Fostering research in pediatric interventional radiology: needs assessment and suggestions for support.

BACKGROUND: Due to the rarity of pediatric diseases, collaborative research is the key to maximizing the impact of research studies. A research needs assessment survey was created to support initiatives to foster pediatric interventional radiology research. OBJECTIVE: To assess the status of pediatric interventional radiology research, identify perceived barriers, obtain community input on areas of research/education/support, and create metrics for evaluating changes/responses to programmatic initiatives. MATERIALS AND METHODS: A survey link was sent to approximately 275 members of the Society for Pediatric Interventional Radiology (SPIR) between May and October 2020. Data was collected using a web-based interface. Data collected included practice setting, clinical role, research experience, research barriers, and suggestions for future initiatives. RESULTS: Fifty-nine surveys were analyzed with a staff physician survey response rate of 28% (56/198). A wide range of practice sizes from 15 countries were represented. Respondents were predominantly staff physicians (95%; 56/59) with an average of 11 years (range: 1-25 years) of clinical experience working at academic or freestanding children's hospitals. A total of 100% (59/59) had research experience, and 70% (41/58) had published research with a mean of 30 peer-reviewed publications (range: 1-200). For job security, 56% (33/59) of respondents were expected or required to publish, but only 19% (11/58) had research support staff, and 42% (25/59) had protected research time, but of those, 36% (9/25) got the time "sometimes or never." Lack of support staff, established collaborative processes, and education were identified as top barriers to performing research. CONCLUSIONS: The needs assessment survey demonstrated active research output despite several identified barriers. There is a widespread interest within the pediatric interventional radiology community for collaborative research.

Update on Pediatric Interventional Radiology.

The field of pediatric interventional radiology encompasses the treatment of a broad range of patients. Whether treating a premature infant who weighs less than 1 kg or treating an adult-sized teenager who weighs more than 100 kg, the innovative skills of the interventional radiologist are required to adapt equipment designed for adult patients, to meet the needs of children. Moreover, children cannot be treated simply as small adults owing to a number of factors, including differences in physiology, disease processes, and treatment techniques between pediatric and adult patients. In this article, the unique medical needs of children are highlighted, noting specific areas the interventional radiologist should be aware of when treating patients of all ages. Specific focus is placed on the unique considerations related to children in terms of their periprocedural needs and the procedural modifications required for routine pediatric procedures, with specific diseases of the liver, chest, and musculoskeletal system highlighted. The broader topic of vascular anomalies, although an important part of pediatric interventional radiology, was intentionally excluded to highlight some of the lesser-known procedures performed. ©RSNA, 2022.

Giant Congenital Melanocytic Nevus Treated With Trametinib.

Giant congenital nevi are melanocytic proliferations of the skin that may be complicated by melanoma, neurocutaneous melanocytosis, pain, pruritus, and disfigurement. Current treatment options include surgical resection and medical management of associated symptoms. There is limited efficacy in these modalities. No effective pharmacologic treatments are available for the treatment of these lesions. We present the case of a 7-year-old girl with a giant congenital melanocytic nevus that had an AKAP9-BRAF fusion and was treated with trametinib, which resulted in rapid resolution of the patient's lifelong, intractable pain and pruritus as well as dramatic improvement in the extent of her nevus.

Differentiation of Deep Venous Thrombosis Among Children With or Without Osteomyelitis.

BACKGROUND: Children with osteomyelitis are at risk for deep venous thrombosis (DVT). This study evaluates the characteristics of DVT among children to differentiate between those with and without osteomyelitis. METHODS: Children with DVT of any cause were studied between 2008 and 2016. Children with DVT and osteomyelitis were compared with those with DVT without osteomyelitis. Another comparison cohort included children with osteomyelitis but without DVT. Comorbidities, severity of illness (SOI), and clinical course were compared between cohorts. RESULTS: DVT was identified in 224 children, a prevalence of 2.5 per 10,000 children. Among those with DVT, 28 (12.1%) had osteomyelitis. The DVT rate among 466 children with osteomyelitis was 6.0%. Children with osteomyelitis and DVT had greater SOI (9.1 vs. 2.7), bacteremia rate (82.1% vs. 38.4%), methicillin-resistant Staphylococcus aureus rate (89.3% vs. 21.2%), surgeries per child (2.1 vs. 0.7), and intensive care unit admission rate (67.9% vs. 5.9%) than that of children without DVT (P<0.00001). Of 196 children who had DVT without osteomyelitis, 166 (84.7%) had comorbidities including defined hypercoagulability (27 or 13.8%). Children with DVT due to osteomyelitis were without comorbidities or hypercoagulability (P<0.00001). The rate of pulmonary embolism was similar for children with DVT with or without osteomyelitis (3/28, or 10.7% vs. 18/196, or 9.2%). CONCLUSIONS: Children with DVT and osteomyelitis differ substantially from other children with DVT by the absence of comorbidities or post-thrombotic syndrome. They also differ from children with osteomyelitis without DVT by higher SOI, methicillin-resistant S. aureus rate, and occurrence of intensive care. Awareness of for the characteristics of DVT among children with osteomyelitis will reduce delay to diagnostic ultrasound and improve anticoagulation management which must be carefully coordinated given the high rate of surgery of these children. LEVEL OF EVIDENCE: Level II-prognostic, retrospective cohort comparison.

Common and rare collateral pathways in aortoiliac occlusive disease: a pictorial essay.

OBJECTIVE: The development of collateral pathways for arterial blood flow is common in the presence of atherosclerotic occlusive disease of the abdominal aorta and iliac arteries. The collateral pathways are divided into systemic-systemic and systemic-visceral pathways. MDCT is commonly used to evaluate aortic stenosis and the resulting collateral pathways. CONCLUSION: Common and rare arterial collateral pathways are reviewed by 3D volume-rendered CT images. Visceral and lower extremity arterial embryology is reviewed.

A policy of dedicated follow-up improves the rate of removal of retrievable inferior Vena Cava Filters in trauma patients.

Retrievable Inferior Vena Cava Filters (IVCF) for prophylaxis against pulmonary embolus have been associated with low rates of removal. Strategies for improving the rates of retrieval have not been described. We hypothesized that a policy of dedicated follow-up would achieve a higher rate of filter removal. Trauma and Nontrauma patients who had a retrievable IVCF placed during 2006 were identified. A protocol existed for trauma patients with chart stickers, arm bracelets, and dedicated follow-up by nurse practitioners from three trauma teams. No protocol existed for nontrauma patients. Statistical analysis was performed using χ(2) analysis or analysis of variance. One hundred sixty-seven retrievable IVCFs were placed over 12 months; 91 in trauma patients and 76 in nontrauma patients. Trauma patients were more likely to have their IVCF removed than nontrauma patients, 55 per cent versus 19 per cent, P < 0.001. There were differences between the three trauma teams, with removal rates of 44 per cent, 42 per cent, and 86 per cent respectively (P < 0.05). On multivariate analysis young age and trauma patient status were independent predictors of filter removal. A policy of dedicated follow-up of patients with IVCFs can achieve significantly higher rates of filter removal than have been previously reported. Similar policies should be adopted by all centers placing retrievable IVCFs to maximize retrieval rates.

Improving the tracking and removal of retrievable inferior vena cava filters.

Therapeutic and prophylactic inferior vena cava (IVC) filters should be placed based on currently accepted indications to prevent a fatal pulmonary embolism (PE). The protective effect of filters is offset by the potential for lower extremity deep venous thrombosis (DVT), caval thrombosis, and possible otherwise unnecessary life-long anticoagulation (AC). The duration of treatment for most DVTs or PEs is 3 to 6 months of AC/filter. Filters should be retrieved when duration of treatment for a DVT/PE has been met, the risk of a PE is no longer high, and/or there is no longer a contraindication to AC. An effective system that leads to improving the retrieval rate of filters must include education of the patient, a tracking system to minimize patient lost to follow-up, and dedicated personnel to oversee the process. If these goals are accomplished, interventionalists can help decrease the incidence of a fatal PE during the high-risk period, and also decrease the risk of a DVT or the use of otherwise unnecessary life-long AC in subsequent years. Currently, there is much room for improvement in the frequency that IVCF patients are systematically followed and filters are retrieved. The principles discussed in this report will be helpful in this process.

Rapid cortisol assays improve the success rate of adrenal vein sampling for primary aldosteronism.

OBJECTIVE: We hypothesized that an adrenal vein sampling (AVS) algorithm incorporating rapid cortisol assays, which enables resampling of the adrenal veins, would improve the success rate by a team of radiologists. SUMMARY BACKGROUND DATA: AVS is the most accurate means to localize aldosterone production in primary aldosteronism (PA). However, cannulation of the right adrenal vein (RAV) is difficult, and success is assumed from venography without the support of steroid assays. Furthermore, few institutions can assign all studies to 1 dedicated and experienced AVS interventional radiologist. METHODS: Retrospective chart review of patients with PA at our university hospitals who underwent AVS. We compared results for 30 AVS studies incorporating rapid cortisol assays with 30 conventional AVS studies. RESULTS: The success rate for the control period was 73% (22/30 studies). For the first 30 studies after incorporating rapid cortisol assay, the success rate increased to 97% (29/30 studies). Resampling the RAV was required for 2 studies, and prolonged sheath insertion did not cause any complications. CONCLUSIONS: High AVS success rates may be achieved by a team of interventional radiologists at 1 center using defined AVS protocols. Rapid cortisol assay allows for resampling of the RAV and improves AVS success rates.

Obstetric and gynecologic emergencies: a review of indications and interventional techniques.

There are many interventional techniques that can be used to aid the obstetrician or gynecologist in caring for their patients in the acute setting. Embolization can be life saving in the case of postpartum hemorrhage. Bleeding related to cervical cancer or the threat of bleeding from cervical ectopic pregnancy is amenable to embolization as is hemorrhage related to uterine arteriovenous malformations. Postpartum women are also at a uniquely high risk for deep vein thrombosis and pulmonary emboli and may benefit from consultation and treatment by an interventional radiologist. The goal of this article is to discuss the valuable role that the interventional radiologist plays in the treatment of these obstetric and gynecologic conditions.

Measurement of 18-hydroxycorticosterone during adrenal vein sampling for primary aldosteronism.

CONTEXT: In primary aldosteronism, elevated serum 18-hydroxycorticosterone (18OHB) suggests aldosterone-producing adenoma (APA) rather than bilateral, idiopathic hyperaldosteronism (IHA), but little is known about the relative production of 18OHB and aldosterone (A) in APAs compared with IHA. OBJECTIVES: We measured 18OHB, A, and cortisol (F) in blood from adrenal vein sampling (AVS) studies. We compared the discriminatory power of gradients in 18OHB/A and 18OHB/F ratios with A/F ratio gradients for distinguishing APA from IHA. DESIGN, SETTING, AND SUBJECTS: We measured 18OHB and A in excess serum from 23 AVS studies performed at our university hospitals. MAIN OUTCOME MEASURES: We calculated the ratios 18OHB/A, 18OHB/F, and A/F for all specimens, and determined the adrenal vein gradients for these ratios. RESULTS: The 18OHB/A ratios were much lower in blood draining APAs (2.17 +/- 0.62) than in blood draining the contralateral adrenals (12.96 +/- 12.76; P < 0.001) but similar to blood draining IHA adrenals (4.69 +/- 4.32; P = 0.02). In contrast, the 18OHB/F ratios were elevated in specimens from APAs (26.03 +/- 11.51) compared with IHA adrenals (9.22 +/- 5.18; P < 0.001) or the contralateral adrenals (6.23 +/- 2.97; P < 0.001). Using 18OHB/F gradient greater than two or 18OHB/A gradient less than 0.5 as criteria for lateralization, interpretations agreed with lateralizations based on A/F gradients in 21 of 23 cases. CONCLUSIONS: High serum 18OHB in APA reflects augmented production of both 18OHB and A, not disproportionate 18OHB secretion relative to A. The 18OHB/A and 18OHB/F gradients are useful adjuncts but not as reliable as A/F gradients for A lateralization during AVS.

Contemporary techniques and safety of cardiovascular procedures in the surgical management of renal cell carcinoma with tumor thrombus.

OBJECTIVE: Renal cell carcinomas often form venous thrombi that extend into the vena cava. Frequently, cardiovascular consultation is necessary for complete surgical excision. We sought to investigate the risk factors, surgical techniques, and outcomes of patients treated for renal cell carcinoma with venous extension. METHODS: We reviewed the records of 46 consecutive patients who underwent surgical management of renal cell carcinoma with venous extension between 1991 and 2005. Data on patient history, staging, surgical techniques, morbidity, and survival were analyzed. RESULTS: There were 29 men and 17 women with a mean age of 60.2 +/- 12.0 years. Twenty-five (54%) procedures were completed with cardiovascular assistance. Nephrectomy was performed in 44 (96%) cases. Three (7%) patients underwent right heart venovenous bypass, and 2 (5%) patients underwent cardiopulmonary bypass with circulatory arrest. Fourteen (32%) patients had perioperative complications, including 1 (2%) perioperative death. Patients who required cardiovascular procedures (inferior vena cava clamping, right heart venovenous bypass, and cardiopulmonary bypass with circulatory arrest) had higher risks of perioperative complications (P < .02). The 1-, 2-, and 5-year overall survival rates were 78%, 69%, and 56%. CONCLUSIONS: This large series demonstrates that aggressive treatment of renal cell carcinoma with venous thrombus provides favorable outcomes. Our 5-year survival is among the highest of recent reviews, and our perioperative morbidity and mortality rates are comparable with those of other series. Tumors that require cardiovascular procedures are associated with increased complications when compared with radical nephrectomy and thrombectomy alone. Nevertheless, this aggressive treatment approach offers encouraging patient survival.

Techniques in interventional radiology: renal CT angiography.

Multidetector row CT angiography has become an important tool in the evaluation of patients with suspected renovascular hypertension. The following article presents a review of the published data on accuracy of this method of evaluation as well as a comparison to other diagnostic strategies, in particular, renal MR angiography.

Percutaneous radiofrequency ablation of renal tumors: technique, limitations, and morbidity.

OBJECTIVES: To evaluate our evolving experience with percutaneous radiofrequency (RF) renal tumor ablation and focus on our technique to ensure maximal treatment efficacy and reduce the possibility of complications. METHODS: Fifteen patients with small (less than 4 cm) posterior or lateral contrast-enhancing (more than 10 Hounsfield units) renal tumors were candidates for RF treatment. Of these patients, 12 (13 tumors) received computed tomography-guided percutaneous RF ablation. General anesthesia was administered in all but our first 2 patients, who received intravenous sedation. After treatment, patients were closely followed up with computed tomography scans at 6 weeks and 3, 6, and 12 months, and every 6 months thereafter. Successful ablation was defined as a lesion along with a margin of normal parenchyma that no longer enhanced (less than 10 Hounsfield units) on follow-up contrast imaging. RESULTS: The mean tumor size was 2.4 +/- 0.6 cm. The average procedure time was 95 minutes (range 60 to 150) and length of stay 0.9 days. All patients underwent the procedure without any major complications. At a mean follow-up of 4.9 months, 12 (93%) of 13 tumors were successfully ablated. In 3 patients, the procedure was not performed because of intervening bowel or lung parenchyma when positioned in the prone position before the procedure. Computed tomography-guided percutaneous RF ablation of small renal tumors is a viable minimally invasive treatment option with a high short-term success rate and low morbidity. This new technology must be uniformly applied to assess its long-term efficacy.