Embolization for pediatric trauma.

BACKGROUND: The management of pediatric trauma with trans-arterial embolization is uncommon, even in level 1 trauma centers; hence, there is a dearth of literature on this subject compared to the adult experience. OBJECTIVE: To describe a single-center, level 1 trauma center experience with arterial embolization for pediatric trauma. MATERIALS AND METHODS: A retrospective review was performed to identify demographics, transfusion requirements, pre-procedure imaging, procedural details, adverse events, and arterial embolization outcomes over a 19-year period. Twenty children (age 4.5 months to 17 years, median 13.5 years; weight 3.6 to 108 kg, median 53 kg) were included. Technical success was defined as angiographic resolution of the bleeding-related abnormality on post-embolization angiography or successful empiric embolization in the absence of an angiographic finding. Clinical success was defined as not requiring additional intervention after embolization. RESULTS: Seventy-five percent (n=15/20) of patients required red blood cell transfusions prior to embolization with a mean volume replacement 64 ml/kg (range 12-166 ml/kg) and the median time from injury to intervention was 3 days (range 0-16 days). Technical success was achieved in 100% (20/20) of children while clinical success was achieved in 80% (n=16/20). For the 4 children (20%) with continued bleeding following initial embolization, 2 underwent repeat embolization, 1 underwent surgery, and 1 underwent repeat embolization and surgery. Mortality prior to discharge was 15% (n=3). A post-embolization mild adverse event included one groin hematoma, while a severe adverse event included one common iliac artery pseudoaneurysm requiring open surgical ligation. CONCLUSIONS: In this single-center experience, arterial embolization for hemorrhage control in children after trauma is feasible but can be challenging and the clinical failure rate of 20% in this series reflects this complexity. Standardization of pre-embolization trauma assessment parameters and embolic techniques may improve outcomes.

Endovascular closure of a congenital extrahepatic portosystemic shunt for the treatment of hepatopulmonary syndrome in an infant.

Congenital portosystemic shunts may result in the development of hepatopulmonary syndrome, typically presenting with progressive hypoxemia in later childhood. We describe a case of a 5-month-old male with heterotaxy with polysplenia presenting with new onset hypoxemia. Subsequent evaluation identified an extrahepatic portosystemic shunt arising from the confluence of the main portal and superior mesenteric veins draining into the left renal vein. To treat his hypoxemia and prevent future complications of shunting, the patient underwent a successful single-stage endovascular closure.

Prevalence, management and efficacy of treatment in portal vein obstruction after paediatric liver transplantation: protocol of the retrospective international multicentre PORTAL registry.

INTRODUCTION: Portal vein obstruction (PVO) consists of anastomotic stenosis and thrombosis, which occurs due to a progression of the former. The aim of this large-scale international study is to assess the prevalence, current management practices and efficacy of treatment in patients with PVO. METHODS AND ANALYSIS: The Portal vein Obstruction Revascularisation Therapy After Liver transplantation registry will facilitate an international, retrospective, multicentre, observational study, with 25 centres around the world already actively involved. Paediatric patients (aged <18 years) with a diagnosed PVO between 1 January 2001 and 1 January 2021 after liver transplantation will be eligible for inclusion. The primary endpoints are the prevalence of PVO, primary and secondary patency after PVO intervention and current management practices. Secondary endpoints are patient and graft survival, severe complications of PVO and technical success of revascularisation techniques. ETHICS AND DISSEMINATION: Medical Ethics Review Board of the University Medical Center Groningen has approved the study (METc 2021/072). The results of this study will be disseminated via peer-reviewed publications and scientific presentations at national and international conferences. TRIAL REGISTRATION NUMBER: Netherlands Trial Register (NL9261).

Novel method to biopsy aneurysmal bone cysts in children.

PURPOSE: The thin and friable septations composing aneurysmal bone cysts (ABC) may be challenging to target for percutaneous biopsy. The purpose of this study was to describe and evaluate a novel method of ABC biopsy using endomyocardial biopsy forceps as an attempt to capture larger fragments of tissue for diagnosis. METHODS AND MATERIALS: This was a retrospective study performed over a 17-year period. Patients <18 years old who underwent percutaneous biopsy for a presumed ABC, based on pre-procedure imaging, were included. Medical records were reviewed to identify age, sex, lesion location, biopsy procedure details, complications, and pathology results. A diagnostic biopsy was defined as conclusive histologic confirmation. Inconclusive findings or findings suggestive of but not diagnostic of an ABC were treated as non-diagnostic, even if imaging and clinical findings were characteristic. Biopsy device selection and quantity of tissue obtained was at the discretion of the pediatric interventional radiologist. Fisher's exact test was used to compare the diagnostic yield of standard biopsies to those employing biopsy forceps. RESULTS: Twenty-three biopsies were performed in 18 patients (11 female) with a median age of 14.7 years (IQR 10.6-15.6). Lesions were located in the extremities (7, 30.4%), chest (6, 26.1%), pelvis (5, 21.7%), spine (4, 17.4%), and mandible (1, 4.3%). Specimens were obtained using a 13- or 15-gauge bone coring needle (11, 47.8%); 14-, 16-, or 18-gauge soft tissue needle (6, 26.1%); or a combination of bone and soft tissue (4, 17.4%) needles. Endomyocardial biopsy forceps were utilized in 7 cases (30.4%), 2 in which it was the only device used. Overall, a conclusive pathologic diagnosis was made in 13/23 (56.5%) biopsies. Of the diagnostic biopsies, 1 was a unicameral bone cyst and all others were ABCs. No malignancy was identified. Compared to the standard approach, the use of forceps was more likely to result in a diagnostic biopsy (40.0% vs 100.0%, p = 0.008). There were no complications. CONCLUSIONS: Endomyocardial biopsy forceps offer an additional, novel technique to biopsy presumed ABCs and may improve diagnostic yield.

In utero torsion of an accessory hepatic lobe mimicking a congenital tumor.

Accessory hepatic lobes are rare anatomic variants connected to the liver by a fibrous stalk or parenchymal attachments. They are usually detected incidentally, but torsion is a rare complication. Here, we report torsion of an accessory hepatic lobe occurring in utero with a focus on the MRI findings. The lesion mimicked a congenital tumor, and we provide potential clues that may have narrowed the differential diagnosis prior to surgical exploration.

Length of Bowel Rest Does Not Predict Gastrojejunostomy Tube-Associated Intussusception Recurrence.

OBJECTIVES: One potential treatment for gastrojejunostomy (GJ) tube-related intussusception is bowel rest, whereby the GJ tube is replaced with a gastrostomy tube. The aim of this study was to determine whether bowel rest length was associated with decreased risk of re-intussusception. METHODS: Pediatric patients with GJ tube-related intussusceptions were identified during the study period of January 1, 2010 and August 1, 2021. Records were reviewed for demographics, symptoms, need for central access to initiate parenteral nutrition, and length of stay. Comparison was made between patients with intussusception recurrence within 30 days and those without. Those undergoing earlier replacement, defined as the first quartile of rest time, or 72 hours, were then compared to longer periods of bowel rest. RESULTS: Forty-six intussusceptions were included, with a median age of 2.8 years (interquartile range, IQR: 1.4-4.1) and weight of 12 kg (IQR: 8.9-15.4). All patients diagnosed as outpatient (54.3%) required hospital admission and 9 of 46 (19.6%) required central access. There were 7 recurrences (15.2%). There was no difference in recurrence based on time of bowel rest (5 days in those without vs 6 days in those with, P = 0.30) nor a difference in recurrence with <72 hours of bowel rest compared to >72 hours (1/15, 6.7% vs 6/31, 19.3%). Patients undergoing earlier exchange had a shorter median length of hospital stay (3 vs 8.5 days, P = 0.003). CONCLUSION: Length of bowel rest was not associated with recurrent GJ tube-related intussusceptions. If bowel rest is utilized, <72 hours may be sufficient to decrease length of hospital stay.

Imaging of pediatric pancreas tumors: A COG Diagnostic Imaging Committee/SPR Oncology Committee White Paper.

Primary pancreatic tumors in children are rare with an overall age-adjusted incidence of 0.018 new cases per 100,000 pediatric patients. The most prevalent histologic type is the solid pseudopapillary neoplasm, followed by pancreatoblastoma. This paper describes relevant imaging modalities and presents consensus-based recommendations for imaging at diagnosis and follow-up.

Adjunctive techniques for percutaneous enteral access in children: a pictorial review.

Primary percutaneous gastrostomy and gastrojejunostomy tube placements are fundamental procedures performed in pediatric interventional radiology, with both antegrade and retrograde techniques described. In pediatric patients, however, challenges may arise due to smaller patient size and anatomical variations. Several adjunctive techniques may facilitate safe percutaneous access in the setting of a limited percutaneous gastric access window. These include the intra-procedural use of cone beam computed tomography (CT), percutaneous needle decompression in the setting of distended air-filled bowel interposed between the stomach and abdominal wall, post-pyloric balloon occlusion to facilitate gastric distension, ultrasound-guided gastric puncture, and intra-gastric contrast-enhanced ultrasound (ceUS) to define the relationship of the gastric wall and the anterior abdominal wall. Adjunctive techniques may increase successful primary percutaneous gastroenteric tube placement and may improve operator confidence in safe placement.

Multifocal Kaposiform Hemangioendothelioma in a Newborn With Confirmatory Histopathology.

Kaposiform hemangioendothelioma is classified as a locally aggressive vascular tumor of childhood resulting from abnormal angiogenesis and lymphangiogenesis. Most commonly, KHE presents as a single tissue mass, ranging from an erythematous papule to a violaceous indurated tumor. Definitive diagnosis requires tissue sampling with the demonstration of ill-defined nodules and fascicles of spindle-shaped D2-40 positive endothelial cells, forming slit-like vascular channels. This newborn presented with multifocal cutaneous Kaposiform hemangioendothelioma associated with Kasabach-Merritt phenomenon confirmed on histopathology with immunostaining.

Guideline for Children With Cancer Receiving General Anesthesia for Procedures and Imaging.

Children with cancer and those undergoing hematopoietic stem cell transplantation frequently require anesthesia for imaging as well as diagnostic and therapeutic procedures from diagnosis through follow-up. Due to their underlying disease and side effects of chemotherapy and radiation, they are at risk for complications during this time, yet no published guideline exists for preanesthesia preparation. A comprehensive literature review served as the basis for discussions among our multidisciplinary panel of oncologists, anesthesiologists, nurse practitioners, clinical pharmacists, pediatric psychologists, surgeons and child life specialists at the Children's Hospital of Philadelphia. Due to limited literature available, this panel created an expert consensus guideline addressing anesthesia preparation for this population.

Impact of routine chest radiographs after removal of pigtail chest tubes placed by pediatric interventional radiology.

BACKGROUND: Chest radiographs are commonly obtained after chest tube removal to assess for complications. The benefit of this practice in children is uncertain. OBJECTIVE: To determine the clinical impact of a routine chest radiograph following removal of chest tubes placed by pediatric interventional radiology. MATERIALS AND METHODS: This single-center retrospective study evaluated 200 chest tube removals in 176 patients (median age: 4 years, interquartile range [IQR]: 1.2-12; median weight: 17.2 kg, IQR: 10.67-37.6), who had a chest tube placed and removed by pediatric interventional radiology over a 16-year period. A chest radiograph obtained on the day of removal was compared to the preceding study. For patients with imaging changes, medical records were reviewed to determine whether clinical actions occurred as a result. All records were reviewed for 7 days after tube removal or hospital discharge, whichever occurred first. RESULTS: The most common indication for chest tube insertion was simple effusion (53%, 106/200) and the most common tube size was 10.2 French (38.7%, 81/209). The median tube dwell time was 8 days (IQR: 5-17). There was a median of 14 h (IQR: 7-33.5) between imaging before and after tube removal. Imaging changes occurred in 10% (n = 20/200) of chest tube removals. Three of 200 (1.5%) of these were symptomatic after removal and only 0.5% (1/200) required chest tube reinsertion. For the remaining removals resulting in chest radiograph changes, patients were asymptomatic and required no change in clinical management. CONCLUSION: For chest tubes placed by pediatric interventional radiology, these findings do not support the practice of a routine chest radiograph after removal in asymptomatic children.

Contrast-enhanced ultrasound in pediatric interventional radiology.

There is growing interest in the use of contrast-enhanced ultrasound (CEUS) in diagnostic and interventional radiology. CEUS applications in interventional radiology are performed with intravascular or intracavitary administration of microbubble-based US contrast agents to allow for real-time evaluation of their distribution within the vascular bed or in body cavities, respectively, providing additional information beyond gray-scale US alone. The most common interventional-radiology-related CEUS applications in children have been extrapolated from those in adults, and they include the use of CEUS to guide lesion biopsy and to confirm drain placement in pleural effusions and intra-abdominal fluid collections. Other applications are emerging in interventional radiology for use in adults and children, including CEUS to optimize sclerotherapy of vascular malformations, to guide arthrography, and for lymphatic interventions. In this review article we present a wide range of interventional-radiology-related CEUS applications, emphasizing the current and potential uses in children. We highlight the technical parameters of the CEUS examination and discuss the main imaging findings.

Central venous catheter fracture leading to TPN extravasation and abdominal compartment syndrome diagnosed with bedside contrast-enhanced ultrasound.

Central venous lines may require contrast injection under fluoroscopy to evaluate for dysfunction such as occlusion, fibrin sheath development or catheter fracture. Rarely, some patients may be too ill to travel to the interventional radiology suite for this examination. We present a case utilizing contrast-enhanced ultrasound (CEUS) at the bedside to assess catheter integrity in a critically ill infant with a large intra-abdominal fluid collection. CEUS demonstrated extravasation into the collection, confirming catheter fracture and prompting immediate cessation of line use and recommendation for exchange. This case shows the utility of CEUS to evaluate central venous access devices in children who are unable to travel to interventional radiology for a standard contrast injection.

Contrast-enhanced US in Pediatric Patients: Overview of Bowel Applications.

Contrast material-enhanced US is a technique that is approved by the U.S. Food and Drug Administration for the characterization of liver lesions and intravesicular applications in children; however, contrast-enhanced US has several other pediatric applications in clinical practice. The most common application is for patients with inflammatory bowel disease (IBD). Contrast-enhanced US can be used to diagnose IBD, distinguish regions of active or chronic inflammation of the bowel wall, and evaluate associated complications such as abscesses, fistulas, and strictures. Dynamic contrast material evaluation provides qualitative and quantitative information about mural and mesenteric blood flow, which is essential in the determination of disease activity in these patients. It also has the potential to provide a means of monitoring the response to therapy beyond endoscopy or MR enterography. In addition to its use for IBD, contrast-enhanced US can be used to assess for bowel perfusion when problem solving in patients with necrotizing enterocolitis, neonatal bowel infarction, or intussusception. It is a useful imaging technique to fortify diagnoses that may otherwise be indeterminate, such as appendicitis, epiploic appendagitis, intraluminal bowel masses, and complex cysts. Finally, innovative applications such as shear-wave elastography have the potential to provide information about the stiffness of the bowel wall. Online supplemental material is available for this article. ©RSNA, 2020 See discussion on this article by Watson and Humphries.

Abdominal Applications of Pediatric Body MR Angiography: Tailored Optimization for Successful Outcome.

OBJECTIVE. The purpose of this article is to summarize current common techniques and indications for pediatric abdominopelvic MR angiography and strategies for optimizing them to achieve successful outcomes. We also discuss newer MR angiography techniques, including whole-body imaging and blood pool contrast agents, as well as various approaches to reducing the need for anesthesia in pediatric MRI. CONCLUSION. Pediatric body vascular imaging presents a unique set of challenges that require a tailored approach. Emerging pediatric abdominopelvic MR angiography techniques hold promise for continued improvement in pediatric body MR angiography.

Implantable venous access devices in children with severe hemophilia: a tertiary pediatric institutional experience.

BACKGROUND: Clotting factor replacement forms the pillar of treatment for children with hemophilia. Most children can be treated using peripheral venipuncture, but very young children and children with poor venous access might require a central venous catheter. Short-term and long-term complications of implantable venous access device placement (also known as port placement) can result in important morbidity and mortality in children with hemophilia. OBJECTIVE: The purpose of this study is to describe our experience with port placement in children and adolescents with severe hemophilia (<1% of the Factors VIII or IX). MATERIALS AND METHODS: We performed a retrospective review over a 10-year period to identify port placement in pediatric patients with severe hemophilia. We reviewed demographic and procedural information, access frequency, mechanical complications, and central-line-associated bloodstream infections (CLABSI). Eighteen males were included, with median age at insertion of 3.9 years (0.7-22.7 years). Fifteen of the 18 patients had hemophilia Type A and 3/18 had Type B. Thirteen had high neutralizing inhibitor titers. RESULTS: Technical success in port placement was achieved in 26/27 (96.3%) patients, with 1 port failure caused by venous occlusion from prior catheter placement. Port catheter size ranged from 5 French (Fr) to 7.5 Fr. All were single-lumen and placed via right (76.9%) or left (23.1%) internal jugular vein; 59.3% were placed during general anesthesia, and all had factor replacement prophylaxis. A peripherally inserted central catheter (PICC) was placed concurrently in 69.2% of the cases; per hospital policy, the port was only accessed 15 days post-placement to reduce the risk of site hematoma. Two patients were lost to follow-up. The total catheter days was 15,893. Ports were removed in 14/24 cases, most commonly because of CLABSI (7/24; 29.2%) and transition to peripheral infusion (3/24; 12.5%). Bleeding was the most common complication in the first 30 days after placement. There were nine CLABSI events (0.57 per 1,000 catheter days), all in patients with high neutralizing inhibitor titers. A higher frequency of port access (more or equal to daily vs. less than daily) correlated with higher infection rates (P=0.02). Median time from port insertion to first infection was 348 days (range 167-1,055 days). There were four fibrin-sheath-related catheter occlusions (0.25 per 1,000 catheter days): three catheters were salvaged with intra-catheter tissue plasminogen activator (tPA) instillation resulting in a salvage of an additional 1,214 catheter days, and one catheter was removed after tPA failure (0.06 per 1,000 catheter days). CONCLUSION: Port maintenance in boys with severe hemophilia is challenging given the need for long-term frequent device access that is associated with catheter-related infections. The rate of bleeding or infection did not differ in patients whether the device was accessed immediately or 15 days post placement. With appropriate pre- and post-procedural factor replacement, immediate and early term severe complications are not common.

Imaging surveillance for children with predisposition to renal tumors.

Effective surveillance is necessary for early detection of tumors in children with cancer predisposition syndromes. Instituting a surveillance regimen in children comes with practical challenges that include determining imaging modality and timing, and considering cost efficiency, accessibility, and the significant consequences of false-positive and false-negative results. To address these challenges, the American Association for Cancer Research has recently published consensus recommendations that focus on surveillance of cancer predisposition syndromes in children. This review condenses the imaging surveillance recommendations for syndromes that carry a predisposition to renal tumors in childhood, and includes summaries of the predisposition syndromes and discussion of considerations of available imaging modalities.

Whole-body magnetic resonance imaging of pediatric cancer predisposition syndromes: special considerations, challenges and perspective.

Cancer predisposition syndromes increase the incidence of tumors during childhood and are associated with significant morbidity and mortality. Imaging is paramount for ensuring early detection of neoplasms, impacting therapeutic interventions and potentially improving outcome. While conventional imaging techniques involve considerable exposure to ionizing radiation, whole-body MRI is a radiation-free modality that allows continuous imaging of the entire body and has increasingly gained relevance in the surveillance, diagnosis, staging and monitoring of pediatric patients with cancer predisposition syndromes. Nevertheless, widespread implementation of whole-body MRI faces several challenges as a screening tool. Some of these challenges include developing clinical indications, variability in protocol specifications, image interpretation as well as coding and billing practices. These factors impact disease management, patient and family experience and research collaborations. In this discussion we review the aforementioned special considerations and the potential direction that might help overcome these challenges and promote more widespread use of whole-body MRI in children with cancer predisposition syndromes.