Hybrid and Redo Strategies for Descending and Thoracoabdominal Aorta

  • Rana O. Afifi
  • Hazim J. Safi
  • Anthony L. EstreraEmail author


Aortic aneurysm is the 13th leading cause of death in the United States. The prevalence of aortic aneurysms appears to be increasing, due in part to a higher level of awareness, advancement in imaging modalities, and an aging population. The incidence of thoracic aortic aneurysms is estimated to be around 10.4 cases per 100,000 person-years. In the future, it is likely that hybrid repair will be replaced by total endovascular techniques in most centers. Future applications may be for patients who are high risk for open TAAA repair, those who fail total endovascular repair or in centers with no access or experience with fenestrated and branched endografts. Keys for successful outcomes include patient selection, case planning, and knowledge of the technical aspects of the procedure.


TEVAR Endovascular Hybrid repair Debranching 


  1. 1.
    Beckman JA. Aortic aneurysms: pathophysiology, epidemiology, and prognosis. In: Creager MA, Dzau VJ, Loscalzo J, editors. Vas Med. Philadelphia, PA: Saunders Elsevier Inc; 2006.Google Scholar
  2. 2.
    LaRoy LL, Cormier PJ, Matalon TA, Patel SK, Turner DA, Silver B. Imaging of abdominal aortic aneurysms. AJR Am J Roentgenol. 1989;152:785–92.CrossRefGoogle Scholar
  3. 3.
    Clouse WD, Hallett JW Jr, Schaff HV, Gayari MM, Ilstrup DM, Melton LJ 3rd. Improved prognosis of thoracic aortic aneurysms: a population-based study. JAMA. 1998;280:1926–9.CrossRefGoogle Scholar
  4. 4.
    Volodos NL, Karpovich IP, Shekhanin VE, Troian VI and Iakovenko LF. [A case of distant transfemoral endoprosthesis of the thoracic artery using a self-fixing synthetic prosthesis in traumatic aneurysm]. Grudn Khir 1988: 84-86.Google Scholar
  5. 5.
    Gopaldas RR, Huh J, Dao TK, et al. Superior nationwide outcomes of endovascular versus open repair for isolated descending thoracic aortic aneurysm in 11,669 patients. J Thorac Cardiovasc Surg. 2010;140:1001–10.CrossRefGoogle Scholar
  6. 6.
    Cheng D, Martin J, Shennib H, et al. Endovascular aortic repair versus open surgical repair for descending thoracic aortic disease. a systematic review and meta-analysis of comparative studies. J Am Coll Cardiol. 2010;55:986–1001.CrossRefGoogle Scholar
  7. 7.
    Hughes K, Guerrier J, Obirieze A, et al. Open versus endovascular repair of thoracic aortic aneurysms: A Nationwide Inpatient Sample Study. Vasc Endovascular Surg. 2014;Google Scholar
  8. 8.
    Arnaoutakis DJ, Arnaoutakis GJ, Abularrage CJ, et al. Cohort-comparison of thoracic endovascular aortic repair with open thoracic aortic repair using modern end-organ preservation strategies. Ann Vasc Surg. 2015;Google Scholar
  9. 9.
    Gloviczki P, Pairolero P, Welch T, et al. Multiple aortic aneurysms: the results of surgical management. J Vasc Surg. 1990;11:19–27.. discussion -8CrossRefGoogle Scholar
  10. 10.
    Kawaharada N, Morishita K, Fukada J, Hachiro Y, Takahashi K, Abe T. Thoracoabdominal aortic aneurysm repair through redo leftsided thoracotomy. Ann Thorac Surg. 2004;77:1304–8.CrossRefGoogle Scholar
  11. 11.
    Etz CD, Zoli S, Kari FA, et al. Redo lateral thoracotomy for reoperative descending and thoracoabdominal aortic repair: a consecutive series of 60 patients. Ann Thorac Surg. 2009;88:758–66.. discussion 67CrossRefGoogle Scholar
  12. 12.
    Crawford ES, Cohen ES. Aortic aneurysm: a multifocal disease. Presidential address. Arch Surg (Chicago, IL: 1960). 1982;117:1393–400.Google Scholar
  13. 13.
    Carrel T, Pasic M, Jenni R, Tkebuchava T, Turina MI. Reoperations after operation on the thoracic aorta: etiology, surgical techniques, and prevention. Ann Thorac Surg. 1993;56:259–68.. discussion 69CrossRefGoogle Scholar
  14. 14.
    Fox AD, Berkowitz HD. Thoracoabdominal aneurysm resection after previous infrarenal abdominal aortic aneurysmectomy. Am J Surg. 1991;162:142–4.CrossRefGoogle Scholar
  15. 15.
    Curl GR, Faggioli GL, Stella A, D’Addato M, Ricotta JJ. Aneurysmal change at or above the proximal anastomosis after infrarenal aortic grafting. J Vasc Surg. 1992;16:855–9.. discussion 9-60CrossRefGoogle Scholar
  16. 16.
    Edwards JM, Teefey SA, Zierler RE, Kohler TR. Intraabdominal paraanastomotic aneurysms after aortic bypass grafting. J Vasc Surg. 1992;15:344–50.. discussion 51-3CrossRefGoogle Scholar
  17. 17.
    Lombardi JV, Carpenter JP, Pochettino A, Sonnad SS, Bavaria JE. Thoracoabdominal aortic aneurysm repair after prior aortic surgery. J Vasc Surg. 2003;38:1185–90.CrossRefGoogle Scholar
  18. 18.
    Coselli JS, Poli de Figueiredo LF, LeMaire SA. Impact of previous thoracic aneurysm repair on thoracoabdominal aortic aneurysm management. Ann Thorac Surg. 1997;64:639–50.CrossRefGoogle Scholar
  19. 19.
    Estrera AL, Sheinbaum R, Miller CC 3rd, Harrison R, Safi HJ. Neuromonitor-guided repair of thoracoabdominal aortic aneurysms. J Thorac Cardiovasc Surg. 2010;140:S131–5.. discussion S42-S46CrossRefGoogle Scholar
  20. 20.
    Estrera AL, Sandhu H, Afifi RO, et al. Open repair of chronic complicated type B aortic dissection using the open distal technique. Ann Cardiothorac Surg. 2014;3:375–84.PubMedPubMedCentralGoogle Scholar
  21. 21.
    Miller CC 3rd, Grimm JC, Estrera AL, et al. Postoperative renal function preservation with nonischemic femoral arterial cannulation for thoracoabdominal aortic repair. J Vasc Surg. 2010;51:38–42.CrossRefGoogle Scholar
  22. 22.
    De Rango P, Estrera AL, Miller C 3rd, et al. Operative outcomes using a side-branched thoracoabdominal aortic graft (STAG) for thoraco-abdominal aortic repair. Eur J Vasc Endovasc Surg. 2011;41:41–7.CrossRefGoogle Scholar
  23. 23.
    Chaer RA, Makaroun MS. Late failure after endovascular repair of descending thoracic aneurysms. Semin Vasc Surg. 2009;22:81–6.CrossRefGoogle Scholar
  24. 24.
    Lima B, Roselli EE, Soltesz EG, et al. Modified and “reverse” frozen elephant trunk repairs for extensive disease and complications after stent grafting. Ann Thorac Surg 2012; 93: 103.-9; discussion 9.CrossRefGoogle Scholar
  25. 25.
    Safi HJ, Estrera AL, Miller CC, et al. Evolution of risk for neurologic deficit after descending and thoracoabdominal aortic repair. Ann Thorac Surg 2005; 80: 2173.-9; discussion 9.CrossRefGoogle Scholar
  26. 26.
    Coselli JS, Bozinovski J and LeMaire SA. Open surgical repair of 2286 thoracoabdominal aortic aneurysms. Ann Thorac Surg 2007; 83: S862.-4; discussion S90-2.CrossRefGoogle Scholar
  27. 27.
    Safi HJ, Winnerkvist A, Miller CC 3rd, et al. Effect of extended cross-clamp time during thoracoabdominal aortic aneurysm repair. Ann Thorac Surg. 1998;66:1204–9.CrossRefGoogle Scholar
  28. 28.
    Engle J, Safi HJ, Miller CC 3rd, et al. The impact of diaphragm management on prolonged ventilator support after thoracoabdominal aortic repair. J Vasc Surg. 1999;29:150–6.CrossRefGoogle Scholar
  29. 29.
    Safi HJ, Miller CC 3rd. Spinal cord protection in descending thoracic and thoracoabdominal aortic repair. Ann Thorac Surg. 1999;67:1937–9.. discussion 53-8CrossRefGoogle Scholar
  30. 30.
    Safi HJ, Subramaniam MH, Miller CC, et al. Progress in the management of type I thoracoabdominal and descending thoracic aortic aneurysms. Ann Vasc Surg. 1999;13:457–62.CrossRefGoogle Scholar
  31. 31.
    Azizzadeh A, Huynh TT, Miller CC 3rd, et al. Postoperative risk factors for delayed neurologic deficit after thoracic and thoracoabdominal aortic aneurysm repair: a case-control study. J Vasc Surg. 2003;37:750–4.CrossRefGoogle Scholar
  32. 32.
    Estrera AL, Miller CC, 3rd, Huynh TT, et al. Preoperative and operative predictors of delayed neurologic deficit following repair of thoracoabdominal aortic aneurysm. J Thorac Cardiovasc Surg 2003; 126: 1288-1294.CrossRefGoogle Scholar
  33. 33.
    Safi HJ, Miller CC, 3rd, Huynh TT, et al. Distal aortic perfusion and cerebrospinal fluid drainage for thoracoabdominal and descending thoracic aortic repair: ten years of organ protection. Ann Surg 2003; 238: 372-80; discussion 80-1.Google Scholar
  34. 34.
    Hassoun HT, Miller CC, 3rd, Huynh TT, Estrera AL, Smith JJ and Safi HJ. Cold visceral perfusion improves early survival in patients with acute renal failure after thoracoabdominal aortic aneurysm repair. J Vasc Surg 2004; 39: 506-512.CrossRefGoogle Scholar
  35. 35.
    Huynh TT, Miller CC, 3rd, Estrera AL, et al. Correlations of cerebrospinal fluid pressure with hemodynamic parameters during thoracoabdominal aortic aneurysm repair. Ann Vasc Surg 2005; 19: 619-624.CrossRefGoogle Scholar
  36. 36.
    Huynh TT, van Eps RG, Miller CC 3rd, et al. Glomerular filtration rate is superior to serum creatinine for prediction of mortality after thoracoabdominal aortic surgery. J Vasc Surg. 2005;42:206–12.CrossRefGoogle Scholar
  37. 37.
    Achouh PE, Madsen K, Miller CC 3rd, et al. Gastrointestinal complications after descending thoracic and thoracoabdominal aortic repairs: a 14-year experience. J Vasc Surg. 2006;44:442–6.CrossRefGoogle Scholar
  38. 38.
    Estrera AL, Miller CC, Azizzadeh A and Safi HJ. Adjuncts during surgery of the thoracoabdominal aorta and their impact on neurologic outcome: distal aortic perfusion and cerebrospinal fluid drainage. Multimed Man Cardiothorac Surg 2006; 2006: mmcts 2006 001933.Google Scholar
  39. 39.
    Achouh PE, Estrera AL, Miller CC 3rd, et al. Role of somatosensory evoked potentials in predicting outcome during thoracoabdominal aortic repair. Ann Thorac Surg. 2007;84:782–7.. discussion 7-8CrossRefGoogle Scholar
  40. 40.
    Winnerkvist A, Anderson RE, Hansson LO, et al. Multilevel somatosensory evoked potentials and cerebrospinal proteins: indicators of spinal cord injury in thoracoabdominal aortic aneurysm surgery. Eur J Cardiothorac Surg. 2007;31:637–42.CrossRefGoogle Scholar
  41. 41.
    Miller CC 3rd, Villa MA, Achouh P, et al. Intraoperative skeletal muscle ischemia contributes to risk of renal dysfunction following thoracoabdominal aortic repair. Eur J Cardiothorac Surg. 2008;33:691–4.CrossRefGoogle Scholar
  42. 42.
    Keyhani K, Miller CC, 3rd, Estrera AL, Wegryn T, Sheinbaum R and Safi HJ. Analysis of motor and somatosensory evoked potentials during thoracic and thoracoabdominal aortic aneurysm repair. J Vasc Surg 2009; 49: 36-41.CrossRefGoogle Scholar
  43. 43.
    Roselli EE, Greenberg RK, Pfaff K, Francis C, Svensson LG, Lytle BW. Endovascular treatment of thoracoabdominal aortic aneurysms. J Thorac Cardiovasc Surg. 2007;133:1474–82.CrossRefGoogle Scholar
  44. 44.
    Verhoeven EL, Katsargyris A, Bekkema F, et al. Editor’s Choice—Ten-year experience with endovascular repair of thoracoabdominal aortic aneurysms: results from 166 consecutive patients. Eur J Cardiothorac Surg. 2015;49:524–31.Google Scholar
  45. 45.
    Greenberg RK, Lu Q, Roselli EE, et al. Contemporary analysis of descending thoracic and thoracoabdominal aneurysm repair: a comparison of endovascular and open techniques. Circulation. 2008;118:808–17.CrossRefGoogle Scholar
  46. 46.
    Greenberg R, Eagleton M, Mastracci T. Branched endografts for thoracoabdominal aneurysms. J Thorac Cardiovasc Surg. 2010;140:S171–8.CrossRefGoogle Scholar
  47. 47.
    Haulon S, D’Elia P, O’Brien N, et al. Endovascular repair of thoracoabdominal aortic aneurysms. Eur J Cardiothorac Surg. 2010;39:171–8.Google Scholar
  48. 48.
    Sweet MP, Hiramoto JS, Park KH, Reilly LM, Chuter TA. A standardized multi-branched thoracoabdominal stent-graft for endovascular aneurysm repair. J Endovasc Ther. 2009;16:359–64.CrossRefGoogle Scholar
  49. 49.
    Rodd CD, Desigan S, Cheshire NJ, Jenkins MP, Hamady M. The suitability of thoraco-abdominal aortic aneurysms for branched or fenestrated stent grafts--and the development of a new scoring method to aid case assessment. Eur J Cardiothorac Surg. 2011;41:175–85.Google Scholar
  50. 50.
    Lachat M, Veith FJ, Pfammatter T, et al. Chimney and periscope grafts observed over 2 years after their use to revascularize 169 renovisceral branches in 77 patients with complex aortic aneurysms. J Endovasc Ther. 2013;20:597–605.CrossRefGoogle Scholar
  51. 51.
    Schwierz E, Kolvenbach RR, Yoshida R, Yoshida W, Alpaslan A, Karmeli R. Experience with the sandwich technique in endovascular thoracoabdominal aortic aneurysm repair. J Vasc Surg. 2014;59:1562–9.CrossRefGoogle Scholar
  52. 52.
    Kolvenbach R. The role of periscopes and chimneys in complex aneurysm cases. J Endovasc Ther. 2011;18:661–5.CrossRefGoogle Scholar
  53. 53.
    Oderich GS, Ricotta JJ 2nd. Modified fenestrated stent grafts: device design, modifications, implantation, and current applications. Perspect Vasc Surg Endovasc Ther. 2009;21:157–67.CrossRefGoogle Scholar
  54. 54.
    Hughes GC, Andersen ND, Hanna JM, McCann RL. Thoracoabdominal aortic aneurysm: hybrid repair outcomes. Ann Cardiothorac Surg. 2012;1:311–9.PubMedPubMedCentralGoogle Scholar
  55. 55.
    Oderich GS, Mendes BC, Gloviczki P, Kalra M, Duncan AA, Bower TC. Current role and future directions of hybrid repair of thoracoabdominal aortic aneurysms. Perspect Vasc Surg Endovasc Ther. 2012;24:14–22.PubMedGoogle Scholar
  56. 56.
    Quinones-Baldrich WJ, Panetta TF, Vescera CL, Kashyap VS. Repair of type IV thoracoabdominal aneurysm with a combined endovascular and surgical approach. J Vasc Surg. 1999;30:555–60.CrossRefGoogle Scholar
  57. 57.
    Drinkwater SL, Goebells A, Haydar A, et al. The incidence of spinal cord ischaemia following thoracic and thoracoabdominal aortic endovascular intervention. Eur J Vasc Endovasc Surg. 2010;40:729–35.CrossRefGoogle Scholar
  58. 58.
    Lachat M, Mayer D, Criado FJ, et al. New technique to facilitate renal revascularization with use of telescoping self-expanding stent grafts: VORTEC. Vascular. 2008;16:69–72.CrossRefGoogle Scholar
  59. 59.
    Fulton JJ, Farber MA, Marston WA, Mendes R, Mauro MA, Keagy BA. Endovascular stent-graft repair of pararenal and type IV thoracoabdominal aortic aneurysms with adjunctive visceral reconstruction. J Vasc Surg. 2005;41:191–8.CrossRefGoogle Scholar
  60. 60.
    Resch TA, Greenberg RK, Lyden SP, et al. Combined staged procedures for the treatment of thoracoabdominal aneurysms. J Endovasc Ther. 2006;13:481–9.CrossRefGoogle Scholar
  61. 61.
    Black SA, Wolfe JH, Clark M, Hamady M, Cheshire NJ, Jenkins MP. Complex thoracoabdominal aortic aneurysms: endovascular exclusion with visceral revascularization. J Vasc Surg. 2006;43:1081–9.. discussion 9CrossRefGoogle Scholar
  62. 62.
    Donas KP, Schulte S, Krause E, Horsch S. Combined endovascular stent-graft repair and adjunctive visceral vessel reconstruction for complex thoracoabdominal aortic aneurysms. Int Angiol. 2007;26:213–8.PubMedGoogle Scholar
  63. 63.
    Lee WA, Brown MP, Martin TD, Seeger JM, Huber TS. Early results after staged hybrid repair of thoracoabdominal aortic aneurysms. J Amer Coll Surg. 2007;205:420–31.CrossRefGoogle Scholar
  64. 64.
    Gawenda M, Aleksic M, Heckenkamp J, Reichert V, Gossmann A, Brunkwall J. Hybrid-procedures for the treatment of thoracoabdominal aortic aneurysms and dissections. Eur J Vasc Endovasc Surg. 2007;33:71–7.CrossRefGoogle Scholar
  65. 65.
    Ballard JL, Razavi M, Harward TR, Flanigan DP. Visceral/renal artery debranching for complex thoracoabdominal hybrid procedures via retroperitoneal abdominal aortic exposure: a preliminary report. Ann Vasc Surg. 2008;22:173–8.CrossRefGoogle Scholar
  66. 66.
    van de Mortel RH, Vahl AC, Balm R, et al. Collective experience with hybrid procedures for suprarenal and thoracoabdominal aneurysms. Vascular. 2008;16:140–6.CrossRefGoogle Scholar
  67. 67.
    Quinones-Baldrich W, Jimenez JC, DeRubertis B, Moore WS. Combined endovascular and surgical approach (CESA) to thoracoabdominal aortic pathology: A 10-year experience. J Vasc Surg. 2009;49:1125–34.CrossRefGoogle Scholar
  68. 68.
    Biasi L, Ali T, Loosemore T, Morgan R, Loftus I, Thompson M. Hybrid repair of complex thoracoabdominal aortic aneurysms using applied endovascular strategies combined with visceral and renal revascularization. J Thorac Cardiovasc Surg. 2009;138:1331–8.CrossRefGoogle Scholar
  69. 69.
    Da Rocha MF, Miranda S, Adriani D, Urgnani F, Riambau VA, Mulet J. Hybrid procedures for complex aortic pathology: initial experience at a single center. Rev Esp Cardiol. 2009;62:896–902.CrossRefGoogle Scholar
  70. 70.
    Donas KP, Lachat M, Rancic Z, et al. Early and midterm outcome of a novel technique to simplify the hybrid procedures in the treatment of thoracoabdominal and pararenal aortic aneurysms. J Vasc Surg. 2009;50:1280–4.CrossRefGoogle Scholar
  71. 71.
    Drinkwater SL, Bockler D, Eckstein H, et al. The visceral hybrid repair of thoraco-abdominal aortic aneurysms—a collaborative approach. Eur J Vasc Endovasc Surg. 2009;38:578–85.CrossRefGoogle Scholar
  72. 72.
    Kabbani LS, Criado E, Upchurch GR Jr, et al. Hybrid repair of aortic aneurysms involving the visceral and renal vessels. Ann Vasc Surg. 2010;24:219–24.CrossRefGoogle Scholar
  73. 73.
    Patel HJ, Upchurch GR Jr, Eliason JL, et al. Hybrid debranching with endovascular repair for thoracoabdominal aneurysms: a comparison with open repair. Ann Thorac Surg. 2010;89:1475–81.CrossRefGoogle Scholar
  74. 74.
    Kuratani T, Kato M, Shirakawa Y, Shimamura K, Sawa Y. Long-term results of hybrid endovascular repair for thoraco-abdominal aortic aneurysms. Eur J Cardiothorac Surg. 2010;38:299–304.CrossRefGoogle Scholar
  75. 75.
    Chiesa R, Tshomba Y, Marone EM, et al. Hybrid procedures for the treatment of thoracoabdominal aortic aneurysms and dissections. J Cardiovasc Surg (Torino). 2010;51:821–32.Google Scholar
  76. 76.
    Smith TA, Gatens S, Andres M, Modrall JG, Clagett GP, Arko FR. Hybrid repair of thoracoabdominal aortic aneurysms involving the visceral vessels: comparative analysis between number of vessels reconstructed, conduit, and gender. Ann Vasc Surg. 2011;25:64–70.CrossRefGoogle Scholar
  77. 77.
    Lin PH, Kougias P, Bechara CF, et al. Clinical outcome of staged versus combined treatment approach of hybrid repair of thoracoabdominal aortic aneurysm with visceral vessel debranching and aortic endograft exclusion. Perspect Vasc Surgery Endovasc Ther. 2012;24:5–13.CrossRefGoogle Scholar
  78. 78.
    Patel R, Conrad MF, Paruchuri V, Kwolek CJ, Chung TK, Cambria RP. Thoracoabdominal aneurysm repair: hybrid versus open repair. J Vasc Surg. 2009;50:15–22.CrossRefGoogle Scholar
  79. 79.
    Chiesa R, Tshomba Y, Melissano G, et al. Hybrid approach to thoracoabdominal aortic aneurysms in patients with prior aortic surgery. J Vasc Surg. 2007;45:1128–35.CrossRefGoogle Scholar
  80. 80.
    Tshomba Y, Melissano G, Logaldo D, et al. Clinical outcomes of hybrid repair for thoracoabdominal aortic aneurysms. Ann Cardiothorac Surg. 2012;1:293–303.PubMedPubMedCentralGoogle Scholar
  81. 81.
    Hurie J, Patel HJ, Criado E, Eliason JL, Deeb GM, Upchurch GR Jr. Postoperative fluid collection after hybrid debranching and endovascular repair of thoracoabdominal aortic aneurysms. J Vasc Surg. 2011;54:1623–8.CrossRefGoogle Scholar
  82. 82.
    Ham SW, Chong T, Moos J, et al. Arch and visceral/renal debranching combined with endovascular repair for thoracic and thoracoabdominal aortic aneurysms. J Vasc Surg. 2011;54:30–40.. discussion -1CrossRefGoogle Scholar
  83. 83.
    Bakoyiannis C, Kalles V, Economopoulos K, Georgopoulos S, Tsigris C, Papalambros E. Hybrid procedures in the treatment of thoracoabdominal aortic aneurysms: a systematic review. J Endovasc Ther. 2009;16:443–50.CrossRefGoogle Scholar
  84. 84.
    Moulakakis KG, Mylonas SN, Avgerinos ED, Kakisis JD, Brunkwall J, Liapis CD. Hybrid open endovascular technique for aortic thoracoabdominal pathologies. Circulation. 2011;124:2670–80.CrossRefGoogle Scholar
  85. 85.
    Moulakakis KG, Mylonas SN, CN A, Liapis CD. Combined open and endovascular treatment of thoracoabdominal aortic pathologies: a systematic review and meta-analysis. Ann Cardiothorac Surg. 2012;1:267–76.PubMedPubMedCentralGoogle Scholar
  86. 86.
    Hughes GC, Barfield ME, Shah AA, et al. Staged total abdominal debranching and thoracic endovascular aortic repair for thoracoabdominal aneurysm. J Vasc Surg. 2012;56:621–9.CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Austria, part of Springer Nature 2019

Authors and Affiliations

  • Rana O. Afifi
    • 1
  • Hazim J. Safi
    • 1
  • Anthony L. Estrera
    • 1
    Email author
  1. 1.Department of Cardiothoracic and Vascular SurgeryMcGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth)HoustonUSA

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