Distal Ventriculoperitoneal Shunt Catheter Research Articles

Migration of the distal ventriculoperitoneal shunt catheter into the stomach with or without trans-oral extrusion: A systematic literature review and meta-analysis.

Intra-gastric migration of the distal ventriculoperitoneal shunt (VPS) catheter clinically presenting with or without trans-oral extrusion is one of the rare complications of VPS catheter insertion. To identify the demographics, clinical presentation, clinical findings, and results of surgical therapy offered for the treatment of intra-gastric migration of the distal VPS catheter, clinically presented with or without trans-oral extrusion. An online search was performed for the extraction/retrieval of the published/ available literature pertaining to the above-mentioned VPS complication. Manuscripts were searched from PubMed, PMC (PubMed Central), ResearchGate, and Google Scholar databases using various terminology relating to the VPS complications. The first case of migration of a VPS catheter into the stomach was reported in the year 1980, and the data were retrieved from 1980 to December 2022. Cases were categorized into two groups; Group A: Cases who had migration of the distal VPS catheter into the stomach and clinically presented with trans-oral extrusion of the same, and Group B: Cases who had migration of the distal VPS catheter into the stomach, but presented without trans-oral extrusion. A total of n = 46 cases (n = 27; 58.69% male, and n = 19; 41.3% females) were recruited for the systematic review. Group A included n = 32, and Group B n = 14 cases. Congenital hydrocephalus was the indication for the primary VPS insertion for approximately half of the (n = 22) cases. Approximately sixty percent (n = 27) of them were children ≤ 5 years of age at the time of the diagnosis of the complication mentioned above. In seventy-two percent (n = 33) cases, this complication was detected within 24 mo after the VPS insertion/last shunt revision. Clinical diagnosis was evident for the entire group A cases. Various diagnostic modalities were used to confirm the diagnosis for Group B cases. Various surgical procedures were offered for the management of the complication in n = 43 cases of both Groups. In two instances, intra-gastric migration of the distal VPS catheter was detected during the autopsy. This review documented four deaths. Intra-gastric migration of the peritoneal end of a VPS catheter is one of the rare complications of VPS catheter implantation done for the treatment of hydrocephalus across all age groups. It was more frequently reported in children, although also reported in adults and older people. A very high degree of clinical suspicion is required for the diagnosis of a case of an intra-gastric migration of the distal VPS catheter clinically presenting without trans-oral extrusion.

Management of ventriculoperitoneal shunt complications in children: A review of 34 cases.

The primary objective of this study was to analyse the demographics of the children who presented with ventriculoperitoneal shunt (VPS) complications. The secondary objectives were to review the clinical characteristics, surgical procedures performed for the management of VPS complications and the final outcome. This is a single-institution observational study that included children below 12 years of age who required VPS revisions during the study period. During the study period of 10 years, n = 336 VPS catheters were implanted for the treatment of hydrocephalus in children. Forty (11.90%) children developed various VPS complications and required VPS revisions in the follow-up period. A total of n = 30 (8.92%) children (n = 21 boys and n = 9 girls) were selected/recruited for the present study, and they required n = 34 revision procedures. The mean interval from VPS insertion to the diagnosis of the complication was 7.29 months. VPS complications that required revisions occurred in the following order of frequency: (1) VPS catheter, cerebrospinal fluid (CSF) or shunt tract infection n = 8 (2.38%); (2) malfunction of distal VPS catheter n = 7 (2.08%); (3) coiling of distal VPS catheter at abdominal area n = 6 (1.78%); (4) extrusion of VPS catheter n = 5 (1.48%); (5) CSF leak from abdominal wound site/umbilicus n = 4 (1.19%); (6) malfunction of ventricular catheter n = 3 (0.89%) and (7) CSF pseudocyst peritoneal cavity n = 1 (0.29%). Surgical procedures were performed for the treatment of abovementioned complications in the following order of frequency: (1) revision of distal VPS catheter n = 14 (4.16%), (2) removal of entire VPS catheter ± external ventricular drainage (EVD) n = 7 (2.08%), (3) distal VPS catheter converted as EVD n = 6 (1.78%), (4) revision of proximal VPS catheter n = 3 (0.89%), (5) revision of entire VPS catheter n = 3 (0.89%) and (6) CSF pseudocyst excision n = 1 (0.29%). This study also documented n = 2 (6.6%) deaths during the post-operative period. VPS insertion done for the treatment of hydrocephalus in infants and children was associated with various complications. Seventy per cent of the complications occurred within the first 6 months after the VPS insertion. Two-thirds of the complications were related to the distal VPS catheter.

Systematic literature review of the management of transanal extrusion of distal ventriculoperitoneal shunt catheter: 1966–2020

Perforation of the colon with or without transanal extrusion of the distal ventriculoperitoneal shunt (VPS) catheter is a well-known but a serious complication after VPS insertion done for the treatment of hydrocephalus. The objectives were to review the demographics, clinical characteristics, operative procedures performed, postoperative complications, and the final outcome of the published cases, relating to the transanal extrusion of the distal VPS shunt catheter. Electronic database search was performed to retrieve the published/available literature relating to the transanal extrusion of VPS catheter. The manuscripts relating to the above-mentioned complication were retrieved from 1966 to December 2020. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines are followed for this review. This review included 210 cases comprising 142 (67.6%) males and 68 (32.3%) females. In two-third (n = 141) of the cases, the indication for the initial VPS insertion was the congenital hydrocephalus. In 60% of the cases, the initial VPS insertion was done during infancy. In 70% of the cases, the interval from VPS insertion to the diagnosis of transanal extrusion of the distal VPS catheter was within 12 months. Transanal extrusion of the distal VPS catheter was the chief complaint. In two-third of the cases, it was asymptomatic transanal extrusion of distal VPS catheter. In remaining one-third of the cases, it was symptomatic transanal extrusion of the distal VPS catheter, and they had either symptoms relating to the central nervous system or gastrointestinal tract. Three-fourth of the cases were managed by the removal of the entire or the distal VPS catheter with or without external ventricular drainage (EVD). Fifty percent of the above-mentioned complication was managed by doing percutaneous surgical procedures, and another one-third of them were managed by doing laparotomy. Complications were also evident in 16 (7.6%) of the cases during the postoperative period. This review revealed only 6 (2.8%) deaths. Transanal extrusion of the distal VPS catheter occurred across all the age groups. Eighty percent of the complications occurred in children below the age of 10 years. Three-fourth of the cases were managed by the removal of the entire or distal VPS catheter with or without EVD. In three-fourth of the cases, repair of the perforated bowel/colon was not done and that healed spontaneously after the removal of the extruded VPS catheter.

Systematic review of migration of distal ventriculoperitoneal shunt catheter into the urinary bladder with or without per-urethral extrusion

Ventriculoperitoneal shunt (VPS) insertion is the most widely performed surgical procedure for the treatment of hydrocephalus across all age groups but is associated with several complications. The objectives of the present review were to review the demographics, clinical characteristics, operative procedures executed, postoperative major complications, and outcome of the cases published on the management of migration of the distal VPS catheter into the urinary bladder with or without per-urethral extrusion. PubMed, Medline, PubMed Central, Embase, ResearchGate, and Google Scholar database online search was performed to retrieve the published/available literature relating to the above-mentioned complication. Literature/Case reports were retrieved from the year 1974 to June 30, 2020, and those were available in the English language. Thirty-seven cases were included for review, and included n = 20 (54.05%) male, n = 15 (40.54%) female and gender details were not available for n = 2 (5.4%) of the cases. The mean age of the cases at the time of diagnosis of the above complication was 15.27 years. The mean interval from the VPS insertion to the diagnosis of the complication for the entire case was 4.7 years and ranged from 1 day to 26 years. Surgical procedures were performed for the management and were in order of frequency as; (a) removal of entire VPS catheter n = 20, (b) removal of distal VPS catheter n = 10, (c) removal/relocation of distal VPS catheter n = 6, and (d) details not available n = 1. Migration of the distal VPS catheter into the urinary bladder with or without per-urethral extrusion occurred across all the age groups. Seventy percent of the cases were children below the age of 15 years. In 50% of the cases, the complication was documented within 24 months after the VPS insertion. In two-third of the cases, repair of the urinary bladder perforation was not done and that healed spontaneously after the removal of the intra-vesical migrated VPS catheter.

Subcutaneous Migration of Distal Ventriculoperitoneal Shunt Catheter in Morbidly Obese Patients: Two Case reports

Background: VP shunt failure due to distal catheter migration is an uncommon complication mainly associated with increased intra-abdominal pressure related to obesity. Observations: We report two cases of morbidly obese patients who presented with recurrent distal catheter migration and pseudocyst formation in the subcutaneous space less than a month following VP shunt placement for the management of hydrocephalus. Conclusion: Special attention must be given when placing a VP shunt in morbidly obese patients. There are various methods to prevent tube migration in such patients, like using a longer catheter tube, tight closure of the peritoneum while placing the catheter between the fat and abdominal muscles, using a hernia patch, and using laparoscopic techniques. We advocate for using different surgical procedures in obese patients prophylactically to avoid VP shunt failure and distal tube migration in patients with associated risk factors. Keywords: Shunt Complication, Subcutaneous Migration, Ventriculoperitoneal Shunt, Obesity

Extrusion of the distal ventriculoperitoneal shunt catheter through the umbilicus: a systematic literature review from 1973 to 2021

Trans-umbilical extrusion of the distal ventriculoperitoneal shunt catheter is a rare complication of the VPS insertion. The objectives of this review were to analyze various variables like the age, sex, indication for VPS insertion, clinical presentation, the operative therapy offered for the management, and outcome of the cases published/managed for the trans-umbilical extrusion of the distal VPS shunt catheter. In 1973, the maiden case of trans-umbilical extrusion of the distal VPS catheter was published. Literature/case reports were retrieved from 1973 to October 31, 2021. A total of n=24 (12 males, 12 females) cases were recruited for this systematic review. All of them were children below the age of 13-years. In four-fifths (n=19) of children, the initial VPS catheter was inserted during the first 6-months of life. The median age of children at the time of diagnosis of the above-described VPS complication was 7.5 (42.21 SD) months, and it ranged from 2 months to 13 years of age. The median interval from the initial VPS insertion/last VPS revision to the diagnosis of complication was 4 (24.77 SD) months, and it ranged from 3 weeks to 8 years. The main complaint was the extrusion of the distal VPS catheter through the umbilicus. Surgical procedures performed for the management were (a) removal of the entire VPS catheter n=15, (b) removal of distal/part of distal VPS catheter n=5, and (C) others n=2. For VPS catheter revision; delayed re-VPS insertion was performed in n=10, immediate revision of the distal VPS catheter in n=3, and others. Three (12.5%) children died during the postoperative and follow-up period. The distal VPS catheter extrusion through the umbilicus is a rare complication of VPS insertion, and it occurred exclusively in children. In 70% (n=17) of children, it was documented ≤6 months afterward of the VPS insertion. Delayed re-VPS catheter insertion was preferred for 40% of the children for VPS revision procedures.

Protrusion of ventriculoperitoneal shunt catheter tip through anus with silence abdomen

Introduction: Ventriculoperitoneal shunt (VPS) is most commonly performed surgical treatment for hydrocephalus by draining excessive cerebrospinal fluid (CSF) in ventricles to peritoneal cavity. Despite significant improvement in shunt procedure and being a relatively simple procedure, shunt complications remain common. Aim: The aim of this paper is to report a case of perforated bowel presented with silence abdomen following VPS insertion. Case study: We report a case of protrusion of distal VPS catheter through anus with silent abdomen, managed successfully with minimal intervention. Patient, 11-months-old male infant, diagnosed with congenital communicating hydrocephalus and VPS placement was done at 6 months of life, presented with tip of VPS protruding from anus after 4 months of VPS insertion. Patient was scheduled for removal of VPS, where shunt was disconnected through superficial abdominal incision, distal portion removed through anus without resistance. Postoperative patient recovers well without abdominal complication. Results and discussion: Perforation of bowel by distal peritoneal catheter is rare and only accounts for 0.1%–0.7% of complication. The exact pathogenesis for spontaneous bowel perforation is unclear. Management of bowel perforation secondary to VPS is highly individualized, mainly depending on its clinical symptoms and signs. Conclusions: Although bowel perforation following VPS insertion is rare, it carries high mortality up to 15% especially if unrecognized and delayed in treatment. Early detection and appropriate management are key in reducing VPS related morbidity and mortality.

Anatomical Classification for the Migration of the Distal Catheter of the Ventriculoperitoneal Shunt

There have been many reports on migration of the distal catheter of the Ventriculoperitoneal shunt (VPS) since this complication was recognized more than 50 years ago. However, there have been no attempts to analyze its different anatomical patterns and to assess the potential risk of these patterns to the patients. We comprehensively reviewed all reports of distal VPS catheter migration indexed in PubMed and were able to identify three different anatomical patterns of migration based on the catheter extension and the organs involved: (1) internal migration, when the catheter invades any viscus inside the thoracic, abdominal, or pelvic cavity; (2) external migration, when the catheter penetrates through the body wall either incompletely (subcutaneously) or completely (to outside of the body); and (3) compound migration, when the catheter penetrates a hollow viscus and then protrudes through a pre‐existing anatomical orifice. In addition, we analyzed the association between each migration type and several key factors, which could affect the incidence of this complication such as patient’s age, sex, shunt duration, and previous shunt revision. External migration occurred mostly in infants. In contrast, internal migration occurred mostly in adults. A body wall weakness was not a risk factor for catheter protrusion in external migration. Shunt duration was a very critical factor in the migration pattern, as most newly replaced shunts tended to migrate externally. Clinicians must pay close attention to cases of large bowel perforation by the catheter, since these cases were most often associated with intracranial infections. The organ involved in the compound type of migration could determine the route of extrusion, as the bowel was involved in all trans‐anal migrations and the stomach in most trans‐oral cases.

Endovascular Retrieval of Migrated Distal End of Ventriculoperitoneal Shunt from Bilateral Pulmonary Arteries: A Technical Note

Ventriculoperitoneal (VP) shunting of cerebrospinal fluid is one of the most common procedures performed by neurosurgeons around the world. Migration of distal VP shunt catheter into bilateral segmental pulmonary arteries is an extremely rare complication of VP shunt placement. In the present case, a 30-year-old male underwent VP shunting complicated by migration of distal VP shunt catheter into the bilateral pulmonary arteries. Despite manual attempt at externalizing the distal VP shunt catheter at the level of the clavicle, a small piece of distal VP shunt catheter in bilateral pulmonary arteries was noted on computed tomography of the chest obtained after manual externalization. This persistent distal VP shunt catheter was likely left behind after a break in the distal VP shunt catheter during manual externalization procedure. Given the small size of the segmental pulmonary arteries, a novel endovascular technique was used to move the distal VP shunt catheter from the bilateral segmental pulmonary arteries to the main pulmonary trunk. Once in the main pulmonary trunk, a snare device was used to retrieve the distal shunt catheter through the femoral vein. In this technical note, the authors highlight the relevant endovascular technical details to first move the VP shunt catheter from the bilateral segmental arteries followed by successful catheter retrieval using snare device.

Migration of the distal catheter of the ventriculoperitoneal shunt in hydrocephalus: A Comprehensive Analytical Review from an Anatomical Perspective.

There have been many reports on migration of the distal catheter of the ventriculoperitoneal shunt (VPS) since this phenomenon was recognized 50 years ago. However, there have been no attempts to analyze its different patterns or to assess these patterns in terms of potential risk to patients. We comprehensively reviewed all reports of distal VPS catheter migration indexed in PubMed and identified three different anatomical patterns of migration based on catheter extension and organs involved: (1) internal, when the catheter invades any viscus inside the thoracic, abdominal, or pelvic cavity; (2) external, when the catheter penetrates through the body wall either incompletely (subcutaneously) or completely (outside the body); and (3) compound, when the catheter penetrates a hollow viscus and protrudes through a pre-existing anatomical orifice. We also analyzed the association between each migration type and several key factors. External migration occurred mostly in infants. In contrast, internal migration occurred mostly in adults. A body wall weakness was not a risk factor for catheter protrusion. Shunt duration was a critical factor in the migration pattern, as most newly-replaced shunts tended to migrate externally. Clinicians must pay close attention to cases of large bowel perforation, since they were most often associated with intracranial infections. The organ involved in compound migration could determine the route of extrusion, as the bowel was involved in all trans-anal migrations and the stomach in most trans-oral cases. Clin. Anat. 30:821-830, 2017. © 2017Wiley Periodicals, Inc.

Large pseudocyst in the anterior extraperitoneal space as a complication of ventriculoperitoneal shunt

Ventriculoperitoneal shunts are used as a common treatment for hydrocephalus to divert cerebrospinal fluid into the peritoneal cavity. However, the shunt devices have a high incidence of malfunction mainly caused by catheter obstruction or infection and are associated with various complications, 10–30% of which are abdominal. These complications include: peritoneal pseudocysts; pseudotumor of the mesentery; inguinal hernia; volvulus; ascites; peritonitis; migration of the catheter through the vagina, scrotum, umbilicus, or intestinal tract; and intestinal obstruction. In this paper, we report a patient with a large pseudocyst in the anterior extraperitoneal space caused by migration of a distal ventriculoperitoneal shunt catheter (peritoneal catheter) that migrated from the peritoneal cavity to the anterior extraperitoneal space.

Intracardiac migration and knotting of a ventriculoperitoneal shunt

We report a patient with delayed migration of the distal ventriculoperitoneal shunt catheter from the peritoneum to the right atrium with associated knotting of the catheter complicating removal. We also review the literature on this topic.

Ventriculomammary shunt: An unusual ventriculoperitoneal shunt complication

Ventriculoperitoneal (VP) shunt malfunctions are common and can result in significant consequences for patients. Despite the prevalence of breast augmentation surgery and breast surgery for other pathologies, few breast related VP shunt complications have been reported. A 54-year-old woman with hydrocephalus post-subarachnoid hemorrhage returned 1 month after VP shunt placement complaining of painful unilateral breast enlargement. After investigation, it was determined that the distal VP shunt catheter had migrated from the peritoneal cavity into the breast and wrapped around her breast implant. The breast enlargement was the result of cerebrospinal fluid retention. We detail this unusual case and review all breast related VP shunt complications reported in the literature. To avoid breast related complications related to VP shunt procedures, it is important to illicit pre-procedural history regarding breast implants, evade indwelling implants during catheter tunneling and carefully securing the abdominal catheter to prevent retrograde catheter migration to the breast.

Migration of distal catheter of ventriculoperitoneal shunt into heart:report of 2 cases and review of literature

Objective To discuss the mechanism,clinical features,complications,diagnosis criteria and treatment of intracardiac migration of the distal catheter of ventriculoperitoneal shunt.Method The diagnosis criteria and treatment of 2 cases of intracardiac migration of the distal catheter of ventriculoperitoneal shunt were studied,and relative literatures were reviewed.Results The migratory catheter was successfully extracted after definite diagnosis according to clinical features and imaging findings.There was no postoperative abnormality.Conclusions This is the first report of migration of the distal catheter of ventriculoperitoneal shunt into heart in China.The possible measures to minimize the incidence of the migration include avoiding deep or superficial neck tunneling and using blunt tunneling devices.Head CT,chest and abdominal x - ray are needed if postoperative abnormality is noticed.Percutaneous removal of the catheter from the retroauricular fomer incision is simple and safe. Key words: Ventriculoperitoneal shunt ; Hydrocephalus ; Complication ; Hunt migration ; Heart ;

Laparoscopic versus open insertion of the peritoneal catheter in ventriculoperitoneal shunt placement: review of 810 consecutive cases

Traditional ventriculoperitoneal (VP) shunt surgery involves insertion of the distal catheter by minilaparotomy. However, minilaparotomy may be a significant source of morbidity during shunt surgery. Laparoscopic insertion of the distal catheter is an alternative technique that may simplify and improve the safety of shunt surgery. The authors performed a retrospective review of hospital records of all patients undergoing new VP shunt insertion at a tertiary care center between 2004 and 2009. Patient characteristics and outcomes were compared between patients undergoing open or laparoscopic insertion of the distal catheter. Independent variables in the analysis included age, sex, race, body mass index, surgical technique, previous VP shunt placement, previous abdominal procedures, American Society of Anesthesiology (ASA) score, and indication for shunt placement. Dependent variables included the occurrence of shunt failure, cause of shunt failure, complications, length of stay (LOS), LOS after shunt placement, estimated blood loss, and operative time. The authors identified 810 patients who met the inclusion criteria; open or laparoscopic distal catheter insertion was performed in 335 and 475 patients, respectively. There were no significant differences between the groups regarding age, race, ASA score, or indication for shunt placement. The most common indication was hydrocephalus due to subarachnoid hemorrhage, followed by tumor-associated hydrocephalus, normal pressure hydrocephalus (NPH), and hydrocephalus due to trauma. The incidence of shunt failure was not statistically different between cohorts, occurring in 20.0% of laparoscopic and 20.9% of open catheter placement cases (p = 0.791). With analysis of causes of shunt failure, shunt obstruction occurred significantly more often in the open surgery cohort (p = 0.012). In patients with a known cause shunt obstruction, distal obstruction occurred in 35.7% of the open cohort obstructions and 4.8% of the laparoscopic cohort obstructions (p = 0.014). The relative risk of distal obstruction in open cases compared with laparoscopic cases was 7.50. Infections occurred in 8.2% of laparoscopic cases compared with 6.6% of open cases (p = 0.419). Within the NPH subgroup, the laparoscopically treated patients had significantly more overdrainage (p = 0.040), whereas those in the open cohort experienced significantly more shunt obstructions (p = 0.034). Laparoscopically treated patients had shorter operative times (p < 0.0005), inpatient LOS (p < 0.001), and inpatient LOS after VP shunt placement (p = 0.01) as well as less blood loss (p = 0.058). To our knowledge this is the largest reported comparison of distal VP shunt catheter insertion techniques. Compared with minilaparotomy, the laparoscopic approach was associated with decreased time in the operating room and a decreased LOS. Moreover, laparoscopy was associated with fewer distal shunt obstructions. Laparoscopic shunt surgery is a viable alternative to traditional shunt surgery.

Armored brain: A case report and review of the literature

Background:Calcified chronic subdural hematomas occur infrequently. When the calcifications are extensive and bilateral, the condition is termed “armored brain”. We describe a case of “armored brain” incidentally discovered in an adult presenting with abdominal pain and mild headaches, long after initial placement of a ventriculo-peritoneal (VP) shunt.Case Description:A 38-year-old woman, treated at infancy with a VP shunt, presented with a 2-month history of abdominal pain associated with nausea and chills. She was neurologically intact on exam. An abdominal computed tomography (CT) scan demonstrated a rim-enhancing loculated fluid collection surrounding the patient's distal VP shunt catheter tip. As a part of her initial work-up, she received a head CT to evaluate the proximal VP shunt, which demonstrated large bilateral chronic subdural hematomas with heavily calcified walls. She was eventually taken to the operating room (OR) for replacement of the distal catheter. It was felt that her acute clinical presentation was unrelated to the bilateral, calcified subdural hematomas and thus the decision was made to manage them conservatively.Conclusions:This rare complication of chronic shunting for hydrocephalus is sometimes referred to as armored brain. Surgery for armored brain is infrequently indicated and beneficial in only small subgroup of patients, with management guided by clinical presentation. Our patient fully recovered after shunt revision alone.

Migration of a Distal Ventriculoperitoneal Shunt Catheter Into the Internal Jugular Vein and Heart Through the External Jugular Vein -Case Report-

A 6-year-old boy had undergone ventriculoperitoneal (VP) shunt for acute hydrocephalus because of a brain tumor at the age of 11 months, and presented with vomiting and somnolence after the shunt malfunctioned 6 days after VP shunt reconstruction, during which the right external jugular vein was injured during the tunneling process and the peritoneal catheter was not fixed to the peritoneum with a purse string suture. Radiography revealed an abnormal route of the peritoneal catheter, suggesting that the distal VP shunt catheter had migrated into venous vasculature through the right external jugular vein. Computed tomography revealed that the peritoneal catheter had migrated into the internal jugular vein and the right atrium. At surgery, the peritoneal catheter was exposed through a small incision on the subclavicular region, was easily extracted from the internal jugular vein and the heart as there was no coiling or adhesion of the distal catheter to the vascular tissues, and was repositioned into the peritoneum with weak fixing between the subcutaneous tissues of the right subclavicular region and the right abdominal rectus muscle fascia as a temporary emergency measure. Peritoneal shunt migration into the internal jugular vein and the heart through the external jugular vein can be lethal because of pulmonary infarction or arrhythmia, and must be detected as soon as possible. Periodic follow-up radiography should be scheduled after VP shunt placement, even in the absence of symptoms.

Subcutaneous Migration of Distal Ventriculoperitoneal Shunt Catheter Caused by Abdominal Fat Pad Shift -Three Case Reports-

Aberrant migration of a ventriculoperitoneal shunt catheter is an infrequent complication and the mechanism is unclear. We report three cases of subcutaneous migration of the distal catheter. The relationship between thick abdominal fat and catheter migration was suggested in all three cases. Abdominal radiography showed that the subcutaneous fat pad had slid down in the standing position, pulling the catheter out of the peritoneal cavity. We suggest the following mechanisms: Changing from the supine position to the standing position caused subcutaneous fat pad to slide down, the shifted fat pad pulled out the catheter from the peritoneal cavity, and anchoring prevents the catheter returning into the peritoneal cavity. Subcutaneous fat pad shift might act as a "windlass," resulting in coiling of the catheter in the subcutaneous tissue. During daily life, the peritoneal catheter was pulled out repeatedly and finally was coiled within the subcutaneous fat tissue. Placement of the catheter between the subcutaneous fat pad and the abdominal muscle wall will help to avoid this rare complication. This preventive measure is especially recommended for obese patients with a high risk of subcutaneous migration of the peritoneal catheter.

Intracardiac migration of the distal catheter of ventriculoperitoneal shunt: a case report

Migration of the distal catheter into the heart is an extremely rare complication of ventriculoperitoneal shunt, with only 11 cases reported in literature; in only four of them, there was also the migration into the pulmonary artery. The authors report the case of a young patient with this rare complication that was managed simply converting the ventriculoperitoneal shunt into a ventriculoatrial shunt. The migration of the distal catheter occurred through the internal jugular vein probably as the consequence of direct damage of the vessel during tunneling. Venous flow and negative intrathoracic pressure may have gradually pulled the catheter up into the heart; the upward migration may also be encouraged by the continuous movements of the patient that was agitated in the postoperative period as the consequence of her psychiatric disorder. The authors review the literature regarding migration of distal tubing into the heart and pulmonary artery. Diagnosis and management of this complication is discussed.

Distal revision of ventriculoperitoneal shunts using a peel-away sheath

The authors describe a new technique for revision of an occluded distal ventriculoperitoneal shunt catheter that obviates the need for laparotomy or trocar insertion into the peritoneal cavity. The authors review their early experience with 34 patients suffering from a distal ventriculoperitoneal shunt failure and treated with this technique. There were no incidents of intraabdominal injury or wound complications. In 2 patients conversion to a minilaparotomy was required for safe placement of the shunt. Proper peritoneal placement was confirmed with abdominal radiographs in all cases. This technique has been safe and effective and may be considered an alternative to traditional laparotomy or laparoscopic methods.