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. 2021 Nov 29;22(1):20–27. doi: 10.1227/ONS.0000000000000009

Encephaloduroarteriosynangiosis Operative Technique and Intraoperative Anesthesia Management: Treatment From Both Sides of the Curtain

Julie L Chan *, Miguel D Quintero-Consuegra *, Robin M Babadjouni *, Daniel Chang *, Zachary R Barnard *, Neil A Martin ‡, Keren Ziv §, Barbara M Van de Wiele §, Nestor R Gonzalez *,✉
PMCID: PMC10602499  PMID: 34982901

Abstract

BACKGROUND:

Encephaloduroarteriosynangiosis (EDAS) is a form of indirect revascularization for cerebral arterial steno-occlusive disorders. EDAS has gained growing interest as a technique applicable to pediatric and adult populations for several types of ischemic cerebral steno-occlusive conditions.

OBJECTIVE:

To present a team-oriented, multidisciplinary update of the EDAS technique for application in challenging adult cases of cerebrovascular stenosis/occlusion, successfully implemented in more than 200 cases.

METHODS:

We describe and demonstrate step-by-step a multidisciplinary-modified EDAS technique, adapted to maintain uninterrupted intensive medical management of patients' stroke risk factors and anesthesia protocols to maintain strict hemodynamic control.

RESULTS:

A total of 216 EDAS surgeries were performed in 164 adult patients, including 65 surgeries for patients with intracranial atherosclerotic disease and 151 operations in 99 patients with moyamoya disease. Five patients with intracranial atherosclerotic disease had recurrent strokes (3%), and there was one perioperative death. The mean clinical follow-up was 32.9 mo with a standard deviation of 31.1. There was one deviation from the surgical protocol. There were deviations from the anesthesia protocol in 3 patients (0.01%), which were promptly corrected and did not have any clinical impact on the patients' condition.

CONCLUSION:

The EDAS protocol described here implements a team-oriented, multidisciplinary adaptation of the EDAS technique. This adaptation resides mainly in 3 points: (1) uninterrupted administration of intensive medical management, (2) strict hemodynamic control during anesthesia, and (3) meticulous standardized surgical technique.

KEY WORDS: Anesthesia, EDAS, Encephaloduroarteriosynangiosis, Indirect revascularization, Intracranial atherosclerotic disease, Moyamoya

ABBREVIATIONS:

CPP

cerebral perfusion pressure

EDAS

encephaloduroarteriosynangiosis

ICAD

intracranial atherosclerotic disease

IMM

intensive medical management

MMD

moyamoya disease

SBP

systolic blood pressure

STA

superficial temporal artery

TIA

transient ischemic attack

Encephaloduroarteriosynangiosis (EDAS) is an indirect revascularization technique first described in 1980 in pediatric patients with moyamoya disease (MMD).1 Soon after, Spetzler et al2 described its use as an alternative to direct bypass when an appropriate middle cerebral artery vessel was unavailable. Since then, the technique has been applied to pediatric and adult patients with MMD3,4 and more recently to patients with atherosclerotic steno-occlusive disorders.5-8

The application of EDAS in adult patients with poor cerebrovascular reserve and high risk for recurrent stroke during the operation requires precise control of variables that may alter outcomes. In association with stroke neurologists and neuroanesthesiologists, we developed protocols focused on continuous maintenance of intensive medical management (IMM) of stroke risk factors and strict intraoperative control of hemodynamic parameters, which improved EDAS outcomes in challenging patients with intracranial atherosclerotic disease (ICAD) and hemodynamic failure.6,7,9,10 Specifically, we have generated and implemented medical management and anesthesia-specific guidelines to reduce cerebral perfusion pressure (CPP) variability during surgery.9,10 To adapt to the medical and physiologic demands during surgery, we modified the surgical technique with standardized methods that reduce undesirable surgical events during the operation.

An earlier report regarding the application of EDAS to patients with ICAD produced suboptimal outcomes,11 mainly because of lack of standardized medical management, particularly the use of antiplatelets, and absence of hemodynamic guidelines for anesthesia management. The treatment of cerebrovascular steno-occlusive disease extends beyond a good operative technique. It necessarily encompasses prevention of factors that may increase the risk of intraoperative and perioperative stroke, such as artery-to-artery embolism or hemodynamic failure. These aspects can be addressed with IMM of stroke risk factors and rigorous control of hemodynamic variables during surgery, which we present here.

METHODS

Selection of Patients

The selection of appropriate EDAS candidates is based on medical history, physical examination, and imaging tests, as described in Table 1.

TABLE 1.

Selection Criteria for Patients Undergoing Encephaloduroarteriosynangiosis

Inclusion criteria

  • 1. Diagnosis of MMD (based on the guidelines of the Research Committee on Spontaneous Occlusion of the Circle of Willis diagnostic criteria27,28) or ICAD (based on the diagnostic criteria for ICAD from the SAMMPRIS trial29)

  • 2. Correlation of symptoms with >70% intracranial artery stenosis of the ICA or the MCA, confirmed by CTA, magnetic resonance angiography, or catheter angiography.

  • 3. Perfusion studies demonstrating hypoperfusion or stroke patterns consistent with decreased perfusion such as border-zone strokes.
Exclusion criteria

  • 1. Symptoms that are attributed to other causes of TIA or stroke, such as cardiac embolism or extracranial carotid artery disease.

  • 2. Diagnosis of conditions that diffusely affect cerebral vessels, such as vasculitic or reactive vasoconstrictive syndromes.

  • 3. Significant systemic conditions, particularly unstable coronary artery disease or heart failure.

  • 4. TIAs of increased frequency, duration, or severity.

  • 5. Ischemic stroke within 7 d before planned surgery.

  • 6. Infarct with hemorrhagic transformation within 30 d before surgery.

  • 7. Untreated chronic subdural hematoma >5 mm in thickness.

  • 8. Myocardial infarction within 1 mo before surgery.

  • 9. Unstable or severe angina.

  • 10. Ejection fraction <40%.

  • 11. Known allergy or contraindication to general anesthesia.

  • 12. Current alcohol or substance abuse.

  • 13. Uncontrolled severe hypertension (SBP >180 mm Hg or DBP >115 mm Hg).

  • 14. Dementia or a psychiatric diagnosis that prevents the patient from reliably following an outpatient program.

  • 15. Evidence of active untreated systemic or serious infections (ie, pneumonia and complicated urinary infection).
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CTA, computed tomography angiography; DBP, diastolic blood pressure; ICAD, intracranial atherosclerotic disease; MCA, middle cerebral artery; MMD, moyamoya disease; SBBP, systolic blood pressure; TIA, transient ischemic attack.

Preoperative Compliance and IMM

Patients selected for operative intervention are taken to the operating room within 30 to 40 d of initial transient ischemic attack (TIA) or stroke, but not sooner than 7 d. The patient's perioperative compliance with IMM, smoking cessation, and physical activity are essential to proceeding with the surgery. A critical aspect of IMM is a targeted systolic blood pressure (SBP) goal of <140 mm Hg. In patients who are symptomatic with SBP <140 mm Hg, the goal is then individualized to an asymptomatic level (140-180 mm Hg), and they may require midodrine 2.5 to 10 mg every 8 h. SBP >140 mm Hg is not recommended in patients on dual antiplatelet therapy because of an increased risk of hemorrhage.

Patients with MMD or ICAD receive aspirin 325 mg/d >3 d before surgery and on the day of surgery. Patients with ICAD receive clopidogrel 75 mg/d for 90 d after initial diagnosis except during the perioperative period, 5 d before, and 7 d after surgery. In addition, patients also receive statins for cholesterol management (goal <70 mg/dL), strict glycemic control (goal HbA1c <6%), and counseling regarding physical activity maintenance (30 min daily) and weight management. Patients with dyspnea of unknown origin or previous heart failure should undergo cardiac workup with echocardiography and 12-lead electrocardiogram to evaluate for severe heart failure or active coronary artery disease.12

Anesthesia-Specific Guidelines

Anesthesia management during EDAS surgery is of the utmost importance. The anesthesiology team should have previous experience managing cerebrovascular diseases and must be committed to maintaining the hemodynamic and ventilation goals with prompt correction of any condition that may impair CPP. Tolerance to hemodynamic variation is significantly reduced in patients with MMD or ICAD, and failure of timely correction may result in stroke.10,13,14 As such, tailoring the intraoperative hemodynamic goals to each patient's asymptomatic baseline physiology using defined criteria is crucial.10 Most importantly, to ensure adherence to these intraoperative parameters, we conduct an explicit discussion and checklist review between the surgical and anesthesia teams immediately before induction of anesthesia and surgery (Table 2; Video 1).

TABLE 2.

Checklist of Discussion Points Between the Anesthesia and Surgical Teams

1. Identification of the patient (name and birth date).
2. Identification of the operative side.
3. Confirmation of surgical and blood consent.
4. Discussion of any patient allergies.
5. Determination of prophylactic antibiotics based on institutional guidelines.
6. Confirmation that the patient has received aspirin 325 mg the day of the surgery and that the patient has been taking aspirin for at least 3 d before the procedure.
7. Blood pressure goal. The blood pressure goal will be established for SBP. The baseline SBP is determined before surgery and is defined as the average of 3 SBP measures, at which the patient is asymptomatic. The minimum SBP goal during the surgical procedure is set at a value that corresponds to the baseline SBP, at which the patient was asymptomatic and never below 120 mm Hg.
8. The maximum SBP goal is set at 180 mm Hg. 
9. Hyperventilation will be avoided. Once the patient is intubated, the end-tidal carbon dioxide is maintained between 35 and 45 mm Hg.
10. Confirmation of AED use with slow administration (over 60 min, particularly with Dilantin) to prevent hypotension.
11. Mannitol should not be routinely administered during the procedure.
12. Steroids should not be routinely administered during the procedure with the exception of a small dose (<4 mg) of dexamethasone for postoperative nausea.
13. Target hematocrit is >30%.
14. Continuous SSEP and electroencephalography monitoring.
15. Arterial line catheter placed before the induction of anesthesia.
16. Central venous catheter placed in a femoral vein.
17. Intraoperative fluid management targeting euvolemia to modest hypervolemia up to 1 L positive.
18. IV fluids before the initiation of the surgery to replace the calculated preoperative fluid-balance deficit.
19. Systemic hypothermia and/or barbiturates should not be routinely used.
20. Target temperature is normothermia.
21. Confirmation that all monitor alarms (blood pressure, end-tidal carbon dioxide heart rate, pulse oximetry, etc) are audible and set to alarm outside the specific goals set above.
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AED, antiepileptic drug; IV, intravenous; SBP, systolic blood pressure; SSEP, somatosensory-evoked potential.

Surgery-Specific Guidelines

The primary objective of EDAS revascularization was to provide pathways for the formation of collaterals from the external carotid circulation (superficial temporal artery [STA] and middle meningeal artery) to the intracranial circulation. The collaterals are not formed immediately after EDAS surgery; thus, it is essential to maintain strict IMM and hemodynamic control during the entire perioperative period to prevent cerebral ischemia. These requirements pose challenges, such as the need for patients to receive antiplatelet agents, even on the day of surgery. Blood pressure is maintained relatively elevated compared with other neurosurgical interventions, and traditional cranial surgery measures such as the use of mannitol and steroids are avoided to prevent hypovolemia and supression of angiogenesis, respectively. The following guidelines are tailored to address these specific parameters.

Patient Positioning

The patient is positioned supine. To maintain adequate venous return without excessive head turning, the ipsilateral shoulder is elevated 45° (Figure 1A). The Mayfield skull clamp should be applied carefully to avoid injuries of vessels providing collateral arterial supply. The operative side of the head is turned contralaterally and positioned parallel to the floor to facilitate STA dissection. The head is also elevated above the level of the heart to further promote venous return. The head of the bed is positioned 90° or 180° to the right of the anesthesia station. The bed position is independent of the surgery laterality and selected to facilitate comfortable dissection of the STA from proximal to distal by a right-handed surgeon. The STA is identified with Doppler ultrasound (Figure 1B). To prevent injury to any other scalp arteries, we also avoid local anesthesia injections and use electroencephalography scalp electrodes instead of needles.

FIGURE 1.

FIGURE 1.

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Incision planning and positioning. A, Portable Doppler ultrasound is used to demarcate the STA for a length of 10 to 15 cm. B, The patient is positioned supine with the head turned to the contralateral, avoiding extreme rotation of the head, and the ipsilateral shoulder elevated 45°. STA, superficial temporal artery.

STA Dissection

The operative microscope is used to dissect the STA and perform all intracranial manipulations after bone flap elevation to ensure precise dissection, minimize coagulation while maintaining strict hemostasis, and improve visualization of the artery to avoid inadvertent injuries.

An incision is made along the STA to the depth of the dermal fat. Hemostasis of the skin edges is achieved with bipolar cautery set at low power <25 W (Figure 2A). Dissection is carried out in 20- to 30-mm sections maintaining strict hemostasis during exposure of the artery. Fine-tip mosquito forceps are used to spread the connective tissue over the artery while the Colorado (Stryker) needle is used to cut the connective tissue, taking care not to injure the STA. The Bovie (Symmetry Surgical) is set to coagulation at <8 W and cutting at 0 (Figure 2B).

FIGURE 2.

FIGURE 2.

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STA dissection. A, Immediate hemostasis of the skin edges is achieved with low bipolar cautery (25 W). Mosquito forceps are used to dissect the subdermal tissue. B, The Colorado needle is used to separate the lateral aspect of the artery, leaving a cuff no larger than 2 to 3 mm. STA, superficial temporal artery.

A small cuff of connective tissue (2-3 mm) is left on each side of the STA. The neovascularization provided by EDAS originates from the lateral branches of the STA. A longer cuff can preclude the formation of new vessels; for this reason, excessive coagulation of those lateral branches should also be avoided.

Once the STA has been completely dissected, it can be elevated from the temporalis fascia and moved laterally. The temporalis fascia is incised with the Colorado (Stryker) needle and elevated with the periosteum to reduce bleeding and prevent muscle atrophy.

A protective cuff for the STA is made with the temporalis muscle and periosteum. Two to three superficial stitches are placed between the periosteum and skin edge, and the STA is wrapped to the side. Adequate blood flow and patency of the STA are confirmed with the Doppler. The wrapped STA and skin are then carefully retracted with blunt fishhooks, although sharp fishhooks are applied to the contralateral side. The tension on the side with the artery should be modified as necessary to ensure adequate blood flow as measured by Doppler ultrasound.

Craniotomy and STA Placement

Two small burr holes are created at the inferior and superior edges of the operative site for safe entry and exit of the STA under the bone flap (Figure 3A). An oval craniotomy is generated by connecting the burr holes, and vein retractors are used to protect the STA from any damage with the drill (Figure 3B). The bone flap is then carefully elevated while preserving the middle meningeal artery branches (Figure 3C). The dura is opened in a cruciate manner (Figure 4A), and the dural flaps are elevated with sutures in each corner.

FIGURE 3.

FIGURE 3.

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Craniotomy and bone flap elevation. A, Demonstration of the planned craniotomy with 2 burr holes at the inferior and superior aspects of the exposure. Notice how the side with the retracted artery is secured with blunt fishhooks (yellow) to prevent arterial injury. B, Use of vein retractors protects the proximal STA from potential injuries during the craniotomy. C, Careful separation of the dura mater is performed during elevation of the bone flap to prevent injury to the MMA. MMA, middle meningeal artery; STA, superficial temporal artery.

FIGURE 4.

FIGURE 4.

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Dural dissection. A, The dura mater is opened in a cruciate manner, preserving the branches of the MMA as much as possible. B, The arachnoid is gently dissected to prevent inadvertent SAH. C, The inner layer of the dura mater is separated to expose the most vascularized superficial layer. D, The STA cuffs are attached to the dural leaflets with an 8-0 suture to reduce horizontal displacement during pulsations. MMA, middle meningeal artery; SAH, subarachnoid hemorrhage; STA, superficial temporal artery.

If the brain appears tense, or there is a concern for elevated intracranial pressure, gentle dissection to expose the arachnoid sulci is performed to allow aspiration of cerebrospinal fluid (Figure 4B). During the arachnoid dissection, it is vital to avoid small vessel injuries and prevent subarachnoid hemorrhage, which may subsequently induce vasospasm and seizures. If any bleeding occurs, gently irrigate the area with saline or use local hemostatic agents to stop the bleeding.

The inner dural layer is dissected from each of the reflected dural flaps to expose the more vascularized outer layer of the dura mater (Figure 4C). To increase the chance of neovascularization, it is important to reduce the horizontal and vertical displacement of the STA during pulsation. To reduce horizontal displacement, several 8-0 Ethilon (ETHICON) sutures are applied between the arterial cuff and the dural leaflets (Figure 4D). A collagen sponge is then placed over the dura before replacing the bone flap to reduce vertical displacement of the vessel and ensure the artery is in apposition to the brain's surface. In addition, the collagen sponge reduces the risk of cerebrospinal fluid leak because the dura is not closed in a water-tight fashion.

Closure

The inner surface of the bone flap is trimmed to create a trough for the STA. This prevents excessive compression and kinking of the artery because it reroutes under the bone flap (Figure 5A). The bone flap is replaced and secured with titanium plates on the anterior and posterior aspects of the craniotomy (Figure 5B), leaving the burr holes open for transit of the artery. The temporalis muscle is approximated with interrupted sutures 5 to 7 mm (Figure 6) apart while monitoring STA flow with the Doppler.

FIGURE 5.

FIGURE 5.

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Bone flap preparation. A, The bone flap is trimmed to permit the transit of the STA without any kinking. B, Examples of the prepared bone flap with a trough for the passage of the STA and a collagen sponge applied over the artery to reduce vertical displacement during pulsation. STA, superficial temporal artery.

FIGURE 6.

FIGURE 6.

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Closure. The bone flap has been replaced using titanium plates and screws with the distal artery exiting through the distal burr hole. During muscle closure, care is taken to prevent strangling of the artery.

The dissection of the STA often causes retraction of the galea on both sides of the incision. To reduce the risk of wound dehiscence during skin closure, inverted galeal sutures should be passed along the entire length of the incision before tying them. This technique provides visualization of the galeal edge for each stitch. The sutures are tied systematically, starting from the end of the incision and finishing with the central sutures. Finally, STA flow is reconfirmed with the Doppler at the zygomatic arch (Video 2).

Immediate Postoperative Management

The patient is admitted to the intensive care unit for close neuromonitoring and hemodynamic control. Patients are placed on bed rest with the head of the bed at 30°. Fluid balance is targeted to maintain euvolemic to 1 L positive. SBP is managed strictly with antihypertensive or vasopressor drips to stay within the intraoperative low boundary target and 160 mm Hg.15,16 We recommend avoiding as needed pushes, but rather achieve immediate correction of deviation from the SBP goals with intravenous drips. Sodium should be maintained between 135 and 145 mEq/L, and the use of mannitol or other diuretics avoided.

We also do not recommend steroids or other anti-inflammatory medications given the potential to reduce the surgery-induced angiogenic response. Prophylactic antiepileptic drugs are administered for up to 30 d after surgery to minimize the risk of seizure after manipulation of the arachnoid and possible small subarachnoid hemorrhage.17-19 Aspirin 325 mg daily is continued indefinitely. In addition, postoperative practices such as gastrointestinal prophylaxis, antiemetics, bowel regimen, glycemic control, and pain management are used because they are essential to prevent hyperventilation and straining. Local physical measures for deep vein thrombosis prophylaxis are started immediately, and chemoprophylaxis is started the day after surgery. Patients can be transferred out of the intensive care unit once they are neurologically stable and their SBP is maintained without any drips or as needed medications.

Management of Postoperative Symptoms While Inpatient

After EDAS, some patients might experience symptoms consistent with TIA. If this occurs, the patient should be instructed to lie down with the bed flat, administered supplementary oxygen, and bolused 1 L of normal saline intravenous. If symptoms fail to improve and the patient does not endorse headache, the SBP lower limit can be increased by approximately 20% with vasopressors. If, after 15 min, the patient remains symptomatic, a code stroke should be initiated.

Ethical Considerations

This article did not require Institutional Review Board approval or patient consent because this study did not access any medical records. The study presents technical aspects of the surgical experience of the corresponding author. All patient data presented were collected from previously published studies that had Institutional Review Board approval of the University of California, Los Angeles, and Cedars-Sinai Medical Center.6,7 The participants and any identifiable individuals consented to publication of their image.

RESULTS

Clinical Outcomes

A total of 216 EDAS surgeries were performed in 164 patients, 65 surgeries for patients with ICAD and 151 operations in 99 patients with MMD. Of all the patients who underwent EDAS, 5 had recurrent strokes (5 of 164, 3%), all of which had ICAD (5 of 65, 7.7%). One patient died of a myocardial infarction complication with no associated stroke. Among patients with MMD, none had strokes, but 17 patients had recurrent TIA (10%) in the postoperative period. The mean follow-up was 32.9 mo (standard deviation = 31.1), and angiographic follow-up at 6 mo was completed in 62% of patients.6,9 A limited number of patients who presented with recurrent TIA (1.2%) required repeat craniotomy for the placement of additional burr holes to stimulate angiogenesis.20 No further ischemic symptoms were noted after this intervention.

Complications

Surgical complications occurred in 6 patients (4%): 2 had subdural hemorrhage that required evacuation, 3 had a small wound dehiscence that required debridement and closure, and 1 had wound infection that required washout. There were no cases of postoperative edema or intracranial hemorrhage. In one case, there was an injury of the STA during the dissection, but it did not affect the completion of the surgery or clinical outcome. There were 3 deviations from the predefined SBP goals in which the SBP was lower than the intended goal for longer than 5 min. These instances were corrected in less than 10 min and were not associated with negative clinical outcomes.7

DISCUSSION

Although the EDAS technique has been described several times in the literature, no reports have evaluated the multidisciplinary approach to improve operative outcomes and the effects of maintaining strict medical management in patients at high risk of recurrent stroke. As the role of EDAS potentially expands to treat conditions such as ICAD,3,5,7,21 it is necessary to identify the detailed nuances and variables that can be controlled to ensure good outcomes.

Based on our experience, we believe there are 3 main factors that mitigate the risk of perioperative stroke in patients with ICAD undergoing EDAS: standardized hemodynamic and ventilatory parameters that are strictly controlled during the anesthetic period, consistent and rigorous IMM in the perioperative period, and decreased risk of surgical complications, given the simplicity of the EDAS procedure compared with direct bypass. This hypothesis is further supported by the recent ERSIAS PC trial that showed a 7.7% risk of perioperative stroke after EDAS in patients with ICAD,7 a more favorable rate than those demonstrated in EC-IC (12%)22 and COSS23 (15%) direct bypass trials.

These principles are supported by increasing evidence that anesthesia management plays a significant role in surgical outcomes in patients with cerebrovascular disease. Numerous authors emphasize the importance of anesthetic management of CPP to prevent cerebral ischemia in patients undergoing cerebral revascularization procedures.24-28 Specifically, in a prospective cohort study of patients undergoing EDAS, Laiwalla et al10 found that a strict anesthesia protocol minimized fluctuations in mean arterial pressure and end-tidal carbon dioxide without any intraoperative or postoperative ischemic or hemorrhagic strokes. Individual operator or institutional preferences are common in any surgical intervention; however, the use of standardized protocols helps to reduce variability and consistently improve outcomes.10 We have applied this multidisciplinary approach to standardize surgical, anesthesia, and perioperative management and obtained good clinical outcomes that certainly could be extrapolated to more general applications. As recent literature cannot specifically attribute improved outcomes to anesthesia management alone, it is reasonable to outline operative protocols to include a multidisciplinary approach and reduce external variables that may influence outcomes after EDAS.

Limitations

The application of the protocol presented here requires a cohesive team approach in which cooperation between the neurosurgeon, anesthesiologist, and critical care neurologist is essential. Its application in different institutions depends on this cohesive multidisciplinary approach. We have found that good communication between the teams and the use of structured tools facilitates the application of these protocols. The study presented here is the result of a work that has evolved over many years. Although its development took considerable time, the protocols discussed have been tested in prospective clinical trials of EDAS in patients with ICAD at high risk of recurrent stroke with positive results.7

CONCLUSION

The application of EDAS surgery improves outcomes when following meticulous surgical technique and applying a multidisciplinary approach to strictly maintain hemodynamic parameters in patients with cerebral steno-occlusive diseases who are at risk for ischemia. A team-oriented approach and maintenance of IMM for patients at high risk of stroke reduces the risk of perioperative cerebral infarct after EDAS.

Acknowledgments

We would like to thank Drs Jeffrey L. Saver, Schlee S. Song, David S. Liebeskind, Konrad H. Schlick, Jason D. Hinman, Paul Vespa, Manuel M. Buitrago Blanco, Shouri Lahiri, Shahed Toossi, Maranatha O. Ayodele, and Michael Gezalian for their excellent perioperative management of these patients. We also want to thank Drs Marc I. Chimowitz and Tanya N. Turan for their input regarding the development of these protocols.

Funding

This study did not receive any funding or financial support.

Disclosures

The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

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