Clinical Anatomy 00:00–00 (2017)

REVIEW

Migration of the Distal Catheter of the

Ventriculoperitoneal Shunt in Hydrocephalus:
A Comprehensive Analytical Review from an Anatomical
Perspective
MOHAMMED Z. ALLOUH ,1* MOHAMMED M. AL BARBARAWI,2
HASAN A. ASFOUR,1 AND RAED S. SAID1
1
Department of Anatomy, Faculty of Medicine, Jordan University of Science & Technology,
Irbid, 22110, Jordan
2
Division of Neurosurgery, Department of Neurosciences, Faculty of Medicine,
Jordan University of Science & Technology, Irbid, 22110, Jordan

There have been many reports on migration of the distal catheter of the ventri-
culoperitoneal shunt (VPS) since this phenomenon was recognized 50 years
ago. However, there have been no attempts to analyze its different patterns or
to assess these patterns in terms of potential risk to patients. We comprehen-
sively reviewed all reports of distal VPS catheter migration indexed in PubMed
and identified three different anatomical patterns of migration based on cathe-
ter extension and organs involved: (1) internal, when the catheter invades any
viscus inside the thoracic, abdominal, or pelvic cavity; (2) external, when the
catheter penetrates through the body wall either incompletely (subcutane-
ously) or completely (outside the body); and (3) compound, when the catheter
penetrates a hollow viscus and protrudes through a pre-existing anatomical
orifice. We also analyzed the association between each migration type and sev-
eral key factors. External migration occurred mostly in infants. In contrast,
internal migration occurred mostly in adults. A body wall weakness was not a
risk factor for catheter protrusion. Shunt duration was a critical factor in the
migration pattern, as most newly-replaced shunts tended to migrate externally.
Clinicians must pay close attention to cases of large bowel perforation, since
they were most often associated with intracranial infections. The organ
involved in compound migration could determine the route of extrusion, as the
bowel was involved in all trans-anal migrations and the stomach in most trans-
oral cases. Clin. Anat. 00:000–000, 2017. VC 2017 Wiley Periodicals, Inc.

Key words: catheter extrusion; shunt revision; intracranial infections; bowel

perforation

Additional Supporting Information may be found in the online

INTRODUCTION
Hydrocephalus is an abnormally increased volume of
cerebrospinal fluid (CSF) in the brain’s ventricular sys-
tem, due to either abnormal flow or impaired absorption
(Rekate, 2009). In 1908, Kausch attempted, for the
first time, to divert the flow of CSF into the peritoneal
cavity through a shunt installation (Pudenz, 1981). The
ventriculoperitoneal shunt (VPS) was considered clini-
cally ineffective for about fifty years after its invention
version of this article.
*Correspondence to: Mohammed Z. Allouh, Department of
Anatomy, Faculty of Medicine, Jordan University of Science &
Technology, P. O. Box: 3030, Irbid, 22110, Jordan.
E-mail: m_allouh@just.edu.jo
Received 14 March 2017; Revised 13 May 2017; Accepted 22
May 2017
Published online in Wiley Online Library (wileyonlinelibrary.com).
DOI: 10.1002/ca.22928

C
V 2017 Wiley Periodicals, Inc.
2 Allouh et al.
because of many manufacturing defects and obstruc-
tions in both ventricular and distal parts of the shunt
(Borgbjerg et al., 1995). However, thanks to technologi-
cal advances in shunt manufacture, VPS is nowadays
the preferred and most commonly-used procedure in
managing hydrocephalus (Patwardhan and Nanda,
2005; Kim et al., 2016).
The modern VPS apparatus generally consists of three
segments: a proximal catheter (ventricular end), a
reservoir connected to a unidirectional valve, which con-
nects to the third segment, the distal catheter (perito-
neal end) (Sivaganesan et al., 2012). Ordinarily, the
distal catheter is tunneled subcutaneously with the aid of
an introducer (Pe  rez-Bovet et al., 2013). The introducer
must be placed accurately when located subcutaneously
over specific surface anatomical regions such as the
peri-clavicular area, to avoid injury to vital structures in
the neck or thoracic wall compartments (Rahimi Rad
et al., 2007; Kano et al., 2010). The distal catheter is
then inserted into the peritoneal cavity from its lower
end, and its upper end is subsequently connected to the
lower part of the valve, which is positioned post-
auricularly. Meanwhile, the proximal catheter is directed
into the ventricular cavity after a burr hole is drilled in the
skull; this catheter is then connected by its other end to
the upper part of the valve (Schievink et al., 1993).
Despite its current popularity, VPS is still associated
with multiple complications, which arise more frequently
at the distal than the proximal end (Kast et al., 1994). A
constellation of complications pertaining to the distal end
of the VPS has been reported, including shunt infection
(Kanev and Sheehan, 2003), with (Knuth et al., 2013) or
without (Nakahara et al., 2006) retrograde meningitis;
shunt obstruction (Browd et al., 2006); distal catheter
migration (Abode-Iyamah et al., 2016); re-coiling
(Cho et al., 2013); segmental breakage or disconnection
(Riccardello et al., 2016); ascites (DiLuna et al., 2006);
CSF pseudocyst formation (Tamura et al., 2013); pleural
effusion (Ergu € n et al., 2008); intra-abdominal seeding of
infection (Laucks et al., 1986); allergy (AbdelAziz et al.,
2002); conveyance of the malignant metastatic cells of
an intra-cranial tumor to the abdominal cavity (Donovan
and Prauner, 2005); and even death (Ghritlaharey et al.,
2012). Among these, distal catheter migration is consid-
ered a common complication entailing both clinical and
anatomical concerns (Popa et al., 2009; Ghritlaharey
et al., 2012; Dakurah et al., 2016).
We have reviewed the PubMed-indexed literature
and to the best of our knowledge analyzed all cases of
VPS distal catheter migration reported during the last
five decades. On the basis of this review, we proposed a
new inclusive anatomical classification system and sub-
sequently used it to categorize and analyze these cases.
Lastly, several critical factors related to this complica-
tion were analyzed statistically to reveal any significant
association with VPS distal catheter migration.
METHODS
A PubMed search was performed to retrieve all cases
of distal VPS catheter migration reported over the last
five decades, following the first two cases reported by
Wilson and Bertan (1966). The following keywords and
terms were used in the PubMed search: “migration
of peritoneal catheter,” “distal catheter migration,”
“migration of distal ventriculoperitoneal catheter,”
“extrusion of ventriculoperitoneal shunt catheter,”
“dislocation of ventriculoperitoneal catheter,” “dis-
placement of ventriculoperitoneal catheter,” “ventric-
uloperitoneal shunt malfunction,” “ventriculoperitoneal
shunt complications,” “complications of distal ventriculo-
peritoneal shunt catheter,” “protrusion of ventriculoperi-
toneal catheter,” and “distal catheter perforation.”
However, cases with an abandoned (disconnected) distal
catheter and complete retraction of the shunt into the
subdural or ventricular spaces were disregarded, as they
indicate shunt malfunction resulting from a construction
defect rather than a true migration problem. Cases with
catheter dislocation due to poor placement of the cathe-
ter by the surgeon were also excluded.
Anatomical Classification of Migration
After reviewing the cases retrieved we identified
three anatomical patterns distinguished by the exten-
sion of the catheter tip and the anatomical structures
involved during migration. We categorized these pat-
terns as three types of migration: Internal (Type I),
External (Type II), and Compound (Type III) (Table 1),
as detailed below.
Internal Migration (Type I)
The internal migration type included cases in which
the VPS distal catheter migrated into one of the three
main body cavities (thoracic, abdominal and pelvic).
According to the extension of the catheter, this type was
then further sub-classified into thoracic, abdominal,
and pelvic migration. In cases of thoracic migration, the
catheter could reach the thoracic cavity through one of
two entry routes, either supra-diaphragmatic (SD) or
trans-diaphragmatic (TD) (Taub and Lavyne, 1994). SD
migration could be due to upward retraction of the distal
catheter within a tunnel that was inadvertently created
too deep relative to the ribs. On the other hand, TD
migration could be caused by erosion through the dia-
phragmatic musculature, by passing through any of the
anatomical openings of the diaphragm, or by traversing
a congenital diaphragmatic defect (Fewel and Garton,
2004). The two entry routes can be differentiated radio-
graphically, since the X-ray images will show the entire
catheter above the diaphragm in SD cases, whereas
part of it will still be detectable below the diaphragm in
TD cases (Taub and Lavyne, 1994).
In cases of migration within the abdominal cavity,
the catheter penetrated into either a hollow or a solid
abdominal viscus. The hollow viscera included the
stomach, small bowel, and different parts of the colon.
The liver was by far the most commonly perforated solid
viscus, as the catheter could penetrate deep into its
parenchyma or lodge in a sub-capsular position. We
only encountered nine cases of migration into the pelvic
cavity; perforation of the urinary bladder was reported
in eight of those cases, while in the last, the catheter
compressed and obstructed the right uterine tube.

TABLE 1. Anatomical Classification System for Distal Catheter Migration Following Ventriculoperitoneal
Shunt Placement
Migration type Extension
(I) Thoracic cavity
Internal
Abdominal cavity
Pelvic cavity
(II) Incomplete
External
Complete
(III) Gastrointestinal
Compound
Genitourinary
External Migration (Type II)
The external migration type encompassed cases in
which the catheter was extruded completely through
the body wall to the outside, or passed incompletely
(either penetration or retraction) into the subcutaneous
tissue without protruding further. The catheter is capa-
ble of piercing the intact body wall or passing through a
weakened region of it. Potential weaknesses in the body
wall include the umbilicus, a previous wound scar, an
augmented breast, and the external genitalia (scrotum
and labia majora) via the inguinal canal.
Compound Migration (Type III)
Interno-external or compound migration comprised
cases in which the VPS distal catheter initially perforated
the wall of a hollow viscus, subsequently passed through
the viscus lumen, and was ultimately extruded through
an anatomical body orifice. This type was sub-classified
into four categories according to the system involved
(gastrointestinal or genitourinary) and the orifice
through which the catheter was extruded. The first two
categories included cases in which the catheter pene-
trated a segment of gastrointestinal tract, then migrated
cranially and eventually protruded through the mouth
(trans-oral), or caudally to protrude through the anus
(trans-anal). In the third category, the catheter pene-
trated the urinary bladder and protruded through
the urethra (trans-urethral). In the last category, the
catheter penetrated a part of the female genital tract and
protruded from the vaginal orifice (trans-vaginal).
Analytical Review
All reported cases of distal VPS catheter migration
were allocated to three different tables (provided as sup-
plementary data) on the basis of the aforementioned
anatomical classification. A comprehensive statistical
analysis was then conducted in relation to putative critical
Anatomy of Distal VPS Catheter Migration 3
Course of migration Presentation of catheter tip
Supradiaphragmatic Heart
Transdiaphragmatic Pleural cavity
Lung
Hollow structures Stomach
Solid viscera Small and large intestine
Liver
Spleen
Urinary bladder
Uterine tube
Vagina
- Intact body wall Subcutaneous tissue
- Body wall weakness: Scrotum or Labia majora
Umbilicus Protruded outside
Inguinal region
Wound scar
Augmented breast
Trans-oral Protruded outside
Trans-anal
Trans-urethral
Trans-vaginal
factors that could affect the incidence of this complica-
tion. These factors were: the patient’s sex, patient’s age
at the time of migration, shunt duration (time from place-
ment until migration), and whether the shunt had previ-
ously been revised. We categorized the patients into five
age groups: Infants (age less than one year), children
(age between one and 12 years), adolescents (13 to 19
years), adults (20 to 59 years), and seniors (>60 years).
The reported cases were also sorted into four sets
according whether the shunt had lasted for (1) less than
one month, (2) more than a month but less than a year,
(3) between one and 10 years, and (4) more than a
decade. The influences of the four factors were compared
among the three main types of migration. We also inves-
tigated the effects of these factors on the different sub-
types within each major type of migration.
Two additional analyses were conducted on the
internal migration cases. The first investigated any
association between the thoracic entry route of the
catheter (SD or TD) and the reportedly penetrated
structure (heart, pericardium, lung or pleural cavity).
The second investigated any significant association
between the incidence of intracranial infections (men-
ingitis, encephalitis, ventriculitis and brain abscess)
and the abdominal viscera penetrated.
In cases of external migration we also examined
associations between the incidence of each external
migration subtype (complete and incomplete) and the
site of migration (through intact or weak areas of the
body wall). Furthermore, we compared the incidences
of the two subtypes of external migration through the
four body wall weaknesses described in the External
Migration section. Lastly, we examined the association
between the four subtypes of compound migration
and the incidence of intracranial infections.
Statistical Analysis
The associations among different migration types
and the categorical factors examined were assessed
4 Allouh et al.

TABLE 2. Comparison Between the Three Different Types of Distal Catheter Migration of the Ventriculo-
peritoneal Shunt

Characteristic Internal External Compound p-value*

Total number (%) 164 (37.5) 144 (33.0) 129 (29.5)
Sex, n (%)
Male 86 (52.4) 84 (58.3) 63 (48.8) 0.53
Female 71 (43.3) 55 (38.2) 53 (41.1)
N/A 7 (4.3) 5 (3.5) 13 (10.1)
Patient’s age at migration, n (%)
Infant 19 (11.6)## 48 (33.8)"" 35 (28.2) <0.01
Child 56 (34.1) 45 (31.7)# 70 (56.5)""
Adolescent 15 (9.1) 7 (4.9) 6 (4.8)
Adult 55 (33.5)"" 29 (20.4) 11 (8.9)##
Senior 19 (11.6) 13 (9.2) 2 (1.6)##
Shunt durability, n (%)
<1m 19 (12.8) 26 (19.5)"" 5 (4.3)## <0.01
1 m – <1 y 59 (39.6)## 64 (48.1) 79 (67.5)""
1 y – 10 y 60 (40.3)"" 36 (27.1) 32 (27.4)
> 10 y 11 (7.4) 7 (5.3) 1 (0.9)
Shunt Revision, n (%)
Yes, n (%) 33 (22.8) 22 (15.9) 26 (23.4) 0.25
No, n (%) 112 (77.2) 116 (84.1) 85 (76.6)

Abbreviations: m, month; n, number of patients; p, probability; y, year. *v2-test. ""

p < .01 more than expected
value; #p < .05, ##p < .01 less than expected value (post hoc adjusted residuals).

by Pearson’s v2 test. If the association was significant
(P < 0.05) then post-hoc residual analysis was used to
identify which type of migration contributed most to
the significance in the contingency tables. In addition,
a v2 goodness of fit test was applied to the complete
extrusion cases to assess the consistency of distribu-
tion between cases where the catheter protruded
through an intact body wall versus a potential weak-
ness in it.
RESULTS
We found a total of 323 PubMed indexed articles that
included 437 cases of VPS distal catheter migration over
the past five decades (1966–2016). The characteristics
of these cases are summarized in Table 2.
Incidences of Different Types of Migration
There was no significant association (P > 0.05)
between the type of catheter migration and the gen-
der or shunt revision factors. However, the patient’s
age group (see Analytical Review above) at the time
of migration correlated significantly with the migration
type (Table 2). Post hoc analysis of the contingency
table revealed significant residual values of 24.65
(P < 0.01) and 13.45 (P < 0.01) in infants with internal
and external types of migration, respectively. This
suggests that internal (type I) migration has a lower
than expected chance of occurring in infants, while
the opposite is true for external (type II) migration.
Furthermore, a residual value of 14.49 (P < 0.01),
indicating a significantly higher than expected likeli-
hood of internal migration, was found in adults.
Regarding compound (Type III) migration, a signifi-
cant residual value of 14.50 (P < 0.01) was found in
the children group, while significant values of 24.21
(P < 0.01) and 23.08 (P < 0.01) were found in the
adult and senior groups, respectively. This suggests
that compound migrations have a higher than
expected chance of occurring in children, but a lower
chance of occurring in adults and seniors.
In addition, a significant association (P < 0.01) was
observed between the type of migration and the period
of shunt persistence prior to migration (Table 2). When
shunts had persisted for less than one month, post hoc
analysis revealed a significant residual value of 12.99
(P < 0.01) for external migration. This suggests that
external migration has a higher than expected chance
of occurring within less than one month after shunt
installation. When shunts had persisted for between
one month and one year, the post hoc analysis revealed
a significant residual value of 14.35 (P < 0.01) for com-
pound migration, suggesting that compound migration
has a higher than expected chance of occurring
between one month and one year after shunt installa-
tion. Lastly, in cases with shunts that had persisted for
between one and 10 years, the post hoc analysis
revealed a significant residual value of 12.71 (P < 0.01)
with internal migration, indicating a higher than
expected chance of occurring between one and 10
years after shunt installation.
Incidence of Internal Migration
Our search identified 164 cases of internal migration
(Type I) described in PubMed during the last five deca-
des. The different characteristics of these cases with
their three subtypes are summarized in Table 3. There
was no significant association (P > 0.05) between the
subtype of internal migration and either sex, patient’s
age, or shunt revision (Table 3). However, a significant
association (P < 0.05) was observed between the
extension of internal migration and the period of shunt
persistence prior to migration. In the one to 10 year
 Anatomy of Distal VPS Catheter Migration 5

TABLE 3. Comparison Between Different Extension Patterns of Internal Migration

Characteristic Thoracic Abdominal Pelvic p-value*

Total number (%) 62 (37.8) 93 (56.7) 9 (5.5)
Sex, n (%)
Male 34 (54.8) 48 (51.6) 4 (44.4) 0.97
Female 27 (43.5) 41 (44.1) 3 (33.3)
N/A 1 (1.6) 4 (4.3) 2 (22.2)
Patient’s age at migration, n (%)
Infant 11 (17.7) 7 (7.5) 1 (11.1) 0.07
Child 14 (22.6) 37 (39.8) 5 (55.6)
Adolescent 7 (11.3) 6 (6.5) 2 (22.2)
Adult 20 (32.3) 34 (36.6) 1 (11.1)
Senior 10 (16.1) 9 (9.7) 0 (0)
Shunt durability, n (%)
<1m 10 (17.5) 9 (10.6) 0 (0) 0.03
1 m – <1 y 27 (47.4) 31 (36.5) 1 (14.3)
1 y–10 y 15 (26.3)## 41 (48.2)" 4 (57.1)
> 10 y 5 (8.8) 4 (4.7) 2 (28.6)
Shunt Revision, n (%)
Yes, n (%) 14 (23.0) 17 (22.1) 2 (28.6) 0.93
No, n (%) 47 (77.0) 60 (77.9) 5 (71.4)

Abbreviations: m, month; n, number of patients; NS, not significant; p, probability; y, year. *v2-test. ##
p < .01 less
than expected value, "p < .05, more than expected value (post hoc adjusted residuals).

group, the post hoc analysis revealed a significant
residual value of 12.29 (P < 0.05) with abdominal
extension.
We also investigated the association between the
course of the internal thoracic extension (SD vs.TD)
and the thoracic organ involved. Pearson’s v2 test
showed a significant association (P < 0.01) between the
internal thoracic course taken by the distal catheter and
the thoracic organ penetrated. The SD cases involved
the heart in 71.8% of patients, while only one involved
the lung parenchyma (2.6%). However, 64.7% and
35.3% of TD cases involved the pleural cavity and lung
parenchyma, respectively. No TD case was reported to
involve the heart or the pericardial cavity.
Statistical analysis revealed a significant (P < 0.01)
association between the penetrated viscus in the
abdominal migration and the incidence of intracranial
infection (Table 4). The post hoc analysis showed a
significant residual value for intracranial infections of
14.35 (P < 0.01) for involvement of the large intestine.
This suggests that catheter penetration into the large
intestine causes patients to have a higher than normal
TABLE 4. Internal Migration into Different
Abdominal Viscera and Their Associations with
Intracranial Infections
Intracranial No intracranial
Organ involved infection infection p-value*
Stomach, n (%) 4 (50.0) 4 (50.0) <0.01
Small intestine, 0 (0.0)## 10 (100.0)
n (%)
Large intestine, 23 (69.7)"" 10 (30.3)
n (%)
Liver, n (%) 4 (17.4)## 19 (82.6)
Abbreviations: n, number of patients; p, probability.
*v2-test. ##p < .01 less than expected value, ""p < .01,
more than expected value (post hoc adjusted residuals).
risk of intracranial infections. On the other hand, the
residual analysis showed significant negative values for
intracranial infections of 22.89 (P < 0.01), and 22.87
(P < 0.01) with involvement of the small intestine and
liver, respectively.
Incidence of External Migration
We found 144 cases of external distal catheter
migration (Type II) reported in PubMed during the last
five decades. These are summarized in Table 5. There
was no significant association (P > 0.05) between the
type of extrusion (incomplete vs.complete) and either
sex, patient’s age, or shunt revision (Table 5). How-
ever, a significant association (P < 0.01) was observed
between the extrusion type and shunt persistence
before migration. When a shunt had persisted for less
than one month, post hoc analysis revealed a signifi-
cant residual value of 13.66 (P < 0.01) with incom-
plete extrusion, suggesting that incomplete extrusion
has a higher than expected chance of occurring in less
than one month following shunt installation. However,
when the shunt had persisted between one and 10
years, the post hoc analysis revealed a significant
residual value of 13.19 (P < 0.01) with complete
extrusion, suggesting that complete extrusion has a
higher than expected chance of occurring between
one and 10 years of shunt installation.
No significant associations (P > 0.05) were found
between extrusion type and a body wall weakness,
and the v2 goodness of fit test revealed no significant
difference (P 5 0.88) between the incidences of com-
plete catheter extrusion through an intact body wall
and through a potential weakness in the body wall.
This suggests that a body wall weakness is not a pre-
disposing factor for complete extrusion of the distal
catheter. However, post hoc residual analysis revealed
significantly (P < 0.01) higher chances of complete
extrusion through the umbilicus and scar regions, and
6 Allouh et al.

TABLE 5. Comparison Between Incomplete and Complete Patterns of External Migration

Characteristic Incomplete Complete p-value

Total number (%) 101 (70.1) 43 (29.9)
Sex, n (%)
Male 63 (62.4) 21 (48.8) 0.45
Female 38 (37.6) 17 (39.5)
N/A 0 (0.0) 5 (11.6)
Patient’s age at migration, n (%)
Infant 36 (35.6) 12 (29.3) 0.35
Child 31 (30.7) 14 (34.1)
Adolescent 3 (3.0) 4 (9.8)
Adult 20 (19.8) 9 (22.0)
Senior 11 (10.9) 2 (4.9)
Shunt durability, n (%)
<1m 26 (27.7)"" 0 (0.0)## <0.01
1 m – <1 y 45 (47.9) 19 (48.7)
1 y – 10 y 18 (19.1)## 18 (46.2)""
> 10 y 5 (5.3) 2 (5.1)
Shunt revision, n (%)
Yes, n (%) 18 (18.6) 4 (9.8) 0.20
No, n (%) 79 (81.4) 37 (90.2)
Site of extrusion, n (%)
Intact wall 33 (32.7) 21 (48.8) 0.07
Body wall weakness 68 (67.3) 22 (51.2)
External genitalia 47 (70.1)"" 2 (9.1) <0.01
Umbilicus 4 (6.0) 12 (54.5)""
Scar region 4 (6.0) 8 (36.4)""
Augmented breast 12 (17.9)" 0 (0.0)

Abbreviations: m, month; n, number of patients; p, probability; y, year. "p < .05, ""
p < .01 more than expected
value. ##p < .01 less than expected value.

significantly higher chances of incomplete migration
into the external genitalia (P < 0.01) and the aug-
mented breast (P < 0.05), than other body wall
weaknesses.
Incidence of Compound Migration
We identified 129 cases of compound catheter
migration (Type III) reported in PubMed during the
last five decades. These cases are summarized
according to their catheter exit sites in Table 6. There
was no significant association (P > 0.05) between any
of the four catheter exit sites and either patient age,
shunt persistence prior to migration, or shunt revision.
However, a significant association (P < 0.05) was
observed between the exit site and the sex of the
patient. Post hoc analysis revealed significant residual
values of 12.89 (P < 0.01) for trans-anal migration in
males, and of 12.12 (P < 0.05) for trans-urethral
migration in females. Finally, there was no significant
association (P > 0.05) between the exit site for com-
pound migration and the incidence of intracranial
infections.
DISCUSSION
This is the first study to classify distal VPS catheter
migrations anatomically. The classification enabled us
to offer a comprehensive analysis of the different ana-
tomical patterns of distal catheter migration and the
factors that influence those patterns. In addition, we
examined the complications that could result from this
relatively common clinical condition and determined
the risk factors associated with them.
The patient’s age is considered one of the main
contributors to VPS complications (Wu et al., 2007;
Lee et al., 2015). Children experience a high rate of
shunt complications, probably because of their rapid
growth and the higher risk of shunt infections (Wu
et al., 2007). We noticed that more than half of the
distal VPS migration cases described in the literature
occurred in children under 12 years of age (63.5%).
In addition, our analysis revealed a higher incidence
of external migration than internal and compound
migrations in infants. This could be mainly attributable
to the smaller body size during this period of life,
which provides insufficient internal space for the
migrated catheter. In addition, the weak body muscu-
lature during infancy could make it easier for the cath-
eter to penetrate through the body wall. In contrast,
the analysis revealed a higher rate of internal migra-
tion in adults, suggesting that larger body cavities and
stronger wall musculature could confine the catheter
within the body and prevent its extrusion.
The distal VPS catheter can migrate internally into
various organs within the ventral body cavities (tho-
racic, abdominal and pelvic). The mechanism of distal
catheter penetration is not exactly understood. How-
ever, hypothesized causes include the single or com-
bined effects of pressure erosion after fibrous
adhesion, water hammer pressure by CSF pulsation,
and direct penetration by the sharp, rigid catheter tip
(Oshio et al., 1991; Masuoka et al., 2005; Handa
et al., 2007; Matsuoka et al., 2008; Yang and Sim,
2013). Fibrous adhesion entails the formation of a
 Anatomy of Distal VPS Catheter Migration 7

TABLE 6. Comparison between different patterns of compound migration

Characteristic Anal Oral Urethral Vaginal p-value

Total Number (%) 95 (73.6) 16 (12.4) 12 (9.3) 6 (4.7)
Sex, n (%)
Male 54 (56.8)"" 6 (37.5) 3 (25.0) - .01
Female 29 (30.5) 10 (62.5) 8 (66.7)" -
N/A 12 (12.6) 0 (0.0) 1 (8.3) -
Patient’s age at migration, n (%)
Infant 26 (28.3) 4 (25.0) 2 (20.0) 3 (50.0) .24
Child 53 (57.6) 10 (62.5) 6 (60.0) 1 (16.7)
Adolescent 5 (5.4) 0 (0.0) 1 (10.0) 0 (0.0)
Adult 7 (7.6) 2 (12.5) 0 (0.0) 2 (33.3)
Senior 1 (1.1) 0 (0.0) 1 (10.0) 0 (0.0)
Shunt durability, n (%)
<1m 3 (3.4) 2 (13.3) 0 (0.0) 0 (0.0) .39
1 m – <1 y 62 (70.5) 9 (60.0) 3 (37.5) 5 (83.3)
1 y – 10 y 22 (25.0) 4 (26.7) 5 (62.5) 1 (16.7)
> 10 y 1 (1.1) 0 (0.0) 0 (0.0) 0 (0.0)
Shunt revision, n (%)
Yes 14 (17.9) 6 (37.5) 4 (36.4) 2 (33.3) .22
No 64 (82.1) 10 (62.5) 7 (63.6) 4 (66.7)
Intracranial infection, n (%)
Yes 22 (24.2) 2 (13.3) 1 (9.1) 1 (16.7) .56
No 69 (75.8) 13 (86.7) 10 (90.9) 5 (83.3)

Abbreviations: m, month; n, number of patients; NS, not significant; p, probability; y, year. "p < .05, ""
p < .01 more
than expected value.

fibrous tract that anchors the catheter tip to the viscus
serosa. Additional risk factors that could contribute to
visceral penetration include previous surgery in the
affected organ and increased intra-abdominal pres-
sure (Gupta et al., 2015).
The most serious complication associated with
internal abdominal migration is the development of
intracranial infections including meningitis, encephali-
tis, and ventriculitis. Our analysis revealed that
approximately 42% of the internal abdominal cases
suffered from this complication. The risk of intracranial
infection was greater when the catheter penetrated
the colon. This could be attributed to the retrograde
ascent of pathogenic bacteria (e.g., fecal coliform bac-
teria) within the colic mucosa from the distal catheter
(Knuth et al., 2013; Tseng et al., 2014). Another fre-
quent, albeit less serious, abdominal complication is
the formation of CSF pseudocysts, which were
observed in all cases of liver penetration. Other intra-
abdominal complications due to VPS distal catheter
migration have also been reported, including ascites,
abscess formation, intestinal obstruction, and inguinal
hernia (Faraj et al., 2011).
VPS distal catheter migration into the pelvic viscera
is extremely rare. Our analysis revealed that such
cases reported in PubMed mostly occurred after ten
years of shunt insertion. The scarcity and late onset of
pelvic migration could be attributed to the relative
toughness of pelvic organs such as the urinary blad-
der, which is very difficult to penetrate (Xu et al.,
2016). Penetration of a VPS catheter into the urinary
bladder or the uterine tube can remain asymptomatic
for a long time but can cause abdominal pain, vomit-
ing, and dysuria; in the long term it can also induce
the formation of vesical calculi (Butler et al., 2013;
Gupta et al., 2015; Xu et al., 2016).
Analysis of the external (Type II) migration cases
reported in the literature revealed no significant differ-
ences in complete extrusion of the catheter between
an intact body wall and potential weak areas therein.
This indicates that a potential weakness in the body
wall is not a predisposing factor for complete external
migration of the distal VPS catheter. However, many
previous studies have considered the umbilicus to be
an area of anatomical and congenital weakness (a
Locus Minori Resistantiae) that predisposes the
patient to external migration of the VPS distal catheter
or formation of CSF umbilical fistula resulting from a
patent vitello-intestinal duct or urachal remnant (Das
et al., 1993; Gupta et al., 2006; Mohindra et al.,
2007; Kella et al., 2008; Ardalan et al., 2011). Other
studies have suggested that VPS extrusion through
the umbilicus is simply due to an inflammatory pro-
cess that softens the tissues causing CSF leakage and
catheter extrusion (Eser et al., 2006; Fleissig et al.,
2013; Dolas et al., 2016).
Our study revealed that in about one third (34%) of
external migration cases the distal catheter migrated
into the external genitalia (e.g., scrotum or labia). It is
difficult to explain this tendency completely. Some stud-
ies have suggested that a patent processus vaginalis
could create an outlet through which the distal catheter
in the abdominal cavity can migrate rapidly into the
external genitalia (Lee et al., 2015). This proposed
mechanism is supported by our results, which demon-
strated a higher incidence of external migration in infants
than other age groups. Normally, the processus vaginalis
remains patent in 60–70% of infants during first three
months of life (Sarangi et al., 2016). In addition, the con-
stant CSF drainage into the peritoneal cavity after VPS
placement can increase the intra-abdominal pressure
and prolong the patency of the processus vaginalis,
8 Allouh et al.
which could increase the risk of external migration into
the external genitalia.
We reviewed 14 cases in which the VPS distal cathe-
ter migrated into the breast, with only two cases involv-
ing intact breasts and 12 involved augmented ones.
Catheter migration to the breast could be attributed to
many factors such as increased intra-abdominal pres-
sure, brisk or even violent head movements, and the
elastic memory of the catheter (Mlynek et al., 2016).
Furthermore, inadvertent piercing of the implant by the
catheter during shunt installation could facilitate
this type of migration. However, it is important to note
that catheter migration to the breast can occur
regardless of the time of breast augmentation relative
to that of catheter tunneling (Spector et al., 2005; Iyer
et al., 2006).
Perforation of a hollow viscus and extrusion through
an anatomical orifice is a well-known complication of
distal VPS catheter migration (compound migration).
Our analysis revealed that children are more suscepti-
ble to this kind of migration, perhaps because their
gastrointestinal wall is weaker and peristalsis stronger
than in elderly patients (Yilmaz et al., 2013). In addi-
tion, the study revealed a male dominance in trans-
anal cases and a female dominance in the much rarer
trans-urethral cases. In cases of shunt extrusion
through the anus, the colon was the most common
site of perforation (61.7%). Trans-anal cases could be
more common in men because they have shorter
large intestines than women (Sadahiro et al., 1992).
Moreover, it has been reported that the rate of intesti-
nal emptying is quicker in men owing to their stronger
peristalsis, which could further facilitate extrusion of
the VPS catheter through the anal canal (Ellis et al.,
2008). On the other hand, trans-urethral migration
could predominate in women because the urethra is
much shorter than in their male counterparts (Moore
et al., 2014).
Perforation of the colon by a VPS distal catheter
can be lethal as it can cause intracranial infections,
peritonitis, intraperitoneal abscess, fecal fistulae, and/
or sepsis (Mandhan et al., 2015). However, patients
with trans-anal shunt extrusion do not necessarily
present with significant abdominal symptoms or
develop infections (Bodeliwala et al., 2016). This lack
of symptoms could be due to fibrous tract formation
at the perforation site, which can seal the perforation
and prevent spillage of fecal matter into the peritoneum
(Bansal et al., 2015). This can result in a delayed diagno-
sis, by which time retrograde Gram negative meningitis,
encephalitis or ventriculitis has become fully established,
leading to significant morbidity and mortality (Bodeli-
wala et al., 2016). On the other hand, our results showed
that the outcomes of trans-oral, -urethral and -vaginal
migrations are more favorable, with lower risks of CSF
infection.
CONCLUSIONS
VPS distal catheter migration can be classified ana-
tomically into three main types based on the exten-
sion of the catheter tip and the anatomical structures
involved: (I) internal, in which the catheter invades
any viscus located in the thoracic, abdominal, or pel-
vic cavity; (II) external, in which the catheter pene-
trates through different layers of the body wall either
incompletely to the subcutaneous tissue or completely
to the outside; and (III) compound, in which the cath-
eter penetrates a hollow viscus and then leaves the
body through a pre-existing anatomical orifice. Type II
was more frequently reported in infants, presumably
because of their smaller body size and weaker muscu-
lature, whereas Type I was reported more in adults. A
body wall weakness was not associated with an
increased risk of VPS distal catheter protrusion to the
outside.
The period from shunt installation to migration was
the most critical influence on migration type. Newly
replaced shunts, less than one month, tended to
migrate externally. The internal type of migration
showed a unique pattern in association with shunt
durability: Abdominal migration had a higher than
expected chance of occurrence between one and 10
years after shunt placement, but pelvic migration had
a higher than expected chance of occurrence after at
least 10 years.
Neurosurgeons must pay special attention to cases
where the catheter penetrates the large bowel, since
they are associated with a high incidence of retro-
grade intracranial infections. Moreover, the viscus
involved in compound migration seems to determine
the route of extrusion. For example, the viscus
involved in all trans-anal extrusion cases was the
bowel, while in trans-oral cases the stomach was the
primary organ involved. Lastly, shunt revision had no
significant influence on the incidence of VPS distal
catheter migration.
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