Retrograde migration of the abdominal catheter as a complication of ventriculoperitoneal shunts: the fishhook sign

Evidence for increased intraabdominal pressure as a cause of recurrent migration of the distal catheter of a ventriculoperitoneal shunt: illustrative case

BACKGROUND

Placement of a ventriculoperitoneal (VP) shunt is an effective treatment for several disorders of cerebrospinal fluid flow. A rare complication involves postoperative migration of the distal catheter out of the intraperitoneal compartment and into the subcutaneous space. Several theories attempt to explain this phenomenon, but the mechanism remains unclear.

OBSERVATIONS

The authors report the case of a 37-year-old nonobese woman who underwent placement of a VP shunt for idiopathic intracranial hypertension. Postoperatively, the distal catheter of the VP shunt migrated into the subcutaneous space on three occasions despite the use of multiple surgical techniques, including open and laparoscopic methods of abdominal catheter placement. Notably, the patient repeatedly displayed radiographic evidence of chronic bowel distention consistent with increased intraperitoneal pressure.

LESSONS

In this case, the mechanism of catheter migration into the subcutaneous space did not appear to be caused by pulling of the catheter from above but rather by expulsion of the catheter from the peritoneum. Space in the subcutaneous tissues caused by open surgical placement of the catheter was permissive for this process. Patients with chronic increased intraabdominal pressure, such as that caused by bowel distention, obesity, or Valsalva maneuvers, may be at increased risk for distal catheter migration.

Complications associated with ventriculoperitoneal shunts in dogs and cats with idiopathic hydrocephalus: A systematic review

Background

Several case series and case reports have been published about idiopathic hydrocephalus treatment in dogs and cats using ventriculoperitoneal shunts (VPS).

Objectives

To determine the risk and type of complications in dogs and cats after VPS placement.

Animals

Sixteen papers were included. Sixty dogs and 13 cats with idiopathic hydrocephalus treated by VPS placement were identified.

Methods

The databases CAB, Scopus, and Medline were used. Idiopathic/congenital hydrocephalus, feline/canine patients, ventriculoperitoneal shunting, complications, and outcomes were inclusion criteria. The focus was on complication type and time frame within which they arose.

Results

Complications in dogs (n = 60) were shunt obstruction (6/60; 10%), pain (4/60; 5.5%), shunt infection (3/60; 4.1%), disconnection (3/60; 4.1%), excessive shunting (2/60; 2.7%), and kinking (1/60; 1.6%). Complications in cats (n = 13) were coiling of the shunt in the SC tissue (2/13; 15.4%); kinking (1/13; 7.7%); and shunt obstruction (1/13; 7.7%). Complications were most likely during the first 6 months after shunt placement.

Conclusion and Clinical Importance

Ventriculoperitoneal shunting is considered a viable treatment option for patients with hydrocephalus. Potential complications should be discussed with the owner. Early diagnosis of complications is essential.

Avoiding the pocket: A case report of coiling of distal shunt catheter into subcutaneous pocket

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Recognize patients with previous surgeries, especially those involving subcutaneous implants.

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Distal shunt catheters must be passed around potential spaces to avoid coiling leading to shunt malfunction.

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Note that if a peritoneal catheter does not pass easily a different approach should be considered.

Introduction

Hydrocephalus is one of the most common disorders of neurosurgery and ventricular shunting, the primary surgical intervention, malfunctions in 85% of patients by 10 years.

Presentation of case

Here we present a case of a 12-year-old girl with history of a vagal nerve stimulator (VNS) and ventricular shunt, most recently revised from ventriculoatrial (VA) to ventriculoperitoneal (VP) shunt at an outside hospital. The patient presented with a new left chest bulge, nausea, emesis, and seizures. Imaging revealed the patient’s distal shunt catheter to have completely migrated and coiled into the VNS subcutaneous pocket. Subsequently, the patient’s distal shunt catheter was externalized, and later internalized back to a VA shunt.

Discussion

Potential spaces from previous surgeries such as VNS can lead to coiling of distal shunt catheters. In this case, the coiled distal shunt catheter led to hydrocephalus and the patient’s presenting symptoms.

Conclusion

It is imperative to recognize patients with previous surgeries, especially those involving subcutaneous implants and to avoid passing of distal shunt catheters through these potential spaces.

Retrograde migration and subcutaneous coiling of the peritoneal catheter of a ventriculoperitoneal shunt in a cat

Case summary Ventriculoperitoneal shunt placement is the most commonly utilised surgical treatment for hydrocephalus in human and veterinary patients. Migration of the peritoneal catheter is an uncommon but well-documented complication in people, usually occurring within the first 3 months postoperatively, although only a single feline case report exists. A ventriculoperitoneal shunt was placed in a domestic shorthair cat, aged 4 years and 10 months, following a diagnosis, with MRI, of unilateral, non-communicating hydrocephalus. Diarrhoea, increased vocalisation and pruritus were reported within the first 3 months postoperatively. A shunt-associated seroma developed, which was aspirated under ultrasound guidance. Within 3 days, the entire peritoneal catheter was subcutaneously coiled at the level of the seroma. The peritoneal catheter was replaced within the abdomen via a new subcutaneous tunnel. No further complications had occurred 24 months following revision surgery.

Relevance and novel information This is the second report describing peritoneal catheter migration in a cat. Repetitive head and neck movements during self-grooming, raised intra-abdominal pressure secondary to vocalisation and tenesmus, and negative pressure exerted during seroma aspiration may have contributed to ventriculoperitoneal shunt migration. Excessive loose skin and increased activity may further increase the risk of migration in cats. Diagnostic imaging should be offered prior to and following aspiration of shunt-associated swellings, and minimal negative pressure should be exerted. Attempts to reduce the frequency of postoperative self-grooming, prevention and prompt treatment of conditions predisposing to raised intra-abdominal pressure and moderate exercise restriction, particularly within the first 3 months, may help reduce the risk of peritoneal catheter migration.

Retroperitoneal, paraspinal migration of distal ventriculoperitoneal shunt catheter: a peculiar complication of cerebrospinal fluid shunt

We describe a case of a ventriculoperitoneal shunt malfunction in which the tip of the peritoneal catheter found its way to the paraspinal subcutaneous tissues. The specific findings on physical examination and the results of the imaging made to make the diagnosis are presented. No prior report of migrating shunt tubing into this anatomic area was found in the literature. This curiosity is added to the list of organs or spaces shunts are capable of wandering into.

Ventriculoperitoneal shunt migration and coiling: A report of two cases

Migration of the proximal and distal catheters of the ventriculoperitoneal shunt is a very rare event. Here, we report two infants with hydrocephalus and ventriculoperitoneal shunt who presented later with shunt coiling and migration. The first infant was admitted with scalp swelling around proximal incision 3 months after shunt insertion and migration and coiling of both ventricular and peritoneal catheters occurred under the scalp at that point. The second patient was referred 1 month after shunting with tense fontanel and vomiting. New brain imaging confirmed the whole shunt inside both lateral ventricles. The possible mechanisms causing this very uncommon complication and the management are explained.

A bizarre reentry phenomenon of distal shunt tip causing shunt malfunction

INTRODUCTION

We report a bizarre presentation of a distal shunt malfunction in a 5-year-old child with a ventriculoperitoneal shunt.

DISCUSSION

The plain radiographs done as a workup for possible shunt malfunction demonstrated the distal shunt tip reentering the abdominal wall from inside the peritoneal cavity. We discuss the possible explanation for the phenomenon.

CONCLUSION

We conclude that the case is just another reminder of the fact that shunt malfunctions can have multiple presentations; hence, a regular follow-up with appropriate imaging and high index of suspicion is mandatory in preventing morbidities.

Subcutaneous migration of distal ventriculoperitoneal shunt catheter caused by abdominal fat pad shift--three case reports

Aberrant migration of a ventriculoperitoneal shunt catheter is an infrequent complication and the mechanism is unclear. We report three cases of subcutaneous migration of the distal catheter. The relationship between thick abdominal fat and catheter migration was suggested in all three cases. Abdominal radiography showed that the subcutaneous fat pad had slid down in the standing position, pulling the catheter out of the peritoneal cavity. We suggest the following mechanisms: Changing from the supine position to the standing position caused subcutaneous fat pad to slide down, the shifted fat pad pulled out the catheter from the peritoneal cavity, and anchoring prevents the catheter returning into the peritoneal cavity. Subcutaneous fat pad shift might act as a "windlass," resulting in coiling of the catheter in the subcutaneous tissue. During daily life, the peritoneal catheter was pulled out repeatedly and finally was coiled within the subcutaneous fat tissue. Placement of the catheter between the subcutaneous fat pad and the abdominal muscle wall will help to avoid this rare complication. This preventive measure is especially recommended for obese patients with a high risk of subcutaneous migration of the peritoneal catheter.

Retrograde migration of ventriculoperitoneal shunt to the neck. Case report

We report a patient, given a ventriculoperitoneal shunt at the neonatal period, who presented with a painless subcutaneous mass on his neck. Plain radiographs of the cervical region showed that the swelling was made up by a migrated and coiled peritoneal catheter. We briefly discuss the proposed mechanism for this complication and suggest that this occurrence must be taken into account at the time of evaluating a patient with shunt malfunction.

Intraventricular migration of VP shunt

The proximal migration of a ventriculoperitoneal shunt into the ventricles is very rare. Only 5 cases have been previously reported [4, 8, 10, 11]. We believe that this unusual phenomenon has not been well-studied in the literature. We report a case of a 16-month-old baby girl who suffered a shunt malfunction due to complete migration of the VP shunt into the lateral ventricle. This case and the other 5 cases are studied, and a possible cause is hypothesized. The group of patients at risk is also identified and methods of management are reported.