P.207 Reducing the risks of proximal and distal shunt failure in adult
                        hydrocephalus: A Shunt Outcomes Quality Improvement (ShOut-QI) Study

Background: Ventriculoperitoneal (VP) shunt failures in adult patients are common and subject patients to multiple surgeries and a decreased quality of life. A prospective cohort Shunt Outcomes Quality Improvement (ShOut-QI) initiative was implemented to reduce shunt failure incidence through neuronavigation-assisted proximal catheter insertion and laparoscopy-guided distal catheter anchoring over the liver dome to drain CSF away from the omentum. Methods: “Pre-ShOut” and “Post-ShOut” groups of patients included those with and without neuronavigation/laparoscopy, respectively for insertion of a new VP shunt. The primary outcome was shunt failure which was defined as any return to surgery for shunt revision as determined with a standardized clinical and radiology follow-up protocol. Results: 244 patients (97 Pre-ShOut, 147 Post-ShOut), mean age 73 years, were enrolled over a 7-year interval and observed for a mean duration of 4 years after shunt insertion. Neuronavigation improved proximal catheter placement accuracy by 20% (p<.001), and shunt failure occurred in 57% vs 23% in the Pre-ShOut and Post-ShOut groups, respectively (p=.008), representing a 53% relative risk reduction in the incidence of shunt failure. Conclusions: Adult shunt failure incidence may be significantly reduced by improving the accuracy of proximal catheter placement with neuronavigation and reducing the risk of distal catheter failure with laparoscopic-guided placement.

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Reducing the risks of proximal and distal shunt failure in adult hydrocephalus: a shunt outcomes quality improvement study

Journal of Neurosurgery ◽

10.3171/2021.2.jns202970 ◽

2021 ◽

pp. 1-10

Author(s):

Albert M. Isaacs ◽

Chad G. Ball ◽

Nicholas Sader ◽

Sandeep Muram ◽

David Ben-Israel ◽

...

Keyword(s):

Quality Improvement ◽

Infection Prevention ◽

Shunt Infection ◽

Failure Rates ◽

Shunt Failure ◽

Shunt Surgery ◽

Distal Catheter ◽

Vp Shunt ◽

Catheter Failure ◽

Prevention Protocol

OBJECTIVE Patient outcomes of ventriculoperitoneal (VP) shunt surgery, the mainstay treatment for hydrocephalus in adults, are poor because of high shunt failure rates. The use of neuronavigation or laparoscopy can reduce the risks of proximal or distal shunt catheter failure, respectively, but has less independent effect on overall shunt failures. No adult studies to date have combined both approaches in the setting of a shunt infection prevention protocol to reduce shunt failure. The goal of this study was to determine whether combining neuronavigation and laparoscopy with a shunt infection prevention strategy would reduce the incidence of shunt failures in adult hydrocephalic patients. METHODS Adult patients (age ≥ 18 years) undergoing VP shunt surgery at a tertiary care institution prior to (pre–Shunt Outcomes [ShOut]) and after (post-ShOut) the start of a prospective continuous quality improvement (QI) study were compared. Pre-ShOut patients had their proximal and distal catheters placed under conventional freehand approaches. Post-ShOut patients had their shunts inserted with neuronavigational and laparoscopy assistance in placing the distal catheter in the perihepatic space (falciform technique). A shunt infection reduction protocol had been instituted 1.5 years prior to the start of the QI initiative. The primary outcome of interest was the incidence of shunt failure (including infection) confirmed by standardized criteria indicating shunt revision surgery. RESULTS There were 244 (115 pre-ShOut and 129 post-ShOut) patients observed over 7 years. With a background of shunt infection prophylaxis, combined neuronavigation and laparoscopy was associated with a reduction in overall shunt failure rates from 37% to 14%, 45% to 22%, and 51% to 29% at 1, 2, and 3 years, respectively (HR 0.44, p < 0.001). Shunt infection rates decreased from 8% in the pre-ShOut group to 0% in the post-ShOut group. There were no proximal catheter failures in the post-ShOut group. The 2-year rates of distal catheter failure were 42% versus 20% in the pre- and post-ShOut groups, respectively (p < 0.001). CONCLUSIONS Introducing a shunt infection prevention protocol, placing the proximal catheter under neuronavigation, and placing the peritoneal catheter in the perihepatic space by using the falciform technique led to decreased rates of infection, distal shunt failure, and overall shunt failure.

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ENDOSCOPIC THIRD VENTRICULOSTOMY (ETV) IS A BETTER ALTERNATIVE FOR VP SHUNT FAILURE IN NON-COMMUNICATING HYDROCEPHALUS

10.36106/ijar/9302582 ◽

2021 ◽

pp. 65-67

Author(s):

Ramesh Tanger ◽

Dinesh Kumar Barolia ◽

Arka Chatterjee ◽

Punit Singh Parihar ◽

Arun Gupta

Keyword(s):

Success Rate ◽

Endoscopic Third Ventriculostomy ◽

Obstructive Hydrocephalus ◽

Shunt Revision ◽

Third Ventriculostomy ◽

Communicating Hydrocephalus ◽

Shunt Failure ◽

Shunt Insertion ◽

Vp Shunt

CONTEXT: VP Shunt is most commonly used procedure for hydrocephalus but shunt failure is also the common complication in many patients. Endoscopic third ventriculostomy (ETV) is an accepted procedure for the treatment of obstructive hydrocephalus. The aim of our study is to evaluate the success rate AIM AND OBJECTIVE - of ETV in patients of obstructive hydrocephalus formerly treated by ventriculo-peritoneal (VP shunt) shunt. The failure VP shunt was removed before ETV. MATERIALS AND METHOD: This study was conducted between June 2015 and December 2019 in single unit of our department. Twenty one (n=21) patients were enrolled for this study. All patients were admitted with failure of VP shunt. They were known case of non-communicating hydrocephalus previously operated for VP shunt. Six patients were excluded for ETV because CT/MRI show grossly distorted anatomy of ventricles. Endoscopic third ventriculostomy was attempted in 15 patients, but ventriculostomy was done successfully in 10 patients, rests were treated with revision of VP shunt. All patients in this study were radiologically diagnosed RESULTS: case of hydrocephalus due to aqueduct stenosis. They were experienced VP shunt insertion but there were failure of shunt due to any reason. ETV procedures were done successfully in 10 patients. Out of 10 patients one patient needed shunt insertion due ineffective ETV. Shunt revision was done in 11 patients. There was no serious complication during and after ETV procedures. The follow-up period of patients with successful ETV was 6–60 months. This follow-up was uneventful and peaceful for their parents. ETV can be considered as an alternative treatment for the patients w CONCLUSION: ith VP shunt failure with an acceptable success rate of 80%, although long-term follow-up is needed for these patients.

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The Preventable Shunt Revision Rate: a potential quality metric for pediatric shunt surgery

Journal of Neurosurgery Pediatrics ◽

10.3171/2015.12.peds15388 ◽

2016 ◽

Vol 18 (1) ◽

pp. 7-15 ◽

Cited By ~ 15

Author(s):

Garrett T. Venable ◽

Nicholas B. Rossi ◽

G. Morgan Jones ◽

Nickalus R. Khan ◽

Zachary S. Smalley ◽

...

Keyword(s):

Risk Factors ◽

Operating Room ◽

Revision Surgery ◽

Revision Rate ◽

Catheter Placement ◽

Shunt Revision ◽

Shunt Failure ◽

Shunt Surgery ◽

Distal Catheter ◽

Quality Metric

OBJECTIVE Shunt surgery consumes a large amount of pediatric neurosurgical health care resources. Although many studies have sought to identify risk factors for shunt failure, there is no consensus within the literature on variables that are predictive or protective. In this era of “quality outcome measures,” some authors have proposed various metrics to assess quality outcomes for shunt surgery. In this paper, the Preventable Shunt Revision Rate (PSRR) is proposed as a novel quality metric. METHODS An institutional shunt database was queried to identify all shunt surgeries performed from January 1, 2010, to December 31, 2014, at Le Bonheur Children's Hospital. Patients' records were reviewed for 90 days following each “index” shunt surgery to identify those patients who required a return to the operating room. Clinical, demographic, and radiological factors were reviewed for each index operation, and each failure was analyzed for potentially preventable causes. RESULTS During the study period, there were 927 de novo or revision shunt operations in 525 patients. A return to the operating room occurred 202 times within 90 days of shunt surgery in 927 index surgeries (21.8%). In 67 cases (33% of failures), the revision surgery was due to potentially preventable causes, defined as inaccurate proximal or distal catheter placement, infection, or inadequately secured or assembled shunt apparatus. Comparing cases in which failure was due to preventable causes and those in which it was due to nonpreventable causes showed that in cases in which failure was due to preventable causes, the patients were significantly younger (median 3.1 vs 6.7 years, p = 0.01) and the failure was more likely to occur within 30 days of the index surgery (80.6% vs 64.4% of cases, p = 0.02). The most common causes of preventable shunt failure were inaccurate proximal catheter placement (33 [49.3%] of 67 cases) and infection (28 [41.8%] of 67 cases). No variables were found to be predictive of preventable shunt failure with multivariate logistic regression. CONCLUSIONS With economic and governmental pressures to identify and implement “quality measures” for shunt surgery, pediatric neurosurgeons and hospital administrators must be careful to avoid linking all shunt revisions with “poor” or less-than-optimal quality care. To date, many of the purported risk factors for shunt failure and causes of shunt revision surgery are beyond the influence and control of the surgeon. We propose the PSRR as a specific, meaningful, measurable, and—hopefully—modifiable quality metric for shunt surgery in children.

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Risk of early failure of VP shunts implanted for hydrocephalus after craniotomies for brain tumors in adults

Neurosurgical Review ◽

10.1007/s10143-021-01549-7 ◽

2021 ◽

Author(s):

Sayied Abdol Mohieb Hosainey ◽

John K. Hald ◽

Torstein R. Meling

Keyword(s):

Brain Tumors ◽

Median Time ◽

Statistical Significance ◽

Tumor Resection ◽

Shunt Revision ◽

Shunt Failure ◽

Survival Times ◽

Shunt Insertion ◽

Vp Shunt ◽

Significant Difference

AbstractRisks and survival times of ventriculoperitoneal (VP) shunts implanted due to hydrocephalus after craniotomies for brain tumors are largely unknown. The purpose of this study was to determine the overall timing of VP shunting and its failure after craniotomy for brain tumors in adults. The authors also wished to explore risk factors for early VP shunt failure (within 90 days). A population-based consecutive patient cohort of all craniotomies for intracranial tumors leading to VP shunt dependency in adults (> 18 years) from 2004 to 2013 was studied. Patients with pre-existing VP shunts prior to craniotomy were excluded. The survival time of VP shunts, i.e., the shunt longevity, was calculated from the day of shunt insertion post-craniotomy for a brain tumor until the day of shunt revision requiring replacement or removal of the shunt system. Out of 4774 craniotomies, 85 patients became VP shunt-dependent (1.8% of craniotomies). Median time from craniotomy to VP shunting was 1.9 months. Patients with hydrocephalus prior to tumor resection (N = 39) had significantly shorter time to shunt insertion than those without (N = 46) (p < 0.001), but there was no significant difference with respect to early shunt failure. Median time from shunt insertion to shunt failure was 20 days (range 1–35). At 90 days, 17 patients (20%) had confirmed shunt failure. Patient age, sex, tumor location, primary/secondary craniotomy, extra-axial/intra-axial tumor, ventricular entry, post-craniotomy bleeding, and infection did not show statistical significance. The risk of early shunt failure (within 90 days) of shunts after craniotomies for brain tumors was 20%. This study can serve as benchmark for future studies.

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Ventriculoperitoneal shunt failure causing myelopathy in a patient with bilateral jugular vein occlusion

Journal of Neurosurgery Spine ◽

10.3171/spi.2007.6.1.60 ◽

2007 ◽

Vol 6 (1) ◽

pp. 60-63 ◽

Cited By ~ 10

Author(s):

William E. Humphries ◽

Peter M. Grossi ◽

Linda G. Liethe ◽

Timothy M. George

Keyword(s):

Spinal Cord ◽

Ct Angiography ◽

Jugular Vein ◽

Cervical Spinal Cord ◽

Venous Drainage ◽

Shunt Revision ◽

Shunt Failure ◽

Vp Shunt ◽

Physiological Importance ◽

Vein Occlusion

✓The authors describe the case of a 36-year-old woman with bilateral internal jugular vein occlusion, hydrocephalus, and Dandy–Walker variant who presented with myelopathy that was ultimately attributed to ventriculoperitoneal (VP) shunt failure. Computed tomography (CT) angiography of the head and neck revealed epidural venous engorgement within the cervical spine, greater that 50% narrowing of the C2–5 spinal canal, and compression of the cervical spinal cord. After successful shunt revision, postoperative CT angiography revealed decreased venous engorgement as well as decompression of the cervical spinal cord, and the patient’s myelopathy improved. This case represents a fascinating clinical presentation of VP shunt failure, highlighting the physiological importance of the external jugular pathways involved in cerebral venous drainage.

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Transesophageal Echocardiography-Guided Ventriculoatrial Shunt Insertion

Operative Neurosurgery ◽

10.1093/ons/opz353 ◽

2019 ◽

Vol 19 (1) ◽

pp. 25-31

Author(s):

Albert McAnsah Isaacs ◽

Danae Krahn ◽

Andrew M Walker ◽

Heather Hurdle ◽

Mark G Hamilton

Keyword(s):

Transesophageal Echocardiography ◽

Perioperative Complications ◽

Superior Vena ◽

Vena Cava ◽

Shunt Revision ◽

Shunt Valve ◽

Shunt Insertion ◽

Distal Catheter ◽

Shunt Placement ◽

Time Required

Abstract BACKGROUND Determining an optimal location within the right atrium (RA) for placement of the distal ventriculoatrial (VA) shunt catheter offer several operative challenges that place patients at risk for perioperative complications and downstream VA shunt failure. Utilizing transesophageal echocardiography (TEE) guidance to place distal VA shunt catheters may help to circumvent these risks. OBJECTIVE To review our current practice of VA shunt insertion using TEE guidance. METHODS A retrospective review of all consecutive patients who underwent VA shunt procedures between December 19, 2016 and January 22, 2019, during which time intraoperative TEE was used for shunt placement was performed. Data on the time required for shunt placement and total procedure time, baseline echocardiography findings, and short- and long-term complications of shunt placement were assessed. RESULTS A total of 33 patients underwent VA shunt procedures, with a median follow-up time of 250 (88-412) d. The only immediate complication related to shunt placement or TEE use was transient ectopy in 1 patient. The mean time for atrial catheter insertion was 12.6 ± 4.8 min. Right-heart catheters were inserted between the RA-superior vena cava junction and 22 mm within the RA in all but 3 procedures. A total of 7/33 patients (21%) underwent shunt revision. Indications for revisions included distal clots, proximal obstruction, positive blood culture, and shunt valve revision. No other complications of VA shunt insertion were reported. CONCLUSION VA shunt insertion using TEE allows for precise distal catheter placement. Early patient experience confirms this technique has a low complication rate.

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Pericardial tamponade by Holter ventriculoatrial shunts

Journal of Neurosurgery ◽

10.3171/jns.1971.35.6.0695 ◽

1971 ◽

Vol 35 (6) ◽

pp. 695-699 ◽

Cited By ~ 11

Author(s):

Stavros Tsingoglou ◽

Herbert B. Eckstein

Keyword(s):

Pericardial Tamponade ◽

Shunt Revision ◽

Shunt Insertion ◽

Distal Catheter ◽

Revision Procedure ◽

Content Type ◽

Cardiac Perforation ◽

Cardiac Wall ◽

Cardiac Silhouette ◽

Fine Print

✓ Ten cases of cardiac tamponade caused by pericardial perforation by a Holter catheter in the treatment of hydrocephalus by ventriculoatrial drainage are reported. These 10 cases occurred in an 8-year practice of two surgeons in a period during which approximately 1800 Holter shunts were inserted and an approximately equal number of operations for lengthening of the distal catheter were performed. The etiological factors, the clinical picture, and the diagnosis are discussed. Cardiac perforation is caused either by forceful introduction of the distal catheter during a shunt revision procedure or by too long a distal catheter that ulcerates through the cardiac wall. Enlargement of cardiac silhouette after shunt insertion is virtually diagnostic of a pericardial effusion. If undiagnosed, this condition was invariably fatal, but if diagnosed in time, immediate treatment was always curative. The distal catheter should be shortened, but suture of the cardiac perforation itself is not necessary.

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Umbilical hernia causing ventriculoperitoneal shunt dysfunction: illustrative cases

Journal of Neurosurgery: Case Lessons ◽

10.3171/case21455 ◽

2021 ◽

Vol 2 (17) ◽

Author(s):

Lacey M. Carter ◽

Alejandro Ruiz-Elizalde ◽

Naina L. Gross

Keyword(s):

Pediatric Surgery ◽

Umbilical Hernia ◽

Case Reports ◽

Shunt Revision ◽

Peritoneal Catheter ◽

Distal Catheter ◽

Vp Shunt ◽

Umbilical Hernia Repair ◽

Shunt Dysfunction ◽

Csf Absorption

BACKGROUND When ventriculoperitoneal (VP) shunts and umbilical hernias coexist in the same patient, unique complications can occur. Typically, these are readily identified problems such as cerebrospinal fluid (CSF) fistulas or entrapment of the peritoneal catheter in the hernia. The authors present cases of two children whose VP shunt dysfunction resolved after repair of their umbilical hernias. OBSERVATIONS The authors present two cases of infant patients with shunted hydrocephalus and umbilical hernias. In both cases, the patients presented with distal shunt malfunctions not due to infection. Their shunt function improved once the umbilical hernia was repaired by pediatric surgery. Neither has required shunt revision since umbilical hernia repair. LESSONS Although there are case reports of VP shunts eroding through the umbilicus, developing CSF fistulas, or becoming trapped inside umbilical hernias, there is no case of VP shunt dysfunction caused by just the presence of an umbilical hernia. The authors suspect that the catheter may intermittently enter and exit the hernia. This may cause intermittent obstruction of the distal catheter, or inflammation in the hernia may occur that limits CSF absorption.

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Using a burr hole valve prevents proximal shunt failure in infants and toddlers

Journal of Neurosurgery Pediatrics ◽

10.3171/2019.4.peds18681 ◽

2019 ◽

Vol 24 (3) ◽

pp. 315-322

Author(s):

Chiu-Hao Hsu ◽

Sheng-Che Chou ◽

Shih-Hung Yang ◽

Ming-Chieh Shih ◽

Meng-Fai Kuo

Keyword(s):

Protective Factor ◽

Catheter Insertion ◽

Burr Hole ◽

Ventricular Catheter ◽

Shunt Failure ◽

Shunt Insertion ◽

Vp Shunt ◽

Catheter Migration ◽

The Mean

OBJECTIVEProximal malfunction is the most common cause of ventriculoperitoneal (VP) shunt failure in young children. In this study, the authors sought to determine factors that affect the migration rate of ventricular catheters in hydrocephalic children who undergo shunt implantation in the first 3 years of life.METHODSThe authors reviewed the medical records and imaging studies of newly diagnosed and treated hydrocephalic children who were younger than 3 years. Patients who received VP shunt insertion through the parieto-occipital route were not included. In total, 78 patients were found who underwent VP shunt insertion between December 2006 and April 2017. Eighteen patients were excluded due to mortality, short follow-up period (< 1 year), and lack of imaging follow-up. The age, sex, etiology of hydrocephalus, initial length of ventricular catheter, valve type (burr hole vs non–burr hole), time to ventricular catheter migration, subsequent revision surgery, and follow-up period were analyzed. The diagnosis of a migrated ventricular catheter was made when serial imaging follow-up showed progressive withdrawal of the catheter tip from the ventricle, with the catheter shorter than 4 mm inside the ventricle, or progressive deviation of the ventricular catheter toward the midline or anterior ventricular wall.RESULTSSixty patients were enrolled. The mean age was 5.1 months (range 1–30 months). The mean follow-up period was 50.9 months (range 13–91 months). Eight patients had ventricular catheter migration, and in 7 of these 8 patients a non–burr hole valve was used. In the nonmigration group, a non–burr hole valve was used in only 6 of the 52 patients. Six of the 8 patients with catheter migration needed second surgeries, which included removal of the shunt due to disconnection in 1 patient. The remaining 2 patients with shunt migration were followed for 91 and 46 months, respectively, without clinical and imaging changes. The authors found that patient age at catheter insertion, ventricular catheter length, and the use of a burr hole valve were protective factors against migration. After ventricular catheter length and patient age at catheter insertion were treated as confounding variables and adjusted with multivariable Weibull proportional hazards regression, the use of a burr hole valve shunt remained a protective factor.CONCLUSIONSThe use of burr hole valves is a protective factor against ventricular catheter migration when the shunt is inserted via a frontal route. The authors suggest the use of a burr hole valve along with a frontal entry point in hydrocephalic children younger than 3 years to maintain long-term shunt function.

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Late pediatric ventriculoperitoneal shunt failures: a Singapore tertiary institution's experience

Neurosurgical FOCUS ◽

10.3171/2016.8.focus16277 ◽

2016 ◽

Vol 41 (5) ◽

pp. E7 ◽

Cited By ~ 4

Author(s):

Lester Lee ◽

Sharon Low ◽

David Low ◽

Lee Ping Ng ◽

Colum Nolan ◽

...

Keyword(s):

Retrospective Study ◽

Pediatric Patients ◽

Shunt Revision ◽

Shunt Failure ◽

Shunt Insertion ◽

Ventriculoperitoneal Shunts ◽

Effects Of Aging ◽

Age And Sex

OBJECTIVE The introduction of ventriculoperitoneal shunts changed the way hydrocephalus was treated. Whereas much is known about the causes of shunt failure in the first few years, there is a paucity of data in the literature regarding the cause of late shunt failures. The authors conducted a study to find out the different causes of late shunt failures in their institution. METHODS A 10-year retrospective study of all the patients who were treated in the authors' hospital between 2006 and 2015 was conducted. Late shunt failures included those in patients who had to undergo shunt revision more than 5 years after their initial shunt insertion. The patient's notes and scans were reviewed to obtain the age and sex of the patient, the time it took for the shunt to fail, the reason for failure, and the patient's follow-up. RESULTS Forty-six patients in the authors' institution experienced 48 late shunt failures in the last 10 years. Their ages ranged from 7 to 26 years (12.23 ± 4.459 years [mean ± SD]). The time it took for the shunts to fail was between 6 and 24 years (mean 10.25 ± 3.77 years). Reasons for failure resulting in shunt revision include shunt fracture in 24 patients (50%), shunt blockage in 14 patients (29.2%), tract fibrosis in 6 patients (12.5%), shunt dislodgement in 2 patients (4.2%), and shunt erosion in 2 patients (4.2%). Postoperative follow-up for the patients ranged from 6 to 138 months (mean 45.15 ± 33.26 months). CONCLUSIONS Late shunt failure is caused by the effects of aging on the shunt, and the complications are different from early shunt failure. A large proportion are complications associated with shunt calcification. The authors advocate a long follow-up for pediatric patients with shunts in situ to monitor them for various causes of late shunt failure.

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