Mechanical Complications of Shunts Vasilios Tsitouras and Spyros SgourosEpidemiotogy Haesesituan “The byplumted Material ‘Material Selection and Importance ‘of the Hardware 1) Surpleal Techie i Distocation . Proximal Catheter. 0000.00 ccceceeee Disial Gatherer acacia Preseettion Management... 2.0. becca renee P sous, MD seument of Neurosurgery era” Childrens Hospital, Athens, Greeee pouros, MED (D1) arma of Newrsurgery ‘erty of Athens. Athens, Greece all: spouros@rmed aoa. gr 8.1.1 Epidemiology Fractures or ruptures of the shunt catheters are the camsative events of 4.8-13.6 % of shunt revi sion surgeries [45, 63}, Besides ihe contribution 1 filtienits’ morbidity, there is an increased impact te health care costs, considering the large numbers of patients with CSP shunts and the ‘cumutative long time that these shamts are implanted for, An accurate conclusion regarding the exact impact of mechanical complications to shunt malfunction is difficult w draw because these problems usually present a few years after ‘the implantation and many patients are lost to follow-up. In addition, ina group of patients with such fractures or disconnections the clinical impact is minimal or unnoticed because either the potient has become shunt-independent or the CSP diversion is still patent dhrough a fibrous reactive sleeve over the damaged catheter [75] Farthermore, although a great amount of research focuses on shunt infection issues, mechanical dysfunction has not gained proportionate atten- tion in the Ierature ever the years ‘A large series of 1,719 patients shunted for hydrocephalus and followed for 10 years showed ‘that the uverall risk for shunt malfunetion at the ‘end. of the stucly was 70 % [63 The most fre- ‘quent cause was obstruction (56 %), followed by ‘fracture, disconnection, and me migration which accounted for 19 % of mechanical complicationshave a wide spectrum of properties that to describe andl quantity their feat can be thermal, elect ical, etc. For materials thut are ine and more specifically for nan purposes, all these properties his section will focus on the al characteristics of silicone rubbers correlation with the host's reaetion in their presence. loxanes inorganic and olymers mostly known as sildcom rub These are hased on a silicon and oxy ton, instead of an organic carbon chain Silicon as an element was first discov. $24 by J.J. Berzelins, but it was in the S. Kipping (the Father of silicon achioved extensive symhesis of sili- allowed the industrial p f the new muterial. The high resiswance Ade it superior for medical use because al properties were not affected by ther lization, Hs high Aexibility and bio. ity made silicon ‘plantation use [23 In the early 1980s, rubber marketed for medical use was (Dow Coming. Midland, MI). «il was introduced as the tubing miate- he newly presented CSF diversion Zor the treatment of hydrocephalus. at Tihe same decade. Sinee then, silicon as been the material that was used well suited Fig.8.1 Scanning Electron Microscopy of a shunt valy ‘of dhaphragay (ype, removed from @ patient dis ua shut malfanction. There is precipitation of crys om the din phrogns, which with time deteriorates asd interferes wit the physical properties of the membrane and or black: th gap between diaphragm and case tag nificd kon 104 stirrounding tissixe, The phe studied after the first malfunctions of severa con-niade implants appeared (cardiac prosthe smplants) [17 32, 34). When the loca nsoluble compound into 1 tipm exceeds the limit of solubility, then pre cipisation of the compound from the solution occurs [9, 65, 671 The following stages are thi formation of & small nucieus of precipitate ani then the growth of it hy continaous precipitation 8.1), Thi 18 process is enbanced by the presence of solid interfaces and, especial! for the precipitation of atrium phosphate, i ‘accelerated in an alkaline environment [33]. Tws mechanisins of calcification are known (65, 84] Metastatic calcification iy associated wit increased caleium and phosphorus blood concen vations and is deseribed in renal insuftici and dyssrophic calcification has normal caleiun ‘and phosphorus blood concentrations but alteres cellular metabotisma and is the one encountered itee ae panic polymers mostly known as silteor rub- tr [49], These are based on a silicon and oxy- in skeleton, instead of an organic earbon chain celeton. Silicon as an element was first discov- ed in 1824 by JJ, Berzelius, but it was in the M405 that FS. Kipping (the father of silicon ience) achieved extensive symhesis of sili- me compounds and allowed the industrial pro- iction of the new material. The high resistance heat made it superior for medical use becanise physical properties were not affected hy ther= al sterilization. Its high flexibility and bio- imipatibility made silicon well suited for viva inoplantation use [23]. In the early 1950s, e silicon rubber marketed for medical use was lastic® (Dow Corning, Midland, Mt). tn neu- surgery, it was introduced ay the tubing mate- al of the newly presented CSF diversion stems for the treatment of hydrocephalus, at end of the same decade, Since then, silicon her has been the material that was used most exclusively by the manufacturers of CSP unt systems, slcification is the first step of the process that leads wo: (1) rgnadation and weakness of the catheter and (2) Il aggregation and tethering of the wbe to the surrounding tissue, The phenomenon was w studied afler the first malfunctions of seve silicon-made implants appeared (cardiac prostt ses, breast implants) [17, 32, 34]. When the loc concemation of an insoluble compound ino solution exceeds the limit of solubility, then pi cipitation of the compound from the soluti occurs [9, 65, 67]. The following stapes are t formation of a small anelews of precipitate a then the growth of it by continuous precipitati (Fig. 8.1). This nucleation process is enhanced the presence of solid interfaces and, especia for the precipitation of calcium phosphate, accelerated in am alkaline environment [33]. Ty mechanistns of calcification are known [65, & Metastatic calcification is assuckited we increased calcium and phosphorus blood conce trations and is described in renal insufficiene and dysirophie calvification has normal caleie andl phosphorus blood concentrations but alter cellular metabolism and is the one encountered silicone implants. An accelerated formation nnpetei From the cellivlar debris that accumulate prorximity to the implant has been demonstrat 19, 32], Further formation of initial nuclei resu from cracks and surface irregularities of t material which wiow element extrusion @ interaction with the surrounding cells.8.2 Binal catheter removed during shunt revision ‘2 is obvious calcification on its outer surface a the responding t the novk region, where the shut impiantect une Response sstigation of previously implanted shunts saled eosinophils and giant cells as pans of fibrous sleeve, indicating that a hypersensitiv redetion occurs [74]. Most of these studies lied plain radiographs, scanning electron roscopy (SEM), spectral analysis, and simple slogy. The cell-mediated immunity was sup- ed from the presence of T-cell granulomas, ets have found immuanogiobulin G antibodies sifically directed against silicon, as a part of sonal ithinunity involvement (30). On the tors only found dense linized connective tissue with fibroblasts and ific deposits [85], Heggets et al, supported a onic inflammatory reaction ~ predominantly a ign body giant cell granuloma type — that was ated from the relewse of silicon particles from aging material [34, 38]. Some authors support sae bi calcification in the peritoneal cavity. Furtherm some case reports of distal catheter insertion abdominal hollow viscera suggest that a ‘point for that is the anchoring of the c:ithete the organ sera, which appears to be initiatec a local inflammatory reaction around the di tip that facilitates erosion and perforation (41, (64). The clear mechanism is not yet fully um stood. Regarding the most proximal comparmn of the host invalved, there és no cellular immu in the cerebral parenchyma (similar to the described for the rest of the body yand ventric catheters do not induce a ghiotic reaction in the brain tissue us noticed by the absency adherent cells on the silicone [9, 19] Degradation and Altered Physical Properties ‘The interaction of the silicone catheter with surrounding tissue leads to the calcification whe, The impkant becomes rigid and try Besides the calcified covering sheet, the degr: lion process evwlves, It has been shows that dynamic properties of the silican rubber bei deteriorate about 6 months after the implantat the ultimate tehsile strength and extensiby gradually decreases over the first 3 years becomes remarkably aliered after $ years (23, Dilverent studies have found reticulation dae 3 an imporiant factor [9, 23]. The four ways biopolymers deteriorate were descrihed Kronenthal [43]: (a) the structure ix altered hydration: (b} same covalent bonds of the clealed eosinophils and giant cells as parts of + fibrous sieeve, indicating that a hypersensitiv reaction occurs [74]. Most of these studies plied plain radiographs, scanning electron croscopy (SEM), spectral analysis, and simple sology. The cell-mediated immunity was sup- ted from the presence of T-cell granulomas. hers have found immunoglobulin G antibodies acifically directed against silicon, as a part of moral immunity involvement [30]. On the ser hand, some investigators only found dense alinized connective tissue with fibroblasts and cific deposits [85]. Heggers et al. supported a ‘onic iiflammatory reactioa — predominantly ign body giant cell granuloma type — that was tiated from the release of siticon particles from taging material (34, 58). Some awthors support «different kind of particles are responsible for foreign hhody reaction such as cation fibers, granules, and hair that inadvertently enter the st during surgery [66]. The most profound tis- reaction over the ventriculoperituneal (WP) ant tubing was noticed at the subcutaneous arse of the catheter and especially at the neck «a [9, 75] (Fig. 8.2). Calcification was present ly in catheters placed in subcutaneous or vas- lar ares [46]. It is supported that the cerebral ‘enchyma and the peritoneal cavity ane far bess sctive for the silicon catheters [42]. This suits 4 with the “cellulur reaction” theory since the reutuncous tissue and the intravascular space + areas where migration of immunocompetent Degradation and ahered Physical Properties The interaction of the silicone catheter with surrounding tisiue leads 1 the calcification tube. The implant becomes rigid and frag Besides the calcified covering sheet, the degr: tion process evolves. It bas been shown that dynamic properties of the silicon rubber begit deteriorate about 6 months after the implantat the ultimate tensile strength and extensibi gradually decreases over the first 3 years becomes remarkably allerediafter 5 years [23, Different studies have found reticulation dam as an important factor [9, 23], The four ways biopolymers deteriorate were described Kronenthat (43); (a) the structure is altered hydration; (by some covalent bonds of the ct are weakened; (¢) these bends are broken; and soluble fragments are digested by the mat phages. In the human body, the silicones are subjected to extreine temperatures or innadiat which are known to contribute w degradation, the subsequent chemical and mechanical. ins lespecially in penloaged time periods) can the sime result. This is more evident in prosth heart valves that are exposed to strong Biolog activity (hidod cells) and intense mechan stress (heart heats and Blood flow) (65, 78], In {and yentriculoatrial — VA} shunts, the wr mobile segment is in the neck [23,48]. Repeat head mowements ~ especially extension and ¢ tralateral rotation — increase the tension ofvile neck segment over the fixed parts. ‘The e more visines ss we're Found to he: (a) connection hetween the distal catheter and de voit or the valve, (b) the point of traversing galea, anil (c) the crossing of the clavicle [24]. at are inserted in young children and tin for long time periods are ex tional mechanical stress due 16 the increasing ht of the child, The valaerable partis this case om the eceiput te the peritoneal insertion [24] 3). There are reports that even a minimal roderate external tension over the tethered and. kened catheter ed to fracture as it was the in two boys where the shunt was fractured the occipital area after a haircut with clippers In addition, children have a greater tend shunt calcification from a physiolagical point jew and this maybe related to the increased im phosphorus levels, compzired to adults [9 A reduction in cathetor tubing tensile strength extensibility was demonstrated when the aeaus had been impluntei for more than airs 123], These changes were related to min ican which resulted in a 40 % reduction ings were reported from Tomes et al. who ved that catheters become weaker the longer n tubing thickness, Similar ‘are implanted and that tubing with a greater s-sectional area requires greater force 10 ture (791. 3 Material Selection