Image Guidance in Ventricular Cerebrospinal Fluid Shunt Catheter Placement

Neurosurgery ◽  
2015 ◽  
Vol 77 (3) ◽  
pp. 321-331 ◽  
Author(s):  
Cody L. Nesvick ◽  
Nickalus R. Khan ◽  
Gautam U. Mehta ◽  
Paul Klimo
Keyword(s):  
Image Guidance ◽  
Meta Analysis ◽  
Catheter Placement ◽  
Frameless Stereotaxy ◽  
Ventricular Catheter ◽  
Neurosurgical Procedures ◽  
Shunt Failure ◽  
Premature Failure ◽  
Shunt Catheter ◽  
Shunt Survival

Abstract BACKGROUND: Ventricular shunt placement for treating hydrocephalus is one of the most common neurosurgical procedures. The rate of shunt failure, however, has not appreciably changed with time. OBJECTIVE: To investigate whether intraoperative image guidance using ultrasound or stereotaxy contributes to accurate shunt catheter placement and survival. METHODS: We performed a systematic literature review using PubMed and MEDLINE databases for studies that use ultrasound and frameless stereotaxy for ventricular catheter placement for hydrocephalus. All articles assessed the accuracy of catheter tip placement and/or overall shunt survival, and the rate of accurate shunt catheter placement, the overall failure rate, and the average time to shunt failure were extracted for analysis. RESULTS: Although each modality (ultrasound/stereotaxy) did not increase catheter placement accuracy, a combined random-effects meta-analysis of 738 catheters (136 guided by ultrasound, 168 guided by frameless stereotaxy, and 434 freehand) demonstrated a weak benefit of image guidance (risk ratio: 1.19, 95% confidence interval: 1.02-1.39, P = .02), but this result was limited by considerable heterogeneity among studies (I2 = 86%, P < .001 by Cochrane's Q test). A meta-analysis could not be performed for shunt survival due to heterogeneity in data reporting. CONCLUSION: Although image guidance offers a promising solution to lower the risk of inaccurate catheter placement, which could lead to lower premature failure of ventricular shunts, our review demonstrated that there is not yet a clear benefit of these technologies. Current literature is limited to case series and cohort studies, and significant between-study heterogeneity in methodology and reporting currently limits a higher order analysis.

Endoscope-assisted placement of a multiperforated shunt catheter into the fourth ventricle via a frontal transventricular approach

2007 ◽  
Vol 22 (4) ◽  
pp. 1-8 ◽  
Author(s):  
Kristen Upchurch ◽  
Murisiku Raifu ◽  
Marvin Bergsneider
Keyword(s):  
Fourth Ventricle ◽  
Third Ventricle ◽  
Flexible Endoscope ◽  
Catheter Placement ◽  
Cerebral Aqueduct ◽  
Frameless Stereotaxy ◽  
Ventricular Catheter ◽  
Shunt System ◽  
Shunt Catheter ◽  
Isolated Fourth Ventricle

Object Patients with symptomatic isolated fourth ventricle and multicompartmentalized hydrocephalus benefit from operative treatment, but the optimal surgical approach and technique have yet to be established. The authors report on their experience with the treatment of symptomatic adult patients by endoscope-assisted placement of a fourth ventricle shunt catheter via a frontal transventricular approach. Methods The authors describe a retrospective series of four patients treated for isolated fourth ventricle. The surgical technique is described in detail: use of a flexible endoscope with dual-port intraventricular access for direct visualization and for mechanical manipulation of a multiperforated panventricular catheter guided by frameless stereotaxy. The transventricular approach allowed optimal catheter placement within the fourth ventricle. The use of the flexible endoscope permitted the neurosurgeon to use the endoscope as a tool to guide the ventricular catheter tip within the third ventricle and through the cerebral aqueduct. Clinical outcomes demonstrated neurological and radiographically verified improvement in all patients. Conclusions The endoscope-assisted dual-port technique provides a solution to the technical difficulties of fourth ventricle shunt placement. The multiple advantages of this technique include a single ventricular catheter shunt system that equalizes ventricular pressures, a frontal location for the ventricular catheter that facilitates valve placement and programming, and ventricular catheter placement within the fourth ventricle that does not allow the catheter to impinge on the fourth ventricle floor and makes the catheter less prone to obstruction.

scholarly journals Comparison of the accuracy and proximal shunt failure rate of freehand placement versus intraoperative guidance in parietooccipital ventricular catheter placement

2016 ◽  
Vol 41 (3) ◽  
pp. E10 ◽  
Author(s):  
Thomas J. Wilson ◽  
Kathleen E. McCoy ◽  
Wajd N. Al-Holou ◽  
Sergio L. Molina ◽  
Matthew D. Smyth ◽  
...  
Keyword(s):  
Catheter Placement ◽  
Csf Shunt ◽  
Frameless Stereotaxy ◽  
Ventricular Catheter ◽  
Shunt Failure ◽  
Shunt System ◽  
Distal Catheter ◽  
Freehand Technique ◽  
The University ◽  
Intraoperative Guidance

OBJECTIVE The aim of this paper is to compare the accuracy of the freehand technique versus the use of intraoperative guidance (either ultrasound guidance or frameless stereotaxy) for placement of parietooccipital ventricular catheters and to determine factors associated with reduced proximal shunt failure. METHODS This retrospective cohort study included all patients from 2 institutions who underwent a ventricular cerebrospinal fluid (CSF) shunting procedure in which a new parietooccipital ventricular catheter was placed between January 2005 and December 2013. Data abstracted for each patient included age, sex, method of ventricular catheter placement, side of ventricular catheter placement, Evans ratio, and bifrontal ventricular span. Postoperative radiographic studies were reviewed for accuracy of ventricular catheter placement. Medical records were also reviewed for evidence of shunt failure requiring revision. Standard statistical methods were used for analysis. RESULTS A total of 257 patients were included in the study: 134 from the University of Michigan and 123 from Washington University in St. Louis. Accurate ventricular catheter placement was achieved in 81.2% of cases in which intraoperative guidance was used versus 67.3% when the freehand technique was used. Increasing age reduced the likelihood of accurate catheter placement (OR 0.983, 95% CI 0.971–0.995; p = 0.005), while the use of intraoperative guidance significantly increased the likelihood (OR 2.809, 95% CI 1.406–5.618; p = 0.016). During the study period, 108 patients (42.0%) experienced shunt failure, 79 patients (30.7%) had failure involving the proximal catheter, and 53 patients (20.6%) had distal failure (valve or distal catheter). Increasing age reduced the likelihood of being free from proximal shunt failure (OR 0.983, 95% CI 0.970–0.995; p = 0.008), while both the use of intraoperative guidance (OR 2.385, 95% CI 1.227–5.032; p = 0.011), and accurate ventricular catheter placement (OR 3.424, 95% CI 1.796–6.524; p = 0.009) increased the likelihood. CONCLUSIONS The use of intraoperative guidance during parietooccipital ventricular catheter placement as part of a CSF shunt system significantly increases the likelihood of accurate catheter placement and subsequently reduces the rate of proximal shunt failure.

scholarly journals Ventricular catheter entry site and not catheter tip location predicts shunt survival: a secondary analysis of 3 large pediatric hydrocephalus studies

2017 ◽  
Vol 19 (2) ◽  
pp. 157-167 ◽  
Author(s):  
William E. Whitehead ◽  
Jay Riva-Cambrin ◽  
Abhaya V. Kulkarni ◽  
John C. Wellons ◽  
Curtis J. Rozzelle ◽  
...  
Keyword(s):  
Clinical Research ◽  
Interobserver Agreement ◽  
Catheter Placement ◽  
Survival Advantage ◽  
Research Network ◽  
Ventricular Catheter ◽  
Shunt Failure ◽  
Entry Site ◽  
Catheter Tip ◽  
Shunt Survival

OBJECTIVE Accurate placement of ventricular catheters may result in prolonged shunt survival, but the best target for the hole-bearing segment of the catheter has not been rigorously defined. The goal of the study was to define a target within the ventricle with the lowest risk of shunt failure. METHODS Five catheter placement variables (ventricular catheter tip location, ventricular catheter tip environment, relationship to choroid plexus, catheter tip holes within ventricle, and crosses midline) were defined, assessed for interobserver agreement, and evaluated for their effect on shunt survival in univariate and multivariate analyses. De-identified subjects from the Shunt Design Trial, the Endoscopic Shunt Insertion Trial, and a Hydrocephalus Clinical Research Network study on ultrasound-guided catheter placement were combined (n = 858 subjects, all first-time shunt insertions, all patients < 18 years old). The first postoperative brain imaging study was used to determine ventricular catheter placement for each of the catheter placement variables. RESULTS Ventricular catheter tip location, environment, catheter tip holes within the ventricle, and crosses midline all achieved sufficient interobserver agreement (κ > 0.60). In the univariate survival analysis, however, only ventricular catheter tip location was useful in distinguishing a target within the ventricle with a survival advantage (frontal horn; log-rank, p = 0.0015). None of the other catheter placement variables yielded a significant survival advantage unless they were compared with catheter tips completely not in the ventricle. Cox regression analysis was performed, examining ventricular catheter tip location with age, etiology, surgeon, decade of surgery, and catheter entry site (anterior vs posterior). Only age (p < 0.001) and entry site (p = 0.005) were associated with shunt survival; ventricular catheter tip location was not (p = 0.37). Anterior entry site lowered the risk of shunt failure compared with posterior entry site by approximately one-third (HR 0.65, 95% CI 0.51–0.83). CONCLUSIONS This analysis failed to identify an ideal target within the ventricle for the ventricular catheter tip. Unexpectedly, the choice of an anterior versus posterior catheter entry site was more important in determining shunt survival than the location of the ventricular catheter tip within the ventricle. Entry site may represent a modifiable risk factor for shunt failure, but, due to inherent limitations in study design and previous clinical research on entry site, a randomized controlled trial is necessary before treatment recommendations can be made.

Ultrasound-Guided Insertion of the Ventricular Catheter in Ventriculoperitoneal Shunt Surgery: Evaluation of Accuracy and Feasibility in a Prospective Cohort

2020 ◽  
Vol 82 (01) ◽  
pp. 009-017
Author(s):  
Severina Leu ◽  
Maria Kamenova ◽  
Luigi Mariani ◽  
Jehuda Soleman
Keyword(s):  
Ventriculoperitoneal Shunt ◽  
Perioperative Complications ◽  
Univariate Analysis ◽  
Ventricular Catheter ◽  
Neurosurgical Procedures ◽  
Anatomical Landmarks ◽  
Ultrasound Guided ◽  
The Us ◽  
Evans Index ◽  
Shunt Survival

Abstract Objective Ventriculoperitoneal shunt (VPS) placement is one of the most frequent neurosurgical procedures. The position of the proximal catheter is important for shunt survival. Shunt placement is done either without image guidance (“freehand”) according to anatomical landmarks or by use of various image-guided techniques. Studies evaluating ultrasound-guided (US-G) VPS placement are sparse. We evaluate the accuracy and feasibility of US-G VPS placement, and compare it to freehand VPS placement. Methods We prospectively collected data of consecutive patients undergoing US-G VPS placement. Thereafter, the US cohort was compared with a cohort of patients in whom VPS was inserted using the freehand technique (freehand cohort). Primary outcome was accuracy of catheter positioning, and secondary outcomes were postoperative improvement in Evans' index (EI), rates of shunt dysfunction and revision surgery, perioperative complications, as well as operation, and anesthesia times. Results We included 15 patients undergoing US-G VPS insertion. Rates of optimally placed shunts were higher in the US cohort (67 vs. 49%, p = 0.28), whereas there were no malpositioned VPS (0%) in the US cohort, compared with 10 (5.8%) in the freehand cohort (p = 0.422). None of the factors in the univariate analysis showed significant association with nonoptimal (NOC) VPS placement in the US cohort. The mean EI improvement was significantly better in the US cohort than in the freehand cohort (0.043 vs. 0.014, p = 0.035). Conclusion Based on our preliminary results, US-G VPS placement seems to be feasible, safe, and increases the rate of optimally placed catheters.

Choice of valve type and poor ventricular catheter placement: Modifiable factors associated with ventriculoperitoneal shunt failure

2016 ◽  
Vol 27 ◽  
pp. 95-98 ◽  
Author(s):  
Kealeboga Josephine Jeremiah ◽  
Catherine Louise Cherry ◽  
Kai Rui Wan ◽  
Jennifer Ah Toy ◽  
Rory Wolfe ◽  
...  
Keyword(s):  
Ventriculoperitoneal Shunt ◽  
Catheter Placement ◽  
Ventricular Catheter ◽  
Shunt Failure ◽  
Factors Associated ◽  
Modifiable Factors

Shunt survival after failed endoscopic treatment of hydrocephalus

2012 ◽  
Vol 10 (6) ◽  
pp. 463-470 ◽  
Author(s):  
Benjamin C. Warf ◽  
Salman Bhai ◽  
Abhaya V. Kulkarni ◽  
John Mugamba
Keyword(s):  
Cox Regression ◽  
Cox Proportional Hazards ◽  
Hazard Ratio ◽  
Third Ventriculostomy ◽  
Ventricular Catheter ◽  
Shunt Failure ◽  
Vp Shunt ◽  
Shunt Placement ◽  
Significant Difference ◽  
Shunt Survival

Object It is not known whether previous endoscopic third ventriculostomy (ETV) affects the risk of shunt failure. Different epochs of hydrocephalus treatment at the CURE Children's Hospital of Uganda (CCHU)—initially placing CSF shunts in all patients, then attempting ETV in all patients, and finally attempting ETV combined with choroid plexus cauterization (CPC) in all patients—provided the opportunity to assess whether prior endoscopic surgery affected shunt survival. Methods With appropriate institutional approvals, the authors reviewed the CCHU clinical database to identify 2329 patients treated for hydrocephalus from December 2000 to May 2007. Initial ventriculoperitoneal (VP) shunt placement was performed in 900 patients under one of three circumstances: 1) primary nonselective VP shunt placement with no endoscopy (255 patients); 2) VP shunt placement at the time of abandoned ETV attempt (with or without CPC) (370 patients); 3) VP shunt placement subsequent to a completed but failed ETV (with or without CPC) (275 patients). We analyzed time to shunt failure using the Kaplan-Meier method to construct survival curves, Cox proportional hazards regression modeling, and risk-adjusted analyses to account for possible confounding differences among these groups. Results Shunt failure occurred in 299 patients, and the mean duration of follow-up for the remaining 601 was 28.7 months (median 18.8, interquartile range 4.1–46.3). There was no significant difference in operative mortality (p = 0.07 by log-rank and p = 0.14 by Cox regression adjusted for age and hydrocephalus etiology) or shunt infection (p = 0.94, log-rank) among the 3 groups. There was no difference in shunt survival between patients treated with primary shunt placement and those who underwent shunt placement at the time of an abandoned ETV attempt (adjusted hazard ratio [HR] 1.14, 95% CI 0.86–1.51, p = 0.35). Those who underwent shunt placement after a completed but failed ETV (with or without CPC) had a lower risk of shunt failure (p = 0.008, log-rank), with a hazard ratio (adjusted for age at shunting and etiology) of 0.72 (95% CI 0.53–0.98), p = 0.03, compared with those who underwent primary shunt placement without endoscopy; but this was observed only in patients with postinfectious hydrocephalus (PIH) (adjusted HR 0.55, 95% CI 0.36–0.85, p = 0.007), and no effect was apparent for hydrocephalus of noninfectious etiologies (adjusted HR 0.98, 95% CI 0.64–1.50, p = 0.92). Improved shunt survival after failed ETV in the PIH group may be an artifact of selection arising from the inherent heterogeneity of ventricular damage within that group, or a consequence of the timing of shunt placement. The anticipated benefit of CPC in preventing future ventricular catheter obstruction was not observed. Conclusions A paradigm for infant hydrocephalus involving intention to treat by ETV with or without CPC had no adverse effect on mortality or on subsequent shunt survival or infection risk. This study failed to demonstrate a positive effect of prior ETV or CPC on shunt survival.

scholarly journals Complication avoidance in laser interstitial thermal therapy: lessons learned

2017 ◽  
Vol 126 (4) ◽  
pp. 1238-1245 ◽  
Author(s):  
Rachel Pruitt ◽  
Alexander Gamble ◽  
Karen Black ◽  
Michael Schulder ◽  
Ashesh D. Mehta
Keyword(s):  
Thermal Treatment ◽  
Thermal Injury ◽  
Lessons Learned ◽  
Thermal Therapy ◽  
Catheter Placement ◽  
Frameless Stereotaxy ◽  
Neurosurgical Procedures ◽  
Complication Rates ◽  
Laser Interstitial Thermal Therapy ◽  
Neurological Morbidity

OBJECTIVE Complications of laser interstitial thermal therapy (LITT) are underreported. The authors discuss how they have modified their technique in the context of technical and treatment-related adverse events. METHODS The Medtronic Visualase system was used in 49 procedures in 46 patients. Between 1 and 3 cooling catheters/laser fiber assemblies were placed, for a total of 62 implanted devices. Devices were placed using frameless stereotaxy (n = 3), frameless stereotaxy with intraoperative MRI (iMRI) (n = 9), iMRI under direct vision (n = 2), MRI alone (n = 1), or frame-based (n = 47) techniques. LITT was performed while monitoring MRI thermometry. Indications included brain tumors (n = 12), radiation necrosis (n = 2), filum terminale ependymoma (n = 1), mesial temporal lobe epilepsy (n = 21), corpus callosotomy for bifrontal epilepsy (n = 3), cavernoma (n = 1), and hypothalamic hamartomas (n = 6). RESULTS Some form of adverse event occurred in 11 (22.4%) of 49 procedures. These included 4 catheter malpositions, 3 intracranial hemorrhages, 3 cases of neurological deficit related to thermal injury, and 1 technical malfunction resulting in an aborted procedure. Of these, direct thermal injury was the only cause of prolonged neurological morbidity and occurred in 3 of 49 procedures. Use of frameless stereotaxy and increased numbers of devices were associated with significantly increased complication rates (p < 0.05). A number of procedural modifications were made to avoid complications, including the use of 1) frame-based catheter placement, a 1.8-mm alignment rod to create a track and titanium skull anchors for long trajectories to improve accuracy; 2) a narrow-gauge instrument for dural puncture and coregistration of contrast MRI with CT angiography to reduce intracranial hemorrhage; 3) general endotracheal anesthesia for posterior-placed skull anchors to reduce the likelihood of damage to the cooling catheter; 4) use of as few probes as possible to reduce complications overall; and 5) dose modification of thermal treatment and use of short (3-mm) diffusing tips to limit treatment when structures to be spared do not have intervening CSF spaces to act as heat sinks. CONCLUSIONS Laser ablation treatment may be used for a variety of neurosurgical procedures for patients with tumors and epilepsy. While catheter placement and thermal treatment may be associated with a range of suboptimal operative and postoperative courses, permanent neurological morbidity is less common. The authors' institutional experience illustrates a number of measures that may be taken to improve outcomes using this important new tool in the neurosurgical arsenal.

Peritoneography in the Assessment of Peritoneal Cerebrospinal Fluid Absorption Potential for Distal Ventriculoperitoneal Shunt Catheter Placement: Technical Case Report

Neurosurgery ◽  
2001 ◽  
Vol 49 (5) ◽  
pp. 1267-1269 ◽  
Author(s):  
David McAuley ◽  
Alistair C. Dick ◽  
Annie Paterson
Keyword(s):  
Cerebrospinal Fluid ◽  
Ventriculoperitoneal Shunt ◽  
Contrast Material ◽  
Water Soluble ◽  
Catheter Placement ◽  
Shunt Failure ◽  
Fluid Absorption ◽  
Shunt Catheter ◽  
Water Soluble Contrast ◽  
Cerebrospinal Fluid Absorption

ABSTRACT OBJECTIVE AND IMPORTANCE Distal ventriculoperitoneal shunt failure has been associated with absorption failure secondary to previous peritonitis. This assumption has caused surgeons to seek alternate sites for distal catheter placement. We propose that the absorptive potential of the peritoneal cavity should be assessed before that site is discounted for catheter placement. CLINICAL PRESENTATION The case of a 14-month-old male patient is presented, demonstrating multiple ventriculoperitoneal shunt placement procedures and a diagnostic dilemma with respect to distal shunt placement. Peritoneography was performed to demonstrate peritoneal fluid absorption, allowing subsequent placement of a new distal shunt catheter with good clinical results. TECHNIQUE Using aseptic technique, a 24-gauge spinal needle was inserted in the midline of the abdomen and water-soluble contrast material was instilled. Delayed radiographs delineated peritoneal adhesions and demonstrated renal excretion of the contrast material, confirming peritoneal absorption. CONCLUSION The peritoneal cavity remains the site of choice for distal shunt catheter placement. If failure of peritoneal cerebrospinal fluid absorption is suspected as a cause of shunt failure, then peritoneography with water-soluble contrast material may be safely used to demonstrate the adequacy of fluid absorption before a secondary site is chosen.

scholarly journals Accuracy of Ventricular Catheter Tip Placement Using Freehand Placement

2019 ◽  
Vol 5 (1) ◽  
pp. 59-63
Author(s):  
DM Arman ◽  
Sheikh Muhammad Ekramullah ◽  
Sudipta Kumer Mukherjee ◽  
Samantha Afreen ◽  
Md Anwarul Hoque Faraji ◽  
...  
Keyword(s):  
Ventriculoperitoneal Shunt ◽  
Prospective Observational Study ◽  
Catheter Placement ◽  
Ventricular Catheter ◽  
Shunt Failure ◽  
Single Institution ◽  
Vp Shunt ◽  
Shunt Procedure ◽  
Freehand Technique ◽  
Catheter Tip

Background: Inaccurate placement of VP shunt catheter is related to shunt failure. Objective: The objective of this study was to determine the accuracy of ventricular catheter placement during ventriculoperitoneal shunt operations using the freehand technique. Methodology: This prospective observational study included all patients from a single institution who underwent a ventriculoperitoneal shunt procedure in which a new ventricular catheter was placed between September 2013 and August 2016 for a period of three (03) years. Data abstracted for each patient included age, sex, diagnosis, site and side of ventricular catheter placement. Postoperative CT scan images were reviewed for accuracy of ventricular catheter placement. Results: There were 140 patients included in the study; accuracy ventricular catheter tip placement were 55 (39.28%) using freehand technique. Conclusion: Mechanical malfunction and infection are the most significant problems associated with shunts for the treatment of hydrocephalus. Journal of National Institute of Neurosciences Bangladesh, 2019;5(1): 59-63

Electromagnetic-guided neuronavigation for safe placement of intraventricular catheters in pediatric neurosurgery

2012 ◽  
Vol 10 (4) ◽  
pp. 327-333 ◽  
Author(s):  
Elvis J. Hermann ◽  
Hans-Holger Capelle ◽  
Christoph A. Tschan ◽  
Joachim K. Krauss
Keyword(s):  
Premature Infants ◽  
Therapeutic Option ◽  
Operative Procedure ◽  
Catheter Placement ◽  
Shunt Revision ◽  
Ventricular Catheter ◽  
Shunt Failure ◽  
Stereotactic Techniques ◽  
Shunt Placement ◽  
Operative Revision

Object Ventricular catheter shunt malfunction is the most common reason for shunt revision. Optimal ventricular catheter placement can be exceedingly difficult in patients with small ventricles or abnormal ventricular anatomy. Particularly in children and in premature infants with small head size, satisfactory positioning of the ventricular catheter can be a challenge. Navigation with electromagnetic tracking technology is an attractive and innovative therapeutic option. In this study, the authors demonstrate the advantages of using this technology for shunt placement in children. Methods Twenty-six children ranging in age from 4 days to 14 years (mean 3.8 years) with hydrocephalus and difficult ventricular anatomy or slit ventricles underwent electromagnetic-guided neuronavigated intraventricular catheter placement in a total of 29 procedures. Results The single-coil technology allows one to use flexible instruments, in this case the ventricular catheter stylet, to be tracked at the tip. Head movement during the operative procedure is possible without loss of navigation precision. The intraoperative catheter placement documented by screenshots correlated exactly with the position on the postoperative CT scan. There was no need for repeated ventricular punctures. There were no operative complications. Postoperatively, all children had accurate shunt placement. The overall shunt failure rate in our group was 15%, including 3 shunt infections (after 1 month, 5 months, and 10 months) requiring operative revision and 1 distal shunt failure. There were no proximal shunt malfunctions during follow-up (mean 23.5 months). Conclusions The electromagnetic-guided neuronavigation system enables safe and optimal catheter placement, especially in children and premature infants, alleviating the need for repeated cannulation attempts for ventricular puncture. In contrast to stereotactic techniques and conventional neuronavigation, there is no need for sharp head fixation using a Mayfield clamp. This technique may present the possibility of reducing proximal shunt failure rates and costs for hydrocephalus treatment in this age cohort.

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