For the third quarter, Teleflex generated double-digit constant currency revenue and 27% adjusted earnings-per-share growth on a year-over-year basis despite a greater-than-expected headwind from increased COVID-19 infections due to the Delta variant.
As many investors will be aware, there were restrictions on elective surgical procedures in as many as 28 states during the third quarter.
However, as we have seen since the pandemic began, our broad-based portfolio provides a hedge in periods of increased COVID activity with more than 60% of our business, either benefiting from increased COVID-related treatments or remaining relatively insulated from disruptions due to the pandemic.
Given our year-to-date results and outlook for the fourth quarter, we are reducing our constant currency revenue growth to a range of 8% to 9% from 8.5% to 9.75% previously.
However, given strength in our operating margin performance and improvements in our balance sheet, we are increasing earnings per share guidance to a range of $13.15 to $13.35 versus our previous range of $12.90 to $13.10, implying growth of 23% to 25% year-over-year.
Third quarter revenue was $700.3 million, an increase of 10.3% year-over-year on a constant currency basis.
In comparison to the comparable period in 2019, third quarter revenue increased 5.8% and demonstrated accelerating quarter-over-quarter growth in our Vascular, OEM and Anesthesia businesses, which offset sequential deceleration in areas of the business more exposed to the surge in COVID-19, including Interventional Urology, Interventional and Surgical.
Third quarter adjusted earnings per share of $3.51 increased 26.7% year-over-year and exceeded our internal expectations.
Americas revenues were $417.3 million in the third quarter, which represents 10.9% growth year-over-year.
EMEA revenues of $143.9 million increased 3.6% year-over-year with Interventional and Vascular products leading the growth.
Revenues were $75 million, increasing 6.3% year-over-year.
Japan was strong in the third quarter, growing north of 30%, but was partially offset by the impact of COVID-19 in Southeast Asia.
Third quarter revenue increased 8.5% to $175.5 million.
Our PICC portfolio continues to perform well with 10% growth year-over-year.
Intraosseous was also solid in the third quarter with growth up 12% year-over-year.
Third quarter revenue was $104.3 million, up 10.4% year-over-year.
MANTA momentum remains strong, both in the U.S. and in international markets, with over 80% global growth year-over-year in the third quarter.
Given the year-to-date performance for MANTA, we are confident in our ability to achieve 8% share in 2021 of the $200 million to $300 million global market opportunity.
Third quarter revenue was $97.1 million, up 26.6% year-over-year.
Products from Z-Medica contributed roughly 85% of the growth as the business continues to track to our $60 million to $70 million revenue expectations for 2021, partly offset by lower sales of tracheostomy products.
In our Surgical business, revenue was $92.8 million, representing 10.9% growth year-over-year.
Urology, third quarter revenue was $83.1 million, an increase of 1.5% year-over-year and below our expectations at the time of the quarter two conference call.
We continue to target patients that are suffering from BPH and have either failed or are not satisfied with drug therapy, a population that is estimated to be 1.5 million men in the United States.
When taking into account the softer-than-expected UroLift revenues during the third quarter and our recalibration of the fourth quarter, we are reducing our 2021 Interventional Urology revenue growth guidance to 15% to 17% year-over-year.
Our OEM business, which accounts for roughly 9% of total sales increased 29.4% year-over-year to $64.1 million in the third quarter.
And finally, our other category, which consists of respiratory products that were not included in the divestiture to Medline, manufacturing service agreement revenues and Urology Care products declined by 4.3% to $83.4 million year-over-year.
In the third quarter, we trained 124 urologists.
Interest in UroLift remains strong, and with over 355 doctors trained in the year-to-date, we remain positioned to meet our training target of 450 to 500 urologists in 2021.
We recently won a bronze award for best new branded television campaign from DTC perspective, which is a meaningful accomplishment given 13 finalists.
Moving to UroLift 2.
UroLift two remains an important margin driver as we remain positioned to generate 400 basis points of UroLift gross margin expansion as the revenue base is fully converted.
Japan remains an important long-term opportunity for UroLift with a $2 billion TAM and we are excited for our upcoming launch.
We continue to expect our sales in the region to ramp in a similar fashion to the U.S. in a market that is 1/3 the size.
The proposed rule would negatively impact reimbursement for roughly 600 procedures performed in the doctor's office across a broad range of surgical specialties with a disproportionate hit to device-heavy procedures such as UroLift.
We are pleased with the performance of our recently launched Arrow ErgoPack kit, which contributed over $5 million in revenue during the third quarter.
We intend to file a 510(k) for expanded use of QuikClot Control+ following the completion of the study.
For the third quarter, adjusted gross margin totaled 59.5%, a 230 basis point increase versus the prior year period.
Third quarter adjusted operating margin was 28.5% or a 340 basis point year-over-year increase, driven by the gross margin improvement as well as disciplined expense management and partially offset by planned investment in the business.
For the quarter, net interest expense totaled $11.8 million, a decrease from $16.4 million in the prior year period.
Our adjusted tax rate for the third quarter of 2021 was 11.3% compared to 7% in the prior year period.
At the bottom line, third quarter adjusted earnings per share increased 26.7% to $3.51.
Included in this result is an estimated favorable impact from foreign exchange of approximately $0.13 per share versus prior year.
Year-to-date, cash flow from operations totaled $450.5 million compared to $241.5 million in the prior year period and represented a year-over-year increase of $209 million.
At the end of the third quarter 2021, our cash balance was $481.2 million versus $375.9 million at the end of the fourth quarter of 2020.
As noted previously, we made a $259 million payment in July against our revolving credit facility, using funds primarily generated from the initial close of the respiratory business divestiture.
At the end of the third quarter, we had $342 million drawn on our revolver and net leverage was approximately 2 times.
We are adjusting our 2021 constant currency revenue growth guidance to a range of 8% to 9% year-over-year compared to 8.5% to 9.75% previously.
We continue to assume a 2% tailwind to reported revenue from foreign exchange rates in 2021, which is unchanged from our previous assumption.
As a result, we are reducing our as-reported revenue growth guidance to 10% to 11% year-over-year versus 10.5% to 11.75% previously.
The updated guidance would equate to a dollar range of between $2.791 billion and $2.186 billion.
We are lowering the top end of our 2021 adjusted gross margin guidance by 25 basis points to a range of between 59.25% and 59.5%.
There is no change to our expectation at Z-Medica, will add approximately 50 basis points to gross margin for 2021.
As a result of the expiring shipping contracts and increasing inflation, we now estimate that inflationary costs will be roughly $3 million higher in the fourth quarter than what was incurred in the third quarter.
For adjusted operating margin, we are increasing our 2021 guidance range to 27.5% to 28%, representing an increase of 75 basis points at the low end and 50 basis points at the high end of the range versus prior guidance.
We now expect interest expense to be roughly $57 million versus our previous guidance of $60 million to $62 million.
On taxes, we now expect our adjusted tax rate for 2021 to be roughly 12% to 13% versus the prior range of 13% to 13.5%.
Considering all of these elements, we are raising our adjusted earnings per share outlook for 2021 by $0.25 at the high and low end of the range to $13.15 to $13.35, a 23.2% to 25.1% year-over-year increase.
Third, we raised our earnings per share guidance for 2021, reflecting 23% to 25% earnings growth year-over-year.
Our balance sheet is in a solid position with leverage at 2 times, providing ample financial flexibility for our capital allocation priorities.

Summary:
Given our year-to-date results and outlook for the fourth quarter, we are reducing our constant currency revenue growth to a range of 8% to 9% from 8.5% to 9.75% previously.
However, given strength in our operating margin performance and improvements in our balance sheet, we are increasing earnings per share guidance to a range of $13.15 to $13.35 versus our previous range of $12.90 to $13.10, implying growth of 23% to 25% year-over-year.
Third quarter revenue was $700.3 million, an increase of 10.3% year-over-year on a constant currency basis.
Third quarter adjusted earnings per share of $3.51 increased 26.7% year-over-year and exceeded our internal expectations.
At the bottom line, third quarter adjusted earnings per share increased 26.7% to $3.51.