Upload
others
View
1
Download
0
Embed Size (px)
Citation preview
Michael JacobsNo disclosures
Clinical experience with neuromonitoring during open and endo TAAA repair:a 25 year experience (1993-2018)
Michael Jacobs
Spinal cord ischemia
electrical stimulation
500 V; ~1.2 A, 5 serial stimuli
MEP response
abd. poll. brevis muscle
MEP response
tibialis anterior muscle
pyramidal tract
peripheral nerve
alpha motor neuron in
anterior horn of spinal cord
pyramidal cell
in motor cortex
In post-dissection TAAA (almost) all intercostal and lumbar arteries are patent
Less collateral pathways
The AKA receives direct segmental artery bloodsupply in 86% of patients
In degenerative TAAA the majority of intercostal andlumbar arteries are occluded
The AKA receives direct segmental artery bloodsupply in only 46% of patients
Collateral network
L1
ASA
Direct SA connection
MEP
ASA
MEP
Indirect SA connectionvia collateral pathway
MEP monitoring during open TAAA(800 procedures)
• 0 false positive• 0 false negative• 100% correlation• Paraplegia < 4%
Current protocol• CSF drainage
• BP management
• Preserve LSA and HA perfusion
• Staging by only TEVAR first (type II TAAA)
• B/FEVAR:
• Spinal cord function monitoring (MEP)
• Last branch: 15 min balloon occlusion
• Decision to leave branch open
– MEP >50%
– Endoleak on angiography
– Aneurysms Sac Pressure
Results EndoTAAA
• 103 patients
• m/v : 74 /29
• age: 72 (59-83) jaar
• diameter aneurysma: 70 (59-83) mm
0
5
10
15
20
25
TAAA type I TAAA type II TAAA type III TAAA type IV TAAA type V
Results EndoTAAA
• 30-day/ in-hospital mortality: 10%– 91% 2014 and earlier
• Spinal cord ischemia: 6%– 4/6 delayed paraparesis– 2/6 delayed paraplegia– 4/6 improved (all walking)– 1/6 cured– 1/6 no improvement
0
2
4
6
8
10
12
14
16
2006 2007 2008 2010 2011 2012 2013 2014 2015 2016 2017
SCI
no SCI
0
2
4
6
8
10
12
14
1630-d mort
no 30-d mort
Conclusions
• Neuromonitoring by means of motor evokedpotentials is 100% reliable in detection of spinal cord ischemia
• It serves as a “navigation” system during open and endovascular management of TAAA repair
• It contributes to significantly reduction of paraplegia rates.
Michael JacobsNo disclosures