Tevar Movie Online

[Catherine Nicolo]

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This session (one workshop only, this time) is designed to provide gradually more and more advanced knowledge in the field of planning and sizing. You will learn about the pathology of abdominal aorta, important features, diagnosis, planning and sizing and discuss the steps of the procedure, their importance and role in the process, as well as the consequences of mistakes.

Please note that the course is dependent on final registration numbers. Where registration numbers are too low to run the course, this will be announced on the website no later than 48 hours before the course starts. For cancellations received more than 10 days before the event, a refund will be given less an administration fee of EUR10. For cancellations received less than 5 days before the event, no refund is possible. Participants are aware that the online session will be recorded and may be used by the ESVS on our website, social media channels and e-library. Please be aware that the online session will be recorded and may be used by the ESVS on our website, social media and in the e-library.

Commercial names of medical devices/software/equipment may appear in this content because they are linked to specific medical procedures, which are the focus of this training material. Other products in the market can be used to perform the aforementioned medical procedures. The educational provider does not endorse any particular product.

Our mission is to improve vascular health for the public benefit. We are proud to have over 3,000 members from all over the world. Members are medical specialists involved in the care and treatment of patients suffering from vascular disease.

After "Embrace the martians" rmx, this is my new promo! Thanks to all the people who push my music! M.I.A. vs Aphex Twin - Windowlickin' (Tevar Rmx) Enjoy! Photo link: Federico Tevar a.k.a. Tevar begins djing and producing in the middle of the 90's, and right now is resident dj at Deepsession, one of the best parties in Rome, Italy, playing with artist such as Erol Alkan, A-trak, Bloody Beetroots, Diplo and many more. As one half of the A-team project, he made official remixes for Coolio, Frank Sent Us and Mini K Bros, and his tracks have been played by Congorock, Nic Sarno, Sinden and more. DOWNLOAD LINK: www.myspace.com/tevarmusic

An online test is available for self-directed Continuous Medical Education (CME). It is estimated to take 1 hour to complete. Please record time spent and report this to your accrediting body if you wish to claim CME points. A certificate will be awarded upon passing the test. Please refer to the accreditation policy here.

Ischaemic spinal cord injury (SCI) remains a significant complication of thoracoabdominal aortic surgery. Neurological deficit usually presents immediately after surgery; however, it can be delayed for several days. The impact of paraplegia on both the patient and society is substantial, and this complication increases patient mortality.1

Lumbar cerebrospinal fluid (CSF) drainage has been shown to reduce the risk of ischaemic SCI following aortic surgery. However, spinal drains are associated with significant complications in their own right. As such, an understanding of safe practice surrounding their insertion and management is paramount.

This article will discuss the rationale for lumbar CSF drainage in thoracoabdominal aortic surgery, the risk factors associated with developing SCI following these operations, the indications and contraindications for CSF drains, the technique for insertion and perioperative management, as well as the associated complications.

Blood supply to the spinal cord is from (1) longitudinal arteries: the single anterior spinal artery and paired posterior spinal arteries, which arise from the vertebral arteries and (2) segmental arteries, which contribute to a complex anastomotic network involving the longitudinal vessels (see Figure 1). Segmental arteries include branches of the intercostal, lumbar, inferior mesenteric, internal iliac, and sacral arteries. The artery of Adamkiewicz is a major contributor to the anterior spinal artery supply to the thoracolumbar spinal cord and arises from a segmental artery at T9-12 vertebral level in most people.

Spinal cord perfusion pressure is analogous to cerebral perfusion pressure. It is the difference between the mean arterial pressure (MAP) and the greater of central venous pressure and spinal CSF pressure. Therefore, maintaining sufficient MAP, while limiting central venous pressure and spinal CSF pressure enables preservation of spinal cord perfusion pressure (SCPP), and reduces the risk of ischaemic insult to the spinal cord.

The aetiology of SCI following aortic surgery is multifactorial. During open TAAA repair, clamping of the aorta disrupts collateral blood supply to the spinal cord and increases blood pressure in the head and neck, resulting in increased CSF production and intracranial pressure and increased central venous pressure, and may lead to systemic administration of hypotensive agents. These factors result in a reduction in SCPP. Furthermore, SCPP may be compromised postoperatively due to spinal cord oedema caused by intraoperative ischaemia and reperfusion injury.3

Presentation of SCI may be immediate or delayed up to 48 hours after surgery. Delayed-onset symptoms are more common following TEVAR than open repair and tend to be associated with episodes of hypotension.6,7

CSF drainage was first proposed for the prevention of SCI by McCullough et al8 in 1988 and has since become a popular technique employed in TAAA repair. By monitoring CSF pressure and maintaining it below 10 mm Hg, spinal drains preserve SCPP. The evidence for CSF drainage provides differing results. The positive impact of CSF drainage in open TAAA surgery in preventing SCI is supported by 2 randomised controlled trials9,10 and there are also a number of prospective nonrandomised studies and retrospective studies supporting the use of lumbar drains in TEVAR.11 However, a systematic review of 3 randomised controlled trials found limited evidence in favour of CSF drainage.12 Furthermore, Yoshitani et al13 found an increase in motor deficit at discharge among patients who had spinal drains in a retrospective review of practice in Japan.13

In spite of equivocal evidence, CSF drainage is, nonetheless, recommended by the European Association of Cardiothoracic Surgery, the European Society of Cardiology, the American College of Cardiology Foundation, and the American Heart Association for high-risk thoracoabdominal aortic surgery.3,14,15

Given the potentially devastating consequences of SCI, its prevention has been a key focus of research within aortic surgery. Methods that have been used include surgical revascularisation, for example revascularisation of the subclavian artery when an endograft occludes its origin; monitoring of spinal cord function using motor and somatosensory evoked potentials or near infrared spectroscopy; protection against ischaemic injury with methods such as hypothermia; and drugs, such as intrathecal papaverine.

The incidence of SCI varies depending on a number of surgical, patient, and anaesthetic factors (see Table 1). Length and extent of surgery, previous surgery, chronic kidney disease (an indicator of the extent of atherosclerosis), and hypotension are factors that are commonly reported in the literature.

The decision to insert a spinal drain preoperatively depends on a balance of risks and benefits, which should be considered by the operating consultant surgeon and consultant anaesthetist. Preemptive insertion of a lumbar drain and maintenance of CSF pressure below 10 mm Hg is recommended by the European Association for Cardio-thoracic Surgery and the European Society of Cardiology for all open TAAA repair and high-risk TEVAR (see risk factors in italics in Table 1).3,14 The American College of Cardiology Foundation/American Heart Association guidelines recommend CSF drainage for high-risk open and endovascular thoracic aortic repair.15 Prolonged postoperative ventilation is an indication for CSF drainage since detection of neurological deficit is hindered in these cases. Spinal drains may also be placed postoperatively as an emergency treatment for patients showing signs of SCI.

Drainage of CSF in those with raised intracranial pressure may lead to uncal herniation and tearing of the subdural veins, leading to subdural haematoma. Active infection, either local or systemic, increases the risk of central nervous infection and epidural abscess. Other relative contraindications include previous spinal surgery, physiological instability, and trauma.18

CSF drainage systems consist of an intrathecal catheter connected to a transducer and reservoir. Insertion of the intrathecal catheter should be performed by a consultant anaesthetist or a senior trainee under their supervision. Alternatively, they may be inserted by a neuroradiologist under fluoroscopy guidance. While they are usually inserted immediately preoperatively, some institutions recommend spinal drain insertion the day before elective surgery to provide a longer delay before intraoperative heparinisation. However, this may require the patient to spend an extra night in a high-dependency setting.

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