Coagulopathy Post Peritoneovenous Shunt

Abstract

In 1942, 53% of medically treated patients with cirrhosis were dead 6 months after the onset of ascites. Only 30% survived 1 year. This dismal outlook has improved only slightly with advances in medicine. Yet, some internists reject the peritoneovenous shunt (PVS) for this fatal condition even if they are aware that a diminished blood volume causes the abnormal sodium retention responsible for ascites. Their objections are based on life-threatening complications of PVS, especially post shunt coagulopathy (PSC). Blood shed into the peritoneal cavity becomes incoagulable. Such blood is immediately coagulated by a protocoagulant (soluble collagen) and concurrently lysed by tissue plasminogen activator (TPA) secreted by the peritoneal serosa. Wide zones of lysis surround peritoneal tissue placed on fibrin plates. Large volumes of ascitic fluid infused into circulating blood simulates the fate of blood shed into the peritoneal cavity with lysis playing the major role. Addition of ascitic fluid to normal platelet-rich plasma in vitro initiates clot lysis on thromboelastogram (TEG). Epsilon-aminocaproic acid (EACA) counteracts this lysis. EACA and clotting factors normalize the TEG and arrest PSC. Disposal of ascitic fluid at surgery prevents or ameliorates PSC. Mild PSC was encountered only twice in 150+ consecutive patients (1.3%) with only one case being clinically significant (0.6%). Severe PSC occurred seven times in 98 early shunt patients whose ascitic fluid was not discarded. Severe PSC requires shunt interruption and control of bleeding with clotting factors and EACA. Peritoneal lavage with saline prevents the recurrence of PSC on reopening the shunt. In four patients, EACA and clotting factors were adequate to arrest coagulopathy. Three earlier patients died of PSC before its cause and treatment were understood. Proper management eliminates this life-threatening complication, and PSC cannot be considered a deterrent to PVS. Disseminated intravascular coagulopathy (DIC) is produced in experimental animals only by the injection of thrombin or thromboplastin. PSC is a distinct entity differing from DIC; EACA and not heparin is the antidote for PSC.

Renal failure in liver disease

“…Moreover, although PV shunts may improve and stabilize renal function in some patients [66,67], they have so far not been shown to prolong survival significantly in patients with combined kidney and liver failure. In cirrhotic ascites in general, operative mortality rates up to 25 % have been reported, largely due to hepatic decompensation, disseminated intravascular coagulation, or septicemia [68,69]. In view of these risks, the unproven benefit, and a high incidence of shunt occlusion [70], PV shunting cannot generally be recommended for treatment of renal failure.…”

Transjugular intrahepatic portal-systemic shunt in the treatment of refractory ascites: Effect on clinical, renal, humoral, and hemodynamic parameters

“…Several noncontrolled trials using TIPS in the management of variceal bleeding have been en~ouraging.~.~ However, there are few data concerning the usefulness of TIPS in the treatment of refractory as cite^.^ Apart from liver transplantation and obsolete procedures such as ascites ultrafiltration and reinfusion' and side-to-side portocaval shunt, the only available therapeutic approaches in this situation are large-volume paracentesis with albumin infusion and peritoneovenous These procedures are associated with significant complications or frequent hospital admissions and are unable to modify the poor prognosis of the patients. [8][9][10][11][12][13][14][15][16] A short-term study using TIPS in refractory ascites showed that the procedure allowed a better control of ascites and reversed renal sodium retention. 17 We report on the long-term clinical results of TIPS in patients with refractory ascites.…”

Phase I/II Study of Transjugular Transhepatic Peritoneovenous Venous Shunt, a New Procedure to Manage Refractory Ascites in Cancer Patients: Japan Interventional Radiology in Oncology Study Group 0201

“…In addition, patency of the vena cava, no history of cardiac pacemaker, no history of hepatic lobectomy, and no dilated intestine were included to secure a safe access route for transjugular transhepatic PVS. The exclusion criteria (i.e., cirrhosis and high risk for gastrointestinal bleeding) were added because of previous reports of severe adverse events resulting from PVS placement in cirrhotic patients [7,11,17,18]. Won and coworkers [7] reported that 63% of 55 patients with refractory ascites developed variceal bleeding after Denver shunt placement.…”