Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 9  |  Issue : 2  |  Page : 209-215  

Correlation of computed tomography angiography and digital subtraction angiography in nonspecific aortoarteritis (Takayasu's arteritis)


Department of Radiology, Pondicherry Institute of Medical Sciences, Kalapet, Puducherry, India

Date of Web Publication1-Mar-2016

Correspondence Address:
Linu Cherian Kuruvilla
Department of Radiology, E-5 Quarters, Pondicherry Institute of Medical Sciences Campus, Kalapet, Puducherry - 605 014
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.177667

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  Abstract 

Background: Nonspecific aortoarteritis (NSAA) or Takayasu's arteritis is an inflammatory disorder of large elastic arteries. Imaging plays a vital role in the diagnosis and treatment of such patients. Hence, one should be aware of the imaging profile of NSAA, and the advantages and disadvantages of computed tomography angiography (CTA) and digital subtraction angiography (DSA), which are the two most commonly performed imaging investigations in these patients. Aims: The aims of this study were to evaluate the imaging profile of NSAA in a sub-group of the Indian population, and to compare the efficacy of CTA and DSA in the diagnosis of this entity. Materials and Methods: A prospective study was conducted with 25 patients, who underwent CTA and DSA for suspected NSAA in our institute between January 2009 and September 2010. The data was analyzed in terms of the demographic characteristics of the study group, most common artery involved, most common angiographic type of NSAA, and the CTA and DSA findings in the study group. Results: NSAA predominantly affects young females, as seen in this study, wherein 20 of the 25 patients were females (80%). The most common age group affected was 20-25 years. Most of the patients (44%) had involvement of more than two vessels. The most common aortic branch vessel to be involved was the renal artery. DSA was more sensitive than CTA in detecting aortic or branch vessel stenosis. However, CTA scores over DSA in the evaluation of vessel wall thickness. Conclusion: The imaging profile of NSAA in the Indian population is different from the Japanese population in that the most common branch vessel involved in the Indian population is the renal artery, as opposed to the subclavian artery in the Japanese population. CTA and DSA are both very effective in the diagnosis of NSAA. However, the best imaging modality in NSAA is DSA since it can be used for diagnosis as well as the treatment of NSAA.

Keywords: Aorta, aortoarteritis, computed tomography angiography, digital subtraction angiography, Takayasu′s arteritis


How to cite this article:
Kuruvilla LC. Correlation of computed tomography angiography and digital subtraction angiography in nonspecific aortoarteritis (Takayasu's arteritis). Med J DY Patil Univ 2016;9:209-15

How to cite this URL:
Kuruvilla LC. Correlation of computed tomography angiography and digital subtraction angiography in nonspecific aortoarteritis (Takayasu's arteritis). Med J DY Patil Univ [serial online] 2016 [cited 2024 Mar 28];9:209-15. Available from: https://journals.lww.com/mjdy/pages/default.aspx/text.asp?2016/9/2/209/177667


  Introduction Top


Nonspecific aortoarteritis (NSAA) or Takayasu's arteritis is a rare, chronic granulomatous necrotizing vasculitis that involves large and medium-sized arteries, predominantly the aorta, its branches, and the pulmonary arteries. In 1990, the American College of Rheumatology, defined Takayasu's arteritis as follows: "Takayasu's arteritis is an idiopathic inflammatory disease of the large elastic arteries occurring in the young and resulting in occlusive or ectatic changes mainly in the aorta and its immediate branches as well as the pulmonary artery and its branches." The etiology is unknown, but genetic contribution to disease susceptibility is increasingly recognized. [1] The most common vessels involved apart from the aorta are the subclavian artery, renal artery, and common carotid artery.

Since the clinical diagnosis is presumptive, and the histological diagnosis is not possible due to involvement of the aorta and its major branches, the main diagnosis is made by radiological methods. The modern state of the art investigations such as ultrasound color Doppler (UCD), computed tomography angiography (CTA), magnetic resonance angiography (MRA), and digital subtraction angiography (DSA) have made the diagnosis of this disease much simpler. Historically, DSA has been the criterion-standard imaging tool for the diagnosis and evaluation of NSAA.

In the recent years, CTA and MRA have become equally valuable tools. Their large fields of view, as well as the fact that they are noninvasive and that intravenously administered contrast material is used, rather than intra-arterially administered contrast material in DSA, make them far more attractive as diagnostic tools.

DSA is considered as the gold standard in delineating abnormal vessels in patients with NSAA. It may reveal irregular intimal surface with stenosis of aorta, poststenotic dilatation, saccular aneurysms, and even complete occlusion of the vessels. However, the cause of vascular narrowing (e.g., active inflammation as opposed to intimal and adventitial fibrosis of the vessel wall) cannot be established. Therefore, DSA findings in patients with NSAA have to be interpreted within the clinical context. DSA can also be used as a preliminary imaging modality to find out the lesions, which are amenable to endovascular intervention procedures.

Since NSAA wears many faces, radiological investigations have become mandatory for diagnostic localization, distribution, and dynamics of involvement of the vessels. Due to its various advantages and increased sensitivity, DSA is still considered as the gold standard for the diagnosis of NSAA. The initial investigation is mostly a UCD or CTA, following which DSA is usually done to know the extent of disease and for therapeutic planning.

This study was primarily performed to describe the imaging profile of NSAA in a sub-group of the Indian population, and to compare the efficacy of CTA and DSA in the diagnosis of NSAA.


  Materials and Methods Top


Study design

A prospective study was conducted to all the patients, who underwent CTA and DSA for suspected NSAA in our institute between January 2009 and September 2010.

Our study group consisted of 25 patients (n = 25), who presented to the hospital with symptoms, which raised the clinical suspicion of NSAA. Prior Institutional Ethics Committee clearance was obtained for the study. The written informed consent was obtained from the subjects for inclusion of their images in the study.

Inclusion criteria

  1. Any patient presenting with a high clinical suspicion of NSAA, such as a young hemiplegic, young hypertensive, or patients presenting with features of claudication.
  2. Any patient showing positive signs of the disease on UCD, such as irregular vessels with thickened intima-media complex or tortuous and stenotic vessels.


Exclusion criteria

  1. Any patient refusing to give consent for the procedure.
  2. Any patient with a history of contrast reaction/allergy.
  3. Patients in whom administration of contrast media is contra-indicated such as patients with high serum creatinine levels (serum creatinine of more than 2).
  4. Pregnant females.


Study protocol

The CTA was performed on a Multi-Detector Row CT Scanner (Siemens Somatom Volume Zoom 4-Slice MDCT scanner-Siemens Medical Solutions, Erlangen, Germany). Patients were asked to be nil by mouth for at least 6 h prior to the procedure. No oral contrast was administered prior to or during the study.

Scans were done as per the following computed tomography protocol

Topogram

Covering the chest, abdomen, and pelvis at 120 kV and 50 mAs with a collimation of 1 mm.

Plain thoraco-abdominal computed tomography acquisition

From the level of aortic arch to just below the aortic bifurcation, scans were performed at 120 kV, 155 mAs in all patients, irrespective of body mass index with a nominal slice width of 5 mm and detector collimation of 2.5 mm. Gantry rotation time of 0.5s was the fastest possible on the scanner. The resulting scan durations were between 15 and 20 s, during which patients were requested to hold their breath.

Aortogram

CTA is a fast, thin section, and volumetric spiral (helical) CT examination performed with a time-optimized bolus of contrast medium. The aortogram was initiated by taking an axial premonitoring slice at the level of the ascending aorta. Monitoring was done at a delay of 7 s with the trigger at 100 HU in the ascending aorta. The aortogram was set at a delay of 3 s with a nominal slice width of 5 mm and detector collimation of 2.5 mm. 100 ml of contrast medium (Iohexol 350 mg% w/v) was then injected at a flow rate of 4 ml/s with the help of pressure injector (Medrad), and the scan was taken from the level of the aortic arch till just distal to the aortic bifurcation, ensuring that the proximal part of the aortic arch branches was included in the scanned area. Bolus tracking method was used routinely to achieve optimal synchronization of the contrast media flow through the vessels. Overlapping reconstruction was performed with a reconstructed slice thickness of 3 mm at 2.8 mm intervals. Three-dimensional reconstruction with thin multi-planar reconstruction was performed in coronal and sagittal planes (In cases of suspected renal vessel involvement, scans were performed with a nominal slice width of 2 mm and detector collimation of 1 mm. Overlapping reconstruction was performed with a reconstructed slice thickness of 1 mm at 0.8 mm intervals).

The procedure of DSA was done using a state of the art PHILIPS BV300 DSA System. Patients were asked to keep fasting for at least 6 h prior to the procedure.

The common femoral artery was palpated in the groin and punctured below the inguinal ligament. Transfemoral catheterization was then done by the percutaneous Seldinger technique with the help of a single-puncture or a 16/18-gauge double puncture needle. The intra-arterial route was secured with the help of an intravascular access sheath. A 4 or 5-Fr pigtail catheter was mounted on a guide wire and introduced through the sheath and common femoral artery, into the aorta. Selective angiogram was preceded by a flush abdominal aortogram.

Images were taken of bilateral renal arteries and the aortic bifurcation by injecting contrast through the pigtail catheter. A 4 or 5-Fr headhunter catheter was then introduced into the aorta through the guide wire, and carried up to the thoracic aorta and the aortic arch to take images of the aortic arch branches. Images were also taken of the descending thoracic and abdominal aorta to localize any areas of thrombosis, stenosis, occlusion, or dilatation. After the procedure, the sheath was removed. Compression was given proximal to the puncture site and was released once complete hemostasis was achieved. The patient was asked not to move the punctured lower limb for at least a period of 6 h following the procedure.


  Results Top


Of the patients, who underwent CTA and DSA in our institute between January 2009 and September 2010; 25 patients (n = 25) met the inclusion criteria. 20 of the 25 patients were females with a male:female ratio of 1:4, respectively [Table 1]. The most common age group involved was 20-25 years [Table 2]. The mean age of patients were 24 years with the youngest aged 12 years and the oldest aged 40 years. The early onset of disease before the age of 40 years, and the involvement of aorta and its major branches differentiated NSAA from arteritis due to other causes in these patients. The workup for other causes of arteritis, such as infective or rheumatologic, was negative in these patients.
Table 1: Gender distribution of the study group

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Table 2: Age distribution of the study group

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The most common clinical presenting feature was hypertension, due to renal artery stenosis. Most patients had more than one presenting feature [Table 3]. Since NSAA is a multi-vessel disease, most of the patients (44%) had involvement of more than 2 vessels [Table 4]. The most common artery to be involved was the abdominal aorta in 68% of patients. The most common branch vessel to be involved was the renal artery in 56% of patients [Table 5]. CTA revealed aortic or branch vessel stenosis or occlusion, vessel wall thickening or aortic dilatation in these patients [Table 6] [Figure 1]b, [Figure 4]b and [Figure 5]. DSA also demonstrated similar findings, apart from vessel wall thickening [Table 7] [Figure 1]a, [Figure 2], [Figure 3] and [Figure 4]a. Vessel wall thickening is not very well appreciated on DSA. CTA is better than DSA for evaluation of vessel wall thickness.
Figure 1: (a) Digital subtraction angiography reveals irregularities in the lumen of the proximal abdominal aorta (arrow). (b) Computed tomography angiography, in the same patient, also shows narrowing and wall irregularity of the proximal abdominal aorta (arrow)

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Fgure 2: (a) Digital subtraction angiography shows irregular narrowing of the descending thoracic aorta (arrows). (b) Stenting of the narrow segment of the descending thoracic aorta was performed (arrow). One advantage of digital subtraction angiography over computed tomography angiography is that digital subtraction angiography can also be used for therapeutic purposes, as in this case

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Figure 3: (a) Digital subtraction angiography reveals narrowing at the origin of the right renal artery (arrow). (b) Balloon angioplasty of the narrowed segment of the right renal artery was done (arrow)

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Figure 4: (a) Digital subtraction angiography reveals narrowing at the origin and proximal part of the left subclavian artery (arrow). (b) Computed tomography angiography also shows narrowing and wall thickening at the origin and proximal part of the left subclavian artery (arrow)

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Figure 5: (a) Computed tomography angiography shows wall thickening of the proximal parts of left common carotid artery (white arrow) and left subclavian artery (red arrow). (b) Computed tomography angiography, in the same patient, also shows wall thickening of the aortic arch (arrow). Computed tomography angiography scores over digital subtraction angiography in the assessment of vascular wall thickening. Wall thickening cannot be well appreciated in digital
subtraction angiography


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Table 3: Clinical presenting features of the study group

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Table 4: Number of vessels involved in the study group

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Table 5: Most common vessel involved in the study group

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Table 6: CTA findings in the study group

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Table 7: DSA findings in the study group

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NSAA was classified angiographically into five types in the Tokyo International Conference. Type I involves only the aortic arch branches. Type II involves the ascending aorta, arch, its branches, and/or the thoracic descending aorta. Type III involves the thoracic descending aorta, abdominal aorta, and/or the renal arteries. Type IV involves only the abdominal aorta and/or renal arteries. Type V has mixed features of types II and IV.

The most common angiographic pattern noted in this study was type V, which was seen in 12 patients (48%). Both type I and type II patterns were seen in 4 patients each (16%). Type IV pattern was seen in 3 patients (12%) and type III was seen in 2 patients (8%) [Table 8]. A total of 21 out of the 25 patients were available for follow-up. Seven of the 25 patients were managed conservatively. Seven patients underwent balloon angioplasty and 5 patients underwent vascular stenting to relieve their symptoms. Two patients unfortunately expired during the course of the study, both of them had presented with accelerated hypertension. Four of the 25 patients were lost in follow-up [Table 9].
Table 8: Angiographic types of NSAA in the study group

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Table 9: Follow-up of the study group

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  Discussion Top


This prospective study of 25 patients of NSAA, who were referred to our institute between January 2009 and September 2010; reiterated the fact that NSAA is more common in females and is mostly seen in the young population, especially in the third decade of life.

Most of the patients were referred for CTA, after UCD revealed changes in the vessels suspicious of NSAA. Once CTA confirmed the disease, further disease characterization, vessel involvement, and treatment options were analyzed with DSA.

The most common vessel, apart from aorta, to be found involved in this study was the renal artery, followed by the subclavian artery. Of all the branches of the aorta, the inferior mesenteric artery was the one, which was never involved. This pattern of vessel involvement was similar to that mentioned by Sen et al. in their study. [2] This pattern of involvement varies from the Japanese population where NSAA is very common. The most common branch vessel to be involved in the Japanese population is the subclavian artery, as shown by Moriwaki et al. in their study. [3] Hence, most Indian patients with NSAA present with hypertension due to renal artery involvement, whereas most Japanese patients present with pulselessness in the upper limbs due to subclavian artery involvement. The most common angiographic pattern noted in our study was type V, followed by types I, II, IV, and III.

Correlation of CTA and DSA findings of various patients, in this study revealed that aortic and branch vessel stenosis were seen in more percentage of patients in DSA than in CTA, making DSA more sensitive than CTA in these factors. However, CTA scores over DSA in detecting vessel wall changes and wall thickening, which are more aptly seen in CTA, and for detecting pathology in other adjacent organs.

CTA also has the additional advantage of being relatively faster and less tedious than DSA, and hence along with UCD, it can be used effectively as the initial screening modality in the majority of patients. The utility of noninvasive techniques such as CTA, UCD, or MRA is particularly high in pediatric patients, in whom the complications of DSA are potentially worse than they are in adults. [4],[5] CTA can also be used in the follow-up of patients with NSAA, and any new or progressing lesion can be further analyzed by DSA.

DSA, however, still remains as an important option for diagnosis, accurate imaging of smaller aortic branch arteries, preoperative assessment, and has the additional benefit of allowing accurate measurement of arterial pressure. As revealed in this study and through various other studies conducted throughout the globe, DSA is more sensitive than CTA in detecting vessel changes in NSAA and is hence, considered as the investigation of choice in NSAA.

Despite the disease being recognized for more than 100 years, the outlook for patients with NSAA remains relatively poor and the treatment suboptimal. NSAA is the only form of aortitis that results in stenosis and occlusion of the aorta. [6],[7],[8],[9] Since clinical features may be very nonspecific or even absent, delay in the diagnosis of NSAA is very common. [10] In addition to improved physician awareness, a list of "red flags" raising the possibility of NSAA is helpful, like for example, the index of suspicion must be high in young patients with hypertension; and hence, should trigger a request for further imaging. Even when the diagnosis is achieved, challenges occur in differentiating the acute or "active" phase of the disease and the chronic stenotic phase when symptoms or signs are the result of tissue ischemia from progressive arterial narrowing. [11]

Newer imaging modalities such as positron emission tomography-CT (PET-CT) may help in assessing disease activity and confirming remission in NSAA. [12] Clinicians usually combine clinical features with acute phase reactants such as the erythrocyte sedimentation rate and/or C-reactive protein; imaging techniques such as UCD, MRA, CTA, [13],[14] PET-CT, [15],[16] and DSA, to monitor for disease activity and for stenotic sequelae. DSA is regarded by most as a gold standard and is of particular importance in the assessment of patients potentially requiring revascularization procedures. [17]

Despite the use of noninvasive imaging techniques, the question of "which investigation for which patient?" remains to be answered by prospective studies. However, as seen in this study, any case of NSAA is incomplete without DSA since it helps us to analyze in detail, the vascular involvement and the finer branches, which may not be seen on CTA and also helps in providing therapeutic options. Percutaneous transfemoral angioplasty is an effective therapeutic technique in this debilitating disease. Recently, endovascular stent insertions have also been used in NSAA.


  Conclusion Top


Hence, this study showed that the "renal artery" type of NSAA is probably more common in the Indian population, as compared to the Japanese population where the "subclavian artery" type is more common. However, one limitation of this study is its number of participants (n = 25), which may not be a representative of the entire Indian population. Hence, further studies with more number of participants are warranted to analyze the imaging profile of NSAA in the Indian population. This study also reiterated the fact that though CTA and DSA are very effective for the diagnosis of NSAA, the gold standard for the diagnosis is DSA, since it can not only be used to diagnose the condition, but also to analyze the treatment options, and to determine which lesions are amenable to treatment.

Acknowledgment

This study was carried out when the author was working in Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Morishita KA, Rosendahl K, Brogan PA. Familial Takayasu arteritis - A pediatric case and a review of the literature. Pediatr Rheumatol Online J 2011;9:6.  Back to cited text no. 1
    
2.
Sen PK, Kinare SG, Kelkar MD, Parulkar GB. Nonspecific Aortoarteritis - A Monograph Based on a Study of 101 Cases. Bombay: Tata McGraw-Hill Publishing Co.; 1972. p. 41-2.  Back to cited text no. 2
    
3.
Moriwaki R, Noda M, Yajima M, Sharma BK, Numano F. Clinical manifestations of Takayasu arteritis in India and Japan - New classification of angiographic findings. Angiology 1997;48:369-79.  Back to cited text no. 3
    
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Gupta R, Kavimandan A, Kumar R. Does PET-CT predict disease activity in Takayasu′s arteritis? Scand J Rheumatol 2008;37:237-9.  Back to cited text no. 4
    
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Steeds RP, Mohiaddin R. Takayasu arteritis: Role of cardiovascular magnetic imaging. Int J Cardiol 2006;109:1-6.  Back to cited text no. 5
    
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Cakar N, Yalcinkaya F, Duzova A, Caliskan S, Sirin A, Oner A, et al. Takayasu arteritis in children. J Rheumatol 2008;35:913-9.  Back to cited text no. 6
    
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Chung JW, Kim HC, Choi YH, Kim SJ, Lee W, Park JH. Patterns of aortic involvement in Takayasu arteritis and its clinical implications: Evaluation with spiral computed tomography angiography. J Vasc Surg 2007;45:906-14.  Back to cited text no. 7
    
8.
Maksimowicz-McKinnon K, Hoffman GS. Takayasu arteritis: What is the long-term prognosis? Rheum Dis Clin North Am 2007;33:777-86, vi.  Back to cited text no. 8
    
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Mwipatayi BP, Jeffery PC, Beningfield SJ, Matley PJ, Naidoo NG, Kalla AA, et al. Takayasu arteritis: Clinical features and management: Report of 272 cases. ANZ J Surg 2005;75:110-7.  Back to cited text no. 9
    
10.
Watts R, Al-Taiar A, Mooney J, Scott D, Macgregor A. The epidemiology of Takayasu arteritis in the UK. Rheumatology (Oxford) 2009;48:1008-11.  Back to cited text no. 10
    
11.
Maksimowicz-McKinnon K, Clark TM, Hoffman GS. Limitations of therapy and a guarded prognosis in an American cohort of Takayasu arteritis patients. Arthritis Rheum 2007;56:1000-9.  Back to cited text no. 11
    
12.
Karapolat I, Kalfa M, Keser G, Yalçin M, Inal V, Kumanlioglu K, et al. Comparison of F18-FDG PET/CT findings with current clinical disease status in patients with Takayasu′s arteritis. Clin Exp Rheumatol 2013;31 1 Suppl 75:S15-21.  Back to cited text no. 12
    
13.
Schmidt WA. Imaging in vasculitis. Best Pract Res Clin Rheumatol 2013;27:107-18.  Back to cited text no. 13
    
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Zhu FP, Luo S, Wang ZJ, Jin ZY, Zhang LJ, Lu GM. Takayasu arteritis: Imaging spectrum at multidetector CT angiography. Br J Radiol 2012;85:e1282-92.  Back to cited text no. 14
    
15.
Sager S, Yilmaz S, Ozhan M, Halaç M, Ergül N, Ciftci H, et al. F-18 Fdg PET/CT Findings of a Patient with Takayasu Arteritis Before and After Therapy. Mol Imaging Radionucl Ther 2012;21:32-4.  Back to cited text no. 15
    
16.
Cheng Y, Lv N, Wang Z, Chen B, Dang A. 18-FDG-PET in assessing disease activity in Takayasu arteritis: A meta-analysis. Clin Exp Rheumatol 2013;31 1 Suppl 75:S22-7.  Back to cited text no. 16
    
17.
Khandelwal N, Kalra N, Garg MK, Kang M, Lal A, Jain S, et al. Multidetector CT angiography in Takayasu arteritis. Eur J Radiol 2011;77:369-74.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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