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Ann Thorac Surg 2003;76:231-233
© 2003 The Society of Thoracic Surgeons

Original article: general thoracic

Pleurovenous shunting in the treatment of nonmalignant pleural effusion

Omeros Artemiou, MDa*, Gabriel-Mihai Marta, MDa, Walter Klepetko, MD, PhDa, Ernst Wolner, MD, PhDa, Michael-Rolf Müller, MD, PhDa

a Department of Cardiothoracic Surgery, University of Vienna, Vienna, Austria

Accepted for publication January 24, 2003.

* Address reprint requests to Dr Artemiou, Department of Cardiothoracic Surgery, University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria.
e-mail: omeros.artemiou{at}univie.ac.at


   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Comment
 References
 
BACKGROUND: The goals of treatment of chronic nonmalignant pleural effusion are relief of dyspnea and improved quality of life. Treatment options include needle thoracentesis, tube thoracostomy chemical pleurodesis, and pleurectomy. Pleurovenous shunting (PVS) represents an alternative, minimally invasive method.

METHODS: Since 1999, 12 patients underwent pleurovenous shunting for right-sided pleural effusion in our center. Indications were hepatic hydrothorax (n = 6, one as bridging to liver transplantation), nephrotic syndrome (n = 4), and chylothorax (n = 2, one as bridging to lung transplantation). All patients received Denver shunt systems from the pleural cavity to either the subclavian or jugular vein.

RESULTS: Shunt occlusion was observed in one case (chylothorax) 4 weeks after implantation. There was one early death, which was not related to the procedure (hepatic failure). No air embolism or infection was observed. All systems were patent throughout the observation period of 1 to 40 months (mean = 13.3 months), and none of the patients required further treatment for pleural effusion.

CONCLUSIONS: Pleurovenous shunting offers an efficient, minimally invasive alternative to other surgical methods for treatment of recurrent nonmalignant pleural effusion.


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Comment
 References
 
Effective treatment of chronic recurrent pleural effusion primarily aims at permanent relief from respiratory symptoms and has a high potential for improving the patients’ quality of life. Treatment options include repeated needle thoracentesis, tube thoracostomy chemical pleurodesis, and pleurectomy.

Thoracentesis and tube thoracostomy are essential first steps in the diagnosis and treatment, but usually provide only temporary relief. Pleurodesis with talc poudrage is the most commonly performed procedure with a reported effectiveness of 91% [1]. However, the risk of respiratory failure [2] and systemic distribution of the talc after intrapleural administration [2, 3] make the use of talc for nonmalignant effusions controversial.

Pleurovenous shunting (PVS) can be a minimally invasive alternative. The procedure was discussed previously for six cases [4–9]. For each of these cases, PVS was performed either for malignant pleural effusion (4 patients) or for nonmalignant effusion (2 patients). Beside these case reports no further data in a larger patient collective confirming its efficiency have been available.

We therefore reviewed our initial institutional experience with pleurovenous Denver shunt implantation in patients with otherwise intractable pleural effusion.


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Comment
 References
 
Since 1999, 12 patients (5 men, 7 women, aged 48 to 72 years) were referred to our department for treatment of recurrent right-sided nonmalignant pleural effusion that could not be managed by conservative treatment and repeated thoracentesis or tube thoracostomy. Indications were hepatic hydrothorax (n = 6, one as bridging to liver transplantation), nephrotic syndrome (n = 4), or chylothorax (n = 2, one as bridging to lung transplantation). In all cases Denver shunt systems were used (Denver Biomedical, Inc, Denver, CO).

The procedure was performed under general anesthesia in a modified technique as the one described by Weaver and associates [10]. The patient is placed in the supine position with the body slightly rotated to the contralateral side. The ipsilateral side is prepared and draped from the chin to the umbilicus. The height of the incision is between the sixth and eighth intercostal space beginning from the anterior axillary line to the medioclavicular line. The subcutaneous pocket is created directly over the rib beginning from the medial incision margin. The shunt is then filled and air is removed using normal saline. A purse string suture is placed into the intercostal muscles, the pleura is opened using a clamp, and the proximal part of the shunt inserted and positioned toward the sinus phrenicocostalis (Fig 1).



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  		Fig 1. Intraoperative view of the implantation. The pump is placed through a small incision in the subcutaneous pocket.

 
The shunt is tested by manual compression of the pump. To prevent air embolism, the effusion must not be completely removed. A small incision below the clavicle or above the sternocleidomastoid muscle is then created depending on the preferred vein. A subcutaneous tunnel is created between the two incisions and the venous part of the shunt is passed through this tunnel (Fig 2). The shunt is then cut to the appropriate length. A 16F permanent pacemaker lead introducer is used for insertion of the venous part of the shunt. In small patients, dissection of the vessel and insertion of the venous part of the shunt through a purse string suture under direct view is endeavored.



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  		Fig 2. Overview of the operation field during tunneling between the two incisions.

 
All patients are instructed to pump out the fluid by regular manual compression of the pump (two to three times daily for 10 minutes) at home and maintain periods of recumbent posture during the day (2 to 3 hours). In case of nephrotic syndrome, a salt-free diet and diuretic agents were continued as preoperatively.


   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Comment
 References
 
No complications were noted during the implantation of the system. Mean hospital stay was 3 days (1 to 6 days). However, all patients were discharged from the surgical ward on day 1 after the operation. Mean follow-up was 13.3 months (1 to 40 months). Pleural effusion-related symptoms were reduced to a great extent in all patients within a few days.

One patient with hepatic hydrothorax and 1 with chylothorax due to lymphangioleiomyomatosis were successfully bridged for 3 months to liver and lung transplantation, respectively. The shunts were explanted during transplantation. One shunt occlusion (9.09%) occurred in a patient with idiopathic chylothorax 4 weeks after implantation of the shunt system. A thoracentesis performed in another hospital resulted in hemothorax. An open revision was necessary, the system was explanted, and pleurodesis was performed using 3 g talcum powder. One patient (hepatic hydrothorax) died from liver failure 4 weeks after implantation with the shunt still functioning.

Further complications such as air embolism or infection were not observed. All systems were patent throughout the observation period (Fig 3) and none of the patients required further treatment for pleural effusion.



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  		Fig 3. Chest roentgenogram of a patient with hepatic hydrothorax before (A) and 2 months after (B) shunt implantation. Arrows indicate the course of the shunt system.

 

   Comment
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
References
 
In 1974 LeVeen and associates [11] introduced peritoneovenous shunting for the treatment of ascites. The shunt took advantage of the higher intraabdominal pressure to move ascites fluid into the central venous circulation through a unidirectional valve.

The alternative Denver shunt was introduced in 1979 [12]. It included a unidirectional pump, which was placed subcutaneously and additionally allowed external manual compression to move fluid. Use of the Denver shunt is therefore indicated in cases in which the fluid has to be moved against higher pressure.

Pollock described the first use of pleurovenous shunt in 1975 [4]. Out of 9 patients treated with Holter valves for ascites, 1 received the same device for pleural effusion. The shunt was draining into the superior vena cava.

In 1980 Oosterlee [5] described 20 cancer patients who were given peritoneovenous shunts for ascites. One patient in addition had malignant pleural effusions that could not be treated by conservative means. This patient received an additional shunt between the left pleural cavity and the left internal jugular vein. The patient died 6 weeks later due to her poor condition, although the shunt remained patent.

In 1982 Soderlund [6] described a further case of malignant effusion managed by PVS. The first case of a patient with a nonmalignant pleural effusion (hepatic hydrothorax) treated by PVS was presented by Oizumi and associates [7] in 1989. The shunt showed a good function for 2 months, but then failed due to renal failure and generalized edema. Roukema and associates [8] published the case of a patient with malignant pleural effusion who was treated primarily by a pleuroperitoneal shunt. A few weeks later the patient developed progressive ascites. The pleuroperitoneal shunt was replaced by a PVS. Six months after implantation of the PVS the patient died of progressive pulmonary metastasis. The shunt remained patent.

In all these cases no operative or early postoperative complication was described. Park and associates [9] reported a case of a successful long-term application of PVS. Intractable hydrothorax as a result of transdiaphragmatic migration of hepatic ascites was treated primarily by peritoneovenous shunting. Because of persistent hydrothorax a PVS was inserted. The shunt became occluded 15 days later. Revision of the shunt was successful and the device had good function for a follow-up of 13 months.

All previous reports demonstrated the feasibility of PVS. Potential complications of the device and procedure are bleeding, air embolism, infection, or occlusion. Occlusion was observed in one case reported by Park and associates (hydrothorax) and in one patient of our series (chylothorax), probably due to the higher viscosity of chyle.

Our report supports the feasibility and effectiveness of PVS especially in patients with nonmalignant effusions and a somewhat good prognosis. Especially in these patients the risk of systemic distribution or respiratory failure due to the commonly performed talcum pleurodesis should be considered. In addition, PVS can be performed in patients who are waiting for lung transplantation in whom previous pleurodesis could cause a severe bleeding problem during lung transplantation.

In conclusion, PVS is an attractive treatment alternative for nonmalignant pleural effusions. It is a short and easy procedure, which can also be performed in high-risk patients. The shunt has a long-term patency and can provide efficient control of the effusions. In case of failure, replacement of the system or talc poudrage should be considered.


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 References
 

  1. Rodriguez-Panadero F., Antony V.B. Pleurodesis: state of the art. Eur Respir J 1997;10:1648-1654.[Abstract]
  2. Campos J.R.M., Werebe E.C., Vargas F.S., Jatene F.B., Light R.W. Respiratory failure due to insufflated talc. Lancet 1997;349:251.
  3. Werebe E.C., Pazetti R., Milanez de Campos J.R., et al. Systemic distribution of talc after intrapleural administration in rats. Chest 1999;115:190-193.[Abstract/Free Full Text]
  4. Pollock A.V. The treatment of resistant malignant ascites by insertion of a peritoneo-atrial Holter valve. Br J Surg 1975;62:104-107.[Medline]
  5. Oosterlee J. Peritoneovenous shunting for ascites in cancer patients. Br J Surg 1980;67:663-666.[Medline]
  6. Soderlund C. Treatment of pleural effusion with pleurovenous shunt. Lakartidningen 1982;79:1499-1500.[Medline]
  7. Oizumi H., Inui K., Tatebe S., Ishihara R., Washio M. A case of intractable hepatic hydrothorax treated by pleuro-venous shunt. J Jpn Assoc Thorac Surg 1989;37:751-754.
  8. Roukema J.A., Lobach H.J., van der Werken C. Ascites after pleuroperitoneal shunting. Cancer 1990;66:675-676.[Medline]
  9. Park S.Z., Shrager J.B., Allen M.S., Nagorney D.M. Treatment of refractory, nonmalignant hydrothorax with a pleurovenous shunt. Ann Thorac Surg 1997;63:1777-1779.[Abstract/Free Full Text]
  10. Weaver D.W., Wiencek R.G., Bouwman D.L. Percutaneous Denver peritoneovenous shunt insertion. Am J Surg 1990;159:600-601.[Medline]
  11. LeVeen H.H., Christoudias G., Moon I.P., Luft R., Falk G., Grosberg S. Peritoneovenous shunting for ascites. Ann Surg 1974;180:580-591.[Medline]
  12. Lund R.H., Newkirk J.B. Peritoneovenous shunting system for surgical management of ascites. Contemp Surg 1979;14:31-45.



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This Article
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