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OBJECTIVES:
Nonmalignant chylous ascites refractory to medical therapy can be effectively treated with peritoneo-venous Denver-shunt (CareFusion Corp, San Diego, CA), placed into the superior vena cava via the internal jugular vein. We present a case where shunt placement through an alternate access via the femoral vein was successfully utilized.
METHODS:
A 63 year old male with yellow nail syndrome had medically refractory chylous ascites. He had a thrombosed superior vena cava (SVC) due to multiple previous Denver shunts. The inferior vena cava (IVC) via the right great saphenous and femoral veins was used to provide an alternate channel for drainage of his chylous ascites.
RESULTS:
Under general anesthesia a small right groin crease cutdown was performed to expose the sapheno-femoral junction. The previously placed thrombosed Denver shunt was removed through a small incision at the neck and paracentesis of 4.6 liters of chylous ascites was then performed. A new 11.5Fr double valve Denver shunt was prepared and the peritoneal component inserted using the prior tract. Subsequently, the venous component of the shunt was tunneled subcutaneously, anterior to the anterior superior iliac spine, and brought into the right groin wound. The venous component was inserted into the common femoral vein via the saphenous vein and then advanced into the IVC. Location was confirmed using fluoroscopy. Anticoagulation was restarted in the postoperative period with Eliquist (Bristol-Myers Squibb Company, NYC, New York) and he was discharged on postoperative day one. On follow-up he was symptomatically better with a well functioning shunt.
CONCLUSIONS:
Use of IVC via the saphenofemoral access for drainage of ascites is a safe and feasible option in patients undergoing Denver shunt placement with obstructive pathology of the SVC. Further follow up is necessary to confirm long term outcomes and assess the risk of IVC and shunt thrombosis.