Presentation
Chest pain with clinical suspicion of pulmonary embolism. CTPA ordered. Background of a VP shunt insertion for SAH.
Patient Data
Migrated VP shunt was missed on this study. Patient proceeded to a coronary angiogram for further work-up of chest pain.
The patient's coronary angiogram showed normal coronary arteries and preserved LV systolic function. However, the migrated, intracardiac VP shunt was detected and correlated with the prior CTPA. A non contrast CT chest was then performed to further clarify its position.
Non-contrast CT chest to define position of the migrated VP shunt. Study shows the catheter within the superior vena cava, entering the superior vena cava via the right IJV and right brachiocephalic vein. It then appears to loop within the heart, with the tip sitting in a left pulmonary vein.
Case Discussion
The patient proceeded to thoracic surgery for removal of the migrated VP shunt. The VP shunt was determined to have somehow entered the IJV (the mechanism is not completely known, as previous imaging had shown the VP shunt was appropriately positioned). The VP shunt then traveled via the following pathway (correlating the CT imaging with the coronary angiogram):
- SVC → right atrium → right ventricle → pulmonary trunk bifurcation → looped back on itself back into the right ventricle → right atrium → presumably through a PFO or ASD into a left upper lobe pulmonary vein