Accurate placement of the distal end of a ventriculoatrial shunt with the aid of real-time transesophageal echocardiography

Technical note

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Ventriculoatrial (VA) shunts remain a valid option for the treatment of hydrocephalus, especially in patients in whom ventriculoperitoneal (VP) shunts fail. Correct positioning of the distal end of the catheter in the right atrium is of paramount importance for maintaining shunt patency and reducing the incidence of VA shunt-associated morbidity. The authors present their experience with real-time transesophageal echocardiography (TEE) monitoring for the accurate placement of the distal catheter of a VA shunt.


Four patients underwent conversion of a VP shunt to a VA shunt under the guidance of intraoperative fluoroscopy and TEE between May 2003 and December 2004. After induction of general anesthesia, the TEE transducer was advanced into the esophagus. A cervical incision was made and the external jugular vein was visualized. An introducer was passed through an opening in the jugular vein and a guidewire was placed through the introducer. Under continuous TEE guidance, the guidewire was carefully advanced into the superior vena cava. A distal shunt catheter overlying a J-wire was then passed to the superior vena cava, again under TEE guidance. The catheter was advanced to the right atrium after removing the guidewire.

Final visualization with TEE and fluoroscopy revealed a good position of the catheter in the right atrium in all four cases. The mean duration of the operation was 91 minutes (range 65–120 minutes) and the mean operative blood loss was 23 ml (range 10–50 ml). No procedure-related complication was noted.


Real-time TEE is a safe and simple technique for the accurate placement of the distal catheter of a VA shunt.

Abbreviations used in this paper:SVC = superior vena cava; TEE = transesophageal echocardiography; VA = ventriculoatrial; VP = ventriculoperitoneal.

Article Information

Address reprint requests to: Kostas N. Fountas, M.D., Ph.D., 840 Pine Street, Suite 880, Macon, Georgia 31201. email: .

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Characteristic real-time TEE captured image, obtained in a representative patient, demonstrating a catheter that has been inserted into the right atrium (RA). The tip of the catheter is indicated by the arrowhead. The SVC, tricuspid valve (TV), right atrium appendage (RAA), and inferior vena cava (IVC) are also demonstrated in this image.

  • View in gallery

    Characteristic real-time TEE captured image, obtained in another patient, demonstrating the distal end of the inserted catheter (arrowhead) in the right atrium close to the cavoatrial junction. The SVC is also apparent in this image.



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