AUCTORES
Globalize your Research
Research Article
*Corresponding Author: Charan Reddy, Consultant, Department of Clinical & Interventional Cardiology, Apollo Hospitals, Navi Mumbai, India.
Citation: Rahul.R.Gupta, K.V Charan Reddy, M.G Pillai, Shantesh Kaushik, Haridas Munde. (2022). Challenges to Transcatheter Aortic Valve Implantation through Femoral Access in Elderly with Peripheral Artery Disease: A Case Report. J. Clinical Cardiology and Cardiovascular Interventions, 5(3); Doi:10.31579/2641-0419/248
Copyright: © 2022 Charan Reddy, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 26 November 2021 | Accepted: 10 January 2022 | Published: 19 January 2022
Keywords: transfemoral access; multiple co-morbidities; iliofemoral tortuosity or calcification; carotid approach
Transfemoral (TF) access is the safest and the most preferred option for Transcatheter Aortic Valve Implantation (TAVI). However, femoral access is often difficult in a significant number of patients due to inadequate vessel diameter, iliofemoral tortuosity or calcification. Other access routes for TAVI include transapical, transaortic, subclavian, axillary, carotid and transcaval. Choice of vascular access requires both extensive preoperative work-up and adaptive intraprocedural planning by the heart team. Here, we present a challenging case of TAVI in an elderly patient with peripheral artery disease, which required a change in the vascular access site from femoral to carotid artery, midway during procedure, as a strategy to prevent untoward vascular complications. This case also highlights the limitations of current hardware and technologies in negotiating tricky situations.
The concept of transcatheter insertion of heart valves as a treatment option for valvular heart disease was first reported in mid 1960s [1]. It was not until 2000 that the first implantation of a transcatheter pulmonic valve in human was realized [2]. Cribier et al [3] described the first percutaneous transcatheter implantation of aortic valve prosthesis in a 57 year-old patient with calcific aortic stenosis. For a long time the most preferred vascular access for TAVI was transfemoral (TF). However, 10% -15% of TAVI candidates do not have a favorable iliofemoral anatomy for safe transfemoral access [4]. As the technology advances and operator expertise improved, other routes of vascular access in TAVI have emerged. They include transapical, transaortic, subclavian, axillary, transcaval and carotid artery. Lately, transcarotid (TC) is evolving to be the most preferred route in patients in whom TF access is not feasible.
Trans-carotid TAVI was first reported by French group, Modine et al [5] in 2010. Trans-carotid TAVI appears to be safe when compared to other transthoracic access sites with reduced mortality and stroke risk [6]. However, this procedure is not without its inherent risks. The site of access, type, size, and implant position of the transcatheter valve has to be optimized for individual patients with knowledge of echocardiographic and radiographic measurements along with valve haemodynamics and structural anatomy of the vessels. A well planned procedure can prevent peripheral limb ischaemia, valve malposition, coronary occlusion, device underexpansion, and residual aortic stenosis.
Here, we describe a TAVI procedure in an elderly individual with multiple co-morbidities and peripheral artery disease, which necessitated a change in our approach, when encountered with vascular access challenges. This case also highlights various complications that can occur during a TAVI with emphases on planning and flexibility in the thought process, needed to safely complete the procedure.
A 83-year-old female presented with dyspnea on exertion and orthopnea for the last two months. She gives a past history of Diabetes, Hypertension and Coronary artery bypass graft (CABG) surgery done 10 years back with a left internal mammary artery-left anterior descending (LIMA-LAD) and single vessel bypass-right coronary artery (SVG-RCA) grafts. She also gives history of uterine malignancy with abdominal radiation followed by surgery done 30 years back.
Haemoglobin content was 11 gm/dL. Serum creatinine level was 0.94 mg/dL. TTE showed normal Left atrium (LA) and left ventricle (LV) size. LV ejection fraction was 50% with mild hypokinesia of inferior myocardial wall with mild mitral and tricuspid regurgitation. The aortic valve was tricommmisural, stenosed, calcified with indexed valve area of 0.6 cm2/m2. Peak and mean gradients across the aortic valve were 87 mm and 50 mm of Hg respectively. There was no significant valve regurgitation. There was no PAH.
Computed Tomography (CT) based aortogram showed moderate calcification in the aortic valve, ascending arch and descending aorta. The following diameters were measured on CT scan: Annulus (internal diameter) min/max; 17.6/25.1 mm, effective 22.2/22.9 mm (area/ circumference), mid-sinus 28 mm, sino-tubular junction 27.1 mm, height of the left coronary ostium 12.1 mm and to the right coronary ostium 16 mm (Figure-1a-c).
Both common iliac (8.3 mm) and right femoral artery (6.5 mm) diameters were adequate. However, there was a short calcified, circumferential narrowing in the right external iliac artery where the diameter of the vessel was only 3.6 mm. There was a tortuous bend in the left external iliac artery which was also diffusely calcified (4.7mm) (Figure-2a, b).
CT-coronary angiography showed a patent LIMA-LAD and SVG-PDA grafts. It also showed a patent circle of willis with 80% stenosis in the right internal carotid artery. In view of high surgical risk (STS score of 12%) and multiple comorbidities, a TAVI procedure was planned.
During TAVI procedure under local anaesthesia, a 7 French (Fr) sheath was inserted through the right femoral artery (RFA) and two proglide sutures placed in position. The left femoral artery (LFA) pulsations could not be felt and puncture taken did not yield a good blood flow. Hence, a right radial artery was punctured and a 5Fr sheath inserted. A 5 Fr pigtail was advanced into the non-coronary cusp of the aortic sinus using the radial approach. The 7Fr sheath in the RFA was later changed to a 10Fr sheath. However, it could not negotiate the focal narrowing in the external iliac artery (EIA). Shock wave intravascular lithotripsy (IVL) was planned. A designated 300 pulses were given with 7mm x 60 mm IVL balloon catheter at the site of circumferential calcified lesion in the right EIA. Attempts were made to dilate the stenosis, first with 6 mm x 40 mm and later by 8 mm. x 40 mm.
ARMADA balloon was without much success. The lesion site was then stented with a 8 x 60 mm FLUENCY vascular graft. With the help of 14Fr cook sheath, the calcified native aortic valve was dilated with a 18 mm Z-MED II balloon. Inspite of all our attempts the EVOLUT R bioprosthetic valve could not negotiate the stented segment in the right EIA probably due to a calcified spicule or spur at lesion site. As the last measure, the in-line sheath of the EVOLUT R valve was kept proximal to the stented EIA and attempt was made to cross the lower profile EVOLUT R valve across it. This was also unsuccessful and the patient started complaining of severe pain in the right lower leg probably due to vascular insufficiency caused by prolonged procedure.
After consultation with the heart team, a new strategy was devised. Under general anaesthesia and mechanical ventilatory support, the right common carotid artery was exposed with a 4 cm cervical incision and purse string sutures placed. The vessel was sequentially dilated with 7Fr, 10Fr and finally with a 14Fr sheath. A 26 mm EVOLUT R aortic bioprosthetic valve was quickly deployed during rapid right ventricular pacing. The total procedural time was about 7 minutes. Post-deployment angiography, transesophageal echocardiography and aortogram confirmed good valve placement with only a mild aortic paravalvar leak and reduction in trans-aortic gradient to a mean of 4 mm of Hg (Figure.3a-g).
Patient recovered well and was discharged three days later without any permanent lower limb vascular complications. Left subclavian access was not considered due a patent left internal mammary artery (LIMA) graft and the risk of ischemia due to the presence of an occlusive sheath in the subclavian artery. Other transthoracic access sites were not considered due to their invasiveness and their supposedly inferiority over femoral artery access. This case illustrates the importance of planning and anticipation with constant evolution in strategy when facing some seemingly insurmountable obstacles.
Advanced age, female sex, high preoperative New York Heart Association functional class, left ventricular dysfunction, renal failure, pulmonary disease, cognitive impairment, urgency of operation and technical difficulties caused by chest wall adhesions due to previous cardiac surgeries have been identified as predictors of higher operative risk. The development of TAVI has emerged as a lifeline for patients considered being high risk or inoperable providing both an improvement in symptoms and statistically significant mortality benefit.
Retrograde TF access is considered as the gold-standard route for TAVI as it is less invasive and has relatively lower complication rates. However, 10% to 15% of TAVI candidates do not have a favorable iliofemoral anatomy for a safe transfemoral access. The major impediment to a successful TF approach is inadequate vessel diameter, iliofemoral tortuosity or calcification. With the advent of IVL and orbital atherectomy, coupled with availability of newer low profile bioprosthetic aortic valves for implantation, many operators still prefer the age old TF approach, even in diseased peripheral arteries, as they are more experienced and confident with it.
Total of six non-TF access sites are described in the literature. These include the transapical (TA), transaortic (TAo), axillary/subclavian (SC), brachiocephalic, transcarotid (TC), and transcaval approach. No guidelines exist regarding the choice of the first-line alternative pathway if the TF access is not successful, as it is dependent on the patient’s vascular anatomy and operator experience.
However lately, TC route is slowly becoming the choice of access in those patients in whom the TF approach is not feasible or has failed. TC approach allows a direct and shorter pathway to the native aortic valve from the puncture site, with the added benefit of stable catheter delivery and improved movement precision. Several studies have suggested that the TC access might yield better periprocedural and 30-day clinical outcomes than the transthoracic route with outcomes comparable to the TF access [7, 8].
TC access is not without its risks, which include direct injury to the carotid artery, embolic events during vessel manipulation, or transient reduction in blood flow during the procedure leading to transient ischaemic attack (TIA). Hence, a thorough evaluation of atherosclerotic plaques before intervention via appropriate imaging studies (e.g., Doppler ultrasound, with exclusion of patients presenting >50
A growing number of TAVI procedures with standardized pre-procedural diagnostic algorithms and well established intra-procedural steps, has made it a simplified and safe procedure. Transfemoral access remains the most commonly used route for TAVI with low complication rates. With the advent of IVL and orbital atherectomy in the cardiologist’s armamentarium, even unyielding calcified peripheral artery lesions can now be attempted. However, an alternate access site should always be kept ready as a bail-out if TF access is unsuccessful. TC route can be a good alternative to quickly deliver the valve in such difficult cases.
This study was approved by the Ethics Committee of the Apollo Hospital, Navi Mumbai. Informed consent was obtained from the patient.
None
The authors are thankful to the patient for consenting to publish this study. The authors thank all the staff who was involved for making this study for publication.
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
My Testimonial Covering as fellowing: Lin-Show Chin. The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews.
My experience publishing in Psychology and Mental Health Care was exceptional. The peer review process was rigorous and constructive, with reviewers providing valuable insights that helped enhance the quality of our work. The editorial team was highly supportive and responsive, making the submission process smooth and efficient. The journal's commitment to high standards and academic rigor makes it a respected platform for quality research. I am grateful for the opportunity to publish in such a reputable journal.
My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.
