title: Use of intraoperative venography to guide the distal portion of a ventriculoatrial shunt past an obstruction in the central veins: technical case report.
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.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
authors.forename: Eric N
authors.initials: EN
authors.lastname: Momin
authors.forename: Pablo F
authors.initials: PF
authors.lastname: Recinos
authors.forename: Alexander L
authors.initials: AL
authors.lastname: Coon
authors.forename: Daniele
authors.initials: D
authors.lastname: Rigamonti
mesh_terms: D000328:Adult; D016121:Brachiocephalic Veins / Q000000981:diagnostic imaging* / Q000601:surgery*; D002405:Catheterization, Central Venous / Q000295:instrumentation / Q000379:methods*; D002557:Cerebrospinal Fluid Shunts / Q000295:instrumentation / Q000379:methods*; D006801:Humans; D019586:Intracranial Hypertension / Q000601:surgery; D007601:Jugular Veins / Q000000981:diagnostic imaging / Q000601:surgery; D008297:Male; D016343:Monitoring, Intraoperative / Q000379:methods; D019635:Neurosurgical Procedures / Q000379:methods*; D010690:Phlebography / Q000379:methods*; D011559:Pseudotumor Cerebri / Q000601:surgery; D016896:Treatment Outcome; D055422:Venous Valves / Q000000981:diagnostic imaging / Q000601:surgery; D014696:Ventriculostomy / Q000295:instrumentation / Q000379:methods