Insertion Of Ventriculoatrial Shunt Research Articles

Ventriculo-atrial shunt in idiopathic intracranial hypertension

PurposeCSF diversion is a recognised intervention in idiopathic intracranial hypertension (IIH), particularly in the presence of vision-threatening papilledema. Although ventriculo-atrial (VA) shunt insertion is a routine neurosurgical procedure, ventriculoperitoneal and lumboperitoneal shunts have been mostly used in this particular indication. This study aims to look at a single centre’s experience with VA shunts in idiopathic intracranial hypertension (IIH).MethodsRetrospective case series with a review of electronic records over a 10-year period; exclusion criteria were duplication of same shunt insertion, no VA shunt insertion, paediatric patients and indication other than IIH. Notes were reviewed for demographics, shunt survival (defined by time prior to revision) and reasons for revision.ResultsEight VA shunt procedures were identified in 6 patients (mean age at insertion 34 ± 10 years) with a mean follow-up of 58 ± 25 months. All shunts were secondary procedures; 2 revisions from lumbo-pleural, 2 from ventriculopleural, 2 from ventriculoatrial and one each from ventriculoperitoneal and combined lumbo-/ventriculoperitoneal. At 50 months, 75% of VA shunts had survived, compared to only 58.3% of VPleural shunts in patients with IIH. Revisions were required due to acute intracranial bleed (1 case)—revised at day 1, and thrombus at distal site (1 case)—revised at day 57. Both shunts were later reinserted. From the latest clinic letters, all patients had their treatment optimised with this procedure, although only two patients had documented resolved papilloedema post-procedure.ConclusionsVentriculo-atrial shunts are a safe and efficacious alternative option for CSF diversion in IIH. In this series, only 1 shunt was revised for a VA shunt-specific complication.

Real-time 3D Transesophageal Echocardiography for the Placement of Ventriculoatrial Shunt: A Case Series and Technical Note.

Ventriculoatrial (VA) shunts are used to manage hydrocephalus and idiopathic intracranial hypertension when peritoneal drainage of cerebrospinal fluid is not feasible. The technique of distal catheter placement during VA shunt insertion is controversial, especially between fluoroscopy-guided and transesophageal echocardiography (TEE)-guided techniques. We retrospectively reviewed our utilization of 2-dimensional (2D) ultrasound-guided internal jugular vein catheterization combined with 3-dimensional (3D) TEE-guided distal VA shunt placement and compared it to the conventional fluoroscopy-guided technique. Ten patients underwent 18 VA shunt insertion procedures between November 2012 and October 2022. The patients had a mean (SD) age of 50 (19) years, body mass index of 35 (14)m/kg², and minimal comorbidities. All had previously undergone failed ventriculoperitoneal shunt procedures. The use of 2D ultrasound to guide internal jugular vein catheterization and 3D TEE to guide distal catheter placement resulted in 22-minute shorter surgical times compared with the fluoroscopy-guided technique (91 minutes vs. 113 minutes, respectively). No complications were noted with either technique. The combined use of 2D ultrasound and 3D TEE allowed for faster procedure times and more precise distal catheter confirmation, contributing to a more streamlined surgical procedure. This small case series underscores the feasibility, efficiency, and safety of anesthesiologist-delivered combined 2D ultrasound and 3D TEE during VA shunt insertion. The use of 3D TEE allows repeated confirmation of distal catheter position and has potential to improve patient safety during rare but complex VA shunt insertion procedures.

Experience with Ventriculoatrial Shunt

Cerebrospinal fluid (CSF) diversion through shunting, either internal or external, is the standard of care for hydrocephalic patients. Although Ventriculoperitoneal (VP) shunt is always the first choice, right atrium for Ventriculoatrial (VA) shunt is considered a suitable and convenient option for drainage of excess CSF in patients with history of abdominal surgeries, peritoneal infection or shunt obstruction.1 Here we are reporting our experience with a patient who underwent VA shunt insertion because of a previous malfunctioning VP shunt. A thorough review of the literature revealed that, although reported worldwide, there is an apparent deficiency of similar reports from Arabian Gulf region. Through this case report, we aim to shed light on this internal CSF diversion method, which could be considered in centers lacking advanced care facilities for procedures like Endoscopic 3rd Ventriculostomy (ETV).

In Reply: Transesophageal Echocardiography-Guided Ventriculoatrial Shunt Insertion.

In Reply: Transesophageal Echocardiography-Guided Ventriculoatrial Shunt Insertion.

In Reply: Transesophageal Echocardiography-Guided Ventriculoatrial Shunt Insertion.

In Reply: Transesophageal Echocardiography-Guided Ventriculoatrial Shunt Insertion.

Transesophageal Echocardiography-Guided Ventriculoatrial Shunt Insertion.

Determining an optimal location within the right atrium (RA) for placement of the distal ventriculoatrial (VA) shunt catheter offer several operative challenges that place patients at risk for perioperative complications and downstream VA shunt failure. Utilizing transesophageal echocardiography (TEE) guidance to place distal VA shunt catheters may help to circumvent these risks. To review our current practice of VA shunt insertion using TEE guidance. A retrospective review of all consecutive patients who underwent VA shunt procedures between December 19, 2016 and January 22, 2019, during which time intraoperative TEE was used for shunt placement was performed. Data on the time required for shunt placement and total procedure time, baseline echocardiography findings, and short- and long-term complications of shunt placement were assessed. A total of 33 patients underwent VA shunt procedures, with a median follow-up time of 250 (88-412) d. The only immediate complication related to shunt placement or TEE use was transient ectopy in 1 patient. The mean time for atrial catheter insertion was 12.6±4.8 min. Right-heart catheters were inserted between the RA-superior vena cava junction and 22 mm within the RA in all but 3 procedures. A total of 7/33 patients (21%) underwent shunt revision. Indications for revisions included distal clots, proximal obstruction, positive blood culture, and shunt valve revision. No other complications of VA shunt insertion were reported. VA shunt insertion using TEE allows for precise distal catheter placement. Early patient experience confirms this technique has a low complication rate.

Long term prognosis of ventriculoatrial shunt for idiopathic normal pressure hydrocephalus in the elderly

Abstract Objective: A retrospective study was conducted to access the long-term prognosis of inserting the Ventriculoatrial (VA) shunt in the elderly for the idiopathic normal pressure hydrocephalus (iNPH). Material and Methods: Retrospective data is collected from April 2004 to August 2015, and 1065 patients were selected. Patients who underwent surgical examination or surgery in suspected iNPH were included. Tap test is done in all cases and found to be effective for 968 cases and 656 VA shunts for 614 cases. Out of 614 cases there are 440 cases in which patient age were over 75 years. Of these 440 cases only 141 cases were able to observe 03 years or more after the surgery, 37 deaths and 05 cases with survival and unknown prognosis were found among them. So we analyzed this group mainly in 99 cases that the prognosis after 03 years was known. We access the outcome of VA shunt by the modified Rankin scale (mRS), iNPH grading scale (iNPHGS) and complications in the operative 656 cases and in 03 years follow up of 141 patients. Results: Of 141, there are 78 males and 63 females. Age at the time of VA shunt insertion was 81.5±4.1 years and age at final follow-up was 85.2±4.4 years. The proportion of patients who achieved a favorable outcome by complications was 97.9% in 03 years follow-up period and 87.7% in which follow-up is less than 03 years. At the time of VA shunt insertion out of 141, 57 patients lies between 75-79 years, 57 between 80-84, 24 between 85 to 89, and only 03 were found to be 90 years or more. At the time of final follow-up at 03 years, 15 patients lies between 75 to 79 years, 56 between 80 to 84 years, 57 between 85 to 89 years and 23 patents were found to be 90 years or greater. 70 cases or almost 50% exceeded 85 years. At the time of VA shunt 1, 11, 39, 51, 36, 3, 0 patients were in 0 to 6 modified Rankin Scale Score respectively and at 03 years follow-up 8, 19, 32, 29, 9, 2, 37 were in 0 to 6 mRS respectively. Comparison of the study is done with SIPHONI study on VP shunt and LP shunt. Conclusion: Patients suspected of having idiopathic normal pressure hydrocephalus were treated by VA shunt and found no significant difference in serious adverse effects. This study shows that VA shunt is an effective choice for iNPH in the late elderly population, but it needs more randomized control trial to establish its efficacy.

Difficulties of Distal Catheter Insertion of Ventriculoatrial Shunting in Infants and Little Children.

Ventriculoatrial (VA) shunting is a well-described cerebrospinal fluid diversion method for the treatment of hydrocephalus. However, it may be very challenging in infants and little children because of atrial catheter placement difficulties. This study aimed to create an algorithm to solve problems faced during open surgical procedures based on the present authors' experience. We conducted a retrospective analysis on 18 infants and children who underwent VA shunt insertion at the Department of Neurosurgery, Ondokuz Mayıs University School of Medicine Hospital between 2005 and 2012. Complications, clinical outcomes, revisions, and solutions for overcoming distal catheter placement difficulties were evaluated. Twenty-six VA shunt operations were performed in 18 patients. Six patients required eight VA shunt revisions. VA shunting was primarily performed from the internal jugular, facial, cephalic, and subclavian veins to the right atrium. In revision procedures, the internal jugular, cephalic, and subclavian veins were used. VA shunting in infants and little children requires careful surgical techniques. Neurosurgeons should necessarily have an appropriate strategy for VA shunting considering the complications and revisions. Our results suggest open surgical solutions to overcome distal catheter placement difficulties in this age group.

Ventriculoatrial Shunts in Adults, Incidence of Infection, and Significant Risk Factors: A Single-Center Experience

In recent years, the number of ventriculoatrial (VA) shunt insertions has decreased worldwide, the major cause being the risk of shunt infection. VA shunts remain as an alternative option to ventriculoperitoneal shunts. We describe our 10-year experience with VA shunts by analyzing the incidence of shunt infections and predisposing cofactors. During a median follow-up of 15.3 months, 259 shunt insertions, performed on 255 patients, were analyzed. The infection rate was calculated and the predisposing cofactors age, gender, cause of the hydrocephalus, previous external ventricle drainage, antibiotic-impregnated catheters, the number of revisions, the educational level of the surgeons, and the duration of the operations were analyzed. Two observation times were stratified. We found overall infections in 18 patients (7.1%), 16 deep infections (6.3%) including 1 shunt nephritis (0.4%) and 2 superficial infections (0.8%). Wound dehiscence occurred in 17 patients (6. 6%). Analyzing follow-up time, the infection rate was 3.65% (95% confidence interval, 0.9%-5.9%) at survival time 1, 3.38% (95% confidence interval, 1.1%-6.2%) at survival time 2. In the first 6 months, 95% of patients were free of infection. Only the number of revision procedures was associated with the number of infections (P value < 0.0005). In our patient cohort, the infection rate related to VA shunt insertion is low; the only statistically significant risk factor was the number of revisions. If the VA shunt is applied following a standardized protocol, the infection risk does not represent an argument for reluctance towards the VA draining concept.

Percutaneous ultrasound-guided insertion of ventriculo-atrial shunts

Ventriculo-atrial (VA) shunts have been in use for >60 years but less frequently so of late. This is due to a combination of the risk of cardiac complications, lack of expertise and a lengthy operation. We present our consecutive prospective series of 10 VA shunts inserted using a percutaneous method employing the Sonowand Invite™ neuronavigation system for both the distal and proximal catheters, over a 13-month period. We had two complications of cases needing revision, but our series highlights a safe and reproducible method of inserting a VA shunt. About 30% of the procedures were carried out by a trainee as the primary surgeon. This technique does not necessarily require the expertise of a complex hydrocephalus surgeon and is thus able to be in the armoury of any neurosurgeon needing to do a VA shunt procedure. The indications, operative data and outcomes of our patients are discussed.

Causative role of infection in chronic non-thromboembolic pulmonary hypertension following ventriculo-atrial shunt

A severe complication of ventriculo-atrial (VA) shunt placement for treatment of hydrocephalus is chronic thromboembolic pulmonary hypertension (CTEPH). We report here a patient with a VA shunt for treatment of hydrocephalus who presented two consecutive episodes of VA shunt-induced infection by Staphylococcus epidermidis and who rapidly developed chronic PH. Extensive radiological investigations and normal ventilation/perfusion lung scan allowed us to rule out CTEPH. To our knowledge, no other case of chronic pulmonary hypertension (PH) related to VA shunt insertion has been reported so far. PH in this patient with VA shunt is clinically distinct from CTEPH and has been caused by VA shunt-induced S. epidermidis infection per se.

Calcified Right Atrial and Pulmonary Artery Mass After Ventriculoatrial Shunt Insertion

Insertion of ventriculoatrial (VA) shunts is an effective method of draining cerebrospinal fluid from the cerebral ventricle to the right atrium and significantly improves the survival of patients with hydrocephalus. Some patients who received a VA shunt subsequently developed complications, including thrombus formation around the intracardiac end of the catheter and thromboembolism. The relative rarity of complications and the long latency between shunt insertion and the development of symptoms in VA shunt recipients may result in misdiagnosis or delayed diagnosis. The case presented suggests that such patients may require routine echocardiography at regular intervals. Otherwise, the indwelling foreign body may become the source of a life-threatening thrombotic mass, if not recognised and treated appropriately.

Shunt revision after 33 years in a patient with bilateral calcified chronic subdural hematomas

cation of shunting procedures for infantile hydrocephalus.1,2,4 Bilateral calcified chronic SDHs may be so extensive that they give the appearance of a so-called “armored brain.”3,5 This 33-year-old man was admitted to our department with symptoms of increased intracranial pressure. According to his medical history, the patient had undergone a ventriculoatrial shunt insertion for hydrocephalus 2 months after his birth at a children’s hospital. His mild spastic quadriparesis and learning difficulties were obvious since childhood. One year before the present admission, a brain computed tomographic (CT) scan performed after a minor head injury had shown the presence of large, calcified, bilateral SDHs, together with small ventricles and a ventricular catheter in place (Fig. 1A). At admission, a new brain CT scan revealed ventricular dilation (Fig. 1B). A ventriculoperitoneal shunt was inserted in the patient. The new ventricular catheter was inserted via a right frontal bur hole near the midline, avoiding the calcified hematoma. The old shunt was left in place because the catheter was considered to be entrapped inside the calcification. The postoperative clinical course of the patient was uneventful. The patient improved and returned to his neurological status before the dysfunction of the shunt, and a postoperative CT scan confirmed a reduction of ventricular size (Fig. 1C). Chronic SDHs that remain undiagnosed during childhood may contribute to neurological impairments, therefore intensive followup is necessary after shunting procedures in infants and children. Cases of bilateral extensively calcified SDHs have been rarely reported.5 Revision of the malfunctioning shunt in cases like these may be troublesome. (DOI: 10.3171/JNS/2008/108/2/0401)

Diffuse villous hyperplasia of choroid plexus

Diffuse villous hyperplasia of choroid plexus (DVHCP) is a rare condition which is characterized by the presence of diffuse enlargement of the entire choroid plexus throughout the length of the choroidal fissure and overproduction of CSF. The diagnosis of diffuse villous hyperplasia of choroid plexus can be established by the MR demonstration of diffusely large, contrast enhanced choroid plexus in the cases of overproduction hydrocephalus. Although some authors recommend choroid plexus excision or coagulation, ventriculo-atrial shunt insertion is a simple and effective treatment modality in cases of diffuse villous hyperplasia of the choroid plexus. In this report we present a case of diffuse villous hyperplasia of the choroid plexus and a short review of the literature. To our knowledge, in the CT and MRI era only 5 cases of DVHCP cases have been reported.

A rare but life-threatening complication of ventriculo-atrial shunt

Insertion of ventriculoperitoneal and ventriculoatrial shunts is routinely performed. Infarction pneumonia and atrial thrombus formation are described as very rare complications of ventriculoatrial shunts. We present the case of a female patient with ventriculoatrial shunt insertion as long term treatment for aequeductal stenosis who presented with recurrent episodes of dyspnoea, chest pain, and unilateral pleural effusion. Diagnostic evaluation revealed a positive D-dimer test, bilateral basal infiltrates and pleural effusion. Transesophageal echocardiography established the diagnosis of a thrombus in the right atrium. Laboratory testing for thrombophilia revealed a homozygous factor V Leiden mutation. In the following, a shunt revision was performed.

Ventriculo-atrial shunt insertion: pressure monitoring as an aid to accurate placement

The objective of this paper is to describe a new method to ensure accurate placement of a ventriculo-atrial shunt distal catheter. A technique is described using pressure waveform changes within the right side of the heart. Pressure monitoring is a new method of placing atrial catheters and is easy to perform.

Coronary sinus thrombosis and myocardial infarction secondary to ventriculoatrial shunt insertion

Coronary sinus thrombosis was found at necropsy in a girl with spina bifida who underwent ventriculoatrial shunt revision. There was secondary myocardial infarction, close to the conducting system within the interventricular septum. We suggest that this led to cardiac arrest and sudden death.

Percutaneous insertion of CSF ventriculoatrial shunts--a new technique. Technical note.

In conventional techniques concerning insertion of ventriculoatrial shunt systems, the route to the caval system is accomplished by a lateral rightsided neck dissection and isolation usually of the facial or the external jugular vein, in order to introduce the atrial catheter into the internal jugular vein and consequently the superior vena cava. A new approach for catheterization of the internal jugular vein is proposed. The technique is a combination of the well proven approach for percutaneous catheterization of the vein and a technique used in the implantation of permanent pacemaker leads. We find the method suitable for cases whenever a VA-shunt is preferred.

Tension pneumocephalus following insertion of ventriculoatrial shunt after severe head trauma. Case report

In the present paper, we report about a patient suffering from hydrocephalus following a severe head trauma, who received a ventriculocardial shunt and subsequently developed tension pneumocephalus. The mechanisms leading to this condition are discussed, drawing a parallel to the development of subdural hematoma after CSF shunting.

Fistula detection in cerebrospinal fluid leakage.

In two cases of cerebrospinal fluid rhinorrhoea in which scinticisternography failed to identify the fistulae, the tracts were demonstrated by positive contrast ventriculography. It is postulated that the fistula communicated with the ventricles but was isolated from the subarachnoid space by adhesions (demonstrated at operation in one case). There was `high pressure rhinorrhoea' in one case. The rhinorrhoea ceased after insertion of ventriculoatrial shunt.