Desempeño diagnóstico de la pletismografía arterial frente a la arteriografía en la enfermedad arterial periférica de los miembros inferiores
Introducción: La enfermedad arterial periférica (EAP) es una manifestación relevante de la aterosclerosis sistémica con elevada prevalencia en adultos mayores y personas con comorbilidades crónicas. Su diagnóstico oportuno es esencial para prevenir eventos cardiovasculares mayores y preservar la fun...
- Autores:
-
Durango Tirado, Mauricio Carlos
Puerta Rojas, José David
- Tipo de recurso:
- Article of investigation
- Fecha de publicación:
- 2025
- Institución:
- Universidad de Antioquia
- Repositorio:
- Repositorio UdeA
- Idioma:
- spa
- OAI Identifier:
- oai:bibliotecadigital.udea.edu.co:10495/46325
- Acceso en línea:
- https://hdl.handle.net/10495/46325
- Palabra clave:
- Enfermedad arterial periférica
Peripheral arterial disease
Pletismografía
Plethysmography
Angiografía
Angiography
Índice tobillo braquial
Ankle brachial index
Diagnóstico
Diagnosis
https://id.nlm.nih.gov/mesh/D000792
https://id.nlm.nih.gov/mesh/D058729
https://id.nlm.nih.gov/mesh/D010991
https://id.nlm.nih.gov/mesh/D000792
https://id.nlm.nih.gov/mesh/D055109
https://id.nlm.nih.gov/mesh/D003933
ODS 3: Salud y bienestar. Garantizar una vida sana y promover el bienestar de todos a todas las edades
- Rights
- openAccess
- License
- http://creativecommons.org/licenses/by-nc-sa/4.0/
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Desempeño diagnóstico de la pletismografía arterial frente a la arteriografía en la enfermedad arterial periférica de los miembros inferiores |
| dc.title.translated.none.fl_str_mv |
Diagnostic performance of arterial plethysmography versus arteriography in peripheral arterial disease of the lower limbs |
| title |
Desempeño diagnóstico de la pletismografía arterial frente a la arteriografía en la enfermedad arterial periférica de los miembros inferiores |
| spellingShingle |
Desempeño diagnóstico de la pletismografía arterial frente a la arteriografía en la enfermedad arterial periférica de los miembros inferiores Enfermedad arterial periférica Peripheral arterial disease Pletismografía Plethysmography Angiografía Angiography Índice tobillo braquial Ankle brachial index Diagnóstico Diagnosis https://id.nlm.nih.gov/mesh/D000792 https://id.nlm.nih.gov/mesh/D058729 https://id.nlm.nih.gov/mesh/D010991 https://id.nlm.nih.gov/mesh/D000792 https://id.nlm.nih.gov/mesh/D055109 https://id.nlm.nih.gov/mesh/D003933 ODS 3: Salud y bienestar. Garantizar una vida sana y promover el bienestar de todos a todas las edades |
| title_short |
Desempeño diagnóstico de la pletismografía arterial frente a la arteriografía en la enfermedad arterial periférica de los miembros inferiores |
| title_full |
Desempeño diagnóstico de la pletismografía arterial frente a la arteriografía en la enfermedad arterial periférica de los miembros inferiores |
| title_fullStr |
Desempeño diagnóstico de la pletismografía arterial frente a la arteriografía en la enfermedad arterial periférica de los miembros inferiores |
| title_full_unstemmed |
Desempeño diagnóstico de la pletismografía arterial frente a la arteriografía en la enfermedad arterial periférica de los miembros inferiores |
| title_sort |
Desempeño diagnóstico de la pletismografía arterial frente a la arteriografía en la enfermedad arterial periférica de los miembros inferiores |
| dc.creator.fl_str_mv |
Durango Tirado, Mauricio Carlos Puerta Rojas, José David |
| dc.contributor.advisor.none.fl_str_mv |
Plaza Tenorio, Maribel Arrieta Bechara, Juan Carlos Ospina Ospina , Sigifredo |
| dc.contributor.author.none.fl_str_mv |
Durango Tirado, Mauricio Carlos Puerta Rojas, José David |
| dc.contributor.jury.none.fl_str_mv |
Tobon Acosta, Luis Ignacio Herrera Ramos, Rafael ignacio |
| dc.subject.decs.none.fl_str_mv |
Enfermedad arterial periférica Peripheral arterial disease Pletismografía Plethysmography Angiografía Angiography Índice tobillo braquial Ankle brachial index Diagnóstico Diagnosis |
| topic |
Enfermedad arterial periférica Peripheral arterial disease Pletismografía Plethysmography Angiografía Angiography Índice tobillo braquial Ankle brachial index Diagnóstico Diagnosis https://id.nlm.nih.gov/mesh/D000792 https://id.nlm.nih.gov/mesh/D058729 https://id.nlm.nih.gov/mesh/D010991 https://id.nlm.nih.gov/mesh/D000792 https://id.nlm.nih.gov/mesh/D055109 https://id.nlm.nih.gov/mesh/D003933 ODS 3: Salud y bienestar. Garantizar una vida sana y promover el bienestar de todos a todas las edades |
| dc.subject.lcshuri.none.fl_str_mv |
https://id.nlm.nih.gov/mesh/D000792 |
| dc.subject.meshuri.none.fl_str_mv |
https://id.nlm.nih.gov/mesh/D058729 https://id.nlm.nih.gov/mesh/D010991 https://id.nlm.nih.gov/mesh/D000792 https://id.nlm.nih.gov/mesh/D055109 https://id.nlm.nih.gov/mesh/D003933 |
| dc.subject.ods.none.fl_str_mv |
ODS 3: Salud y bienestar. Garantizar una vida sana y promover el bienestar de todos a todas las edades |
| description |
Introducción: La enfermedad arterial periférica (EAP) es una manifestación relevante de la aterosclerosis sistémica con elevada prevalencia en adultos mayores y personas con comorbilidades crónicas. Su diagnóstico oportuno es esencial para prevenir eventos cardiovasculares mayores y preservar la función de las extremidades, pero sigue siendo subestimada clínicamente, en especial en países con recursos limitados. Aunque la arteriografía ha sido el estándar para definir el compromiso vascular, su carácter invasivo ha impulsado el uso de métodos no invasivos como la pletismografía arterial segmentaria multimodal que permiten una evaluación funcional del flujo arterial. Sin embargo, su validación frente a técnicas invasivas permanece escasa en América Latina. Este estudio busca evaluar el desempeño diagnóstico de la pletismografía arterial segmentaria frente a la arteriografía en una cohorte de pacientes con sospecha de EA y evaluar además sus características clínicas, hemodinámicas y anatómicas en un entorno especializado. Objetivo: evaluar el desempeño diagnóstico de la pletismografía arterial segmentaria multimodal en comparación con la arteriografía en pacientes con sospecha de enfermedad arterial periférica (EAP) de los miembros inferiores. Métodos: estudio retrospectivo de corte transversal realizado en un centro de atención terciaria en Medellín, Colombia, entre enero de 2022 y diciembre de 2023. Se incluyeron 83 pacientes con sospecha clínica de EAP y factores de riesgo cardiovascular. Fueron analizadas variables clínicas, hemodinámicas y de imagen mediante índice tobillo-brazo (ITB), Índice dedo/Brazo (IDB), registro de ondas de volumen, gradientes de presiones segmentarios, ecografía Doppler de onda continua y la arteriografía. Fueron calculadas: sensibilidad, especificidad, valores predictivos, razones de verosimilitud y coeficiente Kappa de Cohen. Resultados: la edad media fue de 68.6 años (DE ± 11.6), con 54.2% de hombres. Las comorbilidades más frecuentes fueron hipertensión (81.9%), diabetes mellitus (55.4%) y tabaquismo (48.2%). Los valores de ITB indicaron EAP en más del 75% de los pacientes, con predominio de afectación infrapoplítea en la pletismografía. Esta última presentó una sensibilidad del 89.8%, especificidad del 88.6%, valor predictivo negativo del 91.9% y un índice Kappa de 0.7797, indicando concordancia sustancial con la arteriografía. Conclusión: la pletismografía arterial segmentaria multimodal de miembros inferiores es una herramienta diagnóstica no invasiva confiable y útil en la evaluación inicial de la EAP, especialmente en contextos con recursos limitados. Su desempeño diagnóstico frente a la arteriografía respalda su integración en los protocolos clínicos. |
| publishDate |
2025 |
| dc.date.accessioned.none.fl_str_mv |
2025-06-11T16:07:25Z |
| dc.date.issued.none.fl_str_mv |
2025 |
| dc.type.none.fl_str_mv |
Trabajo de grado - Especialización |
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http://purl.org/redcol/resource_type/ART |
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J Vasc Surg. 2016;64(6):1696–1707. doi:10.1016/j.jvs.2016.05.123. Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FGR. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg. 2007;33(Suppl 1):S1–S75. doi:10.1016/j.ejvs.2006.09.024. Collins R, Burch J, Cranny G, Aguiar-Ibáñez R, Craig D, Wright K, et al. Systematic review of duplex ultrasonography, magnetic resonance angiography, and computed tomography angiography for diagnosis and assessment of symptomatic lower limb peripheral arterial disease. Health Technol Assess. 2007;11(20):iii–iv, ix–x, 1–184. doi:10.3310/hta11200. Gerhard-Herman MD, Gornik HL, Barrett C, Barshes NR, Corriere MA, Drachman DE, et al. 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease. J Am Coll Cardiol. 2017;69(11):e71–e126. doi:10.1016/j.jacc.2016.11.007. Modarai B, Jamil M, Burnand KG, Smith A. Genetic influences in peripheral artery disease. 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J Vasc Surg. 2014;59(1):220–234.e2. doi:10.1016/j.jvs.2013.08.003. van der Meij E, Tangelder MJ, Moll FL, de Vries JP, van Herwaarden JA. Endovascular revascularization strategies for intermittent claudication. Eur J Vasc Endovasc Surg. 2014;47(6):660–665. doi:10.1016/j.ejvs.2014.02.004. White CJ. Peripheral arterial disease: medical and interventional therapy. Circulation. 2007;116(2):207–209. doi:10.1161/CIRCULATIONAHA.106.621391. Muntner P, Garrett E, Klag MJ, Coresh J. Trends in the prevalence of peripheral arterial disease in the United States. Hypertension. 2004;44(6):831–837. doi:10.1161/01.HYP.0000148997.53029.64. Reunanen A, Takkunen H, Knekt P, Aromaa A. Prevalence and risk factors of intermittent claudication: a population-based study. Eur Heart J. 1982;3(5):343–347. [DOI no disponible]. Coughlin PA, Mavor AI, Armon MP. Lower limb peripheral arterial disease: management and outcome. Br J Surg. 2011;98(9):1290–1296. doi:10.1002/bjs.7561. Hankey GJ, Norman PE, Eikelboom JW. Medical treatment of peripheral arterial disease: a review. JAMA. 2006;295(5):547–553. doi:10.1001/jama.295.5.547. Farber A, Eberhardt RT. The current state of critical limb ischemia: a systematic review. JAMA Surg. 2016;151(11):1070–1077. doi:10.1001/jamasurg.2016.2019. Valdés MM, Vega Á, Parra V, Moraga G, Gonzalez L. Enfermedad arterial periférica en pacientes diabéticos chilenos. Rev Chil Cir. 2017;69(2):151–157. doi:10.4067/S0718-40262017000200151. Mazzolai L, Teixido-Tura G, Lanzi S, Boc V, Bossone E, Brodmann M, Bura-Rivière A, De Backer J, Deglise S, Della Corte A, Heiss C, Kałużna-Oleksy M, Kurpas D, McEniery CM, Mirault T, Pasquet AA, Pitcher A, Schaubroeck HAI, Schlager O, Sirnes PA, Sprynger MG, Stabile E, Steinbach F, Thielmann M, van Kimmenade RRJ, Venermo M, Rodriguez-Palomares JF; ESC Scientific Document Group. 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases. Eur Heart J. 2024 Sep 29;45(36):3538-3700. doi: 10.1093/eurheartj/ehae179. PMID: 39210722. Alzamora MT, Fores R, Baena-Díez JM, Pera G, Torán P, Artigues A, et al. The peripheral arterial disease study (PERART/ARTPER): prevalence and risk factors. BMC Cardiovasc Disord. 2014;14:186. doi:10.1186/1471-2261-14-186. Hirsch AT. A call to action: PAD diagnosis and treatment. J Am Coll Cardiol. 2013;61(7):1239–1241. doi:10.1016/j.jacc.2012.12.008. Reich RS. Surgical treatment of thromboangiitis obliterans. Ann Surg. 1934;99(4):613–622. [DOI no disponible]. Schroder F, Martus P, Kopp I, Gross B, Gassmann KG, Herold J, et al. Validity of ankle–brachial index measurement in general practice. J Vasc Surg. 2006;44(3):531–536. doi: 10.1016/j.jvs.2006.05.036. Lijmer JG, Mol BW, Heisterkamp S, Bonsel GJ, Prins MH, van der Meulen JH, et al. Empirical evidence of design-related bias in studies of diagnostic tests. JAMA. 1999;282(11):1061–1066. doi:10.1001/jama.282.11.1061. Nam SC, Kang D, Kim JW. Impact of duplex ultrasonography on the diagnosis of peripheral artery disease. Angiology. 2010;61(5):392–396. doi:10.1177/0003319709358284. Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FGR. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg. 2007;45(Suppl S):S5–S67. doi:10.1016/j.jvs.2006.12.037. Hirsch AT, Criqui MH, Treat-Jacobson D, Regensteiner JG, Creager MA, Olin JW, et al. Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA. 2001;286(11):1317–1324. doi:10.1001/jama.286.11.1317. Ro DH, Kim SY, Kim W. Prediction of critical limb ischemia using skin perfusion pressure and toe-brachial index. Angiology. 2013;64(4):314–320. doi:10.1177/0003319712452266. Gomes A, Pollick C. The accuracy of a volume plethysmography system as assessed by contrast angiography. J Prev Med. 2018;3(2):15. doi:10.21767/2572-5483.100031. Jaeschke R, Guyatt GH, Sackett DL. Users’ guides to the medical literature. III. How to use an article about a diagnostic test. JAMA. 1994;271(5):389–391. doi:10.1001/jama.271.5.389. McDermott MM, Guralnik JM, Ferrucci L, Liu K, Liao Y, Criqui MH, et al. The epidemiology of PAD: implications for public health. JAMA. 2003;290(4):457–464. doi:10.1001/jama.290.4.457. |
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18 paginas |
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2022-2023 |
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Lat: 06 15 00 N degrees minutes Lat: 6.2500 decimal degrees Long: 075 36 00 W degrees minutes Long: -75.6000 decimal degrees |
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http://vocab.getty.edu/page/tgn/7005073 |
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Medellín |
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Universidad de Antioquia |
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Especialización en Medicina Vascular |
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Departamento de Medicina Interna |
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Medellín, Colombia |
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Facultad de Medicina |
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Campus en el Área de la salud |
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Universidad de Antioquia |
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Universidad de Antioquia |
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Plaza Tenorio, MaribelArrieta Bechara, Juan CarlosOspina Ospina , SigifredoDurango Tirado, Mauricio CarlosPuerta Rojas, José DavidTobon Acosta, Luis IgnacioHerrera Ramos, Rafael ignacio2022-2023Lat: 06 15 00 N degrees minutes Lat: 6.2500 decimal degrees Long: 075 36 00 W degrees minutes Long: -75.6000 decimal degreeshttp://vocab.getty.edu/page/tgn/7005073Medellín2025-06-11T16:07:25Z2025https://hdl.handle.net/10495/46325Introducción: La enfermedad arterial periférica (EAP) es una manifestación relevante de la aterosclerosis sistémica con elevada prevalencia en adultos mayores y personas con comorbilidades crónicas. Su diagnóstico oportuno es esencial para prevenir eventos cardiovasculares mayores y preservar la función de las extremidades, pero sigue siendo subestimada clínicamente, en especial en países con recursos limitados. Aunque la arteriografía ha sido el estándar para definir el compromiso vascular, su carácter invasivo ha impulsado el uso de métodos no invasivos como la pletismografía arterial segmentaria multimodal que permiten una evaluación funcional del flujo arterial. Sin embargo, su validación frente a técnicas invasivas permanece escasa en América Latina. Este estudio busca evaluar el desempeño diagnóstico de la pletismografía arterial segmentaria frente a la arteriografía en una cohorte de pacientes con sospecha de EA y evaluar además sus características clínicas, hemodinámicas y anatómicas en un entorno especializado. Objetivo: evaluar el desempeño diagnóstico de la pletismografía arterial segmentaria multimodal en comparación con la arteriografía en pacientes con sospecha de enfermedad arterial periférica (EAP) de los miembros inferiores. Métodos: estudio retrospectivo de corte transversal realizado en un centro de atención terciaria en Medellín, Colombia, entre enero de 2022 y diciembre de 2023. Se incluyeron 83 pacientes con sospecha clínica de EAP y factores de riesgo cardiovascular. Fueron analizadas variables clínicas, hemodinámicas y de imagen mediante índice tobillo-brazo (ITB), Índice dedo/Brazo (IDB), registro de ondas de volumen, gradientes de presiones segmentarios, ecografía Doppler de onda continua y la arteriografía. Fueron calculadas: sensibilidad, especificidad, valores predictivos, razones de verosimilitud y coeficiente Kappa de Cohen. Resultados: la edad media fue de 68.6 años (DE ± 11.6), con 54.2% de hombres. Las comorbilidades más frecuentes fueron hipertensión (81.9%), diabetes mellitus (55.4%) y tabaquismo (48.2%). Los valores de ITB indicaron EAP en más del 75% de los pacientes, con predominio de afectación infrapoplítea en la pletismografía. Esta última presentó una sensibilidad del 89.8%, especificidad del 88.6%, valor predictivo negativo del 91.9% y un índice Kappa de 0.7797, indicando concordancia sustancial con la arteriografía. Conclusión: la pletismografía arterial segmentaria multimodal de miembros inferiores es una herramienta diagnóstica no invasiva confiable y útil en la evaluación inicial de la EAP, especialmente en contextos con recursos limitados. Su desempeño diagnóstico frente a la arteriografía respalda su integración en los protocolos clínicos.Introduction: Peripheral arterial disease (PAD) is a significant manifestation of systemic atherosclerosis with a high prevalence in older adults and people with chronic comorbidities. Timely diagnosis is essential to prevent major cardiovascular events and preserve limb function, but it remains clinically underestimated, especially in resource-limited countries. Although arteriography has been the standard for defining vascular involvement, its invasive nature has prompted the use of noninvasive methods such as multimodal segmental arterial plethysmography, which allow for functional assessment of arterial flow. However, its validation against invasive techniques remains limited in Latin America. This study seeks to evaluate the diagnostic performance of segmental arterial plethysmography versus arteriography in a cohort of patients with suspected PAD, also assessing their clinical, hemodynamic, and anatomical characteristics in a specialized setting. Objective: To evaluate the diagnostic performance of multimodal segmental arterial plethysmography compared with arteriography in patients with suspected peripheral arterial disease (PAD) of the lower extremities. Methods: A retrospective, cross-sectional study was conducted at a tertiary care center in Medellín, Colombia, between January 2022 and December 2023. Eighty-three patients with clinically suspected PAD and cardiovascular risk factors were included. Clinical, hemodynamic, and imaging variables were analyzed using ankle-brachial index (ABI), finger-brachial index (FBI), volume waveform recording, segmental pressure gradients, continuous wave Doppler ultrasound, and arteriography. Sensitivity, specificity, predictive values, likelihood ratios, and Cohen's Kappa coefficient were calculated. Results: The mean age was 68.6 years (SD ± 11.6), with 54.2% being men. The most common comorbidities were hypertension (81.9%), diabetes mellitus (55.4%), and smoking (48.2%). ABI values indicated PAD in more than 75% of patients, with a predominance of infrapopliteal involvement on plethysmography. Plethysmography had a sensitivity of 89.8%, specificity of 88.6%, negative predictive value of 91.9%, and a Kappa index of 0.7797, indicating substantial agreement with arteriography. Conclusion: Multimodal segmental arterial plethysmography of the lower extremities is a reliable and useful noninvasive diagnostic tool in the initial evaluation of PAD, especially in resource-limited settings. Its diagnostic performance compared to arteriography supports its integration into clinical protocols.EspecializaciónEspecialista en Medicina Vascular18 paginasapplication/pdfspaUniversidad de AntioquiaEspecialización en Medicina VascularDepartamento de Medicina InternaMedellín, ColombiaFacultad de MedicinaCampus en el Área de la saludhttp://creativecommons.org/licenses/by-nc-sa/4.0/info:eu-repo/semantics/openAccessAttribution-NonCommercial-ShareAlike 4.0 Internationalhttp://purl.org/coar/access_right/c_abf2Desempeño diagnóstico de la pletismografía arterial frente a la arteriografía en la enfermedad arterial periférica de los miembros inferioresDiagnostic performance of arterial plethysmography versus arteriography in peripheral arterial disease of the lower limbsTrabajo de grado - Especializaciónhttp://purl.org/coar/resource_type/c_2df8fbb1http://purl.org/coar/resource_type/c_93fchttp://purl.org/redcol/resource_type/ARTTexthttp://purl.org/coar/version/c_b1a7d7d4d402bcceinfo:eu-repo/semantics/reportinfo:eu-repo/semantics/draftCriqui MH, Aboyans V. 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Garantizar una vida sana y promover el bienestar de todos a todas las edadesPublicationORIGINALDurangoMauricio_2025_DesempenoPletismografiaArteriografia.pdfDurangoMauricio_2025_DesempenoPletismografiaArteriografia.pdfapplication/pdf527849https://bibliotecadigital.udea.edu.co/bitstreams/efac071b-c3b2-4526-b7c9-4f5b808ab507/downloadfacbb0837225aedd0ee47a1aced62cbeMD52trueAnonymousREAD2027-06-10LICENSElicense.txtlicense.txttext/plain; charset=utf-814837https://bibliotecadigital.udea.edu.co/bitstreams/51630c39-0d3f-4bff-b9e8-fc69cddfb005/downloadb76e7a76e24cf2f94b3ce0ae5ed275d0MD54falseAnonymousREADCC-LICENSElicense_rdflicense_rdfapplication/rdf+xml; charset=utf-81160https://bibliotecadigital.udea.edu.co/bitstreams/1bdaccbd-1131-49d3-b0f9-141dcd1e743e/download5643bfd9bcf29d560eeec56d584edaa9MD55falseAnonymousREADTEXTDurangoMauricio_2025_DesempenoPletismografiaArteriografia.pdf.txtDurangoMauricio_2025_DesempenoPletismografiaArteriografia.pdf.txtExtracted 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