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Goodwill and Intangible Assets | 12 Months Ended
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Dec. 31, 2021
Goodwill and Intangible Assets Disclosure [Abstract] |
Goodwill and Intangible Assets | 5.GOODWILL AND INTANGIBLE ASSETS The changes in the carrying amount of goodwill for the years ended December 31, 2021 and 2020, are as follows (in thousands):
​ | ​ | ​ | ​ | ​ | ​ | ​
​ |  | 2021 |  | 2020
Goodwill balance at January 1 | ​ | $ | 363,533 | ​ | $ | 353,193
Effect of foreign exchange | ​ |  | (2,078) | ​ |  | 1,941
Additions and adjustments as the result of acquisitions | ​ |  | 286 | ​ |  | 8,399
Goodwill balance at December 31 | ​ | $ | 361,741 | ​ | $ | 363,533
​ Total accumulated goodwill impairment losses aggregated to $8.3 million as of December 31, 2021 and 2020. We did not have any goodwill impairments for the years ended December 31, 2021, 2020 and 2019. The total goodwill balance as of December 31, 2021 and 2020 is related to our cardiovascular segment. Other intangible assets at December 31, 2021 and 2020, consisted of the following (in thousands):
​ | ​ | ​ | ​ | ​ | ​ | ​ | ​ | ​ | ​
​ | ​ | December 31, 2021
​ | ​ | Gross Carrying | ​ | Accumulated | ​ | Net Carrying
​ |  | Amount |  | Amortization |  | Amount
Patents | ​ | $ | 26,349 | ​ | $ | (8,315) | ​ | $ | 18,034
Distribution agreements | ​ |  | 3,250 | ​ |  | (2,519) | ​ |  | 731
License agreements | ​ |  | 12,663 | ​ |  | (7,768) | ​ |  | 4,895
Trademarks | ​ |  | 30,242 | ​ |  | (15,256) | ​ |  | 14,986
Customer lists | ​ |  | 34,985 | ​ |  | (31,195) | ​ |  | 3,790
Total | ​ | $ | 107,489 | ​ | $ | (65,053) | ​ | $ | 42,436
​
​ | ​ | ​ | ​ | ​ | ​ | ​ | ​ | ​ | ​
​ | ​ | December 31, 2020
​ | ​ | Gross Carrying | ​ | Accumulated | ​ | Net Carrying
​ |  | Amount |  | Amortization |  | Amount
Patents | ​ | $ | 23,669 | ​ | $ | (6,460) | ​ | $ | 17,209
Distribution agreements | ​ |  | 3,250 | ​ |  | (2,319) | ​ |  | 931
License agreements | ​ |  | 14,453 | ​ |  | (6,647) | ​ |  | 7,806
Trademarks | ​ |  | 30,273 | ​ |  | (12,414) | ​ |  | 17,859
Customer lists | ​ |  | 35,154 | ​ |  | (29,103) | ​ |  | 6,051
Total | ​ | $ | 106,799 | ​ | $ | (56,943) | ​ | $ | 49,856
​ Aggregate amortization expense for the years ended December 31, 2021, 2020 and 2019 was $49.6 million, $58.6 million and $60.7 million, respectively. Estimated amortization expense for the developed technology and other intangible assets for the next five years consists of the following as of December 31, 2021 (in thousands):
​ | ​ | ​ | ​
Year Ending December 31, |  | Estimated Amortization Expense
2022 | ​ | $ | 48,195
2023 | ​ |  | 47,101
2024 | ​ |  | 44,165
2025 | ​ | ​ | 42,396
2026 | ​ |  | 31,843
​ During the years ended December 31, 2021, 2020 and 2019, we identified indicators of impairment associated with certain acquired intangible assets based on our qualitative assessment that carrying amounts may not be recoverable, which required us to then complete a quantitative impairment assessment. The primary indicators of impairment were planned closure and restructuring activities and uncertainty about future product development and commercialization associated with certain acquired technologies, due in part to the economic impacts of the COVID-19 pandemic in 2021 and 2020. During the year ended December 31, 2021, we recorded total impairment charges related to our intangible assets of $1.6 million for the remaining carrying value of ArraVasc license agreements. During the year ended December 31, 2020, we recorded total impairment charges related to our intangible assets of $28.7 million which included a partial impairment charge of $8.2 million of intangible assets from our acquisition of STD Pharmaceutical, a partial impairment charge of $8.0 million of intangible assets from our acquisition of certain assets from Laurane Medical S.A.S, a partial impairment charge of $4.8 million related to our license agreements with ArraVasc Limited, and other intangible asset impairments charges of $7.7 million related to intangible assets from our acquisition of certain assets from DirectACCESS Medical, LLC, in-process technology intangible assets of Sontina Medical LLC acquired in connection with our acquisition of certain divested assets from Becton, Dickinson and Company, and a customer list intangible asset from our acquisition of ITL Healthcare Pty Ltd (“ITL”). During the year ended December 31, 2019, we recorded impairment charges related to our amortizing intangible assets from our acquisitions of certain assets from Distal Access, LLC, Lazarus Medical Technologies, LLC, and Pleuratech ApS for a total of $3.3 million. The impairment charges recorded in 2021, 2020, and 2019 all pertained to our cardiovascular segment and are reflected within impairment charges in our consolidated statements of income (loss).

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