• Jonathan Pace, Gabriel A Smith, Andrea Pannunzio, Brian Rothstein, Alan Markowitz, and Alan Hoffer.
• Case Western Reserve University School of Medicine, University Hospitals Case Medical Center, Department of Neurological Surgery, Cleveland, Ohio.
• Neurosurgery. 2015 Aug 19.

BackgroundCerebrospinal fluid diversion is one of the most frequent neurosurgical procedures across the world and can be challenging in select patients who fail standard distal drainage sites.ObjectiveTo present the case of a woman after failing peritoneal, pleural, and atrial distal drainage sites who underwent a thorascopic-assisted ventriculo-azygous vein shunt placement.MethodsA 32-year-old woman presented to our hospital with long-standing history of hydrocephalus and shunt dependence. She had failed peritoneal and atrial shunts secondary to infection, scarring, and clot formation. At presentation, she had a pleural shunt in place and developed a large pleural effusion with shortness of breath.ResultsShe was taken to the operating room where a thorascopic-assisted ventriculo-azygous vein shunt was placed through a mini-thoracotomy. Postoperatively, she has not required a shunt revision in >2 years of follow-up.ConclusionWhen other distal sites fail, our case report illustrates a novel surgical technique capable of being performed through a multidisciplinary approach.AbbreviationSVC, superior vena cava.

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