State of the ArtPediatric Interventional

Radiology

Brent Cully, MD• Doug Rivard, DO Brenton

Reading MD

CMH Interventional Radiology

• 3 Physicians• 2 Nurse

Practitioners• 3 Technologists• 2 IR Rooms • 1 CT Fluoro• Dedicated Ultrasound

CMH Interventional Radiology

• Full sedation team under supervision of Dept of Anesthesiology

Sedation• 8 Work Up /

Recovery rooms

• Most patients get sedation

• Must be npo 6 hours– 2 hrs clears

CMH Interventional Radiology

• Services Provided– Vascular Access– Angiography / Angioplasty– GI Access– Lumbar Puncture– Image-Guided Biopsy / Drainage– Ablation / Embolization – Catheter Stripping– Intravascular Foreign Body Retrieval

CMH Interventional Radiology

• Services Provided

– Vascular Anomalies Clinic• In Conjunction with Dermatology and Plastic Surgery• Contact Dermatology Clinic

– Direct Interventional Consults• Imaging Guided Biopsies, Drainages, Vascular Access• Contact CMH Radiology

Vascular Access

109 Port-A-Caths in 2010

• Placed 368 PICCs in 2010• In addition to dedicated Vascular

Access Team of 8 nurses• As small as 2.6 Fr DL

Newborn PICC Placed in NICU

• 23 year old w/ cystic fibrosis

CT Port

Angiography / Angioplasty

• 15 year old with recurrent dialysis graft issues

Balloon Angioplasty

Post Angioplasty

• 4 yo playing with Mom’s BP cuff

• 190 /110 mmHg

• 6 year old girl s/p liver transplant, now with elevated LFTs and splenomegaly

• CT angio shows stenosis at the portal vein anastomosis

• Post-stenotic dilation of the intrahepatic portal vein

• Dilated intrahepatic bile ducts

• Ultrasound-Guided Percutaneous Transhepatic Cholangiogram

• Internal / External Biliary Drain

• Post Angioplasty

GI Access - Cecostomy

• Provide easy colon access for patients needing daily enema therapy

Constipation

GI Access – Perc GT and GJ

• Initial placement of percutaneous GT tubes

• Ultrasound liver margin, contrast enema to outline colon, inflate stomach thru NG

New All-In-1

GT Tube

Jejunal Port

Gastric Port

Percutaneous Drainage

• Percutaneously drained approx 50 periappendiceal abscesses last year

• Currently in study of tPA infusion into abscesses to ? decrease hospital stay

• Can utilize US or CT-Fluoro guidance

Abscess Drainage

• 17 yo female treated with 1 month of steroid therapy for inflammatory bowel disease

• Developed chest pain and right shoulder pain, fever

Pneumonia

• CT chest shows a large liver abscess with diaphragm perforation

• Placed percutaneous drain with US guidance• Cultures grew Streptococcus anginosus

• Percutaneous Drainage

• 15 year old who developed fever and cough after visiting her father in Michigan

• Positive Histoplasma titers

Mediastinal Abscess

• Primary care team requested IR drainage

• Primary care team requested IR drainage

• Primary care team requested IR drainage

Percutaneous Biopsies

Pulmonary Hamartoma

Sclerotherapy

• Imaging – guided injection of lymphatic and venolymphatic malformations for nonsurgical treatment, or size reduction prior to surgery

• Irritation of internal lining of the fluid cavity• Resultant scarring, limited re-expansion• Doxycycline, Sotradecol (detergent)

• 2 year old girl who developed left neck and axilla swelling following URI

• Findings consistent with infected or reactive lymphatic malformation

• Access obtained with Ultrasound• Contrast injected to assess communication between cavities and

ensure no systemic venous runoff • Sclerosant injected, +/- small drain for next few days

Sclerotherapy

• Does not completely resolve lesion

• Goal is cosmetic improvement, functionality

• Will require multiple treatments

Laser Ablation• 2 year old girl with large venous malformation of

right leg

• Laser catheter introduced into vein lumen• Saline injected around vein to act as heat sink• Laser “fired” and slowly withdrawn

Laser Ablation

Pre Operative Embolization

• 18 year old male with lifelong flank mass, biopsy proven AVM

• Requesting excision, surgeon concerned about bleeding

Pre Operative Embolization

• Feeding arteries occluded by nBCA glue injected thru microcatheter

• Blood loss at surgery = 100 mL

Pre Operative Embolization

BEFORE AFTER

Radiofrequency Ablation of Osteoid

Osteoma

• Thermal ablation of osteoid osteoma nidus• If successful, can avoid more invasive excision

Radiofrequency Ablation of Osteoid

Osteoma

Pediatric Interventional Radiology - Summary

• Most Procedures are Less Invasive than Surgery

• Low Radiation Doses, or No Radiation w/ US

• Often Performed with Sedation Rather than General Anesthesia

• Happier, Healthier Patients and Families