Lower Extremity Vascular Access in Neonates and Infants: A Single Institutional Experience.

PURPOSE: To demonstrate feasibility and evaluate outcomes of direct-stick saphenous and single-incision tunneled femoral noncuffed central venous catheters (CVCs) placed in a large series of neonates and infants at a single institution. MATERIALS AND METHODS: A retrospective review was performed for all neonates and infants receiving a lower extremity CVC by interventional radiology between 2007 and 2012. Technical success, mechanical and infectious complications, and catheter outcomes were recorded. RESULTS: There were 271 primary insertions performed in 243 children by interventional radiologists in the interventional radiology suite or at the bedside. CVCs were placed via the femoral vein with single-incision technique (84.9%) or the saphenous vein via a direct-stick technique (15.1%), with a technical success rate of 100%. The total number of catheter-days was 7,917 days (median, 19 d; range, 0-220 d). The number of primary catheter-days was 5,333 days (median, 15 d; range, 0-123.0 d), and salvage procedures prolonged catheter life by 2,584 days (median, 15 d; range, 1.0-101.0 d). The mechanical and adjusted infectious complication rates were 1.67 and 0.44 per 100 catheter-days. CONCLUSIONS: Image-guided placement of saphenous or tunneled femoral catheters using a single incision is a safe and feasible method for vascular access in neonates and infants.

Combined use of Solitaire FR and Penumbra devices for endovascular treatment of cerebral venous sinus thrombosis in a child.

A pre-teenager with newly diagnosed ulcerative colitis presented to an emergency department with acute headache, altered mental status and bilateral lower extremity weakness. Head CT demonstrated acute thrombus in the vein of Galen and straight sinus, and the patient was started on a heparin infusion. The patient clinically deteriorated and became unresponsive. In view of the rapid deterioration despite anticoagulation therapy, the patient was taken for endovascular treatment. A novel endovascular approach was performed with combined use of Solitaire FR and Penumbra devices to enhance access to the straight sinus and to limit intraprocedural blood loss. The post-treatment head CT demonstrated a decrease in hyperattenuation within the vein of Galen and straight sinus. The neurologic status improved within 24 h. The patient was discharged home with a normal neurologic examination.

Transiliopsoas approach: an alternative route to drain pelvic abscesses in children.

OBJECTIVE: To evaluate an alternative route of pelvic abscess drainage in children via a transiliopsoas approach. BACKGROUND: Appendiceal perforations complicated by inflammatory masses, such as abscesses or phlegmon, are a common indication for abdominal drainage in pediatric interventional radiology. Certain locations of collections may present particular challenges for the operator, owing to numerous surrounding structures, including bowel and other pelvic anatomy. This series describes an alternative route for drainage, which involves traversing the iliopsoas muscle under US guidance to drain a deep pelvic abscess. MATERIALS AND METHODS: Retrospective chart review was performed of the transiliopsoas approach for abscess drainage during a 5-year period. The technique, pre- and post-drainage imaging, aspiration/drain output, duration of catheter dwell, procedure-related complications and abscess recurrence were reviewed. RESULTS: Transiliopsoas needle placement was successful in 14 of 14 patients (100%). Catheter placement was successful in 13 patients. Abscess wall rupture precluded catheter placement in one patient. Mean catheter duration was 4.9 days, with a range of 2 to 9 days. Clinical improvement was achieved in all 14 patients (100%). There were no major complications. Post-procedure pain with ambulation was reported in 3 of 14 patients (21.4%), which was successfully controlled in each case with medication, and resolved after 2 days. CONCLUSION: The transiliopsoas route is a safe and effective route for US-guided abscess drainage and catheter placement in children with deep pelvic collections. In selected cases, this approach provides a more easily accessible and safer route than more traditional interventional approaches.

Single-incision technique for placement of tunneled internal jugular vein vascular access in children.

BACKGROUND: Central venous access is indispensable in caring for children with infections, malignancies and chronic illnesses, and image-guided placement of central venous access devices (CVAD) is increasingly used. A single-incision technique for placement of tunneled central venous access devices at the internal jugular vein has been described; however the technique has not been described exclusively in children. OBJECTIVE: To describe our initial experience using the single-incision technique for tunneled central venous access at the internal jugular vein in children. MATERIALS AND METHODS: We conducted a retrospective review of the interventional radiology database and electronic medical records of 15 children who received a tunneled central venous access device (CVAD) using a single incision between 2010 and 2012. Patients included eight boys and seven girls with an average age of 11 years (median 13.3 years, range 1-18.7 years) and average weight of 44.2 kg (median 38.3 kg, range 9.6-99.0 kg). RESULTS: A total of 17 primary insertions were performed. Technical success was 100%. Total catheter life consisted of 1,416 catheter-days (mean 83.3 days, range 8-502 days). There were no procedure-related or early complications. Seven late complications requiring intervention occurred in three catheters. Total mechanical and infectious complications occurred at rates of 0.28 and 0.21 per 100 catheter-days, respectively. The adjusted rate for infectious complications was 0.14 per 100 catheter-days. Medical salvage procedures (83%) and interventional radiology salvage procedures (17%) prolonged catheter life by an average of 94.5 days (range 10-329 days). CONCLUSION: This study demonstrates safe use and technical feasibility of the image-guided single-incision technique for central venous access in children, particularly in children in whom the conventional technique is less desirable.

US-guided placement and tip position confirmation for lower-extremity central venous access in neonates and infants with comparison versus conventional insertion.

PURPOSE: To describe experience with the use of ultrasound (US)-guided placement and tip position confirmation for direct saphenous and single-incision tunneled femoral noncuffed central venous catheters (CVCs) placed in neonates and infants at the bedside. MATERIALS AND METHODS: A retrospective review of the interventional radiology (IR) database and electronic medical records was performed for 68 neonates and infants who received a CVC at the bedside and for 70 age- and weight-matched patients with CVCs placed in the IR suite between 2007 and 2012. Technical success, complications, and outcomes of CVCs placed at the bedside were compared with those in an age- and weight-matched sample of children with CVCs placed in the IR suite. RESULTS: A total of 150 primary insertions were performed, with a technical success rate of 100%. Total catheter lives for CVCs placed at the bedside and in the IR suite were 2,030 catheter-days (mean, 27.1 d) and 2,043 catheter-days (mean, 27.2 d), respectively. No significant difference was appreciated between intraprocedural complications, mechanical complications (bedside, 1.53 per 100 catheter-days; IR, 1.76 per 100 catheter-days), or infectious complications (bedside, 0.39 per 100 catheter-days; IR, 0.34 per 100 catheter-days) between groups. CONCLUSIONS: US-guided placement and tip position confirmation of lower-extremity CVCs at bedside for critically ill neonates and infants is a safe and feasible method for central venous access, with similar complications and catheter outcomes in comparison with CVCs placed by using fluoroscopic guidance in the IR suite.

Combined use of Solitaire FR and Penumbra devices for endovascular treatment of cerebral venous sinus thrombosis in a child.

A pre-teenager with newly diagnosed ulcerative colitis presented to an emergency department with acute headache, altered mental status and bilateral lower extremity weakness. Head CT demonstrated acute thrombus in the vein of Galen and straight sinus, and the patient was started on a heparin infusion. The patient clinically deteriorated and became unresponsive. In view of the rapid deterioration despite anticoagulation therapy, the patient was taken for endovascular treatment. A novel endovascular approach was performed with combined use of Solitaire FR and Penumbra devices to enhance access to the straight sinus and to limit intraprocedural blood loss. The post-treatment head CT demonstrated a decrease in hyperattenuation within the vein of Galen and straight sinus. The neurologic status improved within 24 h. The patient was discharged home with a normal neurologic examination.

Intraoperative cerebral angiography in arteriovenous malformation resection in children: a single institutional experience.

OBJECT: The use of cerebral intraoperative angiography has been described in resection of arteriovenous malformations (AVMs) in adults. More recently, studies have described experiences with intraoperative angiography in a small number of children. However, data on the safety and clinical utility of intraoperative angiography in the pediatric population remains limited in comparison with available data in adults. The aim of the study was to evaluate the use of cerebral intraoperative angiography in children undergoing AVM resection. The clinical utility of intraoperative angiography and procedure-related complications were evaluated. METHODS: A retrospective review was performed for all patients undergoing cerebral AVM resection with intraoperative angiography at The Children's Hospital of Philadelphia between 2008 and 2012. Patient imaging and operative and medical notes were reviewed to evaluate for end points of the study. A total of 17 patients (8 males, 9 females) were identified, with a median age of 12.1 years (range 1.2-17.9 years) and median weight of 45.5 kg (range 12.1-78.9 kg). RESULTS: A total of 21 intraoperative angiography procedures were performed for 18 AVM resections in 17 patients. The technical success rate was 94%. In 2 cases (11%), intraoperative angiography demonstrated a residual AVM, and repeat resections were performed. In both cases, no recurrent disease was noted on postoperative follow-up. One procedure-related complication (4.8%) occurred in 1 patient who was positioned prone. Recurrence to date was noted in 2 (14%) of the 14 cases with available postoperative follow-up at 3.5 and 4.7 months following resection with intraoperative angiography. The median follow-up time from intraoperative angiography to the most recent postoperative angiography was 1.1 years (range 4.3 months to 3.8 years). CONCLUSIONS: Intraoperative angiography is an effective and safe adjunct for surgical management of cerebral AVMs in the pediatric population.

Metabolite quantification and high-field MRS in breast cancer.

In vivo 1H MRS is rapidly developing as a clinical tool for diagnosing and characterizing breast cancers. Many in vivo and in vitro experiments have demonstrated that alterations in concentrations of choline-containing metabolites are associated with malignant transformation. In recent years, considerable efforts have been made to evaluate the role of 1H MRS measurements of total choline-containing compounds in the management of patients with breast cancer. Current technological developments, including the use of high-field MR scanners and quantitative spectroscopic analysis methods, promise to increase the sensitivity and accuracy of breast MRS. This article reviews the literature describing in vivo MRS in breast cancer, with an emphasis on the development of high-field MR scanning and quantitative methods. Potential applications of these technologies for diagnosing suspicious lesions and monitoring response to chemotherapy are discussed.

A role for myotonic dystrophy protein kinase in synaptic plasticity.

Myotonic dystrophy (DM) is associated with an expanded triplet repeat in the 3'-untranslated region of the gene for myotonic dystrophy protein kinase (DMPK), which may reduce DMPK expression. It is unclear how reduced DMPK expression might contribute to the symptoms of DM because the normal function of DMPK is not yet understood. Thus we investigated the function of DMPK to gain insight into how reduced DMPK expression might lead to cognitive dysfunction in DM. We recently demonstrated a role for DMPK in modifying the cytoskeleton, and remodeling of the cytoskeleton is thought to be important for cognitive function. Therefore we hypothesized that DMPK might normally contribute to synaptic plasticity and cognitive function via an effect on actin cytoskeletal rearrangements. To test for involvement of DMPK in synaptic plasticity, we utilized the DMPK null mouse. This mouse showed no changes in baseline synaptic transmission in hippocampal area CA1, nor any changes in long-term synaptic potentiation (LTP) measured 3 h after induction. There was a significant decrease, however, in the decremental potentiation with a duration of 30-180 min that accompanies LTP. These results suggest a role for DMPK in synaptic plasticity that could be relevant to the cognitive dysfunction associated with DM.