A Rare Case of Delayed Ventriculoperitoneal Shunt Catheter Migration Into the Heart: A Case Report

Abstract

The treatment of hydrocephalus with a ventriculoperitoneal (VP) shunt can lead to complications such as shunt migration. A 67-year-old male, who had previously undergone VP shunt surgery for normal-pressure hydrocephalus, presented approximately five years later with symptoms of general weakness and abdominal pain. Imaging revealed shunt malpositioning, with the catheter passing through an abnormal route to the heart. The catheter was successfully removed under fluoroscopic guidance while monitoring patient’s electrocardiogram to prevent potential secondary complications. Although rare, cardiac migration of VP shunts can lead to life-threatening secondary complications. Our case highlights the possibility of delayed upward migration of the shunt catheter in patients with VP shunts, emphasizing the need for various strategies to address and manage this issue.

INTRODUCTION

Hydrocephalus is the abnormal enlargement of the ventricles caused by accumulation of cerebrospinal fluid, which can occur with or without changes in intracranial pressure. This abnormal accumulation may be due to overproduction and insufficient absorption of cerebrospinal fluid, and the latter can occur for various reasons such as infection, tumor, or intracranial hemorrhage.⁷⁾ The effectiveness of pharmaceutical treatments for hydrocephalus is limited, ventriculoperitoneal (VP) shunt placement is the most widely known surgical treatment method for treating hydrocephalus.¹⁶⁾ However, various complications may occur after shunt surgery.¹³⁾ In particular, the most common complications are infection and obstruction, but it has been widely reported that distal (peritoneal) catheters have migrated to various organs including the bowel, urinary bladder, scrotum and the thorax.¹,²,⁸,¹⁰⁾ Cardiac migration of VP shunt has been reported very rarely, necessitating careful planning and implementation of treatment strategies.¹¹⁾ We report on additional cardiac migration and share a case of catheter removal in combination with a cardiologist.

CASE REPORT

A 67-year-old male patient was visited outpatient department of neurosurgery due to memory impairment, gait disturbance and urinary incontinence. Ventricular enlargement was revealed in brain magnetic resonance imaging and he underwent VP shunt operation with the diagnosis of normal pressure hydrocephalus (Codman Certas™ programmable valve) (FIGURE 1). After the surgery, his hydrocephalus symptoms were relieved and he was seen for regular checkups at outpatient department for 5 years (FIGURE 2).

FIGURE 1. Post op on the day after VP shunt placement surgery, skull lateral & A-P view., chest A-P view., simple abdomen A-P view. The positions of the proximal and distal catheters of the VP shunt were normal.

VP: ventriculoperitoneal.

FIGURE 2. Chest P-A view. The image taken at the outpatient clinic two years after VP shunt operation. The VP shunt is properly positioned without any abnormalities.

VP: ventriculoperitoneal.

About 5 years later, the patient visited the hospital with general weakness and abdominal pain. Initially performed chest X-ray revealed shunt malposition (FIGURE 3). On the chest computed tomography scan, it was observed that the distal catheter of the shunt was inserted via right internal jugular vein - superior vena cava - right atrium - right ventricle route, with kinking noted in both pulmonary arteries (FIGURE 4). Echocardiography performed to assess cardiac function revealed a hyperechogenic linear structure extending from the right atrium to the pulmonary artery, suggesting a migrated peritoneal catheter. There were no disturbances observed in the blood flow on color doppler imaging, nor was there any definitive tricuspid regurgitation detected. No abnormalities were noted on electrocardiogram.

FIGURE 3. Chest A-P view. The position of the VP shunt catheter is aberrant (arrow head).

After approximately 5 years post-ventriculoperitoneal shunt surgery, a chest X-ray showed migration of the peritoneal VP shunt catheter into the heart.

VP: ventriculoperitoneal.

FIGURE 4. Chest computed tomography. The distal catheter of the VP shunt enters the heart and pulmonary artery through the right internal jugular vein - superior vena cava - right atrium - and right ventricle route. The shunt catheter was observed to be kinking at both pulmonary arteries.

VP: ventriculoperitoneal.

To consider thromboembolic risk and cardiac events, planning for shunt removal was conducted in collaboration with a cardiologist in the interventional suite under fluoroscopic guidance. The surgery was performed under electrocardiographic monitoring, and while continuously checking with fluoroscopy, a small skin incision was made along the distal catheter on the posterolateral side of the neck. Then the catheter was founded and carefully pulled to ensure there was no resistance before slowly removing it from the heart. After removing the catheter, the incision site was manually compressed to stop the bleeding, and there was no bleeding sign thereafter (FIGURE 5). There were no acute postoperative complications. Additionally, tip culture was performed to determine if the catheter was infected, but the results were negative. The distal catheter was safely removed, but gait disturbance and urinary incontinence worsened. Considering that there was already internal jugular vein damage on the right side, a VP shunt was inserted on the left side three days later, and the symptoms subsequently improved.

FIGURE 5. Fluoroscopic view taken during the removal of the distal catheter of the VP shunt.

(A) The fluoroscopic view shows the distal catheter of the VP shunt entering the heart and both pulmonary arteries via the right internal jugular vein. (B) After making an incision on the posterolateral side of the neck, the distal catheter was removed from the heart. (C) The distal catheter has been completely removed, leaving the proximal catheter in place.

VP: ventriculoperitoneal.

DISCUSSION

VP shunt is the most preferred treatment method for hydrocephalus, but it still has a high risk of complications.⁶⁾ There can be many complications of VP shunt. In particular, migration to other organs can occur. Among them, Intracardiac catheter migration of VP shunt is a rarely reported complication even after it was first reported by Morell et al.¹¹⁾ in 1994. The complication of VP shunt distal catheter migration to the heart is life-threatening as it can cause secondary complications such as thromboembolic event, cardiac failure, arrythmia, pulmonary hypertension, and bacteremia.³,⁶⁾

The first possible mechanism is that subcutaneous tunneling during the surgical procedure can potentially damage large neck vessels. If a vessel injury occurs during surgery, it can lead to proximal migration due to negative intrathoracic pressure and venous flow, ultimately resulting in cardiac migration.⁴,⁹,¹¹⁾ Kim et al.⁹⁾ reported that there was profuse bleeding during the tunneling procedure around the neck, but it is usually not easy to notice that there was vessel injury during surgery. Also, cardiac migration of VP shunt catheters mainly occurs in pediatric patients or individuals aged 60 and above.¹⁴,¹⁵⁾ In pediatric cases, it is assumed that the thin subcutaneous tissue in the neck makes jugular vein injury more likely. Conversely, in individuals aged 60 and above, the looser subcutaneous tissue may lead to more frequent vein injuries during procedures.¹⁵⁾ Therefore, it is advisable to avoid manipulation of guiding too deeply in the neck or cautiously guide near the subclavian fossa during VP shunt placement surgery, particularly emphasizing the need for heightened caution.

The second mechanism is that chronic damage occurs with continued erosion of the jugular wall as the neck moves while the VP shunt catheter is in place, followed by penetration into the jugular wall due to negative inspiration pressure.⁵,¹¹,¹²⁾ In our case, there was no massive bleeding during tunneling near the neck during the VP shunt insertion operation. Also similar to four previously reported case, our experienced case exhibited delayed migration, occurring at 5, 6, 7 months, and 4 years.¹⁵⁾ Therefore, we believe that our patient's case aligns more closely with the second mechanism.

We removed the catheter by cervical incision under fluoroscopic guidance to locate the VP shunt line and retract it. However, if there is intracardiac knotting or coiling of catheter within heart, it can directly injure the valve leaflets and myocardium. Moreover, there is a risk of arrhythmia during removal. Also, if vegetation has formed on the shunt catheter, there is also an embolic risk. Patel et al.¹⁴⁾ reported that open heart surgery was performed to remove a knotted catheter migrated to the heart. Therefore, considering the possible risks, shunt catheter removal should be carefully performed in consultation with a cardiologist.

CONCLUSION

Cardiac migration in VP shunts is a rare complication that can lead to life-threatening secondary complications. Therefore, it is important for neurosurgeons to recognize that in patients with VP shunts, delayed upward migration can occur due to various reasons. Being aware of this possibility, it is necessary to have various strategies in place to address it.