Use of IVUS guided coronary stenting with drug eluting stent

International Journal of Cardiology 170 (2013) 54–63

Contents lists available at ScienceDirect

International Journal of Cardiology

j ourna l homepage: www.e lsev ie r .com/ locate / i j ca rd

Use of IVUS guided coronary stenting with drug eluting stent☆A systematic review andmeta-analysis of randomized controlled clinical trials and highquality observational studies

Catherine Klersy a,⁎,1, Marco Ferlini b,1, Arturo Raisaro b,1, Valeria Scotti c,1, Anna Balduini c,1, Moreno Curti c,1,Ezio Bramucci b,1, Annalisa De Silvestri a,1

a Service of Biometry & Statistics, IRCCS Fondazione Policlinico San Matteo, Pavia, Italyb Department of Cardiology, IRCCS Fondazione Policlinico San Matteo, Pavia, Italyc Center for Scientific Documentation, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy

Abbreviations: BMS, baremetal stent; DES, drug elutingsound; MACE, major adverse cardiac events; MI, myocarlumen diameter; RCT, randomized controlled clinical trialsrisk; SMD, standardized mean difference; 95% CI, 95% confiof Recommendations Assessment, Development and Evalu☆ Disclosures: CK, MF, AR, VS, AB, ADS: non-significanScientific; MC, EB: none to declare.⁎ Corresponding author at: Servizio di Biometria e Statist

San Matteo, 27100 Pavia, Italy. Tel.: +39 0382 503557; faxE-mail address: klersy@smatteo.pv.it (C. Klersy).

1 These authors take responsibility for all aspects of the rof the data presented and their discussed interpretation.

a b s t r a c t

Article history:

Keywords:Meta-analysisIntravascular ultrasoundDrug eluting stentMACEHigh quality observational studies

Background/objectives: Long term safety ofDES, particularly regarding thrombosis is of concern. The hypothesizedunderlying mechanisms (stent underexpansion, malapposition) could be prevented by IVUS guidance.Aim of this meta-analysis of randomized controlled clinical trials (RCT) and high quality observational cohortstudies (HQ-OBS) is to quantify the potential clinical benefit of intravascular ultrasound (IVUS) guidance indrug-eluting stents (DES) implantation.Methods:Weperformed an extensive literature search for full-text articles published in 2003–2013. The primaryoutcome was the rate of major adverse cardiac events (MACE) in RCT and HQ-OBS; secondary outcomes weredeath, myocardial infarction (MI), revascularization, thrombosis and post-procedural minimum lumen diameter(MLD). Fixed/random effect relative risks (RRs) or standardized mean difference (SMD) and 95% confidenceinterval (95% CI) were computed for the meta-analysis.Results: Thirty-four articles were retrieved from 268 found; of these 3 were RCT and 9 were HQ-OBS; 18,707

Table 1Eligibility criteriaa.

Criterium Inclusion Exclusion

Type of design RCT or cohort study (prospective, Case–control

1. Introduction

Drug eluting stents (DES) reduce the need for repeat revasculari-zation, with no influence on death and myocardial infarction, whencompared to bare metal stents (BMS) [1]. However some doubtsabout their long term safety, particularly with regard to thrombosis,

stent; IVUS, intravascular ultra-dial infarction; MLD, minimum; RD, risk difference; RR, relativedence interval; GRADE, Gradingation.t consulting fees from Boston

ica, IRCCS Fondazione Policlinico: +39 0382 502505.

eliability and freedom frombias

retrospective)Type of intervention Guided vs. IVUS not guided stent

positioningSingle uncontrolledIVUS arm

Type of stent First generation drug eluting stent(DES)

Bare metal stent

Type of patients Ischemic patients undergoing DESimplantation

Primary angioplastya

Type of publication Articles in peer-reviewed journals –

Year of publication 2003–2013 Abstract, gray literatureLanguage ofpubblication

English, German, French, Italian,Spanish

a Note: articles including specific case series undergoing primary angioplasty werecollected but used in sensitivity analyses only.

Table 2Bibliographic search strategy.

Database Search strategy Limits Articlesretrieved

Web of Science ‘Intravascular ultrasound guided’ AND (‘DES OR drugeluting stent*’)

Timespan=2003–2013. Databases=SCI-EXPANDED, SSCI, A&HCI, CPCI-S, CPCI-SSH. 34

PubMed (IVUS OR intravascular ultrasound) AND guid* AND(DES OR drug eluting stent*)

Limits: English, French, German, Italian, Spanish, Publication Date from 2003/01/01to 2013/27/03

Cinahl (IVUS OR intravascular ultrasound guid*) AND(DES OR drug eluting stent)

Limiters — Published Date from: 20030101–20132703; Language: English, French,German, Italian, Spanish

Cochrane (IVUS guid* OR intravascular ultrasound guid*) AND(DES or drug eluting stent)

From 2003 to 2013 in all products from 2003 to 2013 in Cochrane central registerof controlled trials

Embase (IVUS OR ‘intravascular ultrasound’) AND guid* AND(DES OR ‘drug eluting stent’)

[embase]/lim AND [medline]/lim AND ([english]/lim OR [french]/lim OR [german]/limOR [italian]/lim OR [spanish]/lim) AND [2003–2013]/py

55C. Klersy et al. / International Journal of Cardiology 170 (2013) 54–63

have been raised [2,3]. Stent underexpansion and malapposition areconsidered as potential mechanisms favoring thrombosis; intravascularultrasound (IVUS), by providing precise visualization of the intracoro-nary anatomy, may optimize DES implantation, potentially reducingthe rate of thrombosis [4]. However, the real clinical benefit of IVUS isstill controversial [5]; most available studies are non-randomized, and

Fig. 1. PRISMA 2009 Flow diagram — IVUS guided vs. not guided coronary stent p

some include a small number of patients. A recent meta-analysis ofrandomized clinical trials by Parise et al. [6] showed that IVUS guidancefor BMS implantation improved acute procedural results (angiographicminimum lumen diameter), reduced angiographic restenosis, andrepeat revascularization and major adverse cardiac events, with aneutral effect on death and myocardial infarction over a follow-up of

lacement. Articles disposition is described. Reasons for exclusion are listed.

56 C. Klersy et al. / International Journal of Cardiology 170 (2013) 54–63

6months to 2.5years. Subsequent meta-analyses [7,8] showed a similareffect size on MACE, though statistical significance was not reached.

Given the concern about long-term outcomes after DES [2] and thesparse and sometimes weak evidence of benefit provided so far [9],we planned a systematic review of the literature and meta-analysis toquantitatively establish whether procedural and clinical superiority ofIVUS guidance of first generation DES placement can be claimed. Bothrandomized clinical trials (RCT) and high quality prospective longitu-dinal observational studies with adjustment for confounding by indica-tion were considered.

2. Methods

2.1. Study outcomes and eligibility criteria

In agreement with the US Agency for Health Care Research and Quality (AHRQ) [10]and the 2011 guidelines for percutaneous coronary intervention [9], we searched theliterature for both angiographic and mid to long term clinical outcomes. Eligibility crite-ria for a study to be included in our meta-analysis are summarized in Table 1. Bothrandomized clinical trials (RCT) and observational longitudinal studies were considered.

2.2. Search strategy and articles classification

PubMed, Cinhal, Cochrane, Embase and Web of Science were searched for pertinentstudies on May 30th, 2011 and updated on March 27th, 2013. Research strategies andkeywords are summarized in Table 2. Also, additional articles were retrieved from thereference lists and finally, a citation analysis was performed to identify newer studiesthat had cited older ones.

The 2 librarians (AB, VS) examined all titles and abstracts and classified them as ‘to beincluded’, ‘to be excluded’ and ‘to be decided upon’, based on the eligibility criteria and thekeywords used. Two cardiologists (MF and AR) reviewed independently all abstracts to

Table 3Clinical and angiographic characteristics of patient enrolled in the 12 considered studies.

Characteristic N studies(N=12)

Clinical

Age (years)Female (% of pts)Diabetes (% of pts)Previous MIa (% of pts)Acute MIa (% of pts)STEMIb (% of pts)NSTEMIb (% of pts)Acute coronary syndrome (% of pts)

Angiographic

Single vessel 5Multiple vessel 6Native vessel 11CABGc 11LADd 9RCAe 9CFXf 8LMCg 10AHA/ACC lesion type A 3AHA/ACC lesion type B 3AHA/ACC lesion type C 3

LMC treatedCalcified lesionLong lesionSmall vesselBifurcation

a MI: myocardial infarction.b STEMI/NSTEMI: (non) ST elevation myocardial infarction.c CABG: coronary artery bypass graft.d LAD: left anterior descending artery.e RCA: right coronary artery.f CFX: circumflex coronary artery.g LMC: left main coronary artery.

ensure that theymet the eligibility criteria andmade thefinal decision regarding inclusionor exclusion of the articles in the systematic review; whenever discrepancy was noted intheir classification, it was reconciled by consensus among the working group participants.

2.3. Systematic review

The full texts of the articles finally included were retrieved. They were examined bytwo biostatisticians (CK and ADS), who classified them as eligible or not eligible formeta-analysis. Reasons for non-inclusion were reported. The quality of the studieswas rated based upon adherence to the CONSORT (for controlled clinical trials) andSTROBE (for observational studies) statements as well as the GRADE and AHRQ guidelines[11–14]. The 2 biostatistician retrieved separately the quantitative information foroutcomes and patients characteristics (clinical and angiographic) from the selectedarticles. Whenever discrepancy was noted, it was reconciled by consensus betweenthem, and if needed with the help of the cardiologists.

2.4. Statistical analysis

ThePRISMAandMOOSEguidelines formeta-analysis, aswell as the Cochranemanual,were used when designing this study [15–17]. The primary population included studieswith estimates of the relative risk (RR), adjusted either by multivariable regression anal-ysis or using the propensity score method, and RCTs. The primary endpoint of the studywas the comparison of the incidence rate of major adverse cardiac events (MACE) be-tween IVUS guided and not guided strategies in stent positioning. MACE included death,acute myocardial infarction (MI) and revascularization. Secondary endpoints includedthe comparison of the incidence of each MACE, of stent thrombosis and post-proceduralMLD. Comparison of MACE incidence between IVUS guided and not guided strategieswas also performed for studies including unadjusted RR estimates only and for studiesincluding pooled RR estimates for DES and BMS. Patient characteristics in the primarypopulation were summarized over studies with the median and 25th–75th percentiles.Within each study, the adjusted relative risk (RR) with its 95% CI for each categoricaloutcome, and standardized mean difference (SMD) with its 95% CI for continuousvariables, was retrieved from the articles. For the analysis of the secondary populationsthe RR was either retrieved from the articles or calculated from the available data. Finally,

IVUS guided(N=9965)

IVUS not guided(N=8742)

Median over studies(25th–75th percentiles)

63 (62–65) 64 (62–65)31 (26–34) 30 (26–33)32 (31–42) 33 (30–44)19 (4–35) 18 (5–33)19 (11–50) 24 (13–50)15 (8–23) 17 (10–19)11 (9–43) 14 (14–39)83 (61–100) 76 (66–100)

N pts N pts

589 580748 751

8606 7872106 136

5282 45252056 21861333 1578888 42359 70

1111 1241359 425

N studies N studies

8/12 7/124/12 4/125/12 5/121/12 1/127/12 7/12

0123456789

10111213

Fig. 2. Availability of the collected outcomes across the studies included in the meta-analysis (primary population). The number of studies with data for each outcome isshown.

study RRs/standardized mean differences were then pooled according to the Mantel–Haenszel's/Cohen's fixed effects method. To account for differences among studies moreeffectively, we also fitted DerSimonian and Laird random effects models. Statisticalheterogeneity was evaluated by the Cochran Q test and measured by the I-squaredstatistic. When the I-squared statistic was N20%, we considered the random effect RR tobe preferable. Both Forrest plots (for displaying effect) and funnel plots (for displayingpublication bias) were drawn.

Stata 12 (StataCorp, College Station, TX, USA) was used for computation.

3. Results

3.1. Bibliographic search and identification of articles

ByMarch 2013, we had retrieved 259 articles from the bibliographicsearch, 74 of which were present in more than one database, leaving uswith 185 abstracts (Table 2); 118 additional articleswere retrieved fromother sources (Fig. 1). After excluding further duplicates, 268 abstractswere evaluated. We retrieved and carefully examined a total of 34papers. Sixteen of them were excluded (listed in the appendix withreasons for exclusion). Three studies were RCT [18–20], while 9 wereobservational with adjusted estimates [21–29].

Table 4Endpoints evaluated in the meta-analysis.

First authora Design MACE

Primary populationChieffo et al., 2013 RCT XJakabcin et al., 2010 RCT XKim et al., 2013 RCT XAhn et al., 2013 Cohort, adjusted XChen et al., 2012 Cohort, adjusted XClaessen et al., 2011 Cohort, adjusted XFujimoto et al., 2008 Cohort, adjusted XHur et al., 2013 Cohort, adjusted XKim et al., 2011 Cohort, adjusted XPark et al., 2009 Cohort, adjusted XRoy et al., 2007 Cohort, adjustedRoy et al., 2008 Cohort, adjusted X

Secondary population (unadjusted)Agostoni et al., 2005 Cohort, unadjusted XGerber et al., 2009 Cohort, unadjusted

Secondary population (mixed)Biondi-Zoccai et al., 2011 Cohort, mixed, adjusted XKim et al., 2010 Cohort, mixed, adjustedPatel et al., 2012 Cohort, mixed, adjustedWakabayashi et al., 2012 Cohort, mixed, adjusted X

a Listed alphabetically within populations.

Two studies were observationally unadjusted [30,31]. Four studiesincluded also a fraction of patients treated with bare metal stents[32–35]. All the studies in the latter group reported adjusted RRs.

3.2. Study design and primary population

Six of the 12 articles included in the primary population werepublished in the last 3 years, 9 (75%) were multicenter. A total of18,707 patients were enrolled, 1037 in the RCT and 17,670 in the cohortstudies, with a median over studies of 758 patients (25th–75th:287–1495). Women were well represented, given the epidemiology ofischemic heart disease (N= 5344, 28%). The median age over studieswas 64 years (25th–75th: 62–65 years). Follow-up median durationwas 20months (25th–75th: 12–24months).

The clinical and angiographic characteristics of the enrolled popu-lations, in each IVUS guided/not guided arm, are summarized inTable 3. As shown, they were well balanced between groups, with theexception of acute myocardial infarction, which was less frequent inthe IVUS guided arm. Among angiographic features, fewer patientshad IVUS guidance for treatment of RCA, CFX or complicated lesions(ACC/AHA type C). Most articles reported treatment of LMC; thisprevalence was not different for the IVUS guided or not guided arms.One study only explicitly included treatment of small vessels, and halfof the studies (7/12) reported treatment of bifurcation lesions in botharms.

3.3. Outcomes and meta-analysis on primary population

As shown in Fig. 2 and in Table 4, clinical outcomes were generallymore frequently reported than angiographic outcomes. Death, MI, TLRand MACE were the most frequent, though thrombosis (mainly earlyand late) was frequently reported as well. MLD was reported in 5articles. Restenosis and late loss were described in only 1 article andthus were not further considered in the meta-analysis.

Themeta-analysis of the primary endpointMACE in RCT and adjustedobservational studies showed that IVUS guidance was associated witha significantly lower rate of events, with a decrease in risk of about20% (fixed effect RR=0.80, 95% CI 0.71 to 0.89, p b 0.001, Fig. 3, upperpanel). Of note, the effect size was larger for RCTs (decrease by 28%)than for the adjusted observational studies (decrease by 19%), thoughstatistical significance was not reached in the former case (p = 0.11

Dead MI TVR_TLR Thrombosis MLD

X X X XX X X X XX X X X X

X XX X X XX X X X

X X X XX X XX X X X XX X

XX X X X

X XX X X X X

X X X XX X XX X X XX X X X

Heterogeneity between groups: p = 0.595

I-V Overall (I-squared = 0.0%, p = 0.829)

Park et al, 2009

Fujimoto et al, 2008

I-V Subtotal (I-squared = 0.0%, p = 0.664)

Ahn et al, 2013

D+L Subtotal

Chen et al, 2012

Jakabcin et al, 2010

Hur et al, 2013

Kim et al, 2013

Roy et al, 2008

Kim et al, 2011

Chieffo et al, 2013

cohort

D+L Overall

Claessen et al, 2011

0.80 (0.71, 0.89)

HR (95% CI)

0.64 (0.39, 1.04)

1.03 (0.28, 3.15)

0.81 (0.72, 0.91)

0.64 (0.44, 0.94)

0.72 (0.48, 1.07)

0.81 (0.72, 0.91)

0.97 (0.58, 1.63)

0.92 (0.38, 2.19)

0.85 (0.70, 1.01)

0.72 (0.48, 1.07)

0.59 (0.28, 1.24)

0.90 (0.70, 1.14)

0.73 (0.44, 1.19)

0.73 (0.41, 1.27)

0.80 (0.71, 0.89)

0.67 (0.46, 1.00)

100.00

Weight

0.80 (0.71, 0.89)

0.72 (0.48, 1.07)

0.92 (0.38, 2.19)

0.72 (0.48, 1.07)

0.59 (0.28, 1.24)

0.73 (0.41, 1.27)

0.80 (0.71, 0.89)

100.00

IVUS reduces risk IVUS increases risk

1.1 .2 .5 1 2 5 10

IVUS & MACE (primary population)

-1.5 -1 -.5 0 .5 1

HRMACE

Funnel plot with pseudo 95% confidence limits (primary population)

Fig. 3. Upper panel: Forrest plot for the primary endpoint of the study (primary population: RCT and adjusted observational studies): comparison of the cumulative incidence of majoradverse cardiac events (MACE); diamonds represent the meta-analytic estimates and 95% CI. (I-V = inverse-variance weighted (fixed effect) meta-analysis (Mantel & Haenszel);D+L=random effect DerSimonian & Laird estimate). Lower panel: Funnel plot to assess publication bias; the symmetry of dots distribution favors the hypothesis of no publication bias.

and pb0.001, respectively). No evidence of publication biaswas elicitedin the funnel plot (Fig. 3, lower panel). Of note, none of the singlestudies, but one [29], provided sufficient support in favor of IVUSguidance.

Among the secondary endpoints, both the rate of death and MI werelower with IVUS guidance, with a risk of events almost halved (death:fixed effect RR=0.60, 95% CI 0.48 to 0.74, p b0.001 andMI: fixed effectRR=0.59, 95% CI 0.44–0.80, p=0.001), while no significant effect wasseen on revascularization (fixed effect RR= 0.95, 95% CI 0.82 to 1.09,

p=0.75) (Fig. 4). The rate of thrombosiswas lowerwith IVUS guidance,with a 50% risk reduction (random effect RR=0.50, 95% CI 0.32–0.80,p=0.007); post-proceduralMLDwas slightly largerwith IVUSguidance(random effect SMD=0.15, 95% CI 0.03 to 0.27, p=0.014) (Fig. 5).

3.4. Outcomes and meta-analysis on secondary populations

Only 1 out of 2 studies (58 patients) with unadjusted RR estimatesand 2 out of 4 studies (5588 patients) with pooled RR estimates for

Kim et al, 2011

D+L Subtotal

Chen et al, 2012

D+L Subtotal

Roy et al, 2008

Hur et al, 2013

cohort

Park et al, 2009

Kim et al, 2013

D+L Overall

Chieffo et al, 2013

0.60 (0.48, 0.74)

0.74 (0.37, 1.47)

0.58 (0.21, 1.61)

1.04 (0.30, 3.56)

0.12 (0.00, 0.93)

0.59 (0.47, 0.73)

0.59 (0.45, 0.78)

HR (95% CI)

0.81 (0.54, 1.19)

1.04 (0.30, 3.56)

1.50 (0.17, 17.96)

0.49 (0.36, 0.67)

0.39 (0.15, 1.02)

1.53 (0.25, 9.25)

0.60 (0.48, 0.74)

0.33 (0.03, 4.17)

100.00

Weight

0.60 (0.48, 0.74)

0.74 (0.37, 1.47)

0.58 (0.21, 1.61)

1.04 (0.30, 3.56)

0.12 (0.00, 0.93)

0.59 (0.47, 0.73)

0.59 (0.45, 0.78)

HR (95% CI)

0.81 (0.54, 1.19)

1.04 (0.30, 3.56)

1.50 (0.17, 17.96)

0.49 (0.36, 0.67)

0.39 (0.15, 1.02)

1.53 (0.25, 9.25)

0.60 (0.48, 0.74)

0.33 (0.03, 4.17)

100.00

Weight

1.1 .2 .5 1 2 5 10

IVUS & dead (primary population)

Kim et al, 2013

Hur et al, 2013

Chieffo et al, 2013

D+L Subtotal

Kim et al, 2011

D+L Overall

D+L Subtotal

Chen et al, 2012

Roy et al, 2008

cohort

Park et al, 2009

0.59 (0.44, 0.80)

0.33 (0.03, 4.21)

0.48 (0.23, 0.98)

0.83 (0.32, 2.10)

0.68 (0.29, 1.59)

HR (95% CI)

0.68 (0.29, 1.59)

0.25 (0.01, 2.53)

0.32 (0.09, 1.18)

0.58 (0.42, 0.80)

0.59 (0.44, 0.80)

0.56 (0.38, 0.82)

0.70 (0.34, 1.37)

0.18 (0.06, 0.57)

0.69 (0.36, 1.31)

0.83 (0.43, 1.57)

100.00

Weight

0.59 (0.44, 0.80)

0.33 (0.03, 4.21)

0.48 (0.23, 0.98)

0.83 (0.32, 2.10)

0.68 (0.29, 1.59)

HR (95% CI)

0.68 (0.29, 1.59)

0.25 (0.01, 2.53)

0.32 (0.09, 1.18)

0.58 (0.42, 0.80)

0.59 (0.44, 0.80)

0.56 (0.38, 0.82)

0.70 (0.34, 1.37)

0.18 (0.06, 0.57)

0.69 (0.36, 1.31)

0.83 (0.43, 1.57)

100.00

Weight

1.1 .2 .5 1 2 5 10

IVUS & MI (primary population)

Chen et al, 2012

Kim et al, 2011

D+L Subtotal

Ahn et al, 2013

cohort

Hur et al, 2013

Roy et al, 2008

Kim et al, 2013

Chieffo et al, 2013

Park et al, 2009

D+L Overall

D+L Subtotal

0.95 (0.82, 1.09)

0.90 (0.51, 1.57)

0.91 (0.52, 1.62)

1.03 (0.28, 3.15)

0.98 (0.84, 1.13)

0.72 (0.43, 1.18)

HR (95% CI)

0.69 (0.42, 1.12)

0.98 (0.84, 1.13)

0.91 (0.63, 1.31)

1.00 (0.27, 3.74)

1.15 (0.90, 1.47)

0.95 (0.68, 1.32)

0.66 (0.31, 1.41)

0.64 (0.30, 1.30)

0.80 (0.35, 1.86)

0.95 (0.82, 1.09)

0.69 (0.42, 1.12)

100.00

Weight

0.95 (0.82, 1.09)

0.90 (0.51, 1.57)

0.91 (0.52, 1.62)

1.03 (0.28, 3.15)

0.98 (0.84, 1.13)

0.72 (0.43, 1.18)

HR (95% CI)

0.69 (0.42, 1.12)

0.98 (0.84, 1.13)

0.91 (0.63, 1.31)

1.00 (0.27, 3.74)

1.15 (0.90, 1.47)

0.95 (0.68, 1.32)

0.66 (0.31, 1.41)

0.64 (0.30, 1.30)

0.80 (0.35, 1.86)

0.95 (0.82, 1.09)

0.69 (0.42, 1.12)

100.00

Weight

1.1 .2 .5 1 2 5 10

IVUS & TVR_TLR (primary population)

Fig. 4. Forrest plot for the secondary endpoints (primary population): components of MACE (death, MI, TVR/TLR in the upper left and right and lower panel, respectively); diamondsrepresent the meta-analytic estimates and 95% CI.

DES and BMS assessed MACE as an outcome. In the first case, the RR forIVUS guided vs. not guided was computed from the article to 0.40 (95%CI 0.04 to 1.13, p = 0.34), with little evidence of usefulness of IVUS,given also the low sample size. In the mixed BMS/DES cohort the fixedeffect RR was 0.77 (95% CI 0.62–0.95, p=0.017), showing a protectiveeffect of IVUS guidance on MACE.

4. Discussion

For this meta-analysis we screened 268 articles; only 18 satisfyingthe inclusion/exclusion criteria could be considered (12 in the primarypopulation and 6 in the secondary populations), representing 7% ofthe abstracts identified from bibliographic search and about 50% ofthe full text examined. Three studies were RCTs [18–20], while 9 ofthe observational studies were large high quality studies with adjustedestimates of RR provided [21–29].

These represented our primary population. Most studies consideredin our meta-analysis included patients with ACC/AHA type B or C and

bifurcation lesions. These cases are expected to most benefit fromIVUS guidance, recognized to provide important anatomical informa-tion on plaque distribution, vessel size, stent expansion, symmetryand apposition. Particularly, bifurcation lesions were shown indepen-dent risk factors for stent thrombosis after DES implantation (possiblydue to shear stress and low flow velocities) [36]. All implanted DESincluded in the present analysis were first generation, assuring homo-geneity in the studied cohorts.

The meta-analysis demonstrates that IVUS guided implantation ofDES reduced the rate of MACE by about 20% and, within MACE, of MIand death but not of TVR/TLR. Also, IVUS guidance was shown todecrease the rate of thrombosis and slightly increase post-proceduralMLD. Only high quality articles, as defined by AHRQ and GRADE guide-lines, were considered. Thus the protective role of IVUS is reliablyconfirmed by our meta-analysis. Indeed, in all articles confounding byindication was accounted for by randomization, multivariable analysisor propensity score matching [13,14]. We acknowledge that the in-cluded RCTs gave less clear-cut results, with lesser evidence of a

D+L Subtotal

Chen et al, 2012

Hur et al, 2013

Kim et al, 2011

Ahn et al, 2013

Roy et al, 2008

D+L Subtotal

Kim et al, 2013

D+L Overall

Roy et al, 2007

cohort

0.61 (0.44, 0.83)

0.46 (0.26, 0.81)

0.20 (0.04, 0.71)

0.89 (0.58, 1.38)

0.33 (0.04, 3.21)

0.07 (0.01, 0.55)

0.60 (0.44, 0.83)

0.75 (0.11, 4.43)

0.70 (0.17, 2.90)

HR (95% CI)

0.50 (0.10, 0.80)

0.67 (0.14, 2.81)

0.70 (0.17, 2.90)

1.02 (0.01, 79.96)

0.50 (0.32, 0.80)

0.40 (0.20, 0.81)

100.00

Weight

0.61 (0.44, 0.83)

0.46 (0.26, 0.81)

0.20 (0.04, 0.71)

0.89 (0.58, 1.38)

0.33 (0.04, 3.21)

0.07 (0.01, 0.55)

0.60 (0.44, 0.83)

0.75 (0.11, 4.43)

0.70 (0.17, 2.90)

HR (95% CI)

0.50 (0.10, 0.80)

0.67 (0.14, 2.81)

0.70 (0.17, 2.90)

1.02 (0.01, 79.96)

0.50 (0.32, 0.80)

0.40 (0.20, 0.81)

100.00

Weight

IVUS reduces risk IVUS increases risk 1.1 .2 .5 1 2 5 10

IVUS & thromb (primary population)

D+L Overall

cohort

Kim et al, 2011

Chieffo et al, 2013

Kim et al, 2013

D+L Subtotal

0.15 (0.07, 0.23)

SMD (95% CI)

0.15 (0.03, 0.27)

0.00 (-0.27, 0.27)

0.03 (-0.17, 0.23)

0.18 (0.06, 0.31)

0.17 (0.05, 0.29)

0.41 (0.18, 0.65)

0.11 (-0.06, 0.28)

0.18 (-0.05, 0.40)

0.13 (-0.01, 0.27)

0.14 (0.03, 0.25)

(SD); IVUS

105, 2.9 (.3)

132, 2.59 (.32)

487, 2.5 (.6)

142, 2.7 (.46)

269, 2.6 (.28)

N, mean

(SD); noIVUS

105, 2.9 (.2)

327, 2.58 (.31)

487, 2.4 (.5)

142, 2.51 (.46)

274, 2.57 (.27)

N, mean

100.00

Weight

0.15 (0.07, 0.23)

SMD (95% CI)

0.15 (0.03, 0.27)

0.00 (-0.27, 0.27)

0.03 (-0.17, 0.23)

0.18 (0.06, 0.31)

0.17 (0.05, 0.29)

0.41 (0.18, 0.65)

0.11 (-0.06, 0.28)

0.18 (-0.05, 0.40)

0.13 (-0.01, 0.27)

0.14 (0.03, 0.25)

(SD); IVUS

105, 2.9 (.3)

132, 2.59 (.32)

487, 2.5 (.6)

142, 2.7 (.46)

269, 2.6 (.28)

N, mean

IVUS reduces MLD IVUS increases MLD 0-.5 -.25 .25 .5

IVUS & MLD (primary population)

Fig. 5. Forrest plot for the secondary endpoints (primary population): angiographic outcomes (thrombosis and MLD in the upper and lower panel, respectively); diamonds represent themeta-analytic estimates and 95% CI.

beneficial effect of IVUS; however, all were afflicted by some biases indesign or conduct (Table 5), such as low power [18], unbalanced cross-over toward the IVUS arms [20] and unbalanced baseline characteristics[19], which might reduce the quality of evidence, as stated in GRADE[13].

Our findings favored the hypothesis that the reduction in MI anddeath ratemight bemediated by the reduced rate of thrombosis. IndeedIVUS guidance, by providing information insight into some of themech-anisms associated with stent thrombosis in DES, may optimize stentdeployment, eliminating technical problems and therefore potential

causes of thrombosis (under-expansion, residual reference segmentstenosis, incomplete stent apposition, coronary dissection after stentimplantations) [2–4,37,38].

Late and very late stent thrombosis has been hypothesized andrelated to premature discontinuation of dual antiplatelet therapy andto arterial wall changes such as delayed endothelization induced bydrug or polymer, but a role of stent malapposition and underexpansioncannot be excluded [39]. The present meta-analysis cannot clearlyanswer this question, because only few data were available for early,late and very late thrombosis as well as on optimal medical therapy;

Table 5Randomized clinical trials in the meta-analysis.

First author N (total) Monthsfollow-up

Main inclusion criterium Primaryendpoint

Type of death Limits

Jakabcin J (2010) 210 18 Complex coronary lesion MACE Any death No sample size calculation (underpowered); no HRreported; no CONSORT adherence

Kim JS (2013) 543 12 De novo stent; ≥28mm no LMC;no bifurcaton

MACE Cardiac death Unbalanced crossover:13 pts IVUS N noIVUD41 pts noIVUS N IVUS; underpowered

Chieffo A (2013) 284 24 Complex coronary lesion MLD Cardiac death MLD pre≠ between groups (lower if IVUS); withacute gain=between groups; not powered for MACE

also the studies considered here did not report the rate of stentmalapposition and underexpansion in the IVUS and in the controlarms, so their contribution to stent thrombosis reduction can only behypothesized.

Our data are at variance with the meta-analysis recently publishedby Parise [6], where IVUS guidance for BMS implantation appeared toreduce MACE and revascularization rates, but not myocardial infarctionor death. Both meta-analyses showed larger post-procedural MLD withIVUS guidance.

We reported a larger post-procedural MLD in the IVUS guided arm; alarger final MLD was previously shown associated with restenosisreduction when a BMS is used [40]. For DES, the local anti-proliferativeeffect of the drug couldmitigate the effect of a smallerMLD on restenosis,and a larger final lumen vessel could be more important to avoid longterm negative outcomes such as thrombosis. No data on thrombosiswere available in Parise's paper [6] to be compared with ours.

Up to now one study only reported data use of IVUS in new genera-tion DES [41], which were shown safer and with improved clinicaloutcomes [42]. No favorable effect of IVUS was shown by Park et al.,though the authors themselves recognized that patients in the IVUSarm had longer lesions, thus with larger total stent length, a factor notaccounted for in the propensity matching process, that could explainpart of their results. Further studies however are needed to clarify thisissue.

4.1. Limits and strength of the study

Apossible limit of this systematic review is the lownumber of RCTs tobe meta-analyzed. Only one, relatively small RCT was published in 2010and 2more in 2013, all with some concern about the reported quality ofevidence. On the other hand, potential selection biasesmighthamper the

Ahmed K; Jeong M H; Chakraborty R; Ahn Y; Sim D S; Park K;Hong Y J; Kim J H; Cho K H; Kim M C; Hachinohe D;Hwang S H; Lee M G; Cho M C; Kim C J; Kim Y J; Park J C;Kang J C; Other Korea Acute Myocardial Infarction RegistryInvestigators

Role of intravascular ultrasmyocardial infarction undeintervention

Bonello L; De Labriolle A; Lemesle G; Roy P; Steinberg D H;Slottow T L; Xue Z; Torguson R; Kaneshige K; Suddath W O;Satler L F; Kent K M; Lindsay J; Pichard A D; Waksman R

Comparison of outcomes obare-metal stents in nonosdescending coronary arteri

Conti C R; Serruys P ABSORB trial: six-month anfrom this first-in-man evalueverolimus-eluting coronarMD, FACC

Furuichi S; Satoh T Intravascular ultrasound-guchronic total occlusion

Gerber R; Colombo A Does IVUS guidance of corooutcome? a prime exampleclinical trials

Gil R J; Pawlowski T; Dudek D; Horszczaruk G; Zmudka K;Lesiak M; Witkowski A; Ochala A; Kubica J; Investigatorsof Direct Stenting vs. Optimal Angioplasty Trial (DIPOL)

Comparison of angiographitechnique with direct stentangioplasty guided with inmulticenter, randomized tr

quality of the evidence in observational studies; for this reasonwe choseto include only those studies in which confounding by indication wascontrolled by using propensity scorematching ormultivariable analyses.Though no complete safeguard against unknown confounders can beobtained with such methods, the large sample sizes considered herewill protect fromunbalanced distribution of confounders [43].Moreover,most of the observational studies included populations from registrieswith lesser risk of selection biases.

Finally, considering good quality cohort rather than, or in additionto, RCT studies in a meta-analysis would better reflect the impact ofIVUS guidance in real life.

We have also to consider that in the case of diagnostic procedures,further large RCTs are, arguably, unlike to emerge (given also costconstraints), while the strength of the evidence from well conductedobservational research can be relevant [13,14].

Least, all studies originated from large volume, experienced centersand the obtained effect sizes might be over-optimistic with respect tothose obtainable in smaller, less experienced ones, due to the learningcurve for the use of IVUS. As suggested by Lee [44] IVUS represents auseful tool in the hands of interventional cardiologists, though a majordrawback of its use could be the poor adherence to IVUS criteria, to beenhanced by education, as well as the lack of consensus on the defini-tion of optimal stent expansion, still to be provided by IVUS experts.Poor adherence would be one of the major factors limiting the benefitsof IVUS-guided PCI in randomized studies.

In conclusion, this meta-analysis demonstrates that IVUS guidancein DES positioning, performed in large volume centers, reduces MACE,specifically by reducing mortality and MI, possibly by reducing throm-bosis rather than restenosis rate. An immediate clinical implication isthat patients at high risk for life threatening thrombosis could representthe best candidates for IVUS guidance in experienced hands.

Authors Title Citation Reject

Appendix A. Studies excluded and reason

ound in patients with acutergoing percutaneous coronary

Am J Cardiol 2011;108:8–14 Not pertinent

f drug-eluting stents versustial proximal left anteriores

giographic and IVUS resultsation of a fully bioabsorbabley stent… Patrick W. Serruys,

ACC CARDIOSOURCE REV J2007;16:46–48

Not pertinent

ided retrograde wiring for Catheter Cardiovasc Interv2010;75:214–221

Not pertinent

nary interventions affectof the failure of randomized

Catheter Cardiovasc Interv2008;71:646–654

Review

cally guided direct stentinging and optimal balloontravascular ultrasound. Theial results

Am Heart J 2007;154:669–675 Not pertinent

(continued on next page)

Appendix A (continued)

Authors Title Citation Reject

Leesar M A Defining a new standard for IVUS optimized drug-elutingstent implantation—the PRAVIO study: do we know theright technique for stent optimization?

Review

Maluenda G, Lemesle G, Ben-Dor I, Collins SD, Syed AI,Torguson R, Kaneshige K, Xue Z, Suddath WO, Satler LF,Kent KM, Lindsay J, Pichard AD, Waksman R.

Impact of Intravascular Ultrasound Guidance in Patientswith Acute Myocardial Infarction Undergoing PercutaneousCoronary Intervention

Catheter Cardiovasc Interv.2010 Jan 1;75:86–92.

Not pertinent

Ozaki Y; Lemos P A; Yamaguchi T; Suzuki T; Nakamura M;Ismail T F; Kitayama M; Nishikawa H; Kato O; Serruys P W

A quantitative coronary angiography-matched comparisonbetween a prospective randomized multicentre cuttingballoon angioplasty and bare metal stent trial (REDUCE III)and the Rapamycin-Eluting Stent Evaluation At RotterdamCardiology Hospital (RESEARCH)

EuroIntervention 2010;6:400–406 Not pertinent

Park K M; Park S W; Lee S W; Lee B K; Park K H; Suh I W;Hwang E S; Kim Y H; Lee C W; Hong M K; Kim J J; Park S J

Efficacy of intravascular ultrasound-guided drug-elutingstent implantation in the real practice

Am J Cardiol 2005;96:134H–134H Abstract

Park,K.W.; Kang,S.-H.; Yang,H.-M.; Lee,H.-Y.; Kang,H.-J.;Cho,Y.-S.; Youn,T.-J.; Koo,B.-K.; Chae,I.-H.; Kim,H.-S

Impact of intravascular ultrasound guidance in routinepercutaneous coronary intervention for conventionallesions: data from the EXCELLENT trial

Int. J. Cardiol 2012 (epub) Not pertinent

Pawlowski T; Gil R; Rzezak J; Golebiewski S Stenting for proximal left descending artery-matchedcomparison of drug eluting stenting and direct stentingguided by intravascular ultrasound

Am J Cardiol 2005;96:177H–177H Abstract

Pawlowski Tomasz; Gil Robert Intravascular Ultrasound Guidance May Be an Option forCoronary Interventions

Review

Roy P; Okabe T; Pinto Slottow T L; Steinberg D H; Smith K;Torguson R; Xue Z; Gevorkian N; Satler L F; Kent K M;Suddath W O; Pichard A D; Waksman R

Correlates of clinical restenosis following intracoronaryimplantation of drug-eluting stents

Seung K; Kim Y; Park D; Lee B; Lee C W; Hong M; Kim P;Chung W; Tahk S; Park S; Park S

Effectiveness of sirolimus-eluting stent implantation forthe treatment of ostial left anterior descending arterystenosis with intravascular ultrasound guidance

J Am Coll Cardiol 2005;46:787–792 Not pertinent

Vautrin,E.; Barone-Rochette,G.; Berthoud,B.; Marliere,S.;Bouvaist,H.; Bertrand,B.; Ormezzano,O.; Machecourt, J.;Vanzetto,G.

Very late stent thrombosis after drug eluting stent:management therapy guided by intravascular ultrasoundimaging

Int.J.Cardiol., 2012, 154, 3, 349–351 Not pertinent

References

[1] Stone GW, Moses JW, Ellis SG, et al. Safety and efficacy of sirolimus- and paclitaxel-eluting coronary stents. N Engl J Med 2007;356:998–1008.

[2] Joner M, Finn AV, Farb A, et al. Pathology of drug-eluting stents in humans: delayedhealing and late thrombotic risk. J Am Coll Cardiol 2006;48:193–202.

[3] Daemen J, Wenaweser P, Tsuchida K, et al. Early and late coronary stent thrombosisof sirolimus-eluting and paclitaxel-eluting stents in routine clinical practice: datafrom a large two-institutional cohort study. Lancet 2007;369:667–78.

[4] Lee CW, Kang SJ, Park DW, et al. Intravascular ultrasound findings in patients withvery late stent thrombosis after either drug-eluting or bare-metal stent implantation.J Am Coll Cardiol 2010;55:1936–42.

[5] Gerber R, Colombo A. Does IVUS guidance of coronary interventions affect outcome?A prime example of the failure of randomized clinical trials. Catheter CardiovascInterv 2008;71:646–54.

[6] Parise H, Maehara A, Stone GW, Leon MB, Mintz GS. Meta-analysis of randomizedstudies comparing intravascular ultrasound versus angiographic guidance ofpercutaneous coronary intervention in pre-drug-eluting stent era. Am J Cardiol2011;107:374–82.

[7] Lodi-Junqueira L, de Sousa MR, da Paixao LC, Kelles SM, Amaral CF, Ribeiro AL. Doesintravascular ultrasound provide clinical benefits for percutaneous coronary inter-vention with bare-metal stent implantation? A meta-analysis of randomizedcontrolled trials. Syst Rev 2012;1:42.

[8] Sbruzzi G, de Quadros AS, Ribeiro RA, et al. Intracoronary ultrasound-guidedstenting improves outcomes: a meta-analysis of randomized trials. Arq Bras Cardiol2012;98:35–44.

[9] Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI Guideline forPercutaneous Coronary Intervention. A report of the American College of CardiologyFoundation/American Heart Association Task Force on Practice Guidelines and theSociety for Cardiovascular Angiography and Interventions. J Am Coll Cardiol 2011;58:e44-122.

[10] Comparative effectiveness of intravascular diagnostic procedures and imagingtechniques versus angiography alone. Eff Health Care 2011:1–17 [9 settembrehttp://www.effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=766, last accessed on 9mar2012].

[11] Moher D, Hopewell S, Schulz KF, et al. CONSORT 2010 explanation and elaboration:updated guidelines for reporting parallel group randomised trials. BMJ 2010;340:c869.

[12] von ElmE, AltmanDG, EggerM, et al. The Strengthening theReporting ofObservationalStudies in Epidemiology (STROBE) statement: guidelines for reporting observationalstudies. J Clin Epidemiol 2008;61:344–9.

[13] Balshem H, Helfand M, Schunemann HJ, et al. GRADE guidelines: 3. Rating thequality of evidence. J Clin Epidemiol 2011;64:401–6.

[14] Owens DK, Lohr KN, Atkins D, et al. AHRQ series paper 5: grading the strength ofa body of evidence when comparing medical interventions—agency for health-care research and quality and the effective health-care program. J Clin Epidemiol2010;63:513–23.

[15] Moher D, Liberati A, Tetzlaff J, Altman DG. PRISMA Group. Preferred reporting itemsfor systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol2009;62:1006–12.

[16] Stroup DF, Berlin JA, Morton SC, et al. Meta-analysis of observational studies inepidemiology: a proposal for reporting. Meta-analysis of observational studies inepidemiology (MOOSE) group. JAMA 2000;283:2008–12.

[17] Higgins JPT, Green S. Cochrane handbook for systematic reviews of intervention.verion 5.1.0 (updated march 2011) ed. The Cochrane collaboration; 2011.

[18] Jakabcin J, Spacek R, Bystron M, et al. Long-term health outcome and mortalityevaluation after invasive coronary treatment using drug eluting stents with orwithout the IVUS guidance. Randomized control trial. HOME DES IVUS. CatheterCardiovasc Interv 2010;75:578–83.

[19] Chieffo A, Latib A, Caussin C, et al. A prospective, randomized trial of intravascular-ultrasound guided compared to angiography guided stent implantation in complexcoronary lesions: the AVIO trial. Am Heart J 2013;165:65–72.

[20] Kim JS, Kang TS, Mintz GS, et al. Randomized comparison of clinical outcomes be-tween intravascular ultrasound and angiography-guided drug-eluting stent implan-tation for long coronary artery stenoses. JACC Cardiovasc Interv 2013;6:369–76.

[21] Fujimoto H, Tao S, Dohi T, et al. Primary and mid-term outcome of sirolimus-elutingstent implantation with angiographic guidance alone. J Cardiol 2008;51:18–24.

[22] Park SJ, Kim YH, Park DW, et al. Impact of intravascular ultrasound guidance onlong-term mortality in stenting for unprotected left main coronary artery stenosis.Circ Cardiovasc Interv 2009;2:167–77.

[23] Roy P, Steinberg DH, Sushinsky SJ, et al. The potential clinical utility of intravascularultrasound guidance in patients undergoing percutaneous coronary interventionwith drug-eluting stents. Eur Heart J 2008;29:1851–7.

[24] Hur S-, Kang S-, KimY-, et al. Impact of intravascular ultrasound-guidedpercutaneouscoronary intervention on long-term clinical outcomes in a real world population.Catheter Cardiovasc Interv 2013;81:407–16.

[25] Claessen BE, Mehran R, Mintz GS, et al. Impact of intravascular ultrasound imagingon early and late clinical outcomes following percutaneous coronary interventionwith drug-eluting stents. JACC Cardiovasc Interv 2011;4:974–81.

[26] Roy P, Torguson R, Okabe T, et al. Angiographic and procedural correlates of stentthrombosis after intracoronary implantation of drug-eluting stents. J Interv Cardiol2007;20:307–13.

[27] Chen SL, Ye F, Zhang JJ, et al. Intravascular ultrasound-guided systematic two-stenttechniques for coronary bifurcation lesions and reduced late stent thrombosis.Catheter Cardiovasc Interv 2013;81:456–63.

[28] Kim JS, Hong MK, Ko YG, et al. Impact of intravascular ultrasound guidance on long-term clinical outcomes in patients treated with drug-eluting stent for bifur-cation lesions: data from a Korean multicenter bifurcation registry. Am Heart J2011;161:180–7.

[29] Ahn JM, Han S, Park YK, et al. Differential prognostic effect of intravascularultrasound use according to implanted stent length. Am J Cardiol 2013;111:829–35.

[30] Agostoni P, Valgimigli M, Van Mieghem CA, et al. Comparison of early outcome ofpercutaneous coronary intervention for unprotected left main coronary arterydisease in the drug-eluting stent era with versus without intravascular ultrasonicguidance. Am J Cardiol 2005;95:644–7.

[31] Gerber RT, Latib A, Ielasi A, et al. Defining a new standard for IVUS optimizeddrug eluting stent implantation: the PRAVIO study. Catheter Cardiovasc Interv2009;74:348–56.

[32] Biondi-Zoccai G, Sheiban I, Romagnoli E, et al. Is intravascular ultrasound beneficialfor percutaneous coronary intervention of bifurcation lesions? Evidence from a4314-patient registry. Clin Res Cardiol 2011;100:1021–8.

[33] Kim SH, Kim YH, Kang SJ, et al. Long-term outcomes of intravascular ultrasound-guided stenting in coronary bifurcation lesions. Am J Cardiol 2010;106:612–8.

[34] Wakabayashi K, Lindsay J, Laynez-Carnicero A, et al. Utility of intravascularultrasound guidance in patients undergoing percutaneous coronary interventionfor type C lesions. J Interv Cardiol 2012;25:452–9.

[35] Patel Y, Depta JP, Novak E, et al. Long-term outcomes with use of intravascularultrasound for the treatment of coronary bifurcation lesions. Am J Cardiol2012;109:960–5.

[36] Iakovou I, Schmidt T, Bonizzoni E, et al. Incidence, predictors, and outcomeof thrombosis after successful implantation of drug-eluting stents. JAMA2005;293:2126–30.

[37] Cheneau E, Leborgne L, Mintz GS, et al. Predictors of subacute stent thrombosis:results of a systematic intravascular ultrasound study. Circulation 2003;108:43–7.

[38] Popma JJ, Weiner B, Cowley MJ, Simonton C, McCormick D, Feldman T. FDA advisorypanel on the safety and efficacy of drug-eluting stents: summary of findings andrecommendations. J Interv Cardiol 2007;20:425–46.

[39] Guagliumi G, Sirbu V, Musumeci G, et al. Examination of the in vivo mechanisms oflate drug-eluting stent thrombosis: findings from optical coherence tomographyand intravascular ultrasound imaging. JACC Cardiovasc Interv 2012;5:12–20.

[40] de Feyter PJ, Kay P, Disco C, Serruys PW. Reference chart derived from post-stent-implantation intravascular ultrasound predictors of 6-month expected restenosison quantitative coronary angiography. Circulation 1999;100:1777–83.

[41] Park KW, Kang S-, Yang H-, et al. Impact of intravascular ultrasound guidance inroutine percutaneous coronary intervention for conventional lesions: data fromthe EXCELLENT trial. Int J Cardiol 2013;167:721–6.

[42] Stone GW, Rizvi A, Newman W, et al. Everolimus-eluting versus paclitaxel-elutingstents in coronary artery disease. N Engl J Med 2010;362:1663–74.

[43] Biondi-Zoccai G, Agostoni P, Abbate A, D'Ascenzo F, Modena MG. Potential pitfalls ofmeta-analyses of observational studies in cardiovascular research. J Am Coll Cardiol2012;59:292–3.

[44] Lee CH. Intravascular ultrasound guided percutaneous coronary intervention: apractical approach. J Interv Cardiol 2012;25:86–94.

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