Transcatheter artery embolization for hemoptysis in patients with destroyed lung: risk factors for recurrence

Abstract

Background

Transcatheter arterial embolization (TAE) is an established treatment of hemoptysis in patients with destroyed lung.

Purpose

To identify the relevant risk factors for the recurrence of hemoptysis after TAE in patients with destroyed lung combined with hemoptysis.

Material and Methods

A retrospective analysis was performed on 179 patients with destroyed lung and hemoptysis who underwent TAE between January 2014 and September 2023. Immediate and clinical success rates were assessed after TAE. Kaplan–Meier analysis estimated hemoptysis-free survival. The Cox regression model was used to identify factors associated with recurrence.

Results

Among 179 patients (124 men, 55 women; mean age = 57.24 ± 12.30 years), immediate and clinical success rates were 92.2% and 89.5%, respectively. Freedom from hemoptysis at 24 h was achieved in 91.5% of patients. Cox regression analysis identified the average number of embolized vessels per damaged lobe as an independent predictor of recurrence (hazard ratio [HR] = 1.346, 95% confidence interval [CI] = 1.001–1.810; P <0.05). Patients with ≥4 embolized vessels per lobe had a significantly higher risk of recurrence than those with fewer vessels. Non-bronchial systemic arteries (NBSAs), particularly intercostal and subclavian artery branches, were key bleeding sources, with the ratio of NBSAs to bronchial arteries (BAs) embolized being approximately 1.38:1.

Conclusion

Although meticulous attention to NBSAs during TAE is essential, our study identifies the average number of embolized vessels per lobe as an independent predictor of recurrence. This indicates a disease state with high revascularization potential, necessitating long-term strategies that also address the underlying lung pathology.

Keywords

Destroyed lung transcatheter artery embolization hemoptysis

Introduction

Destroyed lung is defined as diffuse parenchymal destruction or volume loss of at least one lung lobe, representing an irreversible end-stage structural collapse of pulmonary tissue (1). On chest computed tomography (CT), this manifests as marked volume loss, dense fibrosis, cavitation, and bronchiectasis. Common etiologies include chronic infectious diseases such as tuberculosis, bronchiectasis, and pulmonary aspergillosis (2). Patients with destroyed lung frequently experience hemoptysis and recurrent infections (3). Transcatheter arterial embolization (TAE) is an established treatment for chronic and recurrent hemoptysis, particularly for those unsuitable for surgery due to poor lung function or other chronic conditions (4). However, most existing studies focus on bronchial artery embolization, demonstrating its efficacy and safety in small patient populations with destroyed lungs (5 –9). Therefore, the aim of the present study was to identify the independent risk factors for hemoptysis recurrence after TAE in patients with destroyed lung, through a retrospective analysis of clinical and procedural data.

Material and Methods

This retrospective study was approved by the Institutional Review Board (IRB) of the First Affiliated Hospital of Guangzhou Medical University (ethical approval code ES-2025-K251-01). Taking into account the retrospective nature of the study, the requirement for written informed consent from patients was waived.

Study population

This single-center, retrospective, observational study included patients with destroyed lung combined with hemoptysis who underwent TAE at a level A tertiary hospital between January 2014 and September 2023. The patient cohort was identified through a two-step process. First, we retrieved all consecutive patients (n = 2296) who underwent TAE for hemoptysis during the study period from our institutional database. Subsequently, the pre-procedural chest CT scans of these patients were systematically reviewed to identify those with radiologically confirmed destroyed lung. This process identified 183 patients. After excluding four patients diagnosed with lung cancer, a final cohort of 179 patients was included in the analysis. The severity of the disease was assessed based on the number of destroyed lung lobes as shown on CT.

Inclusion criteria were follows: (i) patients diagnosed with destroyed lung using chest CT; and (ii) patients undergoing TAE due to hemoptysis. Exclusion criteria consisted of patients with lung cancer. The study included data on 179 patients with destroyed lung who underwent TAE. The clinical, imaging, and surgical data of patients were obtained from the hospital information system, and the postoperative conditions of patients were obtained by telephone follow-up. A flow chart of the study is shown in Fig. 1.

Fig. 1.

Flow chart of the study.

Procedural technique

Before TAE, most patients underwent CT angiography (CTA) (Siemens, Erlangen, Germany) to evaluate the pathological conditions of the bronchial arteries (BAs) and non-bronchial systemic arteries (NBSAs). The TAE procedure was performed by interventional radiologists with at least 10 years of experience, using an Artis Zee Floor/Artis Zee III Ceiling Axiom Artis dTA ceiling-mounted digital flat-panel digital subtraction angiography (DSA) system (Siemens, Erlangen, Germany). The right femoral artery was accessed via the Seldinger technique, followed by the insertion of a 5-Fr arterial sheath (Terumo, Tokyo, Japan). Under fluoroscopic guidance, A 4-Fr Cobra C2 catheter (Cordis Corporation, Miami Lakes, FL, USA; assembled in Mexico) or a 4-Fr Yashiro catheter (Terumo Corporation, Tokyo, Japan) was employed to examine the pathological BAs and NBSAs. Vascular interrogation systematically covered the aortic arch, thoracic aorta, abdominal aorta, both subclavian arteries along with their branches, and both diaphragmatic arteries. Iodixanol (320 mg/mL, Nanjing Chia Tai Tianqing Pharmaceutical Co., Ltd., Nanjing, China), an iso-osmolar non-ionic contrast agent, was used for angiography to identify all suspicious pathological vessels. On selective angiography, abnormal congestion, parenchymal hypervascularization, contrast extravasation, and bronchopulmonary shunt were considered pathological findings (10). After the identification of the diseased vessels via angiography, a microcatheter (1.9 Fr Fine Drive, PIOLAX, Yokohama, Japan; 2.5 Fr Cantata, COOK, Bloomington, IN, USA; 2.7 Fr Progreat, Terumo, Tokyo, Japan; 2.8 Fr Maestro, Merit, South Jordan, UT, USA) was utilized to achieve superselective access to the affected arterial branches. Based on clinical requirements, appropriate polyvinyl alcohol (PVA) particles (Cook Incorporated, Bloomington, IN, USA , 100–300 μm) were employed as the primary embolic agent in all patients to achieve distal occlusion while preserving the main arterial trunk. Larger particles (500–1000 μm) supplemented as necessary. To prevent non-target vessels from being embolized, coils (Cook Medical, Bloomington, IN, USA) and gelatin sponge (Jiangxi Zhongqiang Industrial Corporation, Jiangxi, China, 60 × 20 × 5 mm, cut and compressed into 20 mm × (0.5–1) mm strips) were used when necessary.

Data analysis and result evaluation

Continuous variables are reported as mean and standard deviation. The categorical variables are reported as frequency and proportion. The Kaplan–Meier method estimated the hemoptysis-free survival rate of patients with destroyed lung combined with hemoptysis after TAE. Cox regression model analyzed the factors affecting the recurrence of hemoptysis. SPSS 25.0 software was used to analyze the data. A P value <0.05 was considered statistically significant.

The Chinese Expert Consensus on Diagnosis and Treatment of Hemoptysis by the Chinese Medical Association Integrated Respiratory Professional Committee categorizes hemoptysis as follows: massive (>500 mL/24 h or >100 mL in a single episode), moderate (100–500 mL), and minimal (<100 mL) (11).

Immediate success was defined as absence of a hemoptysis episode within 24 h of TAE (12). and clinical success was defined as no hemoptysis for at least 1 month after embolization (13). Repeated hemoptysis was considered to be the recurrence of hemoptysis after the initial successful hemostasis (14). Recurrence-free time referred to the duration between the date of hemostasis and the date of recurrence or last follow-up during this hospitalization (30 December 2023).

Results

A total of 179 patients (124 men [69.3%), 55 women [30.7%]; mean age = 57.24 ± 12.30 years; age range = 24–87 years) were included in this study. The baseline characteristics of the enrolled patients are presented in Table 1, detailing underlying lung diseases, volume of hemoptysis, lung lobe destruction, and history of embolization. The underlying pulmonary conditions were as follows: simple bronchiectasis (n = 54), pulmonary tuberculosis (n = 37), pulmonary aspergillosis (n = 49), concurrent pulmonary tuberculosis and aspergillosis (n = 31), and other causes (n = 11, including seven cases of bronchopleural fistula and one case of pneumonia due to other fungi). Among the cohort, 127 patients exhibited mild hemoptysis, while 44 patients had moderate hemoptysis, and eight patients presented with massive hemoptysis. In addition, 72 patients underwent TAE. There were 156 patients with unilateral lung destruction. A total of 80 patients demonstrated lung damage confined to a single lobe, with the upper lobes being the most frequently affected. Furthermore, 23 patients exhibited bilateral lung destruction, and 14 patients had previously undergone pulmonary resection.

Table 1.

Analysis of patients’ baseline data.

Characteristic	Value (n = 179)
Age (years)	57.24 ± 12.30 (24–87)
Sex
Male	124 (69.3)
Female	55 (30.7)
Underlying lung diseases
Simple bronchiectasis	54 (30.2)
Pulmonary tuberculosis	37 (20.7)
Pulmonary aspergillus	49 (27.4)
Pulmonary tuberculosis combined with pulmonary aspergillus	31 (17.3)
Others	11 (6.1)
Hemoptysis grading
Mild hemoptysis	127 (70.9)
Moderate hemoptysis	44 (24.6)
Massive hemoptysis	8 (4.5)
History of embolization
Yes	72 (40.2)
No	107 (59.8)
Destroyed the lung lobe
Unilateral lung	156 (87.2)
One lung lobe	80 (44.7)
Bilateral lung	23 (12.8)
Pulmonary resection	14 (7.8)

Values are given as n (%) or mean ± SD (range).

The characteristics of TAE are detailed in Table 2. All 179 patients underwent TAE via BAs (including ectopic bronchial arteries) and NBSAs, with three patients also undergoing pulmonary artery transcatheter embolization. The origins of ectopic bronchial arteries in this study were comprehensive and rich, including the subclavian artery (n = 19), the internal thoracic artery (n = 10), the thyrocervical trunk (n = 10), the costocervical trunk (n = 3), the aorta (n = 2), and the thoracoacromial artery (n = 1).

Table 2.

Characteristics analysis of TAE procedures.

Characteristic	Value (n = 179)
BA
Left bronchial artery	231
Right bronchial artery	255
NBSA
Intercostal artery	315
Subclavian artery branches	225
Inferior phrenic artery	89
Proprietary esophageal artery	42
Pulmonary artery	3
The origin of ectopic bronchial arteries
Subclavian artery	19
Internal thoracic artery	10
Thyrocervial trunk	10
Costocervical trunk	3
Aorta	2
Thoracoacromial artery	1
Embolization material
PVA	161
PVA + gelfoam	16
PVA + spring coil	13
Spring coil	2
Minimum embolic particle size of PVA (μm)
100	9
200	124
300	44

BA, bronchial artery; NSBA, non-bronchial systemic artery; TAE, transcatheter arterial embolization.

A total of 1160 arteries were embolized during the procedure: 486 BAs (including 231 left BAs, 255 right BAs; 45 ectopic BAs), 671 NBSAs (315 intercostal arteries, 225 subclavian artery branches, 89 subphrenic arteries, and 42 esophageal arteries), and three pulmonary arteries. NBSAs, particularly intercostal and subclavian artery branches, were key bleeding sources, with the ratio of NBSAs to BAs embolized being approximately 1.38:1.

With the advancement of technology and varying operator preferences, various embolization materials are utilized for TAE, either alone or in combination. In our study, polyvinyl alcohol (PVA) was the most frequently used material, followed by gelatin sponges and spring coils. PVA was solely employed for TAE in 161 patients, while PVA combined with gelatin sponges was used in 16 patients, PVA with spring coils in 13 patients, and spring coils alone were used for embolization in two patients with pseudoaneurysms. The size of PVA particles was in the range of 100–1000 μm, with the minimum particle size for 177 patients using PVA embolization being less than 300 μm.

Of the 179 patients who underwent TAE, complete follow-up data were obtained for 153 patients, and the postoperative outcomes of TAE are presented in Table 3. The average number of embolized vessels per damaged lobe, which was calculated by dividing the total number of arteries embolized during TAE by the total number of radiologically destroyed lung lobes (e.g. 7 embolized arteries / 2 destroyed lobes = 3.5), was in the range of 1–17 (median = 4). Notably, 83 patients had ≥4 embolized vessels per damaged pulmonary lobe. Immediate success was achieved in 141 (92.2%) patients, while clinical success was noted in 137 (89.5%) patients. After TAE, cough and sputum symptoms were alleviated in 114 (74.5%) patients, whereas one patient exhibited no symptoms of cough and sputum both pre- and post-operatively. Wheezing symptoms improved in 81 (49.2%) patients, and 31 patients had no wheezing symptoms before or after the procedure. Postoperatively, 21 patients experienced transient chest pain, which was alleviated with pharmacological treatment; 76 patients developed fever, which was managed with symptomatic supportive care, including physical cooling and antibiotics; and eight patients experienced urticaria due to allergic reactions to the contrast agent. Notably, no severe complications—including contrast-induced nephropathy, bronchial-esophageal fistula, cerebral infarction, or paraplegia—were observed in any of the patients postoperatively.

Table 3.

Complete follow-up of patients after TAE.

Characteristic	Value (n = 153)
Average no. of embolized vessels per damaged pulmonary lobe	1–17 (4)
≥4	83 (54.2)
<4	70 (45.8)
Immediate success
Yes	141 (92.2)
No	12 (7.8)
Clinical success
Yes	137 (89.5)
No	16 (10.5)
Survival rate without hemoptysis
≥24 h	140 (91.5)
≥1 month	137 (89.5)
≥3 months	116 (75.8)
≥6 months	98 (64.1)
≥12 months	70 (45.8)
Symptomatic relief
Reduced cough and sputum	114 (74.5)
Wheezing symptom improvement	75 (49.2)
Complication
Postoperative fever	76 (49.7)
Postoperative chest pain	21 (13.7)
Postoperative allergic reaction	8 (5.2)

Values are given as n (%).

TAE, transcatheter arterial embolization.

The Kaplan-Meier method indicated that the hemoptysis-free survival rates among the 153 patients with destroyed lung combined with hemoptysis after TAE were 91.5%, 89.5%, 75.8%, 64.1%, and 45.8% at 24 h, 1 month, 3 months, 6 months, and 12 months, respectively (Fig. 2).

Fig. 2.

Cumulative hemoptysis-free survival of patients with hemoptysis after TAE (n = 153).

A Cox regression analysis was performed on these patients to evaluate the time to first postoperative hemoptysis recurrence (Table 4). In the univariate analysis, factors potentially associated with recurrence included the average number of embolized vessels per damaged pulmonary lobe, underlying lung diseases, preoperative hemoptysis grading, and the total number of destroyed lobes. To ensure a comprehensive evaluation of potential confounders, all variables with a P value <0.1 from the univariate analysis were included in the multivariate model. The multivariate Cox regression analysis identified an average of ≥4 embolized vessels per damaged lobe as an independent risk factor for hemoptysis recurrence. Specifically, the risk of hemoptysis recurrence was found to be 1.346 times higher in patients with ≥4 embolized vessels per damaged lobe (95% confidence interval [CI] = 1.001–1.810; P <0.05).

Table 4.

Cox regression model analysis.

Variable	Univariate analysis		Multivariate analysis
	HR (95% CI)	P value	HR (95% CI)	P value
Average number of embolized vessels per damaged lobe (≥4)	1.346 (1.001–1.810)	0.049	1.346 (1.001–1.810)	0.049
Underlying lung diseases	–	0.830	–	0.798
Preoperative hemoptysis grading	–	0.023	–	0.300
Total number of destroyed lobes	–	0.136	–	–

Variables with P <0.1 in the univariate analysis were eligible for inclusion in the multivariate Cox regression model.

*P <0.05 indicates statistically significant difference.

CI, confidence interval; HR, hazard ratio.

Discussion

Destroyed lung refers to a pathological state characterized by extensive and structural degradation of lung tissue, resulting in irreversible loss of pulmonary function. The predominant cause of lung destruction is tuberculosis (15), followed by bronchiectasis, pulmonary aspergillosis, necrotic pneumonia, and congenital lung diseases (16,17). In this study, bronchiectasis and pulmonary aspergillosis emerged as the primary causes of lung impairment, which contrasts with reports by Halezeroglu et al. and Li et al. (3,16). This discrepancy may be attributable to regional geographical influences in this single-center investigation. Causes of lung damage can vary significantly across countries, and the epidemiology of respective regions must be considered when extending our findings to broader contexts.

Gelfoam is not recommended as the main embolic material because the vascular bed can recanalize after its absorption, and it is easy to cause hemoptysis recurrence. In this study, we used PVA particles (100–1000 μm) to embolize target vessels for the majority of patients. This study suggests that the primary consideration in embolization of target vessels is to completely close the distal channels of the shunt. To achieve more reliable and long-term embolization results, the use of small, permanent particles (100–300 μm) capable of reaching the distal small arteries of the shunt is advocated. However, this strategy must be balanced against the specific vascular anatomy of destroyed lungs, where a high prevalence of bronchial artery-pulmonary artery shunts is present. In this context, small particles carry a substantial risk of straying through these shunts into the normal pulmonary circulation, leading to non-target peripheral embolization. To resolve this dilemma, we employed a protective embolization strategy. Specifically, after distal embolization with PVA particles (100–300 μm), the proximal segment of the target vessel was secured using gelatin sponge pledges or coils in 29 patients. This two-step approach aims to maximize permanent distal occlusion while mechanically preventing the proximal migration or escape of particles through major shunts. Studies have shown that the presence of non-bronchial lateral branch circulation is significantly related to the higher failure rate of embolization in TAE. Identifying non-bronchial collateral circulation can minimize the recurrence of hemoptysis and enhance overall management (6). In our study, 486 BAs and 671 NBSAs were embolized, the embolization ratio of NBSAs was greater than that of BAs (NBSA:BA ≈ 1.38:1), with the intercostal artery identified as the most common source of bleeding within the non-bronchial system; moreover, ectopic bronchial arteries often originated from the subclavian and internal thoracic arteries (Fig. 3). These findings underscore the need for special attention to these non-bronchial vessels during TAE for patients with destroyed lung and hemoptysis.

Fig. 3.

CT and DSA images. A 60-year-old male was treated with TAE. (a) CT image showed multiple bronchiectasis, infection, and destruction of the left lung. (b) The right bronchial artery shown by the arrow is co-trunk with the right 3rd intercostal artery, and the main bronchial artery is thickened and tortuous. (c) The CT image showed that the co-trunk is thickened and tortuous. (d) The arrow shows an ectopic left bronchial artery emanating from the proximal end of the left subclavian artery. The main artery is thickened and tortuously, supplying blood to the left pulmonary lesion. CT, computed tomography; DSA, digital subtraction angiography; TAE, transcatheter arterial embolization.

We evaluated 179 patients with destroyed lung who underwent TAE. The postoperative immediate and clinical success rates were high, and the postoperative complication rates were low and mild. Bronchiectasis and chronic lung infections (including non-tuberculous mycobacterial infections, pulmonary aspergillosis, and tuberculosis) are the primary etiologies of hemoptysis (6). It is worth noting that tuberculosis is the main cause of hemoptysis-related deaths in low-income countries (18), and TAE has become the first-line treatment for tuberculosis-related hemoptysis in China (4,19,20). Lu et al. reported technical and clinical success rates of TAE in patients with bronchiectasis and hemoptysis of 100% and 92.8% (21), respectively (compared to 92.2% and 89.5% in the present study). Similarly, Yan et al. (22) reported a 12-month hemoptysis-free survival rate of 79.2% for patients with bronchiectasis and hemoptysis after intervention (45.8% in this study). Furthermore, Peng et al. demonstrated that the survival rates for patients with pulmonary tuberculosis and hemoptysis at 1, 3, 6, and 12 months were 98.5%, 94.8%, 88.7%, and 79.9%, respectively (23) (compared to 89.5%, 75.8%, 64.1%, and 45.8% in this study). In terms of immediate success rate, clinical success rate, and hemoptysis-free survival rate, TAE for patients with destroyed lung and hemoptysis is more technically challenging, and the postoperative hemoptysis-free survival rate is comparatively lower than that for bronchiectasis or pulmonary tuberculosis patients. The destroyed lung is usually caused by chronic inflammation (such as tuberculosis and bronchiectasis), which leads to extensive fibrosis, cavitation and abnormal vascular structure of lung tissue (2).

At this time, the probability of NBSAs participating in blood supply is significantly increased, and the anatomical variation of these vessels is considerable, which makes it difficult to completely identify and embolize all bleeding sources during surgery, resulting in reduced immediate success rate. In addition, destroyed lungs are often accompanied by abnormal communication between systemic circulation and pulmonary circulation (such as bronchial artery-pulmonary artery shunt) (24). Embolic agents may enter pulmonary circulation through the shunt, increasing the risk of false embolization, forcing operators to reduce the scope of embolization to avoid complications, thus affecting the possibility of complete embolization. Chronic inflammation often persists in patients with destroyed lungs. Persistent inflammatory stimulation can induce neovascularization or recanalization of existing vessels, resulting in recurrence of hemoptysis (1,25). Therefore, treatment of the underlying lung diseases is necessary to delay the recurrence of hemoptysis.

TAE serves as an effective, albeit temporary, solution for hemoptysis secondary to destroyed lung; however, recurrence is notably common (26). Some research attributes this recurrence to incomplete embolization and undetected NBSA bleeding occurring within 1∼6 months after the procedure (27). Recurrent bleeding, even after adequate embolization, remains a significant issue, affecting 12%–57% of patients (6). In our study, 72 patients received multiple TAE procedures, among which 27 patients (37.5%) experienced recurrent hemoptysis due to revascularization of previously embolized vessels, while others had recurrent hemoptysis resulting from newly formed collateral circulation. The Cox regression model indicated that the average number of embolized vessels per damaged pulmonary lobe is an independent risk factor for hemoptysis recurrence after TAE in this study. Specifically, the risk of recurrence was 1.346 times higher among patients with ≥4 embolized vessels per damaged lobe (95% CI = 1.001–1.810; P <0.05), which may suggest that an increased number of embolized vessels correlates with a heightened risk of revascularization and new collateral circulation formation. The large number of embolized vessels (≥4 vessels/ damaged pulmonary lobe) suggested that the lesion was extensive and the collateral compensation ability was stronger. After TAE, collateral vessels in the destroyed lung that were not embolized dilated compensatory to supply the ischemic area. This compensatory increase in blood flow leads to an increase in local intravascular pressure, increasing the risk of vascular rupture. In addition, the large number of blood vessels to be embolized often reflects the large scope of lung damage and serious structural damage. Such patients are more likely to be infected with deterioration of the condition and hemoptysis recurrence. Ensuring complete embolization of all responsible vessels during TAE and controlling the progression of underlying lung diseases can help delay the recurrence of hemoptysis.

The present study has some limitations. First, the data were sourced from a single center, raising concerns about the homogeneity and specificity of the patient cohorts. Second, the causes of lung damage observed diverged from global trends; in our study, bronchiectasis and pulmonary aspergillosis predominated rather than tuberculosis, which reflects regional epidemiological patterns specific to southern China. Third, the selection of embolization materials was determined by the treating physician, resulting in potential biases that could influence the outcomes.

In conclusion, our comprehensive analysis of a substantial cohort of patients with destroyed lung identifies the average number of embolized vessels per damaged lobe as an independent predictor of hemoptysis recurrence following TAE. This finding underscores that more extensive embolization may reflect a disease state with a higher propensity for revascularization and collateral formation. Although meticulous attention to NBSAs during TAE is crucial, our study highlights that the long-term management of these challenging patients must also include strategies to address the underlying lung disease. We believe that these insights contribute to improved risk stratification and post-procedural care for this specific high-risk population.

Footnotes

Acknowledgments

Author contributions: Bin Xiong takes full responsibility for the content of the manuscript, including the data and analysis. Menglan Chu, Qikun Guo and Tongqiang Li had full access to all of the data in the study and wrote of the manuscript. Weijie Luo , Liguo Dai and Wei Luo contributed substantially to the study design, data analysis and interpretation.

Consent for publication

Not applicable.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study formal consent is not required. This retrospective study was approved by the institutional review board of the Union Hospital, Guangzhou Medical University of Science and Technology.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Informed consent

As a retrospective analysis, informed consent in this study was waived.

ORCID iDs

Menglan Chu

Weijie Luo

Liguo Dai

Wei Luo

Bin Xiong

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