Migration of a Ventriculoperitoneal Shunt into the Pulmonary Vasculature: Case Report, Review of the Literature, and Surgical Pearls

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.

Distal Ventriculoperitoneal Shunt Catheter Migration into the Pulmonary Vasculature and Cardiac Chamber: A Case Report

Ventriculoperitoneal shunting is the most common neurosurgical procedure for treatment of hydrocephalus. Shunt-related complications are relatively common and associated with a high rate of shunt revision. However, migration of the distal ventriculoperitoneal shunt, especially into the cardiac and intravascular regions, has rarely been reported. Awareness of this rare but potentially hazardous complication is important owing to its significant morbidity, which can be prevented by prompt management. Here, we introduce a case of a 23-year-old male with migration of the distal shunt catheter through the left internal jugular vein into the cardiac chamber and both pulmonary arteries, which occurred 2 months after receiving ventriculoperitoneal shunting. Furthermore, we discuss the possible mechanisms and management of this condition.

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.

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.

Clinical Study of Cranioplasty Combined With Ipsilateral Ventriculoperitoneal Shunt in the Treatment of Skull Defects With Hydrocephalus

OBJECTIVE

To explore the clinical effect and safety of cranioplasty combined with ipsilateral ventriculoperitoneal shunts in the treatment of skull defects with hydrocephalus.

METHODS

The clinical data of 78 patients with skull defects with hydrocephalus were analyzed retrospectively. All patients were treated with cranioplasty and ventriculoperitoneal shunts in 1 stage, including 35 cases of cranioplasty combined with ipsilateral ventriculoperitoneal shunts (ipsilateral operation group) and 43 cases of contralateral operations (contralateral operation group).

RESULTS

The incision length (28.97 ± 4.55 cm), operation time (139.00 ± 42.27 minutes), and intraoperative hemorrhage (174.57 ± 79.35 mL) in the ipsilateral operation group were significantly better than those in the contralateral operation group (respectively they were 37.15 ± 5.83 cm, 214.07 ± 34.35 minutes, and 257.21 ± 72.02 mL), and the difference was statistically significant (t = 6.786, 8.656, and 4.815, all P < 0.05). The degree of postoperative hydrocephalus was significantly improved in both groups, but there was no statistically significant difference in the degree of hydrocephalus between the 2 groups (P > 0.05). Among the postoperative complications, there was no statistically significant difference in infection, epilepsy, subdural effusion, titanium plate effusion, or excessive cerebrospinal fluid drainage between the 2 groups (P > 0.05), but the incidence of intracranial hemorrhage in the ipsilateral operation group (2.86%) was significantly lower than that in the contralateral operation group (20.93%, χ2 = 4.138, P = 0.042). The postoperative Glasgow Coma Scale scores of the 2 groups were improved compared with those before the operation (P < 0.05), and there was no statistically significant difference in the postoperative Glasgow Coma Scale scores (P > 0.05). At 6 months after surgery, there was no statistically significant difference in Glasgow Outcome Scale effectiveness between the 2 groups (χ2 = 0.005, P = 0.944).

CONCLUSIONS

Cranioplasty combined with ipsilateral ventriculoperitoneal shunt has the same therapeutic effect as a contralateral operation, but it has the advantage of a short operation time, less intraoperative trauma, less bleeding, and less risk of intracranial hemorrhage, which is suitable for clinical applications.

An unusual cause of shunt failure requiring multidisciplinary treatment

Rarer etiologies of shunt malfunction may be difficult to detect, can present insidiously, and often require a multidisciplinary approach to safely and effectively address.

Systemic Antimicrobial Prophylaxis and Antimicrobial-Coated External Ventricular Drain Catheters for Preventing Ventriculostomy-Related Infections: A Meta-Analysis of 5242 Cases

BACKGROUND

External ventricular drain (EVD) placement is essential for the management of many neurocritical care patients. However, ventriculostomy-related infection (VRI) is a serious complication, and there remains no well-established protocol guiding use of perioperative or extended antibiotic prophylaxis to minimize risk of VRI.

OBJECTIVE

To analyze published evidence on the efficacy of extended prophylactic antimicrobial therapy and antibiotic-coated external ventricular drains (ac-EVDs) in reducing VRI incidence.

METHODS

We searched PubMed for studies related to VRIs and antimicrobial prophylaxis. Eligible articles reported VRI incidence in control and treatment cohorts evaluating prophylaxis with either extended systemic antibiotics (> 24 hr) or ac-EVD. Risk ratios and VRI incidence were aggregated by prophylactic strategy, and pooled estimates were determined via random or mixed effects models. Study heterogeneity was quantified using I2 and Cochran's Q statistics. Rigorous assessment of study bias was performed, and PRISMA guidelines were followed throughout.

RESULTS

Across 604 articles, 19 studies (3%) met eligibility criteria, reporting 5242 ventriculostomy outcomes. Extended IV and ac-EVD prophylaxis were associated with risk ratios of 0.36 [0.14, 0.93] and 0.39 [0.21, 0.73], respectively. Mixed effects analysis yielded expected VRI incidence of 13% to 38% with no prophylaxis, 7% to 18% with perioperative IV prophylaxis, 3% to 9% with either extended IV or ac-EVD prophylaxis as monotherapies, and as low as 0.8% to 2% with extended IV and ac-EVD dual prophylaxis.

CONCLUSION

Management with both extended systemic antibiotics and ac-EVDs could lower VRI risk in ventriculostomy patients, but the impact on associated morbidity and mortality, healthcare costs, and length of stay remain unclear.

Inguinal Extrusion of a Ventriculoperitoneal Shunt

BACKGROUND

Complications of ventriculoperitoneal (VP) shunts include migration into various anatomic compartments and even extrusion through tissue layers.

CASE DESCRIPTION

A 31-year-old female patient with a VP shunt presented with distal shunt tubing extruding through the skin at the level of the inguinal ligament. Shunt hardware was removed, and cultures grew Dermacoccus. The patient was treated with broad-spectrum antibiotics and underwent placement of a lumboperitoneal shunt.

CONCLUSIONS

Dermacoccus is a gram-positive skin organism with rare human pathogenicity and not previously known to cause shunt infections.

Exteriorization of the distal catheter for ventriculoperitoneal shunt protruding through the peritoneal space: experience with 1 case

Ventriculoperitoneal (VP) shunting is the most widely used procedure for diverting cerebrospinal fluid (CSF) for hydrocephalus. Migration of the distal catheter of VP shunts has been reported but extrusion through the abdominal wall is rare. We report a case involving distal catheter extrusion. The catheter was exteriorized without compromising CSF flow while awaiting reoperation. This controlled hydrocephalus and allowed confirmation of CSF sterility prior to shunt replacement.

Migration of a Distal Ventriculoperitoneal Shunt Catheter Into the Pulmonary Vasculature: a Report of an Unusual Case and a Review of the Literature

The authors report an unusual case of distal ventriculoperitoneal shunt catheter into the pulmonary vasculature. The migrated catheter was extracted through a thoracotomy and venotomy, with the cooperation of Neuroneurosurgery and Cardiovascular team. This rare complication after ventriculoperitoneal shunt surgery should be paid enough attention. There were 2 possible mechanisms. To solve the problem, multidisciplinary cooperation should be applied.

Sepsis Caused by Bacterial Colonization of Migrated Distal Ventriculoperitoneal Shunt Catheter into the Pulmonary Artery: A First Case Report and Literature Review

BACKGROUND

Migration of distal ventriculoperitoneal (VP) shunt catheter into another body part has been described as a potentially serious surgical complication. We present the first case of sepsis caused by transcardial and pulmonary migration of a distal catheter into the heart and pulmonary artery, which was subsequently colonized by Klebsiella pneumoniae.

CASE REPORT

A 56-year-old man underwent VP shunt insertion for hydrocephalus that developed after the surgery for intracranial meningioma. Three years later, he was admitted to department for infectious diseases because of persistent fever. Klebsiella pneumoniae was isolated from the blood cultures. Computed tomography (CT) of the thorax showed migration of the distal catheter into the heart and pulmonary artery. The migrated shunt catheter was retrieved without any complication with the assistance of a cardiovascular surgeon; microbiologic analysis confirmed that the catheter was colonized with K. pneumoniae. We decided to delay new VP shunt placement because of the positive blood cultures, and 3 weeks after the surgery, the patient was without signs of increased intracranial pressure and without any heart problems.

CONCLUSION

Migration of a distal VP shunt catheter into the heart should be considered in patients with a previously placed VP shunt presenting with cardiopulmonary problems, arrhythmia, and/or fever. Neurosurgeons should be involved as soon as possible, and a multidisciplinary approach is warranted.

Case report of migration of 2 ventriculoperitoneal shunt catheters to the scrotum: Use of an inguinal incision for retrieval, diagnostic laparoscopy and hernia repair

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A ventriculoperitoneal shunt catheter migrated through an inguinal hernia into the scrotum.

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A single incision was used to for diagnostic laparoscopy, catheter removal and hernia repair.

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Prompt surgical removal of fractured shunt catheters is recommended to prevent organ injury.

Backgroud

Ventriculoperitoneal shunts are commonly used in the treatment of hydrocephalus, and catheter migration to various body sites has been reported. Pediatric and general surgeons are asked on occasion to assist with intraabdominal access for these shunts, particularly when there may be extensive adhesions or other complicating factors.

Methods

We describe a case in which an old shunt catheter was never removed from the abdomen, and it migrated through an inguinal hernia into the scrotum. The catheter became entangled and fibrosed to the testicle. A second and more recent shunt catheter was also in the scrotum. A single incision in the inguinal region was used to remove both shunt catheters, repair the inguinal hernia and perform diagnostic laparoscopy to assist in placing a new ventriculoperitoneal shunt.

Results

Prompt surgical removal is recommended for catheters remaining in the abdomen after ventriculoperitoneal shunt malfunction. These catheters may cause injury to the testicle, or possibly other intraabdominal organs. General or pediatric surgical consultation should be obtained for lost catheters or inguinal hernias.

Conclusion

In the case of an inguinal hernia containing a fractured shunt catheter, the hernia sac can be used to remove the catheter, repair the hernia and gain laparoscopic access to the abdomen to assist with shunt placement.