Endovascular Intervention for Repositioning the Distal Catheter of Ventriculo-Atrial Shunt

Abstract

Ventriculoperitoneal (VP) shunt is the preferred modality for the diversion of the cerebrospinal fluid (CSF) in the treatment of hydrocephalus. However, shunting of fluid into atrial cavity should be sought for if the VP shunt fails due to intraabdominal adhesion, local infections and scarring from the previous surgery, blockage at the peritoneal or ventricular end, shunt infection, intraabdominal pseudocyst formation, fracture, dislodgement and migration of the tubing, and bowel perforation [1]. Appropriate placement of catheter is very important to prevent the serious complications associated with ventriculoatrial (VA) shunt [2]. With complex venous anatomy in the neck, more so of the left side, catheter tip could be misplaced. We present a case that the misplaced distal tip of VA shunt was successfully managed with endovascular intervention via femoral vein. CASE REPORT A 33-year-old male was referred to our hospital with infection of the distal end of the catheter 20 days after the ventriculoperitoneal shunt. He has a past history of head injury in a road traffic accident six months ago. He presented with loss of consciousness and right temporal lobe uncal herniation. CT scan revealed right temporal lobe contusion with hematoma. Emergency craniotomy was performed for drainage of hematoma with decompressive craniectomy. Postoperative period was marked by lost consciousness. A left ventricu-loperitoneal shunt was performed for traumatic hydrocephalus. Cranioplasty was accomplished after three months of decompressive craniectomy. On postoperative day 15, the patient experienced fever with temperature of 39℃ with increased intracranial tension. CT scan revealed recurrence of hydroce-phalus. Blockage of peritoneal end of catheter was confirmed followed by replacement. Catheter tip was positive for staphylococcus epidermis infection. Peritoneal fluid did not show any infection. He was Neurointervention 7, Displacement of distal ventriculo-atrial (VA) shunt is not uncommon. However, misplacement of the distal catheter of VA shunt in the internal jugular vein is a possibility, especially when conducted without intraoperative monitoring. We describe a patient in whom a VA shunt was performed due to failure of ventriculo-peritoneal shunt and the distal catheter of the shunt was found to be misplaced in the left internal jugular vein. Endovascular intervention via femoral vein was used to retrieve the distal catheter.