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(Stroke. 2000;31:1439.)
© 2000 American Heart Association, Inc.

Comments, Opinions, and Reviews

Systematic Comparison of the Early Outcome of Angioplasty and Endarterectomy for Symptomatic Carotid Artery Disease

Jonathan Golledge, MChir; Adam Mitchell, FRCR; Roger M. Greenhalgh, MD Alun H. Davies, DM

From the Department of Vascular Surgery, Imperial College School of Medicine, Charing Cross Hospital, London, UK.

Correspondence to J. Golledge, Department of Vascular Surgery, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF UK. E-mail J.Golledge{at}tesco.net

	Abstract

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Background and Purpose—Endoluminal treatment is being increasingly used for carotid artery disease. The aim of this study was to compare the stroke and death risk within 30 days of endovascular treatment or endarterectomy for symptomatic carotid artery disease.

Methods—A systematic comparison of the 30-day outcome of angioplasty with or without stenting and endarterectomy for symptomatic carotid artery disease reported in single-center studies, published since 1990, was performed.

Results—Thirty-three studies (13 angioplasty and 20 carotid endarterectomy) were included in this analysis. Carotid stents were deployed in 44% of angioplasty patients. Mortality within 30 days of angioplasty was 0.8% compared with 1.2% after endarterectomy (OR 0.68, 95% CI 0.43 to 1.05; P=0.6). The stroke rate was 7.1% for angioplasty and 3.3% for endarterectomy (OR 2.22, CI 1.62 to 3.04; P<0.001), while the risk of fatal or disabling stroke was 3.2% and 1.6%, respectively (OR 2.09, CI 1.3 to 3.33; P<0.01). The risk of stroke or death was 7.8% for angioplasty and 4% for endarterectomy (OR 2.02, CI 1.49 to 2.75; P<0.001), while disabling stroke or death was 3.9% after angioplasty and 2.2% after endarterectomy (OR 1.86, CI 1.22 to 2.84; P<0.01).

Conclusions—In the treatment of symptomatic carotid artery disease, the risk of stroke is significantly greater with angioplasty than carotid endarterectomy. At present, carotid angioplasty is not recommended for the majority of patients with symptomatic carotid artery disease.

Key Words: angioplasty • carotid endarterectomy • carotid stenosis

	Introduction

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Randomized controlled trials have demonstrated the value of carotid endarterectomy in patients with transient ischemic attack (TIA) or stroke with good recovery and severe carotid artery stenosis, with a reduction in risk of major stroke or death of 2-fold compared with medical treatment alone.^{1 2} Carotid surgery can be associated with other morbidity, including myocardial infarction or other cardiac complications (1%), cranial nerve palsy (7%), and wound infection or hematoma (5%).^{2 3} Over the last decade, endovascular treatment of carotid disease has been introduced as an alternative to endarterectomy. Initially, angioplasty alone was used; more recently, stent placement has been employed with increasing frequency. Endovascular treatment has the advantage over endarterectomy of avoiding a neck incision and dissection of the carotid bifurcation. However, for angioplasty of a tight carotid stenosis, a guidewire must be passed across the narrowing and the plaque dilated or stented. This process is associated with a high frequency of cerebral embolization demonstrated on transcranial Doppler insonation of the middle cerebral artery.⁴

A number of randomized trials have been commenced to compare the results of endoluminal therapy and endarterectomy for carotid stenosis.⁵ The findings of only 1 trial have been published.⁶ This trial was stopped after only 17 patients had received their treatment allocation, because the complications of carotid angioplasty were so high: 5 of the 7 patients who underwent carotid angioplasty had strokes, 3 of which were disabling at 30 days. In contrast, there were no complications after the 10 carotid endarterectomies.⁶ Another trial, the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS), has been completed, and limited data have been presented in abstract form.⁷ In contrast to the findings of the Leicester trial, CAVATAS reported equivalent combined stroke and mortality rate for angioplasty and endarterectomy of 10% at 30 days.⁷ Although the results of CAVATAS have not yet been published in a full manuscript, the trial has already received criticism for its method of patient selection.⁸ On the basis of the presented results to date, some authors have argued that angioplasty is a worthwhile alternative to endarterectomy,⁹ while others feel that widespread use of endovascular therapy for carotid artery disease should await the results of further randomized trials.¹⁰

To address the debate regarding the role of angioplasty in carotid artery disease, a systematic comparison of the reported results of angioplasty and endarterectomy has been performed. Because sufficient data are not yet available from randomized trials, the results from single-center reports from 1990 to 1999 have been used to carry out a meta-analysis.

	Methods

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Studies for comparison were identified from PUBMED with the advanced search option. The terms used were "carotid artery," "angioplasty," "stent," and "endarterectomy." Studies were included if the following criteria were fulfilled: (1) number of strokes occurring within 30 days of carotid endarterectomy or endoluminal treatment were reported for patients with symptomatic carotid stenosis; (2) the report was a single-center study, since very few multicenter angioplasty series have been published; (3) the study was published between 1990 and 1999; and (4) only 1 series from any center was included unless there was clearly no overlap in cases.

For each study, the presenting symptom of the patient, the frequency of any stroke, disabling or fatal stroke, death, and TIA per operation was recorded. The risk of stroke and/or death and TIA were calculated using the OR, with 95% CIs, and the ² test.¹¹

	Results

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Thirteen studies of angioplasty with or without stenting^{6 12 13 14 15 16 17 18 19 20 21 22 23} and 20 endarterectomy studies fulfilled our inclusion criteria.^{24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43}

Presenting Symptoms
Most studies did not state separately the number of patients presenting with amaurosis fugax and cortical TIA, despite the differing results of endarterectomy in these groups.³⁴ Two of the angioplasty studies and 2 of the endarterectomy series did not separate patients presenting with TIA and stroke.^{12 21 27 28} Excluding these studies, 58% of patients treated by angioplasty compared with 70% of patients undergoing endarterectomy presented with a TIA (Tables 1 and 3; ²=8.49, P<0.01). Because a previous systematic review⁴⁴ has shown no difference in the outcome of endarterectomy for patients with cortical TIA and stroke (OR 1.01) the ORs for stroke and death were not adjusted. A small number of patients presented with symptoms of vertebrobasilar insufficiency in both angioplasty and endarterectomy series.

View this table: [in this window] [in a new window]   Table 1. Carotid Angioplasty Series: Patient Characteristics and Technical Outcome

View this table: [in this window] [in a new window]   Table 3. Early Outcome of Carotid Endarterectomy

Angioplasty Series
In early series angioplasty alone was performed,^{19 20 21 22 23} while in more recent studies primary stent placement has become more common.^{6 14 15 16 17 18} For ease, the endovascular treatment studies will be referred to as the angioplasty series. Overall, 44% of patients were stented (Table 1). A distal internal carotid cerebral protection balloon was used in 2 studies (11% of patients). Technical success was defined in most studies as balloon dilatation of the carotid stenosis so that a residual stenosis of <50% remained. With these criteria, technical failure occurred in 37 cases (7%); most of these patients went on to have an endarterectomy, although the morbidity associated with this extra procedure has not been stated in most publications. The technical failures included some patients in whom it was not possible to cross the stenosis with a guidewire, in addition to cases in which a residual stenosis was present.

Comparison of Complications of Angioplasty and Endarterectomy
The odds of stroke, death, and TIA within 30 days of procedure are compared for angioplasty and endarterectomy in Table 4. There was a >2-fold increased risk of stroke, whether minor or major, within 30 days of angioplasty compared with endarterectomy (any stroke ²=26.5, P<0.001; fatal/disabling stroke ²=8.8, P<0.01). Death within 30 days of the procedure was less common after angioplasty (0.8%) than after endarterectomy (1.2%), but this difference was not significant (95% CI 0.4 to 1.1; ²=0.57, P=0.6). Combined stroke or death was 7.8% following angioplasty and 4% after endarterectomy (²=20.6, P<0.001). TIA was reported in only 7 of the 20 endarterectomy series, thus making comparison with the endovascular series very difficult (Tables 3 and 4). There is no clear relationship between the year of publication of the angioplasty series and the reported complications (Table 2).

View this table: [in this window] [in a new window]   Table 4. Comparison of Odds of Stroke and Death Within 30 Days of Carotid Angioplasty and Endarterectomy

View this table: [in this window] [in a new window]   Table 2. Early Outcome of Carotid Angioplasty

	Discussion

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Principally, 3 mechanisms have been implicated in stroke complicating carotid endarterectomy.³⁷ First, cerebral embolization during dissection of the carotid arteries and from the endarterectomy surface⁴⁵ ; second, stroke as a result of hypoperfusion during clamping of the carotid arteries⁴⁶ ; and third, stroke due to cerebral hemorrhage following clamp release and hyperperfusion.⁴⁷ During carotid angioplasty, while the risk of hypoperfusion is likely to be less, the frequency of embolization has been demonstrated to be much greater.²² The findings of our systematic review suggest that this increased frequency of embolization is associated with a much greater risk of a perioperative neurological event. The risk of stroke is 2-fold greater after angioplasty than after endarterectomy for patients with symptomatic carotid artery disease (Table 4). Comparison of the incidence of TIA is hampered by the lack of reporting in the endarterectomy series; however, where this was stated, the incidence appeared to be much greater in the endovascular group (Tables 3 and 4). Furthermore, technical failure of angioplasty was reported in 7% of patients, many of whom went on to require endarterectomy. The complications of this additional treatment are usually not included in the report. Although many surgeons do not routinely perform imaging of the endarterectomy site after surgery, it is very rare for repeat surgery to be required for residual stenosis.

Because angioplasty can be performed percutaneously with local anesthetic, whereas endarterectomy is often carried out under general anesthetic, it might be assumed that angioplasty would be associated with a lower risk of perioperative death. A previous systematic review has suggested the complications of endarterectomy are lower when the operation is performed under regional block.⁴⁸ The mortality was slightly lower in the angioplasty series, but the difference was not statistically significant.

As with any systematic review, a number of issues must be borne in mind when assessing the results. First, because the studies compared are not randomized, it is possible that patients in both series are different. For example, more unfit patients may have been selected for angioplasty, since this technique is considered less invasive. Of note, the frequency of TIA as a presenting symptom was more common in the endarterectomy series. Similarly, patients with more stable carotid stenosis may have been selected for angioplasty; indeed, in some studies authors state that balloon dilatation is delayed until 3 months after symptoms.¹⁹ Second, the care with which perioperative complications were identified may have differed between the 2 series. A neurologist was noted to have assessed the patients at follow-up in 9 of the 13 angioplasty studies (69%), whereas this was the case for only 6 of the 20 endarterectomy studies (30%). These differences in follow-up might have allowed the detection of more subtle neurological deficits in the angioplasty patients. However, the 2-fold increase in fatal or disabling stroke following angioplasty support the present superiority of carotid surgery (Table 4). Third, it could be argued that the results reported in single-center series are not representative of the everyday outcomes of carotid surgery. For example, the outcomes reported in the North American Symptomatic Carotid Endarterectomy Trial (NASCET) and the European Carotid Surgery Trial (ECST) are different from those reported in most of the endarterectomy studies presented here. In NASCET the 30-day stroke rate was 5.5% (1.8% disabling/fatal strokes); in ECST the perioperative stroke rate was 6.6% (3.1% disabling/fatal strokes). However, this criticism is likely to apply equally to both endarterectomy and angioplasty studies. Fourth, endovascular treatment of carotid disease is in a process of development, with new techniques such as primary stenting and cerebral protection being introduced; therefore, the results reported in Table 2 may improve with technical advances. Finally, our comparison does not take into account complications other than stroke or death, such as nonfatal myocardial infarction or cranial nerve palsy, which appear too rarely in publications to be assessed.

The best level of clinical evidence is obtained from randomized controlled trials or meta-analysis of such studies. Despite the poor outcome of carotid angioplasty in the only trial published to date,⁶ the frequency of angioplasty reports appears to be increasing. This may be due to the relatively small number of patients included in the Leicester trial before the study had to be stopped, and therefore the possibility that the findings may be a type 2 error. Alternatively, the findings from CAVATAS,⁷ which have been presented in abstract form and suggest an equivalent outcome for angioplasty and endarterectomy, may have encouraged interventionists to expand their practice. The findings of this systematic review support that of the Leicester trial. At present, angioplasty or stenting would not appear suitable for most patients presenting with a symptomatic severe carotid stenosis. In the future, it may be possible to identify certain subgroups, such as high-risk surgical patients and those with symptomatic restenoses or distally positioned stenoses, that are better suited to angioplasty than surgery. More information is also required regarding the long-term results of endovascular treatment of carotid artery disease.

	Acknowledgments

 
This project was funded by the BUPA Foundation.

Received November 8, 1999; revision received February 10, 2000; accepted March 8, 2000.

	References

Top Abstract Introduction Methods Results Discussion References

 

1. European Carotid Surgery Trialists’ Collaborative Group. Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet. 1998;351:1379–1387.[Medline] [Order article via Infotrieve]
2. North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med. 1991;325:445–453.[Abstract]
3. Zannetti B, Parente P, De Rango G, Giordano G, Serafini M, Rossetti M. Role of surgical techniques and operative findings in cranial and cervical nerve injuries during carotid endarterectomy. Eur J Vasc Endovasc Surg. 1998;15:528–531.[Medline] [Order article via Infotrieve]
4. Markus H, Clifton A, Buckenham T, Taylor R, Brown MM. Improvement in cerebral hemodynamics after carotid angioplasty. Stroke.. 1996;27:612–616.[Abstract/Free Full Text]
5. Hobson RW. Status of carotid angioplasty and stenting trials. J Vasc Surg. 1998;27:791. Comment.[Medline] [Order article via Infotrieve]
6. Naylor AR, Bolia A, Abbott R, Pye IF, Smith J, Lennard N, Lloyd AJ, London NJ, Bell PR. Randomized study of carotid angioplasty and stenting versus carotid endarterectomy: a stopped trial. J Vasc Surg. 1998;28:326–334.[Medline] [Order article via Infotrieve]
7. Brown M, on behalf of the Carotid and Vertebral Artery Transluminal Angioplasty Study Investigators. Results of the Carotid and Vertebral Artery Transluminal Angioplasty Study. Brit J Surg. 1999;86:710–711.
8. Naylor R, London NJM, Bell PRF. Carotid endarterectomy versus carotid angioplasty. Lancet. 1997;349:203–204.[Medline] [Order article via Infotrieve]
9. Bergeron P. Carotid angioplasty and stenting: is endovascular treatment for cerebrovascular disease justified? J Endovasc Surg.. 1996;3:129–131.[Medline] [Order article via Infotrieve]
10. Beebe HG. Scientific evidence demonstrating the safety of carotid angioplasty and stenting: do we have enough to draw conclusions yet? J Vasc Surg.. 1998;27:788–790.[Medline] [Order article via Infotrieve]
11. Bland M. An Introduction to Medical Statistics. Oxford, UK: Oxford University Press; 1995.
12. Gaines P, Cleveland T, Sivaguru A, Beard J, Venables G. Endovascular carotid intervention: a single centre audit. Cardiovasc Intervent Radiol. 1998;21(suppl 1):S86. Abstract.
13. Abrahamsen J, Roeder OC, Justesen P, Enevoldsen E. Percutaneous transluminal angioplasty in selected patients with severe carotid artery stenosis: the results of a consecutive series of 24 patients. Eur J Vasc Endovasc Surg. 1998;16:438–442.[Medline] [Order article via Infotrieve]
14. Henry M, Amor M, Masson I, Henry I, Tzvetanov, Chati Z, Khanna N. Angioplasty and stenting of the extracranial carotid arteries. J Endovasc Surg.. 1998;5:293–304.[Medline] [Order article via Infotrieve]
15. McCleary AJ, Nelson M, Dearden NM, Calvey AJ, Gough MJ. Cerebral haemodynamics and embolisation during carotid angioplasty in high-risk patients. Br J Surg. 1997;85:771–774.
16. Yadav JS, Roubin S, Iyer S, Vitek J, King, P, Jordan WD, Fisher WS. Elective stenting of the extracranial carotid arteries. Circulation. 1997;95:376–381.[Abstract/Free Full Text]
17. Wholey MH, Jarmolowski CR, Eles G, Levy D, Buecthel J. Endovascular stents for carotid artery occlusive disease. Eur J Vasc Endovasc Surg. 1997;4:326–338.
18. Criado FJ, Wellons E, Clark NS. Evolving indications for and early results of carotid artery stenting. Am J Surg. 1997;174:111–114.[Medline] [Order article via Infotrieve]
19. Gil-Peralta A, Mayol A, Gonzalez GR, Gonzalez A, Ruano J, Boza F, Duran F. Percutaneous transluminal angioplasty of the symptomatic atherosclerotic carotid arteries. Stroke. 1996;27:2271–2273.[Abstract/Free Full Text]
20. Eckert B, Zanella FE, Thie A, Steinmetz J, Zeumer H. Angioplasty of the internal carotid artery: results complications and follow up in 61 cases. Cerebrovasc Dis. 1996;6:97–105.
21. Kachel R. Results of balloon angioplasty in the carotid arteries. Eur J Vasc Endovasc Surg. 1996;3:22–30.
22. Markus HS, Clifton A, Buckenham T, Taylor R, Brown M. Improvement in cerebral hemodynamics after carotid angioplasty. Circulation. 1996;27:612–616.
23. Munari LM, Belloni G, Perretti A, Ghia AF, Moschini L, Porta M. Carotid percutaneous angioplasty. Neurol Res.. 1992;14:156–158.[Medline] [Order article via Infotrieve]
24. Cantelmo N L, Gordon JK, Hyde C, Samaraweera RN. The significance of early postoperative duplex studies following carotid endarterectomy. Eur J Vasc Endovasc Surg. 1999;7:298–309.
25. Hamdan A D, Pomposelli FB, Gibbons GW, Campbell DR, LoGerfo FW. Perioperative strokes after 1001 consecutive carotid endarterectomy procedures without an electroencephalogram. Arch Surg. 1999;134:412–415.[Abstract/Free Full Text]
26. Blohme L, Sandstrom G, Hellstrom J, Swedenborg J, Takolander R. Complications in carotid endarterectomy are predicted by qualifying symptoms, and preoperative CT findings. Eur J Vasc Endovasc Surg.. 1999;17:213–224.[Medline] [Order article via Infotrieve]
27. Anderson A, Padayachee TS, Dandison AJP, Modaresi KB, Taylor PR. The results of routine primary closure in carotid endarterectomy. Cardiovasc Surg. 1999;7:50–55.[Medline] [Order article via Infotrieve]
28. Fearn S J, McCollum C N. Shortening and reimplication for tortuous internal carotid arteries. J Vasc Surg. 1998;27:936–939.[Medline] [Order article via Infotrieve]
29. Hallett JW, Pietropaoli JA, Ilstrup DM, Gayari MM, Williams PA, Meyer FB. Comparison of North American Symptomatic Carotid Endarterectomy Trial and population-based outcomes for carotid endarterectomy. J Vasc Surg. 1998;27:845–851.[Medline] [Order article via Infotrieve]
30. Zbornikova V, Skoglund L. Early haemodynamic changes in the ophthalmic artery, siphon and intracranial arteries after carotid endarterectomy estimated by transcranial doppler and duplex scanning. Eur J Vasc Endovasc Surg. 1998;15:67–77.[Medline] [Order article via Infotrieve]
31. Wilkinson JM, Rochester JR, Sivaguru A, Cameron IC, Fisher R, Beard JD. Middle cerebral artery blood velocity, embolisation and neurological outcome during carotid endarterectomy: a prospective comparison of the Javid and the Pruitt-Inahara shunts. Eur J Vasc Endovasc Surg. 1997;14:400–402.
32. Hertzer N R, O’Hara PJ, Mascha EJ, Krajewski LP, Sullivan TM, Beven EG. Early outcome assessment for 2228 consecutive carotid endarterectomy procedures: the Cleveland Clinic experience from 1989 to 1995. J Vasc Surg. 1997;26:11–17.[Medline] [Order article via Infotrieve]
33. Plestis KA, Kantis G, Haygood K, Earl N, Howell JF. Carotid endarterectomy with homologous vein patch angioplasty: a review of 1006 cases. J Vasc Surg. 1996;24:109–19.[Medline] [Order article via Infotrieve]
34. Golledge J, Cuming R, Beattie DK, Davies AH, Greenhalgh RM. Influence of patient-related variables on the outcome of carotid endarterectomy. J Vasc Surg. 1996;24:120–126.[Medline] [Order article via Infotrieve]
35. Perler BA. The impact of advanced age on the results of carotid endarterectomy: an outcome analysis. J Am Coll Surg. 1996;183:559–564.[Medline] [Order article via Infotrieve]
36. McCleary AJ, Dearden N M, Dickson DH, Watson A, Gough MJ. The differing effects of regional and general anaesthesia on cerebral metabolism during carotid endarterectomy. Eur J Vasc Endovasc Surg. 1996;12:173–181.[Medline] [Order article via Infotrieve]
37. Riles TS, Imparato AM, Jacobowitz GR, Lamparello PJ, Giangola G, Adelman MA, Landis R. The cause of perioperative stroke after carotid endarterectomy. J Vasc Surg. 1994;19:206–216.[Medline] [Order article via Infotrieve]
38. Gaunt ME, Martin PJ, Smith JL, Rimmer T, Cherryman G, Ratliff DA, Bell PR, Naylor AR. Clinical relevance of intraoperative embolisation detected by transcranial Doppler ultrasonography during carotid endarterectomy: a prospective study of 100 patients. Br J Surg. 1994;81:1435–1439.[Medline] [Order article via Infotrieve]
39. Naik DK, Shirer WC, Stephenson CB, Meech PR. Carotid endarterectomy at Wellington Hospital. N Z Med J. 1994;107:334–335.[Medline] [Order article via Infotrieve]
40. Kadwa AM, Robbs JV. Carotid endarterectomy in Durban: the first 10 years. S Afr Med J. 1993;83:248–252.[Medline] [Order article via Infotrieve]
41. Burns RJ, Willoughby JO. South Australian Carotid Endarterectomy Study. Med J Aust. 1991;154:650–653.[Medline] [Order article via Infotrieve]
42. Maini BS, Mullins TF, Catlin J, O’Mara P. Carotid endarterectomy: a ten-year analysis of outcome and cost of treatment. J Vasc Surg. 1990;12:732–740.[Medline] [Order article via Infotrieve]
43. Hoyne RF. Review of 272 consecutive carotid endarterectomies in a smaller community. Surg Gynecol Obstet. 1990;170:522–525.[Medline] [Order article via Infotrieve]
44. Rothwell PM, Slattery J, Warlow CP. Clinical and angiographic predictors of stroke and death from carotid endarterectomy: systematic review. BMJ. 1997;315:1571–1577.[Abstract/Free Full Text]
45. Smith JL, Evans DH, Fan L, Gaunt ME, London NJ, Bell PR, Naylor AR. Interpretation of embolic phenomena during carotid endarterectomy. Stroke. 1995;26:2281–2284.[Abstract/Free Full Text]
46. Spencer MP. Transcranial Doppler monitoring and causes of stroke from carotid endarterectomy. Stroke. 1997;28:685–691.[Abstract/Free Full Text]
47. Dalman JE, Beenakkers IC, Moll FL, Leusink JA, Ackerstaff RG. Transcranial Doppler monitoring during carotid endarterectomy helps to identify patients at risk of postoperative hyperperfusion. Eur J Vasc Endovasc Surg. 1999;18:222–227.[Medline] [Order article via Infotrieve]
48. Tangkanakul C, Counsell CE, Warlow CP. Local versus general anaesthesia in carotid endarterectomy: a systematic review of the evidence. Eur J Vasc Endovasc Surg. 1997;13:491–499.[Medline] [Order article via Infotrieve]

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