title: Migration of a Ventriculoperitoneal Shunt into the Pulmonary Vasculature: Case Report, Review of the Literature, and Surgical Pearls.
abstract: BACKGROUND
  Ventriculoperitoneal shunts are prone to common complications such as infection or mechanical failure, but more insidious events can easily be missed. Distal shunt migration into the vascular system is a rarely observed phenomenon, and there are no established guidelines for its management. We present a case of a distal catheter migration into the pulmonary vasculature, review existing cases in the literature, and present recommendations for their management.
  
  
  METHODS
  A 71-year-old man presented to the clinic with normal pressure hydrocephalus. He underwent the laparoscopic placement of a ventriculoperitoneal shunt. Surgery was uneventful except for increased venous bleeding noted at the retroauricular incision. Three weeks later, the patient returned with worsening motor and cognitive symptoms. A shunt series showed distal migration of the catheter through his heart. Computed tomography of the chest confirmed the distal wedging of the tube into his pulmonary artery. The migrated shunt catheter was withdrawn in the operating room with the assistance of colleagues from general surgery without complication.
  
  
  CONCLUSIONS
  Although distal shunt migration into the heart and pulmonary vasculature is rare, early recognition is important and precautions should be taken to avoid potentially significant morbidity or mortality. Live fluoroscopic imaging and the help of specialty services can be of great assistance in safely removing the device. Early recognition of potential vascular injury signs during the subcutaneous tunneling procedure is also important.
authors.affiliation: Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
authors.forename: Kristopher
authors.initials: K
authors.lastname: Lyon
authors.affiliation: Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
authors.forename: Vin Shen
authors.initials: VS
authors.lastname: Ban
authors.affiliation: Department of General Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
authors.forename: Nicole
authors.initials: N
authors.lastname: Bedros
authors.affiliation: Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA. Electronic address: Salah.Aoun@phhs.org.
authors.forename: Salah G
authors.initials: SG
authors.lastname: Aoun
authors.affiliation: Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
authors.forename: Tarek Y
authors.initials: TY
authors.lastname: El Ahmadieh
authors.affiliation: Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
authors.forename: Jonathan
authors.initials: J
authors.lastname: White
mesh_terms: D000368:Aged; D016206:Databases, Bibliographic / Q000706:statistics & numerical data; D005548:Foreign-Body Migration / Q000000981:diagnostic imaging / Q000209:etiology*; D006801:Humans; D006850:Hydrocephalus, Normal Pressure / Q000000981:diagnostic imaging; D008297:Male; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000209:etiology*; D011651:Pulmonary Artery / Q000000981:diagnostic imaging; D013909:Thorax / Q000000981:diagnostic imaging; D015898:Tomography Scanners, X-Ray Computed; D017287:Ventriculoperitoneal Shunt / Q000009:adverse effects*
keywords: Pulmonary artery migration; Technical pearls; Ventriculoperitoneal shunt complication; Ventriculoperitoneal shunt migration; Ventriculoperitoneal shunt placement