Acta Neurochir (2016) 158:615–616 DOI 10.1007/s00701-015-2656-5
LETTER TO THE EDITOR - NEUROSURGICAL TECHNIQUES
Distal catheter migration of a direct ventriculo-auricular shunt Frederik Enders 1 & Arjang Ruhparwar 2 & Andreas Unterberg 1 & Jan-Oliver Neumann 1
Received: 28 July 2015 / Accepted: 30 November 2015 / Published online: 11 December 2015 # Springer-Verlag Wien 2015
Dear Editor, Surgery for cerebrospinal fluid (CSF) shunts is one of the most frequently performed procedures in neurosurgery [1, 3]. However, 20–40 % of complications require revision surgery within the first year [3, 9]. The first choice for the placement of the distal catheter is the peritoneal cavity, but distal catheter placement to the venous system can be achieved by cannulating, e.g., the internal jugular vein as well. Nevertheless, infection, thrombosis, or glomerulonephritis can necessitate alternate sites of distal catheter placement. If traditional placement sites of the distal catheter are not suitable, direct placement into the right auricle could be considered. A 34-year-old male patient with a history of internal hydrocephalus had received a ventriculo-atrial shunt (VA-shunt) 3 months after birth. He underwent four revisions with both VA- and ventriculo-peritoneal shunts (VP-shunt). His past medical history was remarkable for multiple abdominal surgeries including two kidney transplantations. The patient presented with evidence of peritonitis and hydrocephalus and cranial computed tomography (cCT) showed increased ventricle size. Abdominal ultrasound revealed massive ascites, therefore the distal catheter of the VP shunt was removed,
* Frederik Enders [email protected] 1
Department of Neurosurgery, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
2
Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
the shunt was externalized, and the patient received antibiotics until recovery from peritonitis. A CT angiogram revealed extensive venous thrombosis and the peritoneal cavity was no longer an option due to previous failure. Concerning the need of 300 ml of CSF drainage per day and the high risk of pleural effusion due to renal insufficiency, pleural catheter placement seemed to be unsuitable as well. Therefore the direct placement of the distal catheter into the right atrium in cooperation with a cardiac surgeon appeared to be the most feasible option. The ventricular catheter was replaced and connected with a burr hole reservoir, an adjustable valve, and adjustable shunt assistant. The thoracotomy was performed and the right lung was deflated, allowing smooth retraction of the lung and exposure of the pericardium. A sub-cutaneous tunnel was constructed from the thoracotomy to a subclavian skin incision where the atrial catheter was inserted. The pericardium was incised and after placement of a felt-reinforced purse string suture, the auricle was opened and the cardiac catheter was placed into the right atrium. After verifying the placement, an additional anchorage to the pericardium was applied by using a plastic catheter fixation (Fig. 1). The amply chosen atrial catheter was fed through the subcutaneous tunnel and connected to the proximal catheter. Postoperative radiograph and cCT showed proper catheter placement and decreased ventricle size. Two months after discharge, the patient presented with right thoracic pain. A chest CT revealed pleural effusion and migration of the atrial catheter to the pleural cavity. Since there were no clinical or radiographic signs of hydrocephalus, the clinical team decided to observe the patient and to avoid a revision surgery. Subsequent chest ultrasounds demonstrated a constant extent of the pleural effusion and the patient reported an improvement of the right thoracic discomfort. Within 10 months of followup, the patient needed several adjustments of the valve, though no revision surgery was necessary.
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Acta Neurochir (2016) 158:615–616
References 1. 2.
3.
4.
5. Fig. 1 Intraoperative photograph after placement and fixation of the atrial catheter (black arrowhead) by a felt-reinforced purse string suture (white arrowhead) and a plastic catheter fixation (black asterisk)
In particular instances, the direct ventriculo-auricular shunt can be an alternative for CSF diversion. It has been described as a safe procedure predominantly in pediatric patients [4, 5, 8, 10] but it can also be an option in the adult. Severe complications like cardiac tamponade or hemothorax are not reported in direct cardiac shunt as compared to VA-shunt [2]. The procedure should be performed in cooperation with neurosurgery and a cardiac/thoracic surgeon. Even if pleural effusion is a known complication of ventriculo-pleural shunts and usually requires puncture or revision surgery [6, 7], the migration of the distal catheter into the pleural cavity, resulting in a ventriculo-pleural shunt, does not always require a mandatory revision. However, patients should be followed closely to recognize possible shunt malfunction. Compliance with ethical standards Disclosure The patient’s guardian has consented to the submission of the case report for submission to the journal. Conflict of interest statement All authors certify that they have no affiliations with or involvement in any organisation or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus, membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.
6.
7. 8.
9.
10.
Bondurant CP, Jimenez DF (1995) Epidemiology of cerebrospinal fluid shunting. Pediatr Neurosurg 23:254–259 El-Eshmawi A, Onakpoya U, Khadragui I (2009) Cardiac tamponade as a sequela to ventriculoatrial shunting for congenital hydrocephalus. Tex Heart Inst J 36(1):58–60 G r e e n N L , Wr e n s c h M R , Z h a o S , G u p t a N ( 2 0 0 7 ) Ventriculoperitoneal shunt complications in California: 1990 to 2000. Neurosurgery 61(3):557–562 Heuer GG, Ranalli NJ, Pisapia J, Storm PB, Gruber PJ, Sutton LN (2012) Direct cardiac ventriculoatrial shunt: technical note. Pediatr Neurosurg 48:118–121 Keucher TR, Mealey J Jr (1979) Long-term results after ventriculoatrial and ventriculoperitoneal shunting for infantile hydrocephalus. J Neurosurg 50(2):179–186 Küpeli E, Yilmaz C, Akçay S (2010) Pleural effusion following ventriculopleural shunt: case reports and review of the literature. Ann Thorac Med 5(3):166–170 Megison DP, Benzel EC (1988) Ventriculo-pleural shunting for adult hydrocephalus. Br J Neurosurg 2(4):503–505 Milhorat TH, McClenathan JE (1975) Direct cardiac shunt for hydrocephalus of infancy and childhood. Technical note. J Neurosurg 42:605–608 Naftel RP, Argo JL, Shannon CN, Taylor TH, Tubbs RS, Clements RH, Harrigan MR (2011) Laparoscopic versus open insertion of the peritoneal catheter in ventriculoperitoneal shunt placement: review of 810 consecutive cases. J Neurosurg 115(1):151–158 Vernet O, Campiche R, de Tribolet N (1993) Long-term results after ventriculoatrial shunting in children. Childs Nerv Syst 9:253–255
Comment With the correct patient selection and technique, VA shunts are an excellent alternative to VP shunting and may be underused. Chronic inflammatory and infectious complications such as glomerulonephritis and renal failure, if depicted early, can be easily avoided and/or treated. With the modern Seldinger technique, a direct placement of the distal catheter into the right atrium via mini-thoracotomy is almost never required. It could, however, be reserved as an alternative for those with superior vena cava syndrome and impossible peritoneal and pleural spaces. As such, local complications such as tamponade, pulmonary hypertension, and pleural effusion should be kept in mind. In the case presented by the authors, although the catheter dislodged from the heart to the pleural cavity, the latter could absorb the CSF. Shlomi Constantini, Jonathan Roth Tel-Aviv, Israel
LETTER TO THE EDITOR - NEUROSURGICAL TECHNIQUES
Distal catheter migration of a direct ventriculo-auricular shunt Frederik Enders 1 & Arjang Ruhparwar 2 & Andreas Unterberg 1 & Jan-Oliver Neumann 1
Received: 28 July 2015 / Accepted: 30 November 2015 / Published online: 11 December 2015 # Springer-Verlag Wien 2015
Dear Editor, Surgery for cerebrospinal fluid (CSF) shunts is one of the most frequently performed procedures in neurosurgery [1, 3]. However, 20–40 % of complications require revision surgery within the first year [3, 9]. The first choice for the placement of the distal catheter is the peritoneal cavity, but distal catheter placement to the venous system can be achieved by cannulating, e.g., the internal jugular vein as well. Nevertheless, infection, thrombosis, or glomerulonephritis can necessitate alternate sites of distal catheter placement. If traditional placement sites of the distal catheter are not suitable, direct placement into the right auricle could be considered. A 34-year-old male patient with a history of internal hydrocephalus had received a ventriculo-atrial shunt (VA-shunt) 3 months after birth. He underwent four revisions with both VA- and ventriculo-peritoneal shunts (VP-shunt). His past medical history was remarkable for multiple abdominal surgeries including two kidney transplantations. The patient presented with evidence of peritonitis and hydrocephalus and cranial computed tomography (cCT) showed increased ventricle size. Abdominal ultrasound revealed massive ascites, therefore the distal catheter of the VP shunt was removed,
* Frederik Enders [email protected] 1
Department of Neurosurgery, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
2
Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
the shunt was externalized, and the patient received antibiotics until recovery from peritonitis. A CT angiogram revealed extensive venous thrombosis and the peritoneal cavity was no longer an option due to previous failure. Concerning the need of 300 ml of CSF drainage per day and the high risk of pleural effusion due to renal insufficiency, pleural catheter placement seemed to be unsuitable as well. Therefore the direct placement of the distal catheter into the right atrium in cooperation with a cardiac surgeon appeared to be the most feasible option. The ventricular catheter was replaced and connected with a burr hole reservoir, an adjustable valve, and adjustable shunt assistant. The thoracotomy was performed and the right lung was deflated, allowing smooth retraction of the lung and exposure of the pericardium. A sub-cutaneous tunnel was constructed from the thoracotomy to a subclavian skin incision where the atrial catheter was inserted. The pericardium was incised and after placement of a felt-reinforced purse string suture, the auricle was opened and the cardiac catheter was placed into the right atrium. After verifying the placement, an additional anchorage to the pericardium was applied by using a plastic catheter fixation (Fig. 1). The amply chosen atrial catheter was fed through the subcutaneous tunnel and connected to the proximal catheter. Postoperative radiograph and cCT showed proper catheter placement and decreased ventricle size. Two months after discharge, the patient presented with right thoracic pain. A chest CT revealed pleural effusion and migration of the atrial catheter to the pleural cavity. Since there were no clinical or radiographic signs of hydrocephalus, the clinical team decided to observe the patient and to avoid a revision surgery. Subsequent chest ultrasounds demonstrated a constant extent of the pleural effusion and the patient reported an improvement of the right thoracic discomfort. Within 10 months of followup, the patient needed several adjustments of the valve, though no revision surgery was necessary.
616
Acta Neurochir (2016) 158:615–616
References 1. 2.
3.
4.
5. Fig. 1 Intraoperative photograph after placement and fixation of the atrial catheter (black arrowhead) by a felt-reinforced purse string suture (white arrowhead) and a plastic catheter fixation (black asterisk)
In particular instances, the direct ventriculo-auricular shunt can be an alternative for CSF diversion. It has been described as a safe procedure predominantly in pediatric patients [4, 5, 8, 10] but it can also be an option in the adult. Severe complications like cardiac tamponade or hemothorax are not reported in direct cardiac shunt as compared to VA-shunt [2]. The procedure should be performed in cooperation with neurosurgery and a cardiac/thoracic surgeon. Even if pleural effusion is a known complication of ventriculo-pleural shunts and usually requires puncture or revision surgery [6, 7], the migration of the distal catheter into the pleural cavity, resulting in a ventriculo-pleural shunt, does not always require a mandatory revision. However, patients should be followed closely to recognize possible shunt malfunction. Compliance with ethical standards Disclosure The patient’s guardian has consented to the submission of the case report for submission to the journal. Conflict of interest statement All authors certify that they have no affiliations with or involvement in any organisation or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus, membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.
6.
7. 8.
9.
10.
Bondurant CP, Jimenez DF (1995) Epidemiology of cerebrospinal fluid shunting. Pediatr Neurosurg 23:254–259 El-Eshmawi A, Onakpoya U, Khadragui I (2009) Cardiac tamponade as a sequela to ventriculoatrial shunting for congenital hydrocephalus. Tex Heart Inst J 36(1):58–60 G r e e n N L , Wr e n s c h M R , Z h a o S , G u p t a N ( 2 0 0 7 ) Ventriculoperitoneal shunt complications in California: 1990 to 2000. Neurosurgery 61(3):557–562 Heuer GG, Ranalli NJ, Pisapia J, Storm PB, Gruber PJ, Sutton LN (2012) Direct cardiac ventriculoatrial shunt: technical note. Pediatr Neurosurg 48:118–121 Keucher TR, Mealey J Jr (1979) Long-term results after ventriculoatrial and ventriculoperitoneal shunting for infantile hydrocephalus. J Neurosurg 50(2):179–186 Küpeli E, Yilmaz C, Akçay S (2010) Pleural effusion following ventriculopleural shunt: case reports and review of the literature. Ann Thorac Med 5(3):166–170 Megison DP, Benzel EC (1988) Ventriculo-pleural shunting for adult hydrocephalus. Br J Neurosurg 2(4):503–505 Milhorat TH, McClenathan JE (1975) Direct cardiac shunt for hydrocephalus of infancy and childhood. Technical note. J Neurosurg 42:605–608 Naftel RP, Argo JL, Shannon CN, Taylor TH, Tubbs RS, Clements RH, Harrigan MR (2011) Laparoscopic versus open insertion of the peritoneal catheter in ventriculoperitoneal shunt placement: review of 810 consecutive cases. J Neurosurg 115(1):151–158 Vernet O, Campiche R, de Tribolet N (1993) Long-term results after ventriculoatrial shunting in children. Childs Nerv Syst 9:253–255
Comment With the correct patient selection and technique, VA shunts are an excellent alternative to VP shunting and may be underused. Chronic inflammatory and infectious complications such as glomerulonephritis and renal failure, if depicted early, can be easily avoided and/or treated. With the modern Seldinger technique, a direct placement of the distal catheter into the right atrium via mini-thoracotomy is almost never required. It could, however, be reserved as an alternative for those with superior vena cava syndrome and impossible peritoneal and pleural spaces. As such, local complications such as tamponade, pulmonary hypertension, and pleural effusion should be kept in mind. In the case presented by the authors, although the catheter dislodged from the heart to the pleural cavity, the latter could absorb the CSF. Shlomi Constantini, Jonathan Roth Tel-Aviv, Israel
