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Ann Thorac Surg 1997;63:1777-1779
© 1997 The Society of Thoracic Surgeons

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Case Report

Treatment of Refractory, Nonmalignant Hydrothorax With a Pleurovenous Shunt

Divisions of General and Thoracic Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota

Accepted for publication January 22, 1997.

	Abstract

Top Footnotes Abstract Introduction Comment References

 
We present a case of long-term successful application of pleurovenous shunting for the management of pleural effusion. Intractable symptomatic hydrothorax developed as a result of transdiaphragmatic migration of hepatic ascites. After failure of traditional treatment by mechanical pleurodesis, a pleurovenous shunt was inserted. After 1 year of follow-up, the effusion is well controlled, and the shunt remains patent.

	Introduction

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The standard treatment of symptomatic recurrent pleural effusion is thoracostomy and chemical pleurodesis. The most commonly used agent, talc, has a reported success rate of 81% [1]. Alternatively, video-assisted thoracic surgery has been used to control effusions. However, in debilitated patients, the video-assisted thoracic surgical approach is associated with a mortality rate of 3% [2]. This report describes an alternative management of a hydrothorax using pleurovenous shunting.

A 53-year-old woman presented with progressive dyspnea and early satiety from massive hepatomegaly secondary to autosomal dominant polycystic liver disease. After hepatic polysegmentectomy, severe refractory ascites and a right pleural effusion developed associated with a large infrahepatic inferior vena cava to right atrial pressure gradient of 13 mm Hg. The pressure was decompressed by cavoatrial bypass via right thoracotomy using a transdiaphragmatic ringed polytetrafluoroethylene graft and fenestration of multiple liver cysts, and the effusion was treated by simultaneous right mechanical pleurodesis. This procedure was complicated by massive right chest tube output (9 to 10 L per day) and a new left pleural effusion. The effusions were attributed to migration of ascites via the diaphragmatic defect adjacent to the polytetrafluoroethylene shunt. The left hydrothorax was controlled with video-assisted thoracic surgical pleurodesis.

To control the right hydrothorax, a LeVeen peritoneovenous shunt was inserted, but this failed, presumably due to preferential transdiaphragmatic flow. The persistent right hydrothorax was then treated with percutaneous placement of a Tenckhoff catheter. The right pleural fluid was aspirated daily and reinfused into the peripheral circulation to prevent nutritional depletion. To facilitate management, a Denver pleurovenous shunt was inserted percutaneously as described by Weaver and colleagues [3]. Briefly, percutaneous insertion was accomplished by placing a strippable sheath over a guide wire that had been placed in the subclavian vein or into the pleural space. The appropriate limb of the Denver shunt was then passed through the sheath. Once adequate flow was confirmed, the sheath was stripped away. After the shunt was placed, the Tenckhoff catheter was removed. Over the next several days, the patient was instructed to pump the shunt for 10 minutes every 4 hours. Permanent control of the right pleural effusion was achieved without creating volume overload or disseminated intravascular coagulation. Fifteen days later, the inflow limb of the shunt became occluded with fibrinous debris. The occlusion did not dissolve after 5,000 units of urokinase was injected into the pump chamber. The shunt was revised according to the method of Moritz and colleagues [4]. After 13 months of follow-up, the shunt remains patent with excellent control of hydrothorax, with the patient following a pumping schedule of 10 minutes twice a day.

	Comment

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In 1974, LeVeen and associates [5] introduced peritoneovenous shunting for the management of ascites. The peritoneovenous shunt uses the positive intraabdominal to central venous pressure gradient to propel ascitic fluid into the central circulation through a unidirectional pressure-activated valve. The alternative Denver peritoneovenous shunt, introduced in 1979 [6], incorporates a unidirectional pump that is positioned in the subcutaneous tissue, allowing manual compression to propel fluid. This innovation broadened the application of shunts to clinical situations in which fluid must be displaced against a pressure gradient such as the gradient between the pleural space and the peritoneal cavity or central venous system. Although pleuroperitoneal Denver shunts have been described, ascites may complicate this procedure; therefore, the presence of ascites is a contraindication to insertion [7]. Five pleurovenous shunts have been previously reported in the worldwide literature [7–11]. Each was placed either for malignant pleural effusion with early death (4 patients) or had very short-term shunt patency (1 patient) [7–11]. In contrast, our patient with a nonmalignant hydrothorax allowed us to assess the long-term efficacy of a pleurovenous shunt.

In a patient with an intractable hydrothorax who has failed pleurodesis, pleurovenous Denver shunt is an attractive alternative for several reasons. First, in high-risk patients, the shunt can be inserted percutaneously via Seldinger technique under local anesthesia. Second, long-term shunt patency, more than 1 year in our patient, can be maintained. Third, although mechanical occlusion and infection pose potential risks, the former complication can be managed by shunt revision. Finally, pleural effusions can be effectively controlled with only minutes spent on daily pumping, causing little disruption of the patient's activities.

There are a few noteworthy points in the management of the shunt. We have found that aggressive, complete emptying of the pleural fluid will cause fibrinous debris to occlude the shunt chamber. Moreover, complete aspiration of pleural fluid may result in pleuritic chest pain. The pumping is considered clinically optimal when the patient is free of both shortness of breath from underpumping and pleuritic chest pain from overpumping. Finally, as alluded to by Roukema and colleagues [7], the shunt insertion must be performed with great care to prevent the theoretical possibility of air embolism. Therefore, pleurocentesis is not performed before insertion of the shunt and, after the insertion of the pleural limb, all air in the pump is expelled from the shunt before positioning of the venous limb.

In summary, pleurovenous shunting is an alternative in the management of intractable pleural effusion. This patient demonstrates that long-term shunt patency can be maintained with effective control of symptoms.

View larger version (98K): [in this window] [in a new window]   Fig 1. . Chest radiograms obtained before (A) and 6 days after (B) placement of right pleurovenous shunt. Arrows outline course into right subclavian vein.

	Footnotes

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	References

Top Footnotes Abstract Introduction Comment References

 

1. Kennedy L, Rusch VW, Strange C, Ginsberg RJ. Pleurodesis using talc slurry. Chest 1994;106:342–6.[Abstract/Free Full Text]
2. Ohri SK, Oswal SK, Townsend ER, Fountain SW. Early and late outcome after diagnostic thoracoscopy and talc pleurodesis. Ann Thorac Surg 1992;53:1038–41.[Abstract]
3. Weaver DW, Wiencek RG, Bouwman DL. Percutaneous Denver peritoneovenous shunt insertion. Am J Surg 1990;159:600–1.[Medline]
4. Moritz MJ, Hoch JR, Rosato FE. Simple revision of the Denver peritoneovenous shunt with nonfunction from inflow occlusion. Surg Gynecol Obstet 1987;165:71–2.[Medline]
5. LeVeen HH, Christoudias G, Moon IP, Luft R, Falk G, Grosberg S. Peritoneovenous shunting for ascites. Ann Surg 1974;180:580–91.[Medline]
6. Lund RH, Newkirk JB. Peritoneovenous shunting system for surgical management of ascites. Contemp Surg 1979;14:31–45.
7. Roukema JA, Lobach HJ, van der Werken C. Ascites after pleuroperitoneal shunting. Cancer 1990;66:675–6.[Medline]
8. Oosterlee J. Peritoneovenous shunting for ascites in cancer patients. Br J Surg 1980;67:663–6.[Medline]
9. Soderlund C. Treatment of pleural effusion with pleurovenous shunt. Lakartidningen 1982;79:1499–500.[Medline]
10. Oizumi H, Inui K, Tatebe S, Ishihara R, Washio M. A case of intractable hepatic hydrothorax treated by pleurovenous shunt. J Jpn Assoc Thorac Surg 1989;37:751–4.
11. Pollock AV. The treatment of resistant malignant ascites by insertion of a peritoneo-atrial Holter valve. Br J Surg 1975;62:104–7.[Medline]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Joseph B. Shrager Mark S. Allen David M. Nagorney Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Park, S. Z. Articles by Nagorney, D. M. Search for Related Content PubMed PubMed Citation Articles by Park, S. Z. Articles by Nagorney, D. M.