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Introduction: Alternate approaches such as ventriculoatrial (VA) or ventriculopleural (VPL) procedures still have a place in the surgical armamentarium for patients with recurrent ventriculoperitoneal (VP) shunt failures related to defective absorption, infections, or frequent malfunctions. Methods: We reviewed the literature and our experience with these techniques, and offered suggestions for safely performing these operations. Historical perspectives were also included to facilitate an improved understanding of the technical developments. Results: Our findings and the available medical literature suggest VA and VPL options are safe and effective alternatives for managing the complex patient with hydrocephalus. Potential issues and complications were discussed along the technical advances for a safer operation. Conclusion: The VA and VPL options should be considered for patients with recurrent VP shunt issues. They are safe and effective options for managing complex hydrocephalus patients.

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