The survival of reimplanted shunts following externalization: a single-institution cohort study

View More View Less
  • 1 Department of Neurological Surgery, Vanderbilt University Medical Center; and
  • 2 Surgical Outcome Center for Kids, Monroe Carell Jr. Children’s Hospital at Vanderbilt University, Nashville, Tennessee
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00
Print or Print + Online

OBJECTIVE

The failure-free survival of ventriculoperitoneal shunts (VPSs) following externalization for distal catheter infection or malfunction has not been adequately explored. Conversion to a ventriculoatrial shunt (VAS) may allow earlier reinternalization in lieu of waiting for the peritoneum to be suitable for reimplantation. This option is tempered by historical concerns regarding high rates of VAS failure, and the risks of rare complications are rampant.

METHODS

In this retrospective cohort study, all patients undergoing externalization of a VPS at a single institution between 2005 and 2020 were grouped according to the new distal catheter terminus location at the time of reinternalization (VPS vs VAS). The primary outcomes were failure-free shunt survival and duration of shunt externalization. Secondary outcomes included early (< 6 months) shunt failure.

RESULTS

Among 36 patients, 43 shunt externalization procedures were performed. Shunts were reinternalized as VPSs in 25 cases and VASs in 18 cases. The median failure-free survival was 1002 (interquartile range [IQR] 161–3449) days for VPSs and 1163 (IQR 360–2927) days for VASs. There was no significant difference in shunt survival according to the new distal catheter terminus (log-rank, p = 0.73). Conversion to a VAS was not associated with shorter duration of shunt externalization (Wilcoxon rank-sum, p = 0.64); the median duration was 7 (IQR 5–11) days for VPSs and 8 (IQR 6–15) days for VASs. No rare complications occurred in the VAS group.

CONCLUSIONS

Shunt failure-free survival rates following externalization are similar to published survival rates for nonexternalized shunts. There was no significant difference in survival between reinternalized VPSs and VASs. Although the VAS was not associated with a shortened duration of externalization, this finding is confounded by strong institutional preference for the VPS over the VAS. Early conversion to the VAS may be a viable treatment option in light of reassuring modern VAS survival data.

ABBREVIATIONS EVD = external ventricular drain; IQR = interquartile range; OR = operating room; VAS = ventriculoatrial shunt; VPS = ventriculoperitoneal shunt.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00

Contributor Notes

Correspondence Patrick D. Kelly: Vanderbilt University School of Medicine, Nashville, TN. patrick.d.kelly@vumc.org.

INCLUDE WHEN CITING Published online February 12, 2021; DOI: 10.3171/2020.8.PEDS20533.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

  • 1

    Davidson RI. Peritoneal bypass in the treatment of hydrocephalus: historical review and abdominal complications. J Neurol Neurosurg Psychiatry. 1976;39(7):640646.

    • Search Google Scholar
    • Export Citation
  • 2

    McLaurin RL, Frame PT. The role of shunt externalization in the management of shunt infections. Concepts Pediatr Neurosurg. 1985;6:133146.

    • Search Google Scholar
    • Export Citation
  • 3

    Tamber MS, Klimo P Jr, Mazzola CA, Flannery AM. Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 8: Management of cerebrospinal fluid shunt infection. J Neurosurg Pediatr. 2014;14(suppl 1):6071.

    • Search Google Scholar
    • Export Citation
  • 4

    Erwood A, Rindler RS, Motiwala M, Management of sterile abdominal pseudocysts related to ventriculoperitoneal shunts. J Neurosurg Pediatr. 2020;25(1):5761.

    • Search Google Scholar
    • Export Citation
  • 5

    Tunkel AR, Hasbun R, Bhimraj A, 2017 Infectious Diseases Society of America’s Clinical Practice Guidelines for healthcare-associated ventriculitis and meningitis. Clin Infect Dis. 2017;64(6):e34e65.

    • Search Google Scholar
    • Export Citation
  • 6

    Vernet O, Rilliet B. Late complications of ventriculoatrial or ventriculoperitoneal shunts. Lancet. 2001;358(9293):15691570.

  • 7

    Rymarczuk GN, Keating RF, Coughlin DJ, A comparison of ventriculoperitoneal and ventriculoatrial shunts in a population of 544 consecutive pediatric patients. Neurosurgery. 2020;87(1):8085.

    • Search Google Scholar
    • Export Citation
  • 8

    Connolly ES Jr, McKhann GM II, Huang J, , eds. Fundamentals of Operative Techniques in Neurosurgery. 2nd ed. Thieme; 2010.

  • 9

    Riva-Cambrin J, Kestle JRW, Holubkov R, Risk factors for shunt malfunction in pediatric hydrocephalus: a multicenter prospective cohort study. J Neurosurg Pediatr. 2016;17(4):382390.

    • Search Google Scholar
    • Export Citation
  • 10

    Browd SR, Gottfried ON, Ragel BT, Kestle JRW. Failure of cerebrospinal fluid shunts: part II: overdrainage, loculation, and abdominal complications. Pediatr Neurol. 2006;34(3):171176.

    • Search Google Scholar
    • Export Citation
  • 11

    McGirt MJ, Leveque J-C, Wellons JC III, Cerebrospinal fluid shunt survival and etiology of failures: a seven-year institutional experience. Pediatr Neurosurg. 2002;36(5):248255.

    • Search Google Scholar
    • Export Citation
  • 12

    Shah SS, Hall M, Berry JG, A multicenter study of factors influencing cerebrospinal fluid shunt survival in infants and children. Neurosurgery. 2009;64(6):E1206.

    • Search Google Scholar
    • Export Citation
  • 13

    Lundar T, Langmoen IA, Hovind KH. Fatal cardiopulmonary complications in children treated with ventriculoatrial shunts. Childs Nerv Syst. 1991;7(4):215217.

    • Search Google Scholar
    • Export Citation
  • 14

    Haffner D, Schindera F, Aschoff A, The clinical spectrum of shunt nephritis. Nephrol Dial Transplant. 1997;12(6):11431148.

  • 15

    Vernet O, Campiche R, de Tribolet N. Long-term results after ventriculoatrial shunting in children. Childs Nerv Syst. 1993;9(5):253255.

    • Search Google Scholar
    • Export Citation
  • 16

    Tomei KL. The evolution of cerebrospinal fluid shunts: advances in technology and technique. Pediatr Neurosurg. 2017;52(6):369380.

    • Search Google Scholar
    • Export Citation
  • 17

    Flannery AM, Duhaime A-C, Tamber MS, Kemp J. Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 3: Endoscopic computer-assisted electromagnetic navigation and ultrasonography as technical adjuvants for shunt placement. J Neurosurg Pediatr. 2014;14(suppl 1):2429.

    • Search Google Scholar
    • Export Citation
  • 18

    Olsen L, Frykberg T. Complications in the treatment of hydrocephalus in children. A comparison of ventriculoatrial and ventriculoperitoneal shunts in a 20-year material. Acta Paediatr Scand. 1983;72(3):385390.

    • Search Google Scholar
    • Export Citation
  • 19

    Drucker MH, Vanek VW, Franco AA, Thromboembolic complications of ventriculoatrial shunts. Surg Neurol. 1984;22(5):444448.

  • 20

    White IK, Shaikh KA, Nyarenchi OM, Analysis of the potential risk of central intravenous lines and/or total parenteral nutrition with ventriculoatrial shunts. Childs Nerv Syst. 2015;31(4):563568.

    • Search Google Scholar
    • Export Citation
  • 21

    Bhasin RR, Chen MK, Pincus DW. Salvaging the “lost peritoneum” after ventriculoatrial shunt failures. Childs Nerv Syst. 2007;23(5):483486.

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 68 68 68
Full Text Views 49 49 49
PDF Downloads 25 25 25
EPUB Downloads 0 0 0