Comparing Ventriculoatrial (VA) and Ventriculopleural (Vpl) Shunts in Pediatric Hydrocephalus - Analysis of Failure Patterns and Shunt Survival: A Hydrocephalus Clinical Research Network Study

Introduction: When the peritoneal cavity is not viable, non-peritoneal shunts (NPS) are utilized and usually terminate in the atrium (VA) or pleural space (Vpl). We directly compared shunt survival and complications rates for VA and Vpl shunts.

Methods: The HCRN Hydrocephalus Registry was searched to identify children < 18 years age who underwent NPS insertion with minimum 6 month follow up. The primary outcome was time to shunt failure. Secondary outcomes included distal site complications and shunt failure following NPS insertion.

Results: Search criteria yielded 415 children from 14 centers with a NPS – either as first line or after conversion from VP shunt. VA shunts were more common (VA =317, Vpl =98) and children who received VA shunts were younger (VA 6.1 years vs. Vpl 12.4 years, p< 0.001) with a larger proportion of children > 10 years of age in the pleural group (62.2% vs. 32.2%, p< 0.001). There was no difference in unadjusted shunt survival (log-rank test, p=0.07) or number of shunt revisions at 6 and 12 months. At 24 months there was a higher revision rate of atrial shunts (VA 44.9% vs. Vpl 32.2%, p=0.024). When stratified by age, VA shunts in children <= 6 years had the lowest shunt survival (log rank test, p= < 0.001). Univariate analysis demonstrated age <= 6, and etiology were associated with failure. Multivariate analysis did not reveal any predictors of failure. When compared to a group of VP shunt patients with a similar number of failures, no difference in shunt survival was found between VA, Vpl, or VP shunts.

Conclusion : VA shunts are more common and are placed in younger patients. Shunt survival was similar between VA and Vpl shunts; however, both demonstrated similar survival to VP shunts; when stratified by age, children <= 6 years with VA shunt had the shortest shunt survival. No differences were found in the cumulative frequency of complications. Both VA and Vpl shunts are viable when NPS is necessary and perform similar to VP shunts.