Agarwal Nitin, Kashkoush Ahmed, McDowell Michael M, Lariviere William R, Ismail Naveed, Friedlander Robert M
J Neurosurg. 2018 May 11;130(4):1252-1259. doi: 10.3171/2017.11.JNS172212. Print 2019 Apr 1.
Ventricular shunt (VS) durability has been well studied in the pediatric population and in patients with normal pressure hydrocephalus; however, further evaluation in a more heterogeneous adult population is needed. This study aims to evaluate the effect of diagnosis and valve type-fixed versus programmable-on shunt durability and cost for placement of shunts in adult patients.
The authors retrospectively reviewed the medical records of all patients who underwent implantation of a VS for hydrocephalus at their institution over a 3-year period between August 2013 and October 2016 with a minimum postoperative follow-up of 6 months. The primary outcome was shunt revision, which was defined as reoperation for any indication after the initial procedure. Supply costs, shunt durability, and hydrocephalus etiologies were compared between fixed and programmable valves.
A total of 417 patients underwent shunt placement during the index time frame, consisting of 62 fixed shunts (15%) and 355 programmable shunts (85%). The mean follow-up was 30 ± 12 (SD) months. The shunt revision rate was 22% for programmable pressure valves and 21% for fixed pressure valves (HR 1.1 [95% CI 0.6-1.8]). Shunt complications, such as valve failure, infection, and overdrainage, occurred with similar frequency across valve types. Kaplan-Meier survival curve analysis showed no difference in durability between fixed (mean 39 months) and programmable (mean 40 months) shunts (p = 0.980, log-rank test). The median shunt supply cost per index case and accounting for subsequent revisions was $3438 (interquartile range $2938-$3876) and $1504 (interquartile range $753-$1584) for programmable and fixed shunts, respectively (p < 0.001, Wilcoxon rank-sum test). Of all hydrocephalus etiologies, pseudotumor cerebri (HR 1.9 [95% CI 1.2-3.1]) and previous shunt malfunction (HR 1.8 [95% CI 1.2-2.7]) were found to significantly increase the risk of shunt revision. Within each diagnosis, there were no significant differences in revision rates between shunts with a fixed valve and shunts with a programmable valve.
Long-term shunt revision rates are similar for fixed and programmable shunt pressure valves in adult patients. Hydrocephalus etiology may play a significant role in predicting shunt revision, although programmable valves incur higher supply costs regardless of initial diagnosis. Utilization of fixed pressure valves versus programmable pressure valves may reduce supply costs while maintaining similar revision rates. Given the importance of developing cost-effective management protocols, this study highlights the critical need for large-scale prospective observational studies and randomized clinical trials of ventricular shunt valve revisions and additional patient-centered outcomes.
脑室分流术（VS）的耐用性已在儿科人群和正常压力脑积水患者中得到充分研究；然而，需要在更多样化的成年人群中进行进一步评估。本研究旨在评估诊断和瓣膜类型（固定型与可编程型）对成年患者分流术耐用性和置管成本的影响。
作者回顾性分析了2013年8月至2016年10月期间在其机构接受脑积水VS植入术的所有患者的病历，术后随访至少6个月。主要结局是分流术翻修，定义为初次手术后因任何原因进行的再次手术。比较了固定瓣膜和可编程瓣膜的供应成本、分流术耐用性及脑积水病因。
在索引时间段内，共有417例患者接受了分流术置管，其中62例为固定分流管（15%），355例为可编程分流管（85%）。平均随访时间为30±12（标准差）个月。可编程压力瓣膜的分流术翻修率为22%，固定压力瓣膜为21%（风险比1.1[95%置信区间0.6 - 1.8]）。不同瓣膜类型的分流术并发症，如瓣膜故障、感染和引流过度，发生频率相似。Kaplan-Meier生存曲线分析显示，固定分流管（平均39个月）和可编程分流管（平均40个月）的耐用性无差异（p = 0.980，对数秩检验）。每例索引病例及后续翻修的分流管供应成本中位数，可编程分流管为3438美元（四分位间距2938 - 3876美元），固定分流管为1504美元（四分位间距753 - 1584美元）（p < 0.001，Wilcoxon秩和检验）。在所有脑积水病因中，发现假性脑瘤（风险比1.9[95%置信区间1.2 - 3.1]）和既往分流术故障（风险比1.8[95%置信区间1.2 - 2.7]）会显著增加分流术翻修风险。在每种诊断中，固定瓣膜分流管和可编程瓣膜分流管的翻修率无显著差异。
成年患者中，固定和可编程分流压力瓣膜的长期分流术翻修率相似。脑积水病因在预测分流术翻修中可能起重要作用，尽管无论初始诊断如何，可编程瓣膜的供应成本更高。使用固定压力瓣膜而非可编程压力瓣膜可能在保持相似翻修率的同时降低供应成本。鉴于制定具有成本效益的管理方案的重要性，本研究强调了对脑室分流瓣膜翻修及其他以患者为中心的结局进行大规模前瞻性观察研究和随机临床试验的迫切需求。
