows for earlier ambulation for the patient. Trans-radial approach more comfortable for the patient because it decreases hospital costs and length of stay in hospital. But, the greater technical complexity of the procedure, its use is limited in our country.

The primary objectives are to assess the feasibility of trans-radial angiography for selective catheterization of the coronary arteries, and to determine the causes of procedural failure.

Objectives of the Study

1. To determine the causes of procedural failure.

2. To determine complication rate.

MATERIALS & METHODS

Patient came with the Complain of angina and angina equivalent at Cardiology OPD or Emergency of R. G. Kar Medical College were screened. Routine history, clinical examination along with relevant biochemical, Echocardiographic and Radionuclide scan were performed. The selected cases were planned for TRCAG after written consent. Then assessment of dual arterial supply to both hands was assessed by performing Allen's test [1] (Modified Allen's [1] test was performed only when Allen's test was be abnormal).

Study Type and Design--Prospective Observational Study.

Study Area--R. G. KAR Medical College and Hospital, Kolkata.

Study Period--1st March 2013-28th February 2014.

Sample Type and Size

Simple random sample, 100 patients (Sample).

Inclusion Criteria

1. Acute coronary syndrome. [2]

2. Significant symptomatic angina.

3. Abnormal stress test or myocardial perfusion scans.

Exclusion Criteria

1. Negative Allen's test.

2. Chronic renal failure requiring regular hemodialysis.

3. Cases where simultaneous right heart catheterization to be attempted.

RESULTS

Chi-square test ([chi square], Pearson's)--A method of testing the significance of difference between two categorical variables.

A p value of <0.05 was considered significant.

Trans-radial coronary angiography (TRCAG) was done in R. G. Kar Medical College in total of hundred (100) patients. Coronary angiography was successfully done in 83 cases (83%) and 17 patients could not be performed through this (Radial) route. They had to convert through femoral route and brachial route. These cases were categorized as a Procedural failure cases.

TRCAG- Trans-Radial Coronary Angiography

Out of 100 patients 78 were male and 22 were female. Transradial coronary angiography (TRCAG) was successfully done in 69 (88.46%) male and 14 (63.63%) female patients. TRCAG failed in 9 (11.53%) male and 8 (36.36%) female. Out of total 17 patients of Procedural failure through trans-radial route 9 (52.94%) patient were male and 8 (47.05%) patients were female. Data is not statistically significant with P value = 0.11

Out of total 100 patents 67 (67%) patients were Smokers and 33 (33%) were non-smoker. Trans-radial coronary angiography (TRCAG) was successfully done in 59 (88.05%) smoker and 24 (72.72%) non-smoker patients. TRCAG failed in 8 (11.94%) smokers and 9 (27.27%) non-smoker. Out of total 17 patients of Procedural failure through radial route 9 (52.94%) patient were non-smokers and 8 cases (47.05%) were smokers. Data is statistically significant with P value = 0.048.

Out of total 100 patents 75 (75%) patients had normal blood pressure (Normotensive) and 25 (25%) had high blood pressure (Hypertensive). Trans-radial coronary angiography (TRCAG) was successfully done in 64 (85.33%) normotensive and 19 (76%) of hypertensive patients. TRCAG failed in 11 (14.66%) normotensive and 6 (24%) hypertensive patient. Out of total 17 patients of Procedural failure through radial route 11 (64.70%) patient were normotensive and 6 cases (35.29%) were hypertensive. This data is statistically insignificant with P value = 0.217

Out of total 100 patents 68 (68%) patients had normal blood glucose level (No-diabetic) and 32 (32%) had high blood glucose (Diabetic). Out of total 17 patients of Procedural failure through radial route 7 (41.17%) patient were non-diabetic and 10 cases (58.82%) were Diabetic. Data is statistically significant with P value = 0.012. Out of total 32 diabetic patients 10 (31.25%) cases had procedural failure.

Out of total 100 patents 94 (94%) patients had normal blood Vessels (No-PVD) and 06 (06%) had Peripheral vascular disease (PVD).Out of total 17 patients of Procedural failure through radial route 16 (94.11%) patient had no-PVD and 1 case (5.88%) had PVD while one out of 06 cases (16.66 %) with PVD were associated with procedural failure, which not statistically significant with P value = 0.731.

Although, patients with smaller height were associated with more procedural failure, {height <150 cm=33.33% (5/15), height 151-160 cm=16.12% (5/31), height 161-170 cm =13.04% (6/46) and height >170 cm =12.5% (1/8)} data is not statistically significant with P value = 0.386.

Out of total 100 patents 66 (66%) there were no radial artery spasm and 34 (34%) had radial artery spasm. Out of total 17 patients of Procedural failure through radial route 02 (11.76%) patient had no radial artery spasm while 15 out of 17 cases (88.23 %) with radial artery spasm were associated with procedural failure. Data is statistically significant with P value = 0.01.

Out of total 100 patents 99 (99%) there were no Peripheral artery dissection and 01 (01%) had Peripheral artery dissection. Out of total 17 patients of Procedural failure through radial route 16 (94.11%) patient had no Peripheral artery dissection while one out of 17 cases (5.88 %) with Brachial artery dissection associated with procedural failure.

All patient with Peripheral artery dissection (1/1, 100%) was associated with procedural failure. The data is statistically insignificant with P value = 0.17.

Out of total 100 patents 93 (93%) there were no Coronary Artery Spasm and 07 (07%) had Coronary Artery Spasm. Out of total 17 patients of Procedural failure through radial route 16 (94.11%) patient had no Coronary Artery Spasm while one out of 17 cases (5.88 %) with Coronary Artery Spasm associated with procedural failure. One out of 7 (14.28%) patient with coronary artery spasm was associated with procedural failure. which is statistically insignificant with p value = 0.66.

Out of total 100 patents 89 (89%) there were no Loop/ Tortuosity of artery and 11 (11%) had Loop/ Tortuosity of artery. Out of total 17 patients of Procedural failure through radial route 12 (70.58%) patient had No Loop/ Tortuosity while 05 (29.41%) had Loop/ Tortuosity of artery. Total of 05 out of 11 (45.45%) patient with loop/tortuosity were associated with procedural failure. Data is statistically significant with P value = 0.042.

Four patients had procedural failure out of total 17 due to abnormal origin of coronary artery and constitute 23.52% (4/17), whereas 11 patients with abnormal origin of coronary artery, 4 patients had procedural failure 36.36 % (4/11). Which is statistically insignificant with P value = 0.198.

Female patients contribute 40% (6/15) of the total number of radial spasms, while 6 out of 8 female patients (75%) had had radial spasm.

Prevalence of Radial artery spasm was more with higher age group, it contributes 33.33% (5/15) in both 61-70 years group, and >70 years of age group. All patient with age group between 61-70 yrs., had radial spasm (100%, 5/5), while 71.42 % (5/7) in patients with age >70 yrs. This data is statistically significant with P value = 0.037.

TRF- Trans-radial failure

Most important cause of procedural failure was radial artery spasm (15/17). Other factors were also associated with radial spasm, but they had not responsible for failure.

DISCUSSION

Radial artery approach for coronary intervention has shown to reduce access site complications; early ambulation and reduced hospital stay. [3] Unfortunately, radial access still accounts for less than 10% of procedures worldwide. [4] Assumption that radial artery approach has excess failure rate and prolonged procedure time could have been the reasons for underutilization of radial artery site. [5] More data is required to convince interventional cardiologist to change their practice.

Our study population comprised of 78 (78%) males and 22 (22%) females with mean age of 56.71 [+ or -] 8.94 years. The overall procedural success rate was 83 (83%) for TRCAG. The reasons for failure of trans-radial procedure included failed radial artery puncture (n=2), radial artery loop and tortuous subclavian artery (N=5), failed catheterization of coronary arteries (N=4) and severe radial artery spasm (N=15). All procedures from radial artery approach ended up safely with standard anticoagulation. There were no major complications encountered in our study, one patient (1%) suffered with minor forearm hematoma and was treated conservatively. None of patients suffered with radial artery occlusion in our study. This observation is similar to International data. That has demonstrated that coronary interventions can be performed more safely than contemporary femoral route. Even the most successful coronary percutaneous intervention can be complicated by vascular access site complications in as much as 2-8% of cases performed from transfemoral route. [6,7] The ACCESS study clearly demonstrated, reduction of major access site complications from radial compared to femoral and brachial approaches (0% vs 2.3% vs 2% respectively). [5] In a recent meta- analysis of 22 randomized controlled trials by Sanjit S Jolly et al, [8] radial access reduced major bleeding by 73% compared to femoral access (0.05% vs 2.3%). Reduction in access site complications is really important in current era when more high-risk interventions are performed in more sick patients with concomitant use of multiple antiplatelet and anti-coagulant medicines. No major access site complications occurred in radial group compared to 7.5% complications at entry site in femoral group among patients receiving abciximab during percutaneous intervention. [6] Transfemoral intervention in acute myocardial infarction carries a risk of access site complications of up to 23%. [9] On the contrary almost no access site complications have been described in patients undergoing transradial percutaneous in acute myocardial infarction who received GpIIb/IIIa inhibitors. [10,11] Our study has also validated that transradial route reduces vascular access site complications considerably, as only one patient (1%) developed minor forearm haematoma which settled successfully with conservative treatment. A study performed at National Institute of Cardiovascular diseases found transradial diagnostic coronary angiogram and percutaneous intervention results to be comparable to femoral approach in terms of success but without any major vascular access site complications. [12]

Out of 100 patient 83 (83%) coronary angiographies were preformed from the trans-radial route in our study in the specified study period. The right hand was selected in all cases. The 5F sheath was most commonly used in (100%) and transradial failure in our study was 17% (17/100). This is correlating well with the previous study. The failure to complete the procedure from radial artery approach has been relatively high among the patients with radial artery spasm, radial loops, subclavian artery tortuosity and abnormal origin of coronary artery. [5] The failure to complete the procedure from radial route was 17% (17/100) in our study. The failure or cross over rate of radial access site was 5.9% in the meta-analysis by Jolly et al, [8] compared to 1.4% in the femoral group. Other factors that may contribute to procedural failure in lesser extent are height; patients with smaller height were associated with more procedural failure, Presence of diabetes Mellitus, Coronary artery spasm and presence of smoking history.

Asymptomatic radial artery occlusion occurs in 3-5% of patients in different studies [13] but, in our study we have not found even a single case of radial artery occlusion. In the first half of our study there was 24% (12/50) procedure failure, while in the second half the study only 10% (5/50) procedure failure noticed, which is statistically significant with p value = 0. 05. other complications are either less or equal in second half the study, but data were not statistically significant. So, trans-radial approach for coronary angiography is more successful and less complicated in experienced hand.

CONCLUSION

1. Radial artery approach is found to be very safe with high degree of success & there are very low vascular access site complications.

2. The main cause of trans-radial failure was radial spasm that was highly prevalent in female sex and older age patients.

3. Tortuous radial and subclavian artery are also related to transradial failure.

4. Trans Radial Failure was more common in female sex, short height, DM and smoker patients.

5. TRCAG should be widely used while performing coronary angiographies because it is appreciated by the patient over femoral access and also convenient for the interventionalist.

6. It may be cost-effective for the institution as well for the patients by reducing hospital stays.

Limitations

1. Sample size was less (N= 100).

2. It is a single- centered study.

3. The absence of a comparative femoral group.

DOI: 10.14260/jemds/2019/57

REFERENCES

[1] McConnell EA. Performing Allen's test. CITA 1997;27(12):26.

[2] Campeau L. Percutaneous radial artery approach for coronary angiography. Cathet Cardiovasc Diagn 1989;16(1):3-7.

[3] Cooper CJ, El-Shiekh RA, Cohen DJ, et al. Effect of transradial access on quality of life and cost of cardiac catheterization: a randomized comparison. Am Heart J 1999;138(3 Pt 1):430-6.

[4] Hamon M, Mehta S, Steg G, et al. Major bleeding in patients with acute coronary syndrome undergoing early invasive management can be reduced by fondaparinux, even in the context of trans-radial coronary intervention: Insights from OASIS-5 Trial. Circulation 2006;114(Suppl 18):552.

[5] Louvard Y, Pezzano M, Scheers L, et al. Coronary angiography by a radial artery approach: feasibility, learning curve. One operator's experience. Arch Mal Coeur Vaiss 1998;91(2):209-15.

[6] Choussat R, Black A, Bossi I, et al. Vascular complications and clinical outcomes after coronary angioplasty with platelet IIb/IIa receptor blockade. Comparison of transradial vs transfemoral arterial access. Eur Heart J 2000;21(8):662-7.

[7] Kiemeneij F, Laarman GJ, Odekerken D, et al. A randomized comparison of percutaneous transluminal coronary angioplasty by the radial, brachial and femoral approaches: the access study. J Am Coll Cardiol 1997;29(6):1269-75.

[8] Jolly SS, Amlani S, Hamon M, et al. Radial versus femoral access for coronary angiography or intervention and the impact on major bleeding and ischemic events: a systematic review and meta-analysis of randomized trials. Am Heart J 2009;157(1):132-40.

[9] Cantor WJ, Kaplan AL, Velianou JL, et al. Effectiveness and safety of abciximab after failed thrombolytic therapy. Am J Cardiol 2001;87(4):439-42, A4.

[10] Saito S, Tanaka S, Hiroe Y, et al. Comparative study on transradial approach vs. transfemoral approach in primary stent implantation for patients with acute myocardial infarction: results of the test for myocardial infarction by prospective unicenter randomization for access sites (TEMPURA) trial. Catheter Cardiovasc Interv 2003;59(1):26-33.

[11] Brasselet C, Tassan S, Nazeyrollas P, et al. Randomized comparison of femoral versus radial approach for percutaneous coronary intervention using abciximab in acute myocardial infarction: results of FARMI trial. Heart 2007;93(12):1556-61.

[12] Saghir T, Jan DM, Masood T, et al. Transradial diagnostic and percutaneous coronary intervention. J Coll Physicians Surg Pak 2003;13(5):242-7.

[13] Brueck M, Bandorski D, Kramer W, et al. A randomized comparison of transradial versus transfemoral approach for coronary angiography and angioplasty. JACC Cardiovasc Interv 2009;2(11):1047-54.

Subrata Basu (1), Biswajit Haidar (2), Anup Singh (3), Rakesh Sarkar (4), Soma Basu (5), Mona Tirkey (6), Aditya Kumar Tewari (7), Suman Biswas (8)

(1) Assistant Professor, Department of Cardiology, North Bengal Medical College, Sushrutanagar, Darjeeling, West Bengal, India.

(2) Associate Professor, Department of Pathology, North Bengal Medical College, Sushrutanagar, Darjeeling, West Bengal, India.

(3) Consultant Cardiologist, Ford Hospital, Patna, Bihar, India.

(4) EP Fellow, Care Hospital, Hyderabad, Andhra Pradesh, India.

(5) MO, Department of Ophthalmology, B. N. Bose SD Hospital, Barackpur, Kolkata, West Bengal, India.

(6) Demonstrator, Department of Pathology, North Bengal Medical College, Sushrutanagar, Darjeeling, West Bengal, India.

(7) Radiologist, 3gen Diagnostics (A Unit of North Bengal Healthcare Pvt. Ltd.), Siliguri, Darjeeling, West Bengal, India.

(8) Postgraduate Trainee, Department of Anaesthesiology, North Bengal Medical College, Sushrutanagar, Darjeeling, West Bengal, India.

'Financial or Other Competing Interest': None.

Submission 01-12-2018, Peer Review 22-01-2019, Acceptance 24-01-2019, Published 28-01-2019.

Corresponding Author:

Dr. Biswajit Haldar, A-10/15, Uttorayon, Matigara, Siliguri, Darjeeling-734010, West Bengal, India.

E-mail: biswajitpath@gmaii.com
Table 1. Procedural Failure in Study Period

                            Number   Percentage (%)

TRCAG Successfully Done       83          83 %
Procedural Failure            17          17%
Total                        100          100%

Table 2. Correlation with Different Factors and Procedural Failure

Variables                                                  Total

                                                          N    (%)

Gender                             Male                  78    78%
                                  Female                 22    22%
H/O Smoking                     Non-Smokers              33    33%
                                  Smokers                67    67%

H/O HTN                      Non-Hypertensive            75    75%
                               Hypertensive              25    25%

H/O Diabetes                   Non-Diabetic              68    68%
                                 Diabetic                32    32%

H/O PVD                           No PVD                 94    94%
                                    PVD                  06    06%

Height in cm                       <=150                 15    15%
                                  151-160                31    31%
                                  161-170                46    46%
                                   >=171                 08    08%

R Radial Artery           No Radial Artery Spasm         66    66%
Spasm                       Radial Artery Spasm          34    34%

Peripheral Artery     No Peripheral Artery Dissection    99    99%
Dissection             Peripheral Artery Dissection      01    01%
                             (Brachial Artery)

Coronary Artery          No Coronary Artery Spasm        93    93%
Spasm                      Coronary Artery Spasm         07    07%

Loop/ Tortuosity            No Loop/ Tortuosity          89    89%
                             Radial Tortuosity           02    02%
                       Subclavian Artery Tortuosity      09    09%

Origin of Coronary   Normal Origin of Coronary Artery    89    89%
Artery                             LMCA                  04    04%
                                    RCA                  07    07%

Variables                                                TRCAG
                                                         Successfully
                                                         Done

                                                         N      (%)

Gender                             Male                  69   88.46 %
                                  Female                 14   63.63%
H/O Smoking                     Non-Smokers              24   72.72%
                                  Smokers                59   88.05%

H/O HTN                      Non-Hypertensive            64   85.33%
                               Hypertensive              19     76%

H/O Diabetes                   Non-Diabetic              61   89.70%
                                 Diabetic                22   68.75%

H/O PVD                           No PVD                 78   82.97%
                                    PVD                  5    83.33%

Height in cm                       <=150                 10   66.66%
                                  151-160                26   83.87%
                                  161-170                40   86.95%
                                   >=171                 07    87.5%

R Radial Artery           No Radial Artery Spasm         64   96.96%
Spasm                       Radial Artery Spasm          19   55.88%

Peripheral Artery     No Peripheral Artery Dissection    83   83.83%
Dissection             Peripheral Artery Dissection      0      00%
                             (Brachial Artery)

Coronary Artery          No Coronary Artery Spasm        77   82.79%
Spasm                      Coronary Artery Spasm         6    85.71%

Loop/ Tortuosity            No Loop/ Tortuosity          77   86.51%
                             Radial Tortuosity           01     50%
                       Subclavian Artery Tortuosity      05   55.55%

Origin of Coronary   Normal Origin of Coronary Artery    76   85.39%
Artery                             LMCA                  02     50%
                                    RCA                  05   71.42%

Variables                                            Procedural Failure

                                                          Number & % in
                                                          Total Cases

                                                          N      (%)

Gender                             Male                   9    11.53%
                                  Female                  8    36.36%
H/O Smoking                     Non-Smokers               9    27.27%
                                  Smokers                 8    11.94%

H/O HTN                      Non-Hypertensive            11    14.66%
                               Hypertensive               6      24%

H/O Diabetes                   Non-Diabetic               7    10.29%
                                 Diabetic                10    31.25%

H/O PVD                           No PVD                 16    17.02%
                                    PVD                   1    16.66%

Height in cm                       <=150                 05    33.33%
                                  151-160                05    16.12%
                                  161-170                06    13.04%
                                   >=171                 01     12.5%

R Radial Artery           No Radial Artery Spasm          2     3.03%
Spasm                       Radial Artery Spasm          15    44.11%

Peripheral Artery     No Peripheral Artery Dissection    16    16.16%
Dissection             Peripheral Artery Dissection      01     100%
                             (Brachial Artery)

Coronary Artery          No Coronary Artery Spasm        16    17.20%
Spasm                      Coronary Artery Spasm         01    14.28%

Loop/ Tortuosity            No Loop/ Tortuosity          12    13.48%
                             Radial Tortuosity           01      50%
                       Subclavian Artery Tortuosity      04    44.44%

Origin of Coronary   Normal Origin of Coronary Artery    13    14.60%
Artery                             LMCA                  02      50%
                                    RCA                  02    28.57%

Variables                                           Procedural Failure

                                                         % in 17
                                                          Cases

                                                          (%)

Gender                             Male                  52.94%
                                  Female                 47.05%
H/O Smoking                     Non-Smokers              52.94%
                                  Smokers                47.05%

H/O HTN                      Non-Hypertensive            64.70%
                               Hypertensive              35.29%

H/O Diabetes                   Non-Diabetic              41.17%
                                 Diabetic                58.82%

H/O PVD                           No PVD                 94.11%
                                    PVD                  5.88%

Height in cm                       <=150                 29.41%
                                  151-160                29.41%
                                  161-170                35.29%
                                   >=171                 5.88%

R Radial Artery           No Radial Artery Spasm         11.76%
Spasm                       Radial Artery Spasm          88.23%

Peripheral Artery     No Peripheral Artery Dissection    94.11%
Dissection             Peripheral Artery Dissection      5.88%
                             (Brachial Artery)

Coronary Artery          No Coronary Artery Spasm        94.11%
Spasm                      Coronary Artery Spasm         5.88%

Loop/ Tortuosity            No Loop/ Tortuosity          70.58%
                             Radial Tortuosity           5.88%
                       Subclavian Artery Tortuosity      23.52%

Origin of Coronary   Normal Origin of Coronary Artery    76.47%
Artery                             LMCA                  11.76%
                                    RCA                  11.76%

PVD--Peripheral Vascular Disease, LMCA- Left Main Coronary Artery,
RCA--Right Coronary Artery

Table 3. Radial Artery Spasm Gender Wise Distribution

                         Male                  Female

                    Number   Percentage    Number   Percentage
                                 (%)                    (%)

No Radial Artery      0          00%         2         100%
Spasm
Radial Artery         9          60%         6          40%
Spasm
Total                 09       52.94%        08       47.05%

                          Total

                    Number   Percentage
                                (%)

No Radial Artery      02         2%
Spasm
Radial Artery         15         15%
Spasm
Total                 17         17%

Table 4. Procedural Failure Associated with Radial Artery Spasm Age
Wise Distribution

                                      Age (Years)

                       41-50             51-60             61-70

                   Number    (%)     Number    (%)     Number    (%)

No Radial Artery     0       00%       0       00%       0       00%
Spasm
Radial Artery        2      13.33%     3       20%       5      33.33%
Spasm
Total                2      11.76%     3      17.64%     5      29.41%

                      Age (Years)        Total

                        >70

                   Number    (%)     Number    (%)

No Radial Artery     2       100%       2      02%
Spasm
Radial Artery        5      33.33%     15      15%
Spasm
Total                7      41.17%     17      17%

Table 5. Causes of Procedural Failure

Total Procedural Failure was 17

Causes of TRF            Number   Percentage (%) out
                                         of 17

Radial Artery Spasm        15           88.23%
Abnormal Origin of CA      4            23.52%
Loop/Tortuosity            5            29.41%
Peripheral Artery          1            05.88%
Dissection
Coronary Artery Spasm      1            05.88%
Puncture Failure           2            11.76%

Table 6. Causes and Complication of Procedural Failure with Level
Experience

                   First 50 Patients        Second 50 Patients

                     Yes         No           Yes         No

                  No.   (%)   No.   (%)    No.   (%)   No.   (%)

Procedure         12    24%   38    76%     5    10%   45    90%
Failure
Radial Artery     15    30%   35    70%    15    30%   35    70%
Spasm
Coronary Artery    3    6%    47    94%     2    4%    48    96%
Spasm
Peripheral         1    2%    49    98%     0    00%   50    100%
Artery
Dissection
Hematoma           1    2%    49    98%     0    00%   50    100%
Bleeding           1    2%    49    98%     0    00%   50    100%
Pain              14    28%   36    72%     9    18%   41    82%
Infection          1    2%    49    98%     0    00%   50    100%
Granuloma          0    0%    50    100%    0    00%   50    100%
Compartment        0    0%    50    100%    0    00%   50    100%
Syndrome
AV Fistula         0    0%    50    100%    0    00%   50    100%
Pseudoan-          0    0%    50    100%    0    00%   50    100%
eurysm
Neurologic         0    0%    50    100%    0    00%   50    100%
Complaint
COPYRIGHT 2019 Akshantala Enterprises Private Limited
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2019 Gale, Cengage Learning. All rights reserved.

Article Details
Printer friendly Cite/link Email Feedback
Title Annotation:Original Research Article
Author:Basu, Subrata; Haidar, Biswajit; Singh, Anup; Sarkar, Rakesh; Basu, Soma; Tirkey, Mona; Tewari, Adit
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Report
Geographic Code:9INDI
Date:Jan 28, 2019
Words:3729
Previous Article:IMMUNOHISTOCHEMICAL STUDY OF SYNDECAN-1 EXPRESSION IN DIFFERENT HISTOLOGICAL SUBTYPES OF AMELOBLASTOMA AND ODONTOGENIC KERATOCYSTS.
Next Article:ORBITAL PSEUDOTUMOUR--THE OCULOMOTOR NERVE PALSY MIMICKER.
Topics:

Terms of use | Privacy policy | Copyright © 2021 Farlex, Inc. | Feedback | For webmasters |