Ventriculoatrial Shunt Placement Research Articles

A novel utility of central venous catheter during ventriculoatrial shunt placement.

A novel utility of central venous catheter during ventriculoatrial shunt placement.

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.

Percutaneous Ventriculoatrial Shunting as a Salvage Method in the Pediatric Hydrocephalus Patients with Peritoneal Problems.

To evaluate the efficacy of percutaneous ventriculoatrial shunting as a salvage method for pediatric patients with abdominal complications. Data obtained from 9 patients with ventriculoperitoneal shunt dysfunctions owing to abdominal complications, who underwent ventriculoatrial shunting as salvage treatment at a single institution between January 2019 and September 2021 were retrospectively analyzed. All operations were conducted under the guidance of intraoperative fluoroscopy and ultrasound. The mean age of the enrolled patients was 8.1 ± 1.2 years (2-15 years). Six (67%) patients were male and 3 (33%) were female. The mean number of the patients? ventriculoperitoneal shunt revisions until atrial catheter placement was 7.5 times. The reasons for intraperitoneal catheter failure included peritoneal adhesions in 4 (44.5%) patients, pseudocyst formation in 3 (33.3%), and peritonitis in 2 (22.2%). Seven patients from the study cohort had no problem after ventriculoatrial shunt placement. Only 1 patient had shunt dysfunction related to the ventricular catheter, and ventricular catheter and shunt valve revision was performed 26 months after ventriculoatrial shunt placement. The atrial catheter of the patient was intact. One patient died from the progression of her primary disease (medulloblastoma in the 4 < sup > th < /sup > ventricle), which was unrelated to the ventriculoatrial shunt. Percutaneous ventriculoatrial shunting under the guidance of intraoperative fluoroscopy and ultrasound is a safe, effective, and easy alternative in patients with peritoneal complications and a history of multiple operations.

Direct Ventriculoatrial Shunt Placement for Cerebrospinal Fluid Diversion in the Management of Posthemorrhagic Hydrocephalus: 2-Dimensional Operative Video.

Coulibaly, Nangorgo BS*; Zhao, Xiaochun MD*; Burkhart, Harold M MD‡; Gernsback, Joanna MD* Author Information

Should not we be using aspirin in patients with a ventriculoatrial shunt? Borrowing a leaf from other specialities: a case for surrogate evidence.

Ventriculoatrial (VA) shunts are life-saving in circumstances where ventriculoperitoneal shunts (VP) have failed. They are at risk for different complications, and more specific of them are cardiopulmonary complications. Currently, there are no standard recommendations concerning screening for risk factors, prophylaxis, or anticoagulation treatment in patients after VA shunt placement. Our study aims to prospectively study the possible role and efficacy of the use of aspirin to increase the survival of shunts in children with VA shunt and avoid secondary morbidity. In this article, the authors describe the interim results of an ongoing prospective study which supports the use of aspirin for VA shunt. The study design is prospective. The duration of the study is 2011 onwards and is ongoing. Hospital ethics board clearance and consent from the family were taken before inclusion in the study. All patients who had VA shunt were given a once-a-day low-antiplatelet dose of aspirin 5mg/kg, from the first postoperative day onwards. Primary endpoints of the study are as follows: (1) major distal end malfunction documented on echocardiography or (2) any cardiac complications associated with the VA shunt catheter. We have 6 patient since march 2011, who are being followed up. None of the shunts had malfunctioned until the reporting. None of the patients had any cardiac issues reported. The patients are to be followed continually. The present follow-up ranges from 2.5 to 10years. The patient follow-up is being continued. Aspirin is a drug with well-accepted safety profile, and its use and our preliminary observation and outcome of the use of aspirin in VA shunt are promising.

Technical Nuances of Ventriculoatrial Shunt Using Seldinger Technique for Percutaneous Insertion of Distal Shunt Catheter

Abstract Introduction One of the most seen neurosurgical complications is the ventriculoperitoneal (VP) shunt failure. The cause can be often due to peritoneal malabsorption of cerebrospinal fluid. The next safer alternative is to place a ventriculoatrial (VA) shunt. Various methods of access to the right atrium had been described. The percutaneous method of insertion of distal catheter using Seldinger technique is a safer alternative to open method. We describe the percutaneous insertion of distal catheter using Seldinger technique, modifications in the method, and specific tools required for the insertion. Clinical History The patient is a 22-year-old male who is a known case of tubercular meningitis with recurrent failure of VP shunt due to malabsorption at peritoneal end of catheter. During the last hospital visit, he presented with altered sensorium and computed tomography scan brain showed ventriculomegaly. He was planned for VA shunt placement. Surgical Technique The insertion of ventricular end of the catheter is similar to any other shunt placement. The internal jugular vein (IJV) was punctured using introducer needle and guide wire was placed in the IJV at the level of T6-T7 and the serial dilators passed on the guide wire for creating a track for passage of shunt catheter. The shunt catheter was passed over the guide wire to the desired vertebral level and distal shunt catheter is connected proximally to the shunt catheter in the neck. Conclusion The percutaneous insertion of distal catheter with serial dilators using Seldinger technique is a safe and effective method for VA shunt placement.

Ultrasound-guided percutaneous brachiocephalic vein cannulation for ventriculoatrial shunt placement in a child.

As far as the ventriculoatrial shunt placement in children is concerned, the percutaneous approach to the internal jugular vein under ultrasonographic control has been hitherto strongly recommended. Unfortunately, children still represent a challenge, having them peculiar characteristics for which the internal jugular vein cannulation shows some disadvantages. In this manuscript, we describe a percutaneous placement of ventriculoatrial shunt via right brachiocephalic vein under intraoperative ultrasonographic control. Brachiocephalic vein cannulation in surgery provides notable advantages in paediatric population and it may be considered as the first choice in younger children.

Case Series of Ventriculoatrial Shunt placement in Hybrid Room: Reassessment of Ventriculoatrial Shunt.

ObjectiveVentriculoatrial shunt (VAS) remains an alternate option for treatment of hydrocephalus in patients with ventriculoperitoneal shunt (VPS) failure. Unfamiliar anatomy for a neurosurgeon has resulted in the VAS falling out of favor as a treatment option. However, there are unsatisfactory reports on the long-term result of VPS, and VAS has been recently re-evaluated. We are to report the simple way to do the VAS using a peel-away sheath in a hybrid operation room.MethodsA jugular vein path was drawn by ultrasound, a small incision was made above the clavicle, and a shunt catheter was tunneled into it. The jugular vein was punctured beside the tunneled catheter with a Seldinger needle under ultrasound guidance. A flexible guide wire was introduced into the vein and 6-Fr peel-away sheath was advanced into the vein along the wire. Under fluoroscopic guidance, the catheter was cut to position approximately mid-level in the atrium. After the guide wire was removed, the distal shunt catheter was passed down. After confirming proper position of the distal catheter under the fluoroscope, the catheter-guiding sheath was pulled out as a peeling-away manner. We performed this surgical procedures in 5 cases.ResultsAll the procedures of the VAS using a peel-away sheath were performed in a hybrid operation room Of 5 patients, 3 patients had the distal catheter failures in the peritoneal cavity and 2 patients had shunt A distal catheter was successfully indwelling in all the cases without any difficulties. After the surgery, neither shunt infection nor thromboembolic event happened.ConclusionVAS using fluoroscopy and a peel-away sheath is a good alternative option for hydrocephalus patients with shunt failure related to peritoneal cavity complications.

Test-Retest Reliability of Outpatient Telemetric Intracranial Pressure Measurements in Shunt-Dependent Patients with Hydrocephalus and Idiopathic Intracranial Hypertension

Some patients with hydrocephalus and idiopathic intracranial hypertension treated for elevated intracranial pressure (ICP) with a cerebrospinal fluid shunt may continue to experience symptoms or develop new symptoms despite valve adjustments. Use of telemetric ICP measurements may help confirm clinical suspicion of cerebrospinal fluid underdrainage or overdrainage in these patients. However, point in time, duration, and activity during the measurements have never been standardized. We devised a simple, repeatable maneuver for outpatient telemetric ICP recording and evaluated its test-retest reliability. Data of patients who underwent ventriculoperitoneal or ventriculoatrial shunt placement and subsequent telemetric ICP sensor implantation were retrospectively reviewed. Telemetric ICP recordings in patients were conducted in a standardized manner: The standing-supine-sitting paradigm requires postural changes in 10-minute intervals over 30 minutes. First, the patient is requested to walk; second, to lay down; third, to sit down with a headrest elevation of 60°. ICP data (in mmHg) were reported as mean ± SD values. Test-retest validity was assessed using Pearson correlation analysis. We evaluated 66 ICP datasets obtained repeatedly with a time difference of at least 24 hours. Overall test-retest reliability was excellent (Pearson correlation coefficient 0.99, P < 0.001), as were the scores for individual postures: standing (correlation 0.98, P < 0.001), supine (correlation 0.98, P < 0.001), and sitting (correlation 0.99, P < 0.001). The sum of square differences of the test-retest measures reflected a comparable validity of all tested positions. We confirmed high test-retest reliability of the standing-supine-sitting paradigm for telemetric ICP measurements in the outpatient setting. High test-retest reliability should be considered as prerequisite for clinical decision making.

Ultrasound-guided percutaneous ventriculo-atrial shunt placement: Technical nuances with video demonstration

Abstract Hydrocephalic patients with abdominal pathologies often need a ventriculo-atrial (VA) shunt placement. Cut-down on the internal jugular vein has historically been used to insert a VA shunt. This technique is more time consuming and has greater complications. Less invasive methods, such as ultrasound-guided percutaneous VA shunt placement provides greater comfort for surgeon, is more rapid, and has fewer complications. However, this technique has not been demonstrated on video. Here we demonstrate ultrasound-guided and ECG-aided VA shunt catheter placement in a 70-year-old patient with normal pressure hydrocephalus. The internal jugular vein is punctured under ultrasound guidance with an 18-gauge needle. A guidewire is introduced through the needle, the needle is removed, and a small skin incision is placed at the entry point of the guidewire. A skin dilator with a sheath introducer is advanced to the vein using the guidewire and the guidewire is thereafter removed. An atrial shunt catheter (e.g. Codman® Medos® Atrial catheter) filled with sterile water is inserted through the sheath. The sheath is removed and a syringe filled with sterile aqua is connected to the catheter with a metal tip. The ECG connection of the right upper limb is connected to the tip of syringe to adjust for the optimal depth of the catheter under ECG guidance (point of highest p-wave amplitude). The catheter is clamped and tunneled to reach the site for the valve on the scalp. The ventricle catheter is placed at the Kocher point and connected to the valve (Video 1). Conclusion Ultrasound-guided VA shunt placement is safe, comfortable, rapid, and has a reduced rate of complications.

An easy and feasible way of confirming correct placement of ventriculoatrial shunt intraoperatively.

An easy and feasible way of confirming correct placement of ventriculoatrial shunt intraoperatively.

An easy and feasible way of confirming correct placement of ventriculoatrial shunt intraoperatively

An easy and feasible way of confirming correct placement of ventriculoatrial shunt intraoperatively

Electrocardiographic-Guided Technique for Placement of Ventriculoatrial Shunts: A Valid and Cost-Effective Technical Simplification.

Ventriculoatrial (VA) shunt is a routine technique for the treatment of hydrocephalus. The correct position at the superior vena cava-right atrium junction is generally assessed by radiography. We present the first experience of an alternative, nonradiographic technique to assess the distal end of the VA shunts through an electrocardiographic (EKG) method. The technique has developed from the large experience of central venous catheters (CVC) worldwide; the EKG-guided method is a common and validated alternative to standard radiologic control of the location of the tip of any CVC. Five consecutive patients underwent VA shunt with venous catheter positioned with the EKG-guided technique. The position of the catheter tip was verified by standard chest radiography. Four men and 1 woman (mean age, 45.4 years) underwent VA shunt for hydrocephalus with the EKG-guided technique. The side of internal jugular vein puncture was the right side in 4 cases and the left side in 1 case. As confirmed by radiography, all VA shunt tips were located within the correct range. There was no radiologic evidence of procedure-related complication or catheters that had to be replaced. The EKG-guided technique for VA shunts is as accurate as fluoroscopy, but simpler, more readily available, less expensive, safer, and more cost effective. It reduces the need of radiography and radiologic exposition for both patients and operators. The EKG method may be a valid and cost-effective alternative to standard radiologic control in VA shunts, as for any central venous access device, and could become the preferential method for confirming tip position during VA shunt surgery.

Ventriculoatrial versus ventriculoperitoneal shunt complications in idiopathic normal pressure hydrocephalus

BackgroundIdiopathic normal pressure hydrocephalus (iNPH) is a devastating condition that affects the elderly population. Although ventriculoatrial (VA) shunts can be used to manage iNPH, concerns for associated cardiopulmonary and renal complications have decreased their use. However, the rate of these complications is not well understood within this population of patients. Patients and methodsA retrospective review of the electronic medical records of patients diagnosed with iNPH by the senior author between 1993 and 2015 was performed. Demographic information and baseline symptoms were assessed. Complications including infection, shunt obstruction, overdrainage, cardiopulmonary events, renal dysfunction, and shunt revision were recorded. Complication rates were compared between VA and VP shunted patients. Statistical analysis using Chi-square test, Fisher’s exact test, logistic regression, Wald t-test, Poisson regression, ANOVA, and ANCOVA was performed. Results496 Patients, including 150 receiving VA shunts and 346 receiving VP shunts, were included in the study. The median age was 74 and 73 for VA and VP shunted patients, respectively, with slight male predominance in both (58.0% and 58.4% for VA and VP groups, respectively). A total of 36.0% of VA shunted patients and 42.5% of VP shunted patients experienced at least one post-operative complication. Overdrainage was the most commonly experienced complication in both VA (27.4%) and VP patients (19.9%). Infection occurred in only 2.0% of patients, and renal complications occurred in 1.3%. No patients had cardiopulmonary complications. VA shunted patients were significantly less likely to experience shunt obstruction and require shunt revision compared to VP shunted patients (p=0.008 and <0.001, respectively). Only dizziness and gait disturbance at baseline were correlated with a shorter time to revision in VA shunted patients (p=0.002 for both). ConclusionAlthough cardiopulmonary and renal complications are serious concerns associated with VA shunt placement, they were uncommon in patients with iNPH. VA shunted patients were less likely to experience shunt obstruction and require shunt revision compared to VP shunted patients. Therefore, VA shunts should be considered as an alternative primary treatment option in the iNPH population.

Ultrasound guided placement of the distal catheter in paediatric ventriculoatrial shunts-an appraisal of efficacy and complications.

PurposeVentriculoatrial (VA) shunts are commonly used as a second-line treatment of hydrocephalus when the peritoneum is an unsuitable site for the distal catheter. Many centres now utilise ultrasound and interventional radiology techniques to aid placement of the distal catheter. The purpose of this study was to conduct a contemporary audit of VA shunting in children using interventional radiology techniques for placement of the distal catheter.MethodsA retrospective analysis of all patients who had VA shunts inserted between June 2000 and June 2010 was conducted using a prospectively updated surgical database and case notes review.ResultsNinety-four VA shunts were inserted in 38 patients. Thirty-seven patients had been treated initially with ventriculoperitoneal (VP) shunts. Twenty-two patients required at least 1 shunt revision (58 %). The 6-month, 1- and 2-year shunt survival rates were 53, 43 and 27 %, respectively. Blockage was the commonest reason for shunt failure (68 %). The site of failure was proximal (ventricular catheter +/− valve) in 32 % and distal (atrial catheter) in 21 % of cases. The overall infection rate was 6 % per procedure and 11 % per patient. There were 7 deaths, of which 3 were shunt related.ConclusionsVA shunting provides a viable second-line option for shunt placement in complex hydrocephalus. The causes of shunt failure (blockage, infection and equipment failure) are similar to VP shunting though shunt survival rates are inferior to VP shunts. Ultrasound guided VA shunt placement provides a relatively safe, second-line alternative to the placement of a ventriculoperitoneal shunt when this route is unsuitable.

Venous air embolism during ventriculoatrial shunt placement!

Venous air embolism during ventriculoatrial shunt placement!

Pleural effusion in a child with a ventriculoperitoneal shunt and congenital heart disease.

We present the unique case of an 8 month old infant who required extracorporeal membrane oxygenation (ECMO) after neonatal repair of tetralogy of Fallot. While on ECMO, he developed grade 3 intraventricular hemorrhage resulting in hydrocephalus requiring ventriculoperitoneal (VP) shunt placement at 5 months of life. He presented to cardiology clinic with a 2-month history of poor weight gain, tachypnea, and grunting and was found to have a large right sided pleural effusion. This was proven to be cerebrospinal fluid (CSF) accumulation secondary to poor peritoneal absorption with subsequent extravasation of CSF into the thoracic cavity via a diaphragmatic defect. After diaphragm repair, worsening ascites from peritoneal malabsorption led to shunt externalization and ultimate conversion to a ventriculoatrial (VA) shunt. This is the second reported case of VA shunt placement in a child with congenital heart disease and highlights the need to consider CSF extravasation as the cause of pleural effusions in children with VP shunts.

Diagnostic laparoscopy for intraabdominal evaluation and ventriculoperitoneal shunt placement in children: a means to avoid ventriculoatrial shunting.

Laparoscopic assistance for the placement of a ventriculoperitoneal shunt (VPS) has been shown to be a safe, effective, and minimally invasive approach for distal peritoneal shunt placement. The purpose of our study was to review our experience with laparoscopy for VPS placement in patients with a potential hostile abdomen. After institutional review board approval, a retrospective analysis of all patients who underwent diagnostic laparoscopy for VPS placement from March 2009 to March 2013 was performed. Patient demographics and outcomes were analyzed. Twenty-seven patients underwent diagnostic laparoscopy for VPS placement at a mean age of 7.7 ± 6.8 years. Twenty-five patients had previous shunts placed in the peritoneum, whereas 2 underwent initial placement. Sixteen patients (59%) had undergone previous non-shunt abdominal operations. Twenty-three patients (85%) had successful peritoneal shunt placement. Distal peritoneal shunt placement was unsuccessful at the time of laparoscopy in 4 patients (15%) secondary to adhesions. Of the 23 patients who had successful peritoneal shunt placement, 57% did not require further shunt intervention, 22% underwent conversion to a ventriculoatrial shunt, 17% underwent re-externalization, and 4% required distal shunt revision. Of the 4 patients who required externalization, 3 underwent a second laparoscopic procedure with successful peritoneal shunt placement. Diagnostic laparoscopy eliminated the need for ventriculoatrial shunt placement in 85% of patients with a potentially hostile abdomen. Sixty percent required no further shunt revision. Laparoscopic-assisted peritoneal shunt insertion is a safe, minimally invasive technique in children with the added benefit of allowing full exploration and adhesiolysis.

Ultrasound and Angiography-assisted Ventriculoatrial Shunting Through the Right Internal Jugular Vein

Purpose: Ventriculoatrial shunt placement is one of the most important treatment options for patients in whom the abdominal cavity is not functioning properly because of poor absorption following infections or abdominal surgery. In such cases, management should be aimed at eradicating major vascular anomalies preoperatively to prevent operative failures. Methods: We describe a 7-year-old girl who had been repeatedly operated upon for shunt dysfunction. Routinely performed ventriculoatrial shunt operation failed and postoperative cervical magnetic resonance angiography revealed a potential vascular anomaly; therefore, we performed an ultrasound and angiography-assisted ventriculoatrial shunting technique. Results: The patient’s clinical condition improved and postoperative neuroimaging studies did not show any evidence of hydrocephalus. Conclusions: The ultrasound and angiography-assisted ventriculoatrial shunting technique is a safe and efficient choice for patients in whom a vascular anomaly is detected preoperatively.

RE: Reasons, procedures, and outcomes in ventriculoatrial shunts: A single-center experience

Dear Editor, We read with interest the article of Yavuz et al., “Reasons, procedures and outcomes in ventriculoatrial (VA) shunts: A single-center experience. ” The authors describe 10 patients who had repeated shunt dysfunction or infection, which were converted to a VA shunt. In my personal experience of 1292 shunt operations spanning over a period of 40 years, there were 489 ventriculoperitoneal (VP) shunts and 186 VA shunts. The rest were revision of VP shunts in 410, VA in 66. The other operations were conversion of VA to VP and VP to VA. Initially, in the early years, the VA shunt was performed, however, because of complications primarily related to jugular venous thrombosis and difficulty in reestablishing the site of the atrial implant, we shifted to VP shunt. Needless to say, we had a few patients who had quite a bit of trouble with VP shunt with repeated operations and had to be converted to VA shunt. The entire operation of VA shunt placement is done by the neurosurgeon. By canalizing the common facial vein through a small incision under the angle of the right mandible, the distal end of the cardiac catheter is placed in the right atrium under electrocardiogram (EKG) control until the P wave become biphasic. With experience and good anesthetic monitoring, the operation can be performed in a short period of time. In any event, we are happy that the authors have refocused again on the place of VA shunt in specific cases.