What is the treatment for a shunt?

Treatment Approaches for Different Types of Shunts

The treatment for a shunt depends on the specific type of shunt and its associated complications, with surgical intervention being the primary approach for most shunt dysfunctions.

Systemic-to-Pulmonary Artery Shunts

Acute Shunt Thrombosis

• Acute thrombosis of a systemic-to-pulmonary artery shunt requires emergency management with:
  • Immediate anticoagulation with heparin (50-100 U/kg) 1
  • Increased systemic blood pressure using phenylephrine to maximize shunt perfusion 1
  • Controlled ventilation to optimize oxygen delivery and minimize consumption 1
  • Alternative interventions may include epinephrine (10 μg/kg), emergency catheterization for thrombus removal, or emergent sternotomy for thrombectomy 1
  • If these measures fail, ECMO may be required for stabilization 1

Risk Factors for Shunt Occlusion

• Conditions that cause intravascular volume depletion 1
• Persistently draining pleural effusions 1
• Infection 1
• Smaller shunt size (for modified Blalock-Taussig shunts) 1

Cerebrospinal Fluid (CSF) Shunts

Shunt Infection Management

• Complete removal of the infected shunt with placement of an external ventricular drain is recommended 1
• Appropriate antibiotic therapy based on culture results 1
• Delayed replacement of the shunt after CSF sterilization (typically after negative cultures for 3 days off antibiotics) 1
• Complete shunt replacement is associated with lower risk of relapse compared to partial replacement 1

Shunt Malfunction

• For non-functioning shunts, evaluation of proximal and distal flow intraoperatively is necessary to identify the area of failure 1
• Complete replacement may be required if the failure is due to clogging from highly proteinaceous fluid 1
• For patients with hydrocephalus and increased intracranial pressure, initial management includes medical therapy and repeated lumbar punctures 1
• Most patients with increased intracranial pressure will ultimately require permanent shunt placement 1

Transjugular Intrahepatic Portosystemic Shunts (TIPS)

Insufficient Shunting

• For shunt stenosis or occlusion, progressive dilation of a controlled expansion stent is the least invasive approach 1
• Coverage defects can be treated with angioplasty or a new stent 1
• In exceptional cases, placement of a new shunt may be considered 1
• Follow-up of shunt function should be performed every 6 months, typically with Doppler ultrasound 1

Excessive Shunting

• Reduction of the shunt is recommended for:
  • Early severe liver failure 1
  • Chronic hepatic encephalopathy refractory to medical therapy 1
  • Cardiac failure refractory to medical therapy 1
• Shunt reduction has been shown to improve hepatic encephalopathy in 92% of cases 1

Pleuroperitoneal Shunts

Indications

• Trapped lung with large effusions refractory to chemical pleurodesis 1
• Malignant pleural effusions when length of hospitalization needs to be minimized 1

Management of Complications

• Shunt occlusion (occurs in 12-25% of cases) typically requires replacement of the shunt 1
• Contraindications include pleural infection, multiple pleural loculations, and inability to compress the pump chamber 1

Patent Foramen Ovale (PFO) Shunts

Residual Shunts After Closure

• For moderate-to-large residual shunts after percutaneous PFO closure, implantation of a second closure device is safe and effective 2, 3
• This approach has shown complete PFO closure in up to 90% of patients at 6-month follow-up 2
• The 24-hour post-procedure shunt is the strongest predictor of residual shunting at six months 3

General Considerations for All Shunts

• The specific treatment approach must be tailored to the type of shunt and the underlying condition 1
• Regular follow-up imaging is essential to monitor shunt function and detect complications early 1
• Surgical expertise is critical for successful shunt management, particularly for complex cases 1, 4