Huge Thrombosis as a Consequence of VA-Shunts
Thrombosis is a rare but serious consequence of VA-shunts. We present two cases of near fatal thrombosis and its successful (but in case 2, atypical) management.
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Abstract Objective Thrombosis is a rare but serious consequence of VA-shunts. We present two cases of near fatal thrombosis and its successful (but in case 2, atypical) management. Results Case 1: A 38-year-old woman with VA-shunt suffered from rapidly progressing heart failure and later from progressing underdrainage signs nine years after shunting due to a thrombus on the atrial shunt catheter that occluded >80% of the right atrium. Cardio-surgical removal of thrombus and VA-shunt catheter and VP-shunting normalized neurological and cardiological state. Case 2: A 40-year-old woman received a VA-shunt 5 years before she suddenly suffered dyspnea and venous congestion. Secondarily, underdrainage occurred. The underlying huge thrombosis of the superior caval vein could not be excised because the necessary thoracotomy would have interrupted vital venous bypasses along the thoracic wall. Anticoagulants (heparin, cumarin) and ETV relieved all neurological and cardiological symptoms. Conclusion Sudden or unexpected symptoms of cardiac failure in the presence of a VA-shunt must be recognized as serious. Interestingly, despite distal shunt occlusion, underdrainage symptoms might be initially mild. Keywords Hydrocephalus • complication • thrombosis • VA-shunt • shunt • side-effects • venous congestion • vena cava syndrome • pulmonary hypertension • foreign material reaction • thromboplastin
M. Kiefer (*) Department of Neurosurgery, Saarland University Medical School, Kirrberger Street, Building 90.1, Homburg-Saar 66421, Germany e-mail: [email protected] R. Eymann Department of Neurosurgery, Medical School, Saarland University, Kirrberger Street, Building 90, Homburg-Saar, Saarland 66421, Germany
Introduction With the introduction of modern hydrocephalus shunt therapy, the right atrium has been the preferred site for cerebrospinal fluid (CSF) diversion because the initial experiences with ventriculo-peritoneal (VP) shunts were unfavorable (6) (probably due to the materials used (4)). As the incidence of VP-shunt failure dropped with the usage of silicone catheters, VP-shunts became the preferred technique in the 1970s. Some, however, continued to prefer ventriculo-atrial (VA) shunts until the 1990s, when gravitational shunts became available because overdrainage risk was higher with VP-shunts (4, 11, 15–17). However, nowadays, preconditions such as multiple intraperitoneal adhesions after repeated abdominal interventions or intraperitoneal infections or other conditions (1, 12, 27, 28) might force VA-shunting. We report two cases of huge thrombosis due to VA-shunts and its different treatments and discuss as well treatment and prophylaxis options as the still enigmatic incidence and pathophysiology of cardio-pulmonary complications of VA-shunts.
Case Reports Case 1 A 26-year-old patient with a triventricular hydrocephalus initially had a stereotatically guided third ventriculostomy, followed by VA-shunting some months later due to lack of symptom resolution after ventriculostomy, despite open stoma. After shunt
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