Original Article
Paracentesis with Intravenous Infusion of Albumin as Compared with Peritoneovenous Shunting in Cirrhosis with Refractory Ascites
N Engl J Med 1991; 325:829-835September 19, 1991
- Abstract
- Abstract
Background.
There is no satisfactory treatment for refractory ascites in patients with cirrhosis. Both peritoneovenous shunts and paracentesis have been used, but there is uncertainty about their relative merits.
Methods.
We studied 89 patients with cirrhosis and refractory ascites who were randomly assigned to receive either repeated large-volume paracentesis plus intravenous albumin or a LeVeen peritoneovenous shunt. Patients in the paracentesis group in whom recurrent tense ascites developed during follow-up were treated with paracentesis, and those in the peritoneovenous-shunt group with diuretic agents or by the insertion of a new shunt if there was shunt obstruction.
Results.
During the first hospitalization, ascites was removed in all 41 patients in the paracentesis group and in 44 of the 48 patients in the peritoneovenous-shunt group. The mean (±SD) duration of hospitalization in the two groups was 11±5 and 19±9 days, respectively (P<0.01 ). There were no significant differences in the number of patients who had complications or died. During follow-up, 37 patients in each group were hospitalized again. In the paracentesis group, the number of rehospitalizations for any reason (174 vs. 97 in the peritoneovenous-shunt group) or for ascites (125 vs. 38) was significantly higher, and the median time to a first readmission for any reason (1±1 vs. 2±2 months) or for ascites (2±2 vs. 8±17 months) was significantly shorter than in the peritoneovenous-shunt group. The total times in the hospital during follow-up, however, were similar in the two groups (48±49 and 44±39 days, respectively). Three patients had obstructions of their peritoneovenous shunts during their first hospitalizations, and 15 patients had a total of 20 obstructions during follow-up. Survival was similar in both groups.
Conclusions.
The LeVeen shunt and paracentesis are equally effective in relieving refractory ascites. The former may provide better long-term control of ascites, but shunt occlusion is common and survival is not improved. (N Engl J Med 1991; 325:829–35.)
Media in This Article
Figure 1
Probability of Readmission to the Hospital during Follow-up for Any Complication (Top) or Ascites (Bottom) in the Patients in the Two Study Groups.Figure 2
Probability of Renal Impairment after Entry into the Study in the Peritoneovenous-Shunt Group (Dashed Line) and the Paracentesis Group (Solid Line).Article Activity
- Article
REFRACTORY ascites is an infrequent but debilitating condition in patients with cirrhosis.1 , 2 Peritoneovenous shunting does not improve survival in these patients,3 , 4 has serious complications,3 , 5 6 7 8 and is associated with a high rate of obstruction of the shunt.3 , 9 Nevertheless, shunting is widely used to treat refractory ascites, since it usually decreases the ascites and increases the natriuretic response to diuretic therapy in these patients.10 , 11 Furthermore, until very recently no alternative treatment for patients with refractory ascites was available.
During the past few years several studies, including five controlled trials, have demonstrated that therapeutic paracentesis, in the form of either repeated large-volume paracentesis12 13 14 15 or total paracentesis16,17 associated with an intravenous infusion of albumin (6 to 8 g per liter of ascitic fluid removed), is a rapid, effective, and safe therapy for refractory ascites in patients with cirrhosis. Therefore, therapeutic paracentesis could be an alternative to peritoneovenous shunting in such patients. This report describes the results of a multicenter randomized trial comparing repeated large-volume paracentesis plus intravenous albumin with peritoneovenous shunting in patients with refractory ascites.
Methods
We studied 89 patients with cirrhosis at six hospitals who were admitted for tense ascites refractory to medical treatment. The diagnosis of cirrhosis was based on the results of liver biopsy in 71 patients and on the following clinical and laboratory findings in 18 patients: signs of chronic liver disease, prolonged prothrombin time, hypoalbuminemia, hypergammaglobulinemia, an abnormal radioisotope scan of the liver and spleen, and esophageal varices seen on endoscopy or collateral circulation seen on echography. The cause of the cirrhosis was alcoholic in 65 patients, cryptogenic in 19, and associated with hepatitis B surface antigen in 5. The number of patients studied at the various hospitals ranged from 23 (at the Hospital Clínic i Provincial, Barcelona) to 10 (at the Hospital Marqués de Valdecilla, Santander). A patient was considered to have refractory ascites whenever one of two criteria was present: (1) no response, defined as a loss of body weight less than 200 g per day, to a restriction of sodium intake (to 40 mmol per day) and to maximal doses of diuretic therapy for five days during a hospitalization in which the dosage of diuretic agents was increased stepwise every five days from 40 to 120 mg of furosemide per day and from 100 to 300 mg of spironolactone per day; or (2) three or more episodes of tense ascites requiring hospitalization during a nine-month period before the start of the study, despite adequate diuretic treatment and sodium restriction. Patients meeting the second criterion were entered in the trial without an assessment of their response to diuretic treatment in the hospital. We excluded patients with a serum bilirubin concentration above 171 μmol per liter, a prothrombin time below 40 percent, a platelet count below 40×109 per liter, a serum creatinine concentration above 265 μmol per liter, gastrointestinal hemorrhage due to variceal rupture within the preceding two months unless sclerotherapy was done, hepatocellular carcinoma, or respiratory or cardiac failure. Patients who were hospitalized with hepatic encephalopathy or bacterial infection were considered candidates for the trial after recovery from these complications. The study was approved by the investigation and ethics committee of each hospital in the trial, and all patients gave informed consent to participate.
The patients were studied after following a low-sodium diet (40 mmol per day) without any diuretic therapy, for five days. On the sixth day, urine was collected for 24 hours to measure electrolyte excretion. Blood samples were taken on the morning of the seventh day to determine liver and renal function. The patients at each hospital were then randomly assigned to two groups with use of a random-number table. One group consisted of 41 patients who were treated with repeated paracentesis, with the removal of 4 to 6 liters of fluid daily, until the ascites disappeared; intravenous albumin (200 ml of a 20 percent albumin solution, with a sodium concentration of 30 mmol per liter) was given at a rate of 2 ml per minute after each paracentesis. The mean (±SD) number of paracenteses performed during the first hospitalization in the whole group was 4±2 (range, 2 to 9). The second group consisted of 48 patients who were treated with LeVeen peritoneovenous shunting. Patients with and without renal impairment (defined as a serum creatinine concentration >133 μmol per liter) were randomized separately. In 12 patients from each group, the glomerular filtration rate (as determined by inulin clearance), free water clearance after a water load of 20 ml per kilogram of body weight, plasma renin activity, and plasma aldosterone concentrations were also measured before treatment.
Paracentesis was performed as described elsewhere.12 The peritoneovenous shunt was inserted by a standard surgical technique.9 Most of the ascitic fluid was removed during the operation, before the insertion of the shunt. Intraoperative roentgenography was performed to ensure correct positioning of the venous end of the shunt in the superior vena cava, immediately before the right atrium or within the right atrium itself. Cloxacillin (1 g every 6 hours) was given intravenously immediately before the operation and for 48 hours afterward.
The patients in the paracentesis group were discharged three days after the mobilization of ascites, and those in the peritoneovenous-shunt group five days after operation, unless a continued hospital stay was required for diagnostic or therapeutic purposes. Tests of liver and renal function were performed two to seven days after the end of treatment in all patients. The glomerular filtration rate, free water clearance, plasma renin activity, and plasma aldosterone concentrations were measured seven days after treatment in the 24 patients in whom they had been measured previously. The administration of diuretic agents was started immediately after treatment in both groups. The patients in the paracentesis group were given furosemide (80 mg per day) and spironolactone (200 mg per day), and those in the peritoneovenous-shunt group received furosemide (80 mg per day) intravenously for two days and furosemide (80 mg per day) and spironolactone (200 mg per day) orally thereafter. The dosage of these drugs was subsequently adjusted according to the individual responses.
The follow-up period started at the end of the first hospitalization. The patients were examined in the outpatient clinic weekly for one month, monthly for the next two months, and bimonthly thereafter. The same schedule was used after all readmissions to treat episodes of tense ascites. The patients in the paracentesis group in whom tense ascites developed during follow-up were treated with repeated large-volume paracentesis plus intravenous albumin, as described above. The patients in the peritoneovenous-shunt group in whom tense ascites developed during follow-up first had the patency of their shunts checked by Doppler ultrasonography18 or by scintigraphy after the intraperitoneal injection of technetium-99m sulfur colloid.19 When the shunt was obstructed, a contrast medium was injected into it to identify the site of obstruction.20 Venacavography was performed in patients with obstruction at the venous limb of the shunt to rule out thrombosis of the superior vena cava. Patients with no shunt obstruction were treated with diuretic agents, those with occlusion of the valve by replacement of the valve and the peritoneal tubing only, and those with occlusion of the venous segment of the shunt by replacement of the entire shunt. Whenever a patient in the peritoneovenous-shunt group required an invasive procedure, cloxacillin was administered prophylactically as described above.
Renal impairment during the first hospitalization or the follow-up period was defined as an increase in the serum creatinine concentration of more than 50 percent from the pretreatment value, to a level greater than 133 μmol per liter. Hyponatremia during the first hospitalization was defined as a decrease in the serum sodium concentration of more than 5 mmol per liter, to a level below 130 mmol per liter. To simplify the presentation of the results, patients with serum sodium concentrations below 130 mmol per liter before treatment who had decreases in these concentrations of more than 5 mmol per liter during hospitalization were also included among the patients in whom hyponatremia developed.
Readmissions to the hospital during follow-up were grouped according to five causes: ascites, hepatic encephalopathy, severe bacterial infection, gastrointestinal hemorrhage, and other complications. When two of these causes were present at the time of readmission, the following criteria were arbitrarily used to define the cause of readmission: (1) when tense ascites was associated with gastrointestinal hemorrhage, severe bacterial infection, grade II to IV (moderate to severe) hepatic encephalopathy, or some other complication requiring emergency treatment, the associated condition was considered to be the cause of readmission; (2) when tense ascites was associated with grade I (mild) hepatic encephalopathy or another condition not requiring emergency treatment, ascites was considered to be the cause; (3) when hepatic encephalopathy was associated with severe bacterial infection or gastrointestinal hemorrhage, it was considered to be secondary; and (4) when patients had gastrointestinal bleeding and bacterial infection, the hemorrhage was considered to be the cause of readmission, since bacterial infection frequently follows gastrointestinal bleeding in cirrhosis.21 These criteria were also used to define the cause of readmission in the very few patients who had three complications when they entered the hospital.
Methods of Measurement
Plasma renin activity was measured by radioimmunoassay (Clinical Assays, Baxter, Cambridge, Mass.) of angiotensin I generated after 20 minutes of incubation of the plasma sample at 37°C (pH 7.4) in the presence of an inhibitor of the conversion of angiotensin I to angiotensin II.22 Plasma aldosterone was measured by radioimmunoassay (Coat-a-Count Aldosterone, Diagnostic and Products Corporation, Los Angeles), norepinephrine by a radioenzymatic assay, and inulin by the method of Heyrovsky.23 Other measurements were made by standard laboratory techniques.
Statistical Analysis
Categorical data were evaluated by the chi-square test or by Fisher's exact test when the number in a cell was five or less. Confidence intervals for the relative risks were calculated with Miettinen's method.24 Continuous data were compared by paired and unpaired Student's t-tests and the Mann—Whitney nonparametric test. Probability curves were constructed by the Kaplan–Meier method and compared with the Mantel–Cox test with use of the BMDP statistical package.25 The results are presented as means ±SD. All reported P values are two-tailed, with values less than 0.05 considered to indicate statistical significance.
Results
Characteristics of the Patients
There were no significant initial differences between the paracentesis group and the peritoneovenous-shunt group with respect to clinical characteristics, liver and renal function, mean arterial pressure, Child-Pugh score,26 glomerular filtration rate, free water clearance, plasma renin activity, or plasma aldosterone concentration (Table 1Table 1
Clinical and Laboratory Data at Base Line in the Two Groups of Patients with Cirrhosis and Refractory Ascites.*). The groups were also similar with respect to the number of patients with previous episodes of ascites (38 and 47 patients, respectively), hepatic encephalopathy (15 and 20), and gastrointestinal hemorrhage (12 and 16), and the number who met the criteria for inclusion on the basis of their lack of response to sodium restriction and maximal diuretic therapy (26 patients in the paracentesis group and 28 in the peritoneovenous-shunt group).Results during the First Hospitalization
The two therapeutic procedures were equally effective in relieving ascites. Among the 41 patients treated with paracentesis, 38 were discharged from the hospital with minimal or no ascites. The remaining three patients, in whom paracentesis was also effective in eliminating the ascitic fluid, died in the hospital of liver failure (two patients) and bacteremia and liver failure (one). Among the 48 patients treated with peritoneovenous shunting, 42 were discharged from the hospital with minimal or no ascites. One of these 42 patients had to be operated on again during the first hospitalization because of a shunt obstruction. Among the remaining six patients, four had progressive liver failure and a reaccumulation of ascites, and they died in the immediate postoperative period; two of these patients had an obstruction of the shunt, and one had bacterial peritonitis. The remaining two patients died of bacterial peritonitis and gastrointestinal hemorrhage, respectively, without reaccumulation of ascitic fluid. The volume of ascitic fluid removed in the two groups was similar, as estimated from the weight loss during hospitalization in the patients surviving to discharge (13.1±3.7 kg in the paracentesis group and 13.5±4.5 kg in the peritoneovenous-shunt group). The mean duration of the first hospitalization was 11±5 days in the paracentesis group and 19±9 days in the peritoneovenous-shunt group (P<0.01).
Table 2Table 2
Tests of Liver and Renal Function, Mean Arterial Pressure, Plasma Renin Activity, and Plasma Aldosterone Concentration before and One Week after the End of Treatment in the Two Study Groups.* shows the results of tests of liver and renal function and other measurements before and after treatment in the two groups. The serum albumin concentration increased significantly in the patients treated with paracentesis. The patients treated with peritoneovenous shunting had a significant decrease in serum albumin, prothrombin time, plasma renin activity, and plasma aldosterone level and a significant increase in the serum sodium concentration.Nine of the 41 patients in the paracentesis group (22 percent) and 15 of the 48 patients in the peritoneovenous-shunt group (31 percent) had complications during the first hospitalization (relative risk, 0.7; 95 percent confidence interval, 0.3 to 1.4). Table 3Table 3
Complications during the First Hospital Stay in the Two Study Groups. shows the types of complications involved. Hyponatremia was slightly more frequent in the paracentesis group, but most other complications were more frequent in the peritoneovenous-shunt group. Among the patients with gastrointestinal bleeding, the source of bleeding was esophageal varices in three patients (two in the peritoneovenous-shunt group), erosive gastritis in two (one from each group), and esophagitis in one from the peritoneovenous-shunt group. Six patients in the peritoneovenous-shunt group had complications related to their shunts (symptomatic disseminated intravascular coagulation and severe abdominal pain in three patients in each group). As has been indicated, three patients in the paracentesis group and six in the peritoneovenous-shunt group died during the first hospitalization (relative risk, 0.6; 95 percent confidence interval, 0.2 to 2.2).Results during Follow-up
Of the 80 patients surviving to discharge, 3 (2 from the paracentesis group) were lost to follow-up after 1, 3, and 18 months. The mean follow-up period was 437±367 days (range, 3 to 1267) in the paracentesis group and 441±414 days (35 to 1490) in the peritoneovenous-shunt group. Of the 60 patients with alcoholic cirrhosis discharged from the hospital (29 in the paracentesis group and 31 in the peritoneovenous-shunt group), 19 (8 and 11 patients in the two groups) continued drinking alcohol during follow-up.
Thirty-seven patients in each group required one or more readmissions to the hospital during follow-up (relative risk, 1.1; 95 percent confidence interval, 1.0 to 1.2). Thirty of the 38 patients treated with paracentesis (79 percent) and 25 of the 42 patients treated with peritoneovenous shunting (59 percent) had to be readmitted for ascites at least once during follow-up (relative risk, 1.3; 95 percent confidence interval, 1.0 to 1.8). Other major reasons for readmission were encephalopathy, bacterial infection, and gastrointestinal bleeding, which were responsible for readmission in 37, 24, and 16 percent of the patients in the paracentesis group and 26, 36, and 9 percent of the patients in the peritoneovenous-shunt group, respectively. The relative risks for readmission for these conditions were similar in the two groups.
Table 4Table 4
Readmissions to the Hospital during Follow-up in the Two Study Groups. shows the number of readmissions to the hospital during follow-up, with their causes, in the patients in both groups. Overall, there were 174 readmissions for the patients treated with paracentesis and 97 for the patients treated with a peritoneovenous shunt (P<0.001). On 224 occasions (150 in the paracentesis group and 74 in the peritoneovenous-shunt group), the readmission was due to a single complication. The higher frequency of hospitalization during follow-up in the patients treated with paracentesis was due exclusively to a higher number of readmissions for ascites. Figure 1Figure 1Probability of Readmission to the Hospital during Follow-up for Any Complication (Top) or Ascites (Bottom) in the Patients in the Two Study Groups. shows that the time to a first readmission for ascites during follow-up was significantly shorter in the patients treated with paracentesis (median, 2±2 months) than in those treated with peritoneovenous shunting (median, 8±17 months). The differences were less pronounced when the time to a first readmission for any complication was considered (median, 1±1 vs. 2±2 months in the paracentesis and peritoneovenous-shunt groups, respectively) (Fig. 1). The mean need for diuretics during follow-up was significantly higher (P<0.01) in the paracentesis group (furosemide, 69±54 mg per day; spironolactone, 228±102 mg per day) than in the peritoneovenous-shunt group (33±41 and 134±96 mg per day, respectively). The probability that renal impairment would develop after a patient's inclusion in the study was almost identical in both groups (Fig. 2Figure 2Probability of Renal Impairment after Entry into the Study in the Peritoneovenous-Shunt Group (Dashed Line) and the Paracentesis Group (Solid Line).).The total time spent in the hospital during follow-up and the time spent on the treatment of ascites or other complications did not differ significantly between the two groups (Table 5Table 5
Mean (±SD) Time in the Hospital during Follow-up in the Two Study Groups.). Since the number of readmissions was higher among the patients treated with paracentesis, the mean duration of hospital stays during follow-up was significantly shorter in that group than in the peritoneovenous-shunt group, particularly when ascites was the cause of readmission (Table 5).The peritoneovenous shunt was obstructed in 20 readmissions for ascites among 15 patients. The site of obstruction was the valve in 12 readmissions, the venous tube in 4, and thrombosis of the superior vena cava in 4; a superior vena cava syndrome developed in two patients. The shunt was replaced on 11 occasions in eight patients, but in the remaining nine readmissions it was not replaced, because the patient was terminally ill (six patients), responded to diuretic therapy (two patients), or rejected the insertion of a new shunt (one patient). In the remaining 18 readmissions for ascites in this group, the shunt was patent and the cause of ascites was the abandonment of treatment (five patients), an impairment of renal function (five patients), the administration of a nonsteroidal anti-inflammatory drug (two patients), and unknown (six patients). In four other patients, the shunt was removed during follow-up because of spontaneous bacterial peritonitis. Three of these patients died as a consequence of the infection. The fourth patient declined to have a new shunt inserted. Figure 3Figure 3
Probability of a Peritoneovenous-Shunt Obstruction after Entry into the Study in Patients with Cirrhosis and Ascites. shows the probability of a peritoneovenous-shunt obstruction after entry into the trial. The probabilities of an obstruction after one and two years were 40 and 52 percent, respectively.Twenty-five patients in the paracentesis group (66 percent) and 28 in the peritoneovenous-shunt group (67 percent) died during follow-up (relative risk, 0.99; 95 percent confidence interval, 0.7 to 1.3). The cause of death was liver failure in 14 patients in each group; gastrointestinal hemorrhage in 6 patients in the paracentesis group and 4 in the peritoneovenous-shunt group; bacterial infection in 3 and 5 patients, respectively; and another cause in 2 and 5 patients, respectively. Figure 4Figure 4
Probability of Survival after Entry into the Study in the Two Study Groups. shows that the cumulative probability of survival after entry into the trial was similar in the two groups.Discussion
Three randomized controlled trials assessing the efficacy of peritoneovenous shunting in the treatment of patients with cirrhosis and ascites have been published. The first, by Wapnick et al.,27 compared peritoneovenous shunting with diuretic treatment in 34 patients with cirrhosis. Peritoneovenous shunting significantly shortened the first hospital stay and prolonged survival. The criterion used to define prolongation of survival in that study (survival for at least three more weeks in one member of a pair of study patients than in the other member) has been questioned, however.3 , 4 Bories et al.3 compared peritoneovenous shunting with a variety of medical treatments in 57 patients with alcoholic cirrhosis and refractory ascites. Although shunting was more effective for the initial control of ascites, complications were more frequent and mortality higher. Finally, Stanley et al.4 compared shunting with medical treatment in 299 patients with cirrhosis and massive ascites. The criteria for inclusion in this study were similar to those used in our study. Although early mortality and the probability of survival were similar in both groups, peritoneovenous shunting was more effective in the management of ascites than medical treatment, as indicated by a shorter first hospitalization, a longer time to the recurrence of ascites, and lower diuretic requirements during follow-up. These results are not surprising, however, since peritoneovenous shunting, a well-established, effective method of relieving ascites, was compared with a treatment known to be ineffective.
We compared peritoneovenous shunting with another effective treatment in patients with cirrhosis and refractory ascites and relatively well preserved renal and hepatic function. Peritoneovenous shunting and repeated large-volume paracentesis plus intravenous albumin infusion were equally effective in relieving the ascites and were associated with a similar incidence of complications and mortality during the first hospital stay. Peritoneovenous shunting was more effective than paracentesis in the long-term control of ascites, as indicated by the longer time to first readmission for ascites, lower number of readmissions for ascites, and lower requirements for diuresis. These results were not unexpected, since peritoneovenous shunting improves the renal response to diuretic therapy by suppressing the activity of endogenous systems of sodium and water retention, but paracentesis does not.10 , 11 , 13 This beneficial effect did not, however, result in substantial improvement in the quality of life. First, the total time spent in the hospital during follow-up was similar in both groups. Second, a large proportion of the patients treated with peritoneovenous shunting had to undergo reoperation because of shunt obstruction. As in most previous trials, peritoneovenous shunting did not result in an improved prognosis. The probability of survival and the causes of death were similar in the two groups.
Two aspects of the use of therapeutic paracentesis or peritoneovenous shunting to treat patients with cirrhosis who have refractory ascites merit discussion. First, the relatively low rate of complications in this study in the patients treated with paracentesis or peritoneovenous shunting cannot be extended to the entire population of patients with cirrhosis who have refractory ascites. By design, we studied patients who had only slight impairment of renal function and mild hyponatremia, and most were able to excrete dilute urine after a water load. The rate of complications could have been higher if patients with severe hepatic or renal insufficiency had been included. Second, although the insertion of a peritoneovenous shunt and paracentesis are simple procedures, they should be performed by experienced physicians. Paracentesis should be done under strict sterile conditions with specially designed needles to avoid local complications, and with concomitant plasma volume expansion.13
In conclusion, peritoneovenous shunting and therapeutic paracentesis were equally effective in relieving ascites in patients with cirrhosis, refractory ascites, and relatively well preserved hepatic and renal function. Shunting improved the long-term control of ascites, but it did not reduce the total time in the hospital during follow-up or prolong survival, and it required frequent reoperation because of shunt obstruction. Therapeutic paracentesis is, therefore, an alternative treatment to peritoneovenous shunting in patients with cirrhosis who have refractory ascites.
Supported by a grant (2018/84) from the Fondo de Investigaciones Sanitarias de la Seguridad Social and by the Fundació Catalana per a l'Estudi de les Malalties del Fetge.
We are indebted to Drs. J. Llach L. Titó, F. Pons, J. Berenguer, J. Gaya, A. Obrador, C. Dolz, F. Borda, F. Diaz, L. Rodrigo, D. Acero, W. Jiménez, J. Viver, and M.A. Gassull for their participation in the study.
Source Information
From the Liver Unit, Hospital Clínic i Provincial (P.G., V.A., A.R., J.M.S., A.G., J.R.), and the Liver Unit, Hospital de la Vall d'Hebró (V. V., L. V., R.E.), both in Barcelona; the Gastroenterology Unit, Hospital Germans Trias i Pujol, Badalona (R.P., R.M.); the Gastroenterology Unit, Hospital Marqués de Valdecilla, Santander (F.C.); the Gastroenterology Unit, Hospital Mutua, Terrassa (J.P.); and the Gastroenterology Unit, Hospital La Fe, Valencia (M.H.); all in Spain. Address reprint requests to Dr. Arroyo at the Liver Unit, Hospital Clínic i Provincial, Villarroel 170, 08036 Barcelona, Spain.
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Shunsuke Sugawara, Miyuki Sone, Yasuaki Arai, Noriaki Sakamoto, Takeshi Aramaki, Yozo Sato, Yoshitaka Inaba, Yoshito Takeuchi, Teruko Ueno, Kiyoshi Matsueda, Michihisa Moriguchi, Takahiro Tsushima. (2011) Radiological Insertion of Denver Peritoneovenous Shunts for Malignant Refractory Ascites: A Retrospective Multicenter Study (JIVROSG-0809). CardioVascular and Interventional Radiology 34:5, 980-988
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