reported case underwent a thoracotomy and open heart surgery for treatment. Frazier describes a sub-xyphoid pericardial window for direct observation of the heart as the catheter was withdrawn [3]. Fluoroscopic guided removal of the distal catheter and placement in the peritoneal cavity is the most common treatment, but some authors used the assistance of interventional radiology and percutaneous techniques to remove the tubing from the heart. Imamura and Ruggiero both elected to withdraw the catheter into the right atrium under fluoroscopy, but chose not to reposition the catheter in the peritoneum [4,5]. They used a cervical incision to shorten the distal catheter and left their patients with a ventriculo-atrial (VA) shunt. They point out the advantages of this procedure: a shorter opera- tive time without the need for general anesthesia. However, VA shunts carry the risks ofcardiac insufficiency, cardiac ar- rhythmias, tamponade, mural thrombi, pulmonary emboli, as well as endocarditis and sepsis in the setting of infection. CONCLUSION This case shows a rare yet dangerous complication of a basic surgical procedure. Migration of a peritoneal catheter into the heart puts the patient at risk for pulmonary em- boli, cardiac arrhythmias, sepsis, tamponade, and valvular damage. The diagnosis is easily made with plain films, but CT scanning and an echocardiogram should be part of the complete workup. Treatment options include removing the catheter under fluoroscopic guidance, with assistance of loop snare devices, grasping forceps, and helical baskets per interventional radiology should there be difficulty with the manual retrieval. Moreover, the majority of cases reported in the literature describe the catheter passing intravascular through the external or internal jugular vein. This likely happened because the shunts were passed too medial and too deep, placing the catheter either through or adjacent to these vessels. There does not appear to be a need for more invasive procedures, such as a thoracotomy or pericardial window, given the success and lack of complications with minimally invasive techniques. Perhaps the open surgical procedures should be reserved for more complicated cases not amenable to percutaneous methods. Most importantly, the case report presented demonstrates the need for care- ful and proper technique in the setting of a basic surgical procedure. Remaining cognizant of the path of the shunt passer and obtaining proper post-operative imaging are the best ways to avoid this complication. REFERENCES 1. TaubE, LavyneMH. Thoracic complications of ventriculoperitoneal shunts: case report and review of the literature. Neurosurgery 1994;34:181-183. 2. Morel l RC, Bel l WO, Hertz GE, et al . Migrat ion of a ventriculoperitoneal shunt into the pulmonary artery. J Neurosurg Anesthesiol 1994;6:132-134. 3. Frazier JL, Wang PP, Patel SH, et al. Unusual migration of the
distal catheter of a ventriculoperitoneal shunt into the heart: case report. Neurosurgery 2002;51:819-822. 4. Imamura H, Nomura M. Migration of ventriculoperitoneal shunt into the heart – case report. Neurol Med-Chir (Tokyo) 2002;42:181- 183. 5. Ruggiero C, Spennato P, De Paulis D, et al. Intracardiac migration of the distal catheter of ventriculoperitoneal shunt: a case report. Childs Nerv Syst 2010;26:957-962.
Drs. Manix, Sin, and Nanda are with the Louisiana State University Health Sciences Center-Shreveport’s Department of Neurosurgery.
J La State Med Soc VOL 166 January/February 2014 25
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