Minimally invasive procedure for removal of infected ventriculoatrial shunts

Lorenzo Magrassi,David Shepetowsky,Angela Di Matteo,Lorenzo Paolo Moramarco,Gianluca Mezzini,Elena Seminari,Pietro Quaretti,Nicola Cionfoli

doi:10.1007/s00701-020-04675-1

Abstract

BackgroundVentriculoatrial shunts were one of the most common treatments of hydrocephalus in pediatric and adult patients up to about 40 years ago. Thereafter, due to the widespread recognition of the severe cardiac and renal complications associated with ventriculoatrial shunts, they are almost exclusively implanted when other techniques fail. However, late infection or atrial thrombi of previously implanted shunts require removal of the atrial catheter several decades after implantation. Techniques derived from management of central venous access catheters can avoid cardiothoracic surgery in such instances.MethodsWe retrospectively investigated all the patients requiring removal of a VA shunt for complications treated in the last 5 years in our institution.ResultsWe identified two patients that were implanted 28 and 40 years earlier. Both developed endocarditis with a large atrial thrombus and were successfully treated endovascularly. The successful percutaneous removal was achieved by applying, for the first time in this setting, the endoluminal dilation technique as proposed by Hong. After ventriculoatrial shunt removal and its substitution with an external drainage, both patients where successfully weaned from the need for a shunt and their infection resolved.ConclusionPatients carrying a ventriculoatrial shunt are now rarely seen and awareness of long-term ventriculoatrial shunt complications is decreasing. However, these complications must be recognized and treated by shunt removal. Endovascular techniques are appropriate even in the presence of overt endocarditis, atrial thrombi, and tight adherence to the endocardial wall. Moreover, weaning from shunt dependence is possible even decades after shunting.

Highlights

In pediatric patients, ventriculoatrial shunts (VAS) are rarely implanted as a first-line treatment of hydrocephalusThis article is part of the Topical Collection on Neurosurgery generalActa Neurochir limited to few years with a median ranging in those studies from 15 [19] to 42 [28] months, while in pediatric patients reported follow-ups were typically well above 10 years [8, 26].Strong support for early recognition and treatment of VAS complications come from the documented reversibility of most complications after removal of the VAS especially if they result from bacterial infection [8, 39]
We report the endovascular removal of two infected VAS catheters associated with large thrombi that were implanted 28 and 40 years before and were both tightly adherent to the endovascular and endocardial wall
In 2016, during a mild septic episode, a floating atrial thrombus associated to the VAS catheter tip was revealed by transoesophageal echocardiography (TEE)

Summary

Introduction

Ventriculoatrial shunts (VAS) are rarely implanted as a first-line treatment of hydrocephalusThis article is part of the Topical Collection on Neurosurgery generalActa Neurochir limited to few years with a median ranging in those studies from 15 [19] to 42 [28] months, while in pediatric patients reported follow-ups were typically well above 10 years [8, 26].Strong support for early recognition and treatment of VAS complications come from the documented reversibility of most complications after removal of the VAS especially if they result from bacterial infection [8, 39]. Ventriculoatrial shunts (VAS) are rarely implanted as a first-line treatment of hydrocephalus. Removal of a chronically implanted VAS catheter from the right atrium is usually not straightforward due to the frequent presence of adhesions to the endocardial structures [4] and/or the presence of a large atrial thrombus [38]. We report the endovascular removal of two infected VAS catheters associated with large thrombi that were implanted 28 and 40 years before and were both tightly adherent to the endovascular and endocardial wall. Ventriculoatrial shunts were one of the most common treatments of hydrocephalus in pediatric and adult patients up to about 40 years ago. Thereafter, due to the widespread recognition of the severe cardiac and renal complications associated with ventriculoatrial shunts, they are almost exclusively implanted when other techniques fail. Techniques derived from management of central venous access catheters can avoid cardiothoracic surgery in such instances

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