Age-based algorithm for ventriculoatrial versus ventriculopleural shunt selection in pediatric hydrocephalus: a synthesis of contemporary evidence

Abstract Background When ventriculoperitoneal (VP) shunting fails or is contraindicated, selection between ventriculoatrial (VA) and ventriculopleural (VPl) shunts remains largely empirical, driven by surgeon preference rather than evidence-based criteria. Despite increasing use of alternative CSF diversions, systematic guidance for terminus selection remains limited. Methods A narrative review synthesized comparative outcomes between VA and VPl shunts from contemporary studies (2015–2024), prioritizing multicenter registries, systematic reviews, and meta-analyses with emphasis on pediatric populations and age-stratified outcome data. Results When ventriculoperitoneal shunting is not feasible and alternative distal sites must be considered, VA shunts demonstrated significantly lower obstruction rates (OR 0.49, 95% CI 0.34–0.70) and considerable revision reduction in children aged 1–6 years (OR 0.20, 95% CI 0.09–0.44). VPl shunts showed superior 24-month survival in children ≥ 6 years (61.1% vs. 51.4%, p = 0.038). Complication rates were comparable between VA (6.0%) and VPl (9.2%, p = 0.257), with similar infection rates (OR 1.02, 95% CI 0.59–1.74) and zero incidence of historical VA complications. Conclusion A clinical decision algorithm is presented that emphasizes comorbidity evaluation, specifically differentiating pulmonary from cardiac pathology as the principal factor, with age serving as a secondary criterion. VA shunts appear optimal for children aged 1–6 years, while VPl shunts merit consideration in patients 6 years and older. This structured approach offers guidance for clinical decision-making in cases where peritoneal diversion cannot be utilized, although prospective validation remains necessary prior to establishing this as standard practice. The enhanced safety demonstrated by modern VA shunts questions prevailing usage patterns and supports reassessment of how terminus sites are selected.