A team comprising of an Interventional radiologist, nurse, and radiology technician performs the procedure. All the team members must have specialized and extensive training in the procedure.

Before the procedure, the laboratory values obtained are as follows: complete blood count, coagulation profile, blood urea nitrogen(BUN), creatinine, serum albumin, and liver function tests(LFTs). The ascitic fluid is obtained by paracentesis and examined for total polymorph count, protein, and albumin and culture. The serum-ascitic fluid albumin gradient (SAAG) is calculated to establish the cause of ascites. SAAG >1.1g/dl excludes cancer as the cause of ascites. Broad-spectrum prophylactic antibiotics are administered to the patient intravenously before the procedure and for a week after the procedure to prevent the risk of infection. The patient requires moderate sedation for the procedure, mostly in an outpatient setting.

The most commonly used PVS is the Denver shunt, which a modified version of the original design.[8] After the patient is prepped and draped, an all-purpose drainage (APD) catheter is inserted at the upper abdominal region to drain the ascitic fluid. It is then replaced with the peritoneal end of the shunt after priming it with warmed saline. It is inserted between the right hepatic lobe and the ribs. The second incision is made on the lower rib cage for the placement of the compressible pump. It must be placed against a firm, stable rib for effective compression. The third incision is made at the venous access site. Using a long metallic tunneler, the shunt is traversed towards the neck, ideally subcutaneously; however, it can also be placed percutaneously.[3] 

The venous end of the shunt is inserted into the superior vena cava via the internal jugular veins or the subclavian veins under fluoroscopic guidance until the catheter tip ends in the proximal right atrium. A one-way pressure-sensitive valve is attached to prevent the backflow of blood from the venous end of the shunt.

Complications from PVS are common and include peritoneal infection, variceal bleeding, superior vena cava thrombosis, pulmonary edema, disseminated intravascular coagulation (DIC), scar tissue formation, shunt fracture, occlusion, displacement or leakage, pneumothorax, and pneumoperitoneum. The most common complication of PVS is shunt occlusion, with only 18.6% of shunts remaining patent at two years, according to a study.[3] 

About 9% of the patients report with disseminated intravascular coagulation (DIC) after shunt insertion.[9] This condition may be due to the presence of activating factors like tissue factor (TF) that initiate thrombogenesis.[10] Thrombosis of the shunt is a rare occurrence and mainly involves the tip of the venous end of the shunt.[11] Staphylococcal and gram-negative organisms can result in perioperative infections, which may progress to bacterial peritonitis or sepsis.

Regardless of the complications, PVS insertion successfully treats refractory ascites in most patients with chronic liver disease, leading to a significant improvement in the quality of life.[12] PVS is a simple procedure as the placement of the entire shunt is subcutaneous, which allows the patient to be able to perform activities that require submersion in water like swimming and bathing, unlike indwelling tunneled drainage catheters.[13] As the fluid returns from the peritoneal cavity into the circulation, there is no loss of nutrients which benefits by reducing the risk of malnutrition in chronically ill patients.

The most common complication of PVS is shunt blockage. All patients should be instructed to pump the compressible pump of the PVS several times a day in the supine position for maximal drainage. The interventional radiologist should counsel the patient and/or the caregiver regarding clear instructions on how and when to compress the shunt pump before discharging the patient.

Abstinence from alcohol consumption can lead to shunt blockage due to a reduced flow rate, and these patients require careful monitoring. Less common complications, notably coagulopathy and edema, can be prevented by complete drainage of ascitic fluid before shunt placement. Broad-spectrum prophylactic antibiotics help to prevent peri- or post-operative infections; however, complicated infections require shunt removal. Percutaneous PVS has several advantages over subcutaneous PVS as the former is minimally invasive, faster, less painful, cheaper, and doesn’t require sedation.[14] 

The interventional radiologist, hepatologist, and liver transplant surgeon should work closely to explore the best treatment plan for each patient.