Best Endovascular vs. Best Surgical Therapy in Patients With Critical Limb Ischemia
- Conditions
- Critical Limb Ischemia
- Interventions
- Device: Endovascular revascularizationProcedure: Open surgical revascularization
- Registration Number
- NCT02060630
- Lead Sponsor
- Carelon Research
- Brief Summary
This study will compare the effectiveness of best available surgical treatment with best available endovascular treatment in adults with critical limb ischemia (CLI) who are eligible for both treatment options.
- Detailed Description
Male and female subjects aged 18 years or older will be randomized to receive either open surgical treatment or endovascular treatment. They will be followed for at least 2 years and up to 4 years and 2 months after treatment to primarily assess survival and major adverse limb events in the index or treated limb, and secondarily, to determine clinical and cost effectiveness outcomes after treatment. These outcomes (survival-free of major limb events and clinical, functional and cost effectiveness) will be compared within two cohorts of subjects: those with an available single-segment great saphenous vein, and those with an alternative conduit. The null hypotheses for both cohorts is that there will be no difference in MALE-free survival between best endovascular therapy and best surgical therapy.
Recruitment & Eligibility
- Status
- COMPLETED
- Sex
- All
- Target Recruitment
- 1843
- Male or female, age 18 years or older.
- Infrainguinal PAOD (occlusive disease of the arteries below the inguinal ligament).
- CLI, defined as arterial insufficiency with gangrene, non-healing ischemic ulcer, or rest pain consistent with Rutherford categories 4-6.
- Candidate for both endovascular and open infrainguinal revascularization as judged by the treating investigators
- Adequate aortoiliac inflow.
- Adequate popliteal, tibial or pedal revascularization target defined as an infrainguinal arterial segment distal to the area of stenosis/occlusion which can support a distal anastomosis of a surgical bypass.
- Willingness to comply with protocol, attend follow-up appointments, complete all study assessments, and provide written informed consent.
-
Presence of a popliteal aneurysm (>2 cm) in the index limb.
-
Life expectancy of less than 2 years due to reasons other than PAOD.
-
Excessive risk for surgical bypass (as determined by the operating surgeon and the CLI Team)
-
Planned above ankle amputation on ipsilateral limb within 4 weeks of index procedure.
-
Active vasculitis, Buerger's disease, or acute limb-threatening ischemia
-
Any prior index limb infrainguinal stenting or stent grafting associated with significant restenosis within 1 cm of stent or stent-graft, unless the occlusion/restenosis site is outside the intended treatment zone (i.e.,. a tibial vessel that is not currently intended to be revascularized as a part of the treatment for CLI).
-
Any of the following procedures performed on the index limb within 3 months prior to enrollment:
- Infrainguinal balloon angioplasty, atherectomy, stent, or stentgraft;
- Infrainguinal bypass with either venous or prosthetic conduit
-
Open surgical inflow procedure (aortofemoral, axillofemoral, iliofemoral, thoracofemoral or femorofemoral bypass) within 6 weeks prior to enrollment
-
Current chemotherapy or radiation therapy.
-
Absolute contraindication to iodinated contrast due to prior near-fatal anaphylactoid reaction (laryngospasm, bronchospasm, cardiorespiratory collapse, or equivalent) which would preclude patient participation in angiographic procedures.
-
Pregnancy or lactation.
-
Administration of an investigational drug for PAD within 30 days of randomization.
-
Participation in a clinical trial (except observational studies) within the previous 30 days.
-
Prior enrollment or randomization into BEST-CLI.
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description Available vein, endovasc. revasc. Endovascular revascularization Subjects with an available SSGSV cohort randomized to endovascular revascularization Alternative conduit, open surg. revasc. Open surgical revascularization Subjects with an alternative conduit cohort randomized to open surgical revascularization Available vein, open surg. revasc. Open surgical revascularization Subjects with an available SSGSV cohort randomized to open surgical revascularization Alternative conduit, endovasc. revasc. Endovascular revascularization Subjects with an alternative conduit cohort randomized to endovascular revascularization
- Primary Outcome Measures
Name Time Method The primary efficacy endpoint: MALE (Major Adverse Limb Event)-free survival. MALE is defined as above ankle amputation of the index limb or major re-intervention (e.g. new bypass graft, jump/interposition graft revision, or thrombectomy/ thrombolysis) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject * Time to major adverse limb event or death, whichever occurs first in subjects with Single-Segment Great Saphenous Vein (SSGSV) available
* Time to major adverse limb event or death, whichever occurs first in subjects without available SSGSV
- Secondary Outcome Measures
Name Time Method Clinical: Freedom from MALE-POD (POD, defined as death within 30 days of index procedure) (cohort 1) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Time to re-intervention of the index leg, amputation of the index leg, or death within 30 days of index procedure, whichever occurs first in subjects with SSGSV available
Clinical: Re-intervention and amputation-free survival (cohort 2) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Time to re-intervention of the index leg, above ankle amputation of the index leg, or death, whichever occurs first in subjects without available SSGSV
Clinical: Freedom from POD (POD, defined as death within 30 days of index procedure) (cohort 1) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Time to death within 30 days of index procedure in subjects with SSGSV available
Clinical: Freedom POD (POD, defined as death within 30 days of index procedure) (cohort 2) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Time to death within 30 days of index procedure in subjects without available SSGSV
Clinical: Freedom from Myocardial Infarction (cohort 1) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Time to myocardial infarction (MI) in subjects with SSGSV available
Clinical: Freedom from Stroke (cohort 2) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Time to stroke in subjects without available SSGSV
Clinical: Freedom from hemodynamic failure (cohort 1) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Time to hemodynamic failure in subjects with SSGSV available
Clinical: Number of re-interventions (major and minor) in per limb salvaged (cohort 2) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Number of re-interventions (major and minor) in per limb salvaged in subjects without available SSGSV
Clinical: Freedom from clinical failure (cohort 1) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Time to above ankle amputation, major reintervention, MALE, degradation of WIfI stage or death, whichever occurs first in subjects with SSGSV available
Functional: Quality of Life assessment using VasuQoL (cohort 2) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject VasuQOL measurements in subjects without available SSGSV
Clinical: Re-intervention and amputation-free survival (cohort 1) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Time to re-intervention of the index leg, above ankle amputation of the index leg, or death, whichever occurs first in subjects with SSGSV available
Clinical: Number of re-interventions (major and minor) in per limb salvaged (cohort 1) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Number of re-interventions (major and minor) in per limb salvaged in subjects with SSGSV available
Clinical: Freedom from clinical failure (cohort 2) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Time to above ankle amputation, major reintervention, MALE, degradation of WIfI stage or death, whichever occurs first in subjects without available SSGSV
Clinical: Freedom from Critical Limb Ischemia (CLI) (cohort 2) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Time to resolution of presenting CLI symptoms in the index limb in subjects without available SSGSV
Clinical: Freedom from all-cause mortality (cohort 2) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Time to all-cause mortality in subjects without available SSGSV
Functional: Numerical rating scale for Pain, Worst level of Pain (cohort 1) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Scores for Worst level of Pain during the last week in subjects with SSGSV available
Clinical: Clinical: Freedom from MALE-POD (POD, defined as death within 30 days of index procedure) (cohort 2) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Time to re-intervention of the index leg, amputation of the index leg, or death within 30 days of index procedure, whichever occurs first in subjects without available SSGSV
Clinical: Amputation-free survival (cohort 1) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Time to amputation of the index leg, or death, whichever occurs first in subjects with SSGSV available
Clinical: Amputation-free survival (cohort 2) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Time to amputation of the index leg, or death, whichever occurs first in subjects without available SSGSV
Clinical: Freedom from Myocardial Infarction (cohort 2) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Time to myocardial infarction (MI) in subjects without available SSGSV
Clinical: Freedom from Stroke (cohort 1) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Time to stroke in subjects with SSGSV available
Functional: Quality of Life assessment using EuroQoL (cohort 1) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject EuroQOL measurements in subjects with SSGSV available
Functional: Numerical rating scale for Pain, Pain Now (cohort 2) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Scores for Pain Now in subjects without available SSGSV
Functional: Numerical rating scale for Pain, Usual level of Pain (cohort 1) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Scores for Usual level of Pain during the last week in subjects with SSGSV available
Functional: Numerical rating scale for Pain, Worst level of Pain (cohort 2) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Scores for Worst level of Pain during the last week in subjects without available SSGSV
Clinical: Freedom from re-intervention (major and minor) in index leg (cohort 1) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Time to re-intervention (major and minor) in index leg in subjects with SSGSV available
Clinical: Freedom from re-intervention (major and minor) in index leg (cohort 2) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Time to re-intervention (major and minor) in index leg in subjects without available SSGSV
Clinical: Freedom from hemodynamic failure (cohort 2) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Time to hemodynamic failure in subjects without available SSGSV
Clinical: Freedom from Critical Limb Ischemia (CLI) (cohort 1) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Time to resolution of presenting CLI symptoms in the index limb in subjects with SSGSV available
Functional: Quality of Life assessment using VasuQoL (cohort 1) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject VasuQOL measurements in subjects with SSGSV available
Functional: Quality of Life assessment using EuroQoL (cohort 2) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject EuroQOL measurements in subjects without available SSGSV
Functional: Function assessment using SF-12, MCS (cohort 1) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Mental Component Summary (MCS) scores in subjects with SSGSV available
Functional: Function assessment using SF-12, SF-6D R2 (cohort 1) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Utility Index (SF-6D R2) scores in subjects with SSGSV available
Functional: Numerical rating scale for Pain, Best level of Pain (cohort 2) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Scores for Best level of Pain during the last week in subjects without available SSGSV
Clinical: Freedom from all-cause mortality (cohort 1) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Time to all-cause mortality in subjects with SSGSV available
Functional: Function assessment using SF-12, PCS (cohort 1) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Physical Component Summary (PCS) scores in subjects with SSGSV available
Functional: Function assessment using SF-12, PCS (cohort 2) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Physical Component Summary (PCS) scores in subjects without available SSGSV
Functional: Numerical rating scale for Pain, Pain Now (cohort 1) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Scores for Pain Now in subjects with SSGSV available
Functional: Function assessment using SF-12, MCS (cohort 2) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Mental Component Summary (MCS) scores in subjects without available SSGSV
Functional: Function assessment using SF-12, SF-6D R2(cohort 2) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Utility Index (SF-6D R2) scores in subjects without available SSGSV
Functional: Numerical rating scale for Pain, Usual level of Pain (cohort 2) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Scores for Usual level of Pain during the last week in subjects without available SSGSV
Functional: Numerical rating scale for Pain, Best level of Pain (cohort 1) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Scores for Best level of Pain during the last week in subjects with SSGSV available
Function: Six-minute walk test (cohort 2) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Six-minute walk test measurements in subjects without available SSGSV. The six-minute walk test was performed at a subset of clinical sites (for whom this test was standard of care) and was limited to patients for whom rest pain, wounds, or foot surgery (recent or anticipated) did not preclude weight bearing
Function: Six-minute walk test (cohort 1) Through each subject's last regularly scheduled study visit, up to a maximum of 84 months per subject Six-minute walk test measurements in subjects with SSGSV available. The six-minute walk test was performed at a subset of clinical sites (for whom this test was standard of care) and was limited to patients for whom rest pain, wounds, or foot surgery (recent or anticipated) did not preclude weight bearing
Trial Locations
- Locations (160)
Beth Israel Deaconess Medical Center
🇺🇸Boston, Massachusetts, United States
Emory University
🇺🇸Atlanta, Georgia, United States
Florida Hospital Ocala
🇺🇸Ocala, Florida, United States
West Haven VAMC
🇺🇸West Haven, Connecticut, United States
Northwestern Memorial Hospital
🇺🇸Winfield, Illinois, United States
Mercy Hospital Medical Center
🇺🇸West Des Moines, Iowa, United States
Medstar Washington Hospital Center
🇺🇸Washington, District of Columbia, United States
Central DuPage Hospital (Cadence)
🇺🇸Chicago, Illinois, United States
GW Medical Faculty Associates, Inc.
🇺🇸Washington, District of Columbia, United States
Staten Island University Hospital
🇺🇸Staten Island, New York, United States
William Beaumont Hospital
🇺🇸Royal Oak, Michigan, United States
Deborah Heart and Lung Center
🇺🇸Browns Mills, New Jersey, United States
Johns Hopkins Hospital
🇺🇸Baltimore, Maryland, United States
Rush University Medical Center
🇺🇸Chicago, Illinois, United States
University of Chicago Medicine
🇺🇸Chicago, Illinois, United States
University Health System: LSU Health Sciences
🇺🇸Shreveport, Louisiana, United States
St. Louis VA Medical Center
🇺🇸Saint Louis, Missouri, United States
University of Missouri
🇺🇸Columbia, Missouri, United States
VA Western NY Healthcare System
🇺🇸Buffalo, New York, United States
Vascular Health Partners
🇺🇸Queensbury, New York, United States
North Carolina Heart and Vascular Research
🇺🇸Raleigh, North Carolina, United States
Mount Sinai Medical Center
🇺🇸New York, New York, United States
CAMC Clinical Trials Center
🇺🇸Charleston, West Virginia, United States
Columbia University Medical Center
🇺🇸New York, New York, United States
Albany Medical Center
🇺🇸Albany, New York, United States
Wellmont Holston Valley Medical Center
🇺🇸Kingsport, Tennessee, United States
University of Tennessee Medical Center
🇺🇸Knoxville, Tennessee, United States
University of Toledo Medical Center
🇺🇸Toledo, Ohio, United States
Sentara Vascular Specialists
🇺🇸Norfolk, Virginia, United States
Memorial Hermann Hospital TMC
🇺🇸Houston, Texas, United States
Michael E. DeBakey VA Medical Center
🇺🇸Houston, Texas, United States
North Central Heart Institute
🇺🇸Sioux Falls, South Dakota, United States
Prisma Health-Upstate (Formerly Greenville Memorial Hospital)
🇺🇸Greenville, South Carolina, United States
University of Vermont Medical Center
🇺🇸Burlington, Vermont, United States
Toronto General Hospital
🇨🇦Toronto, Ontario, Canada
St. Paul's Hospital
🇨🇦Saskatoon, Saskatchewan, Canada
Harborview Medical Center
🇺🇸Seattle, Washington, United States
Baptist Hospital of Miami
🇺🇸Miami, Florida, United States
Indiana University Medical School
🇺🇸Indianapolis, Indiana, United States
Duke University
🇺🇸Durham, North Carolina, United States
Durham VAMC
🇺🇸Durham, North Carolina, United States
The University of Utah
🇺🇸Salt Lake City, Utah, United States
San Francisco Veterans Affairs Medical Center
🇺🇸San Francisco, California, United States
University of California-San Francisco Medical Center
🇺🇸San Francisco, California, United States
McGill
🇨🇦Montreal, Quebec, Canada
Jewish General Hostpital
🇨🇦Montreal, Quebec, Canada
Minneapolis VAMC
🇺🇸Minneapolis, Minnesota, United States
Minneapolis Heart Hospital/Abbott Northwestern Hosp.
🇺🇸Minneapolis, Minnesota, United States
MedStar Union Memorial Hospital
🇺🇸Baltimore, Maryland, United States
Maine Medical Center
🇺🇸Portland, Maine, United States
University of Arizona - Banner University Medical Center
🇺🇸Tucson, Arizona, United States
University of Arkansas for Medical Services
🇺🇸Little Rock, Arkansas, United States
University of California - Irvine
🇺🇸Irvine, California, United States
San Diego VAMC
🇺🇸La Jolla, California, United States
Loma Linda VA Medical Center
🇺🇸Loma Linda, California, United States
UC San Diego Sulpizio Cardiovascular Center
🇺🇸La Jolla, California, United States
VA Long Beach Healthcare System
🇺🇸Long Beach, California, United States
Loma Linda University Medical Center
🇺🇸Loma Linda, California, United States
Kaiser Permanente Los Angeles Medical Center
🇺🇸Los Angeles, California, United States
VA Greater Los Angeles
🇺🇸Los Angeles, California, United States
Keck Medical Center of USC
🇺🇸Los Angeles, California, United States
UCLA-Gonda Vascular Surgery
🇺🇸Los Angeles, California, United States
Kaiser Permanente (San Diego)
🇺🇸San Diego, California, United States
Kaiser Permanente Northern California
🇺🇸San Francisco, California, United States
Stanford Hospital
🇺🇸Stanford, California, United States
Harbor - UCLA Medical Center
🇺🇸Torrance, California, United States
St. Francis Hospital and Medical Center
🇺🇸Hartford, Connecticut, United States
Loyola University Medical Center
🇺🇸Baltimore, Maryland, United States
Michigan Vascular Center
🇺🇸Flint, Michigan, United States
University Hospitals of Cleveland/Case Western Reserve University
🇺🇸Cleveland, Ohio, United States
University of Pittsburgh Medical Center
🇺🇸Pittsburgh, Pennsylvania, United States
Pinnacle Health System
🇺🇸Wormleysburg, Pennsylvania, United States
Temple University
🇺🇸Philadelphia, Pennsylvania, United States
Swedish Medical Center
🇺🇸Seattle, Washington, United States
Regina Qu'Appelle
🇨🇦Regina, Saskatchewan, Canada
Auckland City Hospital
🇳🇿Grafton, Auckland, New Zealand
Waikato Hospital
🇳🇿Hamilton, Waikato, New Zealand
The University of Alabama at Birmingham
🇺🇸Birmingham, Alabama, United States
Arizona Heart Hospital
🇺🇸Phoenix, Arizona, United States
Denver Health
🇺🇸Denver, Colorado, United States
Vascular Institute of the Rockies
🇺🇸Denver, Colorado, United States
Rocky Mountain Regional VA
🇺🇸Denver, Colorado, United States
Henry Ford Health System
🇺🇸Detroit, Michigan, United States
University of Oklahoma Health Sciences Center
🇺🇸Oklahoma City, Oklahoma, United States
Oregon Health and Science University
🇺🇸Portland, Oregon, United States
Portland VA Medical Center
🇺🇸Portland, Oregon, United States
Mayo Clinic
🇺🇸Rochester, Minnesota, United States
University of Nebraska Medical Center
🇺🇸Omaha, Nebraska, United States
University of Colorado Hospital
🇺🇸Aurora, Colorado, United States
Tampa VAMC
🇺🇸Tampa, Florida, United States
Tampa General Hospital
🇺🇸Tampa, Florida, United States
Medical College of Wisconsin
🇺🇸Milwaukee, Wisconsin, United States
Milwaukee VAMC
🇺🇸Milwaukee, Wisconsin, United States
Atlanta VA Medical Center
🇺🇸Decatur, Georgia, United States
Southern Illinois University School of Medicine
🇺🇸Springfield, Illinois, United States
Decatur Memorial Hospital
🇺🇸Decatur, Illinois, United States
SUNY Upstate Medical University
🇺🇸Syracuse, New York, United States
Stony Brook Medicine
🇺🇸Stony Brook, New York, United States
Westchester Medical Center
🇺🇸Valhalla, New York, United States
Cleveland Clinic Foundation
🇺🇸Cleveland, Ohio, United States
The Ohio State University
🇺🇸Columbus, Ohio, United States
University of Oklahoma College of Medicine at Tulsa
🇺🇸Tulsa, Oklahoma, United States
Allegheny General Hospital
🇺🇸Pittsburgh, Pennsylvania, United States
The Miriam Hospital/Brown Medical School
🇺🇸Providence, Rhode Island, United States
Dallas VA Medical Center
🇺🇸Dallas, Texas, United States
Scott and White - Temple
🇺🇸Temple, Texas, United States
Inova Fairfax Hospital
🇺🇸Falls Church, Virginia, United States
Benaroya Research Institute at Virginia Mason
🇺🇸Seattle, Washington, United States
Providence Sacred Heart Medical Center
🇺🇸Spokane, Washington, United States
Boston Medical Center
🇺🇸Boston, Massachusetts, United States
Brigham and Women's Hospital
🇺🇸Boston, Massachusetts, United States
Penn State Milton S. Hershey Medical Center
🇺🇸Hershey, Pennsylvania, United States
Ohio Health Research Institute
🇺🇸Columbus, Ohio, United States
University of Virginia
🇺🇸Charlottesville, Virginia, United States
St. Boniface General Hospital
🇨🇦Winnipeg, Manitoba, Canada
University of California Davis Medical Center
🇺🇸Sacramento, California, United States
Sacramento VA Medical Center
🇺🇸Sacramento, California, United States
Ochsner Medical Center
🇺🇸New Orleans, Louisiana, United States
Yale-New Haven Hospital
🇺🇸New Haven, Connecticut, United States
VA Ann Arbor Healthcare System
🇺🇸Ann Arbor, Michigan, United States
Michigan Heart/St. Joseph Mercy Ann Arbor Hospital
🇺🇸Ann Arbor, Michigan, United States
University of Michigan Health System
🇺🇸Ann Arbor, Michigan, United States
Midwest Aortic Vascular Institute
🇺🇸Kansas City, Missouri, United States
University of North Carolina
🇺🇸Chapel Hill, North Carolina, United States
Wake Forest Baptist Medical Center
🇺🇸Winston-Salem, North Carolina, United States
Medical University of South Carolina
🇺🇸Charleston, South Carolina, United States
University of Maryland Medical System
🇺🇸Baltimore, Maryland, United States
Sunnybrook Health Sciences Centre
🇨🇦Toronto, Ontario, Canada
Massachusetts General Hospital
🇺🇸Boston, Massachusetts, United States
Steward St. Elizabeth's Medical Center
🇺🇸Brighton, Massachusetts, United States
Providence Heart and Vascular Institute
🇺🇸Portland, Oregon, United States
San Giovanni di Dio Hospital
🇮🇹Florence, Italy
Wellington Hospital
🇳🇿Newtown, Wellington, New Zealand
Vancouver General Hospital
🇨🇦Vancouver, British Columbia, Canada
Queen Elizabeth II Health Science Center
🇨🇦Halifax, Nova Scotia, Canada
Mount Sinai Miami
🇺🇸Miami Springs, Florida, United States
South Shore Hospital
🇺🇸Weymouth, Massachusetts, United States
Dartmouth Hitchcock Medical Center
🇺🇸Hanover, New Hampshire, United States
Englewood Hospital and Medical Center
🇺🇸Englewood, New Jersey, United States
The Ottawa Hospital
🇨🇦Ottawa, Ontario, Canada
Chu de Quebec
🇨🇦Quebec City, Quebec, Canada
Helsinki University Hospital
🇫🇮Helsinki, Finland
VA Boston Healthcare System
🇺🇸Boston, Massachusetts, United States
University of Massachusetts Medical School
🇺🇸Worcester, Massachusetts, United States
University of Western Ontario
🇨🇦London, Ontario, Canada
Rutgers New Jersey Medical School
🇺🇸Newark, New Jersey, United States
Spectrum Health
🇺🇸Grand Rapids, Michigan, United States
Holy Name Medical Center
🇺🇸Teaneck, New Jersey, United States
Gundersen Health System
🇺🇸La Crosse, Wisconsin, United States
University of Florida (Gainesville)
🇺🇸Gainesville, Florida, United States
Kaiser Foundation Hospital
🇺🇸Honolulu, Hawaii, United States
New Mexico Heart Institute
🇺🇸Albuquerque, New Mexico, United States
New Mexico VA Medical Center
🇺🇸Albuquerque, New Mexico, United States
University of Rochester Medical Center
🇺🇸Rochester, New York, United States
University of Wisconsin-Madison
🇺🇸Madison, Wisconsin, United States
Meriter Wisconsin Heart
🇺🇸Madison, Wisconsin, United States
Carondelet Heart & Vascular Institute
🇺🇸Tucson, Arizona, United States
VA Palo Alto Health Care
🇺🇸Palo Alto, California, United States
Montefiore Medical Center
🇺🇸Bronx, New York, United States
Rhode Island Hospital
🇺🇸Providence, Rhode Island, United States