Pleurovenous shunt in treating refractory nonmalignant hepatic hydrothorax: A case report

Abstract

We report a case of successful, long-term pleurovenous shunt (PVS) in treating refractory nonmalignant hepatic hydrothorax. An 82-year-old woman with liver cirrhosis, hypertension complicated with chronic renal failure while on hemodialysis, presented with progressive dyspnea in association with a recurrent right-sided pleural effusion, occurring secondary to transdiaphragmatic migration of ascites. The diagnosis was established by a demonstration of (99m)Tc-sulphur colloid sequential scintigraphic scan. Despite repetitive thoracenteses and traditional medical treatment, she suffered dyspnea without relief. Denver peritoneovenous shunt was inserted into the right-sided pleural cavity to drain effusion into the subclavian vein without short- and long-term complications. Manually pumping schedule of 10 min was performed twice daily to remove pleural fluid into the venous circulation for maintaining shunt patency. After 19 months of follow-up, the patient is doing well and PVS remains patent without significant pleural effusion. PVS opens a window of opportunity and offers an alternative procedure with minimal invasiveness for high-risk patients with refractory hepatic hydrothorax. It could be an alternative treatment to other conventional surgical interventions.

Complications of Denver Shunt

“…The first use of pleurovenous shunt was demonstrated by Pollock in 1975. [8] The shunt serves as a method for returning the lost plasma volume through the shunt placed in the pleural or peritoneal cavity to the central venous system. [6] Two types of peritoneovenous shunts are described: The Le Veen shunt and the Denver shunt.…”

Pleurovenous shunt for treating refractory benign pleural effusion

“…At least five postulated mechanisms of pleural effusion depend on ascites: direct access through diaphragmatic defects, passage of fluid via the diaphragmatic lymphatics [3][4][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].…”

“…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].…”

Evidence-Based Review of the Management of Hepatic Hydrothorax

“…A few case reports have used a pleurovenous shunt for the management of HH [98,99]. Artemiou et al [100] showed the effectiveness of pleurovenous shunts in 12 patients with chronic nonmalignant right-sided pleural effusions.…”