Introduction to interventional oncology: A COG Diagnostic Imaging Committee/SPR Oncology Committee White Paper.

Interventional radiology (IR) is a valuable resource when caring for pediatric solid tumor patients. As minimally invasive, image-guided procedures become more relied upon to answer challenging diagnostic questions and provide alternative therapeutic options, IR is poised to become a contributing member of the multidisciplinary oncology team. Improved imaging techniques allow for better visualization during biopsy procedures, transarterial locoregional treatments have the potential to deliver targeted cytotoxic therapy while limiting systemic side effects, and percutaneous thermal ablation can be used to treat chemo-resistant tumors of various solid organs. Additionally, interventional radiologists are able to perform routine, supportive procedures for oncology patients that include central venous access placement, lumbar punctures, and enteric feeding tube placements with high levels of technical success and excellent safety profiles.

Introduction to interventional radiology's role in palliative care for children with cancer: A COG Diagnostic Imaging Committee/SPR Oncology Committee White Paper.

As palliative care continues to be an area of increasing emphasis in pediatric oncology programs, it is important to raise awareness about minimally invasive, image-guided procedures that can supplement more conventional palliative interventions, such as systemic analgesics, external beam radiation, and locoregional anesthesia. These procedures, when performed for appropriately selected patients, can often facilitate discharge from an inpatient facility, and help patients meet their end-of-life goals. This article specifically discusses three palliative procedures performed by interventional radiologists that can assist pediatric palliative care teams in: (a) percutaneous thermal ablation of painful bone metastases, (b) cryoneurolysis, and (c) tunneled drainage catheter placement for malignant pleural effusions and ascites.

Baseline Quality of Life in Pediatric Patients With Low-flow Vascular Malformations.

OBJECTIVE: The aim of this study was to quantify and describe baseline patient and parent-proxy health-related quality of life scores in patients with low-flow vascular malformations at a single, tertiary-care vascular anomalies clinic. STUDY DESIGN: This is a retrospective study of data collected on patients with low-flow vascular malformations between the ages of 2 to 25 who were seen at a single, tertiary-care center vascular anomalies clinic. A total of 266 patients are included in this study. RESULTS: Patients with lymphatic malformations report decreased quality of life scores as compared with venous malformations in the emotional, psychological, school, and social domains. Patients with lower extremity malformation report decreased quality of life scores as compared with head/neck, trunk, upper extremity, and multifocal malformations; most notably in the physical domain. CONCLUSIONS: Treatment of low-flow vascular malformations should aim to improve patient quality of life. The use of standardized health-related quality of life measures in this study quantifies baseline quality of life scores among patients with low-flow vascular malformations.

Coagulopathy and related complications following sclerotherapy of congenital venous malformations.

BACKGROUND: Congenital venous malformations (VMs) are low-flow vascular anomalies that can cause coagulation abnormalities. This phenomenon, referred to as localized intravascular coagulopathy (LIC), is characterized by elevated D-dimer, hypofibrinogenemia, and/or thrombocytopenia. Increased risk for LIC includes patients with an extensive VM, multifocal VM, and Klippel-Trenaunay and CLOVES syndromes. Peri-procedural anticoagulation has been given to prevent complications from LIC in patients undergoing surgical/interventional procedures; however, the rate of clinically relevant complications from sclerotherapy is largely unknown. The purpose of this study is to describe a single-institution's incidence of LIC in patients with VMs and coagulopathy-related complications following sclerotherapy. DESIGN/METHODS: Retrospective chart review of patients, 0-21 years of age, with VM who underwent sclerotherapy without peri-procedural anticoagulation and had coagulation profiles evaluated within 1 month prior to sclerotherapy. DATA COLLECTED: diagnosis type (high vs. low risk for LIC), coagulation profile (including PT/PTT, D-dimer, fibrinogen, and platelet count), sclerosant used, and post-procedure outcomes. Coagulopathy-related complications included clinically relevant bleeding, deep vein thrombosis (DVT), and pulmonary embolism (PE). RESULTS: N = 138 patients; 59.4% were female. The most common location of VM was the lower extremity (47.8%; 66/138). Of patients with high-risk VMs (29/138 [21%]), 11/29 (37.9%) had laboratory values consistent with LIC, whereas 5% (5/109) of low-risk VMs had LIC. In sum, 492 sclerotherapy procedures were performed with no complications of bleeding, DVT, or PE. CONCLUSION: Patients undergoing sclerotherapy for VM with abnormal coagulation profiles may not require peri-procedural low molecular weight heparin (LMWH). Further studies are needed to precisely define which patients would benefit from anticoagulation.

Percutaneous image-guided treatment of aneurysmal bone cysts: is there a superior treatment option?

BACKGROUND: Aneurysmal bone cysts (ABCs) are often treated with intralesional surgery (curettage) with or without adjuvant treatments. Side effects and conflicting results regarding recurrence rates do not suggest one clearly superior therapy. Percutaneous therapeutic options including sclerotherapy and thermal ablation have gained popularity as potential alternatives. OBJECTIVE: The purpose of this retrospective review is to report this institution's experience and results of various image-guided minimally invasive treatments in a single institution series of cases referred to interventional radiology by orthopedic surgery after surgical failure or in patients with anatomically challenging ABCs. MATERIALS AND METHODS: This study identified all patients ≤18 years old who received percutaneous therapy for an ABC, including cryoablation, doxycycline sclerotherapy, microwave ablation or a combination of these modalities. Procedural details, complications, imaging follow-up and clinical follow-up were analyzed. RESULTS: A total of 21 patients received 41 procedures, with major complications seen in 7.7% (3/39) of procedures involving cryoablation or doxycycline sclerotherapy. Patients receiving cryoablation required an average of 1.7 procedures (median: 1 procedure, range: 1-4 procedures) while patients receiving doxycycline sclerotherapy required an average of 3 procedures (median: 2 procedures, range: 1-6 procedures). Patients were followed clinically and with computed tomography or magnetic resonance imaging (average: 23.9 months, range: 3.9-68.3 months). Follow-up imaging demonstrated improvement in 17 (85%) patients. Clinically, 93.8% (15/16) of patients who presented with fracture or pain had markedly reduced or absent pain as well as no fractures. CONCLUSION: Percutaneous image-guided treatment of ABCs demonstrates a favorable efficacy and safety profile. Adding cryoablation may lead to fewer total procedures than using doxycycline sclerotherapy alone.

Endovascular management of nutcracker syndrome in an adolescent patient population.

BACKGROUND: Nutcracker syndrome is defined as left renal vein compression with concomitant clinical symptoms that include flank pain and hematuria. Historically, pediatric and adolescent patients with mild symptoms of nutcracker syndrome were simply observed while those with more severe symptoms underwent left renal vein transposition. Endovascular stenting of the left renal vein is a potentially efficacious and less invasive alternative for managing nutcracker syndrome in adolescents. OBJECTIVE: The purpose of this study was to investigate the technical feasibility, efficacy and safety of left renal vein stenting in adolescents with nutcracker syndrome. MATERIALS AND METHODS: We conducted a retrospective review of electronic medical records and imaging archives to identify adolescents undergoing endovascular stenting for nutcracker syndrome. We reviewed patient demographics including age, gender, presenting symptoms and diagnostic imaging findings. We compared pre- and post-stent deployment intravascular ultrasound (IVUS) and venography and evaluated patient symptoms in clinic up to 6 months following stent placement. RESULTS: Ten patients (average age 16 years, range 12-20 years) underwent 13 procedures. Initial symptoms included pain (n=10) and gross hematuria (n=5). Diagnostic imaging studies included CT abdomen pelvis (n=8), retroperitoneal US (n=6), MRI abdomen/pelvis (n=4), scrotal US (n=2), pelvic US (n=1) and renal Doppler US (n=2). Venography and IVUS demonstrated venous collaterals, proximal blanching at the left-renal-vein-IVC junction, pre-stenotic dilation and intraluminal compression. Most patients (n=9) experienced symptomatic resolution; however, three patients required reintervention to achieve asymptomatic status. No periprocedural complications occurred. CONCLUSION: In this carefully selected adolescent cohort, left renal vein stenting for nutcracker syndrome was often technically feasible, safe and effective in symptom management.

Catheter-Directed Pharmacologic Thrombolysis for Acute Submassive and Massive Pulmonary Emboli in Children and Adolescents-An Exploratory Report.

OBJECTIVES: The objective of this study is to report a single-center experience of the safety and efficacy of pulmonary artery catheter-directed thrombolysis for both massive and submassive pulmonary emboli in the pediatric and adolescent population. DESIGN: A 22-month retrospective review of the electronic medical record and picture archiving and communication system was performed of patients less than 21 years old, presenting with massive or submassive pulmonary emboli treated with pulmonary artery catheter-directed thrombolysis at a single, tertiary care pediatric hospital. Multiple variables were analyzed including indications, technical success, clinical efficacy, and complications. SETTING: A single, tertiary care pediatric hospital. PATIENTS: Nine patients (mean 13.9 yr; range 6-19 yr) with massive and/or submassive pulmonary emboli who underwent pulmonary artery catheter-directed thrombolysis met inclusion criteria. INTERVENTIONS: Catheter-directed thrombolysis. MEASUREMENTS AND MAIN RESULTS: Pulmonary emboli was diagnosed by CT angiography in all cases. Catheter-directed thrombolysis alone was clinically successful (defined as improved cardiopulmonary function following catheter-directed thrombolysis) in seven patients (78%) with two patients not improving following catheter-directed thrombolysis. There were no immediate bleeding complications from catheter-directed thrombolysis therapy. All patients were maintained on anticoagulation treatment following catheter-directed thrombolysis. Catheter-directed thrombolysis was technically successful (defined as successful placement of pulmonary artery infusion catheters with full or partial resolution of thrombus) in all cases. Follow-up pulmonary angiography at the cessation of catheter-directed thrombolysis revealed complete thrombus resolution in four patients (44%) and partial resolution in five patients (55%). Mean pulmonary artery pressures decreased in all patients (mean precatheter-directed thrombolysis pulmonary artery pressure = 37 ± 11 mm Hg; mean postcatheter-directed thrombolysis pulmonary artery pressure = 28 ± 10 mm Hg; p = 0.0164). CONCLUSIONS: Pulmonary artery catheter-directed thrombolysis is a technically feasible therapeutic option for children and adolescents with submassive and massive pulmonary emboli.

Technical Feasibility and Clinical Effectiveness of Transjugular Intrahepatic Portosystemic Shunt Creation in Pediatric and Adolescent Patients.

PURPOSE: To examine the technical feasibility and clinical efficacy of transjugular intrahepatic portosystemic shunt (TIPS) creation in children and adolescents. MATERIALS AND METHODS: Retrospective review was performed of 59 patients (mean age 12.6 y [range, 1.5-20 y], mean weight 47.5 kg [range, 11.4-112.2 kg], mean Model for End-stage Liver Disease/Pediatric End-stage Liver Disease score 12.5 [range, 6-33]) who underwent 61 TIPS attempts at 3 tertiary children's hospitals from 2001 to 2017 for acute esophageal or gastroesophageal variceal bleeding, primary and secondary prevention of variceal bleeding, and refractory ascites. Pediatric liver disease etiologies included biliary atresia, cystic fibrosis, and ductal plate anomalies. Technical, hemodynamic, and clinical success and patency rates were reported at 1, 6, 12, and 24 months. Statistical analysis evaluated reasons for clinical failure. Kaplan-Meier analysis measured clinical success, patency, and transplant-free survival. RESULTS: Technical success was 93.4% (57/61) in 59 consecutive patients. Most common TIPS indications were treating and preventing esophageal and gastroesophageal variceal bleeding (57/59; 96.6%). Hemodynamic success was 94% (47/50). Clinical success was 80.7% (45/56). Two-year clinical success for acute variceal bleeding and ascites was 94.1% and 100%, respectively. Overall patency at 1, 6, 12, and 24 months was 98.0%, 97.8%, 94.3%, and 91.3%. Two-year transplant-free survival was 88.8%. Overall and major complication rates were 21.2% (13/61) and 8.2% (5/61), with 3 mortalities. Gradient reduction < 12 mm Hg correlated with clinical success (P < .01). CONCLUSIONS: TIPS creation in pediatric patients is technically feasible and clinically efficacious for treatment and prevention of esophageal and gastroesophageal variceal hemorrhage. High 2-year clinical success, patency, and survival rates should encourage providers to consider portosystemic shunts as a bridge to liver transplantation.

Congenital Limb Overgrowth Syndromes Associated with Vascular Anomalies.

Congenital limb length discrepancy disorders are frequently associated with a variety of vascular anomalies and have unique genetic and phenotypic features. Many of these syndromes have been linked to sporadic somatic mosaicism involving mutations of the phosphoinositide 3-kinase (PI3K)/protein kinase B (AKT)/mammalian target of rapamycin (mTOR) pathway, which has an important role in tissue growth and angiogenesis. Radiologists who are aware of congenital limb length discrepancies can make specific diagnoses based on imaging findings. Although genetic confirmation is necessary for a definitive diagnosis, the radiologist serves as a central figure in the identification and treatment of these disorders. The clinical presentations, diagnostic and imaging workups, and treatment options available for patients with Klippel-Trenaunay syndrome, CLOVES (congenital lipomatous overgrowth, vascular anomalies, epidermal nevi, and scoliosis/spinal deformities) syndrome, fibroadipose vascular anomaly, phosphatase and tensin homolog mutation spectrum, Parkes-Weber syndrome, and Proteus syndrome are reviewed. ©RSNA, 2019.

Image-guided placement of percutaneous de novo low-profile gastrojejunostomy tubes in the pediatric population: a study of feasibility and efficacy.

BACKGROUND: De novo low-profile gastrojejunostomy tubes in pediatric patients offer less external catheter bulk and decreased propensity for dislodgement as children become more mobile. While small cohort studies have evaluated de novo placement of coaxial, adjustable-length, percutaneous gastrojejunostomy (GJ) tubes in children, placement of de novo low-profile GJ tubes in pediatric patients has not been analyzed. OBJECTIVE: This study evaluates technical feasibility, safety and clinical efficacy of percutaneous, retrograde placement of de novo low-profile GJ tubes in infants and children. MATERIALS AND METHODS: Following institutional review board approval, all de novo low-profile GJ tube placements in patients were retrospectively reviewed between May 2014 and May 2017. Technical parameters of fluoroscopy time, tube size, T-fasteners and complications were recorded. Clinical data, including age, indication, weight gain and complications, were analyzed. RESULTS: Thirty-four de novo low-profile GJ tubes were placed in 34 patients (median age: 9.4 months, range: 2 months-11.8 years; median pre-procedural weight: 7.5 kg, range: 2.9-31.6 kg). Twenty-one 14-Fr and 13 16-Fr GJ tubes were placed with technical success rate of 100%. Average weight gain 3 months' post procedure was 1.1 kg (range: 0.3-4.8 kg) and average weight percentile for age increase was 9.6% (range: -48.9% to 53.5%). One major complication occurred following balloon inflation within the tract causing pain requiring urgent replacement of the GJ tube. Minor complications occurred in 11 patients (32%): accidental dislodgement (n=9), skin irritation (n=4), tube dysfunction (n=2), leakage (n=2) and tube migration into the esophagus (n=1). CONCLUSION: Percutaneous, antegrade, image-guided placement of de novo low-profile GJ tubes is technically feasible, safe and clinically efficacious in appropriately selected pediatric patients.

Transsplenic splenoportography and portal venous interventions in pediatric patients.

BACKGROUND: Data regarding transsplenic portal venous access for diagnostic imaging and endovascular intervention in children are limited, possibly due to concerns regarding high bleeding risks and resultant underutilization. OBJECTIVE: To investigate the safety and utility of transsplenic splenoportography and portal venous interventions in children. MATERIALS AND METHODS: A retrospective review was performed of all pediatric patients undergoing percutaneous transsplenic portal venous access and intervention at two large tertiary pediatric institutions between January 2012 and April 2017 was performed. Parameters assessed included procedural indications, procedural and relevant prior imaging, technical details of the procedures, laboratory values and clinical follow-up. RESULTS: Transsplenic portal venous access was achieved in all patients. Diagnostic transsplenic splenoportography was performed in 22 patients and was 100% successful at providing the desired anatomical and functional information. Four transsplenic portal venous interventions were performed with 100% success: meso-Rex shunt angioplasty, snare targeted transjugular intrahepatic portosystemic shunt (TIPS) creation through cavernous transformation, pharmacomechanical thrombectomy for acute thrombosis, and transplant portal vein angioplasty. Intraperitoneal bleeding occurred in 2/26 (7.7%) and one case required transfusion (3.8%). No cases of hemorrhage were observed when transsplenic access size was 4 Fr or smaller. CONCLUSION: Transsplenic splenoportography in children is safe and effective when noninvasive imaging methods have yielded incomplete information. Additionally, a transsplenic approach has advantages for complex portal interventions. Bleeding risks are proportional to tract access size and may be mitigated by tract embolization.

Role of interventional radiology in managing pediatric liver tumors : Part 2: percutaneous interventions.

Hepatoblastoma and hepatocellular carcinoma (HCC) are the most common pediatric liver malignancies, with hepatoblastoma occurring more commonly in younger children and HCC occurring more commonly in older children and adolescents. Although surgical resection (including transplant when necessary) and systemic chemotherapy have improved overall survival rate for hepatoblastoma to approximately 80% from 30%, a number of children with this tumor type are not eligible for operative treatment. In contradistinction, pediatric HCC continues to carry a dismal prognosis with an overall 5-year survival rate of 30%. The Paediatric Hepatic International Tumour Trial (PHITT) is an international trial aimed at evaluating both existing and emerging oncologic therapies for primary pediatric liver tumors. Interventional radiology offers a number of minimally invasive procedures that aid in diagnosis and therapy of pediatric liver tumors. For diagnosis, the PHITT biopsy guidelines emphasize and recommend percutaneous image-guided tumor biopsy. Additionally, both percutaneous and endovascular procedures provide therapeutic alternatives that have been, to this point, only minimally utilized in the pediatric population. Specifically, percutaneous ablation offers a number of cytotoxic technologies that can potentially eradicate disease or downstage children with unresectable disease. Percutaneous portal vein embolization is an additional minimally invasive procedure that might be useful to induce remnant liver hypertrophy prior to extended liver resection in the setting of a primary liver tumor. PHITT offers an opportunity to collect data from children treated with these emerging therapeutic options across the world. The purpose of this manuscript is to describe the potential role of minimally invasive percutaneous transhepatic procedures, as well as review the existing data largely stemming from the adult HCC experience.

Role of interventional radiology in managing pediatric liver tumors : Part 1: Endovascular interventions.

Primary liver malignancies are rare in children. Hepatoblastoma and hepatocellular carcinoma (HCC) together represent the overwhelming majority of cases. Overall survival of hepatoblastoma approaches 80% with multimodal treatment approaches that include chemotherapy, surgery and transplantation. However, there remains a subset of children with hepatoblastoma in whom resection or transplantation is not possible. The 5-year survival for children diagnosed with HCC is less than 30% and remains a significant therapeutic challenge. The poor outcomes for children with primary liver tumors motivate investigation of new therapeutic alternatives. Interventional oncology offers a broad scope of percutaneous and transcatheter endovascular cancer therapies that might provide clinical benefits. Minimally invasive approaches are distinct from medical, surgical and radiation oncologic treatments, and in adults these approaches have been established as the fourth pillar of cancer care. Transarterial chemoembolization is a minimally invasive locoregional treatment option performed by interventional radiologists with level-I evidence as standard of care in adults with advanced liver malignancy; transarterial chemoembolization in adults has served to prolong disease-free progression, downstage and bridge patients for surgical and transplant interventions, and improve overall survival. However, while several groups have reported that transarterial chemoembolization is feasible in children, the published experience is limited primarily to small retrospective case series. The lack of prospective trial evidence has in part limited the utilization of transarterial chemoembolization in the pediatric patient population. The purpose of this article is to provide an overview of the role of interventional radiology in the diagnosis and endovascular management of hepatic malignancies in children.

Intravascular ultrasound versus digital subtraction angiography: direct comparison of intraluminal diameter measurements in pediatric and adolescent imaging.

BACKGROUND: Intravascular ultrasound (IVUS) allows intraluminal imaging of blood vessels rather than the one-dimensional luminal outline depicted by digital subtraction angiography (DSA). Despite extensive literature in multiple adult vascular diseases, IVUS has not been directly compared to DSA in pediatric and adolescent vascular pathologies. OBJECTIVE: The purpose of this manuscript is to compare absolute luminal diameter measurements obtained via IVUS and DSA during a variety of pediatric endovascular procedures. MATERIALS AND METHODS: We conducted a retrospective review of all pediatric and adolescent endovascular procedures from October 2014 to March 2016 in which IVUS and DSA were used. We compared the vessel diameter measurements and analyzed them using SAS software with a paired t-test. RESULTS: There were 102 total measurements (DSA = 56; IVUS = 56; 22 procedures; 20 patients). On average, IVUS measured 0.6 ± 2.1 mm larger than DSA (95% confidence interval [CI] -0.01 to 1.12; P = 0.06; r = 0.90). When venous compression syndrome (May-Thurner, Nutcracker, superior vena cava syndrome) measurements were excluded, IVUS measured 0.7 ± 1.6 mm larger than DSA (95% CI 0.14 to 1.18; P = 0.01; r = 0.93). When venous compression syndrome measurements were evaluated separately, IVUS measured 0.3 ± 3.0 mm larger than DSA (95% CI -1.16 to 1.82; P = 0.65; r = 0.45). CONCLUSION: Overall, IVUS measurements were slightly larger than DSA measurements in all data subsets. Absolute vessel diameter measurements obtained with IVUS in the pediatric and adolescent population are statistically significantly larger than those obtained using DSA when excluding venous compression syndromes. In venous compression syndromes, IVUS might provide a more accurate representation of vessel compression and diameter than DSA.

The effects of expanding outpatient and inpatient evaluation and management services in a pediatric interventional radiology practice.

BACKGROUND: Despite a continuing emphasis on evaluation and management clinical services in adult interventional radiology (IR) practice, the peer-reviewed literature addressing these services - and their potential economic benefits - is lacking in pediatric IR practice. OBJECTIVE: To measure the effects of expanding evaluation and management (E&M) services through the establishment of a dedicated pediatric interventional radiology outpatient clinic and inpatient E&M reporting system. MATERIALS AND METHODS: We collected and analyzed E&M current procedural terminology (CPT) codes from all patients seen in a pediatric interventional radiology outpatient clinic between November 2014 and August 2015. We also calculated the number of new patients seen in the clinic who had a subsequent procedure (procedural conversion rate). For comparison, we used historical data comprising pediatric patients seen in a general interventional radiology (IR) clinic for the 2 years immediately prior. An inpatient E&M reporting system was implemented and all inpatient E&M (and subsequent procedural) services between July 2015 and September 2015 were collected and analyzed. We estimated revenue for both outpatient and inpatient services using the Medicare Physician Fee Schedule global non-facility price as a surrogate. RESULTS: Following inception of a pediatric IR clinic, the number of new outpatients (5.5/month; +112%), procedural conversion rate (74.5%; +19%), estimated E&M revenue (+158%), and estimated procedural revenue from new outpatients (+228%) all increased. Following implementation of an inpatient clinic reporting system, there were 8.3 consults and 7.3 subsequent hospital encounters per month, with a procedural conversion rate of 88%. CONCLUSION: Growth was observed in all meaningful metrics following expansion of outpatient and inpatient pediatric IR E&M services.

Single-stick tunneled central venous access using the jugular veins in infants weighing less than 5 kg.

BACKGROUND: Despite the demonstrated feasibility of the single-stick technique in the femoral vein, its use in neonates and infants for placing central lines in internal and external jugular veins has not been reported. OBJECTIVE: Describe and assess the safety and efficacy of tunneled jugular central venous catheter placement performed under ultrasound (US) and fluoroscopic guidance in neonates and infants weighing <5 kg using the single-stick technique at three tertiary pediatric hospitals. MATERIALS AND METHODS: Thirty-three children weighing less than 5 kg received tunneled central venous access in either internal or external jugular veins using the single-stick technique. Patient history, procedural records and clinical follow-up documents were retrospectively reviewed. Complication rates were compared to those of 41 patients receiving single-stick femoral central lines. RESULTS: Technical complications occurred during one (3.0%) jugular placement with the patient having a failed right-side attempt with subsequent successful left-side placement. The catheters did not last the entire course of treatment in three (9.1%) patients with jugular lines. One patient had the catheter removed due to concern for infection, one catheter was accidentally removed during dressing changes, and one catheter was displaced and subsequently exchanged. Of patients receiving femoral central lines, 1 (2.4%) had a technical complication and 5 catheters (12.2%) did not last the entire course of treatment. CONCLUSION: The placement of tunneled central venous catheters in neonates/infants <5 kg is safe and technically feasible using the internal/external jugular vein via the single-stick technique. By theoretically reducing the risks of catheter infection by avoiding the diaper area and thrombosis by using larger veins, it may be preferable in certain patient populations.

Ultrasound-Guided Liver Biopsy With Gelatin Sponge Pledget Tract Embolization in Infants Weighing Less Than 10 kg.

OBJECTIVES: The aim of the study was to describe and assess the technical success and safety of ultrasound-guided liver biopsy with gelatin sponge pledget tract embolization technique in infants <10 kg across 3 tertiary pediatric hospitals. MATERIALS AND METHODS: There were 67 pediatric patients weighing <10 kg (36 boys; 31 girls; average age 202 days; average weight 6 kg, range 1.5-9.9 kg) referred for liver biopsy performed with ultrasound guidance and gelatin sponge pledget tract embolization during a 2-year period. Patient history, procedural records, and clinical follow-up documents were retrospectively reviewed. RESULTS: A total of 67 procedures were included. There was 100% technical success rate and all samples obtained provided adequate tissue for histological assessment. Average number of 18 G biopsy passes was 3 (range 1-6). There were no procedure-related deaths. There was 1 complication (1%) in a 5-kg infant who was readmitted 36 hours after biopsy with a fever and fully recovered after antibiotics were administered. Biliary atresia was the most common underlying diagnosis (20%), whereas others included acute rejection (16%) and biliary obstruction (7%). CONCLUSIONS: Ultrasound-guided percutaneous liver biopsy with gelatin sponge pledget tract embolization technique in children weighing <10 kg is safe, effective, and use of this technique may lead to a reduction in rates of adverse events reported in other pediatric series.

Congenital Cyst of the Pancreas: A Case Report and Review of Literature.

This is a case of a newborn female with congenital pancreatic cysts discovered incidentally. The 5-week-old infant had multiple abdominal cysts originating from the pancreas. When the radiologist catheter placement failed to alleviate the symptoms, the infant underwent laparoscopic excision. The lesion, however, recurred 11 months after the first excision, leading to a second surgical procedure including excision and marsupialization. A review of the literature revealed that this is a rare condition. Herein, we discuss the characteristics of the case, including medical imaging, drainage catheter placement, surgical treatment, pathological findings, and follow-up. Differential diagnoses, clinical presentations, treatment options, and patient outcomes are also discussed. Although rare, congenital pancreatic cyst should be considered in the differential diagnosis of an infant with cystic lesion of the pancreas.