Distal Ventriculoperitoneal Shunt Catheter Migration to the Right Ventricle of the Heart - A Case Report
Marc Manix, MD; Anthony Sin, MD; Anil Nanda, MD, MPH, FACS
Ventriculoperitoneal shunts (VPS) have few complications other thanmechanical obstruction and infection. A VPS catheter located in the chest is a rare complication, while intracardiac catheter migration is rarer still. We present a case of intracardiac migration of a distal VPS catheter after initial documented peritoneal placement. Puncture or erosion of a cervical vein may predispose a patient to such a migration. Negative inspiratory pressure and orthograde blood flow may then draw the catheter proximally through a vein and eventually to the heart or pulmonary artery. We discuss the mechanisms and management of this rare, yet dangerous, complication of a routine neurosurgical procedure.
INTRODUCTION The ventriculoperitoneal shunt (VPS) is the most com- mon surgical treatment for hydrocephalus, and the opera- tion has been practiced for the past 60 years. While it has a low complication rate, complications do sometimes occur. Most often, these tend to be mechanical obstructions or infection. Numerous case reports in the literature illustrate the many possible complications seen with the VPS, but it is rare for a portion of a VPS catheter to travel into the chest as this is not a part of the normal course for tubing since it is tunneled to the peritoneal cavity. We present a case where the distal end of a catheter placed in the peritoneum migrated to the heart. CASE REPORT A 34-year-oldmale presented with reports of gradually worsening headaches. The patient had a prior VPS place- ment at an outside institution (Figure 1) two years prior. The past medical history was significant for spina bifida and tethered cord, for which he had a lipoma removal and release of tethered cord six months prior presentation. The operationwas complicated by a postoperative cerebrospinal fluid leak and development of a pseudomeningocele in the lumbar spine. This led to severe headaches, as well as low back pain and swelling. The VP shunt was then placed for diversion of CSF by an outside neurosurgeon in order to resolve the pseudomeningocele and relieve the pressure in the lumbar cistern, allowing the dural defect to heal. The patient reported good relief of symptoms for eight months,
but the headaches returned, leading to presentation in our clinic. A shunt malfunction was suspected at presentation, so a shunt series of plain film X-rays was ordered as part of the initial workup. The X-rays showed a catheter coiled around itself in the thorax without any extension to the ab- domen (Figure 1d). ACT scan of the neck and chest showed that the catheter extended through the neck into the right subclavian vein and continued through the right heart to the pulmonary vasculature (Figure 2). DISCUSSION Neurosurgeons frequently see VPS complications. However, thoracic complications are rare, as shunt catheters normally do not enter this area. Intracardiac migration is seen even less often, with only 12 cases reported in the literature. Taub described supra- and transdiaphragmatic routes for the migration of the peritoneal catheter to the chest. 1 The routes can be distinguished radiographically, as any tubing seen in the abdomen must pass through the dia- phragm to enter the thorax. Taub and Lavyne hypothesize that transdiaphragmatic migration occurs either when a catheter erodes the diaphragm or when it passes through the Foramen of Bochadalek or Morgagni. 21,26 Because no portion of the catheter was visible in imaging studies of the abdomen, we decided that the site of entry in the case was supradiaphragmatic. Morell, the first to describe the migration of a VPS catheter into the heart, proposed two possible ways it might occur. 2 He first postulated that there is iatrogenic damage
J La State Med Soc VOL 166 January/February 2014 21
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