Shunt Complications Research Articles

A Prospective Study and Analysis of Ventriculoperitoneal Shunt Surgery: Their Indication and Complication in a Single Tertiary Care Center

Abstract Background Ventriculoperitoneal (VP) shunt insertion is routinely performed for the treatment of hydrocephalus due to different indications like congenital, infective, tumor, posttraumatic, and normal pressure hydrocephalus (NPH). A lot of common and rare complications following this procedure have been reported. Objectives To analyze the clinical profile, indications, anesthetic, and postoperative complications for VP shunt surgery in our center. Materials and Methods This prospective clinical review study was conducted in the Department of Neurosurgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, between October 2018 to January 2020 and included 454 cases of hydrocephalus who underwent VP shunt surgery. The data was compiled and analyzed. Results A total of 454 patients with male predominance were studied. Pediatric and adolescent patients were 48.9% (222/454). Obstructive hydrocephalus due to tumors was the etiology of 48.7% (221/454) cases. The incidence of overall shunt complications was 9.7% (44/454), of which obstruction and infection was 5.9% (27/454) and 3.1% (14/454), respectively. Factors associated with increased shunt complications include redo and infective etiology and cases having higher protein in perioperative cerebrospinal fluid (CSF) analysis. Neuronavigation, antibiotic-impregnated shunt and biventricular shunt are associated with lower complications. Conclusion Obstructive hydrocephalus due to tumors happened to be the most common cause of VP shunt, and shunt obstruction is most common complication, especially in infective and redo cases.

Optimal timing and sequence of ventriculoperitoneal shunt and gastrostomy placement

ABSTRACT Background: The optimal timing of ventriculoperitoneal shunt (VPS) and gastrostomy placement, relative to the safety of simultaneous versus staged surgery, has not been clearly delineated in the literature. Objective: To study the optimal inter-procedural timing relative to distal VPS infection and pertinent reoperation. Methods: A fifteen-year, retrospective, single-center study was conducted on adults undergoing VPS and gastrostomy within 30-days. Patients were grouped according to inter-procedural interval: 0–24 hr (immediate), 24 hr-7 days (early), and 7–30 days (delayed). The primary endpoint of the study was VPS infection and distal shunt complications requiring reoperation. Potential predictors of the primary end point (baseline cohort characteristics, procedural factors) were examined with standard statistical methods. Results: A total of 188 patients met inclusion criteria. The average interval between procedures was 7 ± 6 days, with 43.1% undergoing VPS prior to gastrostomy. Primary endpoint was encountered in 5 patients (2.7%): 1 (5.9%) of 17 patients undergoing immediate placement, 3 (2.8%) of 107 with early placement, and 1 (1.6%) of 64 with delayed placement. Although not statistically significant, 3.7% of patients undergoing VPS first had the primary endpoint, compared to 1.9% of those with gastrostomy. There were no statistically significant associations between the primary outcome and peri-operative CSF counts, gastrostomy modality, hydrocephalus etiology, chronic steroid use, or extended antibiotic administration. Conclusion: Although the low overall event rate in this cohort precludes definitive determination regarding differential safety, the data generally support a practice of performing the procedures >24-hours apart, with placement of gastrostomy prior to VPS.

Abstract No. 27 Proton pump inhibitor use is associated with increased risk of post–transjugular intrahepatic portosystemic shunt hepatic encephalopathy: replication in an independent patient cohort

Hepatic encephalopathy (HE) is a common complication of transjugular intrahepatic portosystemic shunt (TIPS) procedures. Proton pump inhibitor (PPI) use has recently been implicated as a risk factor for HE, potentially due to alterations in the gastrointestinal tract microbiome or effects on ammonium ion excretion. Although generally supporting an association between PPI use and HE, multiple meta-analyses have reported heterogeneity and publication bias, and only two previous studies have examined the role of PPI use in post-TIPS HE.

Dramatic Ventricular Shunt Complications in Pulmonary and Critical Care Medicine

Dramatic Ventricular Shunt Complications in Pulmonary and Critical Care Medicine

Acute Hydrocephalus Following a Spontaneous Ventriculoperitoneal Shunt Catheter Fracture With Scrotal Migration

Genitalia-related complications of ventriculoperitoneal shunts, such as scrotal migrations, are rare and most frequently presenting during the first year of the system placement, usually in the pediatric population, due to several factors, including vaginal process patency and increased abdominal pressure. Despite being typically benign, hernias, hydroceles, perforations, and catheter migration to the scrotum can lead to permanent disabilities and lethal complications, such as ventriculoperitoneal shunt dysfunction. We report a case of a late-onset, atraumatic, ventriculoperitoneal shunt fracture and catheter migration to the scrotum in a 22-year-old male, six years after its implantation, presenting in the emergency department due to acute hydrocephalus symptoms.

Characteristics of Patients with VP Shunt Malfunction in Dr. Mohammad Hoesin General Hospital between May 2018 and July 2019

Introduction: Hydrocephalus may occur when the production of cerebrospinal fluid (CSF) is excessive or, the most common cause when, the absorption of CSF is decreased. The VP Shunt is most commonly performed worldwide as the primary treatment for hydrocephalus. The complications of VP Shunt are shunt infection, mechanical malfunction and over or under-drainage. This study aims to see the characteristics of patients affected by post VP shunt infection who are treated at dr. Mohammad Hoesin Palembang
 Methods: This research was a cross-sectional descriptive study. Using secondary data from the medical records of Mohammad Hoesin Hospital, Palembang. Performed in the from May 2018 to July 2019. Samples were all patients diagnosed with malfunction and infection with VP Shunt.
 Results: There were 23 subjects participated who met study critera. VP shunt infections were mostly male (82.6%). The largest age distribution is less than 1 year old (39.1%). The most incidence occured at the age of 1-6 months (60.9%). The most common type of surgery was emergency surgery (60.8%). The most common malfunctions were caused by shunt malfunctions (69.6%).
 Conclusion: Male patients, patients age <1 year old with onset of 1-6 months, and shunt malfunctons were the most common characteristic of patients diagnosed with malfunction and infection with VP Shunt.

Feasibility of Proton Beam Therapy for Infants with Brain Tumours: Experiences from the Prospective KiProReg Registry Study

AimsProton beam therapy (PBT) has increasingly been applied for the treatment of young children when radiotherapy is needed. The treatment requires intensive multimodality care and is logistically demanding. In this analysis, we evaluated our experiences in treating infants with tumours of the central nervous system with PBT. Materials and methodsChildren younger than 2 years of age treated with PBT for central nervous system tumours enrolled in the prospective registry study KiProReg were retrospectively analysed. Information on patient characteristics, treatment, toxicities and outcome were evaluated. Adverse events were classified according to the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE V4.0) before, during and after PBT. ResultsBetween September 2013 and June 2018, 51 infants were eligible. The median age was 19 months (range 11–23 months) at the time of PBT. Tumour entities were ependymoma (51.0%), atypical teratoid rhabdoid tumour (39.0%), high-grade glioma (6.0%), pineoblastoma (2.0%) and medulloblastoma (2.0%). The prescribed median total dose was 54.0 Gy (range 45.0–59.4 Gy). Most received local radiotherapy. In four patients, craniospinal irradiation followed by a boost to the local tumour bed was applied. The median follow-up time was 42.0 months (range 7.3–86.2 months). The estimated 3-year local control, progression-free survival and overall survival rates for all patients were 62.7, 47.1 and 76.5%, respectively. During radiotherapy, 24 events of higher-grade (CTCAE ≥ °III) toxicities were reported. Interruption of radiotherapy for more than 2 days was due to infection (n = 3) or shunt complication (n = 2). Unexpected hospitalisation during radiotherapy affected 12 patients. Late adverse events attributable to radiotherapy included endocrinopathy (CTCAE °II; 7.8%), new onset of hearing loss (CTCAE °III; 5.8%) and visual impairment (CTCAE °IV; 1.9%). Transient radiation-induced imaging changes occurred in five patients (9.8%). ConclusionsOur study indicates that PBT is feasible for very young children with central nervous system tumours, at least in the short term. However, it requires challenging interdisciplinary medical care and high logistical effort. For evaluation of late effects, longer follow-up and evaluation of neurocognitive outcome are desirable. More data have to be gathered to further define the role of radiotherapy in infants over time.

Shunt Infection

The improvement in the management of hydrocephalus comes from the following: early diagnosis, radiological investigation, better knowledge of mechanisms, quality of material, surgical technique of implantation, less shunt complications (e.g.infections) and alternatives to shunt (e.g. Neuroendoscopy). However, shunt infection does not improve in the last decades, ranging from 3 to 12%. Shunt infection can be classified in: would infection, CSF infection, infected shunt system, abdominal complications (infection). The main agent is Staphylococcus, causing 67%-85% of problems, mainly due to colonization of shunt by skin flora. The majority of cases occur during the first 2 months (85%), late infection is rare. Risk factors to infection are the following: the cause of hydrocephalus, clinical condition and the age of children, operation time of the day, the duration of the shunt operation, the number of persons in OR, shunt material (Antibiotic catheter), presence of previously shunt system, postoperative CSF leak, perioperative antibiotics and economic level of Medical Center. Recommended management of shunt infection: removal of the shunt, insertion of an external drainage (EVD) (always in operation room), change EVD after 15 days, intravenous antibiotics, replacement of ventriculoperitoneal shunt after 3 sterile cultures. The most feared complications of Shunt infection are mortality, morbidity and cost. In conclusion: SHUNT INFECTION IS NOT A FATALITY

Management strategies for giant abdominal pseudocyst in a patient with ventriculoperitoneal shunt

Ventriculoperitoneal (VP) shunt is considered as the mainstay treatment of hydrocephalus, it remains as one of the most failure prone surgical interventions worldwide. Abdominal pseudocyst (APC) is one of the rare complications of VP shunt and is more prevalent in paediatric population. In this case, the patient is an 11-year-old male with history of tubercular meningitis with hydrocephalus for which VP shunt was done and the patient developed a giant abdominal pseudocyst which is the 3rd largest pseudocyst reported till date in a paediatric patient known best to our knowledge. This case is particularly unique due to rapid development of such a large pseudocyst in a span as short as 6 weeks. In this article, the causes of formation of APC and the treatment protocol to manage the patient with abdominal pseudocyst secondary to VP shunt are also discussed.

Mechanical complications of cerebrospinal fluid shunt. Differences between adult and pediatric populations: myths or reality?

Shunt malfunctions seem more frequent in children (44 to 81%) than in adults (18 to 29%). Because of discrepancies between studies, it is not possible to affirm this disparity. The objective was to verify whether the incidence of cerebrospinal fluid (CSF) shunt malfunctions is higher in children than adults. We present a retrospective series of child and adult patients who underwent CSF shunt placement between 2000 and 2013 with a Sophysa SM8® valve. 599 adults and 98 children (sex ratio 1.28) underwent CSF shunt placement. Age at first surgery ranged between 1 day of life and 90 years (mean of 55.8 years, SD 25.8, median 64.8 years). The mean follow-up was 4 years (SD 4.264, 0-16; median 3 years). The cumulative complication rate was 25.5% (178/697). Mechanical complications were disconnection (25.1%), migration (11.8%), intracranial catheter obstruction (8.9%) and malposition (8.4%). The mean delay for the first revision was 1.90 years (0-13.9), (SD 2.73, median 0.5). The probability of shunt failure was 65% at 10 years in the child group and 36% at 10 years in the adult group. Moreover, in the child group, 33% of revisions occurred during the first year after shunt placement versus 17% in the adult group. Thus, the probability of shunt failure was higher in children than in adults (log-rank test, p < 0.001). This is the first retrospective study, comparing children and adults undergoing CSF shunt using the same valve, able to confirm the higher rate of complications in children.

Migration of Ventriculoperitoneal Shunt to Scrotum via Patent Processus Vaginalis

Hydrocephalus in children is either treated by ventriculoperitoneal shunt or Endoscopic third ventriculostomy (ETV) dependingupon specific factors pertaining to clinical and radiological diagnosis. There are many complications of ventriculoperitoneal shuntand migration of peritoneal to scrotum, anal canal, urinarry bladder has been reported. The intra abdominal complications aremanaged by a combined team work of neurosurgeon and Pediatric surgeon.We have reported a case in which patient was diagnosed as congenital hydrocephalus with a lumbar myelomeningocele one yearback, Right sided ventriculoperitoneal shunt was passed initially followed by lumbar myelomeningocele repair. Now patient waspresented by parents with scrotal swelling, clinical examination and shunt series X-rays showed migration of lower end ofventriculoperitoneal shunt to scrotum, pediatric surgeon was consulted in same institution, a single incision at right inguinalligament was used to replace the migrated catheter into abdomen and hernia repair.Key Words: Ventriculoperitoneal shunt, Scrotal migration, Post-operative shunt complications

Multimodal Sensing Capabilities for the Detection of Shunt Failure.

Hydrocephalus is a medical condition characterized by the abnormal accumulation of cerebrospinal fluid (CSF) within the cavities of the brain called ventricles. It frequently follows pediatric and adult congenital malformations, stroke, meningitis, aneurysmal rupture, brain tumors, and traumatic brain injury. CSF diversion devices, or shunts, have become the primary therapy for hydrocephalus treatment for nearly 60 years. However, routine treatment complications associated with a shunt device are infection, obstruction, and over drainage. Although some (regrettably, the minority) patients with shunts can go for years without complications, even those lucky few may potentially experience one shunt malfunction; a shunt complication can require emergency intervention. Here, we present a soft, wireless device that monitors distal terminal fluid flow and transmits measurements to a smartphone via a low-power Bluetooth communication when requested. The proposed multimodal sensing device enabled by flow sensors, for measurements of flow rate and electrodes for measurements of resistance in a fluidic chamber, allows precision measurement of CSF flow rate over a long time and under any circumstances caused by unexpected or abnormal events. A universal design compatible with any modern commercial spinal fluid shunt system would enable the widespread use of this technology.

Endoscopic Third Ventriculostomy in Infants Less than One Year of Age: A Short Series of 14 Cases

Background: Endoscopic third ventriculostomy (ETV) is currently considered as an alternative to cerebrospinal fluid (CSF) shunt systems in the treatment of obstructive hydrocephalus. This procedure allows the CSF to drain in the basal cisterns and reabsorbed by arachnoid granulations, and avoiding implantation of exogenous material. Aims and Objectives: The purpose of this study was to assess the success rate of ETV in infants less than 1 year of age with congenital noncommunicating hydrocephalus. Material and Methods: This study was a 2-year prospective study from August 2017 to July 2019. ETVs were performed in 14 patients younger than 1 year with diagnosis of noncommunicating hydrocephalous. A failure was defined as the need for shunt implantation after ETV. Phase-contrast MRI of the brain was done after 6 months to see patency of ETV fenestration and CSF flow through ventriculostomy. Results: ETV was tried in 18 patients and successfully performed in 14 patients. Out of the 14 patients, shunt implantation after ETV was performed in 3 patients (failed ETV). In the successful cases, etiology was idiopathic aqueductal stenosis in 8, shunt complications in 2, and 1 case was a follow-up case of occipital encephalocele; the mean age was 7.7 months (range 3–12). In the 3 failed cases, etiology was aqueductal stenosis, mean age was 7.6 months (range 3–11). In all ETVs, failed patients MPVP shunting was done. Follow-up of nonshunted patients was done from 6 to 24 months (mean 15 months). There was no mortality or permanent morbidity noted following ETV. Conclusion: ETV is a good surgical procedure for less than 1-year-old children.

Abdominal pseudocysts, an unusual complication of ventriculoperitoneal shunt systems: Literature systematic review.

Since the first report in 1954, abdominal pseudocysts have been recognized as a particularly uncommon complication of ventriculoperitoneal shunts of CSF, so their etiology, diagnosis, and therapeutic management remain very controversial. Our objective is to offer a critical and updated systematic review of those controversial points, using a thorough search and review of the most relevant literature available. The clinical presentation of pseudocysts is normally through non-specific abdominal symptoms. The most validated etiology consists on the existence of a concomitant infection of the CSF shunt system, and so, treatment needs of antibiotherapy and total or partial substitution of the system. However, the pseudocyst itself doesn't need an active treatment, except for some specific cases. This management, algorithmically presented in the present work, achieves a lower recurrence rate than other options, but this one is still important, and is also associated with other complications of those shunts related with several other factors which need to be taken in account.

Metastatic Tuberculomas along a Nonfunctioning Ventricular Catheter

AbstractA unique case of tubercular meningitis, developing shunt complication, is being reported. We present a pediatric patient with disseminated tubercular granulomas along the ventricular catheter of a nonfunctional ventriculoperitoneal shunt.

A Retrospective Study on the Avoidability of Ventriculoperitoneal Shunt Infections in a University Hospital in Al-Khobar, Saudi Arabia.

Ventriculoperitoneal shunt infection is a major complication and the main cause of shunt failure, contributing to a high rate of morbidity and mortality among patients requiring prolonged hospitalization. Shunt infection-related complications are considered a global burden of hydrocephalus worldwide. In our hospital, King Fahad Hospital of the University, the rate of infections in similar cases reached 8% during the period from 1999 to 2001; an increase in this rate was observed in the past two years.This study analyzed the infections that occur after ventriculoperitoneal shunt placement in patients with hydrocephalus and related conditions during the period from January 2012 to April 2017. The objectives of this study were to analyze the rate of cerebrospinal fluid infections in different age groups at the King Fahd Hospital of the University and to identify the causative pathogens and methods of reducing the rate and consequences of such infections. In this retrospective study, the electronic medical records of 266 patients were reviewed and those of 131 patients were included and analyzed. We found that the prevalence rate of shunt-related infections was 24.4%, which indicates the importance of this problem. Staphylococcus epidermidis is the most commonly implicated microorganism. The most affected age groups were those of preschool children and infants. Individuals who were older than 74 years were the least affected. It was found that delayed infections were the most common type of VP shunt infection among the study population and there was no difference in the most common organisms between early, delayed, and late infections. The mean duration of antibiotic treatment used was 19.76 days. In conclusion, postoperative infections are significantly common in patients who undergo shunt-related surgeries.

Complications of Ventriculoperitoneal Shunts in Children with Pediatric Hydrocephalus a Local Study at Benha University Hospitals

Ventriculoperitoneal shunting is the main way used for extra-thecal cerebrospinal fluid (CSF) diversion. Despite being the main corner stone of treating different types of hydrocephalus, VP shunts has unfortunately a lot of complications making surgeries to treat these complications much more than initial shunt insertions.Methods:It is a clinical retrospective observational study that was conducted on 221 patients wth congenital hydrocephalus of both genders with age ranging from 0 to 18 yrs old who came with symptoms and signs of shunt complications and were primarily shunted at Benha university hospital between 2016 and 2019. A complete clinical assessment was done, history taking, a final diagnosis was made, and a treatment of individual patients was planned accordingly. Patients were followed up till the end of the study post-operatively. Data was analyzed using the SPSS (version 16.0). VP shunt was inserted for 221 patients. 113 (51.1%) patients had various forms of complications. Obstructive complications accounts for the most common complications as they happened in 48 (42.5%) of complicated patients followed by infective complications as they appeared in 27 (24%) patients.Conclusions: Despite .great revolution in the field of neurosurgery in the past 100 years and sincere efforts from neurosurgeons worldwide , shunt complications still common among shunted patients.Background Hydrocephalus is regarded as an imbalance in the formation and absorption of CSF to a sufficient magnitude producing accumulation of CSF fluid with in ventricular system of the brain leading to an elevation of intracranial pressure. Compensatory adjustments especially in very young subjects may occur that may reduce prevailing CSF pressure to normal range on count of functioning brain tissue [1]. Hydrocephalus is the second most common congenital brain malforma-tion [2].Congenital hydrocephalus is type of hydrocephalus that is present or its underlying cause at birth. majority of cases are attributed to aqueductal stenosis , chiarri malformation , dandy walker malformation ,arachnoid cyst. approximately 55% of all cases of congenital hydrocephalus are due to Primary aqueductal stenosis whereas aqueductal stenosis secondary to neoplasm, infection, or hemorrhage accounts for another 5% [4]. Till now , the standard treatment of hydrocephalus is ventriculoperitoneal shunt. The technique of using the peritoneal cavity for CSF absorption in ventriculoperitoneal shunting (VPS) was developed by Kausch in 1908 [3]. Al- though VPS insertion is the most common neurosurgical Procedure done worldwide, complication rates in Children are high ranging from 10% to 100% [11]. The advent of endoscopic third ventriculostomy has gained popularity due to the high complication and failure rates of ventriculoperitoneal shunt [12]. VP shunts are prone to a lot of complications such as mechanical blockage, shunt infection, shunt migration, and various abdominal complications[13].

Shunt exposure as a ventriculoperitoneal shunt complication: A case series

IntroductionShunting is a technique in neurosurgery for treating hydrocephalus. Shunting is an effective choice for both cases of obstructive or communicative hydrocephalus. However, in some rare cases, complications, such as exposed shunt, can occur. In this case series, the author discusses 6 cases of hydrocephalus patients with exposed shunts. The risk factors, diagnosis, and management of exposed VP shunt will be discussed further in this case series report. MethodsThis study was an analysis of all cases treated in a period of 1 year from January to December 2018 with an inclusion criterion of history of exposed shunt of any age group. This study is a single-centre retrospective report of the clinical presentation and radiology examination before and after treatment. Clinical and radiology evaluation were performed in immediate post procedural period. A detailed clinical examination was performed to look for exposed shunt complication. ResultsIn this series of studies 6 patients with hydrocephalus who had shunts were reported. All patients were pediatric patients. Six patients had exposed shunt on the scalp or abdomen. Radiological examinations including CT scan, chest X-ray or babygram were performed to evaluate the location of the shunt. The data reported was from January to December 2018 and there were 301 VP shunt installment cases. Management included surgical revisions and treatments to prevent further complications. ConclusionShunting is still a routine therapy in the field of neurosurgery, although other modalities such as endoscopic third ventriculostomy (ETV) have started to be performed more frequently. Complications such as exposed shunt are rare in the treatment of pediatrics with hydrocephalus. We presented that exposed shunt is a rare complication (2.3% incidence rate) which might be caused by certain risk factors, such as age of patient when the shunting was performed, and nutritional status. Early diagnosis and treatment are important to prevent further complications, especially infections. Subpericranial technique for shunt tunneling might be useful in preventing exposure of shunts with associated morbidity factors.

Shunt malfunction and endoscopy

Objective: &#x0D; Hydrocephalus is the most common neurological disease in pediatric neurosurgery.(1) The CSF shunts remains as the most common treatment choice for nonobstructive hydrocephalus worldwide, but shunt complications still the most common neurosurgical problem, especially in pediatric neurosurgery. Endoscopy and shunts are the way to treat hydrocephalus. Especially third ventriculostomy is the most effective treatment to obstructive hydrocephalus but shunt still the most important way to treat.(2, 3) Shunt malfunction is frequent and after so many years this is very important problem to the patients. Ventricular problem due to obstruction is responsible up to 72% of shunt problems.(4) The Shunt Trial Study showed that the overall shunt survival was 62% at 1 year, 52% at 2 years, 46% at 3 years, 41% at 4 years. The survival curves for the 3 differents valves were similar to those from the original trial and did not show a survival advantage for any particular valve.(5, 6) We still don´t have one perfect solution to hydrocephalus and shunt malfunction.&#x0D; The major author described his experience in use endoscopy to evaluate and treat shunt malfunction and one new approach and way to evaluate this problem.&#x0D; &#x0D; Results/Discussion:&#x0D; The literature review was performed, and we found 84 articles when we used the keywords. Endoscopy has been one important way to treat and solve shunt problems. In obstructive hydrocephalus third ventriculostomy is the best way to treat these patients.(1-3)&#x0D; The major author first described goals of endoscopy. First goal is safe catheter removal in surgical review, avoiding bleeding when removing catheter addressing all the adhesions on catheter. Second goal is put in optimal position the new catheter with pure endoscopy view or using neuronavigation systems that could help the endoscope system.(7, 8) &#x0D; Optimal new catheter placement and optimal long-term catheter survival are especially important because most of the problems are due to ventricular problems. These good placements could avoid loculations and ventricular collapse with ependymal problems. Avoid new catheter malpositiitioning, you can use the endoscope to follow the old tract to insert the new catheter in one good position avoiding choroid plexus. Another situation is when you have small ventricles especially in slit ventricle syndrome.&#x0D; &#x0D; The major author has been studied some causes to ventricular catheter obstruction. He noticed after some surgical reviews some ventricular ependymal inside catheter. Ventricular ependymal protrusions inside the catheter could cause intermittent occlusion.(8) Some endoscope views showed these protrusion and ependymal changes after intermittent increase and decrease of ventricular pressure. These protrusions correspond to catheter holes a secondary to suction. These protrusions could stuck in the holes in chronicle suction.(8) The major author reported one endoscopic evidence of overdrainage-related ventricular tissue protrusions that cause partial or complete obstruction of the ventricular catheter. He did a retrospective review in fifty patients underwent 83 endoscopic shunt revision procedures that revealed in-growth of ventricular wall tissue into the catheter tip orifices (ependymal bands), producing partial, complete, or intermittent shunt obstructions. Endoscopic ventricular explorations revealed ependymal bands at various stages of development, which appear to form secondarily to siphoning.(8)&#x0D; How to minimize this overshunting? Anti siphon systems could help and decrease proximal shunt malfunction in some complex patients. The other problem is ventricular bleeding. The use of endoscope has been important tool to remove ventricular catheters, when you could see the adhesions.(9)&#x0D; The use the endoscope could be particularly important to open loculations and cysts avoiding ventricular entrapment. Patients with ventricular cysts could need more than one catheter. The use of endoscopy to fenestrate the cyst could keep the patient with one catheter or without any shunt system.(10, 11)&#x0D; &#x0D; Conclusion:&#x0D; Shunt malfunction has a lot of possible causes, but a probably ventricular catheter problem is the most common situation. Choose appropriate endoscope rigid or flexible for each case could help to treat and avoid some of ventricular. Endoscopy could be one important tool to help the surgeon to understand and solve this dangerous situation to the patient. Ventricular wall protrusions are a significant cause of proximal shunt obstruction, and they appear to be caused by siphoning of surrounding tissue into the ventricular catheter orifices.

Temporary intravascular shunts after civilian arterial injury: A prospective multicenter Eastern Association for the Surgery of Trauma study.

We sought to determine the impact of the indication for shunt placement on shunt-related outcomes after major arterial injuries. We hypothesized that a shunt placed for damage control indications would be associated with an increase in shunt-related complications including shunt dislodgement, thrombosis, or distal ischemia. A prospective, multicenter study (eleven level one US trauma centers) of all adult trauma patients undergoing temporary intravascular shunts (TIVS) after arterial injury was undertaken (January 2017-May 2019). Exclusion criteria included age <15years, shunt placement distal to popliteal/brachial arteries, isolated venous shunts, and death before shunt removal. Clinical variables were compared by indication and shunt-related complications. The primary endpoint was TIVS complications (thrombosis, migration, distal ischemia). The 66 patients who underwent TIVS were primarily young (30years [IQR 22-36]) men (85%), severely injured (ISS 17 [10-25]) by penetrating mechanisms (59%), and had their shunts placed for damage control (41%). After a median SDT of 198min [89-622], 9% experienced shunt-related complications. Compared by shunt placement indication (damage control shunts [n=27] compared to non-damage control shunts [n=39]), there were no differences in gender, mechanism, extremity AIS, MESS score, fractures, or surgeon specialty between the two groups (all p>0.05). Patients with shunts placed for damage control indications had more severe injuries (ISS 23.5 compared to 13; SBP 100 compared to 129; GCS 11 compared to 15; lactate 11.5 compared to 3.6; all p<0.05), and had more frequent shunt complication predictors, but damage control shunts did not have significantly more TIVS complications (11.1% compared to 7.7%, p=0.658). Shunt complication patients were discharged home less often (33% vs 65%; p<0.05) but all survived. Shunts placed for damage control indications were not associated with shunt complications in this prospective, multicenter study.