Endovascular repositioning of a ventriculoatrial shunt initially misplaced in the accessory hemiazygos vein: A salvage technique following surgical failure

Ventriculoatrial shunting (VAS) is an established treatment for hydrocephalus, utilizing the right atrium as a favorable site for cerebrospinal fluid (CSF) drainage due to its optimal pressure gradient relative to the intracranial compartment. However, malposition of the distal catheter into veins proximal to the heart can impair shunt function. We report the case of a 10-year-old girl with a history of postinfectious tetraventricular hydrocephalus treated with VAS. She presented with headaches and seizures accompanied by newly observed ventricular enlargement on magnetic resonance imaging (MRI). Suspecting shunt malfunction, surgical revision was undertaken, involving replacement of the valve and distal catheter. Postoperative imaging demonstrated malposition of the distal catheter into the accessory hemiazygos vein. The catheter was successfully repositioned into the right atrium using a minimally invasive endovascular approach. The patient’s symptoms resolved, and follow-up imaging confirmed correct catheter placement and restored shunt function. This case illustrates the utility of endovascular techniques for the management of distal VAS catheter malposition as a safe and effective alternative to open surgery. To our knowledge, this is the first reported case of distal catheter malposition into the accessory hemiazygos vein and its endovascular correction.