RESEARCH ARTICLE Open Access

Endovascular treatment of aortic saddleembolism through percutaneousmechanical Thrombectomy via StraubRotarex catheterHong-Zhi Yu, Xiao-Bo Guo, Zhao Liu, Zhe Zhang, Hai Feng and Xue-Ming Chen*

Abstract

Background: To summarize our experience of endovascular treatment for abdominal aorta saddle embolism (ASE)through percutaneous mechanical thrombectomy (PMT).

Methods: Clinical data of three ASE patients treated with an endovascular approach using percutaneousmechanical thrombectomy (PMT) were reviewed and analyzed.

Results: After PMT, blood flow of limbs was restored in all of the three patients. However, two patients died fromsudden cardiac arrest caused by hyperkalemia several hours after the procedure. The other one patient survivedthrough continuous renal replacement therapy, which was initialized shortly after the surgical procedure.

Conclusion: Endovascular treatment through PMT can quickly restore blood flow in the ASE patients. Bloodpurification through renal replacement therapy is crucial to reduce mortality after restoring blood flow of the limbs.

Keywords: Abdominal aorta saddle embolism (ASE), Endovascular treatment, Percutaneous mechanicalthrombectomy (PMT), Continuous blood purification

BackgroundPeripheral arterial embolism is a common disease in thefield of vascular surgery, but aortic saddle embolism(ASE) is a rare and critical disease with more severecomplications and high death rate. Serious complicationsor even death may occur even if the ASE could be diag-nosed timely and treated properly because of bifurcateembolus “striding” aorta, which may cause arterial ob-struction, and serious hemodynamic and metabolic dis-orders in the femoral arteries in both legs [1–3].Therefore, once ASE is diagnosed, treatment procedureshould be determined immediately based on reasonableclinical judgment. Currently, thrombectomy through

Fogarty catheter incision via both side femoral arteriesor thrombectomy through transabdominal abdominalaorta incision are commonly used [1, 4]. Application ofendovascular treatment through percutaneous mechan-ical thrombectomy (PMT) for ASE, however, has rarelybeen reported. Here, we present three cases of ASE whowere treated through PMT via Straub Rotarex catheter(Sraub Medical, Switzerland).

MethodsPatientsTotal three ASE cases (2 male and one female), whowere hospitalized and treated in the Department of Vas-cular Surgery from October to December 2015, wereretrospectively analyzed in the current study. Acute limbischemia was classified following the Rutherford

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* Correspondence: yuhongzhi2020@sina.comDepartment of Vascular Surgery, Beijing Friendship Hospital, Capital MedicalUniversity, No.95 Yongan Road, Xicheng District, Beijing 100050, China

Yu et al. Journal of Cardiothoracic Surgery (2020) 15:278 https://doi.org/10.1186/s13019-020-01334-5

classification criteria [5]. Laboratory tests including myo-cardial enzyme, cardiac troponin T (TnT), and serumpotassium were performed before and after the oper-ation. Preoperative abdominal contrast-enhanced CT, ar-terial ultrasonic doppler of lower extremities were alsoperformed in all three patients. As shown in Fig. 1, ASEwas diagnosed in all three patients by contrastangiogram.

TreatmentPatients were given sodium polystyrene sulfonate orallyor by clyster for hyperkalemia, and were hospitalized foremergent treatment of ASE with percutaneous mechan-ical thrombectomy (PMT) procedure using 8F Rotarexcatheter. Specifically, one patient was treated with bothsame side and opposite side PMT through a crossoveroperation by unilateral femoral artery retrograde punc-ture under local anesthesia as well as indwelling a cath-eter for thrombolysis in the abdominal aorta andunilateral iliac artery, but without indwelling venoussheath. The other two patients were treated with PMTusing 8F Rotarex catheter through bilateral femoral ar-tery retrograde puncture under general anesthesia, andballoon expanding stent implantation for stenotic seg-ment of artery after thrombus removal. One of themwas given an additional unilateral iliac artery stent, whilethe other patient was given an additional popliteal arterystent and bilateral femoral vein puncture sheath indwell-ing (Fig. 2).To avoid absorption of metabolic toxins, bleeding

through the venous sheath was conducted as openingthe arteries. Total 600 mL blood (300 mL each side) wascollected, washed with an autologous blood collectiondevice, and then infused back after erythrocyte washingand purification.

After the surgical operation, the arterial puncture siteswere sutured through a blood vessel suture instrument(ProGlide, Abott Company, the United States) followedby pressure dressing performance.

ResultsGeneral information of the patients and findings oflaboratory examinationGeneral characteristics of the three patients were listedin the Table 1. Age of the patients was from 28 to 76years old with an average of 55 years old, and the suffer-ing time of ASE were 10 ~ 96 h. Two of them had ser-ious ischemia of unilateral limb, and the other one hadextensive ischemia of both lower extremities.All three patients were transferred from other hospi-

tals. Two out of the three patients were Class IIb andone was Class III by the Rutherford classification criteria.One patient had past history of rheumatic heart diseaseand myocardial infarction, two patients had hyperten-sion, and one patient was long-term ex-smoker. None ofthe three patients had history of atrial fibrillation.

Outcomes of the treatmentAll three patients were treated with PMT within 3 hafter admission to our hospital. Postoperative angio-grams showed that thrombus at iliac artery disappearedin the Case #1 patient, limb blood supply improved sig-nificantly, and no distal embolism was found (Fig. 3a).However, in Case #3, a residual thrombus at the lowerend of abdominal aorta was noticed, which could be thethrombus attached to the wall and was not able to be re-moved through multiple suction (Fig. 3b).Thrombus was not formed at the puncture site of fem-

oral artery. One patient (Case #2) survived after the sur-gical operation and bedside hemofiltration (renal

Fig. 1 Angiogram before treatment. Panel a: Angiogram of Case #2, showing catheter passing through the segment of thrombus and blockageof the lower segment of the main abdominal artery. Panel b: Bilateral femoral artery angiogram of Case #3, showing bilateral common iliacarteries were completely filled with thrombus

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replacement therapy) in the ICU. Osteofascial compart-ment syndrome was not found in this patient. The othertwo patients (Case #1 and #3) died 4 h and 6 h after sur-gical operation, respectively. As shown in Table 2, thesetwo deceased patients had perioperative hyperkalemia,high myocardial enzyme and high TnT.

DiscussionPresent status of ASE treatmentHalf century ago (1950–1970), death rate of ASE was22–75%, and the main causes of death were myocardialinfarction, renal failure, thrombosis or embolism recur-rence, and stroke [3]. A retrospective study showed thatacute aortic occlusion was caused by either embolism(65%) or thrombosis (35%). Heart disease and gender(female) were risk factors of embolism, while smokingand diabetes were risk factors of thrombosis. Mortalityand comorbidity of aortic occlusion were 35 and 74%,respectively [2]. Conventional surgical treatment of ASEmay cause revascularization syndrome, which resultssometime in serious complications such as loss of alimb, multi-organ failure or even death due to compart-ment syndrome, skeletal muscle necrosis, hypovolemicshock, hyperkalemia, myoglobinuria, acute renal failure,acidosis, or arrhythmia. Therefore, early diagnosis andtimely surgical operation are critical in reducing deathrate and disability rate in the ASE patients [1, 6].For ASE treatment, the following potential complica-

tions or outcomes should be considered: 1). Functionalrecovery of ischemic limbs; 2). Perioperative death rateand postoperative death rate; 3). Perioperative complica-tions; and 4). Risk of embolism reoccurrence. The most

common surgical procedure for ASE is thrombectomy viaFogarty catheter through femoral arteries or via abdominalaorta incision. If the patient has serious arteriosclerosis, abypass operation such as axillary artery - femoral arterybypass or abdominal aorta - femoral artery artificial vascu-lar bypass may be performed [1]. For patients with ad-vanced limb ischemia (Class III of acute limb ischemia),amputation is often recommended [5]. In the currentstudy, Case #3 had extensive necrotic plaque of lowerlimbs, which was classified as Class III of acute limb ische-mia, and thus, amputation was recommended to the pa-tient. However, the patient firmly refused it, and therefore,PMT treatment was performed in addition to conservativetreatment including vasodilation drugs, anticoagulationdrugs and sodium polystyrene sulfonate.Whole lumen treatment in ASE has rarely been re-

ported in the literature. In this regard, Yang et al. re-ported one successful case of ASE treatment with film-coated stent (Viabahn stent, W. L. Gore & Associates,the U.S.A) [7]. Specifically, the film-coated stent coveredthe lower abdominal aorta and bilateral iliac arterythrombus, while the distant parts of the iliac arteriesfrom the stent were covered by an additional balloonexpanding stent in order to prevent thrombus transloca-tion [7]. This was a successful case of whole lumen treat-ment without reduction in thrombus volume. However,there was a risk of proximal thrombus translocation inthis case, especially if it was an extensive thrombus with-out volume reduction. In addition, it might block bloodsupply to the bilateral internal iliac arteries, which couldinevitably affect local blood supply and ischemia of pel-vic organs and gluteus muscles.

Fig. 2 Application of sheath during PMT. Panel a: Sheaths. Panel b: Sheaths indwelled in the both side femoral arteriovenous vessels. Panel c:Drainage bag for collecting venous blood through the intravenous sheath

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It was also reported that combination of catheter-directed thrombolysis (CDT) and endovascular stenttreatment had been successfully used to treat infrarenalabdominal aorta thrombosis or iliac artery thrombosis[8]. In this report, 11 patients were treated with CDT

followed by placing a self-expandable stent at the lesionof the main iliac artery in order to prevent potentialcomplications such as embolisms at renal artery or distalarteries. Through this procedure, the patients had sig-nificant improvement in clinical symptoms, signs, and

Table 1 Information of the three patients

Case #1 Case #2 Case #3

Gender Male Female Male

Age (years old) 61 28 76

ASE suffering time (h) 10 96 72

Classification for acutelimb ischemia

Class IIb Class IIb Class III

Complications

Coronary heart disease No No Yes

Hypertension Yes No No

Atrial fibrillation No No No

Other complications Hyperkalemia, chronicbronchitis

No Rheumatic heart disease, hematuria,hyperkalemia

Preoperative high TnT Yes No Yes

Preoperative highmyocardial enzyme

Yes No Yes

Preoperativeultrasonography

Blood flow at the proximal iliacartery was blocked.

Blood flow at the proximal iliacartery was blocked.

Blood flow at the proximal iliac artery wasblocked.

Preoperative CT Diagnosed as ASE Not done Diagnosed as ASE

Surgical anesthesiamethod

Local anesthesia General anesthesia General anesthesia

PMT treatment method Unilateral puncture, crossoveroperation

Bilateral puncture Bilateral puncture

Location of thrombus Thrombus of lower abdominalaorta and double iliac arteries

Thrombus of lower abdominal aortaand double iliac arteries, and leftpopliteal artery thrombus

Thrombus of lower abdominal aorta and doubleiliac arteries, and right iliac artery stenosis

Combined with otherendovascular treatmentmethods

Indwelling catheter forthrombolysis in abdominalaorta and right iliac artery

Left popliteal artery stent Right common iliac artery stent

Intravenous indwellingof the sheath forrecovery of venousblood

No Indwelling for double femoral veins Indwelling for double femoral veins

Volume of recoveredvenous blood (ml)

0 600 600

Postoperativehemofiltration

No Yes No

Postoperative outcome Dead Cured and discharged Dead

Angiogram after PMTtreatment

The thrombus disappeared,and blood supply of limbs wasimproved apparently.

The thrombus disappeared, andblood supply of limbs was improvedapparently.

Thrombus locally attached to the wall ofabdominal aorta was considered, and bloodsupply of limbs was improved apparently

Amputation/death Died early after the operation No Died early after the operation

Osteofascialcompartmentsyndrome

No No No

Occurrence ofcardiopulmonary arrest

Postoperative 120 min No Postoperative 20 min

Time of death 4 h after surgery / 6 h after surgery

Note: 1. ASE aortic saddle embolism; 2. for Case #3, families of the patient refused amputation treatment

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ABI [8]. However, there was a risk of losing therapeuticopportunity if the ischemia progressively accelerated inthese patients, especially in the patients with severe ASE,because CDT is a time-consuming procedure. Therefore,for the patients with severe ASE, establishing blood flowby PMT followed by CDT to remove residual thrombusmight be a safer and more effective procedure.

Innovation and improvement of surgical proceduresCurrently, open operation is the most commonly usedprocedure for ASE although hybrid operation has alsobeen reported [9]. With clinical application of new de-vices for endovascular mechanical removal thrombus,both traditional surgery and hybrid therapy face with arevolution. New devices for mechanical removal ofendovascular thrombus include catheter-directedthrombus aspiration, thrombus aspiration by fragmenta-tion or rheological thrombolysis, isolated segmentalpharmacomechanical thrombolysis, and ultrasound-accelerated thrombolysis [10]. In this regard, a previousstudy indicated that, technically, success rate ofultrasound-accelerated thrombolysis for the treatment ofaorta-femoral artery thrombotic occlusion was relativelyhigh [11]. Application of this technology resulted incomplete disappearance of the thrombus within 24 h innearly 50% of the patients and low recurrence rate of

complications within 30 days. The study further demon-strated that ultrasound-accelerated thrombolysis wassafe and effective, and superior to CDT for the treatmentof thromboembolism in the arteries and bypass graftvessels in the region of the abdominal aorta-femoral ar-tery [11].In European centers, PMT is regularly used for the

treatment of acute and sub-acute thrombosis. Europeanexperience demonstrated that PMT seemed to be a feas-ible technology for acute and sub-acute embolism at thefemoral artery bifurcates. PMT could simply and directlyremove the blood clots and restore the blood flowquickly without delaying the treatment compared to theconventional operation procedure [12].Rotarex®S catheter has been proved to be safe and ef-

fective in the treatment of peripheral artery diseases with95% success rate [13]. Combined application of Rotar-ex®S catheter and Straub power system could be used forpercutaneous endovascular excision of thrombus, embol-ism, or atherosclerotic plaques in the vessels other thancardiopulmonary, coronary, and cerebral vessels. Unlikethe thrombolytic treatment, Rotarex®S catheter can beused for thrombus extraction even in the case of antic-oagulation contraindication exists in the patient and re-sults in rapid blood flow restore. Compared to thrombusextraction by Fogarty catheter through surgical

Fig. 3 Postoperative angiogram. Panel a: Postoperative angiogram of Case #1, showing blood flow of abdominal aorta and iliac artery wasrestored. Panel b: Postoperative angiogram of Case #3, showing residual thrombus attached to the wall of the lower abdominal aorta, while theblood flow of iliac artery was restored

Table 2 Preoperative and postoperative laboratory test results of the three cases

Serialnumber

Myoglobin (ng/ml) Creatine phosphokinase (40 ~ 200 U/L) Creatinine (μmol/L) Serum potassium (mmol/L)

Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative

Case 1 Not examined 694 60,390 63,520 185.3 231.3 5.99 7.2

Case 2 Not examined 753 4267 10,498 117.0* 265.7 3.63* 4.2*

Case 3 Not examined > 1000 > 42,670 > 42,670 162.3 209.4 5.95 4.9*

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operation, thrombus extraction by Rotarex catheter is amini-invasive surgical procedure, and the percutaneouspuncture technique could not only reduce the risk ofdistal thrombus translocation, but also the duration ofsurgical procedure. However, main shortcoming ofRotarex catheter is that the catheter cannot pass througha narrow lesion or smaller lumen, especially in the caseof heavily calcified plaque, and there is a risk of arteryperforation [14]. In the current study, residual thrombuswas not completely removed from the lower end ofthrombus at abdominal aorta by PMT operation in thepatient #3 even after attempting by changing angles ofthe guide wire, suggesting Rotarex catheter could hardlyreach the whole thrombus and thus, unable to com-pletely remove the thrombus in a relatively wide abdom-inal aortic cavity. In patient #1 of the current study, acrossover operation technique was used. We found theangle of guide wire was relatively small at the femoralartery bifurcates, and thus, a retrograde puncture pro-cedure at bilateral femoral arteries was used in the pa-tient #2 and #3 in order to prevent the guide wire frombreaking during the operation. In addition, generalanesthesia was applied in the patient #2 and #3 becausesevere limb pain was noticed in these patients during theprocedure.Our experience of PMT therapy with Rotarex catheter

indicated that the advantages of this therapy were as fol-lowings: 1). Labor saving: one physician with one assist-ant are sufficient to conduct the operation. 2). Shortoperation time: bilateral thrombus removal can be com-pleted within 20 ~ 30 min. Generally, most of thethrombus can be removed after 2–3 times of operation,and the blood flow can be restored rapidly (as shown inFigs. 3 and 4 in the current study). In addition, suturingthe puncture site with a vessel suturing device greatlyshortens the time compared to the conventional surgical

incision and suture time, which requires at least 1.5 h forthrombus extraction and suture of incision given twogroups of personnel operate simultaneously. 3). Applica-tion of the sheath allows to perform angiography evalu-ation or other endovascular procedure during theoperation: bilateral or crossover operation results inquick restore of the blood flow. Angiography throughthe sheath allows to examine the status of thrombus re-moval immediately after PMT procedure, which avoidsthe limited estimation on the thrombus removal statusby blood flow rate in the artery, the complicated hybridprocedure, and repeated procedures of angiography/op-eration/angiography again to confirm the thrombus re-moval status. In addition, CDT procedure or stentimplantation can also be performed through the sheath.

Ischemia-reperfusion injury and renal replacementtherapyRecanalization following limb ischemia may result in re-perfusion syndrome, which causes very high comorbidityand mortality. In this context, insufficient estimation onthe risk of reperfusion syndrome before the emergentoperation might contribute to the high rate of comorbid-ity and mortality in the elderly patients with varietykinds of complications [15]. Ischemia-reperfusion injuryrefers to more serious tissue damage or even irreversiblelesions after the blood flow is restored. Ischemia-reperfusion injury may significantly affect the outcomeof ASE treatment and it is still a challenging problem forthe treatment of severe limb ischemia. In this regard,two patients in the current study died after successfulPMT and blood restore even through these two patientshad received hemofiltration therapy and sodium poly-styrene sulfonate, suggesting that ischemia-reperfusionbe alerted to save ASE patient’s life.

Fig. 4 Postoperative left and right iliac artery angiogram of Case #2

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Following blood flow restore, large amounts of pro-inflammatory cytokines, oxygen radicals, lactic acid andpotassium ions are released to the blood flow, whichaugments myonephropathic metabolic syndrome(MNMS). MNMS results in damage of kidney function(10–15% patients have acute kidney failure) throughrhabdomyolysis and potential nephrotoxin, which causeincrease of myoglobin and creatine phosphokinase (CK).Myoglobin is toxic to kidney and its half-life in the bloodflow is 2 ~ 3 h, while CK is a biomarker of muscle injuryand its half-life is 1.5 days. Accumulation of CK in theblood may indicate the progress of renal failure. Not sur-prisingly, in the current study, the two deceased patientshad high serum potassium, TnT and CK before the sur-gery, indicating serious muscle necrosis existed beforethe surgery, and it became worse after restoring bloodflow by surgery. This might be the direct cause of deathfor the two patients even though they were treated withbicarbonate and mannitol to prevent acute renal failureas well as to reverse oliguria renal failure to non-oliguriarenal failure following the literature reports [3, 15, 16].Toxic metabolites in the venous blood following

ischemia-reperfusion may cause systemic complications.Therefore, bypass the venous blood from returning tosystemic circulation after PMT surgery is a desirable ap-proach to prevent ischemia-reperfusion injury. However,drainage of femoral vein blood flow may cause seriousblood loss and volume consumption, which increasesthe risk of fatality in critically ill patients. In addition,toxic metabolite removal through draining femoral veinblood is technically difficult in clinic even though it hasbeen successful in the experimental study [15]. In thisregard, a successful case of intravenous hemofiltrationtreatment in ASE thrombectomy was first reported byMutirangura et al [17] However, due to the limitation ofintraoperative condition, postoperative continuous renalreplacement therapy, i.e. continuous blood purification(CBP), has become a popular approach to correct life-threatening homeostatic disorders including metabolicacidosis, hyperkalemia, azotemia, and fluid overload.Therefore, initiation of renal replacement therapy atearly stage may not only reduce the damage of kidneyand other organs by acidosis, azotemia, fluid overload,and systemic inflammation, but also increase the survivalrate and promote renal function recovery [18].In the current study, surgical operation for ASE was

started by indwelling 6F sheath at femoral venous onboth sides. Through the sheath, venous blood (approxi-mately 600 mL in total) was continuously drained into acollection bag during the process of arterial thrombusremoval. After being processed by autologous blood re-covery unit, intact erythrocytes were then transfusedback to the patient. This procedure eliminated largeamounts of toxic metabolites in the venous blood and

thus, it minimized ischemia-reperfusion injury in thelimbs. It was found that the oxygen carrying capacity ofred blood cells in the autologous transfused blood wasmuch higher, while amount of acidic substances wasless, than that of the transfused blood from other do-nors. Hemostatic disorder, however, might occur if alarge amount (3000 mL) of autologous blood were trans-fused [19, 20].Considering the critical condition and unstable circu-

lation of ASE patients, our experience indicated that it iscritical to start early in draining venous blood of thelower limbs in order to reduce circulation of the meta-bolic toxins. In this regard, cardiac arrest and suddendeath occurred in the two deceased patients of thecurrent study before CBP was initiated due to the rapidprogress of the disease. One of them died from suddenmyocardial infarction and cardiac arrest 4 h after the op-eration, and the other one had cardiac arrest 20 minafter the operation and died 6 h after the surgical oper-ation. In contrast, the patient #2, who was 28 years oldbut suffered from ASE for 96 h, survived and was dis-charged from hospital after being successfully given CBPtreatment. In these ASE patients with rapid deteriorationof homeostasis during the surgical operation, we recog-nized that application of the arterial or venous sheathduring surgical procedure may have the following advan-tages. 1). Operation time could be shortened by suturingartery puncture point after the patient’s condition isstable. 2). Acute reperfusion injury caused by suddenand rapid open blood flow could be avoided by the 8Farterial sheath through controlling arterial blood flow.3). With the sheath in place, the patient is ready to re-ceive CBP treatment immediately after he/she is trans-ferred to the intensive care unit, which maximizes theopportunity of survival for the patient.

ConclusionIn conclusion, ASE is a serious disease in the field ofvascular surgery that threats patients’ life with high post-operative comorbidity and mortality. In clinical practice,open surgical thrombectomy is still the main method forASE surgical treatment. However, PMT treatment forthe ASE through Rotarex catheter is a minimally inva-sive whole lumen procedure with a high success ratetechnically. Advantages of PMT treatment includ laborsaving, simple and speedy operation, and rapid restor-ation of blood flow. It is a fast, safe and feasible method.However, advanced technology does not always result insuccess in saving patients’ lives, and reperfusion injury isstill a challenging issue in the treatment of severe limbischemia. Continuous renal replacement therapy at earlystage of postoperative care has been gradually recog-nized and applied in clinic, which will be of great

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significance in reducing relevant mortality and amputa-tion rate.

AbbreviationsASE: Aorta saddle embolism; PMT: Percutaneous mechanical thrombectomy;TnT: Cardiac troponin T; CDT: Catheter-directed thrombolysis;MNMS: Myonephropathic metabolic syndrome; CK: Creatine phosphokinase;CBP: Continuous blood purification

AcknowledgementsNone

Availability of data and materialThe datasets generated and analyzed during the current study are availablefrom the corresponding author on reasonable request.

Authors’ contributionsHZY and XMC contributed to the conception and design of the study; XBGand ZL performed the experiments, ZZ and HF collected and analyzed data;HZY and XMC wrote the manuscript; All authors reviewed and approved thefinal version of the manuscript.

FundingNo funding was received for this study.

Ethics approval and consent to participateThe study protocol was approved by the Ethics Committee of BeijingFriendship Hospital, Capital Medical University. Written informed consent wasobtained from all the study subjects before enrollment.

Consent for publicationNot applicable.

Competing interestsThe authors declare that they have no competing interests.

Received: 13 May 2020 Accepted: 22 September 2020

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