Is the ventriculo-atrial shunt a last resort treatment for hydrocephalus? A meta-analysis comparing ventriculo-atrial and ventriculo-peritoneal shunt

Abstract Hydrocephalus is a common pathology in the neurosurgical field. Since the first permanent ventriculo-subarachnoid-subgaleal shunt by Mikulicz in 1893, there were multiple attempts to find a solution to drain the excess production/less reabsorption of the cerebrospinal fluid (CSF) from the brain. Nowadays the most used technique is the Ventriculo-Peritoneal Shunt (VPS), whereas the ventriculo-atrial shunt (VAS) is used only in some rare conditions. To date there are still no specific guidelines or strong evidences in literature to choose between the two methods and the decision usually lying in the confidence and expertise of the surgeon. Since this lack of established recommendations, this systematic review and meta-analysis aims to evaluate the effectiveness and safety of these two shunting techniques. This systematic review was conducted following the PRISMA protocol (Preferred Reporting Items for Systematic Reviews and Meta–Analyses). No chronological limits of study publications were included. Prospective and retrospective clinical studies, and reports of case series with at least five patients per group and reporting data on comparison between VAS and VPS techniques were eligible for inclusion. 9 studies meeting the inclusion and exclusion criteria and reporting on 3197 patients were identified and included in in the quantitative synthesis. The risk for shunt dysfuction/obstruction was significantly lower in the VAS group (0.49, 95%-CI 0.34 to 0.70, I2 0%). As for the risk of infection, it was not significantly different between the two groups (1.02, 95%-CI 0.59 to 1.74, I2 0%). The risk for revision was not significantly different between the two groups, however the heterogeneity between the studies was high (0.73, 95%-CI 0.36 to 1.49, I2 91%). On the other hand, the risk of death was not significantly different between the two groups, however the heterogeneity between the studies was high (1.93, 95%-CI 0.81 to 4.62, I2 64%). VAS represent a valuable alternative to VPS. In this study, it was observed a lower risk of shunt dysfunction/obstruction variable in the VAS group and there was no statistical difference on the occurrence of at least one infection-related complication. The choice between these two techniques must to be tailored to the specific characteristics of patient.