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Neurosurgery. 2010 Jun;66(6 Suppl Operative):370-1; discussion 371. doi: 10.1227/01.NEU.0000369641.61413.D1.

Use of intraoperative venography to guide the distal portion of a ventriculoatrial shunt past an obstruction in the central veins: technical case report.

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  • 1Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

Abstract

OBJECTIVE:

Ventriculoatrial (VA) shunting is commonly used to treat hydrocephalus when ventriculoperitoneal shunting has failed. Placement of a VA shunt in patients with narrowing or occlusion of the central veins presents considerable difficulty because few imaging modalities exist to safely and reliably insert a guidewire or atrial catheter past the occlusion. We report the use of intraoperative venography to guide the placement of the distal portion of a VA shunt in a patient with a valve blocking the left brachiocephalic vein.

CLINICAL PRESENTATION:

A 42-year-old man with pseudotumor cerebri and a left ventriculoperitoneal shunt presented with severe headaches. He was diagnosed with partial distal shunt obstruction. Because of a history of failed attempts at ventriculoperitoneal shunting, conversion to a VA shunt via the left internal jugular vein was planned.

TECHNIQUE:

Surgery was performed by using the standard technique until resistance was encountered when inserting a guidewire into the internal jugular vein. Intraoperative venography of the central veins was performed, which showed a large valve blocking progression of the guidewire in the left brachiocephalic vein. Using fluoroscopic guidance, a 0.035-inch guidewire was successfully directed through the vein past the obstruction and exchanged for a peel-away introducer. The distal shunt catheter was then inserted, and the correct position in the atrium was confirmed fluoroscopically.

CONCLUSION:

When obstruction of the central veins is found during a VA shunting procedure, intraoperative venography is a useful method to aid in the placement of the atrial catheter through the central veins.

PMID:
20489529
[PubMed - indexed for MEDLINE]
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