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[Minimally invasive catheters in varicose vein treatment : New gold standard?]. DERMATOLOGIE (HEIDELBERG, GERMANY) 2023; 74:163-170. [PMID: 36811641 PMCID: PMC9981706 DOI: 10.1007/s00105-023-05113-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 01/12/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Endovenous procedures are commonly used for varicose vein treatment. OBJECTIVES Types, functionality, and significance of endovenous devices. METHODS To describe the different endovenous devices, their mode of action, inherent risks and efficacy according to the literature. RESULTS Long-term data confirm that endovenous procedures are equally effective as open surgery. Postoperative pain is minimal and downtime shorter after catheter interventions. CONCLUSION Catheter-based endovenous procedures increase the diversity of varicose vein treatment options. They are preferred by patients due to less pain and shorter downtime.
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Eggen CAM, Alozai T, Pronk P, Mooij MC, Gaastra MTW, Ünlü Ç, Schreve MA, van Vlijmen CJ. Ten-year follow-up of a randomized controlled trial comparing saphenofemoral ligation and stripping of the great saphenous vein with endovenous laser ablation (980 nm) using local tumescent anesthesia. J Vasc Surg Venous Lymphat Disord 2022; 10:646-653.e1. [PMID: 34450354 DOI: 10.1016/j.jvsv.2021.08.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 08/05/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The long-term results of saphenofemoral ligation and stripping (SFL/S) were compared with 980-nm bare fiber endovenous laser ablation (EVLA) for the treatment of great saphenous vein (GSV) incompetence. METHODS This was a single-center, randomized, controlled trial with a follow-up time of 10 years. Patients with GSV incompetence were randomized to undergo SFL/S or EVLA under tumescent anesthesia. The primary outcome was recurrence of groin-related varicose veins seen on duplex ultrasound imaging and clinical examination. The secondary outcomes were (changes or improvement in) CEAP clinical class, venous symptoms, cosmetic results, quality of life, reinterventions, and complications. RESULTS Between June 2007 and December 2008, 122 patients (130 limbs) were included; of these, 68 limbs were treated with SFL/S and 62 limbs with EVLA. The 10-year estimated freedom from groin recurrence as seen on duplex ultrasound imaging was higher in the SFL/S group (73% vs 44% in the EVLA group; P = .002), and the same trend was seen for clinically evident recurrence (77% vs 58%, respectively; P = .034). Nine reinterventions (17%) were deemed necessary in the SFL/S group vs 18 (36%) in the EVLA group (P = .059). All reinterventions in the SFL/S group consisted of foam sclerotherapy. Reinterventions in the EVLA group included foam sclerotherapy (n = 5), crossectomy (n = 2), and endovenous procedures (n = 11). There was no significant differences in quality of life and relief of venous symptoms. Cosmetic appearance improved, with a better cosmetic rating in the SFL/S group compared with the EVLA group (P = .026). One patient in the SFL/S group had a persisting neurosensory deficit remaining at 10 years. CONCLUSIONS This study showed no clear long-term advantage of EVLA with a 980-nm wavelength and bare-tip fiber over high ligation and stripping of the GSV under local tumescent anesthesia.
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Affiliation(s)
- Céline A M Eggen
- Department of Phlebology, Skin and Vein Clinic Oosterwal, Alkmaar, The Netherlands.
| | - Tamana Alozai
- Department of Surgery, Northwest Clinics, Alkmaar, The Netherlands
| | - Pascal Pronk
- Department of Phlebology, Skin and Vein Clinic Oosterwal, Alkmaar, The Netherlands
| | - Michael C Mooij
- Department of Phlebology, Skin and Vein Clinic Oosterwal, Alkmaar, The Netherlands
| | - Menno T W Gaastra
- Department of Phlebology, Skin and Vein Clinic Oosterwal, Alkmaar, The Netherlands
| | - Çağdaş Ünlü
- Department of Surgery, Northwest Clinics, Alkmaar, The Netherlands
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De Maeseneer MG, Kakkos SK, Aherne T, Baekgaard N, Black S, Blomgren L, Giannoukas A, Gohel M, de Graaf R, Hamel-Desnos C, Jawien A, Jaworucka-Kaczorowska A, Lattimer CR, Mosti G, Noppeney T, van Rijn MJ, Stansby G, Esvs Guidelines Committee, Kolh P, Bastos Goncalves F, Chakfé N, Coscas R, de Borst GJ, Dias NV, Hinchliffe RJ, Koncar IB, Lindholt JS, Trimarchi S, Tulamo R, Twine CP, Vermassen F, Wanhainen A, Document Reviewers, Björck M, Labropoulos N, Lurie F, Mansilha A, Nyamekye IK, Ramirez Ortega M, Ulloa JH, Urbanek T, van Rij AM, Vuylsteke ME. Editor's Choice - European Society for Vascular Surgery (ESVS) 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs. Eur J Vasc Endovasc Surg 2022; 63:184-267. [PMID: 35027279 DOI: 10.1016/j.ejvs.2021.12.024] [Citation(s) in RCA: 242] [Impact Index Per Article: 121.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 11/12/2021] [Indexed: 01/12/2023]
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Guarinello GG, Coral FE, Timi JRR, Machado SF. Assessment of residual stumps 12 months after saphenectomy without high ligation of the saphenofemoral junction. J Vasc Bras 2021; 20:e20210029. [PMID: 34267791 PMCID: PMC8256878 DOI: 10.1590/1677-5449.210029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 05/02/2021] [Indexed: 11/22/2022] Open
Abstract
Background Currently, the first-choice option recommended for varicose vein surgery is thermal ablation of the saphenous vein, but this procedure is not available on the Brazilian National Health Service (SUS - Sistema Único de Saúde). In an effort to improve results, surgical techniques have been developed to mimic the new technologies, without their high costs. The most prominent such method involves conventional saphenectomy, without ligation of tributaries. Objectives To assess progression of the residual stump after saphenectomy without high ligation of the saphenofemoral junction but with stump invagination and to assess the behavior of anterior/posterior accessory veins. Methods Prospective intervention study. A total of 52 limbs were treated with saphenectomy without high ligation of the saphenofemoral junction followed by invagination of the residual stump. Patients were assessed preoperatively and at 7 days, and 3, 6, and 12 months postoperatively using vascular ultrasonography with Doppler to analyze the length of the residual stump, the diameters of the residual stump and the anterior/posterior accessory vein, reflux in the accessory vein, and presence of neovascularization. Statistical analysis involved calculation of means, standard deviations, medians, minimum and maximum values, frequencies, and percentages, and Fisher's test and the binomial test. Results There was evidence of a significant time effect on residual stump diameter (p < 0.001) and length (p = 0.002), but the same was not observed with relation to diameter (p = 0.355) or reflux of the anterior accessory vein. Neovascularization was found in 7 (14.3%) limbs. Conclusions After use of the technique described, the residual stump retracted, its diameter reduced over the 1 year postoperative period, and it did not transfer reflux to the accessory vein. Neovascularization rates were in line with the literature.
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Affiliation(s)
| | - Francisco Eduardo Coral
- Hospital Santa Casa de Curitiba - HSCMC, Curitiba, PR, Brasil.,Pontifícia Universidade Católica do Paraná - PUCPR, Curitiba, PR, Brasil
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Mühlberger D, Zumholz AK, Brenner E, Mumme A, Stücker M, Falkenstein T, Hummel T. Cellular senescence at the saphenofemoral junction in patients with healthy, primary varicose and recurrent varicose veins - A pilot study. Vascular 2021; 30:559-567. [PMID: 33938326 DOI: 10.1177/17085381211012882] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Cellular senescence could play a role in the development of venous disease. Superficial venous reflux at the saphenofemoral junction is a common finding in patients with primary varicose veins. Furthermore, reflux in this essential area is associated with higher clinical stages of the disease and recurrent varicose veins. Therefore, this pilot study aimed to investigate cellular senescence in the immediate area of the saphenofemoral junction in patients with healthy veins, primary varicose veins and additionally in patients with recurrent varicose veins due to a left venous stump. METHODS We analyzed vein specimens of the great saphenous vein immediately at the saphenofemoral junction. Healthy veins were collected from patients who underwent arterial bypass reconstructions. Samples with superficial venous reflux derived from patients who received high ligation and stripping or redo-surgery at the groin, respectively. Sections were stained for p53, p21, and p16 as markers for cellular senescence and Ki67 as a proliferation marker. RESULTS A total of 30 samples were examined (10 healthy, 10 primary varicose, and 10 recurrent varicose veins). We detected 2.10% p53+ nuclei in the healthy vein group, 3.12% in the primary varicose vein group and 1.53% in the recurrent varicose vein group, respectively. These differences were statistically significant (p = 0.021). In the healthy vein group, we found 0.43% p16+ nuclei. In the primary varicose vein group, we found 0.34% p16+ nuclei, and in the recurrent varicose vein group, we found 0.74% p16+ nuclei. At the p < 0.05 level, the three groups tended to be significant without reaching statistical significance (p = 0.085). There was no difference in respect of p21 and Ki67. CONCLUSION We found significantly higher expression rates of p53 in primary varicose veins at the saphenofemoral junction than in healthy veins. p16 expression tended to be increased in the recurrent varicose vein group. These preliminary findings indicate that cellular senescence may have an impact in the development of varicose veins or recurrence. Further studies addressing this issue are necessary.
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Affiliation(s)
- Dominic Mühlberger
- Department of Vascular Surgery, St. Josef Hospital Bochum, Katholisches Klinikum Bochum, Clinic of the Ruhr University Bochum, Bochum, Germany.,Vein Center of the Departments of Dermatology and Vascular Surgery, Katholisches Klinikum Bochum, Bochum, Germany
| | - Anne-Katrin Zumholz
- Department of Vascular Surgery, St. Josef Hospital Bochum, Katholisches Klinikum Bochum, Clinic of the Ruhr University Bochum, Bochum, Germany
| | - Erich Brenner
- Institute of Clinical and Functional Anatomy, Department of Anatomy, Histology and Embryology, Medical University of Innsbruck, Innsbruck, Austria
| | - Achim Mumme
- Department of Vascular Surgery, St. Josef Hospital Bochum, Katholisches Klinikum Bochum, Clinic of the Ruhr University Bochum, Bochum, Germany.,Vein Center of the Departments of Dermatology and Vascular Surgery, Katholisches Klinikum Bochum, Bochum, Germany
| | - Markus Stücker
- Vein Center of the Departments of Dermatology and Vascular Surgery, Katholisches Klinikum Bochum, Bochum, Germany.,Department of Dermatology, St. Josef Hospital Bochum, Katholisches Klinikum Bochum, Clinic of the Ruhr University Bochum, Bochum, Germany
| | - Thomas Falkenstein
- Department of Vascular Surgery, St. Josef Hospital Bochum, Katholisches Klinikum Bochum, Clinic of the Ruhr University Bochum, Bochum, Germany.,Vein Center of the Departments of Dermatology and Vascular Surgery, Katholisches Klinikum Bochum, Bochum, Germany
| | - Thomas Hummel
- Department of Vascular Surgery, St. Josef Hospital Bochum, Katholisches Klinikum Bochum, Clinic of the Ruhr University Bochum, Bochum, Germany.,Vein Center of the Departments of Dermatology and Vascular Surgery, Katholisches Klinikum Bochum, Bochum, Germany
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Müller L, Alm J. Feasibility and potential significance of prophylactic ablation of the major ascending tributaries in endovenous laser ablation (EVLA) of the great saphenous vein: A case series. PLoS One 2021; 16:e0245275. [PMID: 33412566 PMCID: PMC7790536 DOI: 10.1371/journal.pone.0245275] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 12/27/2020] [Indexed: 11/29/2022] Open
Abstract
Background Recurrent varicosities after endovascular laser ablation (EVLA) of the great saphenous vein (GSV) are frequently due to varicose transformed, initially unsealed major ascending tributaries of the saphenofemoral junction (SFJ). Preventive ablation of these veins, especially the anterior accessory saphenous vein, is discussed as an option, along with flush occlusion of the GSV. However, few related data exist to date. Methods A consecutive case series of 278 EVLA procedures of the GSV for primary varicosis in 213 patients between May and December 2019 was retrospectively reviewed. The ablations were performed with a 1470 nm dual-ring radial laser and always included flush occlusion of the GSV, and concomitant ablation of its highest ascending tributaries by additional cannulation and ablation when this seemed anatomically appropriate. The initial technical success, comprising occlusion of the GSV and its major tributaries, was set as the primary endpoint. Possible determinants were explored using downstream multiple logistic regression analysis. Results The early technical success was 92.8%, with the GSV occluded in 99.6% and the highest ascending SFJ tributary, if present, in 92.4%. Additional ablations of ascending tributaries were performed in 171 cases (61.5%), the latter being associated with success (OR 10.39; 95% CI [3.420–36.15]; p < 0.0001). Presence of anterior as opposed to posterior accessory saphenous vein was another positive predictor (OR 3.959; 95% CI [1.142–13,73]; p = 0.027), while a confluence of the tributary in the immediate proximity to the SFJ had a negative impact (OR 0.2253; 95% CI [0.05456–0.7681]; p = 0.0253). An endothermal heat-induced thrombosis (EHIT) ≥ grade 2 was observed in three cases (1.1%). Conclusions A co-treatment of the tributaries is feasible and could improve the technical success of EVLA if a prophylactic closure of these veins is desired, especially if their distance to the SFJ is short. Its effect on the recurrence rate needs further research.
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Affiliation(s)
- Lars Müller
- Department of Vascular Surgery, Dermatologikum Hamburg, Hamburg, Germany
- * E-mail:
| | - Jens Alm
- Department of Vascular Surgery, Dermatologikum Hamburg, Hamburg, Germany
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Spinedi L, Stricker H, Keo HH, Staub D, Uthoff H. Feasibility and safety of flush endovenous laser ablation of the great saphenous vein up to the saphenofemoral junction. J Vasc Surg Venous Lymphat Disord 2020; 8:1006-1013. [PMID: 32284310 DOI: 10.1016/j.jvsv.2020.01.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 01/30/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The optimal ablation distance from the catheter tip to the common femoral vein during endovenous laser ablation (EVLA) of the great saphenous vein (GSV) is a matter of debate. In this study, we evaluated the feasibility and safety of flush ablation (fEVLA) of the GSV. METHODS This single-center, retrospective analysis of prospectively collected data included all consecutive fEVLA interventions of the GSV between September 2017 and October 2018. Interventions were performed with a 1470-nm radially emitting fiber. Primary end points were technical feasibility of fEVLA and endovenous heat-induced thrombosis (EHIT) class 2 to class 4. Secondary end points were procedure-related complications; anatomic success at week 6; and flush occlusion at day 1, day 10, and week 6. RESULTS A total of 135 consecutive intended fEVLA procedures were performed in 113 patients (86 female, 27 male). The average body mass index was 24.9 ± 4.3 kg/m2. The Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) clinical class for these patients was C2 in 78 (57.8%), C3 in 48 (35.6%), C4 in 8 (5.9%), and C5 in 1 (0.7%). The GSV diameter at the saphenofemoral junction was 9.4 ± 2.7 mm with a maximum of 16 mm. In 126 cases (93.3%), concomitant treatment of tributaries with phlebectomy or foam sclerotherapy was performed. In 127 cases (94.1%), fEVLA was technically feasible; in 8 cases (5.9%), appropriate catheter tip placement was not possible. In these cases, "standard" GSV ablation 10 to 20 mm distal to the saphenofemoral junction was performed. In the remaining 127 cases, one (0.8%) EHIT class 2 and one (0.8%) EHIT class 3 developed at day 10. After a 2- to 3-week course of anticoagulation with rivaroxaban, these EHIT cases resolved without sequelae. Furthermore, one (0.8%) superficial vein thrombosis and one (0.8%) calf vein thrombosis at the site of phlebectomy were observed. No local groin complication occurred. Flush occlusion was observed in 94.5%, 95.3%, and 88.2% of the cases at day 1, day 10, and week 6, respectively. Multivariate regression analysis revealed no significant association between flush ablation at day 1 and age, body mass index, CEAP class, fiber type, maximum vein diameter, or applied joules per centimeter. CONCLUSIONS The results of this study suggest that fEVLA of the GSV using a radial emitting laser is feasible and seems to be safe.
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Affiliation(s)
- Luca Spinedi
- Department of Angiology, Ospedale Regionale di Locarno, Locarno, Switzerland.
| | - Hans Stricker
- Department of Angiology, Ospedale Regionale di Locarno, Locarno, Switzerland
| | - Hak Hong Keo
- Department of Angiology, University Hospital Basel, University of Basel, Basel, Switzerland; Vascular Institute Central Switzerland, Aarau, Switzerland
| | - Daniel Staub
- Department of Angiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Heiko Uthoff
- Department of Angiology, University Hospital Basel, University of Basel, Basel, Switzerland; Gefässpraxis am See, Lakeside Vascular Center, Lucerne, Switzerland
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Masuda E, Ozsvath K, Vossler J, Woo K, Kistner R, Lurie F, Monahan D, Brown W, Labropoulos N, Dalsing M, Khilnani N, Wakefield T, Gloviczki P. The 2020 appropriate use criteria for chronic lower extremity venous disease of the American Venous Forum, the Society for Vascular Surgery, the American Vein and Lymphatic Society, and the Society of Interventional Radiology. J Vasc Surg Venous Lymphat Disord 2020; 8:505-525.e4. [PMID: 32139328 DOI: 10.1016/j.jvsv.2020.02.001] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 02/02/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Stimulated by published reports of potentially inappropriate application of venous procedures, the American Venous Forum and its Ethics Task Force in collaboration with multiple other professional societies including the Society for Vascular Surgery (SVS), American Vein and Lymphatic Society (AVLS), and the Society of Interventional Radiology (SIR) developed the appropriate use criteria (AUC) for chronic lower extremity venous disease to provide clarity to the application of venous procedures, duplex ultrasound imaging, timing, and reimbursements. METHODS The AUC were developed using the RAND/UCLA Appropriateness Method, a validated method of developing appropriateness criteria in health care. By conducting a modified Delphi exercise and incorporating best available evidence and expert opinion, AUC were developed and scored. RESULTS There were 119 scenarios rated on a scale of 1 to 9 by an expert panel, with 1 being never appropriate and 9 being appropriate. The majority of scenarios consisted of symptomatic indications were deemed appropriate for venous intervention. For scenarios with anatomically short segments of reflux and/or no symptoms, the indications were rated less appropriate. For the indication of edema, a wide dispersion of ratings was observed especially for short segments of saphenous reflux or stenting for iliac/ inferior vena cava disease, noting that there are multifactorial causes of edema, some of which could coexist with venous disease and possibly impact effectiveness of treatment. Several scenarios were considered never appropriate, including treatment of saphenous veins with no reflux, iliac vein or inferior vena cava stenting for iliac vein compression as an incidental finding by imaging with minimal or no symptoms or signs, and incentivizing sonographers to find reflux. CONCLUSIONS The AUC statements are intended to serve as a guide to patient care, particularly in areas where high-quality evidence is lacking to aid clinicians in making day-to-day decisions for common venous interventions. This may also prove useful when applied on a population level, such as practice patterns, and not necessarily to dictate decision making for individual cases. As a product of a collaborative effort, it is hoped that this could be utilized by physicians and multiple stakeholders committed toward improving patient care and to identify and stimulate future research priorities.
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Affiliation(s)
- Elna Masuda
- Straub Medical Center, Hawaii Pacific Health, Honolulu, Hawaii.
| | | | | | - Karen Woo
- Department of Surgery, University of California, Los Angeles, Los Angeles, Calif
| | | | | | | | - William Brown
- William Beaumont Hospital and Wayne State University School of Medicine, Bingham Farms, Mich
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Residual incompetent tributaries after varicose vein surgery increased the need for reintervention after 8 years. J Vasc Surg Venous Lymphat Disord 2020; 8:378-382.e1. [PMID: 31992538 DOI: 10.1016/j.jvsv.2019.11.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 11/03/2019] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The aim of this study was to determine whether residual incompetent tributaries after varicose vein surgery affected the reintervention rate after longer follow-up. METHODS The study is a retrospective review of data from a cohort of a previous randomized controlled study comparing surgery with and without preoperative duplex ultrasound, with follow-up after 2 months, 2 years, and 5 to 9 years clinically and with duplex ultrasound. The cohort was subdivided according to the duplex ultrasound findings 2 months after surgery: no venous incompetence, residual incompetent tributaries only, truncal incompetence, and combined truncal and tributary incompetence. Reintervention rates were compared between groups. RESULTS There were 280 patients (326 legs) who attended follow-up 2 months postoperatively and 164 patients (190 legs) after a median of 8 years (5-9 years). Another 53 patients (62 legs) were interviewed by telephone or had been reoperated on earlier during follow-up; thus, information was available for 217 patients (252 legs). Of the 252 legs, 56 (22%) were reoperated on during follow-up. In the subgroup with no venous incompetence at all 2 months postoperatively, 4 of 74 legs (5%) were reoperated on; and in the group with residual incompetent tributaries without truncal incompetence, 16 of 56 legs (29%) were reoperated on (P = .000). There was no significant difference in reintervention rate of the group with incompetent tributaries only compared with those with truncal incompetence without incompetent tributaries (12/42 legs [29%]; P = 1) or with combined incompetence of truncal vein and tributaries (22/64 legs [34%]; P = .495). The presence of perforating vein incompetence at 2 months postoperatively did not significantly alter the rate of reoperations (P = .159). In legs that had not been reoperated on, more incompetent veins could be seen progressively. In the group without any incompetent veins postoperatively, 37% still had normal findings at 8 years. CONCLUSIONS Residual incompetent tributaries after treatment of varicose veins will increase the reintervention rate in the long term, as much as leaving a trunk vein untreated. Patients should be informed about the increased risk of reintervention if not all incompetent veins are targeted.
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