Branched stent-grafts deployed in the true and false ...

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The Journal of Cardiovascular surgery 2016 october;57(5):646-52

CASE REPORT VA S C U L A R S E C T I O N

Branched stent-grafts deployed in the true and false lumen to exclude a post dissecting thoracoabdominal aneurysm luca BerToglio 1*, enrico M. Marone 1, efrem Civilini 2, Tommaso CaMBiaghi 1, daniele MasCia 1, roberto Chiesa 1 1Department of Vascular Surgery, Scientific Institute San Raffaele Hospital, Vita Salute San Raffaele University, Milan, Italy; 2humanitas Clinical and research Center, department of vascular surgery, rozzano, italy

*Corresponding author: Luca Bertoglio, Department of Vascular Surgery, Scientific Institute San Raffaele Hospital, Vita Salute San Raffaele University, Via olgettina 60, 20132 Milan, italy. e-mail: [email protected]

aBsTraCT The aim of this case report was to present an endovascular treatment of a residual post-dissection Crawford type iii thoracoabdominal aneurysm (Taa). a 60-year-old man, who had suffered from acute type B aortic dissection (TBad) 8 years ago and had already been treated for both descending thoracic and infrarenal aortic aneurysm with open repair, presented with a 61mm post-dissection Taa. The aneurysm was successfully excluded with a staged fully endovascular procedure by employing two multibranched custom-made stent grafts deployed into the false lumen. The first stent-graft with a proximal monobranch was created to perfuse the right renal artery via the true lumen. The latter, with a triple branch design, was meant to perfuse the visceral arteries and left renal artery arising from the false lumen. available branched custom-made stent-grafts for the treatment of degenerative Taa can be employed also in post TBad aneurysms so as to simplify the procedure. The branched stent-grafts could be deployed within an enlarged false lumen provided that a suitable distal landing zone is available as well as that the visceral vessels can be perfused from the false lumen. a proximal branch for perfusing one of the lumens of the dissection from the proximal tear can be an alternative solution to creating neofenestrations. (Cite this article as: Bertoglio l, Marone eM, Civilini e, Cambiaghi T, Mascia d, Chiesa r. Branched stent-grafts deployed in the true and false lumen to exclude a post dissecting thoracoabdominal aneurysm. J Cardiovasc surg 2016;57:646-52) Key words: aortic aneurysm, thoracic - endovascular procedures - stents.

T

he majority of patients surviving acute type B aortic dissection (TBad) treated medically or by thoracic stent-grafting are left with a residual aortic dissection. about 20-50% of these patients may experience disease progression despite optimal medical treatment causing aneurysmal degeneration and subsequent rupture.1 according to international guidelines, patients with postdissection thoraco-abdominal aneurysms (Taa) after TBad should be preferably treated with open repair;2 however, mortality and morbidity rates are not negligible 3-6 and, for those reasons, patients unfit for open surgery would benefit from a less invasive approach such as an endovascular one. on one hand, simple stent-grafting of both the proxi-

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mal entry tear and the thoracic aorta to promote thrombosis of the false lumen of chronic TBad is often an unsuccessful process. not only may the exclusion of the false lumen occur over a long time, but also it is often limited to the stent-grafted segment of the thoracic aorta so that the reversal of the natural history of aneurysmal disease is inconsistent.1, 7-9 on the other hand, although fenestrated and branched thoracoabdominal (f/b-Tevar) stent-grafts have been widely used for treating degenerative Taa with favorable results,10-12 experience with f/b-Tevar in the treatment of post dissecting Taa has been limited due to anatomical limitations.13-19 This case report describes a patient with a postdis-

The Journal of CardiovasCular surgery

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BranChed sTenT-grafTs dePloyed in The True and false luMen

BerToglio

section Crawford type iii Taa who underwent staged placement of two custom-made branched stent grafts deployed into the false lumen to obtain complete exclusion of the aneurysm while maintaining perfusion of renal and visceral vessels arising from each lumen of the dissection. Case report a 60-year-old gentleman presented with a 61-mm asymptomatic residual postdissection Crawford type iii Taa. despite his complex previous aortic clinical history, the only significant comorbidities were past smoking, hypertension, dyslipidemia. no connective tissue disorders were discovered at genetic analysis (i.e. Marfan, ehlers-danlos and loeys-dietz syndromes). eight years earlier, he had been diagnosed with an acute TBad with the proximal intimal tear located on the convexity of the descending thoracic aorta 2.5 cm caudally to the left subclavian artery and the dissection propagated distally into the abdominal aorta and both common iliac arteries. The dissection was complicated by right lower limb ischemia, which required stenting angioplasty of the right common iliac artery, and by a renal dynamic malperfusion (peak creatinine level of 6.5 mg/dl) which spontaneously recovered. no thrombosis of the false lumen was present. The patient was scheduled for our institutional CT scan follow-up program (at 1 and 6 months and yearly thereafter) and treated with conservative medical therapy (atenolol 100 mg q.d. and losartan 50 mg q.d.). at one year follow-up, the CT scan noted an aneurysmal dilatation (67 mm) of the proximal descending thoracic aorta (Table i).20 for that reason, he underwent open repair of the descending thoracic aorta under deep hypothermic cardiac arrest with a straight 34 mm dacron tube combined to open distal septotomy. The postoperative course was complicated by chylothorax necessitating a video-assisted thoracoscopy of the cavity and subsequent a re-thoracotomy. four years after the initial dissection (Table i), a CT scan documented also an aneurysmatic evolution of the infrarenal abdominal aorta (54 mm) that was treated with open repair and interposition of a straight 16-mm dacron tube combined to open proximal septotomy. a reintervention was performed two Table I.—DISSECTclassification 20atthedifferenttimeintervals. disseCT CriTeria23

Duration Intimal tear location Size Segmental Extent of aortic involvement Clinical complications Thrombosis of false lumen

T0

T+1y

T+4y

T+8y

ac d 37 mm di

Ch d 67 mm dab

Ch d 54 mm dab

Ch d 61 mm dab

C P

C P

C P

C P

T0 at presentation; T+1y: at open Taa repair; T+4t: at open aaa repair; T+8y: at case report time. duration: ac: acute; Ch: chronic. intimal tear location: d: descending aorta. segmental extent of aortic involvement: di = descending to iliac, dab: descending to abdomen. Clinical complications: C: complicated by false lumen dilation and/or overall trans-aortic enlargement of >10 mm within the first 2 weeks of initial diagnosis. Thrombosis of false lumen: P: patent.

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figure 1.—Preoperative CT scan demonstrates a residual post-dissection Crawford type iii Taa in a patient with previous open repair of both the proximal descending thoracic (*) and the infrarenal aorta (**) and right common iliac stenting. Please, note the collapsed true lumen from which the right renal artery arises and the aneurysmal evolution of the false lumen from which the left renal artery arises. Both the celiac trunk and the superior mesenteric artery are dissected and perfused from both the true and false lumen.

years later to fix an incisional abdominal hernia with interposition of a prolene mesh. The preadmission CT scan (figure 1) showed a highly compressed (7 mm) true lumen starting 15 mm distally to the thoracic surgical graft. The right renal artery was perfused only from the true lumen. a 2-mm thick dissecting lamella separated the latter from the aneurysmatic false lumen, which perfused the left renal artery. Both the celiac trunk and the superior mesenteric artery were dissected at the origin and perfused by both true and false lumen. The hypogastric arteries and the left sublavian artery were not dissected. no secondary tears were evident at both preoperative CT scan and transesophageal echocardiography. The pre-admission estimated glomerular filtration was 93 mL/min. despite his age, an open repair of his residual post-dissection Crawford type iii Taa was contraindicated because of the previous open aortic repairs and the thoracic adhesions. The patient was thus scheduled for a complex branched endovascular treatment with two multibranched custom-made stent-grafts (Cook Medical, Brisbane, australia). Taking into consideration the high risk of spinal cord ischemia due to the two previous aortic repairs, the procedure was split in two different stages. The first stage was performed under general anesthesia with systemic heparinization (70 ui/kg adjusted to maintain an activated clotting time >250 s) without cerebrospinal drainage in a standard surgical operative theatre with a portable C-arm (Ziehm imaging, nuremberg, germany). Both common femoral arteries were surgically exposed. Through the right femoral access the false lumen was catheterized and a stiff extended Curve 0.035 lunderquist guide-wire (William Cook europe, aps, Bjaeverskov, denmark) was, then, exchanged into the ascending aorta. Through the left femoral access, the true lumen was catheterized and a 10 fr. and 80-cm long hydrophilic introducer sheath (William Cook europe, aps, Bjaeverskov, denmark) was advanced into the true lumen and its tip was left at the end of the surgical thoracic surgical


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Figure 2.—The first proximal custom-made monobranch stent-graft was designed with two 42-mm proximal sealing stents in order to land in the previous thoracic surgical graft. a single 6 x 21 mm external/internal branch was orientated at 11 o’clock to perfuse the true lumen and then, after being bridged with three long covered stent-graft, to provide the right renal artery with antegrade flow from this proximal branch. The distal end of the stent-graft was designed 22 mm in diameter so as to create a narrow overlapping zone for the second custom made stent-graft described in figure 3.

figure 3.—The second distal custom-made tribranch stent-graft was designed with three 24-mm proximal sealing stents to be overlapped with the distal end of the first stent-graft already deployed in the false lumen. The distal end of the stent-graft was planned with two 24-mm sealing stent in order to land in the previous infrarenal surgical graft. Two 8x18 mm external /internal branch were orientated at 12 and 1 o’clock targeted to the celiac trunk and the superior mesenteric artery and a 6x18 mm external/internal branch was orientated at 2 o’clock targeted to the left renal artery.

graft. A first monobranched custom-made stent-graft (Cook Medical, Brisbane, australia) (figure 2) was advanced and deployed into the false lumen with the first two sealing stents overlapped (5 cm) with the previous thoracic surgical graft and the monobranch was released above the edge of the dissecting lamella. This branch being meant to provide flow through bridging covered stent to the true lumen and thus to the right renal artery, it was selectively catheterized from the left femoral introducer, previously placed into the true lumen. Then, two covered stents fluency 6x120 mm (Bard incorporated, Karlsruhe, germany) were deployed to bridge the gap between the monobranch and the true lumen. The distal edge of the second covered stent was deployed just above the origin of the celiac trunk in order not to interfere with perfusion of the visceral arteries until the second stage would be completed. Then, a second triple-branched custom-made stent-graft (Cook Medical, Brisbane, australia) (figure 3) was deployed into the false lumen, 7 cm overlapped with the previous one, and with the distal sealing stent deployed into the previous abdominal surgical graft. stentgrafts overlapping zones were ballooned with a molding compliant balloon and the monobrach as well as the two fluency covered stents were ballooned with a non-compliant Passeo 6 mm balloon (Biotronik ag, Buelach, switzerland). The duration of the procedure was 2 hours and 45 minutes with an estimated blood loss of 250 ml and the patient was transferred to standard care unit. The patient was discharged on postoperative day 4 after performing a CT scan to both ensure the patency of renal and visceral arteries and plan the length of the bridging stents for the second step (fig-

ure 4). during the inter-surgical interval, the patient was treated with low molecular weight heparin (enoxaparin sodium 40 mg b.i.d.). Two weeks later, the second stage was performed under local anesthesia in a standard angiographic suite. We decided to place cere-

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Figure 4.—Postoperative CT scan performed at the end of the first stage. Partial thrombosis of the proximal third of the false lumen was observed with patency of the cover bridging stent deployed in the true lumen. Please note the patency of the visceral and renal arteries perfused by the unbridged branch of the two custom-made stent-grafts.


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Table II.—Detailsofthebridgingstentsusedtoexcludethepost-dissectionTAAAforthefourbranches. Covered bridging stent a (diameter x length)

Target vessel

Celiac trunk superior mesenteric artery left renal artery right renal artery afluency

distal bare stent b (diameter x length)

13.5x100 mm 8x80 mm 6x80 mm Three 6x120 mm

8x40 mm no 6x40 mm 6x40 mm

non-compliant balloon c

12x30 mm 8x80 mm 6x80 mm 6x120 mm

Bard incorporated, Karlsruhe, germany; bEverflex ev3 Endovascular Inc, Plymouth, Minnesota; cPasseo-35 Biotronik ag, Buelach, switzerland.

bral spinal fluid drainage selectively only in case of spinal cord onset being the procedure performed under local anesthesia. Permissive hypertension was maintained during the procedure and postoperatively with a target of a mean arterial pressure of 80 mmhg. a usguided catheterization of the right brachial artery was performed and a 12 fr. and 45-cm long hydrophilic introducer sheath (William Cook europe, aps, Bjaeverskov, denmark) was advanced through the aortic arch. a 10 fr. and 80 cm long introducer sheath (William Cook europe, aps, Bjaeverskov, denmark), then, was telescopically advanced through the first one into the main body of the custom made triple branched stent-graft. The gaps between the four branches and the target vessels were bridged in a caudal to cranial order with covered stent (fluency Bard incorporated, Karlsruhe, germany), the distal end of the covered stent was overstented in 3 of the 4 targed vessels with a bare self-expandable stent (everflex ev3 Covidien Endovascular Inc, Plymouth, Minnesota) and, in the end, non-compliant ballooning of the whole covered stent area was performed (Passeo Biotronik ag, Buelach, switzerland) (Table ii). The most challenging vessel was the celiac trunk because an angiogram performed through the false lumen revealed static malperfusion of the hepatic artery (figure 5). a large covered

a

stent was deployed into the hepatic artery covering the ostium of the splenic artery. overstenting of the distal edge of the stent-graft with bare self-expandable stent was required followed by large non-compliant ballooning of the entire covered-stent area. lastly, before bridging the last branch targeted to the right renal artery, an occlusion test of 20 min of the monobranch with a 6 mm balloon was performed to detect early onset of spinal cord ischemia. The test being negative, the same procedure performed for the other branches was completed. Completion angiography demonstrated a complete exclusion of the Taa with no endoleaks and patency of the visceral and renal arteries. a small cut down at the site of insertion of brachial introducer sheath was performed and the brachial artery repaired with two single 6/0 Prolene stiches. The duration of the procedure was 3 hours and 15 minutes with an estimated blood loss of 150 ml and the patient was transferred to standard care unit. The postoperative course was uneventful; a CT scan was performed postoperatively and at 6 months and demonstrated technical success of the procedure with patency of all the vessels arising from both the true and false lumen (figure 6). no shrinkage of false lumen was noticed over the first 6 months of follow-up The 6 months estimated glomerular filtration was 87 mL/min.

B

figure 5.—a) selective intraoperative angiogram of celiac trunk (CT) from the false lumen demonstrated the perfusion of the splenic artery and malperfusion of the hepatic artery which wasn’t directly perfused from the false lumen. B) after selectively catheterizing the common hepatic artery, a 13.5x100 mm bridging fluency covered stent (Bard incorporated, Karlsruhe, germany) was advanced over an amplatz 1cm-short-tip guide wire (William Cook europe, aps, Bjaeverskov, denmark) and deployed into the common hepatic artery to intentionally occlude the ostium of the splenic artery. despite the hepatic artery being 8 mm in diameter, the 13.5mm stent graft was oversized to the celiac trunk diameter in order to seal the dissected origin of the vessel and avoid retrograde type ii endoleak from the splenic artery. Morevover, due to the mismatch of caliber between the stent-graft and the hepatic artery, overstenting of the distal edge of the stent-graft with bare self-expandable Everflex 8x40 mm stent (Everflex ev3 Covidien endovascular inc, Plymouth, Minnesota) was required followed by non-compliant ballooning (12 mm) of the entire covered-stent area.

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figure 6.—final postoperative CT scan performed at the end of the second stage. Complete thrombosis of the false lumen was observed with patency of all the visceral and renal arteries.

Discussion indications and methods to treat chronic TBad with f/b-Tevar are debated and different challenges with endovascular exclusion of the dissected aorta have been highlighted by three different centres which have experienced more than 15 cases in this setting.18-20 The critical issues highlighted by those authors can be summarized in: 1. correct selection of the sealing zones; 2. management of the narrow true lumen; 3. ensure perfusion of visceral and renal vessels arising from both true and false lumen; 4. treat the extension of the dissection flap into the origin of the target vessels. The proximal sealing zone should have a length similar to that employed in the treatment of degenerative Taa (i.e. 20 mm). Moreover, it should be a non-dissected area and located in the horizontal or the vertical segment of the aortic arch. if the coverage of a supraaortic vessel is planned (i.e. the left subclavian artery), prophylactic surgical or endovascular revascularization is mandatory to minimize the risk of paraplegia and stroke. TBad usually extends downward into the infrarenal aorta and iliac arteries and often, in order to exclude the false lumen, the distal sealing zone may include the iliac bifurcation. in such cases, the use of iliac branched devices maintaining the patency of the hypogastric arteries to reduce the risk of spinal cord ischemia has been suggested.19, 20 in this case, prior open aortic surgery had created two ideal proximal and

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distal landing zones. Moreover, the presence of the distal surgical graft allowed us to deploy the stent-grafts in either the true or the false lumen. on the other hand, previous aortic surgery does increase the risk of spinal cord ischemia. hence, a staged approach was chosen with the second step under local anesthesia allowing us to perform an occlusion test of the last branch to detect early onset spinal cord ischemia. in case of spinal cord ischemia onset, we would have left the last branch unbridged to precondition the spinal cord for a longer time and complete the exclusion of the aneurysm later with a spinal cord drainage in place.17 recently, staged approach to endovascular treatment of Taa has been demonstrated to lower significantly the risk of spinal cord ischemia.18 The most problematic feature in postdissection Taa is the compressed true lumen of the aorta. as a general rule in the design of f/b-Tevar, branches are selected whenever sufficient room is available (at least 20 mm at the level of the target vessel) and when the vessels have a caudally oriented takeoff. in cases with a smaller diameter or a 90 degrees takeoff, a fenestration may be preferred.19, 20 however, other problems may arise when using a fenestrated stent-graft in TBad.17-20 firstly, fenestration clock position planning is difficult because the true lumen re-expansion induced by the f/b-Tevar may be unpredictable. secondly, orientation and repositioning of a fenestrated graft can be difficult in a narrow true lumen. Furthermore, fenestrations must be catheterized from below and especially the celiac trunk may be challenging. lastly, fenestrations usually should not be left unbridged thus preventing a truly staged procedure. some of these limitations can be overcome by using preloaded catheters to simplify access to the target vessels; by adding double-reducing tie wires at the posterior aspect of the body to limit its expansion during target vessel cannulation; and by adding branches for aneurysmal sac perfusion to be occluded later on in order to stage the procedure and reduce the risk of spinal cord ischemia.11 Conversely, branched grafts are easier to plan and can be left unbridged, even if the branches require extra room, both for correct deployment and catheterization. This room is minimal in post-dissection aneurysms and additional space can be created by deployment of a tube graft first with a distal landing zone a few centimeters above the celiac trunk origin.18 furthermore, oikonomou et


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al.20 proposed an aggressive oversizing of the proximal stent-graft to increase the re-expansion of the true lumen. however, sobocinski et al.19 argued that the persistent perfusion of the false lumen by distal entry tears below the thoracic stent-graft maintains the distal false lumen pressurization thus preventing the true lumen reexpansion below the celiac trunk origin. Moreover, old chronic dissections are difficult to be remodeled due the thickness of the lamella. in our case, the presence of distal surgical graft combined with the dual perfusion from both lumens of the visceral vessels granted us the opportunity to plan a safe deployment of a stent-graft into the false lumen. so far, deployment of f/b-Tevar into the false lumen had already been described once in a case of TBad.17 however, unlike the previously reported case where a fenestrated design was employed, the large false lumen provided us with the opportunity to use a branch design with the above-mentioned advantages. another key point of f/b-Tevar in TBad is ensuring perfusion of visceral or renal vessels originating from different lumens. according to different authors,19, 20 access from the true to the false lumen and then to a target vessel via intimal tear has almost always been possible. otherwise, an endovascular neofenestrations can be created by perforating the dissection flap with guidewires having tips which can be stiffened, by using the back of a wire, or a wire with support of a guiding sheath, or even by employing a needle to perforate the dissection flap as those used in transjugular intrahepatic portosystemic shunt or transeptal procedures.19, 20 in our case, we designed an implant with a first custom-made stent-graft with a mono-branch to target the right renal artery from the true lumen and a second custom-made stent-graft with three branches to target the visceral vessels and the left renal artery from the false lumen. This kind of design, to our knowledge, hasn’t yet been reported and allowed us to perfuse all visceral and renal vessels without being forced to create any neo-fenestration into the dissecting lamella. The only drawback against this design might be the long-term patency of long bridging covered stents such the ones used to target the right renal artery. however data derived from chimney or sandwich approach to Taa demonstrated, so far, reasonable patency rates.19 The last critical point is the management of target

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vessels in which the dissection extends into the side branches. Two problems may arise: malperfusion of the target vessel with increased risk of stent thrombosis and the retrograde aneurysm perfusion through the excluded lumen with possible type ii endoleak formation. Therefore, longer initial sealing zone into the target vessel is advisable to ensure exclusion of the aneurysm combined to the use of distal self-expanding stent into the dissected vessel to improve long-term patency.17-20 in this case report, the most challenging was the celiac trunk with a large diameter origin and the dissection extending into the bifurcation with distal malperfusion of the hepatic artery. The splenic artery was sacrified to treat the malperfusion of the hepatic artery and a large diameter covered stent postdilatated at the origin of the celiac trunk to obtain a good seal at the origin of this vessel. as previously mentioned, the endovascular treatment of TBad with f/b-Tevar is in its pioneering phases. so far, only three small cohort studies have been published with promising results (Table iii). large cohort studies or multicenter registries gathering together different worldwide experience would be helpful to standardize methods employed and analyze the results of use of current available f/b-Tevar in the treatment of TBAD and possibly to design device disease specific. Table III.—Publishedseriesregardingendovasculartreatmentof thoraco-abdominalaneurysmspostchronictypeBdissection.

n. of patients Median age Maximal diameter (mm – range) Connective tissue disease arch involvement Previous aortic surgery Median n. of fenestrations/ branches Median time elapsed (in months) between acute onset and complex evar (median, range) staged procedure Technical success Thirty-day mortality unplanned reintervention Mean fu (months)

greenberg 12 CCf, usa 2013

haulon 13 lille, france 2014

verhoeven 14 nurnberg, germany 2014

15 58 (33-71) 64 (43-97)

15 61 (31-77) 67 (56-79)

31 65 65.7 (55-88)

6 (40%) 1 (7%) 12 (80%) na 124 (24-408)

78% na 0 8 (53%) 20 (1-62)

3 (20%) 1 (3.2%) 6 (40%) na 11 (73%) 24 (77.5%) 4 (0-4)/2 2.5 (0-4)/1.1 (0-2) (0-4) 48 (12-360) 31 (1-176)

45% 100% 1 (7%) 2 (13%) 12 (1-36)

9.7% 93.5% 3 (9.6%) 7 (22.5%) 17 (na)

na: not available.


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BerToglio


Conclusions Current available fenestrated and branched custommade devices can be employed with several limitations also in post TBad aneurysms. The use of branched custom-made stent-grafts might be useful, when anatomically feasible, so as to simplify the procedure. The main stent-graft could be deployed within an enlarged false lumen to employ a branch design provided that a suitable distal landing zone is available as well as that visceral vessels can be perfused from the false lumen. although crossing the dissecting lamella with the bridging stents seems feasible, a proximal branch for perfusing one of the lumens of the dissection from the proximal tear and consequently the vessels arising from that lumen can be an alternative solution to creating neofenestrations.

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Article first published online: September 3, 2015. - Manuscript accepted: August 15, 2015. - Manuscript revised: July 29, 2015. - Manuscript received: June 9, 2015.

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