title: Factors associated with ventricular catheter movement and inaccurate catheter location: post hoc analysis of the hydrocephalus clinical research network ultrasound-guided shunt placement study.
abstract: OBJECTIVE
  Shunt survival may improve when ventricular catheters are placed into the frontal horn or trigone of the lateral ventricle. However, techniques for accurate catheter placement have not been developed. The authors recently reported a prospective study designed to test the accuracy of catheter placement with the assistance of intraoperative ultrasound, but the results were poor (accurate placement in 59%). A major reason for the poor accurate placement rate was catheter movement that occurred between the time of the intraoperative ultrasound image and the first postoperative scan (33% of cases). The control group of non-ultrasound using surgeons also had a low rate of accurate placement (accurate placement in 49%). The authors conducted an exploratory post hoc analysis of patients in their ultrasound study to identify factors associated with either catheter movement or poor catheter placement so that improved surgical techniques for catheter insertion could be developed.
  
  
  METHODS
  The authors investigated the following risk factors for catheter movement and poor catheter placement: age, ventricular size, cortical mantle thickness, surgeon experience, surgeon experience with ultrasound prior to trial, shunt entry site, shunt hardware at entry site, ventricular catheter length, and use of an ultrasound probe guide for catheter insertion. Univariate analysis followed by multivariate logistic regression models were used to determine which factors were independent risk factors for either catheter movement or inaccurate catheter location.
  
  
  RESULTS
  In the univariate analyses, only age < 6 months was associated with catheter movement (p = 0.021); cortical mantle thickness < 1 cm was near-significant (p = 0.066). In a multivariate model, age remained significant after adjusting for cortical mantle thickness (OR 8.35, exact 95% CI 1.20-infinity). Univariate analyses of factors associated with inaccurate catheter placement showed that age < 6 months (p = 0.001) and a posterior shunt entry site (p = 0.021) were both associated with poor catheter placement. In a multivariate model, both age < 6 months and a posterior shunt entry site were independent risk factors for poor catheter placement (OR 4.54, 95% CI 1.80-11.42, and OR 2.59, 95% CI 1.14-5.89, respectively).
  
  
  CONCLUSIONS
  Catheter movement and inaccurate catheter placement are both more likely to occur in young patients (< 6 months). Inaccurate catheter placement is also more likely to occur in cases involving a posterior shunt entry site than those involving an anterior shunt entry site. Future clinical studies aimed at improving shunt placement techniques must consider the effects of young age and choice of entry site on catheter location.
authors.affiliation: Texas Children's Hospital, Houston, Baylor College of Medicine, Houston, Texas;
authors.forename: William E
authors.initials: WE
authors.lastname: Whitehead
authors.forename: Jay
authors.initials: J
authors.lastname: Riva-Cambrin
authors.forename: John C
authors.initials: JC
authors.lastname: Wellons
authors.forename: Abhaya V
authors.initials: AV
authors.lastname: Kulkarni
authors.forename: Samuel
authors.initials: S
authors.lastname: Browd
authors.forename: David
authors.initials: D
authors.lastname: Limbrick
authors.forename: Curtis
authors.initials: C
authors.lastname: Rozzelle
authors.forename: Mandeep S
authors.initials: MS
authors.lastname: Tamber
authors.forename: Tamara D
authors.initials: TD
authors.lastname: Simon
authors.forename: Chevis N
authors.initials: CN
authors.lastname: Shannon
authors.forename: Richard
authors.initials: R
authors.lastname: Holubkov
authors.forename: W Jerry
authors.initials: WJ
authors.lastname: Oakes
authors.forename: Thomas G
authors.initials: TG
authors.lastname: Luerssen
authors.forename: Marion L
authors.initials: ML
authors.lastname: Walker
authors.forename: James M
authors.initials: JM
authors.lastname: Drake
authors.forename: John R W
authors.initials: JR
authors.lastname: Kestle
mesh_terms: D000367:Age Factors; D057785:Catheters; D002540:Cerebral Cortex / Q000473:pathology; D002552:Cerebral Ventricles; D002557:Cerebrospinal Fluid Shunts / Q000295:instrumentation* / Q000379:methods; D005260:Female; D005548:Foreign-Body Migration; D006801:Humans; D006849:Hydrocephalus / Q000473:pathology / Q000601:surgery*; D007223:Infant; D008297:Male; D011446:Prospective Studies; D012307:Risk Factors; D014463:Ultrasonography
keywords: HCRN = Hydrocephalus Clinical Research Network; hydrocephalus; shunt insertion; ventricular catheter; ventriculoperitoneal shunt