Percutaneous placement of the peripheral catheter to the subclavian vein for a VA shunt

Right Transcephalic Ventriculo-Subclavian Shunt in the Surgical Treatment of Hydrocephalus-An Original Procedure for Drainage of Cerebrospinal Fluid into the Venous System

The objectives of this article are to present an original surgical procedure for the temporary or definitive resolution of hydrocephalus, in the case of repeated failure of standard treatment techniques, and to present a case that was resolved using this surgical technique.

MATERIALS AND METHODS

We present the case of a 20-year-old male patient with congenital hydrocephalus who underwent a number of 39 shunt revisions, given the repetitive dysfunctions of various techniques (ventriculo-peritoneal shunt, ventriculo-cardiac shunt). The patient was evaluated with the ventricular catheter externalized at the distal end and it was necessary to find an emergency surgical solution, considering the imminent risk of meningitis. The patient was also associated with the diagnosis of acute lithiasic cholecystitis.

RESULTS AND DISCUSSIONS

The final chosen solution, right ventriculo-venous drainage using the cephalic vein, was a temporary surgical solution, but there are signs that this procedure can provide long-term ventricular drainage.

CONCLUSIONS

Transcephalic ventriculo-subclavian drainage represents an alternative technical option, which can be used when established options become ineffective.

Ventriculoatrial Shunts: Review of Technical Aspects and Complications

Diversion of cerebrospinal fluid is required in many neurosurgical conditions. When a standard ventriculoperitoneal shunt and endoscopic third ventriculostomy are not appropriate options, placement of a ventriculoatrial shunt is a safe, relatively familiar second-line shunting procedure. Herein we reviewed the technical aspects of ventriculoatrial shunt placement using an illustrative case. We focused on the different modalities for inserting and confirming the location of the distal catheter tip. We discussed how to overcome typical difficulties and significant concerns, such as cardiac arrhythmias and venous thrombosis. In addition, we reviewed the current literature for the different complications associated with ventriculoatrial shunt placement.

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

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.

Thromboembolic infarction caused by an unknown patent foramen ovale 30 years after VA shunt insertion: a case report and review of the literature

BACKGROUND

Ventriculoatrial shunt (VA) insertion is one of the possible surgical procedures to treat hydrocephalus. However, it is also associated with several complications such as obstruction and shunt infection as well as life-threatening complications like intraatrial thrombus or thrombosis on the distal catheter. In this case report, we share a rare case of a patient with a VA shunt, who was admitted to our hospital with a stroke.

CASE DESCRIPTION

A 56-year-old female patient with suspected acute stroke was admitted to the stroke unit. CT and MRI scans showed multiple cerebral infarctions in both hemispheres. The transesophageal echocardiography (TEE) showed at the tip of the VA shunt catheter, which was implanted about 30 years ago due to aqueduct stenosis, also a thrombotic formation as the reason of stroke. Interestingly, the tip of the catheter was not in the right atrium as expected, but in the left atrium. Further evaluation showed a patent foramen ovale (PFO), through which the catheter migrated from the right to the left side. At first, conservative treatment with anticoagulation was started with the aim to dissolve the thrombotic formation; however, a control TEE showed an unchanged mass at the catheter tip. Therefore, a ventriculoperitoneal shunt was implanted and the proximal shunt catheter was removed with an additional closure of the PFO by our heart surgeons. Postoperatively, the patient was discharged 10 days later in good condition to a rehabilitation center.

CONCLUSIONS

Thromboembolic events due to a PFO are rare but possible life-threatening complication after VA shunt insertion. Therefore, preoperative cardiac diagnostic might be clinically relevant prior to a VA shunt implantation to avoid such complications.