Eur J Cardiothorac Surg 2008;33:942-943. doi:10.1016/j.ejcts.2008.02.001
Copyright © 2008, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
Pleurovenous shunt for treating refractory benign pleural effusion
Ahmet Sami Bayram*,
Mustafa Köprücüo
lu,
Mert Aygün,
Cengiz Gebitekin
Department of Thoracic Surgery, Medical Faculty of Uludag University, Gorukle-Bursa 16059, Turkey
Received 25 November 2007;
received in revised form 24 January 2008;
accepted 1 February 2008.
* Corresponding author. Tel.: +90 224 2952211; fax: +90 224 4428698. (Email: asbayram2{at}yahoo.com).
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Abstract
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We report the case of a 63-year-old female with hepatic cirrhosis due to chronic hepatitis C, successfully treated for refractory nonmalignant hepatic hydrothorax by using a long-term pleurovenous shunt (PVS). After failure of conventional treatment by mechanical pleurodesis, a PVS was inserted to drain the pleural fluid into the right subclavian vein. After 8 months of follow-up, the effusion is well controlled, and the shunt remains patent.
Key Words: Pleural effusion • Shunt • Ascites
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1. Introduction
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Hepatic hydrothorax is the accumulation of ascitic fluid in the pleural space. It occurs in 0.4–12.2% of cirrhotic patients [1]. The standard treatment for recurrent symptomatic hydrothorax is tube thoracostomy and mechanical pleurodesis. Alternatively, video-assisted thoracic surgery has been used to control pleural effusion [2]. We report a case of successful, long-term pleurovenous shunting as an alternative to conventional interventions.
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2. Case report
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A 63-year-old female with hepatic cirrhosis due to chronic hepatitis C was admitted with dyspnea caused by massive right-sided pleural effusion and ascites. Tube thoracostomy followed by video thoracoscopic talc pleurodesis was performed, but massive reaccumulation of pleural fluid was observed 10 days after discharge (Fig. 1a). Treatment with a pleurovenous shunt (PVS) was planned, and the chest tube was removed to allow reaccumulation of the pleural effusion in order to avoid air embolism after shunt insertion.
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Fig. 1. (a) Massive pleural effusion on 10th day after thoracoscopic talc pleurodesis, (b) roentgenography 1 month after pleurovenous shunt insertion (white arrow: shunt's pleural part, dotted white arrow: shunt's venous part, and square: shunt's pump).
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Under general anesthesia, the patient was placed in the supine position with slight rotation of the body to the left. The right hemithorax was prepared from the chin to the umbilicus. Approximately 3 cm incision was made on the eighth intercostal space (ICS), and the proximal end of the Denver peritoneovenous shunt (Denver Biomedical, Colorado, USA) was inserted into the pleural space (Fig. 2d). The second incision was made just below the middle of the clavicle, and the right subclavian vein was prepared. A subcutaneous tunnel was created from the eighth ICS to the right subclavian vein through the sternum, and the shunt was passed through this tunnel (Fig. 2a and b). The pump of the shunt was placed on the sternum and anchored with two silk sutures (Fig. 2c). The pleural fluid was not drained in order to avoid air embolism through the shunt. The pump was manually compressed for 4 min every 2 h in the first week and for 2 min every 6 h thereafter. By the end of the first month of shunting, the patient's condition was greatly improved (Fig. 1b) despite ascites (Fig. 2d), and pleural fluid was not observed 8 months after the procedure (Fig. 2).
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Fig. 2. Computerized tomography in the eighth month: (a) white arrow shows the catheter in the subclavian vein, (b) white arrow shows the catheter in the VCS, (c) white arrow shows the pump of the catheter, (d) white arrow shows the pleural part of the catheter, and the dotted white arrow shows ascites.
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3. Discussion
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Pleural effusion occurs in approximately 6% of patients with liver cirrhosis and clinical ascites [3]. At least five postulated mechanisms of pleural effusion depend on ascites: direct access through diaphragmatic defects, passage of fluid via the diaphragmatic lymphatics [3–5], thoracic duct lymphatic leakage, azygos vein hypertension and hypoalbunemia. It affects one or both sides with 85% involvement on the right, 13% on the left, and 2% on the bilateral pleural cavities [4].
Effective treatment of recurrent pleural effusion primarily aims at permanent relief from respiratory symptoms and has a high potential for improving the patient's quality of life [4,6]. Thoracentesis and tube thoracostomy are the essential first steps in the diagnosis and treatment of recurrent pleural effusion, but they usually provide only temporary relief [6]. Other methods of treatment include video thoracoscopic repair of diaphragmatic defects with talc pleurodesis [4].
In 1974, LeVeen et al. introduced peritoneovenous shunting for the treatment of ascites [7]. Pollock was the first to describe the use of a PVS in 1975. The author implanted a peritoneo-atrial Holter valve to drain malignant pleural effusion into the superior vena cava [8]. The alternative Denver shunt was introduced in 1979. It included a unidirectional pump, which was placed subcutaneously and additionally allowed external manual compression for fluid drainage [6].
For patients with intractable hydrothorax and for whom other treatments have failed, the pleurovenous Denver shunt is an attractive alternative for several reasons. First, in high-risk patients, the shunt can be inserted percutaneously by the Seldinger technique under local anesthesia. Second, long-term shunt patency could be maintained for 8 months in our patient. 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 a few minutes of daily pumping, thereby causing little disruption of the patient's activities [2]. In our patient, manual compression for 4 min every 2 h in the first week and 2 min every 6 h thereafter has completely cleared the pleural fluid. Potential complications of treatment with a PVS are bleeding, air embolism, infection, or occlusion [6].
In conclusion, treatment with a PVS is an alternative method for managing intractable pleural effusion, and it is a rapid and easy procedure that can also be performed in high-risk patients.
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References
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- Glazer M, Berkman N, Lafair JS. Successful talc slurry pleurodesis in patients with nonmalignant pleural effusion: report of 16 cases and review of the literature. Chest 2000;117:1404-1409.[CrossRef][Medline]
- Hadsaitong D, Suttithawil W. Pleurovenous shunt in treating refractory nonmalignant hepatic hydrothorax: a case report. Respir Med 2005;99:1603-1605.[CrossRef][Medline]
- Siegerstetter V, Deibert P, Ochs A. Treatment of refractory hepatic hydrothorax with transjugular intrahepatic portosystemic shunt: long-term results in 40 patients. Eur J Gastroenterol Hepatol 2001;13:529-534.[CrossRef][Medline]
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- LeVeen HH, Christoudias G, Moon IP. Peritoneovenous shunting for ascites. Ann Surg 1974;180:580-591.[Medline]
- Pollock AV. The treatment of resistant malignant ascites by insertion of a peritoneo-atrial Holter valve. Br J Surg 1975;62:104-107.[Medline]
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Abstract
1. Introduction
