Intracardial Catheter Migration of a Ventriculoperitoneal Shunt: Pathophysiology and Interdisciplinary Management

Ventriculoperitoneal shunt migration into the pulmonary artery: Case report and literature review

Cerebrospinal fluid (CSF) shunt placement is a commonly performed procedure for patients with hydrocephalus of various etiologies. We present the case of a 68-year-old male patient treated with a ventriculoperitoneal shunt for obstructive hydrocephalus management. Eight years later, a computed tomography (CT) scan detected migration of distal catheter into the pulmonary artery. We conducted a systematic review in Medline database using PubMed search engine to identify previous cases and their management. Our literature review identified eighteen single case reports describing this complication and different strategies to attempt catheter retrieval. To the best authors' knowledge, this is the first case where conservative management was chosen.

A case of intestinal perforation with a residual shunt tube placed during childhood: should we remove the non-functioning tube?

We report a 22-year-old man who had abdominal shunt tube migration into colon. He was diagnosed with pilocytic astrocytoma at optic-chiasm to hypothalamus at age of 7, and treated by resection, chemotherapy, and irradiation. He developed hydrocephalus and had multiple ventriculo-peritoneal shunt surgery. At age of 19, he fell in coma due to the subarachnoid and intra-ventricular hemorrhage due to the aneurysm rupture. The ventricle tube was removed, leaving the shunt valve and abdominal tube. The new shunt system was reconstructed at the contralateral side. He was at bed rest after this episode. At age of 20, he had high fever unable to control with antibiotics. The abdominal computed tomogram showed the shunt tube migration in the descending colon. The tube was removed under laparoscopy, and the inflammation was cured. The abandoned peritoneal shunt tube should be removed in patients with high tube migration risks.

Delayed peritoneal shunt catheter migration into the pulmonary artery with indolent thrombosis: A case report and narrative review

Background:

Ventriculoperitoneal (VP) shunts are the preferred surgical treatment for hydrocephalus, and rarely, these operations may be complicated by catheter migration to ectopic sites. We present the case of an asymptomatic VP shunt patient with delayed peritoneal catheter migration into the pulmonary artery shunt catheter migration into the pulmonary artery (SCMPA) complicated by knotting and indolent thrombosis, necessitating open-heart surgery for system retrieval.

Methods:

We conducted a literature review in PubMed, Scopus, and Web of Science of prior similar reported cases and present the results of 24 cases of SCMPA.

Results:

An asymptomatic 12-year-old male presented with SCMPA noted on routine annual follow-up imaging. Preoperative CT angiogram indicated extensive catheter looping into the pulmonary artery without evidence of thrombosis. Less invasive attempts to retrieve the retained catheter were unsuccessful, and open-heart surgery was required. Intraoperatively, a nonocclusive pulmonary arterial thrombus surrounding the knotted catheter was discovered that was lysed successfully before system retrieval.

Conclusion:

VP shunt catheter migration into the pulmonary artery (SCMPA) with concurrent large vessel thrombosis can develop in pediatric patients incidentally without any clinical symptoms. Our report suggests that preoperative CT angiogram may be insufficient to detect arterial thrombosis in the presence of extensive intravascular catheter knotting. An open-chest approach may be the only viable surgical option for catheter retrieval in the presence of complex catheter coiling. The use of anticoagulation following open-heart surgery for retrieval of a migrated VP shunt catheter remains unclear, we here propose that continuation of long-term therapeutic anticoagulation may successfully prevent thrombus relapse.

Upward spontaneous migration of ventriculoperitoneal shunt into the heart: A case report summary

A male infant with a history of ventriculoperitoneal (VP) implantation due to congenital hydrocephalus presented with fever and lethargy at the age of 8 month-old. Pericardial effusion was detected in transthoracic echocardiography, and he underwent pericardial window operation and was discharged in a stable condition. At 11 months of age, he presented again with fever, lethargy, recurrent vomiting, and respiratory distress. In both plain chest radiography and transthoracic echocardiography, VP shunt migration to the heart cavity was observed. The VP shunt had entered into the right ventricle after perforating the diaphragm and pericardium. The patient underwent open-heart surgery due to vegetation at the tip of the VP shunt inside the right heart. Vegetation was removed and the tip of the shunt was returned to the peritoneal cavity. Two weeks after discharge, the patient presented again with symptoms of tachypnea and lethargy. The imaging revealed the entry of the VP shunt about two centimeters into the anterior mediastinum. The patient was transferred to the operation room and the VP shunt was shortened and re-inserted into the peritoneal cavity. Antibiotic treatment was continued for six weeks and the patient was discharged in stable condition. In follow-up visits after two years, the VP shunt functioned well and no particular complication was observed. This case demonstrates that in patients with VP shunt implantation presenting with pulmonary and cardiac symptoms such as respiratory distress, pericardial effusion, and cardiac tamponade after VP shunt implantation, the possibility of VP shunt catheter migration to the mediastinal cavity should be considered.

Thoracic abscess due to unusual migration of a ventriculoperitoneal shunt and literature review

Background:

Thoracic complications of ventriculoperitoneal (VP) cerebrospinal fluid shunting are rare and the diagnosis is difficult without neurological impairment.

Case Description:

We report a case of a 36-year-old woman who had a VP shunt in the right side when she was 13 years for a posterior fossa ependymoma and hydrocephalus. 23 years after surgery, she developed acute yellowfish cough and sputum, and the computed tomography scan found an intrathoracic cyst. She had a thoracotomy for the cyst and during surgery, we found the peritoneal catheter of the VP shunt, with a collected abscess in the left side. The patient was treated for the abscess and the VP shunt was removed. We also review the literature cases of thoracic complications after VP shunts.

Conclusion:

Thoracic abscess due to VP shunt migration is extremely rare and could happen after a long time delay VP shunt surgery.

Spontaneous Migration of a Ventriculoperitoneal Shunt into the Venous System: A Multidisciplinary Approach

Ventriculoperitoneal shunt catheter migration is a rare but documented complication. The exact mechanism of this occurrence is not well understood. We report the case of an 81-year-old male who initially presented with symptoms consistent with normal pressure hydrocephalus. A ventriculoperitoneal shunt was placed uneventfully. Four months later, the patient presented complaining of a persistent headache despite multiple adjustments in the shunt setting. Shunt series radiographs demonstrated the distal catheter passing through the superior vena cava and looping into the right cardiac atrium and ventricle. Catheter retrieval was attempted from a proximal retroauricular incision but required a combination of snare technique by interventional radiology and, ultimately, surgical venotomy by a cardiothoracic surgeon. The distal catheter was replaced in the abdomen, and the patient had no further complications. This case is the first of its kind reported in the literature that includes a treatment team comprising neurosurgery, interventional radiology, and cardiothoracic surgery. We highlight the importance of a multidisciplinary approach to best address the migrated catheter.