{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,15]],"date-time":"2026-06-15T06:53:12Z","timestamp":1781506392408,"version":"3.54.1"},"reference-count":48,"publisher":"MDPI AG","issue":"6","license":[{"start":{"date-parts":[[2026,6,14]],"date-time":"2026-06-14T00:00:00Z","timestamp":1781395200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JPM"],"abstract":"<jats:p>Inadequate vein access is a frequent obstacle during cardiac implantable electronic device (CIED) upgrade procedures; thus, bail-out strategies are employed. A 71-year-old male with dilated cardiomyopathy bearing a 7-year-old right-sided dual-chamber pacemaker was scheduled for upgrade to an implantable cardioverter defibrillator. The case presented two main challenges\u2014first, pacemaker dependency, and second, an occluded right subclavian vein. In a shared decision-making approach, the decision was made to \u201cabandon\u201d the right-sided ventricular lead in situ, reposition the right-sided atrial lead by tunneling over the sternum into the left pectoral area, and implant a new left-sided defibrillator lead. During the 2-year follow-up our patient remained clinically stable and the CIED fully functional. Herein, beyond case presentation we also elaborate on individualized alternative treatment strategies for patients with venous access site occlusion in a literature review.<\/jats:p>","DOI":"10.3390\/jpm16060318","type":"journal-article","created":{"date-parts":[[2026,6,15]],"date-time":"2026-06-15T05:59:47Z","timestamp":1781503187000},"page":"318","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["An Individualized Right-to-Left Tunneling \u201cBail-Out\u201d for Complex ICD Upgrade in a Pacemaker-Dependent Patient: A Case Report and Literature Review"],"prefix":"10.3390","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2385-5365","authenticated-orcid":false,"given":"Dimitrios A.","family":"Vrachatis","sequence":"first","affiliation":[{"name":"Electrophysiology and Pacing Department, Eugenideio Clinic, National and Kapodistrian University of Athens, 115 28 Athens, Greece"},{"name":"Department of Biomedical Engineering, Medical School, National and Kapodistrian University of Athens, 115 28 Athens, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0123-2615","authenticated-orcid":false,"given":"Konstantinos A.","family":"Papathanasiou","sequence":"additional","affiliation":[{"name":"Electrophysiology and Pacing Department, Eugenideio Clinic, National and Kapodistrian University of Athens, 115 28 Athens, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sotiria G.","family":"Giotaki","sequence":"additional","affiliation":[{"name":"Electrophysiology and Pacing Department, Eugenideio Clinic, National and Kapodistrian University of Athens, 115 28 Athens, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0000-8293-7283","authenticated-orcid":false,"given":"Christos","family":"Piperis","sequence":"additional","affiliation":[{"name":"Electrophysiology and Pacing Department, Eugenideio Clinic, National and Kapodistrian University of Athens, 115 28 Athens, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9355-400X","authenticated-orcid":false,"given":"Maria S.","family":"Kousta","sequence":"additional","affiliation":[{"name":"Electrophysiology and Pacing Department, Eugenideio Clinic, National and Kapodistrian University of Athens, 115 28 Athens, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3062-360X","authenticated-orcid":false,"given":"Ioannis","family":"Anagnostopoulos","sequence":"additional","affiliation":[{"name":"Electrophysiology and Pacing Department, Eugenideio Clinic, National and Kapodistrian University of Athens, 115 28 Athens, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christos","family":"Karavasilis","sequence":"additional","affiliation":[{"name":"Electrophysiology and Pacing Department, Eugenideio Clinic, National and Kapodistrian University of Athens, 115 28 Athens, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gerasimos","family":"Deftereos","sequence":"additional","affiliation":[{"name":"Electrophysiology and Pacing Department, Eugenideio Clinic, National and Kapodistrian University of Athens, 115 28 Athens, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Georgios","family":"Giannopoulos","sequence":"additional","affiliation":[{"name":"Third Department of Cardiology, Aristotle University of Thessaloniki, \u201cHippokration\u201d General Hospital, 546 42 Thessaloniki, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sotirios","family":"Patsilinakos","sequence":"additional","affiliation":[{"name":"Electrophysiology and Pacing Department, Eugenideio Clinic, National and Kapodistrian University of Athens, 115 28 Athens, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gerasimos","family":"Siasos","sequence":"additional","affiliation":[{"name":"Third Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Sotiria Chest Disease Hospital, 115 28 Athens, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9611-5002","authenticated-orcid":false,"given":"Spyridon","family":"Deftereos","sequence":"additional","affiliation":[{"name":"Electrophysiology and Pacing Department, Eugenideio Clinic, National and Kapodistrian University of Athens, 115 28 Athens, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,6,14]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"3427","DOI":"10.1093\/eurheartj\/ehab364","article-title":"2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy","volume":"42","author":"Glikson","year":"2021","journal-title":"Eur. Heart J."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"841","DOI":"10.4070\/kcj.2018.0444","article-title":"Temporal Trends of Cardiac Implantable Electronic Device Implantations: A Nationwide Population-based Study","volume":"49","author":"Lee","year":"2019","journal-title":"Korean Circ. J."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"88","DOI":"10.1016\/j.jacep.2021.06.006","article-title":"Trends in Cardiovascular Implantable Electronic Device Insertion Between 1988 and 2018 in Olmsted County","volume":"8","author":"Vaidya","year":"2022","journal-title":"JACC Clin. Electrophysiol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"e001878","DOI":"10.1161\/JAHA.115.001878","article-title":"Venous Stenosis After Transvenous Lead Placement: A Study of Outcomes and Risk Factors in 212 Consecutive Patients","volume":"4","author":"Bhave","year":"2015","journal-title":"J. Am. Heart Assoc."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"16","DOI":"10.1016\/j.ijcard.2023.04.015","article-title":"Prevalence, management, and prediction of venous access site occlusion in patients undergoing lead revision surgery","volume":"381","author":"Kellnar","year":"2023","journal-title":"Int. J. Cardiol."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"3997","DOI":"10.1093\/eurheartj\/ehac262","article-title":"2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death","volume":"43","author":"Zeppenfeld","year":"2022","journal-title":"Eur. Heart J."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"euaf109","DOI":"10.1093\/europace\/euaf109","article-title":"Procedural outcomes of transvenous lead extraction in patients with abandoned leads: Experience from a large single centre","volume":"27","author":"Zhou","year":"2025","journal-title":"Europace"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"euaf252","DOI":"10.1093\/europace\/euaf252","article-title":"Cardiac implantable electronic device upgrades and downgrades: A Clinical Consensus Statement of the European Heart Rhythm Association (EHRA) of the ESC, the Asia Pacific Heart Rhythm Association (APHRS), Canadian Heart Rhythm Society (CHRS), Heart Rhythm Society (HRS), and the Latin American Heart Rhythm Society (LAHRS)","volume":"27","author":"Keene","year":"2025","journal-title":"Europace"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"25","DOI":"10.1016\/j.eupc.2003.09.001","article-title":"Incidence of venous obstruction following insertion of an implantable cardioverter defibrillator. A study of systematic contrast venography on patients presenting for their first elective ICD generator replacement","volume":"6","author":"Lickfett","year":"2004","journal-title":"Europace"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"199","DOI":"10.1111\/j.1540-8159.2007.00650.x","article-title":"Venous Obstruction After Pacemaker Implantation","volume":"30","author":"Korkeila","year":"2007","journal-title":"Pacing Clin. Electrophysiol."},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Czajkowski, M., Polewczyk, A., Jache\u0107, W., Kosior, J., Nowosielecka, D., Tu\u0142ecki, \u0141., Stefa\u0144czyk, P., and Kutarski, A. (2024). Multilevel Venous Obstruction in Patients with Cardiac Implantable Electronic Devices. Medicina, 60.","DOI":"10.3390\/medicina60020336"},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Czajkowski, M., Jache\u0107, W., Polewczyk, A., Kosior, J., Nowosielecka, D., Tu\u0142ecki, \u0141., Stefa\u0144czyk, P., and Kutarski, A. (2021). Risk Factors for Lead-Related Venous Obstruction: A Study of 2909 Candidates for Lead Extraction. J. Clin. Med., 10.","DOI":"10.3390\/jcm10215158"},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Cha, Y.-M., El-Chami, M.F., Liu, C.F., Andreychuk, L.J., Beaver, T.M., Bergen, K.M., Berul, C.I., Birgersdotter-Green, U.M., Breitenstein, A., and Epstein, L.M. (Heart Rhythm, 2026). 2026 HRS\/AHA\/APHRS\/EHRA\/IDSA\/LAHRS\/PACES\/STS expert consensus statement update on cardiovascular implantable electronic device lead management and extraction, Heart Rhythm, in press.","DOI":"10.1016\/j.hrthm.2026.04.015"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1025","DOI":"10.1111\/j.1540-8159.2006.00482.x","article-title":"Upgrading Patients with Chronic Defibrillator Leads to a Biventricular System and Reducing Patient Risk: Contralateral LV Lead Placement","volume":"29","author":"Fox","year":"2006","journal-title":"Pacing Clin. Electrophysiol."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"113","DOI":"10.1016\/j.ipej.2015.07.007","article-title":"Contralateral transvenous left ventricular lead placement of implantable devices with pre-sternal tunnelling in chronically obstructed subclavian veins","volume":"15","author":"Sadarmin","year":"2015","journal-title":"Indian Pacing Electrophysiol. J."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"e9321","DOI":"10.1002\/ccr3.9321","article-title":"Contralateral transvenous left ventricular lead placement of an implantable device with pre-sternal tunneling in an ipsilateral chronically obstructed subclavian vein","volume":"12","author":"Antoun","year":"2024","journal-title":"Clin. Case Rep."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1004","DOI":"10.1093\/europace\/eur072","article-title":"Acute and long-term feasibility of contralateral transvenous lead placement with subcutaneous, pre-sternal tunnelling in patients with chronically implanted rhythm devices","volume":"13","author":"Luthje","year":"2011","journal-title":"Europace"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1923","DOI":"10.1016\/j.hrthm.2024.04.088","article-title":"When and how to perform venoplasty for lead placement","volume":"21","author":"Groenveld","year":"2024","journal-title":"Heart Rhythm"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"526","DOI":"10.1016\/j.hrthm.2010.12.014","article-title":"Subclavian venoplasty by the implanting physicians in 373 patients over 11 years","volume":"8","author":"Worley","year":"2011","journal-title":"Heart Rhythm"},{"key":"ref_20","doi-asserted-by":"crossref","unstructured":"Li, Y.-P., Lee, C.-H., and Chen, J.-Y. (2022). Proposed strategies to overcome venous occlusion in the implantation of a cardiac implantable electronic device: A case report and literature review. Front. Cardiovasc. Med., 9.","DOI":"10.3389\/fcvm.2022.1005596"},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Haeberlin, A., Noti, F., Breitenstein, A., Auricchio, A., Reichlin, T., Conte, G., Klersy, C., Curti, M., Pruvot, E., and Domenichini, G. (2023). Transvenous Lead Extraction during Cardiac Implantable Device Upgrade: Results from the Multicenter Swiss Lead Extraction Registry. J. Clin. Med., 12.","DOI":"10.3390\/jcm12165175"},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Stefa\u0144czyk, P., Nowosielecka, D., Polewczyk, A., Jache\u0107, W., G\u0142owniak, A., Kosior, J., and Kutarski, A. (2022). Efficacy and Safety of Transvenous Lead Extraction at the Time of Upgrade from Pacemakers to Cardioverter-Defibrillators and Cardiac Resynchronization Therapy. Int. J. Environ. Res. Public Health, 20.","DOI":"10.3390\/ijerph20010291"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1356","DOI":"10.1093\/europace\/euu004","article-title":"Safety and efficacy of internal transjugular approach for transvenous extraction of implantable cardioverter defibrillator leads","volume":"16","author":"Bongiorni","year":"2014","journal-title":"Europace"},{"key":"ref_24","first-page":"829","article-title":"Safety and efficacy of the new bidirectional rotational Evolution\u00ae mechanical lead extraction sheath: Results from a multicentre Italian registry","volume":"20","author":"Mazzone","year":"2018","journal-title":"EP Eur."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"81","DOI":"10.1093\/europace\/eut163","article-title":"Laser lead extraction to facilitate cardiac implantable electronic device upgrade and revision in the presence of central venous obstruction","volume":"16","author":"Sohal","year":"2014","journal-title":"Europace"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"634","DOI":"10.1016\/j.hrthm.2010.01.027","article-title":"Excimer laser to open refractory subclavian occlusion in 12 consecutive patients","volume":"7","author":"Worley","year":"2010","journal-title":"Heart Rhythm"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"661","DOI":"10.1111\/j.1540-8159.2005.00163.x","article-title":"Central Venous Occlusion Is Not an Obstacle to Device Upgrade with the Assistance of Laser Extraction","volume":"28","author":"Gula","year":"2005","journal-title":"Pacing Clin. Electrophysiol."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1566","DOI":"10.1016\/j.hrthm.2021.05.007","article-title":"Long-term survival following transvenous lead extraction: Importance of indication and comorbidities","volume":"18","author":"Mehta","year":"2021","journal-title":"Heart Rhythm"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"626","DOI":"10.1111\/pace.14940","article-title":"Long-term outcomes with abandoning versus extracting sterile leads: A 10-year population-based study","volume":"47","author":"Lee","year":"2024","journal-title":"Pacing Clin. Electrophysiol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"243","DOI":"10.1016\/j.amjcard.2007.02.087","article-title":"Comparison of Defibrillation Efficacy and Survival Associated with Right Versus Left Pectoral Placement for Implantable Defibrillators","volume":"100","author":"Gold","year":"2007","journal-title":"Am. J. Cardiol."},{"key":"ref_31","first-page":"1810","article-title":"Defibrillation thresholds with right pectoral implantable cardioverter defibrillators and impact of waveform tuning (the Tilt and Tune trial)","volume":"19","author":"Varma","year":"2017","journal-title":"EP Eur."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"1025","DOI":"10.1111\/j.1540-8159.2008.01130.x","article-title":"Right Pectoral Implantable Cardioverter Defibrillators: Role of the Proximal (SVC) Coil","volume":"31","author":"Varma","year":"2008","journal-title":"Pacing Clin. Electrophysiol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"781","DOI":"10.1111\/j.1540-8159.1983.tb05339.x","article-title":"Use of the Contralateral Subclavian Vein for Placement of Atrial Electrodes in Chronically VVI Paced Patients","volume":"6","author":"Belott","year":"1983","journal-title":"Pacing Clin. Electrophysiol."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"1307","DOI":"10.1016\/j.hrthm.2024.08.063","article-title":"Procedural and long-term outcomes of tunneled transvenous leads","volume":"22","author":"Mekary","year":"2025","journal-title":"Heart Rhythm"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"1596","DOI":"10.1093\/europace\/euq314","article-title":"Supraclavicular vein approach to overcoming ipsilateral chronic subclavian vein obstruction during pacemaker-ICD lead revision or upgrading","volume":"12","author":"Antonelli","year":"2010","journal-title":"Europace"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"957","DOI":"10.1111\/j.1540-8159.2007.00792.x","article-title":"The Innominate Vein as Alternative Venous Access for Complicated Implantable Cardioverter Defibrillator Revisions","volume":"30","author":"Aleksic","year":"2007","journal-title":"Pacing Clin. Electrophysiol."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"144","DOI":"10.1093\/europace\/euj025","article-title":"Cardiac resynchronization via the femoral vein: A novel method in cases with contraindications to the pectoral approach","volume":"8","author":"Yousef","year":"2006","journal-title":"Europace"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"921","DOI":"10.1111\/j.1540-8159.2005.00203.x","article-title":"Placement of Transvenous Pacemaker and ICD Leads Across Total Chronic Occlusions","volume":"28","author":"Mccotter","year":"2005","journal-title":"Pacing Clin. Electrophysiol."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"163","DOI":"10.1016\/j.ccep.2017.11.017","article-title":"Venous System Interventions for Device Implantation","volume":"10","author":"Marcial","year":"2018","journal-title":"Card. Electrophysiol. Clin."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"172","DOI":"10.1161\/CIRCULATIONAHA.125.074576","article-title":"Device-Related Complications in Transvenous Versus Subcutaneous Defibrillator Therapy During Long-Term Follow-Up: The PRAETORIAN-XL Trial","volume":"152","author":"Ghani","year":"2025","journal-title":"Circulation"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"180","DOI":"10.1016\/j.hrthm.2025.02.012","article-title":"Periprocedural outcomes from the postmarket study of the extravascular implantable cardioverter-defibrillator: Preliminary Enlighten study results and meta-analysis","volume":"23","author":"Crozier","year":"2026","journal-title":"Heart Rhythm"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"322","DOI":"10.1161\/CIRCULATIONAHA.124.071795","article-title":"Performance and Safety of the Extravascular Implantable Cardioverter Defibrillator Through Long-Term Follow-Up: Final Results From the Pivotal Study","volume":"151","author":"Friedman","year":"2025","journal-title":"Circulation"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"e014395","DOI":"10.1161\/CIRCEP.125.014395","article-title":"One-Year Outcomes of the MODULAR ATP Trial: A Novel Leadless Pacemaker in Wireless Communication with a Subcutaneous Implantable Cardioverter Defibrillator","volume":"19","author":"Lloyd","year":"2026","journal-title":"Circ. Arrhythmia Electrophysiol."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"1526","DOI":"10.3346\/jkms.2010.25.10.1526","article-title":"Use of a tunneling technique to achieve a lower defibrillation treshold during implantable cardioverter defibrillator implantation via the right subclavian vein","volume":"25","author":"Kim","year":"2010","journal-title":"J. Korean Med. Sci."},{"key":"ref_45","first-page":"1274","article-title":"Cardiac Resynchronization Therapy with the Left Ventricular Lead Placed Through a Tunnel Across the Anterior Chest","volume":"4","author":"Goli","year":"2013","journal-title":"J. Innov. Card. Rhythm Manag."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"1585","DOI":"10.1046\/j.1460-9592.2000.01585.x","article-title":"Transvenous Pacemaker Insertion Ipsilateral to Chronic Subclavian Vein Obstruction: An Operative Technique for Children and Adults","volume":"23","author":"Ovadia","year":"2000","journal-title":"J. Pacing Clin. Electrophysiol."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"157","DOI":"10.1007\/s10840-005-6552-4","article-title":"Coronary Sinus Lead Placement Via the Internal Jugular Vein in Patients with Advanced Heart Failure: A Simplified Percutaneous Approach","volume":"12","author":"Pires","year":"2005","journal-title":"J. Interv. Card. Electrophysiol."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"209","DOI":"10.1007\/s10840-007-9149-2","article-title":"Upgrade of a pacemaker defibrillator to a biventricular device: The internal jugular vein approach in a case of bilateral subclavian veins occlusion","volume":"19","year":"2007","journal-title":"J. Interv. Card. Electrophysiol."}],"container-title":["Journal of Personalized Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2075-4426\/16\/6\/318\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,15]],"date-time":"2026-06-15T06:16:50Z","timestamp":1781504210000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2075-4426\/16\/6\/318"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,6,14]]},"references-count":48,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2026,6]]}},"alternative-id":["jpm16060318"],"URL":"https:\/\/doi.org\/10.3390\/jpm16060318","relation":{},"ISSN":["2075-4426"],"issn-type":[{"value":"2075-4426","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,6,14]]}}}