Removal of Peritnoeo-venous-atrial shunt thrombus without cardiopulmonary bypass.

Thrombus formation is not uncommon in longstanding intracardiac catheters, but formation of a thrombus at the tip of a Peritnoeo-venous-atrial shunt, causing obstruction of the tricuspid valve, is a rare complication and frequently unrecognized. A large intracardiac thrombus causing valve obstruction requires surgical removal with the support of cardiopulmonary bypass which is associated with significant morbidity. We successfully removed a thrombus attached to the tip of peritoneovenous shunt without cardiopulmonary bypass in a 25-year-old man.

Repositioning of surgically placed peritoneovenous shunt catheter by forming "in situ" loop snare: case report and review of literature.

We describe a technique that allows repositioning of malfunctioning peritoneovenous shunt (PVS) catheters. We report a 67-year-old female with refractory ascites, who presented with malfunctioning PVS. The catheter tip was outside the superior vena cava (SVC), possibly in a small mediastinal vein, which makes its tip inaccessible to regular snares and retrieval devices. We used "in situ" loop snare technique to reposition the tip of the catheter into the inferior vena cava (IVC). In situ loop snare technique can be used to reposition malfunctioning PVS catheters caused by a kink or by malposition of its tip. The technique avoids surgical or interventional replacement of these catheters. This technique can be also used for retrieval of foreign body fragments that have no free ends and, therefore, cannot be captured by a snare or other retrieval devices.

Radiological insertion of Denver peritoneovenous shunts for malignant refractory ascites: a retrospective multicenter study (JIVROSG-0809).

PURPOSE: Peritoneal venous shunts (PVSs) are widely used for palliating symptoms of refractory malignant ascites and are recognized as one of the practical methods. However, reliable clinical data are insufficient because most previous reports have been small studies from single centers. We conducted a retrospective, multicenter study to evaluate the safety and efficacy of radiologically placed PVSs in patients with malignant refractory ascites. METHODS: A total of 133 patients with malignant ascites refractory to medical therapies were evaluated for patient characteristics, technical success, efficacy, survival times, adverse events, and changes in laboratory data. RESULTS: PVSs were successfully placed in all patients and were effective (i.e., improvement of ascites symptoms lasting 7 days or more) in 110 (82.7%). The median duration of symptom palliation was 26 days and median survival time was 41 days. The most frequent adverse event was PVS dysfunction, which occurred in 60 (45.1%) patients, among whom function was recovered with an additional minimally invasive procedure in 9. Abnormalities in coagulation (subclinical disseminated intravascular coagulation) occurred in 37 (27.8%) patients, although only 7 (5.3%) developed clinical disseminated intravascular coagulation. Other major adverse events were gastrointestinal bleeding (9.8%), sepsis (3.8%), and acute heart failure (3.0%). PVS was least effective in patients with elevated serum creatinine, bloody ascites, or gynecologic tumor. CONCLUSIONS: Radiological PVS is a technically feasible and effective method for palliating the symptoms from refractory malignant ascites, but preoperative evaluation and monitoring the postprocedural complications are mandatory to preclude severe adverse events after PVS.

[The use of peritoneal port-systems in the treatment of diuretic-resistant cirrhotic ascites].

Treatment results of 54 patients with liver cirrhosis and portal hypertension, complicated by diuretic-resistant ascites, were analyzed. Peritoneal port-system was implanted in 12 cases, the rest 42 patients had peritoneovenous bypass with the use of Levine's valve. Port-system implantation was possible in patients with contraindications for bypass, such as low central venous and intraabdominal pressure gradient, chylous ascites, ventral hernias etc. The use of peritoneal ports provides fractional reinfusion af the ascetic fluid, which excludes such complications as hemodilution and coagulopathy.

Saphenous--peritoneal shunt in refractory ascites: a neglected technique.

Management of intractable ascites has always been a challenge. Peritoneovenous shunt (PVS) plays a major role in the surgery of intractable ascites in patients with liver cirrhosis. Positive pressure gradient between the ascitic fluid and venous pressure leading to one-way drainage of ascitic fluid into venous circulation is the mainstay. Over decades, various modifications of shunting technique have been done. Here we report our experience with this procedure which is safe, easy and effective. Here the long saphenous vein is used as a drainage system. One-way ascites flow is ensured by a natural valve in the saphenous orifice.

Peritoneocystic shunting for ascites.

The study was designed to determine if a prototype pump could be successfully implanted in the abdomen and effectively remove excess fluid without causing complications for a 1-month period. The procedure was performed on four swine under general anesthesia. A standard two-valve Denver shunt was implanted under the skin with the efferent limb implanted in the urinary bladder. The effectiveness of the pump was verified in vivo by pumping normal saline irrigated into the abdomen. The incision was closed and the animals were observed for any problems. After 1 month, a repeat test of the pump was performed. After this second test, the animals were euthanized and examined for complications of the device. All four swine survived the procedure and the 1-month follow-up. Pump function at the end of the 1-month interval was maintained in three of the four animals. None of the swine developed calculi. There were no consistent pathologic findings, although all four swine showed evidence of reactive inflammation at the insertion site of the efferent limb into the bladder. Preliminary data suggests that a subcutaneously implanted peritoneocystic shunt may be an option for the treatment of tense ascites.

[Successful treatment for intractable ascites with uterine cancer using double Denver peritoneovenous shunt system].

A 59-year-old woman, who underwent uterectomy for uterine cancer in February 2000, was diagnosed having carcinomatous peritonitis with intractable ascites due to recurrent uterine cancer in November 2004. We conducted a peritoneovenous shunting at the right side of the abdominal cavity using the Denver peritoneovenous shunt system. A significant reduction in body weight and abdominal girth was seen during the follow up period. After 2 months, the intractable ascites was aggrayating. Because of the partition of the abdominal cavity by the greater omentum, the intractable ascites was dominant in the left side of the abdominal cavity compared with the right side. So we tried additional moreperitoneovenous shunting at the left side of the abdominal cavity using the Denver peritoneovenous shunt system. Finally, ascites and body weight were decreased. She was discharged from our hospital with a good quality of life. Double peritoneovenous shunt (Denver peritoneovenous shunt system) is a useful palliative treatment for intractable such as this case. Further experience and discussion are necessary to indicate this procedure.

Evaluation of LeVeen-shunt patency using Tc-99m labelled macroaggregated albumin.

A LeVeen peritoneo-venous shunt is placed for intractable ascites. Determination of obstruction site in the shunt tube is a difficult problem. We describe a simple nuclear medicine method using 111MBq (3mCi) of Technetium-99m labeled macro-aggregated albumin injected intraperitoneally.

Treatment of neonatal chylous ascites using a modified Denver peritoneovenous shunt: a case report.

Chylous ascites is rarely observed in newborns. Its etiology is not always readily identifiable. The authors report a patient with idiopathic chylous ascites resistant both to conservative treatment with total parenteral nutrition plus diuretics and to dietary treatment (milk with a low-fat content and medium-chain triglycerides). Surgical correction of an associated intestinal malrotation and an annular pancreas failed to resolve the ascites and we therefore placed a modified Denver peritoneovenous shunt. Six months after placement of the shunt, the patient was in good general condition, with restoration of normal oral feeding and regular growth in terms of height and weight. Clinical and ultrasonographic follow-up examinations have not revealed the presence of ascitic fluid in the peritoneal cavity.

Palliative treatment of malignant refractory ascites by positioning of Denver peritoneovenous shunt.

Malignant ascites is relatively common in patients with certain types of end-stage cancer. Traditional treatments based on fluid and salt restriction and diuretic therapy often are not able to contain neoplastic ascites. These patients consequently undergo repeated abdominal paracentesis, with further plasma protein loss and risk of injury to abdominal viscera. The aim of this study was to evaluate our experience with Denver peritoneovenous shunt and the outcome of patients with malignant ascites and suggest some modifications to improve device patency. From February 1997 to December 1999, 44 Denver peritoneovenous shunts were placed in 42 patients, 17 women and 25 men, aged between 38 and 77 years (mean, 62.3), affected with malignant ascites due to advanced abdominal cancer. At the time of admission, 72% of patients had pain, 88% dysphagia, 66% nausea and/or vomiting, and 83% dyspnea. Eleven patients underwent local anesthesia with lidocaine and 33 general anesthesia with rapidly metabolized drugs. In 27 cases we used the peritoneal-internal jugular right vein surgical approach and in 3 cases the peritoneal-femoral vein surgical access, joining the saphena vein to the cross. In 10 cases, a radiological positioning of the Denver peritoneovenous shunt was effected by a trans-subclavian access. Relief of ascites symptoms was obtained in 87.5% of cases, with reduction of dyspnea, an increased appetite and improved ambulation. Denver peritoneovenous shunt is a good device to relieve malignant ascites, thereby reducing the risk of complications and the number of hospital admissions due to repeated paracentesis and consequently improving the quality of life. A careful patient selection, an accurate follow-up and some device modifications could improve the shunt performance, allowing a wider application of the Denver peritoneovenous shunt.

[Percutaneous implant of Denver peritoneovenous shunt: a new opportunity for the interventional radiologist]. / L'impianto percutaneo dello shunt peritoneo-venoso di Denver: Una nuova opportunità per il radiologo interventista.

PURPOSE: The study is aimed at presenting our experience in the implant of Denver peritoneovenous shunts. Medical treatment-resistant ascites, either neoplastic or related to hepatic failure, is highly symptomatic and its treatment is indicated in order to improve patients' quality of life. One of the most efficient methods of treatment consists in implanting a peritoneovenous shunt. The availability of this device and its percutaneous implantation provide Interventional Radiologists with the possibility of expanding their repertoire. MATERIAL AND METHODS: Thirteen shunts were implanted in 12 patients, 10 with neoplastic ascites and 2 with hepatic failure-related ascites. In 1 patient a second device had to be implanted. All the procedures were performed in the Interventional Radiology Department, under local anesthesia and mild sedation. The central venous access was by the subclavian vein in 7 cases and the internal jugular vein in 6 cases. The puncture kit is consists of 2 needles, 1 for venous puncture and 1 for peritoneal puncture, 2 angiographic J-guide wires, 2 peel-away introducers, and a chamber containing the double valve-pump connected with both the venous and the peritoneal catheters. The whole device is placed subcutaneously thus allowing fluids to flow from the peritoneum to the vein either spontaneously, if intra-abdominal pressure exceeds 3cm of water, or by manual compression exerted on the pump itself. RESULTS: All implants were successfully performed. One transient complication occurred consisting in a mild inflammatory reaction along the subcutaneous catheter route, which promptly solved by antibiotic therapy. So far a total of 1773 catheter/days have been accumulated. 7/10 of the neoplastic patients died from progressive disease after 915 catheter/days (median 120, range 30-180). In a cirrhotic patient the first shunt occluded after 430 days due to hemoperitoneum caused by hepatic biopsy: it was removed and a new one implanted. Five shunts are in now use, with a follow-up of 30, 48, 70, 120 and 160 days each. DISCUSSION: The implanting technique was well tolerated by all patients and it could be performed under local anesthesia. The central vein puncture was easy for both accesses but the introducer diameter (12F) and the possibility of clavicle pinch-off induced us to use the internal jugular approach in the last six cases, which provided a reduced risk of pneumothorax and a better catheter track. In the patients with neoplastic ascites we observed neither disease dissemination nor changes in the patients' changed related to the shunt. Our results show that the implant of Denver venous-peritoneal shunts is a relatively easy procedure, which can be performed by Interventional Radiologists on a regular basis.

The use of the pleuro-peritoneal shunt.

The pleuro-peritoneal shunt is a device that uses a pump chamber and one-way valves to control the build-up of excess fluid in the pleural space around the lungs of patients with recurrent pleural effusions. It provides an alternative to repeated needle withdrawls or to chest tube placement. This article looks at the shunt in detail and the post-operative care given to the patient.

Un cuidado singular / A singular care

La experiencia de una enfermera es utilizada para sugerir un procedimiento paliativo novedoso en el medio, aplicado a un cuadro de ascitis maligna. El objetivo de este procedimiento es mejorar la calidad de vida de la paciente. En relación al caso, se hace referencia a la técnica de colocación de la válvula de derivación peritoneo-venosa, a su funcionamiento en los casos de ascitis por metástasis peritoneal

Un cuidado singular / A singular care

La experiencia de una enfermera es utilizada para sugerir un procedimiento paliativo novedoso en el medio, aplicado a un cuadro de ascitis maligna. El objetivo de este procedimiento es mejorar la calidad de vida de la paciente. En relación al caso, se hace referencia a la técnica de colocación de la válvula de derivación peritoneo-venosa, a su funcionamiento en los casos de ascitis por metástasis peritoneal (AU)

Treatment of patients with cirrhosis and refractory ascites using LeVeen shunt with titanium tip: comparison with therapeutic paracentesis.

It has recently been suggested that insertion of a titanium tip at the venous end of the LeVeen shunt drastically reduces the rate of shunt obstruction. To assess whether the LeVeen shunt with titanium tip improves the results obtained with therapeutic paracentesis, 81 patients with cirrhosis and refractory ascites were randomly assigned to therapy with paracentesis plus intravenous albumin (42 patients) or LeVeen shunt with titanium tip (39 patients). If patients were readmitted for ascites during follow-up, those in the first group were treated with paracentesis, and those in the LeVeen shunt group by the insertion of a new valve or a new shunt if obstruction was demonstrated. During first hospitalization, both treatments were equally effective in removing ascites. Complications were similar in both groups except for a higher rate of severe bacterial infection in the LeVeen shunt group. The mean duration of hospitalization was shorter in the paracentesis group than in the shunt group. During follow-up, the total number of readmissions and the number of readmissions for ascites were higher in the paracentesis group than in the shunt group (252 vs. 99, P < .001; and 193 vs. 43, P < .001, respectively). The total time in hospital, however, was similar (38 +/- 38 vs. 39 +/- 43 days, P = NS). Three patients had obstruction of the shunt during first hospitalization and 14 patients had a total of 22 obstructions during follow-up. Long-term survival was similar in both groups. The insertion of a titanium tip at the venous end of the LeVeen shunt does not prevent obstruction.(ABSTRACT TRUNCATED AT 250 WORDS)

A peritoneovenous shunt with an access port enables non surgical reversal of intraperitoneal catheter occlusion.

Management of chronic peritoneal ascites by transfer of the fluid to the right atrium via peritoneovenous shunt (PVS) is often complicated by occlusion of the peritoneal catheter by one, or a combination, of the following: 1) omental plugging of drain holes, 2) fibrin obstruction of the lumen, and 3) encapsulation of the peritoneal segment by a cocoon. A PVS design that includes an access port facilitates the reversal of fibrin obstruction by urokinase. Eight dogs with implanted PVS were tested weekly for patency (indicated by the flow rate of saline into the peritoneum via the access port) and performance (indicated by the percent transfer of saline from the peritoneum to the vasculature). In 256 test sessions performed to date, 15 catheter occlusions occurred. Nine of these were reversed by one or two flushes with 5,000 units of urokinase via the access port. The remaining six were found to be occluded by cocoons (two), omentum (three), and fibrin (one). Although it is an effective treatment for ascites, the PVS is not in common use, because it has a relatively high occlusion rate. The access port and other features of the authors' PVS are designed to reduce the incidence of PVS occlusion.

[Correlation between long survival and shunt patency in patients treated surgically for refractory ascites]. / A késöi túlélés és a shunt vezetöképességének kapcsolata refrakter ascites miatt operált betegekben.

The survival data of 31 patients operated on for refractory ascites in the 7-year-long period between 1983 and 1989 have been analysed in relation to the patency of the shunt. In the follow-up examination of the 7 patients who had survived 3 years flow-through contrast material was used and the patency of the shunt was documented by percutaneous injection of the contrast material under X-ray. The authors search for explanation in cases where the shunt was non-conducting (blocked) in ascites-free patients. No considerable difference was found between the two long survival assuring types of the shunt (LeVeen and Denver). 55% out of the 31 patients operated on had survived 2 years and almost 30% had survived 3 years.

[Obstruction of the Le Veen shunt: a new surgical solution]. / L'ostruzione dello shunt di Le Veen: nuova soluzione chirurgica.

The authors propose an alternative which has been proved valid in four cases of peritoneovenous shunt with an occluded Le Veen valve for venous thrombosis implanted in cirrhotic patients with refractory ascites. After having explored the various possibilities using the vessels adjacent to the superior cava branch, the authors resolved the problem of reimplanting the valve by using an access route through the saphenous vein and inferior vena cava. Using this technique it was possible to reactivate the shunt with a marked improvement in the recurrent ascitic state and above all shunt functionality, and consequently in the clinical conditions and quality of life of these patients.

Peritoneovenous shunting of intractable ascites in patients with cirrhosis: improving results and predictive factors of failure.

BACKGROUND: The clinical results of peritoneovenous shunting have not been entirely satisfactory in spite of dramatic improvement of renal function and decrease of ascites. The purpose of this study is to determine whether certain modifications improved our results. METHODS: A modified LeVeen shunt was electively inserted in 56 patients who had cirrhosis with intractable ascites. In 24 patients (42.9%) the Child-Pugh's score was less than 9, and in 32 patients the score was 9 or above. Fourteen patients (25%) had previous variceal bleeding, and 15 patients (26.8%) had previous spontaneous bacterial peritonitis (SBP). LeVeen shunt was modified by the addition of a titanium venous catheter tip. Prophylactic antibiotic therapy was administered to all patients. RESULTS: No operative deaths occurred, and one patient had severe postshunt coagulopathy. Five patients (8.9%) experienced recurrent ascites resulting from blockage from the shunt. The cumulative rate of shunt blockage was 5.6% at 1 year and 12% at 2 years. Seventeen patients (30.3%) have recently had variceal bleeding. The cumulative risk of variceal bleeding was significantly higher in patients with a previous hemorrhage than in those patients without (p < 0.05). Eight patients (14.3%) had SBP after operation. The cumulative risk of SBP was higher in patients with a history of SBP than in those patients without, although the difference was not significant. Fifty-five percent of late deaths were related to variceal bleeding or to SBP. Overall cumulative 1- and 2-year survival rates were 67.2% and 55.2%, respectively. It was 82% and 71% in patients without previous variceal bleeding or SBP. CONCLUSIONS: These data suggest that peritoneovenous shunting might be beneficial only in selected patients. Previous variceal bleeding and/or SBP indicate liver transplantation in suitable patients.