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

Is the ventriculo-atrial shunt a last resort treatment for hydrocephalus? 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A meta-analysis comparing ventriculo-atrial and ventriculo-peritoneal shunt Enrico Lo Bue, Alberto Morello, Jacopo Bellomo, Leonardo Bradaschia, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3976904/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 09 Aug, 2024 Read the published version in Scientific Reports → Version 1 posted 10 You are reading this latest preprint version 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. Biological sciences/Neuroscience Biological sciences/Neuroscience/Diseases of the nervous system Ventriculoatrial ventriculo-atrial ventriculoperitoneal shunt hydrocephalus Figures Figure 1 Figure 2 Introduction In the 1950s, the creation of a valve system to regulate opening pressure and prevent cerebrospinal fluid (CSF) reflux into the brain initiated a new era of surgical treatments for hydrocephalus. Consequently, it led to the development of the ventriculo-atrial shunt (VAS) in the 1960s ( 1 ) and the ventriculo-peritoneal shunt (VPS) in the 1970s ( 2 ). At the beginning, VAS was considered superior to VPS because of the polyethylene tube of this latter, which had unacceptable rates of peritonitis and distal failure. However, it was quickly noted that VAS carried significant concerns regarding the recognition of various serious and even fatal complications, such as atrial thrombi, pulmonary embolism, bacteremia, pulmonary hypertension, and cor pulmonale ( 3 ). During the years VPS had steadily gained ground in comparison to the VAS because of a multitude of reasons, including the simplicity of surgical technique itself with a faster learning curve. In addition, the peritoneal cavity has a very high absorptive capacity, as demonstrated by its use through peritoneal dialysis, and, in pediatric population, it allows the placement of additional length of catheter for growth avoiding lengthening procedures ( 4 ). Additionally, the VAS represents a last resort treatment for hydrocephalus, when the VPS is not more feasible. Also, VAS may be underutilized due to the technical preferences of neurosurgeon, considering that the new generations are less accustomed to learn the procedure ( 5 ). However, there are no clear guidelines about the use of VAS or VPS as first surgical solution in the shunt placement, demanding the choice to the surgeon or to internal guidelines of each institution. Since the lack of established recommendation, this systematic review and meta-analysis aims to evaluate the effectiveness and safety of these two shunting techniques. Materials and Methods Literature Search This systematic review was conducted following the PRISMA protocol (Preferred Reporting Items for Systematic Reviews and Meta–Analyses) ( 6 ). Potentially relevant literature was retrieved from PubMed/MEDLINE, Embase, and the Cochrane Library. The final search was conducted on the 20th of September 2023. Detailed search strategy is reported in Supplementary Material 1 . Word variations and exploded medical subject headings were searched for whenever feasible. Inclusion and Exclusion criteria Comparative studies with English text that met the following PICO (Patient, Intervention, Comparison, Outcome) criteria were considered eligible. Patients: individuals with symptomatic hydrocephalus. Intervention: VAS. Comparison: VPS. Outcomes: surgical revision, shunt dysfunction, infection, mortality. 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 and reporting at least one outcome of interest (i.e. it was not mandatory that all outcomes of interest were reported in the study) were eligible for inclusion. Meta-analyses, case reports, or studies with less than 5 patients per group, cadaver studies, laboratory and animal studies were excluded. Studies including only one surgical method or other possible shunting techniques such as ventriculo-ureteral, ventriculo-gallbladder, ventriculo-pleural cavity or ventriculo-subgaleal shunt, were not included. Screening and Full-Text Review Title and abstract screening, full-text review, and data extraction were undertaken in parallel by two reviewers (F.L. and L.B.). Disagreements at any stage were resolved by discussion and consensus. Persistent disagreements were resolved by involvement of a third reviewer (A.M.). The process was carried out using Rayyan ( 7 ). Data Extraction Several items were considered in the evaluation of the use of the VAS/VPS surgical techniques and were divided into two main categories: patient demographics and surgery characteristics. In the first group sex, mean age at first placement of the CSF shunt system and the etiology of the hydrocephalus was investigated, while in the second group data on primary surgical choice, VAS/VPS complications in short and long run, resolution of the hydrocephalus, number of revision and the mean time at first revision of the CSF diversion system were collected. The following data were extracted: author name, publication year, the country of studies, study design, sample size, age, etiology of hydrocephalus, size of surgical groups (VAS/VPS), median follow-up time, and outcome measures that were reported as frequencies during follow-up time. Risk-of-Bias Assessment The Cochrane risk-of-bias tool for nonrandomized studies of interventions (ROBINS-I tool) was used for risk-of-bias assessment of the included studies ( 8 ). This was performed by two authors (J. B., and A. M.). Statistical Analysis The statistical analysis was carried out with the statistical program R studio (Posit Software, PBC formerly R Studio, version 02.07.2022). The baseline characteristics of the included studies were analysed using descriptive statistics. The meta-analysis was performed using the package meta (version 6.5-0, published 2023-06-07). A random effect model for the meta-analysis was conducted because of the methodological and clinical differences among the studies. The odds ratio (OR) of frequency data with the corresponding 95% CI were pooled by the inverse-variance test. The I2 test was used to capture the between studies’ heterogeneities, which refers to the proportion of total variation because of the differences among included studies instead of sampling error. All statistical tests were two-tailed, and the significance level was set at P value < 0.05. Results Literature Search As illustrated in the PRISMA flowchart of Figure 1, the PubMed/MEDLINE, Embase and Cochrane Library search provided 10582 articles. After duplicate removal (n=3153), 7429 records were screened, and 753 were then assessed for eligibility through full-text screening. Finally, 9 studies meeting the inclusion and exclusion criteria and reporting on 3197 patients were identified and included in in the quantitative synthesis. Sufficient data was available to perform meta-analysis for surgical revision, shunt dysfunction/obstruction, infection and mortality. Study Characteristics and Quality Table 1 lists the main characteristics of the included studies, including publication year, study design and sample size, etiology of hydrocephalus, size of surgical groups, median follow-up time (in months), mean age at surgery (in years), and the risk of bias evaluated with ROBINS-I tool. These 9 studies yielded 3197 patients with hydrocephalus, of whom 1338 (42%) and 1798 (56%) received VAS and VPS, respectively. Three studies (Olsen and Frykberg, Fernell et al., Keucher and Maeley) investigated paediatric patient cohorts, and other three studies (Lam and Villemure, McGovern et al., and Hung et al.) adult patient cohorts. The remaining three studies (Ignelzi and Kirsch, Borgbjerg et al., and Rymarczuk et al.) included a mixed cohort of paediatric and adult patients. Apart from the study of Hung et al., comparing VPS and VAS in a cohort of idiopathic normal pressure hydrocephalus, all the other studies included patients with different causes of hydrocephalus. All the included studies had a retrospective study design, and they were scored with an overall serious to critical risk of bias according to the Cochrane’s ROBINS-I tool ( Table 1 ). In Table 2 the frequencies of the investigated outcome variables (revision surgery, shunt dysfunction/obstruction, infection-related complication, death) in the included studies are summarized. In this context, it is important to mention that the works of Ignelzi and Kirsch, Fernell et al., Lam and Villemure, and Borgbjerg et al. did not report the median follow-up time between the two surgical groups. Additionally, the median follow-up time showed a consistent difference in the works of Keucher and Maeley, shorter in the VPS group, and Hung et al., shorter in the VAS group. In the studies of Fernell et al. and Keucher and Maeley the total amount of surgical revision was reported, thus not allowing to differentiate the number of patients that needed at least one surgical revision. Over the years, a trend toward performing VPS as primary surgical treatment for hydrocephalus was observed. Indeed, in three most recent studies (McGovern et al., Hung et al. and Rymarczuk et al.) VAS was considered and performed as primary shunt treatment option only in case of contraindications for VPS, such as previous abdominal surgery, suspected increased intra-abdominal pressure, current of history of significant peritonitis or other abdominal infections that could threaten the shunt sterility or challenge its positioning due to tissue adherence, and trauma with the involvement of the abdomen. On contrary, in older studies the decision to perform VPS or VAS depended more on the surgeon’s preference and experience at the time of operation, rather than on patient-related factors. Outcomes In Figure 2 , the results of the meta-analysis of the pooled study findings for the investigated outcomes are reported by means of forest plots. Surgical revision: seven studies reported the frequency of at least one surgical revision (9) (10) (11) (12) (13) (14) (15). 481 events were observed in the VAS group (n = 1111) and 660 in the VPS group (n = 1584). 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%). Shunt dysfunction/obstruction: five studies reported the frequency of at least one shunt dysfunction/obstruction (9) (10) (11) (13) (14).165 events were observed in the VAS group (n = 509) and 211 in the VPS group (n = 759). The risk for shunt dysfuction/obstruction was significantly lower in the VAS group (0.49, 95%-CI 0.34 to 0.70, I2 0%). Infection: five studies reported the frequency of at least one infection (9) (10) (13) (14) (15). 44 events were observed in the VAS (n = 545) and 54 in the VPS group (n = 1145). The risk for infection was not significantly different between the two groups (1.02, 95%-CI 0.59 to 1.74, I2 0%). Mortality: three studies reported the frequency of death (10) (16) (17). 8 events were observed in the VAS group (n = 330) and 22 in the VPS group (n = 283), 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%). Publication Bias Funnel plots of the investigated outcomes can be found in the Supplementary Content 2 – Funnel Plots . Discussion Firstly described in historical medical works by Galen and Hippocrates ( 18 ), hydrocephalus is a common disorder of CSF physiology resulting in abnormal expansion of the cerebral ventricles and affecting an estimated number of 85 per 100,000 individuals in the general population, ranging from children to the elderly population ( 19 ). The first CSF diversion system was proposed by Mikulicz in the 1893 with a permanent ventriculo-subarachnoid-subgaleal shunt which was simultaneously a ventriculostomy and a drainage in to an extrathecal low pressure compartment ( 18 ). Since then several attempts were made to find a practical and reliable solution to the drainage of the exceeded CSF. In 1946 the first silicone implant for human usage was introduced, but only ten years later in 1956 it was firstly utilized in the creation of a CSF shunt by Holter and Pudenz ( 20 ). Almost in the same time period, the creation of a valve system in order to adjust the opening-pressure and to prevent the reflux of CSF back into the brain started a new era of surgical treatments for hydrocephalus, leading to the development of the VAS in the 1960s ( 1 ) and of the VPS in the 1970s ( 2 ). In 1970s and 1980s, different studies by Little et al., Olsen and Frykberg, and Keucher and Mealey reported the inferiority of VAS compared to VPS in pediatric population. It was shown that VAS had a higher mortality and required more lengthening revisions because of the growth of the child; wheares the infection and dysfunction rate was similar ( 21 ) ( 22 ) ( 10 ). After these studies, there was a gradual switching from VAS to VPS. However, few works have been reported in literature comparing the two techniques in adult population. In 2014, McGovernor et al. compared the safety of VAS and VPS in adult/elder patients with normal-pressure hydrocephalus (NPH)( 13 ). In adult population, there is not the risk of revisions to lengthen the distal shunt. Furthermore, elderly patients could have a lower risk of distal thrombi and/or cardiopulmonary complications since they often use anticoagulation or antiplatelet therapy for other comorbidities. The authors suggest that VAS is as safe as VPS for treating NPH ( 13 ). In addition, compared to the 1970s and 1980s studies, there was a relevant improvement in infection control and intraoperative imaging enabling for a safer catheter placement in the right atrium. Despite this, in recent decades, VAS has generally been regarded as a last resort surgical option in both adult and pediatric population. Currently, the VPS represents the first treatment option in almost all patient with hydrocephalus, even in challenging cases of history of abdominal surgery or increased abdominal pressure due to obesity ( 23 ) ( 24 ). At the end, the final choice relies to surgeon preference. During the last years, the new generation of neurosurgeons became more familiar and confident with the VPS technique and this could be another reason of the underutilization of VAS. So, this works aims to evaluate the complications profile of VAS e VPS, including studies that reported comparative data between the two techniques. Through a comprehensive systematic review and meta-analysis of the available literature until September 2023, it was assessed surgical revision, shunt dysfunction/obstruction, infection and mortality among 3197 patients, with a heterogeneous etiology and age-population of hydrocephalus (Table 1 ). The literature does not have high evidence of which type of shunt requires fewer revisions. Puca et al. reported revision rates of 28% for VPS and 27% for VAS ( 25 ). According to Hung et al., The probability of shunt obstruction and shunt revision is lower in patients with VAS than in patients with VPS ( 14 ). In this study, there were no statistical difference regarding the need of at least one surgical revision of the shunt system (OR 0.91; 95% CI 0.76 to 1.09). Additionally, it was observed a lower risk of shunt dysfunction/obstruction variable in the VAS group (OR 0.50; 95% CI 0.36 to 0.69). Furthermore, it has not been identified statistical difference on the occurrence of at least one infection-related complication (OR 1.03; 95% CI 0.62 to 1.73) between the VPS and VAS groups. This result confirms what reported in literature: L.B. Oliveira et al. showed the infection rate was determined to be 5% (95% CI: 3–7%) ( 3 ); Merkler et al. reported an infection rate of 6.1% (95% CI: 5.7–6.5%) for VPS ( 26 ). On the other hand, there was a higher risk of mortality in the VAS group (OR 1.96; 95% CI 1.16 to 3.31). However, this latter result comes from the analysis of three non-recent studies, from the years 1979, 1983 and 1985 ( 17 ) ( 10 ) ( 16 ). A recent meta-analysis on VAS complication, including 52 studies and involving 2862 patients, showed an estimated risk of 0% for glomerulonephritis, intracranial hemorrhage, hygroma, cardiac complications, pulmonary complications, and shunt-related mortality ( 3 ). Performing a brief over review limited to the last 10 years of patients underwent VAS as primary treatment in relevant literature from PubMed/MEDLINE and Embase, it was noted that the main reasons for this choice were previous abdominal surgery, abdominal infections (such as peritonitis, necrotizing enterocolitis) and obesity. Given that abdominal surgeries are more common in adult patients and given the very high incidence of obesity, it is appropriate to evaluate the possibility of VAS in the treatment of hydrocephalus for this patient profile. VAS continues to be 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. This data could change with improvements in technique, overall quality, and availability of diagnostic equipment and interventional radiologists. Our findings suggest that VAS is a safe alternative when VPS is not feasible. Nonetheless, further randomized studies are required to establish the real benefit of one type of shunt over the other. Limitations Some important limitations should be considered. First, as mentioned above in some of the included studies the follow-up time differ significantly among the two surgical groups of patients that underwent VAS and VPS treatment; in this context the variability of the outcome rates is difficult to compare. Second, the analysis included a heterogeneous population with both adults and child patients. Lastly, in the recent years VAS has been often considered as second treatment option due to the technical preferences and biases of neurosurgeons. This is reflected in the studies included in this work, representing an uncontrollable source of confounders and therefore limiting the comparative analysis. Given these limitations, it is crucial to interpret the results with caution. Encouraging future research with randomized clinical trials and comprehensive follow-up data is essential to overcome these limitations and enhance our understanding of the VAS indications and complications. Conclusion VAS is a valuable alternative to VPS. The results of this study suggest that VAS is a safe option when VPS is not feasible. The choice between these two techniques must to be tailored to the specific characteristics of patient. The new generations of neurosurgeons are encouraged to learn both the surgical procedures in order the best option for every patient. Abbreviations CSF: cerebrospinal fluid VPS: ventriculo-Peritoneal Shunt VAS: ventriculo-atrial shunt NPH: normal-pressure hydrocephalus CI: confidence interval OR: odds ratio Declarations Author’s contribution Study concept: ELB, AM. Study design: AM. Data acquisition: LB, FL, SC. Quality control of data and algorithms: JB, AM. Data analysis and interpretation: JB, AM. Statistical analysis: JB, AM. Manuscript preparation: ELB, AM, AF. Manuscript editing: ELB, LR, MML; DG. Manuscript review: LS, DG, FC. All authors agreed to the publication of this work. Data and code availability Data or information needed to re-produce the findings presented are available from the corresponding author upon reasonable request. Funding Financial nor material support have been received. Conflict of interest The authors declare no competing interests. Consent to participate Not applicable. Consent for publication Not applicable. Ethical approval Not applicable. Protocol Registration The review protocol was registered and published in Prospective Register of Systematic Reviews (PROSPERO) (www.crd.york.ac.uk/PROSPERO) website with registration number: CRD42023479365. References JENSEN HP, AMADOR LV. [Ventriculo-auriculostomy in the treatment of hydrocephalus]. Neurochirurgia (Stuttg). 1961;4:99–113. German. doi: 10.1055/s-0028-1095460 . Ames RH. Ventriculo-peritoneal shunts in the management of hydrocephalus. J Neurosurg. 1967;27(6):525–9. doi: 10.3171/jns.1967.27.6.0525 . Oliveira LB, Welling LC, Viegas FAF, Ribas LRC, Junior EOM, Wesselovicz RM, Batista S, Bertani R, Palavani LB, Rabelo NN, Figueiredo EG. Incidence and nature of complications associated with ventriculoatrial shunt placement: A systematic review and single-arm meta-analysis. Clin Neurol Neurosurg. 2023;233:107950. doi: 10.1016/j.clineuro.2023.107950 Tomei KL. The Evolution of Cerebrospinal Fluid Shunts: Advances in Technology and Technique. 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Authors Publication date Study design Nr. of included patients Hydrocephalus Etiology Shunt treatment Median Follow-up time (in months) Mean age at surgery (in years) Overall risk of bias VPS VAS VPS VAS VPS VAS Ignelzi and Kirsch 1975 Retrospective study 300 Aqueductal stenosis (54), aqueductal stenosis and myelomeningocele (43), neoplasm (55), communicating hydrocephalus not further specified (148) 114 177 NA NA NA% NA% Critical Olsen and Frykberg 1983 Retrospective study 172 Spina bifida (55), CNS malformation (46), infection (12), perinatal factors (33), postnatal factors (2), neoplasm (2), unknown (22) 69 103 57 46 0.38 0.41 Serious Fernell et al. 1985 Retrospective study 259 Aqueductal stenosis (84), perinatal complications (69), CNS anomalies (49), congenital or neonatal infection (30), unknown (27) 133 80 NA NA 0.60 0.90 Critical Keucher and Maeley 1979 Retrospective study 228 Myelomeningocele (128), aqueductal stenosis (39), communicating hydrocephalus not further specified (31), infection (12), Dandy-Walker syndrome (9), unknown (9) 81 147 60 97 0.22 0.26 Serious Lam and Villemure 1997 Retrospective study 128 Normal pressure hydrocephalus (55), neoplasm (37), haemorrhage (17), aqueductal stenosis (4), trauma (4), infection (3), congenital (2), unknown (6) 73 49 NA NA NAΔ NAΔ Critical Borgbjerg et al. 1998 Retrospective study 883 NA 366 517 NA NA 27.00 27.00 Serious McGovern et al. 2014 Retrospective study 187 Idiopathic normal pressure hydrocephalus (168), neoplasm (13), aqueductal stenosis (2), CNS cyst (2), trauma (1), Chiari spectrum (1) 157 30 34 42 76.00 73.70 Serious Hung et al. 2017 Retrospective study 496 Idiopathic normal pressure hydrocephalus (496) 346 150 41 15 73.00 74.00 Serious Rymarczuk et al. 2019 Retrospective study 544 Haemorrhage (128), neoplasm (79), spina bifida (72), congenital (45), infection (20), Dandy-Walker syndrome (16), aqueductal stenosis (15), trauma (15), Chiari spectrum (13), encephalocele (7), pseudotumor (6), schizencephaly (6), arachnoid cyst (6), vascular lesion (7), craniofacial syndrome (4), Aicardi syndrome (1), errors of metabolism (2), fibrous dysplasia (1), unknown (21) § 459 85 § 71 64 2.30 7.80 Serious The risk of bias was assessed using the ROBINS-I tool. %, the patients included in the study by Ignalzi and Kirsch represent a mixed pediatric and andult cohort with the age ranging from 1 day to 90 years; no data about the mean age value is provided. Δ, the patients included in the study by Lam and Villemure represent an adult cohort; no data about the mean age value is provided. §, 80 of the 85 patients received VAS as secondary treatment option after VPS failure. CNS indicates central nervous system; VPS, ventriculoperitoneal shunt; VAS, ventriculoatrial shunt. Table 2. Occurrence of the selected outcomes of interest in the included studies. Authors Nr. of patients with at least one revision surgery Nr. of patients with at least one shunt dysfunction/obstruction Nr. of patients with at least one infection-related complication Nr. of death VPS VAS VPS VAS VPS VAS VPS VAS Ignelzi and Kirsch 67 (56%) 85 (48%) 59 (52%) 74 (42%) 7 (6%) 11 (6%) NA NA Olsen and Frykberg 59 (85%) 56 (54%) 60 (87%) 71 (69%) 16 (23%) 31 (30%) 8 (13%) 35 (34%) Fernell et al.% NA NA NA NA NA NA 7 (5%) 8 (10%) Keucher and Maeley% NA NA NA NA NA NA 9 (11%) 15 (10%) Lam and Villemure 28 (38%) 16 (33%) 25 (34%) 8 (16%) NA NA NA NA Borgbjerg et al. 141(38%) 264 (51%) NA NA NA NA NA NA McGovern et al. 17 (11%) 10 (33%) 14 (9%) 2 (7%) 3 (2%) 0 (0%) NA NA Hung et al. 100 (29%) 16 (11%) 53 (15%) 10 (7%) 10 (3%) 2 (1%) NA NA Rymarczuk et al. 248 (54%) 34 (40%) NA NA 18 (4%) 0 (0%) NA NA %, this study reported the total amount of outcome occurrence thus not allowing to extrapolate in how many patients the selected outcomes of interest occurred or did not occur. VPS indicates ventriculoperitoneal shunt; VAS, ventriculoatrial shunt. Additional Declarations No competing interests reported. Supplementary Files SupplementaryContent1SearchStrategy.docx SupplementaryContent2FunnelPlots.docx Cite Share Download PDF Status: Published Journal Publication published 09 Aug, 2024 Read the published version in Scientific Reports → Version 1 posted Editorial decision: Revision requested 19 Apr, 2024 Reviews received at journal 16 Apr, 2024 Reviewers agreed at journal 28 Mar, 2024 Reviews received at journal 10 Mar, 2024 Reviewers agreed at journal 10 Mar, 2024 Reviewers invited by journal 10 Mar, 2024 Editor assigned by journal 10 Mar, 2024 Editor invited by journal 07 Mar, 2024 Submission checks completed at journal 07 Mar, 2024 First submitted to journal 21 Feb, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Morello","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIie3PsWrDMBCA4TOBZlGSVV6cJyicCagd9DAKBXkKdGyWIGNopuzJW/gVjKBe/ACGZHDpC7hbsuUKDoSA7LWD/kk3fJwOwOf7j43Z3dC8QwQQGHpyNxn9EdUNCmFBJCXD3eaRLM3Qmlk2KX7WZwnP2913o1Am+THbNi28blyE2+lbXCkNoioXqFCv8lORpvu+j1kmQqMsiFo/cYV2ldfLNGM9ZG7Zy6Uj4zORBIcI0pbgtoXOt2qQxHRLaLRmovoa0cd0fCBy2CMPjYNE5a74NVJGovwM2vZDzqd10tBjM3Oe38UeZhwCPp/P5+vrCk9CU3PGoRAHAAAAAElFTkSuQmCC","orcid":"","institution":"Neurosurgery Unit, University of Turin","correspondingAuthor":true,"prefix":"","firstName":"Alberto","middleName":"","lastName":"Morello","suffix":""},{"id":278012710,"identity":"a6a2578e-d76a-4b77-928e-1e5337b1f482","order_by":2,"name":"Jacopo Bellomo","email":"","orcid":"","institution":"Department of Neurosurgery, University Hospital Zurich","correspondingAuthor":false,"prefix":"","firstName":"Jacopo","middleName":"","lastName":"Bellomo","suffix":""},{"id":278012711,"identity":"43fa9a45-4d49-4944-ac21-79c9d1049c33","order_by":3,"name":"Leonardo Bradaschia","email":"","orcid":"","institution":"Neurosurgery Unit, University of Turin","correspondingAuthor":false,"prefix":"","firstName":"Leonardo","middleName":"","lastName":"Bradaschia","suffix":""},{"id":278012713,"identity":"44db4fa5-b1a7-4be8-96e3-c53f45d289cb","order_by":4,"name":"Filippo Lacatena","email":"","orcid":"","institution":"Neurosurgery Unit, University of Turin","correspondingAuthor":false,"prefix":"","firstName":"Filippo","middleName":"","lastName":"Lacatena","suffix":""},{"id":278012715,"identity":"c3cd02dc-cec1-4c47-bb6b-f9b11eabf542","order_by":5,"name":"Stefano Colonna","email":"","orcid":"","institution":"Neurosurgery Unit, University of Turin","correspondingAuthor":false,"prefix":"","firstName":"Stefano","middleName":"","lastName":"Colonna","suffix":""},{"id":278012717,"identity":"911fc8fb-9aeb-457c-8534-91d35360c43e","order_by":6,"name":"Alessandro Fiumefreddo","email":"","orcid":"","institution":"Neurosurgery Unit, University of Turin","correspondingAuthor":false,"prefix":"","firstName":"Alessandro","middleName":"","lastName":"Fiumefreddo","suffix":""},{"id":278012718,"identity":"22a2a010-dbdd-4cf5-a4d8-6a6cf2d77eca","order_by":7,"name":"Lennart Stieglitz","email":"","orcid":"","institution":"Department of Neurosurgery, University Hospital Zurich","correspondingAuthor":false,"prefix":"","firstName":"Lennart","middleName":"","lastName":"Stieglitz","suffix":""},{"id":278012719,"identity":"f132f4da-4e6e-4465-953a-efab2e6e5cb4","order_by":8,"name":"Luca Regli","email":"","orcid":"","institution":"Department of Neurosurgery, University Hospital Zurich","correspondingAuthor":false,"prefix":"","firstName":"Luca","middleName":"","lastName":"Regli","suffix":""},{"id":278012720,"identity":"b7cfa4f8-49cc-4608-8615-42046891193c","order_by":9,"name":"Michele Maria Lanotte","email":"","orcid":"","institution":"Stereotactic and Functional Neurosurgery Unit, University of Turin","correspondingAuthor":false,"prefix":"","firstName":"Michele","middleName":"Maria","lastName":"Lanotte","suffix":""},{"id":278012722,"identity":"bb58c9e4-d17f-4f92-9d7a-c47d480bd5a7","order_by":10,"name":"Diego Garbossa","email":"","orcid":"","institution":"Neurosurgery Unit, University of Turin","correspondingAuthor":false,"prefix":"","firstName":"Diego","middleName":"","lastName":"Garbossa","suffix":""},{"id":278012723,"identity":"0ba702f0-e8db-4913-87f8-81678ed1280c","order_by":11,"name":"Fabio Cofano","email":"","orcid":"","institution":"Neurosurgery Unit, University of Turin","correspondingAuthor":false,"prefix":"","firstName":"Fabio","middleName":"","lastName":"Cofano","suffix":""}],"badges":[],"createdAt":"2024-02-21 21:45:35","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3976904/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3976904/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-024-62366-8","type":"published","date":"2024-08-09T15:58:05+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":52450439,"identity":"cf10c22d-bf06-4131-b1fd-9de20c16d299","added_by":"auto","created_at":"2024-03-11 19:06:39","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":574856,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA flowchart\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-3976904/v1/0b0f1cba38af021a255391c2.png"},{"id":52450601,"identity":"130f32a8-17be-4fd9-b930-5e07a0a745e1","added_by":"auto","created_at":"2024-03-11 19:07:23","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":280186,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eForest plots of the pooled analysis of the investigated outcome variables.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eVAS indicates vantriculoatrial shunt; VPS, ventriculoperitoneal shunt. (++) indicates critical risk of bias, whereas (+) serious risk of bias.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-3976904/v1/c3997f17f9ba7d341503d77f.png"},{"id":62298914,"identity":"a55de410-26aa-41eb-b6cb-3811244e0d06","added_by":"auto","created_at":"2024-08-12 16:17:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1488350,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3976904/v1/909bff99-38e5-47fa-840f-fb125fbe907b.pdf"},{"id":52451946,"identity":"547aa644-ca83-4628-8082-e50a002ef557","added_by":"auto","created_at":"2024-03-11 19:15:24","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":15902,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryContent1SearchStrategy.docx","url":"https://assets-eu.researchsquare.com/files/rs-3976904/v1/b508e6ed1a37ee50fbae523a.docx"},{"id":52450604,"identity":"082846f0-aa6e-46dc-abfb-9154ec3ed108","added_by":"auto","created_at":"2024-03-11 19:07:28","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":425939,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryContent2FunnelPlots.docx","url":"https://assets-eu.researchsquare.com/files/rs-3976904/v1/d90cf30e5bd828f643eb161a.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Is the ventriculo-atrial shunt a last resort treatment for hydrocephalus? A meta-analysis comparing ventriculo-atrial and ventriculo-peritoneal shunt","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn the 1950s, the creation of a valve system to regulate opening pressure and prevent cerebrospinal fluid (CSF) reflux into the brain initiated a new era of surgical treatments for hydrocephalus. Consequently, it led to the development of the ventriculo-atrial shunt (VAS) in the 1960s (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) and the ventriculo-peritoneal shunt (VPS) in the 1970s (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). At the beginning, VAS was considered superior to VPS because of the polyethylene tube of this latter, which had unacceptable rates of peritonitis and distal failure. However, it was quickly noted that VAS carried significant concerns regarding the recognition of various serious and even fatal complications, such as atrial thrombi, pulmonary embolism, bacteremia, pulmonary hypertension, and cor pulmonale (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDuring the years VPS had steadily gained ground in comparison to the VAS because of a multitude of reasons, including the simplicity of surgical technique itself with a faster learning curve. In addition, the peritoneal cavity has a very high absorptive capacity, as demonstrated by its use through peritoneal dialysis, and, in pediatric population, it allows the placement of additional length of catheter for growth avoiding lengthening procedures (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAdditionally, the VAS represents a last resort treatment for hydrocephalus, when the VPS is not more feasible. Also, VAS may be underutilized due to the technical preferences of neurosurgeon, considering that the new generations are less accustomed to learn the procedure (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e However, there are no clear guidelines about the use of VAS or VPS as first surgical solution in the shunt placement, demanding the choice to the surgeon or to internal guidelines of each institution. Since the lack of established recommendation, this systematic review and meta-analysis aims to evaluate the effectiveness and safety of these two shunting techniques.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eLiterature Search\u003c/h2\u003e \u003cp\u003eThis systematic review was conducted following the PRISMA protocol (Preferred Reporting Items for Systematic Reviews and Meta\u0026ndash;Analyses) (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Potentially relevant literature was retrieved from PubMed/MEDLINE, Embase, and the Cochrane Library. The final search was conducted on the 20th of September 2023. Detailed search strategy is reported in \u003cb\u003eSupplementary Material 1\u003c/b\u003e. Word variations and exploded medical subject headings were searched for whenever feasible.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eInclusion and Exclusion criteria\u003c/h2\u003e \u003cp\u003eComparative studies with English text that met the following PICO (Patient, Intervention, Comparison, Outcome) criteria were considered eligible. Patients: individuals with symptomatic hydrocephalus. Intervention: VAS. Comparison: VPS. Outcomes: surgical revision, shunt dysfunction, infection, mortality.\u003c/p\u003e \u003cp\u003eNo 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 and reporting at least one outcome of interest (i.e. it was not mandatory that all outcomes of interest were reported in the study) were eligible for inclusion. Meta-analyses, case reports, or studies with less than 5 patients per group, cadaver studies, laboratory and animal studies were excluded. Studies including only one surgical method or other possible shunting techniques such as ventriculo-ureteral, ventriculo-gallbladder, ventriculo-pleural cavity or ventriculo-subgaleal shunt, were not included.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eScreening and Full-Text Review\u003c/h2\u003e \u003cp\u003e Title and abstract screening, full-text review, and data extraction were undertaken in parallel by two reviewers (F.L. and L.B.). Disagreements at any stage were resolved by discussion and consensus. Persistent disagreements were resolved by involvement of a third reviewer (A.M.). The process was carried out using Rayyan (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData Extraction\u003c/h2\u003e \u003cp\u003eSeveral items were considered in the evaluation of the use of the VAS/VPS surgical techniques and were divided into two main categories: patient demographics and surgery characteristics. In the first group sex, mean age at first placement of the CSF shunt system and the etiology of the hydrocephalus was investigated, while in the second group data on primary surgical choice, VAS/VPS complications in short and long run, resolution of the hydrocephalus, number of revision and the mean time at first revision of the CSF diversion system were collected. The following data were extracted: author name, publication year, the country of studies, study design, sample size, age, etiology of hydrocephalus, size of surgical groups (VAS/VPS), median follow-up time, and outcome measures that were reported as frequencies during follow-up time.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eRisk-of-Bias Assessment\u003c/h2\u003e \u003cp\u003eThe Cochrane risk-of-bias tool for nonrandomized studies of interventions (ROBINS-I tool) was used for risk-of-bias assessment of the included studies (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). This was performed by two authors (J. B., and A. M.).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eThe statistical analysis was carried out with the statistical program R studio (Posit Software, PBC formerly R Studio, version 02.07.2022). The baseline characteristics of the included studies were analysed using descriptive statistics. The meta-analysis was performed using the package meta (version 6.5-0, published 2023-06-07). A random effect model for the meta-analysis was conducted because of the methodological and clinical differences among the studies. The odds ratio (OR) of frequency data with the corresponding 95% CI were pooled by the inverse-variance test. The I2 test was used to capture the between studies\u0026rsquo; heterogeneities, which refers to the proportion of total variation because of the differences among included studies instead of sampling error. All statistical tests were two-tailed, and the significance level was set at \u003cem\u003eP\u003c/em\u003e value\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eLiterature Search\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs illustrated in the PRISMA flowchart of \u003cstrong\u003eFigure 1,\u0026nbsp;\u003c/strong\u003ethe PubMed/MEDLINE, Embase and Cochrane Library search provided 10582 articles. After duplicate removal (n=3153), 7429 records were screened, and 753 were then assessed for eligibility through full-text screening. Finally, 9 studies meeting the inclusion and exclusion criteria and reporting on 3197 patients were identified and included in in the quantitative synthesis. Sufficient data was available to perform meta-analysis for surgical revision, shunt dysfunction/obstruction, infection and mortality.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Characteristics and Quality\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e lists the main characteristics of the included studies, including publication year, study design and sample size, etiology of hydrocephalus, size of surgical groups, median follow-up time (in months), mean age at surgery (in years), and the risk of bias evaluated with ROBINS-I tool. These 9 studies yielded 3197 patients with hydrocephalus, of whom 1338 (42%) and 1798 (56%) received VAS and VPS, respectively. Three studies (Olsen and Frykberg, Fernell et al., Keucher and Maeley) investigated paediatric patient cohorts, and other three studies (Lam and Villemure, McGovern et al., and Hung et al.) adult patient cohorts. The remaining three studies (Ignelzi and Kirsch, Borgbjerg et al., and Rymarczuk et al.) included a mixed cohort of paediatric and adult patients. Apart from the study of Hung et al., comparing VPS and VAS in a cohort of idiopathic normal pressure hydrocephalus, all the other studies included patients with different causes of hydrocephalus. All the included studies had a retrospective study design, and they were scored with an overall serious to critical risk of bias according to the Cochrane\u0026rsquo;s ROBINS-I tool (\u003cstrong\u003eTable 1\u003c/strong\u003e). In \u003cstrong\u003eTable 2\u003c/strong\u003e the frequencies of the investigated outcome variables (revision surgery, shunt dysfunction/obstruction, infection-related complication, death) in the included studies are summarized. In this context, it is important to mention that the works of Ignelzi and Kirsch, Fernell et al., Lam and Villemure, and Borgbjerg et al. did not report the median follow-up time between the two surgical groups. Additionally, the median follow-up time showed a consistent difference in the works of Keucher and Maeley, shorter in the VPS group, and Hung et al., shorter in the VAS group. In the studies of Fernell et al. and Keucher and Maeley the total amount of surgical revision was reported, thus not allowing to differentiate the number of patients that needed at least one surgical revision. Over the years, a trend toward performing VPS as primary surgical treatment for hydrocephalus was observed. Indeed, in three most recent studies (McGovern et al., Hung et al. and Rymarczuk et al.) VAS was considered and performed as primary shunt treatment option only in case of contraindications for VPS, such as previous abdominal surgery, suspected increased intra-abdominal pressure, current of history of significant peritonitis or other abdominal infections that could threaten the shunt sterility or challenge its positioning due to tissue adherence, and trauma with the involvement of the abdomen. On contrary, in older studies the decision to perform VPS or VAS depended more on the surgeon\u0026rsquo;s preference and experience at the time of operation, rather than on patient-related factors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn\u003cstrong\u003e\u0026nbsp;Figure 2\u003c/strong\u003e, the results of the meta-analysis of the pooled study findings for the investigated outcomes are reported by means of forest plots.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSurgical revision: seven studies reported the frequency of at least one surgical revision\u0026nbsp;(9)\u0026nbsp;(10)\u0026nbsp;(11)\u0026nbsp;(12)\u0026nbsp;(13)\u0026nbsp;(14)\u0026nbsp;(15). 481 events were observed in the VAS group (n = 1111) and 660 in the VPS group (n = 1584). 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%).\u003c/p\u003e\n\u003cp\u003eShunt dysfunction/obstruction: five studies reported the frequency of at least one shunt dysfunction/obstruction\u0026nbsp;(9)\u0026nbsp;(10)\u0026nbsp;(11)\u0026nbsp;(13)\u0026nbsp;(14).165 events were observed in the VAS group (n = 509) and 211 in the VPS group (n = 759). The risk for shunt dysfuction/obstruction was significantly lower in the VAS group (0.49, 95%-CI 0.34 to 0.70, I2 0%).\u003c/p\u003e\n\u003cp\u003eInfection: five studies reported the frequency of at least one infection\u0026nbsp;(9)\u0026nbsp;(10)\u0026nbsp;(13)\u0026nbsp;(14)\u0026nbsp;(15). 44 events were observed in the VAS (n = 545) and 54 in the VPS group (n = 1145). The risk for infection was not significantly different between the two groups (1.02, 95%-CI 0.59 to 1.74, I2 0%).\u003c/p\u003e\n\u003cp\u003eMortality: three studies reported the frequency of death\u0026nbsp;(10)\u0026nbsp;(16)\u0026nbsp;(17). 8 events were observed in the VAS group (n = 330) and 22 in the VPS group (n = 283), 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%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePublication Bias\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFunnel plots of the investigated outcomes can be found in the \u003cstrong\u003eSupplementary Content 2 \u0026ndash; Funnel Plots\u003c/strong\u003e.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eFirstly described in historical medical works by Galen and Hippocrates (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), hydrocephalus is a common disorder of CSF physiology resulting in abnormal expansion of the cerebral ventricles and affecting an estimated number of 85 per 100,000 individuals in the general population, ranging from children to the elderly population (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). The first CSF diversion system was proposed by Mikulicz in the 1893 with a permanent ventriculo-subarachnoid-subgaleal shunt which was simultaneously a ventriculostomy and a drainage in to an extrathecal low pressure compartment (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Since then several attempts were made to find a practical and reliable solution to the drainage of the exceeded CSF. In 1946 the first silicone implant for human usage was introduced, but only ten years later in 1956 it was firstly utilized in the creation of a CSF shunt by Holter and Pudenz (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Almost in the same time period, the creation of a valve system in order to adjust the opening-pressure and to prevent the reflux of CSF back into the brain started a new era of surgical treatments for hydrocephalus, leading to the development of the VAS in the 1960s (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) and of the VPS in the 1970s (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn 1970s and 1980s, different studies by Little et al., Olsen and Frykberg, and Keucher and Mealey reported the inferiority of VAS compared to VPS in pediatric population. It was shown that VAS had a higher mortality and required more lengthening revisions because of the growth of the child; wheares the infection and dysfunction rate was similar (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). After these studies, there was a gradual switching from VAS to VPS. However, few works have been reported in literature comparing the two techniques in adult population. In 2014, McGovernor et al. compared the safety of VAS and VPS in adult/elder patients with normal-pressure hydrocephalus (NPH)(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). In adult population, there is not the risk of revisions to lengthen the distal shunt. Furthermore, elderly patients could have a lower risk of distal thrombi and/or cardiopulmonary complications since they often use anticoagulation or antiplatelet therapy for other comorbidities. The authors suggest that VAS is as safe as VPS for treating NPH (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). In addition, compared to the 1970s and 1980s studies, there was a relevant improvement in infection control and intraoperative imaging enabling for a safer catheter placement in the right atrium. Despite this, in recent decades, VAS has generally been regarded as a last resort surgical option in both adult and pediatric population. Currently, the VPS represents the first treatment option in almost all patient with hydrocephalus, even in challenging cases of history of abdominal surgery or increased abdominal pressure due to obesity (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). At the end, the final choice relies to surgeon preference. During the last years, the new generation of neurosurgeons became more familiar and confident with the VPS technique and this could be another reason of the underutilization of VAS.\u003c/p\u003e \u003cp\u003eSo, this works aims to evaluate the complications profile of VAS e VPS, including studies that reported comparative data between the two techniques. Through a comprehensive systematic review and meta-analysis of the available literature until September 2023, it was assessed surgical revision, shunt dysfunction/obstruction, infection and mortality among 3197 patients, with a heterogeneous etiology and age-population of hydrocephalus (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe literature does not have high evidence of which type of shunt requires fewer revisions. Puca et al. reported revision rates of 28% for VPS and 27% for VAS (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). According to Hung et al., The probability of shunt obstruction and shunt revision is lower in patients with VAS than in patients with VPS (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). In this study, there were no statistical difference regarding the need of at least one surgical revision of the shunt system (OR 0.91; 95% CI 0.76 to 1.09). Additionally, it was observed a lower risk of shunt dysfunction/obstruction variable in the VAS group (OR 0.50; 95% CI 0.36 to 0.69). Furthermore, it has not been identified statistical difference on the occurrence of at least one infection-related complication (OR 1.03; 95% CI 0.62 to 1.73) between the VPS and VAS groups. This result confirms what reported in literature: L.B. Oliveira et al. showed the infection rate was determined to be 5% (95% CI: 3\u0026ndash;7%) (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e); Merkler et al. reported an infection rate of 6.1% (95% CI: 5.7\u0026ndash;6.5%) for VPS (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). On the other hand, there was a higher risk of mortality in the VAS group (OR 1.96; 95% CI 1.16 to 3.31). However, this latter result comes from the analysis of three non-recent studies, from the years 1979, 1983 and 1985 (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA recent meta-analysis on VAS complication, including 52 studies and involving 2862 patients, showed an estimated risk of 0% for glomerulonephritis, intracranial hemorrhage, hygroma, cardiac complications, pulmonary complications, and shunt-related mortality (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePerforming a brief over review limited to the last 10 years of patients underwent VAS as primary treatment in relevant literature from PubMed/MEDLINE and Embase, it was noted that the main reasons for this choice were previous abdominal surgery, abdominal infections (such as peritonitis, necrotizing enterocolitis) and obesity. Given that abdominal surgeries are more common in adult patients and given the very high incidence of obesity, it is appropriate to evaluate the possibility of VAS in the treatment of hydrocephalus for this patient profile.\u003c/p\u003e \u003cp\u003eVAS continues to be 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. This data could change with improvements in technique, overall quality, and availability of diagnostic equipment and interventional radiologists. Our findings suggest that VAS is a safe alternative when VPS is not feasible. Nonetheless, further randomized studies are required to establish the real benefit of one type of shunt over the other.\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eSome important limitations should be considered. First, as mentioned above in some of the included studies the follow-up time differ significantly among the two surgical groups of patients that underwent VAS and VPS treatment; in this context the variability of the outcome rates is difficult to compare. Second, the analysis included a heterogeneous population with both adults and child patients. Lastly, in the recent years VAS has been often considered as second treatment option due to the technical preferences and biases of neurosurgeons. This is reflected in the studies included in this work, representing an uncontrollable source of confounders and therefore limiting the comparative analysis.\u003c/p\u003e \u003cp\u003eGiven these limitations, it is crucial to interpret the results with caution. Encouraging future research with randomized clinical trials and comprehensive follow-up data is essential to overcome these limitations and enhance our understanding of the VAS indications and complications.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eVAS is a valuable alternative to VPS. The results of this study suggest that VAS is a safe option when VPS is not feasible. The choice between these two techniques must to be tailored to the specific characteristics of patient. The new generations of neurosurgeons are encouraged to learn both the surgical procedures in order the best option for every patient.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eCSF:\u0026nbsp;\u003c/strong\u003ecerebrospinal fluid\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVPS:\u003c/strong\u003e ventriculo-Peritoneal Shunt\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVAS:\u003c/strong\u003e ventriculo-atrial shunt\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNPH:\u003c/strong\u003e normal-pressure hydrocephalus\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCI:\u003c/strong\u003e confidence interval\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOR:\u003c/strong\u003e odds ratio\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contribution\u0026nbsp;\u003c/strong\u003eStudy concept: ELB, AM. Study design: AM. Data acquisition: LB, FL, SC. Quality control of data and algorithms: JB, AM. Data analysis and interpretation: JB, AM. Statistical analysis: JB, AM. Manuscript preparation: ELB, AM, AF. Manuscript editing: ELB, LR, MML; DG. Manuscript review: LS, DG, FC. All authors agreed to the publication of this work.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData and code availability\u003c/strong\u003e Data or information needed to re-produce the findings presented are available from the corresponding author upon reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003eFinancial nor material support have been received.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e The authors declare no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u0026nbsp;\u003c/strong\u003eNot applicable.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProtocol Registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe review protocol was registered and published in Prospective Register of Systematic Reviews (PROSPERO) (www.crd.york.ac.uk/PROSPERO) website with registration number: CRD42023479365.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJENSEN HP, AMADOR LV. 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Comparison of ventriculoperitoneal and ventriculoatrial shunts for hydrocephalus in children. Mayo Clin Proc. 1972;47(6):396\u0026ndash;401.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorosanu CO, Filip GA, Nicolae L, Florian IS. From the heart to the bladder-particularities of ventricular shunt topography and the current status of cerebrospinal fluid diversion sites. Neurosurg Rev. 2020;43(3):847\u0026ndash;860. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10143-018-1033-2\u003c/span\u003e\u003cspan address=\"10.1007/s10143-018-1033-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGiammalva GR, Grassi N, Lo Bue E, Brunasso L, Maugeri R, Iacopino DG, Graziano F. The subway tunneling technique for distal shunt catheter insertion. Br J Neurosurg. 2020;34(1):18\u0026ndash;19. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/02688697.2019.1685648\u003c/span\u003e\u003cspan address=\"10.1080/02688697.2019.1685648\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReddy GK, Bollam P, Caldito G. Long-term outcomes of ventriculoperitoneal shunt surgery in patients with hydrocephalus. World Neurosurg. 2014;81(2):404\u0026ndash;10. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.wneu.2013.01.096\u003c/span\u003e\u003cspan address=\"10.1016/j.wneu.2013.01.096\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVivas-Buitrago T, Lu J, Robison J, Hung A, Adam A, Sankey E, et al. Ventricular-atrial shunting complications rate in normal pressure hydrocephalus. A single surgeon practice experience. Fluids Barriers CNS [Internet]. 2017;14. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12987-017-0054-5\u003c/span\u003e\u003cspan address=\"10.1186/s12987-017-0054-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1. Principle characteristics of the included studies.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"1033\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.960232783705141%\" rowspan=\"2\"\u003e\n \u003cp\u003eAuthors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.244422890397672%\" rowspan=\"2\"\u003e\n \u003cp\u003ePublication date\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.311348205625606%\" rowspan=\"2\"\u003e\n \u003cp\u003eStudy design\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9835111542192045%\" rowspan=\"2\"\u003e\n \u003cp\u003eNr. of included patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.375363724539284%\" rowspan=\"2\"\u003e\n \u003cp\u003eHydrocephalus Etiology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.535402521823473%\" colspan=\"2\"\u003e\n \u003cp\u003eShunt treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.124151309408342%\" colspan=\"2\"\u003e\n \u003cp\u003eMedian Follow-up time (in months)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.124151309408342%\" colspan=\"2\"\u003e\n \u003cp\u003eMean age at surgery (in years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.341416100872939%\" rowspan=\"2\"\u003e\n \u003cp\u003eOverall risk of bias\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.31360946745562%\"\u003e\n \u003cp\u003eVPS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.721893491124261%\"\u003e\n \u003cp\u003eVAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.82248520710059%\"\u003e\n \u003cp\u003eVPS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.159763313609467%\"\u003e\n \u003cp\u003eVAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.82248520710059%\"\u003e\n \u003cp\u003eVPS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.159763313609467%\"\u003e\n \u003cp\u003eVAS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.960232783705141%\"\u003e\n \u003cp\u003eIgnelzi and Kirsch\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.244422890397672%\"\u003e\n \u003cp\u003e1975\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.311348205625606%\"\u003e\n \u003cp\u003eRetrospective study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9835111542192045%\"\u003e\n \u003cp\u003e300\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.375363724539284%\"\u003e\n \u003cp\u003eAqueductal stenosis (54), aqueductal stenosis and myelomeningocele (43), neoplasm (55), communicating hydrocephalus not further specified (148)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.364694471387003%\"\u003e\n \u003cp\u003e114\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.1707080504364695%\"\u003e\n \u003cp\u003e177\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.498545101842871%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.62560620756547%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.498545101842871%\"\u003e\n \u003cp\u003eNA%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.62560620756547%\"\u003e\n \u003cp\u003eNA%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.341416100872939%\"\u003e\n \u003cp\u003eCritical\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.960232783705141%\"\u003e\n \u003cp\u003eOlsen and Frykberg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.244422890397672%\"\u003e\n \u003cp\u003e1983\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.311348205625606%\"\u003e\n \u003cp\u003eRetrospective study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9835111542192045%\"\u003e\n \u003cp\u003e172\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.375363724539284%\"\u003e\n \u003cp\u003eSpina bifida (55), CNS malformation (46), infection (12), perinatal factors (33), postnatal factors (2), neoplasm (2), unknown (22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.364694471387003%\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.1707080504364695%\"\u003e\n \u003cp\u003e103\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.498545101842871%\"\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.62560620756547%\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.498545101842871%\"\u003e\n \u003cp\u003e0.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.62560620756547%\"\u003e\n \u003cp\u003e0.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.341416100872939%\"\u003e\n \u003cp\u003eSerious\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.960232783705141%\"\u003e\n \u003cp\u003eFernell et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.244422890397672%\"\u003e\n \u003cp\u003e1985\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.311348205625606%\"\u003e\n \u003cp\u003eRetrospective study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9835111542192045%\"\u003e\n \u003cp\u003e259\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.375363724539284%\"\u003e\n \u003cp\u003eAqueductal stenosis (84), perinatal complications (69), CNS anomalies (49), congenital or neonatal infection (30), unknown (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.364694471387003%\"\u003e\n \u003cp\u003e133\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.1707080504364695%\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.498545101842871%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.62560620756547%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.498545101842871%\"\u003e\n \u003cp\u003e0.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.62560620756547%\"\u003e\n \u003cp\u003e0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.341416100872939%\"\u003e\n \u003cp\u003eCritical\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.960232783705141%\"\u003e\n \u003cp\u003eKeucher and Maeley\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.244422890397672%\"\u003e\n \u003cp\u003e1979\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.311348205625606%\"\u003e\n \u003cp\u003eRetrospective study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9835111542192045%\"\u003e\n \u003cp\u003e228\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.375363724539284%\"\u003e\n \u003cp\u003eMyelomeningocele (128), aqueductal stenosis (39), communicating hydrocephalus not further specified (31), infection (12), Dandy-Walker syndrome (9), unknown (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.364694471387003%\"\u003e\n \u003cp\u003e81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.1707080504364695%\"\u003e\n \u003cp\u003e147\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.498545101842871%\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.62560620756547%\"\u003e\n \u003cp\u003e97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.498545101842871%\"\u003e\n \u003cp\u003e0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.62560620756547%\"\u003e\n \u003cp\u003e0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.341416100872939%\"\u003e\n \u003cp\u003eSerious\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.960232783705141%\"\u003e\n \u003cp\u003eLam and Villemure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.244422890397672%\"\u003e\n \u003cp\u003e1997\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.311348205625606%\"\u003e\n \u003cp\u003eRetrospective study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9835111542192045%\"\u003e\n \u003cp\u003e128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.375363724539284%\"\u003e\n \u003cp\u003eNormal pressure hydrocephalus (55), neoplasm (37), haemorrhage (17), aqueductal stenosis (4), trauma (4), infection (3), congenital (2), unknown (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.364694471387003%\"\u003e\n \u003cp\u003e73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.1707080504364695%\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.498545101842871%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.62560620756547%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.498545101842871%\"\u003e\n \u003cp\u003eNA\u0026Delta;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.62560620756547%\"\u003e\n \u003cp\u003eNA\u0026Delta;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.341416100872939%\"\u003e\n \u003cp\u003eCritical\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.960232783705141%\"\u003e\n \u003cp\u003eBorgbjerg et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.244422890397672%\"\u003e\n \u003cp\u003e1998\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.311348205625606%\"\u003e\n \u003cp\u003eRetrospective study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9835111542192045%\"\u003e\n \u003cp\u003e883\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.375363724539284%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.364694471387003%\"\u003e\n \u003cp\u003e366\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.1707080504364695%\"\u003e\n \u003cp\u003e517\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.498545101842871%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.62560620756547%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.498545101842871%\"\u003e\n \u003cp\u003e27.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.62560620756547%\"\u003e\n \u003cp\u003e27.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.341416100872939%\"\u003e\n \u003cp\u003eSerious\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.960232783705141%\"\u003e\n \u003cp\u003eMcGovern et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.244422890397672%\"\u003e\n \u003cp\u003e2014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.311348205625606%\"\u003e\n \u003cp\u003eRetrospective study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9835111542192045%\"\u003e\n \u003cp\u003e187\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.375363724539284%\"\u003e\n \u003cp\u003eIdiopathic normal pressure hydrocephalus (168), neoplasm (13), aqueductal stenosis (2), CNS cyst (2), trauma (1), Chiari spectrum (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.364694471387003%\"\u003e\n \u003cp\u003e157\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.1707080504364695%\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.498545101842871%\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.62560620756547%\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.498545101842871%\"\u003e\n \u003cp\u003e76.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.62560620756547%\"\u003e\n \u003cp\u003e73.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.341416100872939%\"\u003e\n \u003cp\u003eSerious\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.960232783705141%\"\u003e\n \u003cp\u003eHung et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.244422890397672%\"\u003e\n \u003cp\u003e2017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.311348205625606%\"\u003e\n \u003cp\u003eRetrospective study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9835111542192045%\"\u003e\n \u003cp\u003e496\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.375363724539284%\"\u003e\n \u003cp\u003eIdiopathic normal pressure hydrocephalus (496)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.364694471387003%\"\u003e\n \u003cp\u003e346\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.1707080504364695%\"\u003e\n \u003cp\u003e150\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.498545101842871%\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.62560620756547%\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.498545101842871%\"\u003e\n \u003cp\u003e73.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.62560620756547%\"\u003e\n \u003cp\u003e74.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.341416100872939%\"\u003e\n \u003cp\u003eSerious\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.960232783705141%\"\u003e\n \u003cp\u003eRymarczuk et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.244422890397672%\"\u003e\n \u003cp\u003e2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.311348205625606%\"\u003e\n \u003cp\u003eRetrospective study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9835111542192045%\"\u003e\n \u003cp\u003e544\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.375363724539284%\"\u003e\n \u003cp\u003eHaemorrhage (128), neoplasm (79), spina bifida (72), congenital (45), infection (20), Dandy-Walker syndrome (16), aqueductal stenosis (15), trauma (15), Chiari spectrum (13), encephalocele (7), pseudotumor (6), schizencephaly (6), arachnoid cyst (6), vascular lesion (7), craniofacial syndrome (4), Aicardi syndrome (1), errors of metabolism (2), fibrous dysplasia (1), unknown (21)\u003cstrong\u003e\u0026sect;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.364694471387003%\"\u003e\n \u003cp\u003e459\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.1707080504364695%\"\u003e\n \u003cp\u003e85\u003cstrong\u003e\u0026sect;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.498545101842871%\"\u003e\n \u003cp\u003e71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.62560620756547%\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.498545101842871%\"\u003e\n \u003cp\u003e2.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.62560620756547%\"\u003e\n \u003cp\u003e7.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.341416100872939%\"\u003e\n \u003cp\u003eSerious\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe risk of bias was assessed using the ROBINS-I tool. %, the patients included in the study by Ignalzi and Kirsch represent a mixed pediatric and andult cohort with the age ranging from 1 day to 90 years; no data about the mean age value is provided. \u0026Delta;, the patients included in the study by Lam and Villemure represent an adult cohort; no data about the mean age value is provided. \u0026sect;, 80 of the 85 patients received VAS as secondary treatment option after VPS failure. CNS indicates central nervous system; VPS, ventriculoperitoneal shunt; VAS, ventriculoatrial shunt.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Occurrence of the selected outcomes of interest in the included studies.\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"1036\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.996138996138995%\" rowspan=\"2\"\u003e\n \u003cp\u003eAuthors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.166023166023166%\" colspan=\"2\"\u003e\n \u003cp\u003eNr. of patients with at least one revision surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.2972972972973%\" colspan=\"2\"\u003e\n \u003cp\u003eNr. of patients with at least one shunt dysfunction/obstruction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.49034749034749%\" colspan=\"2\"\u003e\n \u003cp\u003eNr. of patients with at least one infection-related complication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.05019305019305%\" colspan=\"2\"\u003e\n \u003cp\u003eNr. of death\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.590347923681257%\"\u003e\n \u003cp\u003eVPS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.345679012345679%\"\u003e\n \u003cp\u003eVAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.141414141414142%\"\u003e\n \u003cp\u003eVPS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.784511784511784%\"\u003e\n \u003cp\u003eVAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.24354657687991%\"\u003e\n \u003cp\u003eVPS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.906846240179574%\"\u003e\n \u003cp\u003eVAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.662177328843995%\"\u003e\n \u003cp\u003eVPS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.325476992143658%\"\u003e\n \u003cp\u003eVAS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.996138996138995%\"\u003e\n \u003cp\u003eIgnelzi and Kirsch\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.548262548262548%\"\u003e\n \u003cp\u003e67 (56%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.617760617760618%\"\u003e\n \u003cp\u003e85 (48%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.162162162162161%\"\u003e\n \u003cp\u003e59 (52%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.135135135135135%\"\u003e\n \u003cp\u003e74 (42%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.38996138996139%\"\u003e\n \u003cp\u003e7 (6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.1003861003861%\"\u003e\n \u003cp\u003e11 (6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.16988416988417%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.88030888030888%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.996138996138995%\"\u003e\n \u003cp\u003eOlsen and Frykberg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.548262548262548%\"\u003e\n \u003cp\u003e59 (85%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.617760617760618%\"\u003e\n \u003cp\u003e56 (54%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.162162162162161%\"\u003e\n \u003cp\u003e60 (87%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.135135135135135%\"\u003e\n \u003cp\u003e71 (69%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.38996138996139%\"\u003e\n \u003cp\u003e16 (23%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.1003861003861%\"\u003e\n \u003cp\u003e31 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.16988416988417%\"\u003e\n \u003cp\u003e8 (13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.88030888030888%\"\u003e\n \u003cp\u003e35 (34%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.996138996138995%\"\u003e\n \u003cp\u003eFernell et al.%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.548262548262548%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.617760617760618%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.162162162162161%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.135135135135135%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.38996138996139%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.1003861003861%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.16988416988417%\"\u003e\n \u003cp\u003e7 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.88030888030888%\"\u003e\n \u003cp\u003e8 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.996138996138995%\"\u003e\n \u003cp\u003eKeucher and Maeley%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.548262548262548%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.617760617760618%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.162162162162161%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.135135135135135%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.38996138996139%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.1003861003861%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.16988416988417%\"\u003e\n \u003cp\u003e9 (11%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.88030888030888%\"\u003e\n \u003cp\u003e15 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.996138996138995%\"\u003e\n \u003cp\u003eLam and Villemure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.548262548262548%\"\u003e\n \u003cp\u003e28 (38%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.617760617760618%\"\u003e\n \u003cp\u003e16 (33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.162162162162161%\"\u003e\n \u003cp\u003e25 (34%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.135135135135135%\"\u003e\n \u003cp\u003e8 (16%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.38996138996139%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.1003861003861%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.16988416988417%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.88030888030888%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.996138996138995%\"\u003e\n \u003cp\u003eBorgbjerg et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.548262548262548%\"\u003e\n \u003cp\u003e141(38%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.617760617760618%\"\u003e\n \u003cp\u003e264 (51%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.162162162162161%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.135135135135135%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.38996138996139%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.1003861003861%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.16988416988417%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.88030888030888%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.996138996138995%\"\u003e\n \u003cp\u003eMcGovern et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.548262548262548%\"\u003e\n \u003cp\u003e17 (11%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.617760617760618%\"\u003e\n \u003cp\u003e10 (33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.162162162162161%\"\u003e\n \u003cp\u003e14\u0026nbsp;(9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.135135135135135%\"\u003e\n \u003cp\u003e2 (7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.38996138996139%\"\u003e\n \u003cp\u003e3 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.1003861003861%\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.16988416988417%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.88030888030888%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.996138996138995%\"\u003e\n \u003cp\u003eHung et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.548262548262548%\"\u003e\n \u003cp\u003e100 (29%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.617760617760618%\"\u003e\n \u003cp\u003e16 (11%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.162162162162161%\"\u003e\n \u003cp\u003e53 (15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.135135135135135%\"\u003e\n \u003cp\u003e10 (7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.38996138996139%\"\u003e\n \u003cp\u003e10 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.1003861003861%\"\u003e\n \u003cp\u003e2 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.16988416988417%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.88030888030888%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.996138996138995%\"\u003e\n \u003cp\u003eRymarczuk et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.548262548262548%\"\u003e\n \u003cp\u003e248 (54%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.617760617760618%\"\u003e\n \u003cp\u003e34 (40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.162162162162161%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.135135135135135%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.38996138996139%\"\u003e\n \u003cp\u003e18 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.1003861003861%\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.16988416988417%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.88030888030888%\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e%, this study reported the total amount of outcome occurrence thus not allowing to extrapolate in how many patients the selected outcomes of interest occurred or did not occur. VPS indicates ventriculoperitoneal shunt; VAS, ventriculoatrial shunt.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Ventriculoatrial, ventriculo-atrial, ventriculoperitoneal, shunt, hydrocephalus","lastPublishedDoi":"10.21203/rs.3.rs-3976904/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3976904/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eHydrocephalus 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.\u003c/p\u003e \u003cp\u003e This systematic review was conducted following the PRISMA protocol (Preferred Reporting Items for Systematic Reviews and Meta\u0026ndash;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.\u003c/p\u003e \u003cp\u003e9 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%).\u003c/p\u003e \u003cp\u003eVAS 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.\u003c/p\u003e","manuscriptTitle":"Is the ventriculo-atrial shunt a last resort treatment for hydrocephalus? A meta-analysis comparing ventriculo-atrial and ventriculo-peritoneal shunt","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-11 19:05:31","doi":"10.21203/rs.3.rs-3976904/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-04-19T16:24:35+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-16T16:08:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"4ff0c322-c54c-40f3-84bb-2242251d0e88","date":"2024-03-28T15:36:18+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-03-10T11:42:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"c6ffef66-5e49-466a-a654-1277bd1371bb","date":"2024-03-10T10:50:51+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-03-10T06:34:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-03-10T06:01:14+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-03-07T05:54:34+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-03-07T05:52:34+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2024-02-21T21:39:42+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a5b89480-d60a-432f-a405-33b7b732498a","owner":[],"postedDate":"March 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":29283645,"name":"Biological sciences/Neuroscience"},{"id":29283646,"name":"Biological sciences/Neuroscience/Diseases of the nervous system"}],"tags":[],"updatedAt":"2024-08-12T16:10:16+00:00","versionOfRecord":{"articleIdentity":"rs-3976904","link":"https://doi.org/10.1038/s41598-024-62366-8","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2024-08-09 15:58:05","publishedOnDateReadable":"August 9th, 2024"},"versionCreatedAt":"2024-03-11 19:05:31","video":"","vorDoi":"10.1038/s41598-024-62366-8","vorDoiUrl":"https://doi.org/10.1038/s41598-024-62366-8","workflowStages":[]},"version":"v1","identity":"rs-3976904","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3976904","identity":"rs-3976904","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}