Article
Atrial shunts – Neurosurgical atavism or essential alternative?
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Authors
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A. Aschoff
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg
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K. Zweckberger
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg
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H. Steiner-Milz
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg
| Published: | May 20, 2009 |
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Outline
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Objective: The VA-shunt introduced 1949 by Nulsen, was the most common technique in the 60ties and 70ties. Due to common growth problems in children, the more difficult placement and complications such as embolism, cor pulmonale, shunt-nephritis, the implementation of VA shunts decreased. More recently Cochrane reported 2.3%, Patwardan 0.5% in children. The number of “trained” VA-surgeons (<20 procedures) or “experts” (>100) decreases, in some hospitals to nearly zero. As a result, we see VP-shunt-trials in hopeless conditions, with blind patients and incomplete explantations.
Methods: 35 years after his first VA-shunt, the author presents his experience with a personal series of 170 atrial shunts. In addition he has 20 years of experience in the hydrocephalus ambulance in a high volume hospital (Ø 249 shunts/revisions/year). Of >6000 patients had >1000 VA-shunts.
Results: The author saw no perioperative death due to the atrial catheter, 1 cor pulmonale, 2 patients with emboli of A. pulmonalis requiring cardiosurgery (external cases) and 1 pericard-tamponade in an own patient. 7 patients (1 own) developed a shunt-nephritis. Most were historical cases. The vital atrial complications were rare and in retrospect showed a development over many months or years. In case of regular cardiologic check-ups,an early diagnosis or even a prevention would be possible.
Wandering of 4 catheters into the A. pulmonalis had no cardiopulmonary impact. In all cases, a simple endovascular extraction was possible. The retraction by growth in children was the most frequent problem. The quote of sepsis, primary misplacements, intravenous catheter loops were average. – Actual statements (Bayston 07, Bergsneider 07) confirm, that VA-shunts have a fair risk, not far from VP-shunts.
Conclusions: The horror-image of VA-shunts differs from reality. VA-shunts remain necessary in about 2-3% of children and 5-7% of adults. Every hospital should train at least 2 surgeons in this procedure. New techniques such as Seldinger-catheterization and placement control with intracardial ECG are fast and simple. However, a lifelong check once per year and information of the inherent risks to all involved doctors are obligatory.
