Percutaneous placement and management of the Denver shunt for portal hypertensive ascites.

OBJECTIVE: Many patients with cirrhotic effusions in the peritoneal and pleural spaces lead a difficult existence. In addition to their decreased mobility and physical discomfort, they spend hours in the hospital or an outpatient facility undergoing peritoneal and pleural drainage. Liver transplantation is the ultimate solution for those with cirrhotic effusions refractory to medical management; however, most are on a long waiting list, forcing them to undergo a year or more of percutaneous centesis. Transjugular intrahepatic portosystemic shunts offer relief to those with cirrhotic ascites but at the cost of accelerated hepatic failure and hepatic encephalopathy. This article will review the development of the peritoneovenous and pleurovenous shunt, discuss reasons for its loss of favor, and suggest its current role in the armamentarium of the interventional radiologist. CONCLUSION: Peritoneovenous and pleurovenous shunt creation is a procedure that has the potential to significantly improve the quality of life of the patient by controlling the fluid collections, reducing dependence on frequent drainage procedures, improving renal function, and reducing protein loss.

Percutaneous placement and management of peritoneovenous shunts.

Peritoneovenous shunts are used in the treatment of recurrent ascites or recurrent pleural effusions. Generally speaking, the shunts allow passage of ascites or pleural effusions (by either passive or active means) back into the central venous system. The most recent development in peritoneovenous shunts, known as the Denver Shunt, is a modification of a shunt developed for the treatment of hydrocephalus. In recent years, the Denver shunt has been placed by interventional radiologists. It is used to treat both cirrhotic and malignant effusions in the peritoneal and pleural cavities. Reported complications of the shunt are shunt occlusion, infection, post-shunt coagulopathy, deep vein thrombosis, catheter breakage, and leaks. This article discusses the technical aspects related to the percutaneous placement and maintenance of the Denver Shunt.

Transjugular intrahepatic portosystemic shunt for symptomatic refractory hepatic hydrothorax in patients with cirrhosis.

OBJECTIVES: We sought to study effectiveness, survival, and complications after transjugular intrahepatic portosystemic shunt (TIPS) in patients with cirrhosis and symptomatic refractory hepatic hydrothorax. METHODS: Consecutive patients who underwent TIPS between January 1992 and December 2008 for refractory hydrothorax were reviewed retrospectively. Clinical, laboratory, and procedural data were collected for all patients by retrospective chart review. Chi-square test was used to compare categorical variables and t-test to compare continuous variables. The Kaplan-Meier method was used for survival analysis. Survival curves were compared using the log-rank test. RESULTS: Seventy-three patients were included in the study, and their mean age at TIPS creation was 55.62 years (s.d. 11.65). The mean pre- and post-TIPS portosystemic gradients were 18.9 (s.d. 4.7) mm Hg and 5.7 (s.d. 2.4) mm Hg (P<0.001), respectively. The rates of favorable clinical response within 1 month and at 6 months after TIPS were 79% (58/73) and 75% (30/40), respectively. Median survival of the study group was 517 days (95% CI 11-626). The short-term survival rates at 30, 60, and 90 days were 81, 78, and 72%, respectively. The long-term survival rates at 1, 3, and 5 years were 48, 26, and 15%, respectively. Multivariate analysis by Cox proportional hazards method showed that pre-TIPS model for end-stage liver disease (MELD) score (P=0.039, HR 1.9 (95% CI 1.0-3.7)) and clinical response (P=0.003, HR 2.5 (95% CI 1.4-4.5)) were significantly and independently associated with overall survival. The 30-day mortality rate was 19%. Pre-TIPS creatinine levels (P=0.024, HR 3.42 (95% CI 1.2-9.9)) were significantly associated with 30-day mortality. CONCLUSIONS: TIPS can be successfully used to achieve symptomatic relief in patients with refractory hepatic hydrothorax. Better clinical response after TIPS and pre-TIPS MELD score less than 15 were associated with longer survival after TIPS.

Pyosalpinx developing from a preexisting hydrosalpinx after uterine artery embolization.

The authors describe a case of the development of a pyosalpinx from a preexisting hydrosalpinx after uterine artery embolization (UAE) for leiomyomata. The hydrosalpinx preexisted the UAE procedure and did not cause the patient any symptoms or signs of infection. UAE was performed with standard technique and was technically as well as initially clinically successful. However, the patient presented 8 weeks post-UAE with a pyosalpinx and superinfection of the previously simple fluid collection, requiring treatment with hysterectomy and oophorectomy. A mechanism for the occurrence of this superinfection is proposed, and potential strategies to avoid this serious complication in the future are discussed.