Malnutrition is associated with adverse 30-day outcomes after endovascular repair of abdominal aortic aneurysm

Abstract

Background

Malnutrition is particularly pertinent in patients undergoing vascular surgery, who frequently present with a high burden of comorbidities and advanced age that can impede nutrient absorption. While previous studies have established that vascular surgery patients with malnutrition had poorer outcomes, the impact of nutritional status in patients undergoing endovascular aneurysm repair (EVAR) has not yet been investigated. Therefore, this study aimed to assess the effect of malnutrition on 30-day outcomes following non-ruptured EVAR.

Methods

Patients who had infrarenal EVAR were identified in the ACS-NSQIP targeted database from 2012–2022. Exclusion criteria included age less than 18 years, ruptured aneurysm, and emergency. Malnutrition was defined as patients with preoperative weight loss of greater than 10% decrease in body weight in the 6 months immediately preceding the surgery. A 1:5 propensity-score matching was used to match demographics, baseline characteristics, aneurysm diameter, distant aneurysm extent, anesthesia, and concomitant procedures between patients with and without malnutrition. Thirty-day postoperative outcomes were examined.

Results

There were 154 (0.94%) patients with malnutrition who went under non-ruptured EVAR. Meanwhile, 16,309 patients without malnutrition went under intact EVAR, where 737 of them were matched to all malnutrition patients. Malnourished patients had more comorbidity burdens. After propensity-score matching, patients with malnutrition had elevated but non-significant 30-day mortality (5.92% vs 2.99%, p = .09). However, malnutrition patients had higher risks of renal complications (2.63% vs 0.68%, p = .04), bleeding requiring transfusion (22.37% vs 14.38%, p = .02), and unplanned reoperation (11.18% vs 4.88%, p = .01), as well as longer length of stay (6.11 ± 7.91 vs 4.44 ± 6.22 days, p < .02).

Conclusion

Patients with malnutrition experienced higher rates of morbidity after non-ruptured EVAR. Targeting malnutrition could be a strategy for preventing complications after EVAR and proper preoperative malnutritional management could be warranted.

Keywords

Endovascular aneurysm repair endovascular abdominal aortic aneurysm malnutrition aneurysm weight loss

Introduction

Abdominal aortic aneurysm (AAA) affects about 3% of the U.S. population.^1,2 Endovascular aneurysm repair (EVAR) has emerged as the predominant treatment for AAA, now being the treatment of choice for over 80% of patients in major centers.^3–6 EVAR is often preferred over open surgical repair, mainly due to its lower risks of postoperative complications, which is especially prominent for patients with high-risk profiles.^6,7

Malnutrition is particularly pertinent in patients undergoing vascular surgery, who frequently present with a high burden of comorbidities and advanced age that can impede nutrient absorption.⁸ Patients suffering from malnutrition often face heightened risks of post-surgical complications due to their inability to fulfill energy and protein needs.⁹ Previous studies indicate that in vascular surgeries, malnutrition is associated with elevated risks of postoperative mortality and morbidities.^10,11

Serum albumin is frequently used to reflect a patient’s nutritional status, yet it has relatively low sensitivity, and recent guidelines recommend against relying on serum albumin as an independent measure of malnutrition.^12,13 Instead, significant preoperative weight loss has been increasingly recognized as a more reliable indicator of malnutrition, as recommended by numerous leading nutrition societies.^11,13–15

While previous studies have established that vascular surgery patients with malnutrition had poorer outcomes, the impact of nutritional status in patients undergoing EVAR has not yet been investigated. This is particularly noteworthy given that EVAR is less invasive and typically has a safer outcome profile, potentially leading to reduced physiological stress from the surgery. Consequently, the effects of nutritional status on EVAR patients might differ. Therefore, this study aimed to assess the impact of malnutrition, indicated by significant preoperative weight loss, on 30-day outcomes following non-ruptured EVAR, utilizing data from a national registry.

Methods

Data source

This is a retrospective cohort study that used the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) targeted EVAR database from 2012–2022.

Patient population

Patients with infrarenal AAA who underwent EVAR were identified from the ACS-NSQIP targeted database. Exclusion criteria included age less than 18 years, ruptured AAA, acute intraoperative conversion to open, and emergency presentation. Malnutrition was defined as patients with preoperative weight loss of greater than 10% decrease in body weight in the 6 months immediately preceding the surgery. Patients with intentionally lost weight in a weight reduction program do not qualify. Patients with and without malnutrition were stratified into the two study cohorts.

Preoperative factors

Preoperative variables included sex, age, race and ethnicity, baseline characteristics, aneurysm diameter, distant extent of the aneurysm, and concomitant procedures, as shown in Tables 1–3.

Table 1.

Comparing the demographics of patients with and without malnutrition who underwent intact EVAR before and after the 1:5 propensity-score matching.

	Malnutrition (n = 154)	Pre-match		Post-match
	Malnutrition (n = 154)	No malnutrition (n = 16,309)	p-value	No malnutrition (n = 737)	p-value
Sex (n, %)
Male	119 (77.27%)	13267 (81.35%)	.21	566 (76.8%)	1.00
Female	35 (22.73%)	3042 (18.65%)	.21	171 (23.2%)	1.00
Age (n, %)
Age <55 years old	2 (1.3%)	286 (1.75%)	1.00	13 (1.76%)	1.00
55 ≤ age <65 years old	20 (12.99%)	1991 (12.21%)	.71	94 (12.75%)	.89
65 ≤ age <75 years old	56 (36.36%)	6267 (38.43%)	.62	274 (37.18%)	1.00
75 ≤ age <85 years old	55 (35.71%)	5951 (36.49%)	.87	263 (35.69%)	.93
Age ≥ 85 years old	21 (13.64%)	1814 (11.12%)	.30	93 (12.62%)	.69
Race and ethnicity (n, %)
Caucasian	120 (77.92%)	12253 (75.13%)	.45	570 (77.34%)	.83
African American	12 (7.79%)	857 (5.25%)	.15	60 (8.14%)	1.00
Hispanic	0 (0%)	261 (1.6%)	.18	0 (0%)	NA
Asian American	5 (3.25%)	297 (1.82%)	.21	18 (2.44%)	.78
American Indian or Alaska native	0 (0%)	25 (0.15%)	1.00	0 (0%)	NA
Native Hawaiian or Pacific Islander	0 (0%)	15 (0.09%)	1.00	0 (0%)	NA
Other races	17 (11.04%)	2778 (17.03%)	.05	89 (12.08%)	.89

Abbreviations: AAA: abdominal aortic aneurysm; EVAR: endovascular aneurysm repair.

Table 2.

Comparing the baseline characteristics of patients with and without malnutrition who underwent intact EVAR before and after the 1:5 propensity-score matching.

	Malnutrition (n = 154)	Pre-match		Post-match
	Malnutrition (n = 154)	No malnutrition (n = 16,309)	p-value	No malnutrition (n = 737)	p-value
BMI >30 kg/m²	11 (7.14%)	5599 (34.33%)	<.01	69 (9.36%)	.53
History of smoking	78 (50.65%)	5241 (32.14%)	<.01	391 (53.05%)	.59
DM	19 (12.34%)	2676 (16.41%)	.19	79 (10.72%)	.67
Dyspnea	48 (31.17%)	2447 (15%)	<.01	230 (31.21%)	.85
Independent functional status	135 (87.66%)	15848 (97.17%)	<.01	656 (89.01%)	1.00
Partially dependent functional status	14 (9.09%)	404 (2.48%)	<.01	63 (8.55%)	1.00
Fully dependent functional status	2 (1.3%)	33 (0.2%)	.04	6 (0.81%)	1.00
COPD	44 (28.57%)	2816 (17.27%)	<.01	213 (28.9%)	1.00
CHF	7 (4.55%)	460 (2.82%)	.21	36 (4.88%)	1.00
Hypertension	113 (73.38%)	12918 (79.21%)	.09	551 (74.76%)	.68
AKI	1 (0.65%)	30 (0.18%)	.25	5 (0.68%)	1.00
Dialysis	3 (1.95%)	185 (1.13%)	.26	20 (2.71%)	.78
Preoperative sepsis	9 (5.84%)	189 (1.16%)	<.01	34 (4.61%)	.68
Disseminated cancer	9 (5.84%)	125 (0.77%)	<.01	33 (4.48%)	.67
Infection	7 (4.55%)	149 (0.91%)	<.01	33 (4.48%)	1.00
Steroid use	6 (3.9%)	707 (4.34%)	1.00	25 (3.39%)	.81
Bleeding disorders	23 (14.94%)	1889 (11.58%)	.21	96 (13.03%)	.51
eGFR <60 mL/min/1.73 m²	39 (25.32%)	5469 (33.53%)	.03	189 (25.64%)	1.00
Serum albumin <3.4 g/L	44 (28.57%)	1072 (6.57%)	<.01	204 (27.68%)	1.00
WBC >11,000 counts/mL	18 (11.69%)	1059 (6.49%)	.02	73 (9.91%)	.46
Hematocrit <37%	71 (46.1%)	3180 (19.5%)	<.01	322 (43.69%)	.72
Platelet <150,000 counts/mL	26 (16.88%)	2435 (14.93%)	.50	115 (15.6%)	.63
BUN >23 mg/dL	32 (20.78%)	3737 (22.91%)	.56	140 (19%)	.57
PTT >60 s	6 (3.9%)	122 (0.75%)	<.01	21 (2.85%)	.44
PT >30 s	0 (0%)	4 (0.02%)	1.00	0 (0%)	NA
INR >2	39 (25.32%)	5862 (35.94%)	.01	198 (26.87%)	.84
ASA score of 4 or 5	69 (44.81%)	5120 (31.39%)	<.01	325 (44.1%)	.93
Prior open abdominal surgery	45 (29.22%)	3834 (23.51%)	.10	207 (28.09%)	.84

Abbreviations: AAA: abdominal aortic aneurysm; AKI: acute kidney injury; ASA: American society of anesthesiology; BMI: body mass index; BUN: blood urea nitrogen; CHF: congestive heart failure; COPD: chronic obstructive pulmonary disease; DM: diabetes mellitus; eGFR: estimated glomerular filtration rate; EVAR: endovascular aneurysm repair; INR: international normalized ratio; NA: not applicable; PT: prothrombin time, PTT: partial thromboplastin time; WBC: white blood cells.

Table 3.

Aneurysm diameter, distant aneurysm extent, anesthesia, and concomitant procedures in patients with and without malnutrition who underwent intact EVAR before and after the 1:5 propensity-score matching.

	Malnutrition (n = 154)	Pre-match		Post-match
	Malnutrition (n = 154)	No malnutrition (n = 16,309)	p-value	No malnutrition (n = 737)	p-value
Aneurysm diameter (n, %)
Aneurysm ≤4 cm	12 (7.79%)	957 (5.87%)	.30	51 (6.92%)	.73
4 ≤ aneurysm < 5.5 cm	45 (29.22%)	7663 (46.99%)	<.01	201 (27.27%)	.55
5.5 ≤ aneurysm < 8 cm	80 (51.95%)	6443 (39.51%)	<.01	397 (53.87%)	.59
Aneurysm >8 cm	13 (8.44%)	573 (3.51%)	<.01	62 (8.41%)	1.00
Distal aneurysm extent (n, %)
Aortic	67 (43.51%)	6770 (41.51%)	.62	341 (46.27%)	.66
Common iliac	38 (24.68%)	5104 (31.3%)	.08	186 (25.24%)	1.00
External iliac	10 (6.49%)	707 (4.34%)	.23	51 (6.92%)	1.00
Internal iliac	13 (8.44%)	1086 (6.66%)	.33	49 (6.65%)	.60
Anesthesia (n, %)
General	132 (85.71%)	14880 (91.24%)	.02	652 (88.47%)	.34
Regional	8 (5.19%)	538 (3.3%)	.17	32 (4.34%)	.67
Local/MAC	14 (9.09%)	867 (5.32%)	.05	53 (7.19%)	.40
Concomitant procedures (n, %)
Additional aortic stent	16 (10.39%)	1245 (7.63%)	.22	74 (10.04%)	.88
Renal stent	9 (5.84%)	683 (4.19%)	.31	44 (5.97%)	1.00
Iliac stent	27 (17.53%)	2481 (15.21%)	.43	115 (15.6%)	.54
Iliac branched device	26 (16.88%)	2634 (16.15%)	.83	74 (10.04%)	.88
Hypogastric embolization	16 (10.39%)	984 (6.03%)	.04	74 (10.04%)	1.00
Hypogastric revascularization	11 (7.14%)	723 (4.43%)	.11	45 (6.11%)	.58
Lower extremity revascularization	11 (7.14%)	715 (4.38%)	.11	55 (7.46%)	1.00

Abbreviations: AAA: abdominal aortic aneurysm; EVAR: endovascular aneurysm repair; MAC: monitored anesthesia care; SMA: superior mesenteric artery.

Perioperative outcomes

Thirty-day perioperative outcomes were examined. These included mortality, cardiac complications, stroke, pulmonary complications, renal complications, sepsis, venous thromboembolism (VTE), bleeding that requires transfusion, wound complications, lower extremity ischemia, ischemic colitis, postoperative ruptured aneurysm, unplanned reoperation, and 30-day readmission (Table 4). In addition, operation time and hospital length of stay were compared between patients with and without malnutrition (Table 4).

Table 4.

Thirty-day perioperative outcomes of patients with and without malnutrition who underwent intact EVAR after the 1:5 propensity-score matching.

	Malnutrition (n = 154)	No malnutrition (n = 737)	p-value
Mortality	9 (5.92%)	22 (2.99%)	.09
Cardiac complications	2 (1.32%)	16 (2.17%)	.75
Myocardial infarction	2 (1.32%)	12 (1.63%)	1.00
Cardiac arrest	0 (0%)	4 (0.54%)	1.00
Stroke	0 (0%)	4 (0.54%)	1.00
Pulmonary complications	7 (4.61%)	30 (4.07%)	.82
Pneumonia	5 (3.29%)	16 (2.17%)	.38
Unplanned reintubation	3 (1.97%)	18 (2.44%)	1.00
Prolonged mechanical ventilation over 48 h	2 (1.32%)	9 (1.22%)	1.00
Renal complications	4 (2.63%)	5 (0.68%)	.04
Progressive renal insufficiency	2 (1.32%)	2 (0.27%)	.14
Acute renal failure requiring renal replacement therapy	2 (1.32%)	3 (0.41%)	.20
Sepsis	3 (1.97%)	17 (2.31%)	1.00
VTE	0 (0%)	2 (0.27%)	1.00
Bleeding requiring transfusion	34 (22.37%)	106 (14.38%)	0.02
Wound complications	1 (0.66%)	15 (2.04%)	.33
Dehiscence	0 (0%)	1 (0.14%)	1.00
Superficial surgical site infection	1 (0.66%)	6 (0.81%)	1.00
Deep surgical site infection	0 (0%)	5 (0.68%)	.59
Organ space infection	0 (0%)	5 (0.68%)	.59
Lower extremity ischemia	3 (1.97%)	18 (2.44%)	1.00
Ischemic colitis	0 (0%)	5 (0.68%)	.59
Postoperative ruptured aneurysm	0 (0%)	2 (0.27%)	1.00
Unplanned reoperation	17 (11.18%)	36 (4.88%)	.01
30-day readmission	14 (9.21%)	73 (9.91%)	.88
	Mean ± SD	Mean ± SD	p-value
Operation time (mins)	142.10 ± 79.57	144.50 ± 87.49	.76
Length of stay (days)	6.11 ± 7.91	4.44 ± 6.22	.02

Abbreviations: AAA: abdominal aortic aneurysm; EVAR: endovascular aneurysm repair; LOS: length of stay; SD: standard deviation; VTE: venous thromboembolism.

Major morbidities were defined as composite outcomes. Cardiac complications were defined as myocardial infarction (MI) and cardiac arrest that require cardio-pulmonary resuscitation. Pulmonary complications included pneumonia, unplanned reintubation, and prolonged mechanical ventilation (over 48 h). Renal complications included progressive renal insufficiency (serum creatinine rise by >2 mg/dL compared to the preoperative value) and acute renal failure requiring renal replacement therapy. Wound complications included wound dehiscence, superficial and deep surgical site infection, as well as organ space infection.

Statistical analysis

Fisher’s exact tests were used to compare all preoperative factors between patients with and without malnutrition (Tables 1–3). To adjust for differences in the preoperative factors and a significant mismatch between the patients with and without malnutrition in terms of their sample size, a propensity-score matching was conducted in a 1:5 ratio (malnutrition: no malnutrition) using the Greedy Matching Algorithm with a 2% caliper. After the propensity-score matching, binary perioperative outcomes were compared by Fisher’s exact tests (Table 4) and two-tailed independent t-tests were used to compare continuous perioperative outcomes (Table 4).

All statistical analyses were performed by SAS, version 9.4. A p-value less than .05 was defined as statistically significant. The ACS-NSQIP was accessed from The George Washington University, where all subsequent statistical analyses were conducted. The authors have full access to the ACS-NSQIP database and hold full responsibility for the integrity of all statistical analyses. This study was exempted from the Institutional Review Board (IRB) review at The George Washington University, as it was retrospective and used the de-identified ACS-NSQIP database.

Results

From 2012 to 2022, there were 154 (0.94%) patients with malnutrition who went under intact EVAR. During the same period, 16,309 patients without malnutrition went under unruptured EVAR, where 737 of them were matched to all malnutrition patients by the 1:5 propensity-score matching. Table 1 shows a comparison of the demographics of patients with and without malnutrition who underwent intact EVAR, where there is no difference between the groups.

The baseline characteristics of patients with and without malnutrition who underwent intact EVAR are summarized in Table 2. Before the matching, patients with malnutrition were more likely to have a history of smoking (50.65% vs 32.14%, p < .01), dyspnea (31.17% vs 15.00%, p < .01), partially dependent functional status (9.09% vs 2.48%, p < .01), fully dependent functional status (1.30% vs 0.20%, p = .04), chronic obstructive pulmonary disease (COPD; 28.57% vs 17.27%, p < .01), preoperative sepsis (5.84% vs 1.16%, p < .01), disseminated cancer (5.84% vs 0.77%, p < .01), infection (4.55% vs 0.91%, p < .01), serum albumin <3.4 g/L (28.57% vs 6.57%, p < .01), white blood cells (WBC) >11,000 counts/mL (11.69% vs 6.49%, p = .02), hematocrit <37% (46.10% vs 19.50%, p < .01), partial thromboplastin time (PTT) >60 s (3.90% vs 0.75%, p < .01), American Society of Anesthesiology (ASA) score of 4 or 5 (44.81% vs 31.39%, p < .01). In contrast, patients with malnutrition were less likely to have body mass index (BMI) >30 kg/m² (7.14% vs 34.33%, p < .01), estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m² (25.32% vs 33.53%, p = .03), international normalized ratio (INR) >2 (25.32% vs 35.94%, p = .01). All differences were addressed by the 1:5 propensity-score matching.

Table 3 shows the aneurysm diameter, distant aneurysm extent, anesthesia, and concomitant procedures in patients with and without malnutrition who underwent intact EVAR. Before the propensity-matching, patients with malnutrition were more likely to have aneurysm over 5.5 cm (5.5–8 cm, 51.95% vs 39.51%, p < .01; over 8 cm, 8.44% vs 3.51%, p < .01) and have hypogastric embolization (10.39% vs 6.03%, p = .04). On the other hand, malnutrition patients were less likely to have aneurysm between 4 and 5.5 cm (29.22% vs 46.99%, p < .01) or under general anesthesia (85.71% vs 91.24%, p = .02). The differences were matched after the propensity-score matching.

The 30-day perioperative outcomes of patients with and without malnutrition who underwent intact EVAR after the 1:5 propensity-score matching are summarized in Table 4. Patients with malnutrition had elevated but non-significant 30-day mortality (5.92% vs 2.99%, p = .09). However, malnutrition patients had higher risks of renal complications (2.63% vs 0.68%, p = .04), bleeding requiring transfusion (22.37% vs 14.38%, p = .02), and unplanned reoperation (11.18% vs 4.88%, p = .01), as well as longer length of stay (6.11 ± 7.91 vs 4.44 ± 6.22 days, p < .02). Other 30-day outcomes, including cardiac complications, stroke, pulmonary complications, sepsis, VTE, wound complications, lower extremity ischemia, ischemic colitis, postoperative ruptured aneurysm, 30-day readmission, and operation time were not different between the groups.

Discussion

This study examined the 30-day outcomes in patients with malnutrition (preoperative weight loss of greater than 10% in the past 6 months) who went under non-ruptured EVAR. After propensity-score matching, it was found that patients with malnutrition had higher rates of renal complications, bleeding requiring transfusion, unplanned reoperation, and longer hospital length of stay.

Patients undergoing AAA repair often face a higher comorbidity burden and advanced age,¹⁶ which can predispose them to malnutrition by disrupting nutrient absorption.⁸ This can be evidenced in this study, where patients with significant preoperative weight loss often have more comorbidities, such as dependent functional status, COPD, disseminated cancer, and anemia. While these preoperative differences were accounted for through propensity-score matching, in clinical practice, the high comorbidity burden, which could either contribute to or result from preoperative weight loss, may predispose patients to adverse outcomes after EVAR. For example, while the 30-day mortality rate for non-ruptured EVAR in the general population is approximately 1.2%,¹⁷ this rate significantly increases to 5.92% in patients with malnutrition who underwent non-ruptured EVAR. After accounting for comorbidities, the propensity-matched controls exhibited an elevated 30-day mortality rate of 2.99%. This rate was not significantly different from that of the malnourished patients, likely due to a small sample size and reduced statistical power. Moreover, the 30-day mortality rate of 2.99% in the propensity-matched control group is higher than the 1.2% mortality rate observed in the general population.¹⁷ This suggests that, although malnutrition may not be an independent risk factor for mortality in non-ruptured EVAR, the comorbidities associated with malnutrition could still potentially increase the risk of mortality.

This study did find that patients with malnutrition had increased risks of complications, including renal complications and bleeding requiring transfusion. A higher incidence of renal complications in malnourished patients after surgery has been observed and that can be attributable to multiple mechanisms.^18–20 Firstly, hypoalbuminemia, a marker of malnutrition, is linked with endothelial dysfunction and altered inflammatory pathways and can lead to renal complications.^21,22 Additionally, malnutrition is often associated with low high-density lipoprotein and elevated cholesterol levels, which can potentially disrupt the anti-oxidant pathway and contribute to postoperative renal complications.^23–25 There is also growing evidence of the association between malnutrition and an increased risk of bleeding.^26–28, which could be due to factors like vitamin K deficiency,²⁷ reduced metabolism of anticoagulants and antiplatelets,²⁹ or impaired wound healing from low protein reserves, caloric depletion, and weakened immune defenses.³⁰ The higher morbidity rates in malnourished patients may be linked to more frequent unplanned reoperations and extended hospital stays. Therefore, addressing malnutrition could be a targeted strategy for preventing complications after EVAR that emphasizes the need for proper preoperative management.

This study is constrained by several limitations. First, the ACS-NSQIP database only includes a 30-day postoperative follow-up, which limits our capacity to assess the long-term outcomes for patients with malnutrition following EVAR. This constraint might lead to an underestimation of both mortality and morbidity rates after EVAR. Additionally, there is a potential for selection bias due to the specific hospitals participating in the ACS-NSQIP program, which may affect the study’s applicability to a wider patient population. Despite these limitations, the ACS-NSQIP is a nationally validated database for quality control of surgical outcomes. Its extensive sample size and the comprehensive information offered by targeted databases render ACS-NSQIP a valuable source for examining the outcomes of patients with malnutrition undergoing EVAR.

In conclusion, this study assessed the effect of malnutrition on 30-day outcomes following non-ruptured EVAR. After adjusting for preoperative differences through propensity-score matching, patients with malnutrition experienced higher rates of renal complications, bleeding requiring transfusion, unplanned reoperations, and extended hospital stays. Therefore, targeting malnutrition could be a strategy for preventing complications after EVAR and proper preoperative malnutritional management could be warranted.

Footnotes

Acknowledgments

The authors acknowledge Dr Richard Amdur, PhD, for giving statistical support for this project.

Author contributions

Conceptualization: R.L.; methodology: R.L.; formal analysis: R.L.; investigation: R.L.; resources: R.L., A.S., B.N.; data curation: R.L.; writing (original draft): R.L.; writing (review & editing): R.L., A.S., B.N.; Supervision, A.S., B.N.

Declaration of conflicting interests

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

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical statement

ORCID iD

Renxi Li

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