Comparison of total versus partial revision of initial ventriculoperitoneal shunt failures

Optimal surgical management of patients presenting with shunt failure in the age of neuroendoscopy remains complex. The value of replacing the entire shunt system as opposed to a single shunt component has not been assessed.

We reviewed the records of all pediatric patients who underwent their first shunt revision between January 1992 and December 1998. Patients with primary shunt failure attributed solely to proximal catheter obstruction or distal catheter obstruction were included for analysis. Shunt revisions were classified as total (entire shunt replaced) or partial (only malfunctioning component replaced). Kaplan-Meier (shunt survival curves) and log rank analysis were used to compare failure rates between partially and totally revised shunts according to the underlying diagnosis and failed shunt part. Significant differences in univariate analysis were confirmed with a multivariate proportional hazards regression model.

301 pediatric patients underwent primary shunt revision (183 total, 118 partial revisions). All shunts utilized distal slit peritoneal catheters. In shunt failures attributed to proximal obstruction, reutilization of the distal catheter was associated with a 57% increased risk of subsequent shunt failure (hazard ratio 1.57, 95% confidence interval 1.19-3.49). In shunt failures attributed to distal obstruction, subsequent shunt survival was not affected by reutilization of the proximal catheter (p = 0.581). When stratified according to the etiology of hydrocephalus, only patients with intraventricular hemorrhage (IVH) failed to demonstrate greater survival of totally revised shunts.

In this series, in the setting of proximal shunt catheter obstruction, reutilizing the functional distal catheter was associated with an increase in subsequent shunt failure rates compared to revising the entire shunt system. Total revision was not associated with improved shunt survival in patients with IVH.