Please use agreed template: DD1 V2 - Circulation Foundation



PAD (Purple)

Intermittant Claudication

Leg Amputation

Fempop/Femdistal Bypass

Angioplasty and stent

Aorto/Axillo Bypass

Vascular Disease and Diabetes

Intermittant Claudication

Intermittent Claudication is caused by narrowing or blockage in the main artery taking blood to your leg (femoral artery). This is due to hardening of the arteries (atherosclerosis). The blockage means that blood flow in the leg is reduced.

Blood circulation is usually sufficient when resting, but when you start walking the calf muscles cannot obtain enough blood.  This causes cramp and pain which gets better after resting for a few minutes. If greater demands are made on the muscles, such as walking uphill, the pain comes on more quickly.

Claudication usually occurs in people aged over 50 years; however it can occur much earlier in people who smoke and those who have diabetes, high blood pressure or high levels of cholesterol in the blood.

Unfortunately, the blockage which causes the claudication will not clear itself, but the situation can improve.  Smaller arteries in the leg may enlarge to carry blood around the block in the main artery, this is called collateral circulation.

Many people notice some improvement in their pain as the collateral circulation develops. This normally happens within six to eight weeks of the start of the claudication symptoms.

The following information will help to explain the diagnosis and treatment of claudication.

How is Claudication detected?

Treatments

What are the risks?

How can I help myself?

How is Claudication detected?

A blockage in the circulation can be detected by examining the pulses and blood pressure in the legs. A blockage will lead to loss of one or more pulses in the leg.

The blood pressure in your feet is measures using a handheld ultrasound device called a continuous wave Doppler.  The blood pressure in the foot can be measured and compared with arm blood pressure (which is usually normal).

This measurement is called the ABPI (ankle brachial pressure index) and is expressed as a ratio. The ABPI provides an objective measure of the lower limb circulation.

Sometimes an arteriogram may be performed. An arteriogram is an x-ray of the arteries performed by injecting contrast (dye) into the artery at groin level. The contrast outlines the flow of blood in the arteries as well as any narrowings or blockages.

Treatments

Claudication is not usually limb threatening and it is not necessary to treat it if the symptoms are mild.

Claudication often remains stable with no deterioration in walking distance over long periods.

Less than one in ten patients will notice any reduction in walking distance during their lifetime.

However if your symptoms worsen, there are treatments available which you can discuss with your vascular surgeon.

General measures to improve walking distance include stopping smoking, taking more exercise and making sure you are not overweight.

Blood tests to rule out other causes of atherosclerosis are often done. These will include a blood sugar test to exclude diabetes, thyroid and kidney function tests and a cholesterol test.

There are a number of drugs on the market which claim to improve walking distance. These are not used by vascular surgeons as the evidence for their effectiveness is very limited. There is evidence that taking Aspirin or Clopidogrel is generally good for people with circulation disorders (heart, brain and legs).  Please consult either your G.P or vascular surgeon for more information.

There are three approaches to treating the claudication itself:

Exercise

Exercise has been shown to more than double walking distance. Some hospitals can offer an exercise programme with structured exercises. If this is not available, a brisk (the best you can do) walk three times a week lasting 30 minutes will normally noticeably improve walking distance over 3-6 months.

Angioplasty

Angioplasty(stretching the artery where it is narrowed with a balloon) may help to improve walking distance for some people. Overall it is less effective in the longer term than simple exercise. Angioplasty is usually limited to narrowings or short complete blockages (usually less than 10cm) in the artery.

Surgery

Bypass surgery is usually reserved for longer blockages of the artery, when the symptoms are significantly worse. There may be very short distance claudication, pain at rest, ulceration of the skin in the foot, or even gangrene in the foot or toes.

Is Treatment Successful?

The simple exercise program is very successful at increasing the walking distance. It provides a long term solution for the majority of people, and most importantly it is safe.

Because surgery (and to a lesser extent angioplasty) is not always successful, it can normally only be justified when limb is threatened.  There will usually be pain keeping you awake at night, or ulceration or gangrene of the foot or toes.

Half of the bypasses performed will need some “maintenance” procedure to keep them going. This may be an x-ray procedure or might involve further surgery.

What is the risk of losing my leg?

Very few patients with intermittent claudication will ever be at risk of losing a leg through gangrene. It is the vascular surgeon’s job to prevent this outcome at all costs.

If there is thought to be any risk to the limb a vascular surgeon will always act to save the leg if at all possible.

You can minimise the risk of progression of your symptoms by following the advice below.

It is the simple measures which are the most effective. The vast majority of patients do not need x-ray or surgical procedures to treat their symptoms.

How can I help myself?

There are several things you can do which can help. The most important is to stop smoking and take regular exercise.

If you are a smoker you should make a determined effort to give up completely. Tobacco is particularly harmful to claudicants for two reasons.

• Smoking speeds up the hardening of the arteries, which is the cause of the trouble

• Cigarette smoke prevents development of the collateral vessels which get blood past the blockage.

The best way to give up is to choose a day when you are going to stop completely rather than trying to cut down gradually. If you do have trouble giving up please ask your doctor who can give you advice on additional help, or put you in touch with a support group.

It is also important not to be overweight. The more weight the legs have to carry around, the more blood the muscles will need. If necessary, your doctor or dietician will give you advice about a weight reducing diet.

Leg amputation – already done at concept phase

Femoropopliteal & Femorodistal Bypass

The femoral artery starts in the lower abdomen and runs down into the thigh.  This artery delivers blood to your legs.  When the femoral artery reaches the back of the knee it becomes the popliteal artery.

When there is a blockage in this artery, the circulation of blood to your leg is reduced which may cause you to have pain in your calf when you walk, is known as intermittent claudication.  This operation should allow you to walk further without pain.   This surgery is also recommended when the circulation is so poor that your foot is painful at rest or at night.

Another symptom indicating a possible blockage in the artery may be leg ulcers or black areas of dead skin.  In such cases, this operation can be used to prevent the amputation of your leg below or above the knee.

A femoral popliteal bypass is an operation to bypass the blocked portion of the artery in the leg using a piece of another blood vessel.

The following information will help explain the process of a femoralpopliteal bypass.

Before your operation

Before bypass surgery, there are a number of tests that need to be done. These are of two types: those to assess your general fitness and those to assess your suitability for different types of aneurysm surgery. 

Tests of fitness and suitability are normally done before a decision to operate is made. They normally include:

• Blood tests

• An ECG (electronic heart monitoring)

• An ultrasound scan of the blocked artery

• Ultrasound scan of the blocked artery

• Ultrasound assessment of the vein which will normally be used to perform the bypass

Immediate pre-operative tests include: blood tests, another ECG, and completing the paperwork. These immediate pre-operative tests are usually completed at a pre-admission visit to the hospital a few days before your operation. They may sometimes be done when you are admitted for the operation.

Sometimes, the course of the vein to be used for the bypass will be marked in your leg with an indelible pen. This marking is done with the assistance of ultrasound.

Coming into hospital

Please bring with you all the medications that you are currently taking. You will be admitted to your bed by one of the nurses who will also note down your personal details in your nursing record.

You will be visited by the Surgeon who will be performing your operation and also the doctor who will give you the anaesthetic. If you have any questions regarding the operation please ask the doctors.

The Operation

The Anaesthetic

The first part of the operation involves giving you an anaesthetic. This operation can be done with you asleep(general), or awake.

If you have a general anaesthetic, a tiny needle is placed in the back of your hand. The anaesthetic is injected through the needle and you will be asleep within a few seconds.

If you are to be awake, you will have a small tube placed in your back. This is called a spinal or an epidural.

• A spinal anaesthetic makes it so that you can feel nothing from waist downward on the operation side. The leg is paralysed. This anaesthetic lasts for about 2-2½ hours.

• An epidural again makes it so that you can feel nothing from waist downwards, and affects both legs. There is no paralysis however. The epidural is like a drip and can stay in for several days to provide post-operative pain relief.

A tube (catheter) may be inserted into your bladder to drain your urine if you have a general anaesthetic. The catheter is essential if you have either the spinal or epidural.

For all three options, a drip is placed into a vein in your forearm to give you some fluids during and following surgery.

The Operation

The blocked artery must be exposed both above and below the blockage.   A vertical incision about 10cm (4inches) long is made in the groin to expose the common femoral artery. This is the main artery supplying the leg, and is usually the point from which the bypass starts.

A second incision of similar length is made to expose the artery below the blockage. This may be just above or below the knee and is on the inner side of the leg. Occasionally, the incision is lower in the calf, and may then be on either side.

The tube used to perform the bypass will normally be the principal skin vein of the leg. It is called the long saphenous vein and it runs up the inner side of the leg from ankle to groin.

Helpfully the vein lies in the line of the incisions used to expose the artery. Sometimes the vein can be removed with the addition of another small incision about 5cm long at mid thigh level. Sometimes the two main incisions are joined to make one long incision.

If the long saphenous vein is unavailable, its counterpart in the other leg or a vein from the arm may be used instead. The pre-operative ultrasound assessment of the veins will determine which vein is best.

If no vein is suitable, an artificial tube is used. This is made of plastic and may one of several types.

The bypass tube is joined to the artery at groin level and again to the artery below with very fine permanent stitches. The graft will sometimes lie deep within the leg, and sometimes just beneath the skin. If it is beneath the skin (in situ vein bypass) the pulse in it can easily be felt.

At the end of the operation, the incisions are all closed either with dissolving stitches, which do not need to be removed, or with a non-dissolving stitch or metal clips which will normally be removed after about ten days.

After the operation

After your operation you will be given fluids by a drip in one of your veins until you are well enough to sit up and take fluids and food by mouth.

The nurses and doctors will try and keep you free of pain by giving pain killers by injection, via the epidural tube in your back, or by a machine that you are able to control yourself by pressing a button.   It is likely that you will experience bruising around the area operated on.

Within a day or so, the drip, epidural and bladder catheter will be removed.

You will become gradually more mobile until you are fit enough to go home.

You may be visited by the physiotherapists after your operation. They will help you with your breathing to prevent you developing a chest infection and with your mobilisation to get you walking again.

You may be given aspirin (or in some cases warfarin) to reduce the risk of your bypass blocking. This will usually be continued indefinitely.

An outpatients appointment will be given to you before you are discharged home.

Going home and aftercare

If your stitches or clips are of the type that needs removing, this is usually done whilst you are still in hospital. If not, we will arrange for your GP’s practice or district nurse to remove them and check your wound.  If there is any swelling or discharge from the wound when you are at home, please contact your GP.

You may feel tired for some weeks after the operation but this should gradually improve as time goes by.   Most people are back to work six weeks after the operation.

Please ask staff if you require a sick certificate for work and this will be given to you before you leave hospital. If you require a longer time off work that is indicated on the certificate your GP can provide you with an additional certificate.

You should be able to gradually resume normal activities when you feel well enough. Avoid heavy lifting and frequent stretching at first.

Regular exercise such as a short walk combined with rest is recommended for the first few weeks following surgery followed by a gradual return to your normal activity.

Driving: You will be safe to drive when you are able to perform an emergency stop. This will normally be 2-4 weeks after surgery, but if in doubt check with your own doctor.

Bathing: Once your wound is dry you may bathe or shower as normal.

Work: If this applies to you, you should be able to return to work within 6-12 weeks of surgery. Your GP will advise you of this when you see him/her for your sick-note.

Medicines: You will usually be sent home on a small dose of aspirin if you were not already taking it. This is to make the blood less sticky. If you are unable to tolerate aspirin an alternative drug may be prescribed.

Complications

Chest infections: These can occur following this type of surgery, particularly in smokers, and may require treatment with antibiotics and physiotherapy.

Wound infection: Wounds sometimes become infected and this may need treatment with antibiotics. Bad infections are rare. Occasionally, the incision may need to be cleaned out under anaesthetic.

Graft infection: Very rarely (about 1 in 500), the artificial graft may become infected. This is a serious complication, and usually treatment involves removal of the graft.

Fluid leak from wound: Occasionally the wound may leak fluid. This may be clear but is usually blood stained. It normally settles in time, and does not usually indicate a problem with the bypass itself.

Bowel problems: Occasionally the bowel is slow to start working again after the operation. This requires patience and fluids will be provided in a drip until your bowels get back to normal.

Major Complications: As with any major operation there is a small risk of you having a medical complication such as a heart attack, stroke, kidney failure, chest problems, loss of circulation in the legs or bowel, or infection in the artificial artery. Each of these is rare, but overall it does mean that some patients may have a fatal complication from their operation. For most patients this risk is about 5% - in other words 95 in every 100 patients will make a full recovery from the operation. The doctors and nurses will try to prevent these complications and to deal with them rapidly if they occur.

Bypass blockage: The main specific complication of this operation is blood clotting within the bypass causing it to block. If this occurs it will usually be necessary to perform another operation to clear the bypass.

Limb loss: Very occasionally when the bypass blocks, and the circulation cannot be restored, the circulation ot the foot is so badly affected that amputation is required.

Limb swelling: It is normal for the leg to swell after this operation. The swelling usually lasts for about 2-3 months. It normally goes virtually completely, but may occasionally persist indefinitely.

Skin sensation: You may have patches of numbness around the wound or lower down the leg which is due to the inevitable cutting small nerves to the skin. This can be permanent but usually gets better within a few months.

What can I do to help myself?

If you were previously a smoker you must make a sincere and determined effort to stop completely. Continued smoking will cause further damage to your arteries and your bypass is more likely to stop working.

General health measures such as reducing weight, a low fat diet and regular exercise are also important.

If you develop sudden pain or numbness in the leg which does not get better within a few hours then contact your GP or the hospital immediately.

You may be asked to attend the hospital at intervals after the operation (usually 3 monthly at the start) to have an ultrasound scan of your bypass. This is to ensure that it is working well, and that there is no narrowing of the bypass which might lead on to bypass blockage.

Angioplasty and Stent

When arteries become narrowed or blocked, the circulation of blood round your body is reduced.  This can cause symptoms such as muscle pain, dizziness and tissue damage as the affected regions are deprived of blood and oxygen.

Angioplasty or stenting is a procedure used to treat the narrowing or blockage of an artery. This uses either a balloon to stretch the artery (angioplasty) or metal scaffold to hold the artery open (stent).  These procedures improve blood flow which helps to relieve any symptoms you are experiencing.

If you have been referred for this procedure, you will have seen a vascular surgeon and will have symptoms caused by narrowing or blockages in an artery.

The following information will help explain the process of angioplasty and stenting.

What does the procedure involve?

The procedure is performed in the Vascular X-ray department by a radiologist (x-ray doctor).

Local anaesthetic is used to numb the skin and a small tube is placed in the artery in the groin, this is the only uncomfortable part of the procedure.  In some cases it may not be possible to use the groin artery and an alternative artery in the elbow is used.  

A series of pictures are then taken of the arteries by injecting x-ray dye (contrast) into the tube.  The contrast will give you a warm feeling each time it is injected and may give you the feeling of passing water. Do not be alarmed, this is normal.

Under x-ray guidance a fine wire and tube are passed through the narrowing or blockage in the artery. A special tube with a balloon on the end of it is passed across the narrowing or blockage and the artery is then stretched by inflating the balloon. The balloon is then deflated and removed from the artery. Further pictures are taken to check if the angioplasty has been successful. The angioplasty may need to be repeated.

If the angioplasty fails to improve the blood flow, a metal scaffold (stent) can be placed in the artery. Once the stent is in place it cannot be removed and will eventually become covered by the lining of the artery.

Do I need to come into hospital for the procedure?

You will be sent an appointment for the pre-admission clinic where specialist nurses will assess you a few weeks before you have the procedure to check that you are fit enough to have it and to take some blood for routine tests. This will also give you the opportunity to ask any further questions you may have.

The procedure is usually performed as an inpatient. You will be asked to come directly to the ward the day before, or on the morning of the procedure and will need to stay in overnight.

The procedure generally takes about 30-45 minutes to perform. At the end of the procedure the tube will be removed and the doctor or nurse will press over the entry site in the groin or elbow for 10 minutes until the artery stops bleeding.

Once the bleeding has stopped you will need to remain flat in bed for an hour and then be allowed to sit up. A nurse will escort you back to the ward after the procedure. It is important for you to lie relatively still during this time to prevent the artery from bleeding again.

In some cases, the radiologist will place a special ‘plug’ over the hole in the artery at the end of the procedure to stop the bleeding. If this is the case, further puncture of that particular artery should not be performed for 3 months.

Are there any risks with the procedure?

There are potential complications associated with every procedure. The overall risk of the procedure is extremely low. The potential risks can be divided into the following categories:

At the puncture site:

• Some bruising is common after an artery puncture.

• Very rarely significant bleeding from the artery or blockage of the artery can occur which may require a small operation.

• The risk of requiring an operation is less than 1%

Related to the contrast

• Some patients experience an allergic reaction to the X-ray contrast. In most cases this is minor but very rarely (1 in 3000) a reaction may be severe and require urgent treatment with medicines.

• The x-ray contrast can, in some patients, affect the kidney function. If you are likely to be at risk of this, special precautions will be taken to reduce the chances of this problem occurring.

• If you are a diabetic on Metformin tablets, you should not take this on the day of the procedure and for 48 hours after the procedure.

Related to the treatment

• Vessel blockage can occur after angioplasty of a narrowed artery. It can sometimes be treated with a stent.

• Vessel rupture following angioplasty occurs infrequently. This can sometimes be treated in the x-ray department by putting a stent with a covering around it (stent-graft) into the artery to seal the tear. If this is not possible, an operation may be required to repair the artery.

• Small fragments from the lining of the artery can occasionally break off and lodge in an artery below the angioplasty site (distal embolisation). This may also require an operation to 'fish out' the fragment if it is causing a problem with the blood flow.

The overall risk of requiring an operation is low (1-2%)

Other complications

If the artery in the elbow is used, the tube will pass one or more of the arteries supplying the brain. There is a very small risk that a blood clot could form and cause a stroke (1-2%).

How successful is angioplasty and stenting?

Angioplasty/stenting is successful in treating the narrowing/blockage of the artery in the vast majority of patients (90-95%). In the small number of patients in whom the procedure is unsuccessful, a surgical bypass operation may be offered as an alternative.

Is there anything I can do to help?

You cannot do anything to relieve the actual narrowing or blockage.

You can improve your general health by taking regular exercise, stopping smoking and reducing the fat in your diet.

These actions will help slow down the hardening of the arteries which caused the problem in the first place and may avoid the need for further treatment in the future.

Aortobifemoral and Axillobifemoral Bypass

If you have been recommended the above procedures, you will have been diagnosed with peripheral arterial disease (PAD) and you have significant narrowing of the circulation to the legs located in the main arteries in your abdomen.

In the legs the usual symptoms are of muscle aching related to exercise known as claudication, which settles on resting but some patients may get a constant icy burning pain in the feet, known as rest pain.

In the most severe cases, patients may develop skin ulcers or black toes due to the restriction of blood flow.  After a dye test (arteriogram) to show the extent of disease, an operation to improve the blood flow to the legs may be appropriate.

What operation will be performed?

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Aortobifemoral Bypass

This is the best operation as it recreates the normal anatomy of your aorta and femoral arteries.  A fabric tube in the shape of a pair of trousers is sewn into the existing blood vessels and bypasses the blockages, known as aortobifemoral grafting.

This involves an incision in the abdomen to reach the aorta, and also in the groins to reach the femoral arteries. The graft is then sewn into the arteries to connect them and restore blood flow to the legs.

This surgery is not compatible for all patients.  Before the operation you will be required to undergo preoperative tests.  If the results of these tests suggest that you are at particularly high risk, either from the anaesthetic due to lung problems, or from the surgery due to heart problems, then an alternative operation known as axillo-bifemoral bypass may be considered.

Axillobifemoral Bypass

This operation links your axillary artery in your shoulder to your femoral arteries in your legs using a flexible plastic tube called a graft.  This restores the blood supply to your legs.

The stress of this operation on the heart is less as it avoids opening the abdomen but the graft is more prone to complications, such as blockage and infection, as it is narrower and not well buried in the tissues..

Your surgeon should be able to discuss the risks of operation in your particular case. You should discuss it with your family, friends and GP.  We would advise taking someone to the clinic with you, and have a list of questions ready as people often forget some of their anxieties.

The Operation

Before going into hospital you should consult your GP and consultant about the medications you are currently taking as it may be necessary to stop taking them before the operation.

You will either have an aortobifemoral or axillobifemoral bypass as detailed above.

These procedures can be carried out under regional or general anaesthetic. It is most likely that you will need to be put to sleep,  your anaesthetist and surgeon give you further advice about this.

Recovery and aftercare

In general, you will be sent back to the high dependency unit overnight where you will be monitored to make sure everything is alright.

You will be given something to eat and drink after the operation and will probably return to the ward the following day.

You will have a tube in your bladder for a day or so until, you are mobile.  You can expect to be allowed home around a week after surgery.

Risks and complications 

Like any major operation there are risks related to the anaesthetic and to the operation itself.

These operations will put considerable strain on the heart and most patients will have some sort of cardiac testing before operation to make sure the heart is strong enough.

As a result, the most serious complication is heart attack, a proportion of which will be fatal.  The overall mortality of the operation is about 3% but can vary widely depending on your preoperative fitness, and your surgeon should be able to give you a better personal risk level as well as for the local death rate for this operation.

Other less serious complications can occur such as strain on the kidneys, chest or wound infection, postoperative bleeding, deep vein thrombosis or graft thrombosis which could eventually lead to loss of the leg.

The graft can rarely get infected or blocked, which may require prolonged antibiotics or further surgery.

Younger men should discuss with their surgeon the possible impact of the operation on their sex life.

These complications may extend your stay in hospital but should not have any long term consequences on your activities.

Vascular Disease and Diabetes

People who have diabetes are more at risk of getting vascular disease because their blood sugar levels have spent prolonged periods of time being poorly controlled and higher than normal.  In turn, this affects the lining of the body's arterial walls, making the inside of the blood vessels more likely to fur-up causing them to narrow (atherosclerosis). 

People with type 2 diabetes are also more likely to have raised triglyceride levels and low HDL cholesterol which also increase the risk of atherosclerosis.

So what is diabetes?  There are two types:

Type 1 diabetes (also referred to as early-onset, juvenile or insulin-dependent diabetes). 

Children and young adults are most likely to develop the condition over a short period of time (days and weeks). Type 1 diabetes occurs when the pancreas stops releasing insulin.  It is treated with insulin injections and a healthy diet.

Type 2 diabetes (also referred to as late-onset, maturity-onset or non-insulin-dependent diabetes). 

It is most likely to develop in those over the age of 40-years-old (but can occur in younger people).  It is more likely to affect those who are obese or overweight.  The illness and symptoms of Type 2 diabetes tend to develop gradually (over weeks or months).  Unlike Type 1 diabetes the pancreas still produces insulin, but it may not be as much as the body requires, or the body's cells are not able to use the insulin properly.  This is called insulin resistance.

I have diabetes, so how can I prevent the risk of other complications like vascular disease?

In general, the closer your blood glucose level is to normal, the less likely you risk developing complications.  Your risk of developing complications is also reduced if you deal with any other 'risk factors' that you may have such as:

• high blood pressure

• smoking

• being overweight

• high cholesterol levels

• an unhealthy diet

• lack of exercise

• stress

Therefore you may wish to do the following:

• Keep active

• Eat a healthy diet and control your blood sugar levels

• Lose weight if you are overweight

• If you smoke, kick the habit

• Keep an eye on your blood pressure

• Be aware of any new conditions or changes in your body

• Have regular medical examinations, at least once a year

• Take your medication as prescribed by your doctor

What is a diabetic foot ulcer?

Diabetic foot ulcers affect many people with diabetes.  It's believed that 1 in 10 people with diabetes will have a foot ulcer at some point.  The ulcers are patches of broken skin usually on the lower part of the leg or on the feet that become infected.  For those with diabetes, wounds on the legs and feet are less likely to heal; this is partly because of damage to the nerves caused by fluctuating blood sugar levels.

Why are people with diabetes more likely to get foot ulcers?

People with diabetes may have a reduced nerve functioning due to peripheral diabetic neuropathy.  This is when the nerves that carry pain or sensation to and from the feet do not function well, so stepping on something sharp, wearing tight shoes or sustaining a cut can go unnoticed leading to diabetic foot ulcers.  Narrowed arteries (atherosclerosis) can also reduce blood flow to the feet.

Effects of serious foot ulcers.

In the worst cases, some people with diabetes may have to have an amputation as the result of an ulcer.  Less serious foot ulcers can take a long time to heal and cause a great deal of discomfort. 

How to prevent diabetic foot ulcers.

Taking good care of your feet is crucial in preventing diabetic foot ulcers.  It is recommended that people with diabetes should have their feet checked at least once a year by a doctor or healthcare professional.

 

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