The LeVeen Shunt in the Elective Treatment of Intractable Ascites in Cirrhosis

Abstract

One hundred and forty patients with an intractable ascites complicating a chronic liver disease received a peritoneovenous shunt (PVS) using the LeVeen valve. Operative mortality was ten per cent but was 25% in patients with severe liver failure. Intraoperative drainage of ascites sharply decreased postoperative complications and mortality. One-year actuarial survival rate was 81.4%, respectively 77.7%, 61.3%, and 24.7% in patients with good liver function and moderate or severe liver failure. Variceal hemorrhage occurred in 11 patients and late infection in another 11 patients. Thirty-eight patients (30.5%) had recurrence of ascites. This was mostly due to an obstruction on the venous side of the shunt. An elective portacaval shunt had to be done in 23 patients for recurrence of ascites or variceal bleeding. Among the 57 patients still alive at time of writing, 51 were free of ascites. These results suggest that PVS is an efficient operation. This procedure may be largely indicated in the selected and small group of cirrhotic patients with true intractable ascites and moderate or no liver insufficiency.

Peritoneovenous Shunt as a Bridge to Liver Transplantation

“…PVS was inserted by a standard surgical technique (7,8). As recommended, disseminated intra-vascular coagulopathy was prevented by withdrawing the majority of the ascitic fluid prior to the insertion of the PVS.…”

Pathogenesis and Treatment of Ascites in Hepatic Cirrhosis

“…The thromboxane A2-receptor antagonist, ONO 3708, also induced a significant increase in free water clearance, suggesting that the increased renal thrombox ane A2 production may contribute to diuretic resistance in these patients [94], These experi mental approaches, however, in no way sup plant conventional drug treatment with aldo sterone antagonists and loop diuretics in pa tients with decompensated hepatic cirrhosis and ascites [95], When patients with cirrhotic ascites no longer respond, the physical measures of LeVeen shunt or repeated abdominal paracente sis may be employed. The former measure may result in absorption of ascitic fluid, im provement in the hyperdynamic circulation, reduction of the elevated plasma concentra tions of catecholamines, renin, aldosterone and vasopressin, followed by a recovery of renal excretory functions and a reduction in portal pressure [63,96,97], Unfortunately, the procedure is not without serious sideeffects [98][99][100][101], Repeated therapeutic paracentesis with the administration of human albumin or other plasma volume expanders also affords rapid elimination of ascites with a low incidence of complications [102][103][104][105][106]. Paracentesis may not be effective in inducing an improvement in systemic and renal haemodynamics, plas ma volume, electrolyte and hormonal imbal ances or liver and renal function, but it is easy to perform and permits a lower dose of diuret ic to be used [102], Repeated paracentesis is considered to be as effective as the LeVeen shunt in the treatment of cirrhotic ascites [107], 74 Gcntilini/La Villa/Romanclli/Fosehi/ Laffi…”

The LeVeen Shunt: Mechanisms of Action, Indications and Contraindications to Its Use

“…The overall operative mortality ranges from 10 to 30% [15][16][17][18][19][20] (table I). Causes of death are often multiple and include infection, disseminated intravascular coagulation (DIC), gastrointestinal hemorrhage and continued deterioration in hepatic and renal function.…”

“…Patients with more severe degrees of liver dysfunction have a higher mortality: Smadja et al [20] report that patients with at least 2 of the following criteria: serum bilirubin > 3 5 pmol/1; coagulation factors II and V <45% and chronic encephalopathy, had a 25% operative mortality. This is compared to those with one criterion: 8% mortality; or no criteria: 6% mortality.…”

“…The most common cause found by most authors is blockage of the valve from cellular debris or fibrin strands [22], However, blockage may occur at either end of the shunt. Smadja et al [20] found that occlusion at the venous tip was the most common cause for shunt blockage. It is due either to fibrous encase ment around the catheter tip or to thrombo sis [22], With thrombosis, there is a real risk of central vein thrombosis (see thrombotic complications).…”