Superior Vena Cava Research Articles

Successful mediastinal teratoma resection in a child by assisted VATS: a case report

BackgroundVideo-assisted thoracic surgery (VATS) is widely used for thoracic lesions in pediatric patients. VATS is also applied to pediatric mediastinal tumors if there is no adhesion or invasion between the tumor and adjacent neuronal and cardiovascular structures. Here, we present a pediatric case of mediastinal teratoma in which the tumor adhered to the superior vena cava, and resection was safely completed using assisted VATS, an integrated surgical approach comprising mini-thoracotomy with video assistance.Case presentationA 9 year-old girl presented with right shoulder pain. Chest radiography and computed tomography revealed a 5.4 × 5.1 × 5.8 cm mass in the right upper anterior mediastinum. She was presumed with a mature teratoma, and resection was performed by assisted VATS with muscle sparing axillar skin crease incision (MSASCI) for a mini-thoracotomy. The procedure was safely completed, with the patient discharged on postoperative day 5. At 1 year postoperatively, there was no recurrence with excellent motor and cosmetic results.ConclusionsThe combination of MSASCI and VATS would be useful not only for mediastinal teratomas but also for other mediastinal tumors and almost all other thoracic lesions in pediatric patients.

Biomechanical Analysis of Age-Dependent Changes in Fontan Power Loss.

The hemodynamics in Fontan patients with single ventricles rely on favorable flow and energetics, especially in the absence of a subpulmonary ventricle. Age-related changes in energetics for extracardiac and lateral tunnel Fontan procedures are not well understood. Vorticity (VOR) and viscous dissipation rate (VDR) are two descriptors that can provide insights into flow dynamics and dissipative areas in Fontan pathways, potentially contributing to power loss. This study examined power loss and its correlation with spatio-temporal flow descriptors (vorticity and VDR). Data from 414 Fontan patients were used to establish a relationship between the superior vena cava (SVC) to inferior vena cava (IVC) flow ratio and age. Computational flow modeling was conducted for both extracardiac conduits (ECC, n = 16) and lateral tunnels (LT, n = 25) at different caval inflow ratios of 2, 1, and 0.5 that corresponded with ages 3, 8, and 15+. In both cohorts, vorticity and VDR correlated well with PL, but ECC cohort exhibited a slightly stronger correlation for PL-VOR (>0.83) and PL-VDR (>0.89) than that for LT cohort (>0.76 and > 0.77, respectively) at all ages. Our data also suggested that absolute and indexed PL increase (p < 0.02) non-linearly as caval inflow changes with age and are highly patient-specific. Comparison of indexed power loss between our ECC and LT cohort showed that while ECC had a slightly higher median PL for all 3 caval inflow ratio examined (3.3, 8.3, 15.3) as opposed to (2.7, 7.6, 14.8), these differences were statistically non-significant. Lastly, there was a consistent rise in pressure gradient across the TCPC with age-related increase in IVC flows for both ECC and LT Fontan patient cohort. Our study provided hemodynamic insights into Fontan energetics and how they are impacted by age-dependent change in caval inflow. This workflow may help assess the long-term sustainability of the Fontan circulation and inform the design of more efficient Fontan conduits.

Endovascular Reconstruction of Type 3 Central Venous Obstruction: A Case Report

Highlights Abstract Superior vena cava (SVC) syndrome with central thoracic vein occlusion associated with the use of intravascular devices is increasing and involves younger patients. Hemodialysis patients are at higher risk for central vein occlusion and symptomatic SVC syndrome. It is imperative to preserve venous access, particularly for younger patients who will rely on dialysis for an extended duration. Endovascular venous reconstruction is the recommended treatment but there are not standardized guidelines about the type of stent and technique. In the present case report the primary objective was to resolve the central vein occlusion and maintain vein patency through double barrel and Y technique together, employing bare metal and covered stents.

Cutaneous Manifestations of Liver Disease: A Narrative Review.

Chronic liver disease is a major cause of morbidity and mortality. The most common extrahepatic manifestations are dermatological. The pathophysiology of these dermatological manifestations is not clear, but it is postulated that the mechanisms involved include generalized vasodilatation, hyperdynamic blood circulation, and altered estrogen metabolism. The most common cutaneous manifestations of liver disease are Terry's nails and pruritus. Terry's nails consist of leukonychia with a distal pink band and the absence of the lunula. The main differential diagnosis is Lindsay's nails. Vascular manifestations of liver disease include palmar erythema and arachnoid nevi, the latter located in the vascular territory of the superior vena cava and occurring in chronic alcohol-associated liver disease. Dermatological manifestations generally resolve with improvement or remission of liver disease, and there is no specific treatment for them. However, bile acid chelators are the first line of treatment for cholestatic pruritus. Studying dermatological manifestations of liver disease contributes to early diagnosis and treatment, potentially improving the patient's prognosis.

Application of microcirculatory indicators in predicting the prognosis of patients with septic shock

ObjectiveThe aim of this study is to investigate the predictive value of indicators associated with microcirculation, capillary refill time (CRT), perfusion index (PI), and mottling score, on the prognosis of patients with septic shock. MethodA retrospective clinical study was conducted encompassing 78 patients diagnosed with septic shock and admitted to the Department of Critical Care Medicine at our hospital from January 2019 to January 2022. The study collated the clinical data of these patients, focusing on macrocirculatory hemodynamic parameters and microcirculatory indices. The parameters of interest were recorded at 0, 6, 24, and 48 hours post-admission, including heart rate, mean arterial pressure (MAP), venous-to-arterial carbon dioxide partial pressure difference, superior vena cava oxygen saturation, lactic acid (LAC), CRT, PI, and mottling score. The enrolled patients were stratified into two cohorts based on the 28-day mortality rate: a survival group and a mortality group. A non-parametric statistical test was employed to compare the CRT, PI, and mottling score between the two groups. Furthermore, the predictive value of these microcirculatory indicators for mortality in septic shock patients was assessed using receiver operating characteristic (ROC) curve analysis. This methodology allowed for the evaluation of the prognostic accuracy of CRT, PI, and mottling score as indicators for mortality in the context of septic shock. ResultsThe vasoactive drug dose, PI, LAC, mottling score, and CRT upon admission in the survival group were significantly better than those in the mortality group at hour 6 of treatment, hour 24 of treatment, and hour 48 of treatment (P < 0.05). The predictive value of the three microcirculatory indicators at various time points was highest for the Perfusion Index (PI) at 48 hours of treatment, the mottling score at 24 hours of treatment, and the Capillary Refill Time (CRT) upon admission. The Area Under the Curve (AUC) for PI at 48 hours of treatment was 0.941 (0.885 to 0.996), with a sensitivity of 90.9% and a specificity of 94.1%. For the mottling score at 24 hours of treatment, the AUC was 0.889 (0.805 to 0.972), with a sensitivity of 82.4% and a specificity of 88.6%. The AUC for CRT upon admission was 0.872 (0.788 to 0.956), with a sensitivity of 91.2% and a specificity of 77.3%. Among the three indicators: PI, mottling score, and CRT, PI at hour 48 of treatment had the highest predictive value for the prognosis of patients with septic shock. ConclusionMicrocirculatory indicators have specific predictive value for the prognosis of patients with septic shock.

A mediastinal lesion with superior vena cava obstruction: A diagnostic and therapeutic challenge.

A mediastinal lesion with superior vena cava obstruction: A diagnostic and therapeutic challenge.

Maternal exposure to ambient ozone and fetal congenital heart defects: a national multicenter study in China.

Ambient O3 has demonstrated an aggravated increasing trend in the context of global warming. The available evidence of maternal exposure to ambient O3 on fetal congenital heart defects (CHD) is still limited, especially in high polluted areas. To examine associations of maternal exposure to ambient O3 during early pregnancy with fetal CHDs. We conducted a national multicenter study in 1313 hospitals from 26 provinces in China and collected a total of 27,817 participants athigh risk of CHD from 2013 to 2021. Exposure to ambient O3 during the embryonic period, preconception, the first trimester and periconception was assessed by extracting daily concentrations from a validated grid dataset at each subject's residential district. CHDs were diagnosed based on fetal echocardiography. Each 10 µg/m3 increase of exposure to ambient O3 during the embryonic period was approximately linearly associated with a 12.7% (odds ratio [OR]: 1.127, 95% confidence interval [CI]: 1.098, 1.155) increase in odds of pooled CHD (p < 0.001). The associations remain robust after adjusting for ambient PM2.5 and NO2 exposure. The odds of different types of CHD in association with ambient O3 exposure varied greatly. We observed significant association of ambient O3 exposure with ventricular septal defect (VSD), tetralogy of Fallot (TOF); pulmonary stenosis (PS), pulmonary atresia (PA), transposition of great arteries (TGA) and persistent left superior vena cava (PLSVC), with TOF demonstrating the strongest estimates (OR: 1.194, 95% CI:1.107, 1.288). The estimates for preconception, the first trimester and periconception demonstrate consistent findings with the main analyses, indicating stronger associations of ambient O3 exposure during the periconception period. Our study provides evidence that higher ambient O3 during early pregnancy was significantly associated with increased odds of fetal CHD. Our findings suggest that pregnant women, clinical practitioners, and policy makers need to pay more attention to the exposure to higher ambient O3 during early pregnancy to reduce the risk of developing CHD and to improve outcomes across the life span.

Orthotopic heart transplantation in patient with situs inversus and pectus excavatum: a case report

BackgroundHeart transplantation in patients with situs inversus is challenging, especially in terms of reconstruction of the systemic venous return. Several rerouting techniques have been presented but are associated with vulnerability to external compression, which might cause hemodynamic instability, especially in the presence of chest deformity. In this study, we report a rare case of successful heart transplantation in the presence of situs inversus and pectus excavatum.Case presentationA 55-year-old man, with a history of surgeries for corrected transposition of the great arteries with ventricular septal defect, was registered for heart transplantation owing to progression of heart failure. Subsequently, he had undergone a left ventricular assist device implantation; 14 years after registration, he underwent transplantation of the heart with normal anatomy. The inferior vena cava was reconstructed by anastomosing the left atria with a counterclockwise rotation of the donor heart and by lengthening the recipient inferior vena cava with a conduit made of the residual right atrial tissue. The superior vena cava was reconstructed using a donor innominate vein harvested with sufficient length. After successful weaning from cardiopulmonary bypass, the chest could not be closed because the heart was compressed owing to chest deformity, resulting in hemodynamic instability. Therefore, to exclude the left lung, a left pericardial screen was created using a bovine pericardium, allowing the chest to be closed with acceptable hemodynamics. The patient suffered postoperatively from a higher venous pressure, suggesting an obstruction of venous return early after surgery. The obstruction gradually resolved, and the patient was transferred for rehabilitation.ConclusionsHeart transplantation in the presence of situs inversus is challenging; moreover, the presence of pectus excavatum further complicates the procedure. The paradoxically larger left lung and chest deformity compressed and impaired reconstructed systemic venous return. Although intrathoracic exclusion of the left lung was effective, an intraoperative or early postoperative thoracoplasty for pectus excavatum was also a viable option. Patient-specific management is mandatory, depending on the anatomy.

Transcatheter stenting of superior vena cava to treat postoperative SVC syndrome in a child: a case report

BackgroundSuperior vena cava (SVC) obstruction leading to SVC syndrome is an uncommon but potential complication of cardiac surgeries that involve dissection and anastomosis around the great vein. We present a case of iatrogenic SVC obstruction that was initially treated with transcatheter balloon angioplasty, which provided temporary relief, and ultimately resolved by stenting the affected segment.Case presentationThe index case underwent total anomalous pulmonary venous connection (TAPVC) repair and presented 3 months after surgery with features of SVC obstruction. Initially, transcatheter balloon angioplasty was performed, providing relief from the obstruction; however, the condition recurred within one month. Finally, the patient was treated with percutaneous stenting of superior vena cava, through femoral venous route, using 8 mm × 30 mm balloon-expandable bare metal stent (Formula 418, Cook Medical, Bloomington, IN). Remarkable relief of obstruction was established with decrease in mean gradient across SVC–right atrium junction to 2 mm Hg (from 12 mm Hg before balloon angioplasty and 18 mm Hg before stenting).ConclusionPercutaneous treatment for iatrogenic SVC obstruction developing after cardiac surgery appears to be effective. Close monitoring is required in the postoperative period for early diagnosis and timely intervention.

Lipomatous hypertrophy of the interatrial septum: A benign cardiac mass.

Lipomatous hypertrophy of the interatrial septum (LHIS) is a rare but benign cardiac tumor that can be found on cardiac imaging such as echocardiogram, or during surgery or an autopsy. Cardiac MRI is the best imaging modality to determine the borders of the tumor and its extension into the intraventricular septum and ventricular free wall. Patients require close monitoring because LHIS may cause right or left outflow tract obstruction or superior vena cava obstruction, requiring cardiac surgical intervention. This article describes a patient with LHIS who underwent cardiac surgery because of her increasing symptomatology.

Utility of covered stents as a bypass for the treatment of central venous occlusion: a case report

BackgroundCentral venous occlusion (CVO) is difficult to treat with percutaneous transluminal angioplasty because the guidewire cannot pass through the occluded segments. In this study, we devised a new method for establishing an extra-anatomic bypass between the right subclavian vein and the superior vena cava via a covered stent to treat whole-segment occlusion of the right brachiocephalic vein (BCV) with calcification.Case presentationWe present the case of a 58-year-old female patient who complained of right arm swelling present for 1.5 years. Twelve years prior, the patient began hemodialysis because chronic glomerulonephritis had progressed to end-stage renal disease. During the first 3 years, a right internal jugular vein (IJV)-tunneled cuffed catheter was used as the dialysis access, and the catheter was replaced once. A left arteriovenous fistula (AVF) was subsequently established. Owing to occlusion of the left AVF, a new fistula was established on the right upper extremity 1.5 years prior to this visit. Angiography of the right upper extremity revealed complete occlusion of the right BCV and IJV with calcification. Because of the failure to pass the guidewire across the lesion, we established an extra-anatomic bypass between the right subclavian vein and the superior vena cava with a covered stent. Angiography confirmed the patency of whole vascular access system. After 3 months of follow-up, the patient’s AVF function and the bypass patency were satisfactory.ConclusionsAs a new alternative for the treatment of long, angled CVO with or without calcification, a covered stent can be used to establish an extravascular bypass between central veins.

Surgical Repair of Total Anomalous Pulmonary Venous Connection into the Superior Vena Cava: A Case Report.

Total anomalous pulmonary venous connection is a rare congenital anomaly that has four anatomical subtypes. In the supracardiac type, the common pulmonary vein confluence usually drains into the left innominate vein via a vertical vein; however, it may drain into the superior vena cava. Herein, we present a successful surgical repair of a rare type of total anomalous pulmonary venous connection in which the common pulmonary vein confluence was draining directly into the superior vena cava without a vertical vein.

Redo isolated tricuspid valve replacement in a patient with isolated persistent left superior vena cava: a case report

BackgroundRedo isolated tricuspid valve surgery has high in-hospital mortality and morbidity and is a challenging procedure. We report a successful case of redo isolated tricuspid valve replacement for structural valve deterioration of a bioprosthesis in a patient with isolated persistent left superior vena cava (PLSVC).Case presentationAn 81-year-old man with a history of tricuspid valve replacement using a porcine bioprosthetic valve 9 years previously presented with dyspnea on exertion. Right heart failure due to worsening transvalvular leakage in the bioprosthetic tricuspid valve was considered to be the cause of his symptoms, and the decision was made to replace the tricuspid valve. An isolated PLSVC is considered to be an obstacle in right-sided heart valve surgery. The PLSVC was located deep to the left of the pulmonary artery and, after some effort, was cannulated by obtaining an excellent surgical view using retraction sutures on the left side of the pericardium. Cardiopulmonary bypass was initiated after cannulation of the ascending aorta, PLSVC, and femoral vein. After cross-clamping of the ascending aorta, cold blood cardioplegic arrest was induced under moderate hypothermia, and the PLSVC and inferior vena cava were snared. The right atrium was opened and the prosthetic tricuspid valve was examined. One of the leaflets was shortened, which appeared to cause the transvalvular leak. The prosthetic valve was explanted, the annulus was trimmed, and a new bioprosthetic valve was implanted. The postoperative course was uneventful.ConclusionsIt is important to treat structural valve deterioration of a prosthetic tricuspid valve in a timely manner. We hope that our intervention timing and surgical strategy can help surgeons to consider early intervention in similar cases, even if there are surgical obstacles such as isolated PLSVC.

The Mediastinal Distortions

The case we present involves an atypically developed thoracic aorta, resulting in the consecutive displacement of the trachea and esophagus, combined with the unusual formation of vascular bridges between the ascending and descending thoracic aorta and the arising supraaortic branches. This represents a pathological entity further associated with a cardiac condition of Sick Sinus Syndrome and heterotopy of the excitation center in the pulmonary veins. Multiple descriptions of the combination of dextrocardia and Sick Sinus Syndrome have been reported by Aurora Bakalli et al. 2021 (1), as well as the combination of dextrocardia, persistent left superior vena cava, and Sick Sinus Syndrome by Gangliang Guo et al. 2017 (2), and another case of dextrocardia and Sick Sinus Syndrome by Junqian Luo et al. 2022 (3). Such combinations of anomalies have not been reported in larger statistical collections to date.

The importance of electrode-tissue proximity in creating pulsed field ablation lesions: insights from a sub-acute preclinical model.

We sought to evaluate the anatomic and functional lesion development over time at different atrial sites immediately following delivery of pulsed field ablation (PFA). Using a porcine model, PFA ablations were performed in the superior vena cava (SVC), right atrial lateral wall (RA), left atrial appendage (LAA), and right superior pulmonary vein (RSPV) using four different PFA profiles. Mapping was done sequentially in 5-20-min increments up to 280-min post lesion delivery for low voltage area (LVA) assessment and conduction velocity. Lesion characteristics were noted with voltage mapping immediately post ablation and at the serial time points. In 9 animals, 33 sites were ablated. None of the four different profiles across all sites showed any statistical difference on acute lesion formation or persistence. Higher tissue contact was observed in the SVC and RSPV and lower tissue contact was observed in the LAA and RA locations. Higher contact areas were noted to have higher density electroanatomic low voltage area (LVA) (12/14 vs 5/18, p = 0.01) and larger lesions on gross pathology (2 /14 vs 6/16, p = 0.01) compared to lower contact areas. Lesion regression occurred in 16/33 sites. Sustained lesions were significantly more prevalent in higher versus lower contact sites (65% vs 38%, p = 0.037). The development of significant and durable lesions for PFA in a porcine model appears to be dependent on tissue proximity and contact.

Prenatal Diagnosis of Persistent Left Superior Vena Cava Using High-Definition Flow Render Mode and Spatiotemporal Image Correlation.

This study aimed to assess the use of two-dimensional (2D) ultrasound combined with high-definition flow (HD-flow) render mode and spatiotemporal image correlation (STIC) in diagnosing and classifying fetal persistent left superior vena cava (PLSVC). Overall, 114 cases of fetal PLSVC were diagnosed using 2D ultrasound combined with STIC, and 114 normal fetuses of the same gestational week were selected. These cases were retrospectively analyzed to evaluate the effectiveness of the diagnostic approach. All 114 PLSVC cases were diagnosed using 2D ultrasound combined with STIC. Although the diagnostic coincidence rate of PLSVC in the HD-flow combined with STIC was similar to that in the 2D ultrasound combined with HD-flow (96.8 vs 96.2%), 2D ultrasound with STIC enabled dynamic visualization of the PLSVC, furthering prenatal diagnosis. These cases were classified as type I PLSVC: 80 cases of type Ia, 29 cases of type Ib, and 5 cases of type Ic. Seventy isolated PLSVC cases (61.4%) were noted, whereas 44 cases (35.6%) were associated with concomitant structural abnormalities. Intracardiac structural malformations accounted for the highest proportion (n = 53, 58.89%), followed by single umbilical artery and facial/bodily abnormalities (n = 10, 11.11%). Combining HD-flow and STIC complements 2D ultrasound in diagnosing and classifying fetal PLSVC, demonstrating significant clinical relevance.

Newly Designed, Self-Expanding Large-Bore Nitinol Stents for Symptomatic Central Venous Stenosis: Technical and Long-Term Clinical Outcome.

To retrospectively analyze the technical and long-term clinical outcome of angioplasty and stenting using the Venovo™ venous stent for the treatment of malignant and benign superior vena cava (SVC) occlusive disease. Consecutive patients treated with the Venovo™ venous stent for SVC occlusive disease were included. SVC obstruction symptoms were classified according to the Kishi score. The Wilcoxon signed-rank test was used for testing significance of changes. Technical success, defined as correct placement of the stent, completely covering and re-expanding the obstruction, between groups was tested using the Fisher exact test. Overall survival was calculated using the Kaplan-Meier method. Fifty-five patients underwent stent insertion for symptomatic benign (n = 13; 24%) or malignant (n = 42; 76%) SVC occlusive disease. A significant drop in Kishi score, mean 3.91 before versus mean 1.02 after the procedure (P < 0.0001), was observed. In one patient (1.8%), an additional balloon-expandable stent was needed to manage incomplete expansion of the nitinol stent. In one patient, a procedure-related lung embolic complication was noted. Early thrombotic occlusion of the stent occurred in one patient. Late symptomatic restenosis occurred in 3 patients. Overall primary stent patency and primary-assisted stent patency were 86% (95% CI 66-95) and97% (95% CI 83-100) at 1-year follow-up and 98% (95% CI 87-100), 98% (87-100) at 2-year follow-up, respectively. In this retrospective analysis, angioplasty and stent placement using the Venovo™ venous stent is safe and clinically effective for the treatment of both benign and malignant SVC occlusive disease. Reintervention for symptomatic restenosis is rare.

A case of successful treatment with repeated segmental embolization for downhill esophageal varices caused by giant goiter.

Downhill esophageal varices often develop because of venous hypertension caused by either superior vena cava obstruction or compression. We herein present a case of downhill esophageal varices caused by a giant goiter in a patient with postoperative Graves' disease. A 66-year-old man presented with an enlarged goiter. Gastrointestinal endoscopy revealed upper esophageal varices. This patient was successfully treated with repeated segmental embolization of the thyroid arteries that fed the goiter, followed by embolization of the inflow vein for downhill esophageal varices. Three years later, no re-enlargement of either the goiter or the appearance of downhill varices was observed. Segmental embolization therapy is thus considered to be a safe alternative for the treatment of downhill esophageal varices caused by giant goiter.

Usefulness of empiric superior vena cava isolation in paroxysmal atrial fibrillation ablation: a meta-analysis of randomized clinical trials.

The long-term success rate of pulmonary vein isolation (PVI) is suboptimal due to the presence of non-pulmonary vein (PV) foci that can trigger atrial fibrillation (AF) in up to 11%. Among non-PV triggers, the superior vena cava (SVC) is a major site of origin of ectopic beats initiating AF. To compare data from randomized controlled trials (RCTs) assessing PVI + empiric SVC isolation (SVCI) versus PVI alone in terms of AF recurrence, procedure-related complications, and fluoroscopic and procedural times. A search of online scientific libraries (from inception to April 1, 2024) was performed. Four RCTs were considered eligible for the meta-analysis totaling 600 patients of whom 287 receiving PVI + SVCI and 313 receiving PVI alone. In the overall population, SVCI + PVI was associated with a non-significant reduction of AF recurrence at follow-up (0.66 [0.43;1.00], p = 0.05, I2 0%). In patients with paroxysmal AF (PAF), a significant reduction of AF recurrence was related to SVCI + PVI (11.7%) as compared to PVI alone (19.9%) (0.54 [0.32;0.92], p = 0.02, I2 0%). No statistical differences were found among the groups in terms of fluoroscopic (3.31 [- 0.8;7.41], p = 0.11, I2 = 91%), procedural times (5.69 [- 9.78;21.16], p = 0.47, I2 = 81%), and complications (1.06 [0.33;3.44], p = 0.92, I2 = 0%). The addition of SVCI to PVI in patients in PAF is associated with a significant lower rate of AF recurrence at follow-up, without increasing complication rates and procedural and fluoroscopy times.

Ventriculoperitoneal shunt tube migration into the heart and pulmonary artery: successful tube removal. Illustrative case.

Ventriculoperitoneal (VP) shunt tube migration is recognized as an occasional complication; however, migration into the cardiac system is rare. The authors report a case of VP shunt tube migration into the heart and pulmonary artery and the safe removal of the tube. The patient had a VP shunt implanted for hydrocephalus after a subarachnoid hemorrhage. The screening chest radiograph taken a few months later showed the migration of the abdominal tube into the heart. Examinations revealed that the abdominal tube had migrated from the left subclavian vein, passed through the superior vena cava, right atrium and ventricle, and looped into the pulmonary artery. The patient had no symptoms; however, there were some risks, such as damage to the valves or fatal arrhythmia. The authors therefore decided to remove the tube. To avoid various intraoperative risks, in particular tube knot formation, the tube was removed under fluoroscopy with a guidewire inserted, which was 0.035 inches for the angiography catheter. The tube was successfully removed without any complications. Knot formation can be one of the fatal complications of shunt tube removal. The authors' technique is an effective method for safe removal. https://thejns.org/doi/10.3171/CASE24127.