Case report
Percutaneous closure of a giant left ventricular wall pseudoaneurysm: Anterograde approach with a double snare technique
Encerramento percutâneo de um volumoso pseudoaneurisma do ventrículo esquerdo: abordagem anterógrada utilizando a técnica de duplo snare
Marta Afonso Nogueira
, António Fiarresga, Lídia de Sousa, Ana Agapito, Ana Galrinho, Rui Cruz Ferreira
Corresponding author
Department of Cardiology, Santa Marta Hospital, Lisbon, Portugal
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"identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "António" "apellidos" => "Fiarresga" ] 2 => array:2 [ "nombre" => "Lídia" "apellidos" => "de Sousa" ] 3 => array:2 [ "nombre" => "Ana" "apellidos" => "Agapito" ] 4 => array:2 [ "nombre" => "Ana" "apellidos" => "Galrinho" ] 5 => array:2 [ "nombre" => "Rui" "apellidos" => "Cruz Ferreira" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Cardiology, Santa Marta Hospital, Lisbon, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Encerramento percutâneo de um volumoso pseudoaneurisma do ventrículo esquerdo: abordagem anterógrada utilizando a técnica de duplo <span class="elsevierStyleItalic">snare</span>" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1426 "Ancho" => 1585 "Tamanyo" => 127106 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Computed tomography angiography showing a large left ventricular wall pseudoaneurysm with a defect in the ventricular wall.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Left ventricular (LV) pseudoaneurysm is a rare complication of acute myocardial infarction, cardiac surgery, trauma or infection.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The risk of rupture of a LV pseudoaneurysm, according to the literature, ranges from 30% to 45% during the first year.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Open surgical repair has been accepted as the standard of care, but it is associated with significant morbidity and mortality, related to anatomic complexity and patient characteristics, particularly older age and comorbidities.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1,2</span></a> Consequently, percutaneous closure has been described as a viable alternative to surgical intervention in high-risk patients.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1–7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In this regard, we present the case of a patient at high surgical risk in which it was necessary to use a double snare technique for percutaneous closure of a giant LV pseudoaneurysm.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0025" class="elsevierStylePara elsevierViewall">An 81-year-old woman, with a history of surgical correction of an interventricular septal defect following anterior myocardial infarction (four years previously) and chronic obstructive pulmonary disease, complained of atypical thoracic pain. The physical examination revealed a grade II/VI systolic murmur, loudest at the apex.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The diagnostic investigation, including computed tomography (CT) angiography (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>) and left ventricular angiography (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>), showed a large (52 mm×48 mm×55 mm) left ventricular wall pseudoaneurysm and a 21 mm×24 mm defect in the ventricular wall.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Since the patient was considered to have a high risk of mortality, she was not accepted for surgery and was consequently referred to percutaneous treatment, which was performed under transesophageal echocardiographic guidance.</p><p id="par0040" class="elsevierStylePara elsevierViewall">An initial attempt at a retrograde approach (through the left femoral artery) was unsuccessful because the delivery sheaths were too small, so an anterograde approach was adopted. A 260 cm 0.35″ hydrophilic wire (ZIPwire<span class="elsevierStyleSup">®</span>) was positioned retrogradely in the left atrium with an Amplatz left diagnostic catheter from the left femoral artery. After transseptal puncture through the right femoral vein, this wire was snared and brought into the inferior vena cava (Video 1). From the right jugular vein, the wire was then snared a second time and exteriorized (Videos 2 and 3), creating an arteriovenous loop (left femoral artery – right jugular vein).</p><p id="par0045" class="elsevierStylePara elsevierViewall">A 10F Amplatzer<span class="elsevierStyleSup">®</span> TorqueVue<span class="elsevierStyleSup">®</span> delivery sheath was then advanced from the right jugular vein, crossing both the interatrial septum and mitral valve and subsequently entering the left ventricle.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The pseudoaneurysm was engaged with a standard 0.035″ wire and a left mammary diagnostic catheter inside the delivery sheath that successfully entered its cavity.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Finally, a 24 mm Amplatzer<span class="elsevierStyleSup">®</span> ASD occluder was implanted in a stable position, closing the free wall defect (Videos 4-7).</p><p id="par0060" class="elsevierStylePara elsevierViewall">At six-month follow-up, the patient remains asymptomatic, with no adverse events, and the device is in the appropriate position confirmed by CT (<a class="elsevierStyleCrossRefs" href="#fig0015">Figures 3 and 4</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion and Conclusion</span><p id="par0065" class="elsevierStylePara elsevierViewall">This case report illustrates a rare complication of cardiac surgery, namely an LV pseudoaneurysm.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Considering the patient's high surgical risk, she was treated by percutaneous closure of the pseudoaneurysm, as described in the literature.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1–7</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Since a retrograde approach (via the left femoral artery) was not possible due to the fact that the delivery sheaths were too small, an anterograde approach by transseptal puncture (through the right femoral vein) with a double snare technique (the first snare from the left atrium to the inferior vena cava and the second snare to the right jugular vein) was chosen. This had the additional advantage of creating a direct non-tortuous path to the left ventricular chamber, facilitating sheath maneuvers and advancing and positioning of the device.</p><p id="par0080" class="elsevierStylePara elsevierViewall">This technique enabled successful implantation of an Amplatzer<span class="elsevierStyleSup">®</span> ASD device to close the free wall defect.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Despite all the technical difficulties, percutaneous closure of the ventricular wall defect with a double snare technique had both imaging and clinical success, rendering the patient asymptomatic and event-free.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Consequently, this result confirms that this procedure is an effective alternative to surgery in patients at high surgical risk.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of human and animal subjects</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres825314" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec821802" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres825315" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec821801" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion and Conclusion" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Right to privacy and informed consent" ] ] ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-07-02" "fechaAceptado" => "2015-11-21" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec821802" "palabras" => array:4 [ 0 => "Left ventricle" 1 => "Pseudoaneurysm" 2 => "Percutaneous closure" 3 => "Double snare" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec821801" "palabras" => array:4 [ 0 => "Ventrículo esquerdo" 1 => "Pseudoaneurisma" 2 => "Encerramento percutâneo" 3 => "Duplo <span class="elsevierStyleItalic">snare</span>" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Left ventricular pseudoaneurysm is a rare complication of acute myocardial infarction, cardiac surgery, trauma or infection.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Since surgical repair is associated with high morbidity and mortality, percutaneous closure has been described as an alternative.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">In this regard, we present a case in which a symptomatic large left ventricular pseudoaneurysm was treated by percutaneous closure due to the patient's high surgical risk, using a double snare technique.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Despite the technical difficulties, this procedure had a good final result followed by clinical success, confirming that this procedure is an effective alternative to surgery in high-risk patients.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">O pseudoaneurisma do ventrículo esquerdo consiste numa complicação rara após enfarte agudo do miocárdio, cirurgia cardíaca, trauma ou infeção.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Dado que a sua correção cirúrgica se associa a uma elevada morbi-mortalidade, o encerramento percutâneo tem sido descrito como uma possível alternativa.</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Neste contexto, apresentamos um caso de um volumoso pseudoaneurisma do ventrículo esquerdo, o qual fora encerrado percutaneamente, utilizando uma técnica de duplo <span class="elsevierStyleItalic">snare</span>, devido ao elevado risco cirúrgico da doente.</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Apesar de algumas dificuldades técnicas, este procedimento teve um bom resultado final, com sucesso clínico a longo prazo, confirmando que o encerramento percutâneo constitui uma alternativa efetiva à cirurgia, em doentes de alto risco operatório.</p></span>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0120" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia><elsevierMultimedia ident="upi0010"></elsevierMultimedia><elsevierMultimedia ident="upi0015"></elsevierMultimedia><elsevierMultimedia ident="upi0020"></elsevierMultimedia><elsevierMultimedia ident="upi0025"></elsevierMultimedia><elsevierMultimedia ident="upi0030"></elsevierMultimedia><elsevierMultimedia ident="upi0035"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary material" "identificador" => "sec0050" ] ] ] ] "multimedia" => array:11 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1426 "Ancho" => 1585 "Tamanyo" => 127106 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Computed tomography angiography showing a large left ventricular wall pseudoaneurysm with a defect in the ventricular wall.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1603 "Ancho" => 1651 "Tamanyo" => 291126 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Left ventricular angiography showing a large left ventricular wall pseudoaneurysm with a defect in the ventricular wall.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1588 "Ancho" => 1585 "Tamanyo" => 190322 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Computed tomography angiography (coronal view) showing the Amplatzer<span class="elsevierStyleSup">®</span> ASD device six months after the procedure.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1432 "Ancho" => 1585 "Tamanyo" => 217861 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Computed tomography angiography (axial view) showing the Amplatzer<span class="elsevierStyleSup">®</span> ASD device six months after the procedure.</p>" ] ] 4 => array:6 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 164875 "Video" => array:2 [ "mp4" => array:2 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" ] "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Video 1</span> Anterograde approach by transseptal puncture (right femoral vein) with the first snare from left atrium to inferior vena cava.</p>" ] ] 5 => array:6 [ "identificador" => "upi0010" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc2.mp4" "ficheroTamanyo" => 1097383 "Video" => array:2 [ "mp4" => array:2 [ "fichero" => "mmc2.m4v" "poster" => "mmc2.jpg" ] "flv" => array:5 [ "fichero" => "mmc2.flv" "poster" => "mmc2.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Videos 2 and 3</span> Sequential steps of the second snare from left atrium to right jugular vein.</p>" ] ] 6 => array:5 [ "identificador" => "upi0015" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc3.mp4" "ficheroTamanyo" => 1495236 "Video" => array:2 [ "mp4" => array:2 [ "fichero" => "mmc3.m4v" "poster" => "mmc3.jpg" ] "flv" => array:5 [ "fichero" => "mmc3.flv" "poster" => "mmc3.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] 7 => array:6 [ "identificador" => "upi0020" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc4.mp4" "ficheroTamanyo" => 616952 "Video" => array:2 [ "mp4" => array:2 [ "fichero" => "mmc4.m4v" "poster" => "mmc4.jpg" ] "flv" => array:5 [ "fichero" => "mmc4.flv" "poster" => "mmc4.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Video 4</span> Deployment of the left side disk of the Amplatzer<span class="elsevierStyleSup">®</span> ASD device.</p>" ] ] 8 => array:6 [ "identificador" => "upi0025" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc5.mp4" "ficheroTamanyo" => 1277141 "Video" => array:2 [ "mp4" => array:2 [ "fichero" => "mmc5.m4v" "poster" => "mmc5.jpg" ] "flv" => array:5 [ "fichero" => "mmc5.flv" "poster" => "mmc5.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Video 5</span> Contrast injection to test the Amplatzer<span class="elsevierStyleSup">®</span> ASD device function.</p>" ] ] 9 => array:6 [ "identificador" => "upi0030" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc6.mp4" "ficheroTamanyo" => 721348 "Video" => array:2 [ "mp4" => array:2 [ "fichero" => "mmc6.m4v" "poster" => "mmc6.jpg" ] "flv" => array:5 [ "fichero" => "mmc6.flv" "poster" => "mmc6.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Video 6</span> Deployment of the right side disk of the Amplatzer<span class="elsevierStyleSup">®</span> ASD device.</p>" ] ] 10 => array:6 [ "identificador" => "upi0035" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc7.mp4" "ficheroTamanyo" => 1968761 "Video" => array:2 [ "mp4" => array:2 [ "fichero" => "mmc7.m4v" "poster" => "mmc7.jpg" ] "flv" => array:5 [ "fichero" => "mmc7.flv" "poster" => "mmc7.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Video 7</span> Amplatzer<span class="elsevierStyleSup">®</span> ASD in its final position after deployment.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 10 | 17 |
| 2024 October | 29 | 31 | 60 |
| 2024 September | 33 | 22 | 55 |
| 2024 August | 43 | 32 | 75 |
| 2024 July | 29 | 27 | 56 |
| 2024 June | 30 | 17 | 47 |
| 2024 May | 42 | 31 | 73 |
| 2024 April | 30 | 21 | 51 |
| 2024 March | 29 | 29 | 58 |
| 2024 February | 19 | 38 | 57 |
| 2024 January | 26 | 38 | 64 |
| 2023 December | 25 | 26 | 51 |
| 2023 November | 35 | 22 | 57 |
| 2023 October | 16 | 17 | 33 |
| 2023 September | 17 | 19 | 36 |
| 2023 August | 25 | 17 | 42 |
| 2023 July | 25 | 10 | 35 |
| 2023 June | 13 | 12 | 25 |
| 2023 May | 35 | 17 | 52 |
| 2023 April | 19 | 6 | 25 |
| 2023 March | 23 | 14 | 37 |
| 2023 February | 26 | 23 | 49 |
| 2023 January | 13 | 16 | 29 |
| 2022 December | 30 | 17 | 47 |
| 2022 November | 28 | 30 | 58 |
| 2022 October | 31 | 19 | 50 |
| 2022 September | 15 | 18 | 33 |
| 2022 August | 33 | 35 | 68 |
| 2022 July | 26 | 32 | 58 |
| 2022 June | 20 | 16 | 36 |
| 2022 May | 24 | 38 | 62 |
| 2022 April | 18 | 22 | 40 |
| 2022 March | 22 | 30 | 52 |
| 2022 February | 15 | 22 | 37 |
| 2022 January | 18 | 21 | 39 |
| 2021 December | 14 | 31 | 45 |
| 2021 November | 32 | 37 | 69 |
| 2021 October | 27 | 37 | 64 |
| 2021 September | 27 | 32 | 59 |
| 2021 August | 23 | 34 | 57 |
| 2021 July | 15 | 25 | 40 |
| 2021 June | 21 | 22 | 43 |
| 2021 May | 23 | 37 | 60 |
| 2021 April | 43 | 42 | 85 |
| 2021 March | 40 | 17 | 57 |
| 2021 February | 34 | 28 | 62 |
| 2021 January | 24 | 13 | 37 |
| 2020 December | 44 | 16 | 60 |
| 2020 November | 30 | 20 | 50 |
| 2020 October | 24 | 20 | 44 |
| 2020 September | 40 | 13 | 53 |
| 2020 August | 27 | 12 | 39 |
| 2020 July | 47 | 15 | 62 |
| 2020 June | 28 | 15 | 43 |
| 2020 May | 38 | 15 | 53 |
| 2020 April | 47 | 17 | 64 |
| 2020 March | 38 | 9 | 47 |
| 2020 February | 52 | 23 | 75 |
| 2020 January | 39 | 9 | 48 |
| 2019 December | 27 | 11 | 38 |
| 2019 November | 32 | 8 | 40 |
| 2019 October | 33 | 8 | 41 |
| 2019 September | 24 | 9 | 33 |
| 2019 August | 32 | 11 | 43 |
| 2019 July | 31 | 7 | 38 |
| 2019 June | 28 | 15 | 43 |
| 2019 May | 33 | 5 | 38 |
| 2019 April | 27 | 17 | 44 |
| 2019 March | 136 | 12 | 148 |
| 2019 February | 98 | 9 | 107 |
| 2019 January | 85 | 7 | 92 |
| 2018 December | 51 | 13 | 64 |
| 2018 November | 52 | 5 | 57 |
| 2018 October | 144 | 16 | 160 |
| 2018 September | 38 | 12 | 50 |
| 2018 August | 33 | 10 | 43 |
| 2018 July | 15 | 7 | 22 |
| 2018 June | 26 | 7 | 33 |
| 2018 May | 38 | 9 | 47 |
| 2018 April | 41 | 8 | 49 |
| 2018 March | 57 | 4 | 61 |
| 2018 February | 25 | 5 | 30 |
| 2018 January | 50 | 6 | 56 |
| 2017 December | 55 | 3 | 58 |
| 2017 November | 24 | 4 | 28 |
| 2017 October | 31 | 12 | 43 |
| 2017 September | 26 | 12 | 38 |
| 2017 August | 22 | 15 | 37 |
| 2017 July | 24 | 12 | 36 |
| 2017 June | 22 | 13 | 35 |
| 2017 May | 38 | 9 | 47 |
| 2017 April | 15 | 6 | 21 |
| 2017 March | 28 | 2 | 30 |
| 2017 February | 32 | 2 | 34 |
| 2017 January | 16 | 2 | 18 |
| 2016 December | 31 | 6 | 37 |
| 2016 November | 21 | 4 | 25 |
| 2016 October | 15 | 10 | 25 |
| 2016 September | 35 | 6 | 41 |
| 2016 August | 19 | 1 | 20 |
| 2016 July | 3 | 0 | 3 |
Show all
