Real-time 3D Transesophageal Echocardiography for the Placement of Ventriculoatrial Shunt: A Case Series and Technical Note

Abstract

Background: Ventriculoatrial (VA) shunts are used to manage hydrocephalus and idiopathic intracranial hypertension when peritoneal drainage of cerebrospinal fluid is not feasible. The technique of distal catheter placement during VA shunt insertion is controversial, especially between fluoroscopy-guided and transesophageal echocardiography (TEE)-guided techniques. Methods: We retrospectively reviewed our utilization of 2-dimensional (2D) ultrasound-guided internal jugular vein catheterization combined with 3-dimensional (3D) TEE-guided distal VA shunt placement and compared it to the conventional fluoroscopy-guided technique. Results: Ten patients underwent 18 VA shunt insertion procedures between November 2012 and October 2022. The patients had a mean (SD) age of 50 (19) years, body mass index of 35 (14) m/kg², and minimal comorbidities. All had previously undergone failed ventriculoperitoneal shunt procedures. The use of 2D ultrasound to guide internal jugular vein catheterization and 3D TEE to guide distal catheter placement resulted in 22-minute shorter surgical times compared with the fluoroscopy-guided technique (91 minutes vs. 113 minutes, respectively). No complications were noted with either technique. Conclusions: The combined use of 2D ultrasound and 3D TEE allowed for faster procedure times and more precise distal catheter confirmation, contributing to a more streamlined surgical procedure. This small case series underscores the feasibility, efficiency, and safety of anesthesiologist-delivered combined 2D ultrasound and 3D TEE during VA shunt insertion. The use of 3D TEE allows repeated confirmation of distal catheter position and has potential to improve patient safety during rare but complex VA shunt insertion procedures.