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Published online: 2019-09-24
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Drug-coated balloon treatment in coronary artery disease: Recommendations from an Asia-Pacific Consensus Group

Ae-Young Her, Eun-Seok Shin, Liew Houng Bang, Amin Ariff Nuruddin, Qiang Tang, I-Chang Hsieh, Jung-Cheng Hsu, Ong Tiong Kiam, ChunGuang Qiu, Jie Qian, Wan Azman Wan Ahmad, Rosli Mohd Ali
DOI: 10.5603/CJ.a2019.0093
·
Pubmed: 31565793

open access

Ahead of print
Review articles
Published online: 2019-09-24

Abstract

Coronary artery disease (CAD) is currently the leading cause of death globally, and the prevalence of this disease is growing more rapidly in the Asia-Pacific region than in Western countries. Although the use of metal coronary stents has rapidly increased thanks to the advancement of safety and efficacy of newer generation drug eluting stent (DES), patients are still negatively affected by some the inherent limitations of this type of treatment, such as stent thrombosis or restenosis, including neoatherosclerosis, and the obligatory use of dual antiplatelet therapy (DAPT) with unknown optimal duration.

Drug-coated balloon (DCB) treatment is based on a leave-nothing-behind concept and therefore it is not limited by stent thrombosis and long-term DAPT; it directly delivers an anti-proliferative drug which is coated on a balloon after improving coronary blood flow. At present, DCB treatment is recommended as the first-line treatment option in metal stent-related restenosis linked to DES and bare metal stent. For de novo coronary lesions, the application of DCB treatment is extended further, for conditions such as small vessel disease, bifurcation lesions, and chronic total occlusion lesions, and others. Recently, several reports have suggested that fractional flow reserve guided DCB application was safe for larger coronary artery lesions and showed good long-term outcomes. Therefore, the aim of these recommendations of the consensus group was to provide adequate guidelines for patients with CAD based on objective evidence, and to extend the application of DCB to a wider variety of coronary diseases and guide their most effective and correct use in actual clinical practice.

Abstract

Coronary artery disease (CAD) is currently the leading cause of death globally, and the prevalence of this disease is growing more rapidly in the Asia-Pacific region than in Western countries. Although the use of metal coronary stents has rapidly increased thanks to the advancement of safety and efficacy of newer generation drug eluting stent (DES), patients are still negatively affected by some the inherent limitations of this type of treatment, such as stent thrombosis or restenosis, including neoatherosclerosis, and the obligatory use of dual antiplatelet therapy (DAPT) with unknown optimal duration.

Drug-coated balloon (DCB) treatment is based on a leave-nothing-behind concept and therefore it is not limited by stent thrombosis and long-term DAPT; it directly delivers an anti-proliferative drug which is coated on a balloon after improving coronary blood flow. At present, DCB treatment is recommended as the first-line treatment option in metal stent-related restenosis linked to DES and bare metal stent. For de novo coronary lesions, the application of DCB treatment is extended further, for conditions such as small vessel disease, bifurcation lesions, and chronic total occlusion lesions, and others. Recently, several reports have suggested that fractional flow reserve guided DCB application was safe for larger coronary artery lesions and showed good long-term outcomes. Therefore, the aim of these recommendations of the consensus group was to provide adequate guidelines for patients with CAD based on objective evidence, and to extend the application of DCB to a wider variety of coronary diseases and guide their most effective and correct use in actual clinical practice.

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Keywords

drug-coated balloon, Asia-Pacific, coronary artery disease, in-stent restenosis, de novo lesion

About this article
Title

Drug-coated balloon treatment in coronary artery disease: Recommendations from an Asia-Pacific Consensus Group

Journal

Cardiology Journal

Issue

Ahead of print

Article type

Review paper

Published online

2019-09-24

DOI

10.5603/CJ.a2019.0093

Pubmed

31565793

Keywords

drug-coated balloon
Asia-Pacific
coronary artery disease
in-stent restenosis
de novo lesion

Authors

Ae-Young Her
Eun-Seok Shin
Liew Houng Bang
Amin Ariff Nuruddin
Qiang Tang
I-Chang Hsieh
Jung-Cheng Hsu
Ong Tiong Kiam
ChunGuang Qiu
Jie Qian
Wan Azman Wan Ahmad
Rosli Mohd Ali

References (80)
  1. Scheller B, Speck U, Abramjuk C, et al. Paclitaxel balloon coating, a novel method for prevention and therapy of restenosis. Circulation. 2004; 110(7): 810–814.
  2. Kleber FX, Rittger H, Bonaventura K, et al. Drug-coated balloons for treatment of coronary artery disease: updated recommendations from a consensus group. Clin Res Cardiol. 2013; 102(11): 785–797.
  3. Neumann FJ, Sousa-Uva M, Ahlsson A, et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. EuroIntervention. 2019; 14(14): 1435–1534.
  4. Ong PJ, Zeymer U, Waliszewski M, et al. Differences in clinical and angiographic profiles between Asian and Western patients with coronary artery disease: insights from the prospective "real world" paclitaxel-coated balloon registry. Int J Cardiol. 2014; 175(1): 199–200.
  5. Akiyama T, Moussa I, Reimers B, et al. Angiographic and clinical outcome following coronary stenting of small vessels: a comparison with coronary stenting of large vessels. J Am Coll Cardiol. 1998; 32(6): 1610–1618.
  6. Hori M, Connolly SJ, Ezekowitz MD, et al. Efficacy and safety of dabigatran vs. warfarin in patients with atrial fibrillation: sub-analysis in Japanese population in RE-LY trial. Circ J. 2011; 75(4): 800–805.
  7. Kohsaka S, Kimura T, Goto M, et al. Difference in patient profiles and outcomes in Japanese versus American patients undergoing coronary revascularization (collaborative study by CREDO-Kyoto and the Texas Heart Institute Research Database). Am J Cardiol. 2010; 105(12): 1698–1704.
  8. Misumida N, Ogunbayo GO, Kim SM, et al. Higher risk of bleeding in asians presenting with st-segment elevation myocardial infarction: analysis of the national inpatient sample database. Angiology. 2018; 69(6): 548–554.
  9. Wöhrle J, Zadura M, Möbius-Winkler S, et al. SeQuentPlease World Wide Registry: clinical results of SeQuent please paclitaxel-coated balloon angioplasty in a large-scale, prospective registry study. J Am Coll Cardiol. 2012; 60(18): 1733–1738.
  10. Mehilli J, Byrne RA, Tiroch K, et al. Randomized trial of paclitaxel- versus sirolimus-eluting stents for treatment of coronary restenosis in sirolimus-eluting stents: the ISAR-DESIRE 2 (Intracoronary Stenting and Angiographic Results: Drug Eluting Stents for In-Stent Restenosis 2) study. J Am Coll Cardiol. 2010; 55(24): 2710–2716.
  11. Abizaid A, Costa JR, Banning A, et al. The sirolimus-eluting Cypher Select coronary stent for the treatment of bare-metal and drug-eluting stent restenosis: insights from the e-SELECT (Multicenter Post-Market Surveillance) registry. JACC Cardiovasc Interv. 2012; 5(1): 64–71.
  12. Alli OO, Teirstein PS, Satler L, et al. Five-year follow-up of the Sirolimus-Eluting Stents vs Vascular Brachytherapy for Bare Metal In-Stent Restenosis (SISR) trial. Am Heart J. 2012; 163(3): 438–445.
  13. Scheller B, Hehrlein C, Bocksch W, et al. Treatment of Coronary In-Stent Restenosis with a Paclitaxel-Coated Balloon Catheter. N Engl J Med. 2006; 355(20): 2113–2124.
  14. Unverdorben M, Vallbracht C, Cremers B, et al. Paclitaxel-coated balloon catheter versus paclitaxel-coated stent for the treatment of coronary in-stent restenosis. Circulation. 2009; 119(23): 2986–2994.
  15. Alfonso F, Pérez-Vizcayno MJ, Cárdenas A, et al. A randomized comparison of drug-eluting balloon versus everolimus-eluting stent in patients with bare-metal stent-in-stent restenosis: the RIBS V Clinical Trial (Restenosis Intra-stent of Bare Metal Stents: paclitaxel-eluting balloon vs. everolimus-eluting stent). J Am Coll Cardiol. 2014; 63(14): 1378–1386.
  16. Habara S, Mitsudo K, Kadota K, et al. Effectiveness of paclitaxel-eluting balloon catheter in patients with sirolimus-eluting stent restenosis. JACC Cardiovasc Interv. 2011; 4(2): 149–154.
  17. Rittger H, Brachmann J, Sinha AM, et al. A randomized, multicenter, single-blinded trial comparing paclitaxel-coated balloon angioplasty with plain balloon angioplasty in drug-eluting stent restenosis: the PEPCAD-DES study. J Am Coll Cardiol. 2012; 59(15): 1377–1382.
  18. Xu Bo, Gao R, Wang J, et al. A prospective, multicenter, randomized trial of paclitaxel-coated balloon versus paclitaxel-eluting stent for the treatment of drug-eluting stent in-stent restenosis: results from the PEPCAD China ISR trial. JACC Cardiovasc Interv. 2014; 7(2): 204–211.
  19. Byrne RA, Neumann FJ, Mehilli J, et al. Paclitaxel-eluting balloons, paclitaxel-eluting stents, and balloon angioplasty in patients with restenosis after implantation of a drug-eluting stent (ISAR-DESIRE 3): a randomised, open-label trial. Lancet. 2013; 381(9865): 461–467.
  20. Indermuehle A, Bahl R, Lansky AJ, et al. Drug-eluting balloon angioplasty for in-stent restenosis: a systematic review and meta-analysis of randomised controlled trials. Heart. 2013; 99(5): 327–333.
  21. Liu L, Liu B, Ren J, et al. Comparison of drug-eluting balloon versus drug-eluting stent for treatment of coronary artery disease: a meta-analysis of randomized controlled trials. BMC Cardiovasc Disord. 2018; 18(1): 46.
  22. Lee JM, Park J, Kang J, et al. Comparison among drug-eluting balloon, drug-eluting stent, and plain balloon angioplasty for the treatment of in-stent restenosis: a network meta-analysis of 11 randomized, controlled trials. JACC Cardiovasc Interv. 2015; 8(3): 382–394.
  23. Alfonso F, Pérez-Vizcayno MJ, Cárdenas A, et al. A prospective randomized trial of drug-eluting balloons versus everolimus-eluting stents in patients with in-stent restenosis of drug-eluting stents: the RIBS IV randomized clinical trial. J Am Coll Cardiol. 2015; 66(1): 23–33.
  24. Baan J, Claessen BE, Dijk KBv, et al. A randomized comparison of paclitaxel-eluting balloon versus everolimus-eluting stent for the treatment of any in-stent restenosis: the DARE trial. JACC Cardiovasc Interv. 2018; 11(3): 275–283.
  25. Kawamoto H, Ruparelia N, Latib A, et al. Drug-Coated balloons versus second-generation drug-eluting stents for the management of recurrent multimetal-layered in-stent restenosis. JACC Cardiovasc Interv. 2015; 8(12): 1586–1594.
  26. Kufner S, Joner M, Schneider S, et al. Neointimal modification with scoring balloon and efficacy of drug-coated balloon therapy in patients with restenosis in drug-eluting coronary stents: a randomized controlled trial. JACC Cardiovasc Interv. 2017; 10(13): 1332–1340.
  27. Belkacemi A, Agostoni P, Nathoe HM, et al. First results of the DEB-AMI (drug eluting balloon in acute ST-segment elevation myocardial infarction) trial: a multicenter randomized comparison of drug-eluting balloon plus bare-metal stent versus bare-metal stent versus drug-eluting stent in primary percutaneous coronary intervention with 6-month angiographic, intravascular, functional, and clinical outcomes. J Am Coll Cardiol. 2012; 59(25): 2327–2337.
  28. Fischer D, Scheller B, Schäfer A, et al. Paclitaxcel-coated balloon plus bare metal stent vs. sirolimus-eluting stent in de novo lesions: an IVUS study. EuroIntervention. 2012; 8(4): 450–455.
  29. Cortese B, Micheli A, Picchi A, et al. Paclitaxel-coated balloon versus drug-eluting stent during PCI of small coronary vessels, a prospective randomised clinical trial. The PICCOLETO study. Heart. 2010; 96(16): 1291–1296.
  30. Latib A, Colombo A, Castriota F, et al. A randomized multicenter study comparing a paclitaxel drug-eluting balloon with a paclitaxel-eluting stent in small coronary vessels. J Am Coll Cardiol. 2012; 60(24): 2473–2480.
  31. Zeymer U, Waliszewski M, Spiecker M, et al. Prospective 'real world' registry for the use of the 'PCB only' strategy in small vessel de novo lesions. Heart. 2014; 100(4): 311–316.
  32. Unverdorben M, Kleber FX, Heuer H, et al. Treatment of small coronary arteries with a paclitaxel-coated balloon catheter in the PEPCAD I study: are lesions clinically stable from 12 to 36 months? EuroIntervention. 2013; 9(5): 620–628.
  33. Jeger RV, Farah A, Ohlow MA, et al. Drug-coated balloons for small coronary artery disease (BASKET-SMALL 2): an open-label randomised non-inferiority trial. Lancet. 2018; 392(10150): 849–856.
  34. Mitomo S, Jabbour RJ, Mangieri A, et al. Mid-term clinical outcomes after bailout drug-eluting stenting for suboptimal drug-coated balloon results: Insights from a Milan registry. Int J Cardiol. 2018; 263: 17–23.
  35. Mok KH, Wickramarachchi U, Watson T, et al. Safety of bailout stenting after paclitaxel-coated balloon angioplasty. Herz. 2017; 42(7): 684–689.
  36. Tang Y, Qiao S, Su Xi, et al. Drug-Coated balloon versus drug-eluting stent for small-vessel disease: the RESTORE SVD china randomized trial. JACC Cardiovasc Interv. 2018; 11(23): 2381–2392.
  37. Shin ES, Ann SH, Balbir Singh G, et al. Fractional flow reserve-guided paclitaxel-coated balloon treatment for de novo coronary lesions. Catheter Cardiovasc Interv. 2016; 88(2): 193–200.
  38. Ann SH, Balbir Singh G, Lim KH, et al. Anatomical and physiological changes after paclitaxel-coated balloon for atherosclerotic de novo coronary lesions: serial IVUS-VH and FFR study. PLoS One. 2016; 11(1): e0147057.
  39. Ann SH, Her AY, Singh GB, et al. Serial morphological and functional assessment of the paclitaxel-coated balloon for de novo lesions. Rev Esp Cardiol (Engl Ed). 2016; 69(11): 1026–1032.
  40. Poerner TC, Duderstadt C, Goebel B, et al. Fractional flow reserve-guided coronary angioplasty using paclitaxel-coated balloons without stent implantation: feasibility, safety and 6-month results by angiography and optical coherence tomography. Clin Res Cardiol. 2017; 106(1): 18–27.
  41. Her AY, Shin ES, Lee JM, et al. Paclitaxel-coated balloon treatment for functionally nonsignificant residual coronary lesions after balloon angioplasty. Int J Cardiovasc Imaging. 2018; 34(9): 1339–1347.
  42. Yu X, Ji F, Xu F, et al. Treatment of large de novo coronary lesions with paclitaxel-coated balloon only: results from a Chinese institute. Clin Res Cardiol. 2019; 108(3): 234–243.
  43. Steigen TK, Maeng M, Wiseth R, et al. Randomized study on simple versus complex stenting of coronary artery bifurcation lesions: the Nordic bifurcation study. Circulation. 2006; 114(18): 1955–1961.
  44. Koo BK, Kang HJ, Youn TJ, et al. Physiologic assessment of jailed side branch lesions using fractional flow reserve. J Am Coll Cardiol. 2005; 46(4): 633–637.
  45. Her AY, Ann SH, Singh GB, et al. Serial morphological changes of side-branch ostium after paclitaxel-coated balloon treatment of de novo coronary lesions of main vessels. Yonsei Med J. 2016; 57(3): 606–613.
  46. Stella PR, Belkacemi A, Dubois C, et al. A multicenter randomized comparison of drug-eluting balloon plus bare-metal stent versus bare-metal stent versus drug-eluting stent in bifurcation lesions treated with a single-stenting technique: six-month angiographic and 12-month clinical results of the drug-eluting balloon in bifurcations trial. Catheter Cardiovasc Interv. 2012; 80(7): 1138–1146.
  47. Mathey DG, Wendig I, Boxberger M, et al. Treatment of bifurcation lesions with a drug-eluting balloon: the PEPCAD V (Paclitaxel Eluting PTCA Balloon in Coronary Artery Disease) trial. EuroIntervention. 2011; 7 Suppl K: K61–K65.
  48. Lopez Minguez JR, Nogales Asensio JM, Doncel Vecino LJ, et al. A prospective randomised study of the paclitaxel-coated balloon catheter in bifurcated coronary lesions (BABILON trial): 24-month clinical and angiographic results. EuroIntervention. 2014; 10(1): 50–57.
  49. Kleber FX, Rittger H, Ludwig J, et al. Drug eluting balloons as stand alone procedure for coronary bifurcational lesions: results of the randomized multicenter PEPCAD-BIF trial. Clin Res Cardiol. 2016; 105(7): 613–621.
  50. Wöhrle J, Werner GS. Paclitaxel-coated balloon with bare-metal stenting in patients with chronic total occlusions in native coronary arteries. Catheter Cardiovasc Interv. 2013; 81(5): 793–799.
  51. Köln PJ, Scheller B, Liew HB, et al. Treatment of chronic total occlusions in native coronary arteries by drug-coated balloons without stenting - A feasibility and safety study. Int J Cardiol. 2016; 225: 262–267.
  52. Hofma SH, van der Giessen WJ, van Dalen BM, et al. Indication of long-term endothelial dysfunction after sirolimus-eluting stent implantation. Eur Heart J. 2006; 27(2): 166–170.
  53. Lee CH, Lee JY, Park GM, et al. Predictors of restenosis after placement of drug-eluting stents in one or more coronary arteries. Am J Cardiol. 2006; 97(4): 506–511.
  54. D'Ascenzo F, Bollati M, Clementi F, et al. Incidence and predictors of coronary stent thrombosis: evidence from an international collaborative meta-analysis including 30 studies, 221,066 patients, and 4276 thromboses. Int J Cardiol. 2013; 167(2): 575–584.
  55. Costopoulos C, Latib A, Naganuma T, et al. The role of drug-eluting balloons alone or in combination with drug-eluting stents in the treatment of de novo diffuse coronary disease. JACC Cardiovasc Interv. 2013; 6(11): 1153–1159.
  56. Zhu MM, Feit A, Chadow H, et al. Primary stent implantation compared with primary balloon angioplasty for acute myocardial infarction: a meta-analysis of randomized clinical trials. Am J Cardiol. 2001; 88(3): 297–301.
  57. De Luca G, Suryapranata H, Stone GW, et al. Coronary stenting versus balloon angioplasty for acute myocardial infarction: a meta-regression analysis of randomized trials. Int J Cardiol. 2008; 126(1): 37–44.
  58. Suryapranata H, De Luca G, van 't Hof AWJ, et al. Is routine stenting for acute myocardial infarction superior to balloon angioplasty? A randomised comparison in a large cohort of unselected patients. Heart. 2005; 91(5): 641–645.
  59. Laarman GJ, Suttorp MJ, Dirksen MT, et al. Paclitaxel-eluting versus uncoated stents in primary percutaneous coronary intervention. N Engl J Med. 2006; 355(11): 1105–1113.
  60. Kastrati A, Dibra A, Spaulding C, et al. Meta-analysis of randomized trials on drug-eluting stents vs. bare-metal stents in patients with acute myocardial infarction. Eur Heart J. 2007; 28(22): 2706–2713.
  61. De Luca G, Smits P, Hofma SH, et al. Efficacy and safety of drug-eluting stents in ST-segment elevation myocardial infarction: a meta-analysis of randomized trials. Int J Cardiol. 2009; 133(2): 213–222.
  62. Nakazawa G, Finn AV, Joner M, et al. Delayed arterial healing and increased late stent thrombosis at culprit sites after drug-eluting stent placement for acute myocardial infarction patients: an autopsy study. Circulation. 2008; 118(11): 1138–1145.
  63. Stone SG, Serrao GW, Mehran R, et al. Incidence, predictors, and implications of reinfarction after primary percutaneous coronary intervention in ST-segment-elevation myocardial infarction: the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction Trial. Circ Cardiovasc Interv. 2014; 7(4): 543–551.
  64. Gonzalo N, Barlis P, Serruys PW, et al. Incomplete stent apposition and delayed tissue coverage are more frequent in drug-eluting stents implanted during primary percutaneous coronary intervention for ST-segment elevation myocardial infarction than in drug-eluting stents implanted for stable/unstable angina: insights from optical coherence tomography. JACC Cardiovasc Interv. 2009; 2(5): 445–452.
  65. Gobić D, Tomulić V, Lulić D, et al. Drug-Coated balloon versus drug-eluting stent in primary percutaneous coronary intervention: a feasibility study. Am J Med Sci. 2017; 354(6): 553–560.
  66. Uskela S, Kärkkäinen JM, Eränen J, et al. Percutaneous coronary intervention with drug-coated balloon-only strategy in stable coronary artery disease and in acute coronary syndromes: An all-comers registry study. Catheter Cardiovasc Interv. 2019; 93(5): 893–900.
  67. Ito R, Ueno K, Yoshida T, et al. Outcomes after drug-coated balloon treatment for patients with calcified coronary lesions. J Interv Cardiol. 2018; 31(4): 436–441.
  68. Ellis SG, Roubin GS, King SB, et al. Angiographic and clinical predictors of acute closure after native vessel coronary angioplasty. Circulation. 1988; 77(2): 372–379.
  69. Cappelletti A, Margonato A, Rosano G, et al. Short- and long-term evolution of unstented nonocclusive coronary dissection after coronary angioplasty. J Am Coll Cardiol. 1999; 34(5): 1484–1488.
  70. Leimgruber PP, Roubin GS, Anderson HV, et al. Influence of intimal dissection on restenosis after successful coronary angioplasty. Circulation. 1985; 72(3): 530–535.
  71. Huber MS, Mooney JF, Madison J, et al. Use of a morphologic classification to predict clinical outcome after dissection from coronary angioplasty. Am J Cardiol. 1991; 68(5): 467–471.
  72. Rhee TM, Lee JM, Shin ES, et al. Impact of optimized procedure-related factors in drug-eluting balloon angioplasty for treatment of in-stent restenosis. JACC Cardiovasc Interv. 2018; 11(10): 969–978.
  73. Kim HS, Rhee TM. Farewell to drug-eluting balloons for in-stent restonsis?: appropriate technique of drug-eluting balloons implantation matters. JACC Cardiovasc Interv. 2018; 11(10): 992–994.
  74. Kleber FX, Mathey DG, Rittger H, et al. How to use the drug-eluting balloon: recommendations by the German consensus group. EuroIntervention. 2011; 7 Suppl K: K125–K128.
  75. Hwang DS, Shin ES, Kim SJ, et al. Early differential changes in coronary plaque composition according to plaque stability following statin initiation in acute coronary syndrome: classification and analysis by intravascular ultrasound-virtual histology. Yonsei Med J. 2013; 54(2): 336–344.
  76. Clever YP, Peters D, Calisse J, et al. Novel sirolimus-coated balloon catheter: in vivo evaluation in a porcine coronary model. Circ Cardiovasc Interv. 2016; 9(4): e003543.
  77. Cremers B, Toner JL, Schwartz LB, et al. Inhibition of neointimal hyperplasia with a novel zotarolimus coated balloon catheter. Clin Res Cardiol. 2012; 101(6): 469–476.
  78. Lemos PA, Farooq V, Takimura CK, et al. Emerging technologies: polymer-free phospholipid encapsulated sirolimus nanocarriers for the controlled release of drug from a stent-plus-balloon or a stand-alone balloon catheter. EuroIntervention. 2013; 9(1): 148–156.
  79. Ali RM, Abdul Kader MA, Wan Ahmad WA, et al. Treatment of coronary drug-eluting stent restenosis by a sirolimus- or paclitaxel-coated balloon. JACC Cardiovasc Interv. 2019; 12(6): 558–566.
  80. Granada JF, Tellez A, Baumbach WR, et al. In vivo delivery and long-term tissue retention of nano-encapsulated sirolimus using a novel porous balloon angioplasty system. EuroIntervention. 2016; 12(6): 740–747.

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