Comparing ventriculoatrial and ventriculopleural shunts in pediatric hydrocephalus: a Hydrocephalus Clinical Research Network study

Vijay M. Ravindra Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah;
Department of Neurosurgery, University of California, San Diego, California;
Division of Pediatric Neurosurgery, Rady Children’s Hospital, San Diego, California;
Department of Neurosurgery, Naval Medical Center, San Diego, California;

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Jay Riva-Cambrin Department of Clinical Neurosciences, University of Calgary, Alberta, Canada;

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Hailey Jensen Department of Pediatrics, University of Utah, Salt Lake City, Utah;

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William E. Whitehead Department of Neurosurgery, Division of Pediatric Neurosurgery, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas;

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Abhaya V. Kulkarni Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Ontario, Canada;

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David D. Limbrick Jr. Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia;

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John C. Wellons III Department of Neurological Surgery, Division of Pediatric Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee;

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Robert P. Naftel Department of Neurological Surgery, Division of Pediatric Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee;

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Curtis J. Rozzelle Division of Neurosurgery, Section of Pediatric Neurosurgery, Children’s Hospital of Alabama, University of Alabama–Birmingham, Alabama;

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Brandon G. Rocque Division of Neurosurgery, Section of Pediatric Neurosurgery, Children’s Hospital of Alabama, University of Alabama–Birmingham, Alabama;

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Ian F. Pollack Division of Neurosurgery, Children’s Hospital of Pittsburgh, Pennsylvania;

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Michael M. McDowell Division of Neurosurgery, Children’s Hospital of Pittsburgh, Pennsylvania;

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Mandeep S. Tamber Department of Surgery, Division of Neurosurgery, British Columbia Children’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada;

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Jason S. Hauptman Department of Neurosurgery, University of Washington, Seattle Children’s Hospital, Seattle, Washington;

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Samuel R. Browd Department of Neurosurgery, University of Washington, Seattle Children’s Hospital, Seattle, Washington;

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Jonathan Pindrik Department of Neurosurgery, Nationwide Children’s Hospital, Columbus, Ohio;

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Albert M. Isaacs Department of Neurosurgery, Nationwide Children’s Hospital, Columbus, Ohio;

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Patrick J. McDonald Department of Surgery, Section of Neurosurgery, University of Manitoba, Winnipeg, Manitoba, Canada;

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Todd C. Hankinson Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Colorado School of Medicine, Aurora, Colorado;

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Eric M. Jackson Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland;

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Jason Chu Department of Neurosurgery, Division of Neurosurgery, Children’s Hospital Los Angeles, University of Southern California, Los Angeles, California;

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Mark D. Krieger Department of Neurosurgery, Division of Neurosurgery, Children’s Hospital Los Angeles, University of Southern California, Los Angeles, California;

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Tamara D. Simon Department of Pediatrics, Children’s Hospital Los Angeles, University of Southern California, Los Angeles, California; and

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Jennifer M. Strahle Department of Neurosurgery, St. Louis Children’s Hospital, Washington University in St. Louis, Missouri

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Richard Holubkov Department of Pediatrics, University of Utah, Salt Lake City, Utah;

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Ron Reeder Department of Pediatrics, University of Utah, Salt Lake City, Utah;

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John R. W. Kestle Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah;

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 MD , for the Hydrocephalus Clinical Research Network
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OBJECTIVE

When the peritoneal cavity cannot serve as the distal shunt terminus, nonperitoneal shunts, typically terminating in the atrium or pleural space, are used. The comparative effectiveness of these two terminus options has not been evaluated. The authors directly compared shunt survival and complication rates for ventriculoatrial (VA) and ventriculopleural (VPl) shunts in a pediatric cohort.

METHODS

The Hydrocephalus Clinical Research Network Core Data Project was used to identify children ≤ 18 years of age who underwent either VA or VPl shunt insertion. The primary outcome was time to shunt failure. Secondary outcomes included distal site complications and frequency of shunt failure at 6, 12, and 24 months.

RESULTS

The search criteria yielded 416 children from 14 centers with either a VA (n = 318) or VPl (n = 98) shunt, including those converted from ventriculoperitoneal shunts. Children with VA shunts had a lower median age at insertion (6.1 years vs 12.4 years, p < 0.001). Among those children with VA shunts, a hydrocephalus etiology of intraventricular hemorrhage (IVH) secondary to prematurity comprised a higher proportion (47.0% vs 31.2%) and myelomeningocele comprised a lower proportion (17.8% vs 27.3%) (p = 0.024) compared with those with VPl shunts. At 24 months, there was a higher cumulative number of revisions for VA shunts (48.6% vs 38.9%, p = 0.038). When stratified by patient age at shunt insertion, VA shunts in children < 6 years had the lowest shunt survival rate (p < 0.001, log-rank test). After controlling for age and etiology, multivariable analysis did not find that shunt type (VA vs VPl) was predictive of time to shunt failure. No differences were found in the cumulative frequency of complications (VA 6.0% vs VPl 9.2%, p = 0.257), but there was a higher rate of pneumothorax in the VPl cohort (3.1% vs 0%, p = 0.013).

CONCLUSIONS

Shunt survival was similar between VA and VPl shunts, although VA shunts are used more often, particularly in younger patients. Children < 6 years with VA shunts appeared to have the shortest shunt survival, which may be a result of the VA group having more cases of IVH secondary to prematurity; however, when age and etiology were included in a multivariable model, shunt location (atrium vs pleural space) was not associated with time to failure. The baseline differences between children treated with a VA versus a VPl shunt likely explain current practice patterns.

ABBREVIATIONS

DVT/PE = deep vein thrombosis/pulmonary embolism; HCRN = Hydrocephalus Clinical Research Network; IVH = intraventricular hemorrhage; VA = ventriculoatrial; VP = ventriculoperitoneal; VPl = ventriculopleural.

OBJECTIVE

When the peritoneal cavity cannot serve as the distal shunt terminus, nonperitoneal shunts, typically terminating in the atrium or pleural space, are used. The comparative effectiveness of these two terminus options has not been evaluated. The authors directly compared shunt survival and complication rates for ventriculoatrial (VA) and ventriculopleural (VPl) shunts in a pediatric cohort.

METHODS

The Hydrocephalus Clinical Research Network Core Data Project was used to identify children ≤ 18 years of age who underwent either VA or VPl shunt insertion. The primary outcome was time to shunt failure. Secondary outcomes included distal site complications and frequency of shunt failure at 6, 12, and 24 months.

RESULTS

The search criteria yielded 416 children from 14 centers with either a VA (n = 318) or VPl (n = 98) shunt, including those converted from ventriculoperitoneal shunts. Children with VA shunts had a lower median age at insertion (6.1 years vs 12.4 years, p < 0.001). Among those children with VA shunts, a hydrocephalus etiology of intraventricular hemorrhage (IVH) secondary to prematurity comprised a higher proportion (47.0% vs 31.2%) and myelomeningocele comprised a lower proportion (17.8% vs 27.3%) (p = 0.024) compared with those with VPl shunts. At 24 months, there was a higher cumulative number of revisions for VA shunts (48.6% vs 38.9%, p = 0.038). When stratified by patient age at shunt insertion, VA shunts in children < 6 years had the lowest shunt survival rate (p < 0.001, log-rank test). After controlling for age and etiology, multivariable analysis did not find that shunt type (VA vs VPl) was predictive of time to shunt failure. No differences were found in the cumulative frequency of complications (VA 6.0% vs VPl 9.2%, p = 0.257), but there was a higher rate of pneumothorax in the VPl cohort (3.1% vs 0%, p = 0.013).

CONCLUSIONS

Shunt survival was similar between VA and VPl shunts, although VA shunts are used more often, particularly in younger patients. Children < 6 years with VA shunts appeared to have the shortest shunt survival, which may be a result of the VA group having more cases of IVH secondary to prematurity; however, when age and etiology were included in a multivariable model, shunt location (atrium vs pleural space) was not associated with time to failure. The baseline differences between children treated with a VA versus a VPl shunt likely explain current practice patterns.

In Brief

The authors compared shunt survival between cohorts that received ventriculoatrial and ventriculoperitoneal shunts for hydrocephalus because these are the two most common sites for shunt placement when the peritoneum is not an option. Shunt survival was similar between the two groups, although ventriculoatrial shunts were used more often, particularly in young children. Children aged < 6 years with ventriculoatrial shunts had the shortest shunt survival. This study demonstrates that both atrial and pleural sites are viable when the abdomen is not usable.

In some children who undergo CSF shunt insertion for the treatment of hydrocephalus, the peritoneal cavity, which is the most common distal shunt catheter placement site,1,2 may not be viable because of concerns for necrotizing enterocolitis, congenital gastrointestinal conditions, history of extensive abdominal surgery, adhesions due to peritoneal scarring, abdominal pseudocysts, intraperitoneal infections, and ascites.35 In these patients, nonperitoneal sites are necessary to accomplish successful CSF diversion. The optimal location for the shunt terminus in patients with a nonviable peritoneal cavity is not known. Gmeiner et al.6 evaluated 61 patients who received ventriculoatrial (VA) shunts and determined that the atrium is an appropriate alternative for children who require shunt placement. Oyon et al.7 and Christian et al.8 have provided evidence that ventriculopleural (VPl) shunts are another option when ventriculoperitoneal (VP) shunt insertion is not possible.

The complication profile for VPl shunts includes pleural effusions secondary to the smaller absorptive surface area, particularly in children < 10 years of age.8 Similarly, VPl shunts are not used in children with baseline lung disease or diminished lung capacity in the setting of severe spinal deformity. Complications for VA shunts include venous thrombosis requiring anticoagulant or antiplatelet administration, endocarditis, immune complex–mediated shunt nephritis, and the potential for bloodstream infection requiring shunt externalization or explantation. Additionally, VA shunts may require periodic distal revision or lengthening procedures to keep the tip within the atrium.8 VA shunts also commonly require the support of a pediatric surgeon to assist with obtaining access.

Shunt survival, revision rates, and complication profiles of the VA and VPl distal implantation sites have not been directly compared. Additionally, although risk factors for VP shunt failure are well known, they remain unknown for VPl and VA shunts. In this study, we compared cohorts of children with hydrocephalus and either a VA or a VPl shunt. We investigated whether either distal catheter location was associated with time to shunt failure (revision or infection) after adjusting for age and hydrocephalus etiology. We hypothesized that 1) there is no difference in shunt survival between these two common nonperitoneal shunt sites, and 2) differences in baseline factors influence the decision to place either a VA or a VPl shunt.

Methods

Patient Identification

Data were extracted from the prospective Hydrocephalus Clinical Research Network (HCRN) Core Data Project (registry) for all children with either a VA or a VPl shunt who were treated between April 2008 and January 2023 at 14 HCRN centers (Children’s of Alabama, Birmingham, AL; Primary Children’s Hospital, Salt Lake City, UT; Seattle Children’s Hospital, Seattle, WA; Children’s Hospital of Pittsburgh, Pittsburgh, PA; St. Louis Children’s Hospital, St. Louis, MO; Texas Children’s Hospital, Houston, TX; The Hospital for Sick Children, Toronto, ON, Canada; Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN; British Columbia Children’s Hospital, Vancouver, BC, Canada; Alberta Children’s Hospital, Calgary, AB, Canada; Children’s Hospital of Los Angeles, Los Angeles, CA; Children’s Hospital Colorado, Aurora, CO; Nationwide Children’s Hospital, Columbus, OH; and Johns Hopkins Children’s Center, Baltimore, MD). The registry tracks all hydrocephalus-related shunt surgeries at each center beginning on the date the center joined HCRN. Institutional review board approval with a waiver of individual patient consent was obtained from each clinical site as well as the data coordinating center.9

Pediatric patients (≤ 18 years of age) with first-time VA or VPl shunt placement were included. We included children whose first shunt was a VA or VPl shunt and also children in the database who had at least one earlier peritoneal shunt that was converted to a VA or VPl shunt. Patients were excluded if they had a shunt in a nonatrial or nonpleural terminus.

Using the registry, we also identified a cohort of children with VP shunts who had at least one previous shunt revision and the same median number of shunt surgeries. This cohort was entered into a multivariable model to determine whether any shunt terminus was associated with failure when compared with our cohort of children with VA and VPl shunts. For this analysis, we included all procedures through January 14, 2023, allowing for at least 6 months of follow-up, unless a subject had a shunt failure or censor event.

Data Collection

Demographic characteristics collected included sex, race/ethnicity, and age (at initial VA or VPl shunt implantation), which was categorized into four groups (0–2, 3–5, 6–12, and > 12 years). Clinical factors included etiology of hydrocephalus (intraventricular hemorrhage [IVH] secondary to prematurity, myelomeningocele, aqueductal stenosis, or other etiology), number of previous shunt surgeries, time from last shunt operation to implant at nonperitoneal site, first shunt insertion versus conversion from VP shunt, use of an endoscope to place the ventricular catheter, imaging guidance, antisiphon device use, comorbid cardiac conditions, complex chronic conditions, presence of gastrostomy tube, adherence to HCRN protocol during nonperitoneal shunt insertion, whether previous shunt surgery was performed within 12 weeks, and complications before discharge.

Factors collected from the failure surgery included the location of malfunction (distal, proximal, both, or valve), the type of failure for the VA or VPl shunt (revision or infection), and the next shunt surgery terminus (peritoneal, pleural, atrial, or other).

Outcomes

The primary outcome for the study was time to shunt failure (years). Secondary outcomes included number of shunt revisions (any hydrocephalus-related surgical procedures, including multiple procedures per patient) by 6-, 12-, and 24-month time points; type of shunt failure (revision or infection); location of shunt failure (proximal or distal); and hydrocephalus-related perioperative complications before hospital discharge (ascites, cardiac arrest, CSF leak, deep vein thrombosis/pulmonary embolism [DVT/PE], bacterial meningitis, hyponatremia, motor deficit, visual/ocular deficit, pneumonia, pneumothorax, IVH, subdural hematoma, pressure sore, pseudomeningocele, seizure, urinary tract infection, wound problem, and sepsis).

Statistical Analysis

The primary analysis compared time to first failure of VA and VPl shunts using Kaplan-Meier curves. Risk factors for VA or VPl shunt failure were assessed with a Cox proportional hazards model. Variables included in the model were those with p < 0.2 on univariable analysis or those identified as clinically important based on earlier studies (e.g., recent revision, use of endoscope for ventricular catheter placement, and cardiac comorbidity). The proportional hazards assumption was plausible. Interacting variables were tested. An interaction between age and VA or VPl shunt was included in the model.

Several secondary analyses were also performed. To identify factors associated with the decision to place either a VPl or a VA shunt, we compared demographic and baseline clinical and hydrocephalus-related variables. Descriptive statistics were used to summarize patient demographics and outcome measures and are reported as counts and percentages for categorical variables and as the median [first quartile, third quartile] for continuous variables. Associations among continuous variables were assessed using a Wilcoxon rank-sum test. All categorical variables were compared using Fisher’s exact test. Lastly, a multivariable analysis was performed to examine time to shunt failure; this analysis included the group of patients with VP shunts identified in the registry. All analyses were conducted using SAS 9.4 (SAS Institute). Significance levels were set at p < 0.05.

Results

At the time of the investigation, data for 11,969 shunt patients from 14 North American centers were available in the registry. Among them, data existed for 491 children (4.1%) with nonperitoneal shunts; 416 children within the network were included in the analysis as having a first-time VA or VPl shunt either as the first-line shunt or after conversion from a VP shunt. Twenty-two subjects had censor events and were not included in the number of failures within 6 months because they lacked 6-month follow-up. Of these, 7 patients relocated out of network, 3 transitioned to adult care, and 12 died, including 6 within 30 days of surgery. Only one of the deaths was related to hydrocephalus. The CONSORT (Consolidated Standards of Reporting Trials) diagram is shown in Fig. 1.

FIG. 1.
FIG. 1.

CONSORT diagram for the study.

Demographics

Overall in the HCRN, among children with nonperitoneal shunts, VA shunts were more common than VPl shunts (318 VA, 98 VPl) (Table 1). Children who received VA shunts had a lower median age at insertion (6.1 years vs 12.4 years, p < 0.001) and a lower proportion were ≥ 10 years of age (32.4% vs 62.2%, p < 0.001) when compared with children with VPl shunts. When examining the age groupings, we found that most VPl shunts were placed in children ≥ 6 years (77.6%) whereas 50.9% of VA shunts were placed in children ≥ 6 years, resulting in a useful natural cutoff within our dataset. No significant differences were seen in race or ethnicity with respect to shunt terminus.

TABLE 1.

General characteristics of children with nonperitoneal distal shunt terminus

VariableOverall (n = 416)VA (n = 318)VPl (n = 98)p Value
Cohort0.001
 Comprehensive*155 (37.3)132 (41.5)23 (23.5)
 Noncomprehensive261 (62.7)186 (58.5)75 (76.5)
Male sex237 (57.0)175 (55.0)62 (63.3)0.163
Age at time of procedure, yrs7.8 [1.4, 13.1]6.1 [1.0, 11.6]12.4 [6.8, 14.9]<0.001§
Age ≥10 yrs164 (39.4)103 (32.4)61 (62.2)<0.001
Age range at implant, yrs<0.001§
 0–2134 (32.2)121 (38.1)13 (13.3)
 3–544 (10.6)35 (11.0)9 (9.2)
 6–12110 (26.4)87 (27.4)23 (23.5)
 >12128 (30.8)75 (23.6)53 (54.1)
Age <6 yrs178 (42.8)156 (49.1)22 (22.4)<0.001
Race, collapsedn = 376n = 296n = 80>0.999
 White252 (67.0)198 (66.9)54 (67.5)
 Black or African American108 (28.7)85 (28.7)23 (28.8)
 Other16 (4.3)13 (4.4)3 (3.8)
Ethnicity0.582
 Not Hispanic or Latino327 (78.6)259 (81.4)68 (69.4)
 Hispanic or Latino50 (12.0)38 (11.9)12 (12.2)
 Unknown or not reported39 (9.4)21 (6.6)18 (18.4)
Etiology of hydrocephalusn = 358n = 281n = 770.024
 IVH secondary to prematurity156 (43.6)132 (47.0)24 (31.2)
 Myelomeningocele71 (19.8)50 (17.8)21 (27.3)
 Aqueductal stenosis19 (5.3)17 (6.0)2 (2.6)
 Other etiology112 (31.3)82 (29.2)30 (39.0)
Shunt procedure type0.291
 Primary, 1st-time shunt placement38 (9.1)33 (10.4)5 (5.1)
 Secondary shunt revisions, no infection156 (37.5)117 (36.8)39 (39.8)
 Secondary shunt placement, infection222 (53.4)168 (52.8)54 (55.1)
Presence of antisiphon device71/386 (18.4)55/291 (18.9)16/95 (16.8)0.761
Time from previous shunt surgery, wks8.0 [3.0, 33.0]7.0 [3.0, 29.0]10.0 [4.5, 43.5]0.200§
Previous shunt surgeryn = 295n = 227n = 680.007
 Primary58 (19.7)52 (22.9)6 (8.8)
 Revision189 (64.1)135 (59.5)54 (79.4)
 Infection48 (16.3)40 (17.6)8 (11.8)
No. of previous shunt surgeries in HCRN registry1 [1, 2]1 [0, 2]2 [1, 2]0.936§
CCCs
 Cardiovascular63 (15.1)53 (16.7)10 (10.2)0.147
 Neuromuscular162 (38.9)116 (36.5)46 (46.9)0.075
 Respiratory70 (16.8)60 (18.9)10 (10.2)0.046
 Renal17 (4.1)12 (3.8)5 (5.1)0.563
 Gastrointestinal38 (9.1)32 (10.1)6 (6.1)0.316
 Hematology &/or immunodeficiency7 (1.7)5 (1.6)2 (2.0)0.670
 Metabolic9 (2.2)7 (2.2)2 (2.0)>0.999
 Congenital or genetic defect60 (14.4)43 (13.5)17 (17.3)0.411
 Non-CNS malignancies9 (2.2)8 (2.5)1 (1.0)0.692
No. of CCCs0.621
 0155 (37.3)125 (39.3)30 (30.6)
 1146 (35.1)102 (32.1)44 (44.9)
 ≥2115 (27.6)91 (28.6)24 (24.5)
Ultrasound63 (15.1)49 (15.4)14 (14.3)0.873
Stereotaxis63 (15.1)48 (15.1)15 (15.3)>0.999
Endoscopy41 (9.9)35 (11.0)6 (6.1)0.179
HCRN protocol followed during NPS insertion115/158 (72.8)92/115 (80.0)23/43 (53.5)0.001
Antibiotic catheters placed
 Proximal163 (39.2)123 (38.7)40 (40.8)0.724
 Distal221 (53.1)151 (47.5)70 (71.4)<0.001
 Distal & proximal114 (27.4)79 (24.8)35 (35.7)0.039

CCC = complex chronic condition; NPS = nonperitoneal shunt.

Values are reported as number of patients (%) or median [IQR] unless otherwise indicated.

Subject’s entire shunt history is known and within the HCRN registry.

Entire shunt history is not within the HCRN registry, but at least one shunt surgery is within the registry.

Cochran-Armitage trend test.

Fisher’s exact test.

Among children with VA shunts, those with a hydrocephalus etiology of IVH secondary to prematurity made up a higher proportion (47.0% vs 31.2%) and those with myelomeningocele a lower proportion (17.8% vs 27.3%) when compared with children with VPl shunts (p = 0.024). For 38 children, VA or VPl shunt placement was the primary (initial) shunt surgery for the patient. The median time from previous shunt surgery was similar (VA 7 weeks vs VPl 10 weeks, p = 0.2). For those in whom the VA or VPl shunt placement was not the initial shunt surgery, infection as the reason for previous shunt failure was higher in VA than in VPl shunt subjects (17.6% vs 11.8%, p = 0.007). There was no significant difference in the median number of previous shunt surgeries (VA 1 vs VPl 2, p = 0.936). No differences were seen in the presence of cardiovascular complex chronic conditions or the total number of complex chronic conditions between VA and VPl shunt subjects. Children who received VA shunts had a higher proportion of respiratory complex chronic conditions (18.9% vs 10.2%, p = 0.046).

No differences were seen between VA and VPl shunt surgery in the use of ultrasound (p = 0.873), stereotaxis (p > 0.999), or endoscopy (p = 0.179) for ventricular catheter placement. HCRN shunt protocols were followed in a higher proportion of children who received VA shunts (80% vs 53.5%, p = 0.001). Antibiotic-impregnated catheters were used more often in patients receiving VPl shunts (35.7% vs 24.8%, p = 0.039); further analysis demonstrated this was driven by disparities in distal (VPl 71.4% vs VA 47.5%, p < 0.001) rather than proximal (VPl 40.8% vs VA 38.7%, p = 0.724) antibiotic catheter use.

Complications occurred infrequently in both groups (VA 6.0% vs VPl 9.2%, p = 0.257) (Table 2). Specifically for VPl shunts, pneumothorax occurred in 3 patients (3.1%) and no instances of pneumonia were discovered. DVT/PE occurred in 1 child (0.3%) with a VA shunt, and sepsis occurred in 2 children (0.6%) with a VA shunt.

TABLE 2.

Complications for each cohort

VariableVA (n = 318)VPl (n = 98)p Value
Complication occurred19 (6.0)9 (9.2)0.257
Ascites3 (0.9)0 (0.0)>0.999
Cardiac arrest1 (0.3)1 (1.0)0.416
CSF leak2 (0.6)1 (1.0)0.554
Minor CSF leak1 (0.3)0 (0.0)>0.999
Major CSF leak2 (0.6)1 (1.0)0.554
DVT/PE1 (0.3)0 (0.0)>0.999
Documented bacterial meningitis, positive CSF culture2 (0.6)0 (0.0)>0.999
Hyponatremia1 (0.3)1 (1.0)0.416
Motor deficit1 (0.3)0 (0.0)>0.999
Visual/ocular deficit1 (0.3)0 (0.0)>0.999
Pneumonia1 (0.3)0 (0.0)>0.999
Pneumothorax0 (0.0)3 (3.1)0.013
IVH3 (0.9)0 (0.0)>0.999
SDH1 (0.3)0 (0.0)>0.999
Pressure sores0 (0.0)1 (1.0)0.236
Pseudomeningocele2 (0.6)0 (0.0)>0.999
Seizure4 (1.3)2 (2.0)0.629
Sepsis2 (0.6)0 (0.0)>0.999
UTI1 (0.3)0 (0.0)>0.999
Wound problem2 (0.6)0 (0.0)>0.999

SDH = subdural hematoma; UTI = urinary tract infection.

Values are reported as number of patients (%) unless otherwise indicated. Fisher’s exact test was used for analysis.

Shunt Survival

Univariable analysis of VA versus VPl shunt survival demonstrated that age < 6 years and etiology of hydrocephalus had unadjusted associations with shunt survival (Table 3). Kaplan-Meier curves stratified by age showed that children < 6 years of age with VA shunts had significantly lower survival than other cohorts (Fig. 2), but survival of VPl shunts in children ≥ 6 and < 6 years of age was similar. Multivariable regression analysis including age, type of shunt (atrial or pleural), and etiology did not reveal any significant predictors for time to shunt failure (Table 4).

TABLE 3.

Univariable proportional hazards models for shunt failure (all subjects)

VariableHR (95% CI)p Value
Type of shunt0.101
 VPl0.77 (0.56–1.05)
 VAReference
Age <6 yrs<0.001
 NoReference
 Yes1.60 (1.24–2.07)
Etiology of hydrocephalus0.046
 Aqueductal stenosis0.60 (0.32–1.11)
 Myelomeningocele0.67 (0.46–0.97)
 Other etiology0.71 (0.51–0.98)
 Post-IVH secondary to prematurityReference
No. of CCCs0.925
 0Reference
 10.95 (0.70–1.28)
 ≥20.95 (0.69–1.31)
Cardiovascular CCCs0.091
 NoReference
 Yes1.33 (0.96–1.85)
Conversion to VA or VPl shunt occurred after infection0.451
 NoReference
 Yes0.91 (0.70–1.17)

Results are based on univariable models.

FIG. 2.
FIG. 2.

Stratified Kaplan-Meier survival curves comparing VA and VPl shunts in children < 6 and ≥ 6 years of age. Figure is available in color online only.

TABLE 4.

Multivariable proportional hazards models for shunt failure (all subjects)

VariableHR (95% CI)p Value
Etiology
 Post-IVH secondary to prematurityReference0.058
 Aqueductal stenosis0.57 (0.30–1.07)
 Myelomeningocele0.77 (0.52–1.12)
 Other0.68 (0.49–0.94)
VA shunt, compared w/ VPl shunt
 For age ≥6 yrs0.67 (0.44–1.04)0.072
 For age <6 yrs1.73 (0.93–3.22)0.085

Results are based on multivariable models including age, type of shunt, and etiology.

We found no difference in the percentage of children who experienced shunt failure (yes or no) at 6 months (VA 34% vs VPl 32%, p = 0.700), 12 months (VA 39% vs VPl 35%, p = 0.349), and 24 months (VA 49% vs VPl 39%, p = 0.038) (Table 5). To assess the cumulative hydrocephalus surgery burden, we compared procedure counts (including multiple procedures per patient) over time. We found no difference at 6 and 12 months, but by 24 months of follow-up, more surgeries had been performed in the VA cohort. Most of the failures in both groups combined were revision (84%), with no difference between VA and VPl shunts. More than 58% of failures for both VA and VPl shunts were proximal, whereas 4% of the failures were distal (16% both proximal and distal, 22% unknown). After shunt failure, VPl shunts were reimplanted in the child’s pleural space 41.7% of the time and in the abdominal cavity 27.1% of the time, whereas VA shunt failures were replaced into the child’s atrium 62.8% of the time (p < 0.001) (Table 5).

TABLE 5.

Cohort and shunt characteristics for failure after nonperitoneal shunt implantation

VariableVA (n = 318)VPl (n = 98)p Value
No. of revisions/failures after implantation*
 w/in 6 mosn = 299n = 950.700
  0197 (65.9)65 (68.4)
  159 (19.7)18 (18.9)
  225 (8.4)6 (6.3)
  ≥318 (6.0)6 (6.3)
 w/in 12 mosn = 291n = 910.349
  0178 (61.2)59 (64.8)
  151 (17.5)20 (22.0)
  235 (12.0)3 (3.3)
  ≥327 (9.3)9 (9.9)
 w/in 24 mosn = 284n = 900.038
  0146 (51.4)55 (61.1)
  158 (20.4)23 (25.6)
  242 (14.8)2 (2.2)
  ≥338 (13.4)10 (11.1)
Location of failuren = 188n = 480.228
 Unknown42 (22.3)9 (18.8)
 Proximal112 (59.6)26 (54.2)
 Distal6 (3.2)4 (8.3)
 Both28 (14.9)9 (18.8)
Shunt failure after converting to NPSn = 188n = 480.816
 Revision160 (85.1)39 (81.3)
 Infection26 (13.8)7 (14.6)
 Other2 (1.1)2 (4.2)
Next shunt surgery terminusn = 188n = 48<0.001
 VP34 (18.1)13 (27.1)
 VPl7 (3.7)20 (41.7)
 VA118 (62.8)7 (14.6)
 Other1 (0.5)0 (0.0)
 Unknown28 (14.9)8 (16.7)

Children were excluded from the number of revision summaries if they were censored in the registry for relocation out of network, death unrelated to hydrocephalus, or transitioning to adult care prior to the end of the time period in review.

Cochran-Armitage trend test.

Fisher’s exact test.

Additional multivariable analysis including a cohort of patients from the registry with VP shunts indicated that VPl shunts have similar survival to VP shunts, with VA shunts demonstrating a 1.42 higher odds of failure (Table 6).

TABLE 6.

Multivariable proportional hazards model examining shunt failure

VariableHR (95% CI)p Value
Type of shunt<0.001
 VPReference
 VPl1.34 (0.98–1.82)
 VA1.42 (1.21–1.68)
Age <6 yrs0.374
 NoReference
 Yes1.05 (0.94–1.18)
Etiology of hydrocephalus<0.001
 Aqueductal stenosis0.71 (0.57–0.87)
 Myelomeningocele0.68 (0.58–0.79)
 Other etiology0.84 (0.74–0.95)
 IVH secondary to prematurityReference

Results are based on multivariable models, adjusting for each of the predictors in the table.

Discussion

In this multicenter study using data from the HCRN registry, we directly compared the use of VA and VPl shunts, because the atrial and pleural spaces are the most common sites of nonperitoneal shunt terminus. Most children received VA shunts (3:1 in this report), and children who received first-time nonperitoneal shunts terminating in the atrium tended to be younger. There was no difference in the shunt revision burden at 6 and 12 months. At 24 months, more shunt revisions had been performed in subjects with VA shunts. Children < 6 years of age with VA shunts appeared to have shorter shunt survival than those ≥ 6 years or those of any age with VPl shunts, but in a multivariable model, shunt type (VA vs VPl) was not associated with shunt survival.

It was previously suggested that young age influenced the decision to avoid VPl shunts. However, in our survival analysis, although the sample of children < 6 years of age with VPl shunts was small (n = 22), age did not appear to influence VPl shunt survival.

Hydrocephalus etiology differed between the cohorts in this study, with a higher proportion of children with myelomeningocele in the VPl cohort versus a higher proportion of premature children with IVH in the VA cohort. This may be secondary to a challenging neonatal abdominal environment in the premature cohort and the predilection for premature children to have concurrent lung dysfunction and bronchopulmonary dysplasia. Univariable modeling suggested that etiology may indeed influence failure of nonperitoneal shunts, but no independent association was found on multivariable analyses.

Among 14 HCRN centers, we identified and included 98 VPl subjects, with VA shunts being 3 times more common. Christian et al.8 suggested that the pleural space is not more widely used because of unfamiliarity with the procedure. In their study, 73 patients (43%) required shunt revision—most commonly because of proximal obstruction (44%)—which is similar to our finding (58.5%). Twenty-two children in their series required revision for a symptomatic pleural effusion, which may be mirrored in our results of failure of VPl shunts, where reimplantation back into the pleural space occurred 41.7% of the time and reimplantation in the abdominal cavity occurred 27.1% of the time.

The initial report of VPl cases was presented by Ransohoff10 in 1954. Hoffman et al.11 reported on 59 patients with a revision rate of 61% and an infection rate of 19%, but follow-up was lacking in their report. To date, the literature on the use of VPl shunts in children is based on single-center reports. Oyon et al.7 demonstrated a 30% overall shunt survival with 19 of 27 VPl shunts requiring revisions. They did not reveal any risk factors for shunt failure, although patients who underwent an early revision tended to be younger. The incidence of pleural effusion in their series was 26%. Our multicenter experience represents a modern experience with VPl shunts. Since 2000, only five studies have reported on VPl shunt outcomes, two of which reported on pediatric patients.8,1215

Proponents of VPl shunts often cite thromboembolic and cardiopulmonary complications, as well as the potential for shunt nephritis, as significant complications of VA shunts.3,6,1619 A recent comparison of nonperitoneal shunts demonstrated a lower complication rate in VA compared with VPl shunts (4% vs 15.6%); complications in VA shunts included distal catheter displacement, shunt disconnection, endocarditis, and shunt nephritis.20

In our cohort of children, however, we did not find a difference in the aggregate complication rates between VA and VPl shunts. Pneumothorax was diagnosed in 3 patients in the VPl cohort. Although granular data are not available on the need for anticoagulation and other non–shunt-related treatment interventions, this study demonstrates an overall similar safety profile of VA and VPl shunts in the HCRN. It has also been suggested that VA shunts are not an attractive alternative in young children because of the potential need for lengthening to accommodate for growth over time.7 We found that at 2 years the proportion of VA shunts revised was higher than that of VPl shunts. Our survival analysis revealed that children < 6 years of age with VA shunts had a significantly lower shunt survival; this may have been secondary to the need for distal catheter lengthening, although the location of failure analysis does not reveal a disproportionately large proportion of distal VA failures.

Christian et al.8 found that age < 10 years was an independent risk factor for the development of pleural effusion; however, they did not report on risk factors for VPl shunt failure. Our univariable analysis demonstrated that age ≥ 6 years was protective against failure for nonperitoneal shunts. Although the concept of younger children being at higher risk for shunt failure is not novel,21 this cohort study of VA and VPl shunts confirms a previous finding that younger children are more prone to shunt failure, specifically those with VA shunts.

As part of an additional analysis, we found that VPl shunts have similar survival to VP shunts, with VA shunts demonstrating a 1.42 higher odds of failure; this finding suggests that VPl and VP shunts may have similar survival rates, both of which are better than that of VA shunts. As previously discussed, this is likely a function of age; in our comparison of children with a similar number of previous shunt surgeries and age ≥ 6 years, VA, VPl, and VP shunts all had similar shunt survival.

Our analysis revealed that the utilization of antibiotic catheters was lower in the VA cohort. This was driven by distal rather than proximal catheter use patterns. Information about the specific type of catheter (traditional VP shunt tubing vs type E catheters) is not available in the registry; however, we hypothesize that dedicated atrial catheters, which are not antibiotic impregnated, may have been utilized.

Limitations

The study is derived from a registry of patients treated surgically for hydrocephalus. The current cohort includes those entered in the registry prospectively, but some children are missing data from previous shunt surgeries. Although all children have at least one prior surgery reported in the registry, a significant proportion of the children included are derived from the noncomprehensive cohort, in which a subject’s entire shunt surgery history may not be available.

Additional limitations include the disparity in cohort sample size. Although we adjusted for differences in baseline characteristics, specifically age and etiology, the cohort size disparity limits our ability to directly compare the two treatment types. Additionally, the low number of patients in the VPl cohort < 6 years of age limits our ability to explore outcomes and make meaningful comparisons.

All data were collected with protocols for fidelity, validation, and quality control. The HCRN includes centers in North America only, so the findings should be carefully interpreted with respect to practice patterns and protocols worldwide. As with any surgical study, the choice of nonperitoneal site is subject to the bias of the treating surgeon. Treatment centers may have an undetected influence over shunt terminus choice; in this study, 4 sites had a > 50% proportion of VPl shunts placed, but in aggregate the site frequencies are small and were not included in the statistical model. There is currently no protocol in place in the HCRN to influence terminus choice, which was the impetus for this investigation. Several variables, such as using pediatric surgery assistance, intraoperative technique (cut-down vs Seldinger), and intraoperative imaging adjuncts (fluoroscopy, echocardiography, and electrocardiography), are not recorded in the registry; these may represent important factors in assessing shunt survival and should be examined in future studies.

As mentioned previously, granular data were not available for major complications for VA shunts (need for anticoagulation or antiplatelet therapy, development of pulmonary hypertension, and stroke) or VPl shunts (treatment for pneumothorax and delayed symptomatic pleural effusions) and other non–shunt-related treatment interventions in the HCRN registry. Despite these limitations, this investigation represents the largest comparative study of VA versus VPl shunts and provides context in relation to VP shunt survival. Our analysis affirms that patients selected for atrial and pleural termini are fundamentally different; our goal was to explore those differences and report shunt survival outcomes for this specific population of children (those who cannot receive peritoneal shunts). It should be noted that the focus of the investigation was not to directly compare nonperitoneal and peritoneal shunts.

Conclusions

In this study comparing VA and VPl shunts, we found that VA shunts are used more often overall and are placed in younger patients, especially those who were premature and had IVH. VPl shunts were more commonly placed in older children with myelomeningocele. When stratified by age, children < 6 years with VA shunts had the shortest shunt survival, which may be explained by the different etiologies; however, shunt location (VA vs VPl) was not associated with shunt survival in the multivariable model that included age and etiology. No differences were found in the cumulative frequency of complications. These results support that both atrial and pleural sites are viable when the abdomen is not usable. Overall, the findings suggest that the baseline differences observed between the cohorts of children treated with a VA versus a VPl shunt, specifically with respect to age and etiology, likely account for current practice patterns.

Acknowledgments

We thank our colleagues for their past and ongoing support of HCRN: D Brockmeyer, M Walker, R Bollo, S Cheshier, R Iyer, J Blount, J Johnston, L Acakpo-Satchivi, WJ Oakes, P Dirks, G Ibrahim, J Rutka, M Taylor, D Curry, G Aldave, R Dauser, A Jea, S Lam, H Weiner, T Luerssen, R Ellenbogen, J Ojemann, A Lee, A Avellino, S Greene, E Tyler-Kabara, R Kellogg, T Abel, TS Park, J Strahle, J Roland, S McEvoy, M Smyth, N Tulipan, F Haji, A Singhal, P Steinbok, D Cochrane, W Hader, C Gallagher, M Benour, P Chiarelli, S Durham, E Kiehna, JG McComb, A Robison, A Alexander, M Handler, B O’Neill, C Wilkinson, L Governale, A Drapeau, J Leonard, E Sribnick, A Shaikhouni, E Ahn, A Cohen, M Groves, S Robinson, CM Bonfield, and C Shannon.

In addition, our work would not be possible without the outstanding support of the dedicated personnel at each clinical site and the data coordinating center. Special thanks go to A Ludwick, L Holman, J Clawson, P Martello, N Tattersall, T Bach (Salt Lake City, UT); T Caudill, P Komarova, A Arynchyna, A Bey (Birmingham, AL); N Emami, H Ashrafpour, M Lamberti-Pasculli, L O’Connor (Toronto, ON); E Santisbon, E Sanchez, S Martinez, S Ryan (Houston, TX); H Willis, K Hall, C Gangan, J Klein, A Anderson, G Bowen (Seattle, WA); S Thambireddy, K Diamond, A Luther (Pittsburgh, PA); N Reinhold, A Morgan, H Botteron, D Morales, M Gabir, D Berger, D Mercer (St. Louis, MO); M Stone, A Wiseman, J Stoll, D Dawson, S Gannon (Nashville, TN); H Willis, I Watson, A Cheong, R Hengel (Vancouver, BC); R Rashid, S Ahmed (Calgary, AL); J Yea, A Loudermilk (Baltimore, MD); H Berroya, N Chapman, N Rea, C Cook (Los Angeles, CA); N Volz, S Staulcup (Aurora, CO); J Haught, H Lehmann, S Saraswat, A Sheline (Columbus, OH); and N Nunn, M Langley, V Wall, D Austin, B Conley, V Freimann, L Herrera, B Miller (Utah Data Coordinating Center).

We thank Kristin Kraus and Cortlynd Olsen for editorial support.

The HCRN is thankful for the following sources of funding: National Institute of Neurological Disorders and Stroke (NINDS grant nos. 1RC1NS068943-01 Challenge and 1U01NS107486-01A1 ESTHI), private philanthropy, and the Hydrocephalus Association.

Dr. Ravindra is a military service member. This work was prepared as part of his official duties. Title 17, USC, §105 provides that copyright protection under this title is not available for any work of the US Government. Title 17, USC, §101 defines a US Government work as a work prepared by a military service member or employee of the US Government as part of that person’s official duties.

Disclaimer

The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or US Government.

None of the sponsors participated in the design and conduct of this study; collection, management, analysis, and interpretation of the data; or preparation, review, or approval of this manuscript. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of the sponsors.

Disclosures

Dr. Limbrick reported being the CMO of Rhaeos Inc. outside the submitted work. Dr. Hauptman reported personal fees from Medtronic and BK Medical outside the submitted work. Dr. Jackson reported consulting fees from Integra LifeSciences outside the submitted work.

Author Contributions

Conception and design: Kestle, Riva-Cambrin, Whitehead, Kulkarni, Wellons, Rozzelle, Rocque, McDowell, Krieger. Acquisition of data: Kestle, Riva-Cambrin, Whitehead, Limbrick, Naftel, Rozzelle, Rocque, Pollack, McDowell, Tamber, Hauptman, Pindrik, Isaacs, McDonald, Hankinson, Jackson, Krieger, Simon, Strahle. Analysis and interpretation of data: Kestle, Ravindra, Riva-Cambrin, Jensen, Whitehead, Limbrick, Pollack, McDowell, Pindrik, Krieger, Strahle, Holubkov, Reeder. Drafting the article: Kestle, Ravindra, Riva-Cambrin, Jensen, Rocque, Krieger. Critically revising the article: Kestle, Ravindra, Riva-Cambrin, Jensen, Whitehead, Kulkarni, Limbrick, Wellons, Rocque, Pollack, McDowell, Tamber, Hauptman, Pindrik, Isaacs, McDonald, Hankinson, Jackson, Chu, Krieger, Strahle. Reviewed submitted version of manuscript: Kestle, Riva-Cambrin, Whitehead, Kulkarni, Wellons, Naftel, Rozzelle, Rocque, Pollack, McDowell, Tamber, Browd, Pindrik, Isaacs, McDonald, Hankinson, Jackson, Chu, Krieger, Simon, Strahle, Holubkov, Reeder. Approved the final version of the manuscript on behalf of all authors: Kestle. Statistical analysis: Ravindra, Jensen, Krieger, Reeder. Administrative/technical/material support: Limbrick, Krieger. Study supervision: Kestle, Riva-Cambrin, Krieger, Holubkov.

Supplemental Information

Previous Presentations

This work was previously presented at the AANS/CNS Section on Pediatric Neurological Surgery, Oklahoma City, OK, December 1–4, 2023.

References

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    Symss NP, Oi S. Is there an ideal shunt? A panoramic view of 110 years in CSF diversions and shunt systems used for the treatment of hydrocephalus: from historical events to current trends. Childs Nerv Syst. 2015;31(2):191202.

    • PubMed
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    Vernet O, Campiche R, de Tribolet N. Long-term results after ventriculo-atrial shunting in children. Childs Nerv Syst. 1995;11(3):176179.

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    Hanak BW, Bonow RH, Harris CA, Browd SR. Cerebrospinal fluid shunting complications in children. Pediatr Neurosurg. 2017;52(6):381400.

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    Zhang J, Qu C, Wang Z, et al. Improved ventriculoatrial shunt for cerebrospinal fluid diversion after multiple ventriculoperitoneal shunt failures. Surg Neurol. 2009;72(suppl 1):S29S34.

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    Gmeiner M, Wagner H, van Ouwerkerk WJR, Senker W, Holl K, Gruber A. Abdominal pseudocysts and peritoneal catheter revisions: surgical long-term results in pediatric hydrocephalus. World Neurosurg. 2018;111:e912e920.

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    Oyon DE, Behbahani M, Sharma S, et al. Ventriculopleural shunt outcomes for pediatric hydrocephalus: a single-institution experience. Childs Nerv Syst. 2023;39(8):21052113.

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    Ransohoff J. Ventriculo-pleural anastomosis in treatment of midline obstructional neoplasms. J Neurosurg. 1954;11(3):295298.

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    Hasegawa H, Rinaldo L, Meyer FB, Lanzino G, Elder BD. Reevaluation of ventriculopleural shunting: long-term efficacy and complication rates in the modern era. World Neurosurg. 2020;138:e698e704.

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    Craven C, Asif H, Farrukh A, Somavilla F, Toma AK, Watkins L. Case series of ventriculopleural shunts in adults: a single-center experience. J Neurosurg. 2017;126(6):20102016.

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    Richardson MD, Handler MH. Minimally invasive technique for insertion of ventriculopleural shunt catheters. J Neurosurg Pediatr. 2013;12(5):501504.

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    Ajlan B, Maghrabi Y, Mokhtar G, Baeesa S. Timing of ventriculoatrial shunt removal on renal function recovery of patients with shunt nephritis: case report and systematic review. Clin Neurol Neurosurg. 2022;218:107279.

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    Babigumira M, Huang B, Werner S, Qunibi W. Delayed manifestation of shunt nephritis: a case report and review of the literature. Case Rep Nephrol. 2017;2017:1867349.

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  • 18

    Harland TA, Winston KR, Jovanovich AJ, Johnson RJ. Shunt nephritis: an increasingly unfamiliar diagnosis. World Neurosurg. 2018;111:346348.

  • 19

    Völker LA, Burkert K, Scholten N, et al. A case report of recurrent membranoproliferative glomerulonephritis after kidney transplantation due to ventriculoatrial shunt infection. BMC Nephrol. 2019;20(1):296.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    De John BG, Figaji AA, Enslin JMN. Analysis of non-ventriculoperitoneal shunts at Red Cross War Memorial Children’s Hospital. Childs Nerv Syst. 2024;40(4):10991110.

    • PubMed
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  • 21

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

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  • Collapse
  • Expand
  • FIG. 1.

    CONSORT diagram for the study.

  • FIG. 2.

    Stratified Kaplan-Meier survival curves comparing VA and VPl shunts in children < 6 and ≥ 6 years of age. Figure is available in color online only.

  • 1

    Symss NP, Oi S. Is there an ideal shunt? A panoramic view of 110 years in CSF diversions and shunt systems used for the treatment of hydrocephalus: from historical events to current trends. Childs Nerv Syst. 2015;31(2):191202.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Vernet O, Campiche R, de Tribolet N. Long-term results after ventriculo-atrial shunting in children. Childs Nerv Syst. 1995;11(3):176179.

  • 3

    Hanak BW, Bonow RH, Harris CA, Browd SR. Cerebrospinal fluid shunting complications in children. Pediatr Neurosurg. 2017;52(6):381400.

  • 4

    Zhang J, Qu C, Wang Z, et al. Improved ventriculoatrial shunt for cerebrospinal fluid diversion after multiple ventriculoperitoneal shunt failures. Surg Neurol. 2009;72(suppl 1):S29S34.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Gmeiner M, Wagner H, van Ouwerkerk WJR, Senker W, Holl K, Gruber A. Abdominal pseudocysts and peritoneal catheter revisions: surgical long-term results in pediatric hydrocephalus. World Neurosurg. 2018;111:e912e920.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Gmeiner M, Wagner H, van Ouwerkerk WJR, et al. Long-term outcomes in ventriculoatrial shunt surgery in patients with pediatric hydrocephalus: retrospective single-center study. World Neurosurg. 2020;138:e112e118.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Oyon DE, Behbahani M, Sharma S, et al. Ventriculopleural shunt outcomes for pediatric hydrocephalus: a single-institution experience. Childs Nerv Syst. 2023;39(8):21052113.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Christian EA, Quezada JJ, Melamed EF, Lai C, McComb JG. Ventriculopleural shunts in a pediatric population: a review of 170 consecutive patients. J Neurosurg Pediatr. 2021;28(4):450457.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Tamber MS, Kestle JRW, Reeder RW, et al. Temporal trends in surgical procedures for pediatric hydrocephalus: an analysis of the Hydrocephalus Clinical Research Network Core Data Project. J Neurosurg Pediatr. 2020;27(3):269276.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Ransohoff J. Ventriculo-pleural anastomosis in treatment of midline obstructional neoplasms. J Neurosurg. 1954;11(3):295298.

  • 11

    Hoffman HJ, Hendrick EB, Humphreys RP. Experience with ventriculo-pleural shunts. Childs Brain. 1983;10(6):404413.

  • 12

    Küpeli E, Yilmaz C, Akçay S. Pleural effusion following ventriculopleural shunt: case reports and review of the literature. Ann Thorac Med. 2010;5(3):166170.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Hasegawa H, Rinaldo L, Meyer FB, Lanzino G, Elder BD. Reevaluation of ventriculopleural shunting: long-term efficacy and complication rates in the modern era. World Neurosurg. 2020;138:e698e704.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Craven C, Asif H, Farrukh A, Somavilla F, Toma AK, Watkins L. Case series of ventriculopleural shunts in adults: a single-center experience. J Neurosurg. 2017;126(6):20102016.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Richardson MD, Handler MH. Minimally invasive technique for insertion of ventriculopleural shunt catheters. J Neurosurg Pediatr. 2013;12(5):501504.

  • 16

    Ajlan B, Maghrabi Y, Mokhtar G, Baeesa S. Timing of ventriculoatrial shunt removal on renal function recovery of patients with shunt nephritis: case report and systematic review. Clin Neurol Neurosurg. 2022;218:107279.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Babigumira M, Huang B, Werner S, Qunibi W. Delayed manifestation of shunt nephritis: a case report and review of the literature. Case Rep Nephrol. 2017;2017:1867349.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Harland TA, Winston KR, Jovanovich AJ, Johnson RJ. Shunt nephritis: an increasingly unfamiliar diagnosis. World Neurosurg. 2018;111:346348.

  • 19

    Völker LA, Burkert K, Scholten N, et al. A case report of recurrent membranoproliferative glomerulonephritis after kidney transplantation due to ventriculoatrial shunt infection. BMC Nephrol. 2019;20(1):296.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    De John BG, Figaji AA, Enslin JMN. Analysis of non-ventriculoperitoneal shunts at Red Cross War Memorial Children’s Hospital. Childs Nerv Syst. 2024;40(4):10991110.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

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

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