SURGICAL ANATOMY AND TECHNIQUE

Paratrigeminal, Paraclival, Precavernous, or All

of the Above? A Circumferential Anatomical Study
of the C3-C4 Transitional Segment of the Internal
Carotid Artery
Eleonora Marcati, MD∗
Norberto Andaluz, MD∗ § ¶
Sebastien C Froelich, MD||
Lee A. Zimmer, MD, PhD∗ ‡ §
James L. Leach, MD#
Juan Carlos
Fernandez-Miranda, MD∗∗
Almaz Kurbanov, MD∗
Jeffrey T. Keller, PhD∗ § ¶
∗
Department of Neurosurgery, University
of Cincinnati College of Medicine,
Cincinnati, Ohio; ‡ Department of
Otolaryngology Head and Neck
Surgery, University of Cincinnati
College of Medicine, Cincinnati, Ohio;
§
Comprehensive Stroke Center at
University of Cincinnati Neuroscience
Institute, Cincinnati, Ohio; ¶ Mayfield
Clinic, Cincinnati, Ohio; || Department
of Neurosurgery, Lariboisiere University
Hospital, Paris, France; # Department of
Pediatric Radiology, Cincinnati Children’s
Hospital Medical Center, Cincinnati, Ohio;
∗∗
Department of Neurological Surgery,
University of Pittsburgh Medical Center,
Pittsburgh, Pennsylvania
Correspondence:
Jeffrey T. Keller
c/o Medical Communications,
Department of Neurosurgery,
University of Cincinnati College of
Medicine,
PO Box 67015,
Cincinnati, OH 45237.
BACKGROUND: Although the term paraclival carotid pervades recent skull base literature,
no clear consensus exists regarding boundaries or anatomical segments.
OBJECTIVE: To reconcile various internal carotid artery (ICA) nomenclatures for
transcranial and endoscopic-endonasal perspectives, we reexamined the transition
between lacerum (C3) and cavernous (C4) segments using a C1-C7 segments schema. In
this cadaveric study, we obtained a 360◦ -circumferential view integrating histological,
microsurgical, endoscopic, and neuroradiological analyses of this C3-C4 region and
identified a distinct transitional segment.
METHODS: In 13 adult, silicone-injected, formalin-fixed cadaveric heads (26 sides),
transcranial-extradural-subtemporal and endoscopic-endonasal CTguided dissections
were performed. A quadrilateral area was noted medial to Meckel’s cave between cranial
nerve VI, anterolateral and posterolateral borders of the lateral-paratrigeminal aspect
of the precavernous ICA, and posterior longitudinal ligament. Endoscopically, a medial-
paraclival aspect was defined. Anatomical correlations were made with histological and
neuroradiological slides.
RESULTS: We identified a distinct precavernous C3-C4 transitional segment. In 18 (69%)
specimens, venous channels were absent at the quadrilateral area, on the paratrigeminal
border of the precavernous ICA. A trigeminal membrane, seen consistently on the superior
border of V2, defined the lateral aspect of the cavernous sinus floor. The medial aspect of
the precavernous ICA corresponded with the paraclival ICA.
CONCLUSION: Our study revealing the juncture of 2 complementary borders of the ICA,
endoscopic endonasal (paraclival) and transcranial (paratrigeminal), reconciles various
nomenclature. A precavernous segment may clarify controversies about the paraclival ICA
and support the concept of a “safe door” for lesions involving Meckel’s cave, cavernous
sinus, and petrous apex.
KEY WORDS: Cavernous sinus, Internal carotid artery, Nomenclature, Paraclival, Paratrigeminal, Precavernous,
Transitional segment
Operative Neurosurgery 0:1–9, 2017 DOI: 10.1093/ons/opx121
(C3) segment identified by Bouthillier et al6

E-mail: jthomaskeller@gmail.com
Received, September 8, 2016.
Accepted, April 20, 2017.
Copyright 
C 2017 by the
Congress of Neurological Surgeons
T
he ongoing expansion of endoscopic-
endonasal skull base surgery techniques
has rekindled interest in anatomical
structures (ie, paraclival carotid, vidian nerve,
sphenopalatine arteries) previously considered
of little relevance in microsurgical anatomical
studies.1-5 Relevant to this topic is the lacerum
ABBREVIATIONS: CN, cranial nerve; ICA, internal
carotid artery
and the cavernous (C4) segment of the internal
carotid artery (ICA).7-12 Although the terms
“paraclival” and “parasellar” gained significant
popularity related to endoscopy that then
resulted in a tacit validation of their existence,
consensus is lacking regarding the boundaries of
these anatomical ICA segments.1,2,5,9,13-26
Aiming to provide greater clarity and specific
microanatomical detail for the lacerum, precav-
ernous, and cavernous ICA segments, our study

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MARCATI ET AL
FIGURE 1. Segments of the ICA featuring the new precavernous or C3-C4
transitional segment. Our 1996 schema defined a lacerum (C3) segment that
extended from the posterolateral aspect of the foramen lacerum to the superior
border of the petrolingual ligament, immediately caudal to the origin of the
cavernous (C4) segment. Printed with permission from Mayfield Clinic.
applied an integrated approach that included histology, micro-
surgery, endonasal endoscopy, and neuroradiology. Based on
our findings that reconciled perspectives from endonasal and
transcranial approaches, we propose the existence of a distinct,
mostly nonvenous segment between the C3 and C4 called the
precavernous, or C3-C4 transitional, segment (Figure 1).
METHODS
Cadaveric Dissections
Thirteen formalin-fixed cadaveric heads (26 sides) were injected
with colored silicone using our previously reported technique.27 In
10 specimens, bilateral transcranial and endoscopic endonasal dissec-
tions were performed to expose a quadrilateral area bordered by the
petrolingual ligament inferiorly, cranial nerve (CN) VI superiorly, and
anterolateral and posterolateral margins of the posterior ascending C4.
Measurements and areas for of each structure were calculated.
In 3 additional specimens, the posterior venous confluence connected
to the posterior cavernous sinus was exposed. This exposure included
drainage from the basilar plexus and superior petrosal sinus to the inferior
petrosal sinus.28,29
Transcranial Perspective
By extradural subtemporal approach, the middle cranial fossa was
exposed from the superior orbital fissure anteriorly to Kawase’s rhomboid
area posteriorly. The dural fold between Meckel’s cave and temporal dura
was incised. Careful dissection of the outer layer of the lateral wall of the
cavernous sinus exposed a thin, inner membranous layer of the cavernous
sinus and CNs III through V. Next, sectioning of the porus trigeminus at
the posterolateral aspect of Gruber’s ligament and its reflection anteriorly
allowed visualization of the quadrilateral area.
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Endoscopic Endonasal Perspective
After initial dissections with a 0◦ endoscope (Stryker Endoscopy, San
Jose, California), use of angled endoscopes of 30◦ , 45◦ , and 70◦ helped
to expose the quadrilateral area through a transmaxillary-transpterygoid
approach.
With the BrainLab navigation system (Feldkirchen, Germany), we
identified the lingular recess and posterior end of the Vidian canal,
landmarks for the C3 and C4 segments. After resection of the Vidian
nerve, the drilling of the maxillary strut, foramen rotondum, and
foramen ovale allowed lateral mobilization of Meckel’s cave. The dura
at the “quadrangular door” between Meckel’s cave and ICA was then
opened and further dissected toward the posterior venous confluence.30
Neuroradiological Study
During dissections, the BrainLab frameless stereotactic-image
guidance system based on CT images confirmed landmarks of the
quadrilateral area. Subsequent analyses included CT, MR, and angio-
graphic images.
Histological Study
In 2 cadaveric heads (4 sides), en bloc sections containing the Meckel’s
cave, cavernous sinus, and ICA were removed and processed as previously
reported.22
RESULTS
In transcranial and endoscopic endonasal dissections, our
integrated approach revealed microanatomical detail for the
lacerum and proximal cavernous ICA segments. A distinct, mostly
nonvenous ICA segment between the superior border of the
carotid canal and petrolingual ligament inferiorly and the origin
of the cavernous sinus superiorly was termed precavernous, or C3-
C4 transitional segment (Figure 1).
Cadaveric Dissections: Transcranial Perspective
Dural Aspects
Inferiorly, the lateral and medial walls of the cavernous
sinus extended from the lateral and medial aspects of the
superior orbital fissure, respectively, to the lower aspect of the
carotid sulcus, the lingula, and fused at the junction between
the ophthalmic (V1) and maxillary (V2) roots and trigeminal
ganglion. Superiorly, they extended to the anterior petroclinoid
and interclinoid dural folds, 2 sides of the oculomotor triangle.
The posterior wall of the cavernous sinus opened at the level of
the petrous apex into the posterior venous confluence; the lateral
and medial walls joined at the junction between the upper and
middle third of the ostium of Meckel’s cave (Figures 2A and 2B).
At this level, the ostium of Meckel’s cave was divided
to identify the quadrilateral area. The petrolingual ligament
appeared anteriorly at the level of the lingula, continuous with the
medial wall of the cavernous sinus. Posteriorly, it was dissected
from the ventromedial wall of the lower third of Meckel’s cave,
toward its slightly inferior insertion on the anterior process of the
petrous bone.
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 C3-C4 TRANSITIONAL SEGMENT OF THE INTERNAL CAROTID ARTERY

FIGURE 2. Lateral-paratrigeminal aspect of the precavernous or C3-C4 transitional segment. A, Lateral (yellow dashes) and medial (green dashes) walls of the
cavernous sinus (CS) at the quadrilateral area fuse anteriorly at the V1-V2 junction with the trigeminal ganglion (TG) and posteriorly at the junction between
upper and middle third of Meckel’s cave (MC) ostium. B, Details of the quadrilateral area (green dashes) after cut of V1 (purple dashes) and its lateral reflection. C,
After cutting the porus trigeminus (orange), MC is reflected anteriorly and the quadrilateral area is identified (green dashes). Trigeminal membrane (yellow dotted
line), dissected from the petrolingual ligament (PLL), runs from the superior border of V2 to the upper third of the porus. D, Three-dimensional schema showing the
relationship of CS, cranial nerves (CNs) III-VI, and ICA. Paratrigeminal border of the precavernous or C3-C4 transitional segment, between the PLL and the CS
floor (black dashes). ACP, anterior clinoidal process; APP, anterior process of the petrous apex; GSPN, greater superficial petrous nerve; ILT, inferolateral trunk; IPS,
inferior petrosal sinus; SPS, superior petrosal sinus. Printed with permission from Mayfield Clinic.

A meningeal membrane, coursing over the superior border
of V2 to the junction between the upper and middle
thirds of the ostium of Meckel’s cave, was consistently
identified; it represented the lateral aspect of the cavernous
sinus floor. We named this the trigeminal membrane—a
consistent boundary marking the origin of the cavernous (C4)
segment. A denuded, wedge-shaped area on the dorsal posterior
ascending C4 (between the petrolingual ligament and trigeminal
membrane) was termed the precavernous or C3-C4 transi-
tional segment. Considering its relationship with the trigeminal
ganglion, we referred to its lateral aspect as paratrigeminal
(Figures 2C and 2D).

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MARCATI ET AL

FIGURE 3. Quadrilateral area, type 2. A, Posterior wall of the cavernous sinus (CS) after resection of its roof, that is, CNs III and IV.
Posterior venous confluence (PVC) identified with its major components of basilar plexus (BP), superior petrosal sinus (SPS), and inferior
petrosal sinus (IPS). Gruber’s ligament (GL) and petrolingual ligament (PLL) identified at their insertion on the posterior and anterior
processes of the petrous apex, respectively. B, Magnification of area outlined in Figure 2A. Partial removal of the PVC and Meckel’s cave
(MC) highlighting the quadrilateral area (green dashes). Trigeminal membrane, dissected from the PLL, at the junction between upper
and middle third of MC is highlighted (white arrow). C, Example of the type 2 quadrilateral area (green dashes) in lateral view after
complete removal of the MC. PCP, posterior clinoidal process; MHT, meningohypophyseal trunk; MMA, middle meningeal artery; VA,
vertebral artery; BA, basilar artery. Printed with permission from Mayfield Clinic.

Venous Patterns
The cavernous sinus drained posteriorly into the inferior
petrosal sinus receiving drainage from the superior petrosal
sinus and basilar plexus (Figure 3A). In 8 (31%) specimens, an
extension of cavernous sinus venous content was observed below
CN VI; this connected the cavernous sinus and posterior venous
confluence (type 1). Conversely, in 18 (69%) cases, no venous
structures were found on the paratrigeminal aspect of the precav-
ernous or C3-C4 transitional segment (type 2); thus, no commu-
nication was seen between the cavernous sinus and posterior
venous confluence on this side. This virtual space devoid of
veins corresponded to the quadrilateral area was described earlier
(Figures 3B and 3C).
Neurovascular Relationships
The Meckel’s cave, cavernous sinus, and CNs II to XII were
exposed. At the level of Parkinson’s triangle, the meningohy-
pophyseal trunk was identified in each specimen, originating from
the posterior bend of the C4 ICA (Figure 3A). The basal tentorial
artery of Bernasconi-Cassinari consistently coursed along the
tentorium. The dorsal meningeal artery was visible medial to
the CN VI, toward the upper clivus in most specimens. The

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inferolateral trunk, which was identified after dividing the
ophthalmic and maxillary branches of CN V, originated from
the lateral aspect of the horizontal C4 segment (Figure 2A). In
all specimens, CN VI clearly coursed in an arachnoidal sleeve; it
attached medially in 91% of specimens to the ophthalmic branch
of CN V medially. Arachnoid granulations were seen along CN
VI and the inner wall of Meckel’s cave (Figures 3A and 3B). When
CN VI crossed anteriorly the posterior bend of the C4 segment,
it anastomosed with the internal carotid nerve. All specimens
had thin sympathetic fibers participating in the internal carotid
plexus, specifically on the dorsal aspect of the quadrilateral area
(Figures 2A and 2B).
Cadaveric Dissections: Endoscopic Endonasal
Perspective
Through a transmaxillary-transpterygoid approach, the vidian
nerve and lingular recess served as the landmarks to identify the
precavernous or C3-C4 transitional segment. After a durotomy,
the trigeminal ganglion was retracted laterally. Angled 45◦ and
70◦ endoscopes better visualized the paratrigeminal border and
quadrilateral area. There, sympathetic fibers and CN VI were
identified and followed posteriorly to the petrous apex. Two
patterns (types 1 and 2), with and without venous content, respec-
tively, were identified.
The paratrigeminal border’s area averaged 25.8 ± 9.6 mm2 and
23.8 ± 9.1 mm2 from the transcranial and endonasal perspec-
tives, respectively. Medially, bone removal at the lateral wall of
the sphenoid sinus allowed exposure of the corresponding medial
aspect of the precavernous segment of the ICA. This C3-C4
transitional segment was covered by periosteal dura. Continuity
of this dura followed inferiorly, with the dura of the lacerum and
petrous ICA; superiorly, with the anterior wall of the cavernous
sinus immediately underneath the posterior bend of C4; and
posteriorly, with the periosteal layer at the inner surface of the
clivus, at the level of the superior aspect of the petroclival fissure
and inferior petrosal sinus. Considering the relationship of the
C3-C4 transitional segment with the clivus, we referred to its
medial aspect as paraclival (Figures 4A-4E).
Neuroradiological and Histological Study
Correlation of the types 1 and 2 venous patterns seen in
cadaveric dissections and CT scans was confirmed with stereo-
tactic navigation. With CT and MR images, we analyzed the
relationships between the cavernous sinus, Meckel’s cave, and
ICA. Paratrigeminal and paraclival aspects of the proposed C3-
C4 transitional segment were identified (Figures 5A and 5B).
In the 3 coronal histological sections, the upper limit of the
precavernous segment was represented by the cavernous sinus
origin at the superior aspect of the petroclival fissure. The inferior
limit consisted of the petrolingual ligament, between the lingula
(lower aspect of the carotid sulcus) and anterior process of
the petrous bone. No venous structures appeared to connect
OPERATIVE NEUROSURGERY
C3-C4 TRANSITIONAL SEGMENT OF THE INTERNAL CAROTID ARTERY
the cavernous sinus to the posterior venous confluence on the
paratrigeminal border of the precavernous ICA (Figures 5C-5E).
DISCUSSION
By integration of both transcranial and endonasal anatomical
perspectives, we reconciled various ICA nomenclatures and estab-
lished a circumferential anatomical correlation of the contro-
versial paraclival ICA with its surrounding structures. Our
anatomical, histological, and radiographic analyses identified a
distinct precavernous segment of the ICA. Seen in a 360◦ view,
this C3-C4 transitional segment represented the juncture of 2
complementary borders, the paraclival and paratrigeminal. This
finding appears to clarify the controversies around the paraclival
ICA and support the concept of a safe “front door” for lesions
that involve Meckel’s cave, cavernous sinus, and petrous apex.
Given that a transcranial approach to that transitional segment
is seldom performed or rarely exposed, the value of our study was
to reexamine and redefine its boundaries and provide practical
relevance for endonasal endoscopic surgery in that region where
that carotid segment (loosely called “paraclival”) has been poorly
defined. The transcranial perspective may have valuable implica-
tions to allow better interpretation of cerebral angiograms for the
study of dural arteriovenous malformations and their treatment.
Transcranial Perspective to ICA Segmentation:
Controversies Concerning the Lacerum Segment
Since Vesalius’ illustrations and Willis’ earliest classification
schemas,31,32 the ICA has been the subject of anatomical
dissertations. Subsequent schemas were proposed, including our
1996 nomenclature that defined a new lacerum (C3) segment,
which was surgically applicable and followed blood flow in an
anterograde fashion. This C3 segment extended from the postero-
lateral aspect of the foramen lacerum to the superior border of
the petrolingual ligament, immediately caudal to the origin of the
cavernous (C4) segment of the ICA (Figure 1).6
Subsequently, the anatomy of the “enigmatic” foramen lacerum
was redefined, with the end of the carotid canal identified at
the petrolingual ligament itself.9 Specifically, the vertical portion
of C3 appeared to run above the foramen lacerum into the
lacerum portion of the carotid canal.33 This concept of a
new lacerum segment was initially criticized by some authors
who considered both the lacerum and petrous segments to be
components of the petrous ICA.14,15 As a result, other terms
emerged to describe this segment, including trigeminal and
paragangliar.9,11
Endoscopic Perspective to ICA Segmentation:
Controversies Concerning the Paraclival ICA
With the increasing popularity of endonasal endoscopic proce-
dures for skull base surgery, investigators reconsidered the ICA
nomenclature related to this perspective.1-3,5,17,30,34 In referring
to the vertical cavernous segment as paraclival, Kassam et al30
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FIGURE 4. Endoscopic-endonasal perspective of C3-C4 transitional area (green dashes). A, After a transmaxillary-transpterygoid approach, dura not opened. Vidian
nerve (VN) and lingula (L) are landmarks for the C3-C4 transitional segment. B, Dura of the cavernous sinus (CS) is partially resected to show its venous content.
With medial reflection of dura, note the floor of the CS at the superior border of V2. C3-C4 transitional segment is outlined (green dashes) and trigeminal membrane
shown. C, The CS is retracted laterally to expose the paratrigeminal border of the C3-C4 transitional segment devoid of veins (type 2). C3-C4 transitional segment
is highlighted (green dashes). D, Detailed schema and magnification of the quadrilateral area occupied by veins (type 1). E, Detailed schema and magnification of
the quadrilateral area devoid of veins (type 2). OCR, opticocarotid recess; ICN, internal carotid nerve; PA, petrous apex; MC, Meckel’s cave. Printed with permission
from Mayfield Clinic.

considered it the medial border of the quadrangular “door” to
Meckel’s cave. Its boundaries were defined by CN VI superiorly,
the lacerum ICA inferiorly, the paraclival ICA medially, and
V2 laterally. This nomenclature was subsequently adopted by
others.5,30
In another study, Labib et al2 included both the lacerum
and posterior ascending cavernous segments as components of
the paraclival ICA. Their schema divided the paraclival ICA by
an imaginary horizontal line, at the level of the lingular recess,
into an upper intracavernous paraclival and lower extracavernous
paraclival portion. In agreement, Alikhani et al35 correlated the
endonasal paraclival segment to both the transcranial lacerum
and posterior ascending cavernous segments. Their method was
simple and direct. However, we caution that the angulation
of the aneurysm clips placed to identify the borders of the
paraclival ICA transcranially and endonasally may be neither an
objective nor reproducible finding. Similarly, Alfieri and Jho1
divided the paraclival ICA into an inferior (lacerum) and superior
(trigeminal) portion.
Precavernous or C3-C4 Transitional Segment and Its
Clinical Implications
In our earlier work, we adapted our microsurgical segmentation
of the ICA to the endonasal endoscopic approach. In these cases,
the C3-C4 bend was used to identify the upper border of C3
because the petrolingual ligament was not visible from a median
endonasal endoscopic approach.3,34
Integrating the open transcranial and endoscopic vantage
points, we could observe the ICA from a circumferential 360◦
perspective. By following its anatomic course and relationships as
it traversed the lacerum portion of the carotid canal ascending
into the cavernous sinus, we identified a distinct, wedge-shaped
segment previously unrecognized that we named the precavernous
or C3-C4 transitional segment.
The consistently observed trigeminal membrane, together with
the petrolingual ligament, bordered a quadrilateral area at the
lateral aspect of the posterior ascending C4. This represented
the paratrigeminal border of the precavernous segment that
could be identified both transcranially and endonasally. As the

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 C3-C4 TRANSITIONAL SEGMENT OF THE INTERNAL CAROTID ARTERY

FIGURE 5. Segmentation of the internal carotid artery (ICA), featuring the new precavernous or C3-C4 transitional segment. A, Neuroradiological sections showing
relationship of this segment with the clivus medially and Meckel’s cave (MC) laterally. B-D, Coronal histological sections. B, Cut at the level of the anterior process of
the petrous apex (APP), representing the posterior insertion of the petrolingual ligament (PLL). Section shows lacerum (C3) segment of the ICA. C, Cut at the level of
the petroclival fissure (PCF); lingula is not visible. Section showing beginning of the C3-C4 transitional segment with its paraclival and paratrigeminal borders. D,
Cut at the base of the lingula (L) representing the anterior insertion of the PLL. Section shows the C3-C4 transitional segment and part of the posterior bend of C4.
Printed with permission from Mayfield Clinic.

paraclival border of the precavernous segment of the ICA, we
referred only to the medial aspect of the posterior ascending
C4 identified endonasally, in agreement with Fortes et al5 and
Kassam et al.30
The precavernous (C3-C4 transitional) segment is reminiscent
of the clinoidal (C5) segment found between the proximal and
distal dural rings. At the entrance and exit of the cavernous sinus,
these wedge-shaped areas represented distinct extracavernous
transitional segments. Therefore, we speculate that an “incom-
petent” trigeminal membrane at the entrance of the cavernous
sinus may allow the extension of its venous content over the
paratrigeminal border of the precavernous segment. An identical
feature described at the exit of the cavernous sinus over the
clinoidal segment was associated with an “incompetent” proximal
dural ring.
Although the surgical value of a transcranial access to the C3-
C4 transitional segment is unclear, it has practical implications
for endoscopy. Anteromedial mobilization of V3 affords limited
exposure of its paratrigeminal border. For example, the intradural
transtrigeminal approach (between V1 and V2 or V2 and V3)
poses high risk of injuring the sympathetic fibers and/or CNs IV
through VI.19,25,26,36-46 Conversely, endonasal surgical relevance
of this segment relates to its paratrigeminal or lateral side for
the middle fossa (Meckel’s cave) approach and its paraclival or
medial side for medial petrous apex approaches. For instance,
accessing the medial petrous apex for chordoma removal or petro-
clival meningiomas requires full exposure and medial-to-lateral
mobilization of the C3-C4 transitional ICA segment, which is
anchored inferiorly at the foramen lacerum.2,30,47
In most of our specimens, the histological, anatomical, and
neuroradiological analyses demonstrated the absence of venous
structures at the paratrigeminal border of the precavernous
segment. Like others’ findings, the venous extension of the
cavernous sinus on its paraclival border is not common.48
Therefore, the denuded paratrigeminal border of the precav-
ernous ICA can provide a relatively safe access route for the

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MARCATI ET AL
endonasal endoscopic “front door” trajectory as was proposed by
Kassam et al. Adequate preoperative planning, CT angiography,
venography, and stereotactic navigation should be considered
mandatory for a safe approach to this area.
CONCLUSION
In this integrated anatomical, histological, and radiographic
analysis, our findings based on reexamination of the precav-
ernous or C3-C4 transitional segment of the ICA has practical
implications for endonasal endoscopic surgery. In our 360◦ view
of the juncture of 2 complementary borders, the paraclival
and paratrigeminal, this new segment appears to clarify actual
controversies around the paraclival ICA. It further supports the
concept of a safe “front door” for lesions involving Meckel’s cave,
cavernous sinus, and petrous apex.
Disclosure
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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