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Commentary on:
Failed Ventriculoperitoneal Shunt: Is
Retrograde Ventriculosinus Shunt
a Reliable Option?
by Oliveira et al. World Neurosurg 92:445-453, 2016
Key words Abbreviations and Acronyms From the 1Division of Pediatric Neurosurgery, Department of Neurological Surgery, St. Louis
- Failed ventriculoperitoneal shunt CSF: Cerebrospinal fluid University School of Medicine, St. Louis, Missouri, USA; and 2Department of Neurosurgery,
- Hydrocephalus ETV: Endoscopic third Neurooncology and Skull Base Unit, Miguel Hernandez University Hospital General
- Neurosurgery ventriculostomy Universitario de Alicante, Alicante, Spain
- Retrograde ventriculosinus shunt ICP: Intracranial pressure To whom correspondence should be addressed: Samer K. Elbabaa, M.D.
IJV: Internal jugular vein [E-mail: selbabaa@slu.edu]
VAS: Ventriculoatrial shunt Citation: World Neurosurg. (2016) 96:599-601.
VPS: Ventriculoperitoneal shunt http://dx.doi.org/10.1016/j.wneu.2016.08.119
VSS: Ventriculosinus shunt
patients (mostly VPSs), hardware variables such as valve design, An experimental study by Van Canneyt et al10 using a built model
valve programmability, and peritoneal entry method were not of the cerebral ventricles, the arachnoid villi, and the superior
associated with increased rates of CSF shunt failure.7 sagittal sinus to assess the VSS concluded that no
overdrainage was found in either the antegrade or retrograde
VPSs are the most commonly used CSF shunts draining into the position of the sinus shunt. Their optimal results were obtained
peritoneal cavity because of their simplicity and low rate of with the shunt positioned in the most downstream half of the
complications. The peritoneum has a large absorptive surface superior sagittal sinus.10 Toma et al11 carried a literature search
and accommodates large volumes of CSF per day. In some reviewing 7 VSS clinical series with a total of 265 patients.
patients, many abdominal conditions such as peritoneal adhe- None of the patients developed venous sinus thrombosis, air
sions, history of peritonitis or shunt infections, history of mul- embolism, or excessive intraoperative sinus bleeding.11
tiple laparotomies, or suboptimal peritoneal catheter position
can lead to frequent distal VPS malfunctions, usually in the form Patients with frequent failures of CSF shunts are best managed
of infected or sterile abdominal pseudocysts requiring shunt by neurosurgeons who are experienced in converting VPSs into
externalization. After multiple failed VPS attempts, surgeons other less commonly used shunts such as VASs, ven-
classically try converting VPSs into either ventriculoatrial shunts triculopleural shunts, or VSSs. The option of complete removal of
(VASs) or ventriculopleural shunts.8 Both atrial and pleural a problematic shunt followed by performing an endoscopic third
shunts have their own limitations and risks, especially in the ventriculostomy (ETV) in patients with a history of obstructive
very young pediatric population. Risks of VASs include hydrocephalus (preferably due to idiopathic aqueductal stenosis)
thromboembolic complications and high revision rates. The can be the treatment of choice in such scenarios. ETV, after
most common risks of pleural shunts include CSF shunt removal, can have a success rate ranging from 40%!
underabsorption leading to progressive pleural effusion and 100% when other ETV risk factors for failure such as shunt
respiratory distress. infection and age <6 months are being considered.12 The
success rate of secondary ETV in well-selected cases is not
It was suggested by El-Shafei that the most physiologic way of different from that of primary ETV. Many experts consider it
treating hydrocephalus is by establishing a watertight connection reasonable to offer all patients with frequently failed shunts and
that will drain CSF into the upper end of the internal jugular vein suitable anatomy indicating an obstructive cause the opportunity
(IJV) or a dural sinus against the direction of blood flow. On the for shunt independence regardless of the original cause of the
basis of early results, there were no common complications hydrocephalus.13
related to incorrect or suboptimal CSF drainage or thromboem-
bolic complications in patients undergoing VSS, although there Surgeons who are inherently opposed to the concept of
were considerable difficulties placing the shunts into IJVs in attempting conversion of problematic and frequently failed VPSs
infants and young children because of the small caliber of neck into other types of less commonly used shunts such as VAS or
veins. The IJV is a collapsible tube with contour change capa- VSS, or even achieving shunt independence via ETV in appro-
bilities according to changes in its transmural pressure, acting as priate patients, argue that such surgical treatments achieve low
a self-regulating siphon control mechanism, which protects the success rates at the expense of higher morbidity rates. The
ICPs against the effect of gravity and posture.5 The technique of experience of Oliveira and colleagues treating failed VPS patients
placing the distal end of the catheter into the sagittal sinus carries with retrograde VSS leading to acceptable success rates with
the risk of excessive bleeding or air embolism, although a low morbidities in their adult patients is another unconventional
modification of the technique using a Seldinger guidewire example of thinking outside the box while treating challenging
technique was described by Samadandi et al.9 patients with shunted hydrocephalus.
effect of valve type on cerebrospinal uid shunt 7. Riva-Cambrin J, Kestle JR, Holubkov R, Butler J,
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1878-8750/$ - see front matter 2016 Elsevier Inc. All
rights reserved.
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