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CASE REPORT
Year : 2018  |  Volume : 13  |  Issue : 1  |  Page : 78-80
 

Endovascular retrieval of detached ventriculoatrial shunt into pulmonary artery in pediatric patient: Case report


1 Department of Neurosurgery, Aseer Central Hospital, Abha, Saudi Arabia
2 Pediatric Cardiology, King Khalid University, Abha, Saudi Arabia
3 Neurosurgery, King Khalid University, Abha, Saudi Arabia

Date of Web Publication16-May-2018

Correspondence Address:
Dr. Mohammed Aloddadi
Aseer Central Hospital, Abha, K.S.A.
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JPN.JPN_143_17

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   Abstract 

The management of hydrocephalus represents a neurosurgical challenge. Ventriculoperitoneal (VP) shunts are usually the treatment of choice for hydrocephalus. However, when VP shunt is not an option, ventriculoatrial (VA) shunt becomes a second choice. VA shunts have special complications such as postoperative neck hematomas, shunt nephritis, and migration of the distal segment. There are two main techniques for the retrieval of migrated VA shunt: either by retrieval of the broken segment by thoracotomy, which is highly invasive, or by transvenous approach. A 9-year-old boy presented with severe cerebral palsy, who was VP shunt dependent since birth. The patient developed generalized cerebrospinal fluid (CSF) ascites with peritonitis. The shunt was externalized and infection was treated with intravenous antibiotics. Two weeks later, and due to previous multiple abdominal procedures, it was decided to go for VA shunt and the procedure went well without complications. One month later, the patient presented to emergency department with neck swelling; shunt x-ray showed shunt breakage at clavicular level and the tip of the shunt was dislodged into the pulmonary artery. Under general anesthesia and after getting informed consent, through femoral vein, VA shunt was retrieved successfully without complications and new VP shunt was inserted. Migration of the distal segment of a broken atrial catheter is rare, but has a significant complication and is major cause of mortality. Endovascular retrieval of migrated shunts is less invasive, is feasible, and prevents further complications. There has been similar case in the adult English literature; however, to the best of our knowledge, this is the first reported case in the English literature of a successful endovascular retrieval of migrated dislodged VA shunt in pediatrics.


Keywords: Endovascular retrieval, migrated, ventriculoatrial shunt


How to cite this article:
Aloddadi M, Alshahrani S, Alnaami I. Endovascular retrieval of detached ventriculoatrial shunt into pulmonary artery in pediatric patient: Case report. J Pediatr Neurosci 2018;13:78-80

How to cite this URL:
Aloddadi M, Alshahrani S, Alnaami I. Endovascular retrieval of detached ventriculoatrial shunt into pulmonary artery in pediatric patient: Case report. J Pediatr Neurosci [serial online] 2018 [cited 2019 Sep 22];13:78-80. Available from: http://www.pediatricneurosciences.com/text.asp?2018/13/1/78/232427





   Introduction Top


The management of hydrocephalus represents a neurosurgical challenge. Ventriculoperitoneal (VP) shunts are usually the treatment of choice for hydrocephalus. However, when VP shunt is not an option due to abdominal complications such as cerebrospinal fluid (CSF) ascites, peritonitis, and others, ventriculoatrial (VA) shunt becomes a second choice. VA shunts share common complications with VP shunts such as shunt infection and obstruction; however, VA shunts have their own specific complications such as postoperative neck hematomas, short lower end of the tube that needs revision for growing children, shunt nephritis, and migration of the distal segment.[1] Migration of the distal segment is a very rare complication of VA shunt. Akhtar et al.[1] reported that it was seen in 1.56% cases. There are two main techniques for retrieval of VA shunt, either by retrieval of the broken segment from inside the heart via thoracotomy,[2] which is highly invasive, or by transvenous approach.[3],[4],[5]


   Case Report Top


A nine-year-old boy with severe cerebral palsy was presented, who was VP shunt dependent since birth. The patient presented with abdominal distention. On examination, the patient was found to have severe developmental delay, with spasticity on all limbs. His workup revealed mild leukocytosis and elevated erythrocyte sedimentation rate (ESR). Imaging including x-rays, abdominal ultrasound, and computed tomography revealed intact shunt system. As severe generalized ascites was seen, so the shunt was externalized and infection was treated with intravenous antibiotics. After 2 weeks, and due to multiple pervious abdominal procedures, it was decided to go for VA shunt insertion, where the procedure went well without complications. The patient was discharged in good condition and seen after 2 weeks in clinic with no major concern. One month later, the patient came to emergency department, with progressive neck swelling over few days with no other complaints. X-ray of the VA shunt system showed atrial shunt breakage at clavicular level and a 10-cm tip of the shunt dislodged in the pulmonary artery [Figure 1]. Echocardiogram revealed that the broken tip is free within the right atrium with most of the migrated distal tip at the origin of pulmonary artery and no injury of cardiac tissues. The situation was explained to the family and consent was taken for two separate procedures, where under general anesthesia and through right femoral vein access, the VA shunt was retrieved successfully without complications [Figure 2], and VA was then laparoscopically converted to VP shunt without complications.
Figure 1: Chest x-ray showing shunt breakage at clavicular level and the tip of the shunt dislodged in the pulmonary artery

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,
Figure 2: Chest x-ray showing the retrieval of the VA shunt through the femoral vein

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   Discussion Top


Migration of the distal segment of a broken atrial catheter is rare,[1] but has a significant complication and is major cause of mortality. There has been similar case in the adult English literature.[6] Mori et al.[3] reported a successful retrieval of a detached intracardiac segment of an atrial catheter that was migrated into the pulmonary arterial trunk of a 21-year-old. Matsubara et al.,[4] in the Japanese literature reported the retrieval of a migrated shunt that was in the right ventricle of a 67-year-old, although the rostral catheter segment remained because of adhesions. Weisse et al.[5] reported the only pediatric case in the German literature of a successful retrieval of the migrated shunt that was found in the right branch of the pulmonary artery in a 17-year-old patient. Endovascular retrieval of migrated shunts is less invasive, is feasible, and prevents further complications.[7] The relationship between the catheter and the adjacent cardiac structure is important in decision-making and how safe the retrieval procedure is going to be. This should be assessed by echocardiogram before the retrieval.


   Conclusion Top


To the best of our knowledge, this is the first reported case in the English literature of a successful endovascular retrieval of migrated dislodged VA shunt in pediatrics. Endovascular retrieval is a safe, feasible approach for such complications. Pre-procedural echocardiogram is essential to assess the catheter location in relation to adjacent structures.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Akhtar N, Khan AA, Yousef M. Experience and outcome of ventricular-atrial shunt: A multicenter study. J Ayub Med Coll Abbottabad 2015;13:817-20.  Back to cited text no. 1
    
2.
Holder TM, Crow ML. Free intracardiac foreign body: A complication of ventriculo-venous shunt for hydrocephalus. J Thorac Cardiovasc Surg 1963;13:138-40.  Back to cited text no. 2
    
3.
Mori T, Arisawa M, Fukuoka M, Tamura K, Kurisaka M, Mori K. Management of a broken atrial catheter migrated into the heart: A rare complication of ventriculoatrial shunt–case report. Neurol Med Chir (Tokyo) 1993;13:713-5.  Back to cited text no. 3
    
4.
Matsubara N, Miyachi S, Tsukamoto N. Intra-cardiac migration of a ventriculoatrial shunt catheter treated by endovascular transvenous retrieval. No Shinkei Geka 2012;13:539-45.  Back to cited text no. 4
    
5.
Weisse G, Vogt J, Fassbender D, Seggewiss H, Gleichmann U. [The percutaneous extraction of an embolized Pudenz-Heyer catheter fragment from the pulmonary artery].Dtsch Med Wochenschr 1992;13:490-3.  Back to cited text no. 5
    
6.
Elhammady MS, Benglis DM, Bhatia S, Sandberg DI, Ragheb J. Ventriculoatrial shunt catheter displacement in a child with partial anomalous pulmonary venous return. J Neurosurg Pediatr 2008;13:68-70.  Back to cited text no. 6
    
7.
Gopal VV, Peethambaran AK. Rare sequelae following ventriculoatrial shunt: Case report and review of literature. Asian J Neurosurg 2016;13:173.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2]



 

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    Abstract
   Introduction
   Case Report
   Discussion
   Conclusion
    References
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