Ventriculoatrial shunting for recurrent ventriculoperitoneal shunt failure in pediatric hydrocephalus: A viable alternative with improved outcomes.

Repeated ventriculoperitoneal (VP) shunt failures in children with hydrocephalus often result from abdominal complications or low-pressure hydrocephalus, posing challenges to long-term cerebrospinal fluid (CSF) diversion. Ventriculoatrial (VA) shunting has re-emerged as a viable alternative, supported by modern imaging and venous cannulation techniques. This study evaluated outcomes and revision patterns following VP-to-VA shunt conversion in pediatric patients, focusing on timing and indications for transition. A retrospective cohort study included 52 children (mean age 7.1 years) who underwent conversion between 2012 and 2021 due to abdominal complications or low-pressure hydrocephalus. Primary outcome was shunt survival; secondary outcomes included revision rates, complications, and VP failure trends. After conversion, VA shunts demonstrated longer survival than the preceding VP shunt periods in the same patients, with one-year survival rates of 95.4% versus 68.0% (p = 0.0004). Revision frequency was significantly lower after conversion (0.79 ± 1.25 vs. 4.60 ± 4.79 per patient, p < 0.001). In patients with ≥ 3 VP revisions, inter-revision intervals shortened progressively (295 → 123 days; p = 0.0002), indicating accelerated VP failure. Conversion indications were abdominal complications (69.2%) and low-pressure hydrocephalus (30.8%). The main VA revision causes were lengthening (n = 8), proximal obstruction (n = 4), and thrombosis (n = 4); infection occurred in 6.4% of cases, with no cardiac perforation or shunt nephritis. Our findings suggest VA shunting may serve as a viable and durable salvage option for recurrent VP shunt failure. The third VP failure may represent a practical decision point for considering alternative distal sites, particularly ventriculoatrial shunting. These findings do not advocate VA shunts as first-line therapy but support earlier consideration in selected patients with a failing peritoneal environment.