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Oliveira LDB, Welling LC, Viegas FAF, Ribas LRC, Junior EOM, Wesselovicz RM, Batista S, Bertani R, Palavani LB, Rabelo NN, Figueiredo EG. Incidence and nature of complications associated with ventriculoatrial shunt placement: A systematic review and single-arm meta-analysis. Clin Neurol Neurosurg 2023; 233:107950. [PMID: 37673013 DOI: 10.1016/j.clineuro.2023.107950] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/22/2023] [Accepted: 08/22/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Ventriculoatrial shunt (VAS) is considered the second option for treating hydrocephalus, but there remains a lack of robust evidence regarding its complications profile. PURPOSE Evaluate the complications associated with VAS. METHODS Adhering to PRISMA guidelines, the authors searched Embase, PubMed, and Web of Science databases to identify articles reporting on the complications of VAS. Eligible articles were required to report whether complications occurred in a cohort of at least four patients. The extraction process focused on various outcome measures, including overall complications, pulmonary complications, cardiac complications, mortality, shunt revisions, glomerulonephritis, intracranial hemorrhage, and hygroma. Complications were defined as any adverse events related to the procedure, including revisions. RESULTS After retrieving a total of 2828 articles, 53 studies met the predefined criteria, involving 2862 patients. The overall complication rate was estimated at 33 % (95 % CI: 25-42 %), while the long-term complications rate was found to be 49 % (95 % CI: 32-67 %). Among the pediatric population, the complication rate was calculated to be 53 % (95 % CI: 39-68 %). The overall revision rate was estimated at 32 % (95 % CI: 23-41 %), with an infection rate of 5 % (95 % CI: 3-7 %). Notably, in the pediatric group, the infection rate was 10 % (95 % CI: 6-13 %). The random analysis indicated an estimated risk of 0 % for glomerulonephritis, intracranial hemorrhage, hygroma, cardiac complications, pulmonary complications, and shunt-related mortality. CONCLUSION VAS is a safe alternative when ventriculoperitoneal shunting is not feasible. Risk of classic severe complications is minimal. Nevertheless, caution is required when shunting critical patients. Further randomized studies are warranted to establish the ideal shunt for different patients.
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Affiliation(s)
| | | | | | | | | | | | - Savio Batista
- Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Raphael Bertani
- Department of Neurosurgery, University of São Paulo, São Paulo, Brazil
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Kelly PD, Yengo-Kahn AM, Naftel RP. The survival of reimplanted shunts following externalization: a single-institution cohort study. J Neurosurg Pediatr 2021; 27:382-390. [PMID: 33578377 PMCID: PMC8357850 DOI: 10.3171/2020.8.peds20533] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 08/31/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The failure-free survival of ventriculoperitoneal shunts (VPSs) following externalization for distal catheter infection or malfunction has not been adequately explored. Conversion to a ventriculoatrial shunt (VAS) may allow earlier reinternalization in lieu of waiting for the peritoneum to be suitable for reimplantation. This option is tempered by historical concerns regarding high rates of VAS failure, and the risks of rare complications are rampant. METHODS In this retrospective cohort study, all patients undergoing externalization of a VPS at a single institution between 2005 and 2020 were grouped according to the new distal catheter terminus location at the time of reinternalization (VPS vs VAS). The primary outcomes were failure-free shunt survival and duration of shunt externalization. Secondary outcomes included early (< 6 months) shunt failure. RESULTS Among 36 patients, 43 shunt externalization procedures were performed. Shunts were reinternalized as VPSs in 25 cases and VASs in 18 cases. The median failure-free survival was 1002 (interquartile range [IQR] 161-3449) days for VPSs and 1163 (IQR 360-2927) days for VASs. There was no significant difference in shunt survival according to the new distal catheter terminus (log-rank, p = 0.73). Conversion to a VAS was not associated with shorter duration of shunt externalization (Wilcoxon rank-sum, p = 0.64); the median duration was 7 (IQR 5-11) days for VPSs and 8 (IQR 6-15) days for VASs. No rare complications occurred in the VAS group. CONCLUSIONS Shunt failure-free survival rates following externalization are similar to published survival rates for nonexternalized shunts. There was no significant difference in survival between reinternalized VPSs and VASs. Although the VAS was not associated with a shortened duration of externalization, this finding is confounded by strong institutional preference for the VPS over the VAS. Early conversion to the VAS may be a viable treatment option in light of reassuring modern VAS survival data.
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Affiliation(s)
- Patrick D. Kelly
- Department of Neurological Surgery, Vanderbilt University Medical Center
- Surgical Outcome Center for Kids, Monroe Carell Jr. Children’s Hospital at Vanderbilt University, Nashville, Tennessee
| | - Aaron M. Yengo-Kahn
- Department of Neurological Surgery, Vanderbilt University Medical Center
- Surgical Outcome Center for Kids, Monroe Carell Jr. Children’s Hospital at Vanderbilt University, Nashville, Tennessee
| | - Robert P. Naftel
- Department of Neurological Surgery, Vanderbilt University Medical Center
- Surgical Outcome Center for Kids, Monroe Carell Jr. Children’s Hospital at Vanderbilt University, Nashville, Tennessee
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Forte D, Peraio S, Huttunen TJ, James G, Thompson D, Aquilina K. Ventriculoatrial and ventriculopleural shunts as second-line surgical treatment have equivalent revision, infection, and survival rates in paediatric hydrocephalus. Childs Nerv Syst 2021; 37:481-489. [PMID: 32986152 DOI: 10.1007/s00381-020-04887-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 09/09/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE Ventriculoatrial (VA) and ventriculopleural (VPL) shunts are used as alternatives when CSF diversion to the peritoneal compartment with a ventriculoperitoneal (VP) shunt is not possible. The objective of this study is to compare directly the shunt survival and complications for both procedures in this setting in children. METHODS A retrospective analysis of 54 consecutive patients who underwent VA (36) or VPL (18) shunt insertion between January 2002 and December 2017 was conducted. RESULTS The overall mean follow-up was 4.1 (SD 4.3) years, 2.8 (SD 4.1) for VPL and 4.7 (SD 4.4) for VA shunts, respectively (p = 0.11). Twenty-four (66.7%) patients in the VA group and 9 (50.0%) in the VPL group underwent shunt revision (p = 0.236); mean number of revisions was 2.2 (SD 3.0) and 0.94 (SD 1.4) in the VA and VPL groups (p = 0.079). Median time to failure was 8.5 (IQr 78, range 0-176) months for VA and 5.50 (IQr 36, range 0-60) for VPL shunts (log rank (Mantel-Cox) 0.832). Shunt survival at 3, 6, 12 and 30 months was 60.6, 51.5, 36.4 and 27.3%, respectively, for VA and 56.3, 43.8, 37.5 and 37.5% for VPL shunts (log rank (Mantel-Cox) test value 0.727). The infection rate was 13.8% for VA and 5.6% for VPL shunts (p = 0.358). Four patients with VPL shunts (22.2%) developed pleural effusions. Fourteen deaths (25.9%) were recorded during follow-up, 8 (22.2%) in the VA and 6 (33.3%) in the VPL group (p = 0.380); two of the deaths in the VA group were shunt-related. CONCLUSION This study demonstrates that the outcomes of VA and VPL shunts, when used as second-line surgical treatment in paediatric hydrocephalus, were similar, as were the revision, infection and survival rates. The shorter longevity of these shunts compared with the general shunted population may reflect the complex nature of these children.
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Affiliation(s)
- Dalila Forte
- Department of Neurosurgery, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Simone Peraio
- Department of Neurosurgery, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Terhi J Huttunen
- Department of Neurosurgery, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Greg James
- Department of Neurosurgery, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Dominic Thompson
- Department of Neurosurgery, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Kristian Aquilina
- Department of Neurosurgery, Great Ormond Street Hospital NHS Foundation Trust, London, UK.
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Entezami P, Devejian NS, Rubino S, Smith N, Savery P, Crnkovic A, Adamo MA. Vegetation of Ventriculoatrial Shunt Managed via Multidisciplinary Surgical Approach. World Neurosurg 2020; 144:15-18. [PMID: 32791225 DOI: 10.1016/j.wneu.2020.08.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/03/2020] [Accepted: 08/04/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The popularity of the ventriculoatrial shunt as a means for cerebrospinal fluid diversion was temporally limited, overcome by the success of the peritoneum as a site for distal drainage. Nevertheless, it remains an important tool for patients for whom ventriculoperitoneal shunting is not an option. CLINICAL PRESENTATION We present the case of a 9-year-old girl with a ventriculoatrial shunt, who had undergone multiple revisions. Ultimately, she suffered a wound dehiscence, resulting in infectious seeding of the bloodstream and formation of a thrombus, presumed granuloma, at the tip of the distal catheter in the right atrium. She underwent successful removal of the lesion via an open approach by our cardiothoracic colleagues. DISCUSSION Previous authors have noted a high number of mortalities as a result of these lesions. A collaborative approach resulted in a successful outcome for our patient. Although limited in utility today, the ventriculoatrial shunt remains a common procedure for neurosurgeons today. CONCLUSION Recognizing the potential for atrial thrombus formation and using a team approach can help avoid a poor outcome.
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Affiliation(s)
- Pouya Entezami
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA.
| | - Neil S Devejian
- Department of Pediatric Cardiothoracic Surgery, Albany Medical College, Albany, New York, USA
| | - Sebastian Rubino
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA
| | - Nathan Smith
- Department of Pediatric Cardiothoracic Surgery, Albany Medical College, Albany, New York, USA
| | - Patrick Savery
- Department of Anesthesia, Albany Medical College, Albany, New York, USA
| | - Anica Crnkovic
- Department of Anesthesia, Albany Medical College, Albany, New York, USA
| | - Matthew A Adamo
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA
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Ezgu MC, Kural C, Guler S, Izci Y. Port-a-cath and ventriculoatrial shunt at the same atrium: technical note. Childs Nerv Syst 2019; 35:857-860. [PMID: 30726527 DOI: 10.1007/s00381-019-04079-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 01/29/2019] [Indexed: 10/27/2022]
Abstract
Hydrocephalus is a rare complication of brain involving acute lymphoblastic leukemia (ALL). The standard treatment is ventriculoperitoneal (VP) shunting, while ventriculoatrial (VA) shunting is the second option in a case of VP shunt failure in young children. But the presence of port catheter at the right atrium restricts and makes a VA shunt difficult to place in the same atrium. We presented a 4-year-old boy who had the diagnoses of ALL and underwent chemotherapy through a port-a-cath. He also had hydrocephalus due to the brain invasion of the ALL. He firstly underwent VP shunting for the treatment of hydrocephalus, but it failed due to an intraabdominal cyst. Then, he underwent VA shunting through the left internal jugular vein. This is the first case in the literature showing both catheters in the right atrium.
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Affiliation(s)
- Mehmet Can Ezgu
- Department of Neurosurgery, University of Health Sciences, Gulhane Training and Research Hospital, 06010 Etlik, Ankara, Turkey
| | - Cahit Kural
- Department of Neurosurgery, University of Health Sciences, Gulhane Training and Research Hospital, 06010 Etlik, Ankara, Turkey
| | - Salih Guler
- Department of Cardiovascular Surgery, University of Health Sciences, Gulhane Training and Research Hospital, Ankara, Turkey
| | - Yusuf Izci
- Department of Neurosurgery, University of Health Sciences, Gulhane Training and Research Hospital, 06010 Etlik, Ankara, Turkey.
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Lee RP, Venable GT, Vaughn BN, Lillard JC, Oravec CS, Klimo P. The Impact of a Pediatric Shunt Surgery Checklist on Infection Rate at a Single Institution. Neurosurgery 2017; 83:508-520. [DOI: 10.1093/neuros/nyx478] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 08/31/2017] [Indexed: 01/22/2023] Open
Abstract
Abstract
BACKGROUND
Shunt infections remain a significant challenge in pediatric neurosurgery. Numerous surgical checklists have been introduced to reduce infection rates.
OBJECTIVE
To introduce an evidence-based shunt surgery checklist and its impact on our shunt infection rate.
METHODS
Between January 1, 2008 and December 31, 2015, pediatric patients who underwent shunt surgery at our institution were indexed in a prospectively maintained database. All definitive shunt procedures were included. Shunt infection was defined according to the Center for Disease Control and Prevention's National Hospital Safety Network surveillance definition for surgical site infection. Clinical and procedural variables were abstracted per procedure. Infection data were compared for the 4 year before and 4 year after protocol implementation. Compliance was calculated from retrospective review of our checklists.
RESULTS
Over the 8-year study period, 1813 procedures met inclusion criteria with a total of 37 shunt infections (2%). Prechecklist (2008-2011) infection rate was 3.03% (28/924) and decreased to 1.01% (9/889; P = .003) postchecklist (2012-2015), representing an absolute risk reduction of 2.02% and relative risk reduction of 66.6%. One shunt infection was prevented for every 50 times the checklist was used. Those patients who developed an infection after protocol implementation were younger (0.95 years vs 3.40 years (P = .027)), but there were no other clinical or procedural variables, including time to infection, that were significantly different between the cohorts. Average compliance rate among required checklist components was 97% (range 85%-100%).
CONCLUSION
Shunt surgery checklist implementation correlated with lower infection rates that persisted in the 4 years after implementation.
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Affiliation(s)
- Ryan P Lee
- College of Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Garrett T Venable
- Department of Neurosurgery, The University of Tennessee Health Science Center, Memphis, Tennessee
| | | | - Jock C Lillard
- College of Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Chesney S Oravec
- College of Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Paul Klimo
- Department of Neurosurgery, The University of Tennessee Health Science Center, Memphis, Tennessee
- Le Bonheur Children's Hospital, Memphis, Tennessee
- Semmes Murphey, Memphis, Tennessee
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Evangelos D, Dimitrios G, Georgios S, Nikolaos E, Filippos P, Marios T. Percutaneous placement of the peripheral catheter to the subclavian vein for a VA shunt. Pan Afr Med J 2017; 27:42. [PMID: 28761618 PMCID: PMC5516673 DOI: 10.11604/pamj.2017.27.42.11374] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Accepted: 05/01/2017] [Indexed: 12/02/2022] Open
Abstract
Hydrocephalus is a common neurosurgical pathology that affects people of all ages and especially the pediatric population. It can be very often a life threatening condition that pediatric neurosurgeons must deal with. Therefore a number of CSF diversion techniques have been established. The gold standard treatment currently is the placement of a ventriculo-peritoneal shunt. Because of hydrocephalus being a lifelong condition, it is almost in daily practice dealing with cases of shunt failures for a number of reasons. Herewith we present a 4 year old child with multiple ventriculo-peritoneal shunt revision surgeries and ventriculo-atrial failure due to distal catheter malfunction that was treated with percutaneous placement of the peripheral catheter in the subclavian vein.
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Affiliation(s)
- Drosos Evangelos
- Department of Neurosurgery, University of Athens Medical School, "Evangelismos" General Hospital, Athens, Greece
| | - Giakoumettis Dimitrios
- Department of Neurosurgery, University of Athens Medical School, "Evangelismos" General Hospital, Athens, Greece
| | - Sfakianos Georgios
- Department of Neurosurgery, Children's Hospital "Agia Sofia", Athens, Greece
| | | | - Papadopoulos Filippos
- Department of Neurosurgery, University of Athens Medical School, "Evangelismos" General Hospital, Athens, Greece
| | - Themistocleous Marios
- Department of Neurosurgery, University of Athens Medical School, "Evangelismos" General Hospital, Athens, Greece
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Garcia CAB, Catalão CHR, Machado HR, Júnior IM, Romeiro TH, Peixoto-Santos JE, Santos MV, da Silva Lopes L. Edaravone reduces astrogliosis and apoptosis in young rats with kaolin-induced hydrocephalus. Childs Nerv Syst 2017; 33:419-428. [PMID: 27988876 DOI: 10.1007/s00381-016-3313-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 12/01/2016] [Indexed: 01/17/2023]
Abstract
PURPOSE We investigated the possible neuroprotective effects of the free radical scavenger edaravone in experimental hydrocephalus. METHODS Seven-day-old Wistar rats were divided into three groups: control group (C), untreated hydrocephalic (H), and hydrocephalic treated with edaravone (EH). The H and EH groups were subjected to hydrocephalus induction by 20% kaolin intracisternal injection. The edaravone (20 mg/kg) was administered daily for 14 days from the induction of hydrocephalus. All animals were daily weighed and submitted to behavioral test and assessment by magnetic resonance imaging. After 14 days, the animals were sacrificed and the brain was removed for histological, immunohistochemical, and biochemical studies. RESULTS The gain weight was similar between groups from the ninth post-induction day. The open field test performance of EH group was better (p < 0.05) as compared to untreated hydrocephalic animals. Hydrocephalic animals (H and EH) showed ventricular ratio values were higher (p < 0.05), whereas magnetization transfer values were lower (p < 0.05), as compared to control animals. Astrocyte activity (glial fibrillary acidic protein) and apoptotic cells (caspase-3) of EH group were decreased on the corpus callosum (p > 0.01), germinal matrix (p > 0.05), and cerebral cortex (p > 0.05), as compared to H group. CONCLUSIONS We have demonstrated that administration of edaravone for 14 consecutive days after induction of hydrocephalus reduced astrocyte activity and that it has some beneficial effects over apoptotic cell death.
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Affiliation(s)
- Camila Araújo Bernardino Garcia
- Department of Surgery and Anatomy, Division of Anatomy, Ribeirao Preto Medical School, University of Sao Paulo, 3900 Av. dos Bandeirantes, Ribeirao Preto, SP, 14049-900, Brazil
| | - Carlos Henrique Rocha Catalão
- Department of Neurosciences and Behavioral Sciences, Ribeirao Preto Medical School, University of Sao Paulo, Sao Paulo, Brazil
| | - Hélio Rubens Machado
- Department of Surgery and Anatomy, Division of Anatomy, Ribeirao Preto Medical School, University of Sao Paulo, 3900 Av. dos Bandeirantes, Ribeirao Preto, SP, 14049-900, Brazil
| | - Ivair Matias Júnior
- Department of Surgery and Anatomy, Division of Anatomy, Ribeirao Preto Medical School, University of Sao Paulo, 3900 Av. dos Bandeirantes, Ribeirao Preto, SP, 14049-900, Brazil
| | - Thais Helena Romeiro
- Department of Surgery and Anatomy, Division of Anatomy, Ribeirao Preto Medical School, University of Sao Paulo, 3900 Av. dos Bandeirantes, Ribeirao Preto, SP, 14049-900, Brazil
| | - José Eduardo Peixoto-Santos
- Department of Neurosciences and Behavioral Sciences, Ribeirao Preto Medical School, University of Sao Paulo, Sao Paulo, Brazil
| | - Marcelo Volpon Santos
- Department of Surgery and Anatomy, Division of Anatomy, Ribeirao Preto Medical School, University of Sao Paulo, 3900 Av. dos Bandeirantes, Ribeirao Preto, SP, 14049-900, Brazil
| | - Luiza da Silva Lopes
- Department of Surgery and Anatomy, Division of Anatomy, Ribeirao Preto Medical School, University of Sao Paulo, 3900 Av. dos Bandeirantes, Ribeirao Preto, SP, 14049-900, Brazil.
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