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Reiff T, Eckstein HH, Mansmann U, Jansen O, Fraedrich G, Mudra H, Böckler D, Böhm M, Brückmann H, Debus ES, Fiehler J, Mathias K, Ringelstein EB, Schmidli J, Stingele R, Zahn R, Zeller T, Niesen WD, Barlinn K, Binder A, Glahn J, Ringleb PA. Contralateral Stenosis and Echolucent Plaque Morphology are Associated with Elevated Stroke Risk in Patients Treated with Asymptomatic Carotid Artery Stenosis within a Controlled Clinical Trial (SPACE-2). J Stroke Cerebrovasc Dis 2021; 30:105940. [PMID: 34311420 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/30/2021] [Accepted: 06/01/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Asymptomatic carotid artery stenosis (ACS) has a low risk of stroke. To achieve an advantage over noninterventional best medical treatment (BMT), carotid endarterectomy (CEA) or carotid artery stenting (CAS) must be performed with the lowest possible risk of stroke. Therefore, an analysis of risk-elevating factors is essential. Grade of ipsilateral and contralateral stenosis as well as plaque morphology are known risk factors in ACS. METHODS The randomized, controlled, multicenter SPACE-2 trial had to be stopped prematurely after recruiting 513 patients. 203 patients were randomized to CEA, 197 to CAS, and 113 to BMT. Within one year, risk factors such as grade of stenosis and plaque morphology were analyzed. RESULTS Grade of contralateral stenosis (GCS) was higher in patients with any stroke (50%ECST vs. 20%ECST; p=0.012). Echolucent plaque morphology was associated with any stroke on the day of intervention (OR 5.23; p=0.041). In the periprocedural period, any stroke was correlated with GCS in the CEA group (70%ECST vs. 20%ECST; p=0.026) and with echolucent plaque morphology in the CAS group (6% vs. 1%; p=0.048). In multivariate analysis, occlusion of the contralateral carotid artery (CCO) was associated with risk of any stroke (OR 7.00; p=0.006), without heterogeneity between CEA and CAS. CONCLUSION In patients with asymptomatic carotid artery stenosis, GCS, CCO, as well as echolucent plaque morphology were associated with a higher risk of cerebrovascular events. The risk of stroke in the periprocedural period was increased by GCS in CEA and by echolucent plaque in CAS. Due to small sample size, results must be interpreted carefully.
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Affiliation(s)
- Tilman Reiff
- Department of Neurology, University Hospital of Heidelberg, Heidelberg, Germany.
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
| | - Ulrich Mansmann
- Institute of Medical Informatics, Biometry and Epidemiology, Ludwig-Maximilians-Universität München, Munich, Germany.
| | - Olav Jansen
- Department of Radiology and Neuroradiology, UKSH Campus Kiel, Kiel, Germany.
| | - Gustav Fraedrich
- Department of Vascular Surgery, University Hospital of Innsbruck, Innsbruck, Austria.
| | - Harald Mudra
- Department of Cardiology, München Klinik, Klinikum Neuperlach, Munich, Germany.
| | - Dittmar Böckler
- Department of Vascular and Endovascular Surgery, University Hospital of Heidelberg, Heidelberg, Germany.
| | - Michael Böhm
- Department of Internal Medicine, University Hospital of Homburg/Saar, Homburg, Germany.
| | - Hartmut Brückmann
- Department of Neuroradiology, Ludwig-Maximilians-Universität München, Munich, Germany.
| | - E Sebastian Debus
- Department of Vascular Surgery, University Hospital of Hamburg, Hamburg, Germany.
| | - Jens Fiehler
- Department of Neuroradiology, University Hospital of Hamburg, Hamburg, Germany.
| | - Klaus Mathias
- Department of Radiology, Klinikum Dortmund, Germany.
| | | | - Jürg Schmidli
- Department of Vascular Surgery, University Hospital of Bern, Bern, Switzerland.
| | - Robert Stingele
- Department of Neurology, DRK-Kliniken Berlin, Berlin, Germany.
| | - Ralf Zahn
- Department of Internal Medicine, Klinikum Ludwigshafen, Ludwigshafen, Germany.
| | - Thomas Zeller
- Department of Angiology, University Heart-Center Freiburg-Bad Krozingen, Bad Krozingen, Germany.
| | - Wolf-Dirk Niesen
- Department of Neurology, University Hospital Freiburg, Freiburg, Germany.
| | - Kristian Barlinn
- Department of Neurology, University Hospital of Dresden, Dresden, Germany.
| | - Andreas Binder
- Department of Neurology, UKSH Campus Kiel, Kiel, Germany.
| | - Jörg Glahn
- Department of Neurology, Johannes Wesling Klinikum, Minden, Germany.
| | - Peter Arthur Ringleb
- Department of Neurology, University Hospital of Heidelberg, Heidelberg, Germany.
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Sun Y, Ding Y, Meng K, Han B, Wang J, Han Y. Comparison the effects of carotid endarterectomy with carotid artery stenting for contralateral carotid occlusion. PLoS One 2021; 16:e0250580. [PMID: 34014931 PMCID: PMC8136671 DOI: 10.1371/journal.pone.0250580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 04/08/2021] [Indexed: 11/18/2022] Open
Abstract
Background There have been inconsistent results regarding the use of carotid artery endarterectomy (CEA) versus carotid artery stenting (CAS) for contralateral carotid occlusion (CCO). This study aimed to determine the optimal revascularization technique for patients with CCO. Methods We systematically searched the PubMed, Embase, and Cochrane Library databases to identify eligible studies published from inception to January 2, 2021. Odds ratios (ORs) with 95% confidence intervals (CIs) were used to calculate pooled effect estimates using a random-effects model. Sensitivity, subgroup, and publication bias analyses were also performed. Results Six studies involving 6,953 patients were selected for inclusion in this meta-analysis. Our results showed that while CEA was not associated with an increased risk of stroke compared to CAS (OR: 1.07; 95% CI: 0.75–1.51; P = 0.713), CEA was associated with a reduced risk of death compared to CAS (OR: 0.45; 95% CI: 0.29–0.70; P < 0.001). Furthermore, there were no significant differences between CEA and CAS for the risks of myocardial infarction (OR: 1.38; 95% CI: 0.73–2.62; P = 0.319) or major adverse cardiovascular events (OR: 1.03; 95% CI: 0.56–1.88; P = 0.926). Finally, the risk of myocardial infarction for CEA versus CAS was affected by disease status, while the risk of major adverse cardiovascular events was affected by the proportions of patients with male gender, coronary artery disease, and current or prior smoking. Conclusion This study found that CEA and CAS resulted in similar outcomes for patients with CCO, while the risk of death was reduced in patients treated with CEA. Further high-level evidence should be collected to verify the results of this study.
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Affiliation(s)
- Yaxuan Sun
- Department of Neurology, Shanxi Provincial People’s Hospital, Taiyuan, Shanxi, China
- * E-mail:
| | - Yongxia Ding
- College of Nursing, Shanxi Medical University, Shanxi, China
| | - Kun Meng
- Department of Neurology, Shanxi Provincial People’s Hospital, Taiyuan, Shanxi, China
| | - Bin Han
- Department of Neurology, Shanxi Provincial People’s Hospital, Taiyuan, Shanxi, China
| | - Jing Wang
- Department of Neurology, Shanxi Provincial People’s Hospital, Taiyuan, Shanxi, China
| | - Yan Han
- Department of Neurology, Shanxi Provincial People’s Hospital, Taiyuan, Shanxi, China
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Liu D, Li ZL, Wang M, Wu RD, Wang JS, Wang SM, Yao C, Chang GQ. Comparative Analysis of Patch Angioplasty Versus Selective Primary Closure during Carotid Endarterectomy Performed at a Single Vascular Center in China. Ann Vasc Surg 2020; 73:344-350. [PMID: 33383139 DOI: 10.1016/j.avsg.2020.11.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 10/30/2019] [Accepted: 11/14/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND One of the ongoing debates about carotid endarterectomy (CEA) is the closure technique of arterial wall in the operation. Current guidelines recommend routine patch closure (PAC); this recommendation is based on the evidence reported 10-20 years ago. Therefore, the exact role of PAC and primary closure (PRC) remains uncertain. The objectives of this study were to compare the perioperative and long-term outcomes of patients who underwent CEA with different closure techniques. METHODS From January 2013 and December 2018, one senior vascular surgeon performed CEA for 126 patients in the First Affiliated Hospital, Sun Yat-sen University. The closure technique (PAC or PRC) was determined on the characteristics (diameter and level) of carotid arteries. Patient demographics and clinical data were retrospectively collected by two research fellows by reviewing the hospital medical records and relevant radiologic studies, as were carotid duplex reports, indications, intraoperative data, closure technique, and perioperative complications. Data of long-term outcomes were gathered by reviewing outpatient clinic visits and associated supplementary examinations. RESULTS PRC was performed in 78 operations (61.9%), and PAC was performed in 48 operations (38.1%). There were no statistical differences in demographic and clinical data between the two groups. Carotid clamp time (P < 0.001) and operating time (P < 0.001) were significantly longer when performing PAC (P < 0.001), and intraoperative blood loss was significantly more when performing PAC than that of PRC (P < 0.001). The postoperative outcome and the follow-up results showed that there was no significant difference in the short-term and middle-term overall survival rate and restenosis-free survival rate between the two groups. CONCLUSIONS There are no differences in postoperative and middle-term outcomes between PAC and selective PRC, whereas PRC technique can save operation time and shorten the intraoperative carotid clamp time. PRC can be safely applied in patients with a greater than 5 mm internal carotid artery (ICA).
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Affiliation(s)
- Duan Liu
- Division of Vascular Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Zi-Lun Li
- Division of Vascular Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Mian Wang
- Division of Vascular Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Ri-Dong Wu
- Division of Vascular Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Jin-Song Wang
- Division of Vascular Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Shen-Ming Wang
- Division of Vascular Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Chen Yao
- Division of Vascular Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Guang-Qi Chang
- Division of Vascular Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China.
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Casana R, Domanin M, Malloggi C, Tolva VS, Odero Jr A, Bissacco D, Trimarchi S, Silani V, Parati G. Influence of contralateral carotid artery occlusions on short- and long-term outcomes of carotid artery stenting: a retrospective single-center analysis and review of literature. INT ANGIOL 2020; 40:87-96. [PMID: 33274909 DOI: 10.23736/s0392-9590.20.04525-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND In the current literature, correlations between a contralateral carotid artery occlusion (CCO) with mortality and major adverse cardiac or cerebrovascular events (MACCE) rates after carotid artery stenting (CAS) are often described with controversial conclusions. Moreover, long-term results of mortality, MACCE and restenosis rate are scarcely reported. This study examined the association between a CCO and the short- and long-term outcomes after CAS. METHODS One hundred and forty-six patients with CCO and without (No-CCO) who underwent between 2010 and 2017 to a CAS procedure in a single institution were retrospectively evaluated. The primary aim of the study was to evaluate mortality and MACCE rates in the short-term (defined as the occurrence during hospitalization and within 30-day) and after 3-year follow-up. The secondary aim of the study was to examine the restenosis rates in the short- and long-term period. RESULTS The overall success of CAS was 99.3% and the 30-day all-cause mortality rate was 0.7% (one death). About MACCE, there were no major strokes in the CCO groups and 1 (1.4%) in the No-CCO group (P=1.00). The rate of 30-day minor strokes was 1.4% (1 patient) in the CCO group and 2.7% (2 patients) in the No-CCO group (P=1.00). In the 3-year follow-up, death occurred in 11 CCO vs. 6 No-CCO patients, respectively (15.1% vs. 8.2%, P=0.30). Regarding MACCE, major stroke occurred in 6 CCO vs. 2 No-CCO patients (8.2% vs. 2.7%, P=0.27), minor stroke in 6 CCO vs. 6 No-CCO (8.2% vs. 8.2%, P=1.0) and myocardial infarction in 6 CCO (8.2%) vs. 3 No-CCO patients (8.2 vs. 4.1%, P=0.49), respectively. Regarding the 30-day restenosis rate, it was observed in one patient (1.4%) in the CCO group while no cases were recorded in the No-CCO group, respectively (P=1.00). In the 3-year follow-up, greater than >50% restenosis was observed in 7 patients (9.6%) in the CCO group and in one patient (1.4%) in the No-CCO group (P=0.06), respectively. Kaplan-Meier survival analysis revealed that CCO patients had a lower 3-year freedom from restenosis rate with respect to the No-CCO group (87.6% vs. 98.6%, P=0.024). A Cox regression model on 3-year restenosis highlighted female gender and hypertension to be statistically significant predictors of restenosis. CONCLUSIONS Patients with a preexisting CCO did not show a significative increased risk of procedural adverse events after CAS both in the immediate and long-term follow-up, but on the long term they are more likely to experience restenosis. CCO condition should be considered always as a clinical manifestation of a more aggressive carotid atherosclerosis.
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Affiliation(s)
- Renato Casana
- Department of Surgery, IRCCS Istituto Auxologico Italiano, Milan, Italy - .,Laboratory of Research in Vascular Surgery, IRCCS Istituto Auxologico Italiano, Milan, Italy -
| | - Maurizio Domanin
- Vascular Surgery Unit, IRCCS, Ospedale Maggiore Policlinico, Milan, Italy.,Università degli Studi di Milano, Milan, Italy
| | - Chiara Malloggi
- Laboratory of Research in Vascular Surgery, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Valerio S Tolva
- Department of Vascular and Endovascular Surgery, Policlinico di Monza, Monza, Monza-Brianza, Italy
| | - Andrea Odero Jr
- Department of Surgery, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Daniele Bissacco
- Vascular Surgery Unit, IRCCS, Ospedale Maggiore Policlinico, Milan, Italy
| | - Santi Trimarchi
- Vascular Surgery Unit, IRCCS, Ospedale Maggiore Policlinico, Milan, Italy.,Università degli Studi di Milano, Milan, Italy
| | - Vincenzo Silani
- Department of Neurology-Stroke and Neuroscience, IRCCS Istituto Auxologico Italiano, Ospedale San Luca, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, San Luca Hospital, Milan, Italy.,Department of Medicine and Surgery, Università di Milano-Bicocca, Monza, Monza-Brianza, Italy
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Machin M, Salim S, Onida S, Davies AH. The less invasive paradox, why carotid artery stenting is not suitable for the high-risk patient. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1269. [PMID: 33178801 PMCID: PMC7607106 DOI: 10.21037/atm-19-4085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Carotid artery stenosis causes significant morbidity and mortality accounting for approximately 8% of all ischaemic strokes. Carotid artery stenting (CAS) offers an endovascular alternative to carotid endarterectomy (CEA), suggested as a viable option in those deemed high-risk for open CEA due to comorbidities or operative technical considerations. A number of large randomised-controlled trials (RCTs) and meta-analysis comparing CAS vs. CEA in unselected patient populations support the conclusion that CAS is associated with a higher risk of stroke and CEA is associated with a higher risk of myocardial infraction. Initial promise for CAS in high-risk patients was demonstrated by The Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) trial that reported CAS was non-inferior to CEA. However, there is evidence to suggest age-related adverse outcome in patients undergoing CAS. There is limited evidence to suggest that CEA could be suitable even in patients deemed high-risk for medical or technical reasons. Further contemporary research on the use of CAS and CEA in high-risk patients is required to re-evaluate current guidelines and high-risk criterion. It is common for a composite outcome of death, ipsilateral stroke and MI which should be questioned as subsequent quality of life is likely to differ after suffering a stroke in comparison to MI. This literature review will discuss the current evidence for CAS and CEA interventions in unselected populations and high-risk patients with carotid disease requiring intervention.
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Affiliation(s)
- Matthew Machin
- Academic Department of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK.,Imperial Vascular Unit, Imperial Healthcare NHS Trust, London, UK
| | - Safa Salim
- Academic Department of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK.,Imperial Vascular Unit, Imperial Healthcare NHS Trust, London, UK
| | - Sarah Onida
- Academic Department of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK.,Imperial Vascular Unit, Imperial Healthcare NHS Trust, London, UK
| | - Alun Huw Davies
- Academic Department of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK.,Imperial Vascular Unit, Imperial Healthcare NHS Trust, London, UK
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Dakour-Aridi H, Schermerhorn ML, Husain F, Eldrup-Jorgensen J, Lane J, Malas MB. Outcomes of transcarotid artery revascularization with dynamic flow reversal in patients with contralateral carotid artery occlusion. J Vasc Surg 2020; 73:524-532.e1. [PMID: 32569716 DOI: 10.1016/j.jvs.2020.04.529] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 04/21/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND The outcomes of carotid revascularization in patients with contralateral carotid artery occlusion (CCO) are controversial. CCO has been defined by the Centers for Medicare and Medicaid Services as a high-risk criterion and is used as an indication for transfemoral carotid artery stenting. With the promising outcomes associated with transcarotid artery revascularization (TCAR), we aimed to study the perioperative outcomes of TCAR in patients with CCO and to assess the feasibility of TCAR in these high-risk patients. METHODS All patients in the Vascular Quality Initiative database who underwent TCAR with flow reversal between September 2016 and May 2019 were included. Patients with trauma, dissection, or more than two treated lesions were excluded. Univariable and multivariable logistic analyses were used to compare the primary outcome of in-hospital stroke or death after TCAR in patients with CCO and those without CCO (patent and <99% stenosis). Secondary outcomes included intraoperative neurologic changes and the individual outcomes of in-hospital stroke, death, and myocardial infarction as well as 30-day mortality. RESULTS A total of 5485 TCAR cases were included, of which 593 (10.8%) had CCO. In patients with CCO, mean flow reversal time was shorter (10.1 ± 6.7 minutes vs 11.1 ± 7.8 minutes; P < .01); intraoperative neurologic changes occurred in 1% of these patients compared with 0.7% of those with patent contralateral carotid arteries (P = .43). On univariable analysis, no significant difference in in-hospital stroke or death was shown between patients with and patients without CCO (1.7% vs 1.5%; P = .65). Similarly, no significant differences were noted between the groups in terms of in-hospital death (0.7% vs 0.4%; P = .27), stroke (1.7% vs 1.2%; P = .32), and stroke/death/myocardial infarction (2.2% vs 1.8%; P = .53) as well as 30-day mortality (0.8% vs 0.6%; P = .55). The results remained statistically nonsignificant after adjustment for baseline differences between the groups; the adjusted odds ratio (OR) of in-hospital stroke/death in patients with CCO compared with those with patent contralateral carotid arteries was not significant (OR, 1.39; 95% confidence interval, 0.65-3.0; P = .40). In symptomatic patients presenting with prior stroke, CCO was associated with significantly higher odds of stroke or death (OR, 4.63; 95% confidence interval, 1.39-15.4; P = .01) compared with no CCO. On the other hand, in asymptomatic patients, no significant difference in outcomes was observed between the groups. CONCLUSIONS In this analysis, TCAR seems to be safe in patients with CCO. Caution should be taken in symptomatic patients with CCO and a history of prior stroke as they might have worse outcomes compared with patients with patent contralateral carotid arteries. Studies with larger sample size and longer follow-up are needed to assess the perioperative and long-term outcomes of TCAR in patients with CCO in comparison to other procedures.
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Affiliation(s)
- Hanaa Dakour-Aridi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, Calif
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass
| | - Farhan Husain
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, Calif
| | - Jens Eldrup-Jorgensen
- Division of Vascular Surgery, Department of Surgery, Maine Medical Center, Portland, Me
| | - John Lane
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, Calif
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, Calif.
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