In interventional radiology, what does LVP (large‑volume paracentesis) refer to and how is the procedure performed?

LVP in Interventional Radiology: Large-Volume Paracentesis

LVP stands for large-volume paracentesis, defined as the removal of more than 4–5 liters of ascitic fluid in a single session, and represents the first-line treatment for patients with grade 3 (tense) ascites due to cirrhosis. 1

Procedure Definition and Indications

• Large-volume paracentesis removes >4–5 L of ascitic fluid and is the treatment of choice for massive or refractory ascites in cirrhotic patients. 1
• Complete drainage to dryness in a single session (1–4 hours) is recommended rather than serial smaller procedures, as this approach is faster, more effective, and minimizes repeated needle insertions. 1, 2, 3
• LVP is indicated when diuretics fail to control ascites or when patients develop diuretic-related complications (renal impairment, severe hyponatremia, hepatic encephalopathy). 1

Pre-Procedure Requirements

Patient Consent and Risk Assessment

• Obtain informed consent before every therapeutic or diagnostic paracentesis. 1, 3
• Routine correction of coagulopathy is NOT recommended, even with INR up to 8.7 or platelets as low as 19×10³/μL, because hemorrhagic complications are rare and show no correlation with coagulation parameters. 1, 3
• The only absolute contraindication is disseminated intravascular coagulation; loculated ascites is a relative contraindication. 1, 3

Ultrasound Guidance

• Ultrasound guidance should be used when available because it reduces bleeding complications by 68% and lowers overall adverse event rates. 1, 3
• The left lower quadrant is the preferred site, as ultrasound studies demonstrate thinner abdominal wall and greater ascites depth at this location. 1, 3

Procedural Technique

Needle Placement

• Insert the needle at least 8 cm from the midline and 5 cm above the symphysis pubis to avoid the inferior epigastric artery and minimize risk of liver or spleen injury. 1, 2
• Use the "Z-track" technique: perpendicular skin entry with oblique subcutaneous advancement. 2
• A cannula with multiple side perforations prevents blockage by bowel wall. 2

Drainage Protocol

• Remove all ascitic fluid to dryness over 1–4 hours at a rate of approximately 2–9 liters per hour. 1, 2
• Assist drainage by gentle mobilization of the cannula or turning the patient onto their side if flow slows. 1, 2
• Do NOT leave the drainage catheter in place overnight. 2, 3

Albumin Replacement: Critical Component

Mandatory Dosing for >5 L

• For paracentesis removing >5 L, administer 8 g of albumin per liter of ascites removed (e.g., 40 g for 5 L, 80 g for 10 L). 1, 2
• Use 20% or 25% hyperoncotic albumin solutions; 5% albumin is inadequate and adds excessive sodium load. 2, 4
• Infuse albumin AFTER the paracentesis is completed, not during the procedure, slowly over 1–2 hours to avoid cardiac overload in patients with cirrhotic cardiomyopathy. 1, 2, 4

Evidence Supporting Albumin

• Post-paracentesis circulatory dysfunction (PICD) occurs in 70–80% of patients without albumin versus ≈18% with proper replacement. 2, 4
• Renal impairment develops in ≈21% without albumin versus 0% with albumin. 2, 4
• Hyponatremia occurs in ≈17% without albumin versus ≈8% with albumin. 2, 4

Optional Albumin for <5 L

• For volumes <5 L, albumin at 8 g/L is optional but should be considered in patients with acute-on-chronic liver failure or high risk of post-paracentesis acute kidney injury. 1, 2
• Synthetic plasma expanders (dextran-70, polygeline) may be used for <5 L in uncomplicated cases, but albumin remains superior. 1, 2

Post-Procedure Management

Immediate Care

• Have the patient lie on the opposite side for 2 hours if there is ascitic fluid leakage, and consider a purse-string suture around the drainage site for persistent leakage. 1, 2, 3

Diuretic Resumption

• Re-start diuretics within 1–2 days after paracentesis to prevent rapid re-accumulation of ascites (93% recurrence without diuretics versus 18% with spironolactone). 2, 4
• Recommended regimen: spironolactone 100 mg daily (titrated to 400 mg) plus furosemide 40 mg daily (titrated to 160 mg), maintaining a 100:40 mg ratio. 1, 2

Monitoring for Complications

• Monitor for bleeding, ascitic fluid leak, perforation, and infection at the puncture site. 3
• Daily serum sodium and creatinine checks for 6 days to detect hyponatremia and acute kidney injury. 2, 4
• A decline in mean arterial pressure >8 mmHg may indicate advancing circulatory failure. 2, 4

Common Pitfalls to Avoid

• Do NOT artificially slow the drainage rate out of concern for hemodynamic instability—this outdated practice is not supported by evidence and delays symptom relief. 2
• Do NOT use synthetic colloids (hydroxyethyl starch, dextran, polygeline) for >5 L paracentesis; they are inferior to albumin and increase renal risk. 1, 2
• Do NOT underdose albumin (e.g., 4 g/L instead of 8 g/L); this markedly increases PICD incidence and renal complications. 2, 4
• Do NOT withhold paracentesis due to coagulopathy or thrombocytopenia—routine correction of INR or platelet count is not recommended. 1, 3

Special Considerations

LVP in Spontaneous Bacterial Peritonitis (SBP)

• LVP is NOT recommended in critically ill ACLF patients with SBP because it may worsen circulatory dysfunction in the setting of septic shock. 1
• If SBP develops after paracentesis, use a different albumin regimen: 1.5 g/kg within 6 hours of diagnosis, followed by 1.0 g/kg on day 3. 1, 2

Long-Term Management

• Patients requiring repeated LVP every 2–3 weeks should be evaluated for transjugular intrahepatic portosystemic shunt (TIPSS) or liver transplantation. 1, 2
• Development of ascites signals poor prognosis (≈50% two-year survival); assess transplant eligibility promptly. 2