Distal catheter migration of a direct ventriculo-auricular shunt

Abstract

Dear Editor, Surgery for cerebrospinal fluid (CSF) shunts is one of the most frequently performed procedures in neurosurgery [1,3]. However, 20-40 % of complications require revision surgery within the first year [3,9]. The first choice for the placement of the distal catheter is the peritoneal cavity, but distal catheter placement to the venous system can be achieved by cannulating, e.g., the internal jugular vein as well. Nevertheless, infection, thrombosis, or glomerulonephritis can necessitate alternate sites of distal catheter placement. If traditional placement sites of the distal catheter are not suitable, direct placement into the right auricle could be considered.A 34-year-old male patient with a history of internal hydrocephalus had received a ventriculo-atrial shunt (VA-shunt) 3 months after birth. He underwent four revisions with both VA-and ventriculo-peritoneal shunts (VP-shunt). His past medical history was remarkable for multiple abdominal surgeries including two kidney transplantations. The patient presented with evidence of peritonitis and hydrocephalus and cranial computed tomography (cCT) showed increased ventricle size. Abdominal ultrasound revealed massive ascites, therefore the distal catheter of the VP shunt was removed, the shunt was externalized, and the patient received antibiotics until recovery from peritonitis. A CT angiogram revealed extensive venous thrombosis and the peritoneal cavity was no longer an option due to previous failure. Concerning the need of 300 ml of CSF drainage per day and the high risk of pleural effusion due to renal insufficiency, pleural catheter placement seemed to be unsuitable as well. Therefore the direct placement of the distal catheter into the right atrium in cooperation with a cardiac surgeon appeared to be the most feasible option.The ventricular catheter was replaced and connected with a burr hole reservoir, an adjustable valve, and adjustable shunt assistant. The thoracotomy was performed and the right lung was deflated, allowing smooth retraction of the lung and exposure of the pericardium. A sub-cutaneous tunnel was constructed from the thoracotomy to a subclavian skin incision where the atrial catheter was inserted. The pericardium was incised and after placement of a felt-reinforced purse string suture, the auricle was opened and the cardiac catheter was placed into the right atrium. After verifying the placement, an additional anchorage to the pericardium was applied by using a plastic catheter fixation (Fig. 1). The amply chosen atrial catheter was fed through the subcutaneous tunnel and connected to the proximal catheter.Postoperative radiograph and cCT showed proper catheter placement and decreased ventricle size. Two months after discharge, the patient presented with right thoracic pain. A chest CT revealed pleural effusion and migration of the atrial catheter to the pleural cavity. Since there were no clinical or radiographic signs of hydrocephalus, the clinical team decided to observe the patient and to avoid a revision surgery. Subsequen...