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ABSTRACT: BACKGROUND: Few published series are dedicated solely to CT-guided vertebral bone biopsy in children. OBJECTIVE: The objective of our study was to review the diagnostic yield of CT-guided vertebral bone biopsy in children. MATERIALS AND METHODS: A retrospective review of 26 consecutive CT-guided vertebral bone biopsies during a 7-year period in 24 children (16 girls and 8 boys), mean age 8.8 years (range 1-16 years) was performed at our institution. Procedures were reviewed for diagnostic accuracy, biopsy location, complications and final diagnosis. RESULTS: Twenty-five of 26 biopsies (96%) were technically successful. Twenty-one of 26 biopsies were diagnostic (81%); 2/26 (8%) were false-negative removing non-lesional tissue, 2/26 (8%) were nondiagnostic, and 1/26 (4%) was technically unsuccessful. The diagnoses were as follows: 12/26 biopsies (46%) were osteomyelitis, 3/26 (11%) biopsies were Langerhans cell histiocytosis, 3/26 biopsies (11%) were normal bone, 2/26 (8%) biopsies were malignant tumors, and 1/26 (4%) biopsies was osteoblastoma. There was one self-limited, procedure-related complication: a small right-sided pneumothorax occurred in the setting of attempting to create a protective extrapleural biopsy window. CONCLUSION: Percutaneous CT-guided vertebral bone biopsy can be performed safely in children with a high degree of diagnostic accuracy.
Pediatric Radiology 11/2012; · 1.67 Impact Factor
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ABSTRACT: To report the outcome of tunneled dialysis catheter insertion in 120 patients.
A retrospective review of the interventional radiology database and electronic medical records of 120 patients who had tunneled dialysis catheters inserted from April 1997 to July 2010 was performed with institutional review board approval. There were 61 female patients and 59 male patients, with a mean age of 13.3 years (range, 0.2-28.5 y). A total of 193 primary insertions and 330 salvage procedures were performed.
The technical success rate for primary catheter insertions was 100%. Immediate complications included self-limiting tract bleeding and air embolism in two of 193 insertions each (1.03%). Mean indwell duration for primary insertions was 66 catheter-days (range, 1-765 d), compared with a total mean of 159.4 catheter-days (range, 1-1,034 d). Rates of infection and mechanical complications were 0.21 and 0.9 per 100 total catheter-days, respectively. Mechanical and infections complications were increased in children younger than 9 years of age and weighing less than 20 kg. The catheter removal rates for infection and mechanical complications were 0.084 and 0.081 per 100 catheter-days, respectively. Medical salvage procedures, ie, intracatheter thrombolytic agent use or antibiotic therapy (52.1%) and interventional radiologic catheter salvage procedures (47.1%), increased catheter survival by an average of 54.8 days (range, 0-959 d).
Radiologic placement of tunneled hemodialysis catheters is a safe and technically successful procedure in pediatric patients. However, there is a high rate of infectious and mechanical complications, particularly in younger and smaller patients.
Journal of vascular and interventional radiology: JVIR 03/2012; 23(5):604-12. · 1.81 Impact Factor
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ABSTRACT: The use of vascular lines both venous and arterial in children has significantly increased in the last decade with the potential risk that an intravascular device may become an intravascular foreign body. Percutaneous retrieval by interventional radiology has become an accepted method of foreign body removal.
The objective of this study is to describe a single center's experience of percutaneous intravascular foreign body removal in pediatric patients.
Between January 2000 and December 2008, 18 patients underwent percutaneous intravascular foreign body retrieval as a complication of venous access devices. The mean catheter days were 181.2 catheter days (1 to 1,146 days). A retrospective review was performed and demographic data and clinical information were recorded, including type, duration, location of access device, embolization location and retrieval technique.
Eighteen of 19 (94.7%) retrievals were performed with single-loop snares and 1/19 (5.3%) was a triple-loop snare. Seventeen of 19 (89.5%) retrievals were successful. One unsuccessful retrieval was successfully removed by surgery, while the other was retained.
Percutaneous intravascular foreign body retrieval by interventional radiologists is a safe and effective method of retrieving embolized fragments from venous access devices in pediatric patients.
Pediatric Radiology 12/2011; 42(1):24-31. · 1.67 Impact Factor
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ABSTRACT: To evaluate the clinical outcomes of percutaneous sclerotherapy for congenital head and neck lymphatic malformations in our institution.
Over a 7-year period, 17 children (10 M, 7 F) mean age 5.8 months (5 days to 13 months) underwent 49 sclerotherapy procedures for congenital head and neck malformations. The imaging and clinical records were reviewed for each patient. Ten of 17 had macrocystic disease; 7 of 17 had microcystic disease. Imaging response was categorized by volume reductions of 0% to 25%, 25% to 50%, 50% to 75%, or 75% to 100%. A concentration of 10 mg/mL doxycycline was used routinely via catheter in 3 instillations with a dose range of 50 to 500 mg per session as per our standard protocol in 17 of 17 patients. In more recent patients, systemic doxycycline levels were obtained after instillations. Additional treatments included direct injection doxycycline (10/17), instillation of absolute ethanol (7/17) or sodium tetradecyl sulfate (4/17), or a combination of these methods.
Imaging improvement of ≥ 76% was noted in 11 of 17. Of these, 8 of 11 had macrocystic disease. Four of 17 had 51% to 75% resolution, of which 3/4 were mixed. Two of 17 children had 25% to 50% resolution with a mixed lesion. Seven of 49 peri-procedural complications: hemolytic anemia in 2 infants, hypoglycemic and metabolic acidosis in 3 neonates aged 7 to 10 days, transient hypotension during absolute alcohol instillation in 1 neonate, and self-limiting skin excoriation secondary to peri-catheter leakage of doxycycline in one neonate. Neonates prone to these systemic complications had doxycycline doses of greater than 250 mg and resulted in serum levels of >5 μg/mL but as high as 21 μg/mL. Delayed neural complications occurred in 7 of 49 procedures, Horner's syndromes in 4 of 49 procedures, transient left lip weakness in 1 of 49 procedures, right facial nerve palsy in 1 of 49 procedures, and transient left hemidiaphragm paralysis in 1/49 procedures.
Our experience with catheter directed doxycycline sclerotherapy provides excellent results for large macrocystic head and neck lymphatic malformations. Microcystic and mixed lesions continue to provide a therapeutic challenge.
Journal of Pediatric Surgery 11/2011; 46(11):2083-95. · 1.45 Impact Factor
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ABSTRACT: The Mulliken and Glowacki classification (1982) differentiated vascular anomalies into two groups based on their endothelial characteristics: hemangiomas and vascular malformations. Vascular anomalies are localized defects of the vasculature that affect a limited number of vessels in a restricted area of the body. These defects are secondary to errors in vascular morphogenesis. Depending on the type of vessel involved, the vascular malformation group was subdivided into high-flow (such as arteriovenous malformation and arteriovenous fistula) and low-flow lesions (such as venous and lymphatic malformations). Depending on the type of lesion, the location and degree of involvement and the clinical effect, different types of treatment would be required. For the purpose of this review, we concentrate solely on vascular malformations: the clinical features, genetics, diagnosis, and current treatment options.
CardioVascular and Interventional Radiology 03/2011; 34(4):691-704. · 2.09 Impact Factor
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ABSTRACT: Vascular anomalies are disorders of abnormal vasculogenesis or lymphogenesis. All types of vascular anomalies may involve the airway, causing varying degrees of upper airway obstruction as well as dysphagia and bleeding. Certain signs and symptoms may implicate airway involvement with a hemangioma or vascular malformation. It is necessary to distinguish a vascular anomaly from other airway lesions such as a congenital cyst. This is accomplished with imaging and endoscopy.
Clinics in plastic surgery 01/2011; 38(1):121-31. · 0.95 Impact Factor
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ABSTRACT: Enteral feeding is considered a widespread, well-accepted means of delivering nutrition to adults and children who are unable to consume food by mouth or who need support in maintaining adequate nutrition for a variety of reasons, including acute and chronic disease states. Delivery of enteral feeding to nutritionally deprived patients may be achieved by several means. In this article, the indications and insertion of enteral access in children will be reviewed. In addition, common complications and management of problems will be discussed.
CardioVascular and Interventional Radiology 12/2010; 33(6):1101-10. · 2.09 Impact Factor
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ABSTRACT: Manufacturers have provided C-arm CT imaging technologies for applications in interventional radiology in recent years. However, clinical imaging protocols and radiation doses have not been well studied or reported.
The purpose of this study is to develop low-dose settings for clinically acceptable CT imaging of temporomandibular joint in interventional radiology suites, using a C-arm imaging angiography system.
CT scans were performed with a flat-panel digital C-arm angiographic system on a 5-year-old anthropomorphic phantom. The CTDI was determined for various rotation times, dose settings and Cu filter selections. The CTDI values were compared with those of conventional low-dose CT for the same phantom. The effectiveness of using Cu filters to reduce dose was also investigated. Images were reviewed by a senior radiologist for clinical acceptance.
The manufacturer's default setting gave an equivalent CTDI of 4.8 mGy. Optimizing the dose settings and adding copper filtration reduced the radiation dose by 94%. This represents a 50% reduction from conventional CT.
Use of Cu filters and low-dose settings significantly reduced radiation dose from that of standard settings. This phantom study process successfully guided the clinical implementation of low-dose studies for all ages at our institution.
Pediatric Radiology 11/2010; 41(4):476-82. · 1.67 Impact Factor
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ABSTRACT: Fibromuscular dysplasia (FMD) and neurofibromatosis type 1 (NF1) are the most common causes of pediatric renal artery stenosis (RAS) in western countries, and characterization of their angiographic features could aid in an accurate diagnosis and in treatment.
This study characterizes renal angiographic findings in pediatric fibromuscular dysplasia (FMD) and neurofibromatosis type 1(NF1).
We reviewed 68 angiograms performed over 11 years on 43 children with renovascular hypertension (20 male, 23 females; ages 1 month to -19 years; median/average 9.8 years). Ten patients were diagnosed with NF1, and 33 had presumed FMD. The frequency, extent and distribution of lesions were determined and analyzed.
Stenosis was found in 91% of patients (n=39/43), with 86% showing stenosis of 1st or 2nd order arteries, and 12% distal to 2nd order. Stenoses in multiple 1st/2nd order arteries were found in 32% of patients, and 36/43 patients had 1-2 stenoses. The most common lesion was a ≤ 5 mm stenosis in a 1st/2nd order artery, in 42%. Mean percentage of stenosis in a 1st/2nd order vessel was 62%; ≥ 70% stenosis was found in 53%, and ≥ 90% stenosis in 29%. Bilateral disease was noted in 30% of patients. Intraparenchymal disease, distal to 2nd order branches, was seen in 30%. Aneurysms were seen in 28%, beading in 19% and collaterals in 51% (associated with ≥ 70% stenosis). Mid-aortic narrowing was seen in 16%, more often in patients with NF1.
We provide a descriptive characterization of renal angiographic findings in pediatric FMD and NF1.
Pediatric Radiology 10/2010; 41(3):308-16. · 1.67 Impact Factor
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ABSTRACT: Studies of long-term percutaneous transluminal angioplasty (PTA) results have been less extensive in children than in adults. The authors sought to evaluate the outcomes of PTA for pediatric renovascular hypertension.
The authors retrospectively evaluated 19 hypertensive children (ages 2-18 years) who underwent renal PTA from 1997-2009. Angiograms were reviewed in consensus to characterize lesions. This information was correlated with data from chart review to determine clinical outcomes.
Seven patients had neurofibromatosis type 1 (NF1), and 12 had fibromuscular dysplasia (FMD); one was lost to follow-up. Technical success was achieved in 29 of 32 lesions (91%). Cure of hypertension was achieved in seven of 18 patients (39%) and improvement in three (17%). There was a failed hypertension response in eight (44%): two with refractory stenosis, four with recurrent stenosis, and two with no response despite technical success. PTA was repeated in five children, all with failed response. Cure or improvement was seen in five of seven patients with NF1 and five of 11 with FMD. Most (nine of ten) patients with cure/improvement had single lesions or discrete lesions ≤ 10 mm. Residual stenosis < 10% was associated with cure/improvement (P = .0395). Three of five with bilateral and two of two with intraparenchymal disease demonstrated failure. The percentage of initial stenosis and presence of ostial lesions, aneurysms, or collaterals were not predictive of clinical response to PTA (P > .05). Cutting balloons were used after failure to efface with conventional balloons in seven patients and was successful in five of seven.
Despite a high rate of technical success, PTA provided a clinical benefit in a smaller majority of children. This study characterizes the utility of pediatric renal angioplasty and suggests criteria that may be prognostic of patient response.
Journal of vascular and interventional radiology: JVIR 09/2010; 21(11):1672-80. · 1.81 Impact Factor
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ABSTRACT: A 13-month-old boy with Gaucher disease presented with severe thrombocytopenia, anemia and massive splenomegaly. In addition he had significant respiratory compromise caused by abdominal compartment syndrome, requiring mechanical ventilation. Because of the degree of respiratory compromise and his existing bone marrow suppression, splenic artery embolization was chosen as an alternative to splenectomy. Splenic artery embolization was performed using 355-500-microm polyvinyl alcohol particles, with 70% ablation achieved. Within 24 h of the procedure the platelet count had risen to greater than 70,000/mm(3) and to more than 170,000/mm(3) on postoperative day 4. At the 8-month follow-up the splenic size had decreased from 18 cm to 8 cm, with a platelet count of 578,000/mm(3). Partial splenic embolization provides a minimally invasive alternative to splenectomy in patients with Gaucher disease with massive splenomegaly and bone marrow suppression.
Pediatric Radiology 06/2009; 39(9):1006-9. · 1.67 Impact Factor
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ABSTRACT: To review outcomes of ultrasound (US)-guided percutaneous submandibular gland injection of botulinum toxin A (BTX-A) in the treatment of drooling and chronic aspiration.
A 3-year retrospective review was performed of 220 US-guided salivary gland injections in 36 patients. There were 21 male patients and 15 female patients with an age range of 1.4 to 19.8 years (mean, 8.6 y) and a weight range of 7.8 to 73 kg (mean, 24.4 kg). The mean pretreatment analysis period was 48 months and the mean follow-up period was 21 months. The study group was divided into groups with anterior (n = 9) and posterior (n = 27) drooling, with those with both (n = 10) included in the posterior group.
All procedures were technically successful. Bilateral submandibular injections were performed in 34 procedures and bilateral submandibular and parotid injections were performed in 38 procedures. Of the 27 patients with posterior drooling, improvement occurred in 24 patients (88%), no improvement was seen in two (8%), and one (4%) was lost to follow-up. Of the nine patients with anterior drooling, six (66%) showed improvement, there was no response in two (22%), and one (12%) was lost to follow-up. The total number of hospitalizations for respiratory issues and presumed aspiration pneumonia decreased by 56.4% per year in the patients with posterior drooling. There was one procedure-related complication: an episode of self-limited oral bleeding.
Salivary gland BTX-A injection for salivary control shows promising results in decreasing saliva production and frequency of respiratory symptoms in children with drooling and chronic aspiration.
Journal of vascular and interventional radiology: JVIR 02/2009; 20(3):368-73. · 1.81 Impact Factor
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ABSTRACT: Percutaneous techniques offer several advantages over open surgery in the treatment of many pediatric genitourinary diseases.
The pediatric interventionalist routinely treats patients with conscious sedation on an outpatient basis that would require
general anesthesia and lengthy hospital admissions if treated surgically. The minimally invasive nature of percutaneous therapy
also results in cost reduction. The outcomes of percutaneous techniques have now been established as equal to or better than
the corresponding surgical technique in many instances. In spite of this, pediatric genitourinary intervention has grown relatively
slowly over the past decade. Limited growth in this area is likely due to a variety of factors, especially the preference
of urologists to perform combined percutaneous and surgical procedures in the operating room. Most referrals to pediatric
interventional radiologists are cases that are difficult to treat operatively or with endoscopic techniques. Consequently,
a minority of children is referred for routine procedures.
11/2008: pages 473-494;
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ABSTRACT: The use of inferior vena cava (IVC) filters to prevent pulmonary embolism (PE) has increased with the advent of retrievable filters (Crowther: Am J Med 120: S13-S17, 2007). Both permanent and retrievable filters have been used in the pediatric population, though reports describing such patients and their outcomes are limited.
Our center has established a longitudinal prospective cohort study of consecutive patients with acute venous thromboembolism (VTE) at our pediatric tertiary care institution. Data collection in this study includes medical history, risk factors, radiologic and laboratory studies, therapy, and follow-up.
Two hundred ten patients were enrolled into this cohort from January 2003 to January 2007. IVC filters were percutaneously placed into 11 patients, ranging in age from 6.8 to 23.4 years. The primary reason for filter placement was a VTE and a contraindication to anticoagulation. Nine patients had retrievable filters placed and two received permanent filters. Seven of the nine retrievable filters were removed 21-97 days (median 37 days) after placement. In the remaining two patients, thrombus prevented removal in one, and the filter was electively retained in the other. One patient with a permanent filter died from malignancy. The three patients who are alive and well with IVC filters have had them for 25-60 months. No patient with an IVC filter developed a subsequent PE.
Approximately 5% of patients in this pediatric thrombosis cohort received an IVC filter. The placement and removal of these devices is technically feasible in children.
Pediatric Blood & Cancer 07/2008; 51(4):517-20. · 1.89 Impact Factor
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ABSTRACT: To determine the prevalence of temporomandibular joint (TMJ) disease in a cohort of children with new-onset juvenile idiopathic arthritis (JIA), and to compare magnetic resonance imaging (MRI) with ultrasound (US) for the detection of acute and chronic changes of TMJ arthritis.
Between January 2005 and April 2007, children with newly diagnosed JIA were prospectively evaluated for TMJ arthritis. Prior to imaging, jaw pain and disability were assessed with questionnaires and physical examination. The TMJs of all patients were imaged with MRI and US within 8 weeks of diagnosis.
Of the 32 patients enrolled, 78% were female, and the median age was 8.6 years (range 1.5-17.2 years). Acute TMJ arthritis was diagnosed in 75% of the children by MRI and in none by US; chronic arthritis was diagnosed in 69% by MRI and in 28% by US. Findings of both acute and chronic TMJ disease were detected by MRI in 53% of the patients. Of those with acute TMJ arthritis, 71% were asymptomatic, and 63% had normal findings on jaw examination. Fifty-six percent of patients with acute disease had an improved maximal incisal opening after corticosteroid injection. Among these responders, 56% had been asymptomatic and had normal jaw examination findings.
TMJ arthritis was present in the majority of patients with new-onset JIA. Findings on MRI along with responses to treatment among asymptomatic patients with normal jaw examination findings suggest that a history review and physical examination are not sufficient to screen for TMJ disease. Our results also suggest that MRI and US findings are not well correlated, and that MRI is preferable for the detection of TMJ disease in new-onset JIA.
Arthritis & Rheumatism 05/2008; 58(4):1189-96. · 7.87 Impact Factor
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ABSTRACT: To quantify the anatomic relationships of the cavoatrial junction and propose a system for describing central venous access device tip location on the basis of structures visible on chest radiographs.
The authors performed a retrospective study of 100 consecutive computed tomographic (CT) studies from a predominantly pediatric population consisting of 52 male and 48 female patients aged 12-28 years (mean age, 16 years). With use of multiplanar and scout images, relevant mediastinal structures were marked, vertebral levels were noted, and measurements were made electronically. Catheter tip positions were recorded in the 26 children who had central catheters.
A vertebral body unit was defined as the distance between the inferior endplate of one vertebra to the inferior endplate of the next, with the upper intervertebral disk included. The most reliable estimate of cavoatrial junction position is a point two vertebral body units below the carina; there was no association with patient age or other parameters.
A more accurate understanding of the superior vena cava anatomy is essential for the correct interpretation of central venous access device position. The true cavoatrial junction is located more inferiorly than commonly believed and is not accurately estimated with commonly used imaging landmarks. A point two vertebral body units below the carina enables the reliable estimate of the position of the cavoatrial junction. Catheter tip position can be most reliably described in vertebral body units below the carina, with use of the thoracic spine as an internal ruler.
Journal of Vascular and Interventional Radiology 04/2008; 19(3):359-65. · 2.08 Impact Factor
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ABSTRACT: Children with systemic hypertension resulting from a renovascular stenosis commonly have fibromuscular dysplasia and respond to percutaneous transluminal renal angioplasty (PTRA). There is a subset of children, however, with conditions that appear to be resistant to PTRA (eg, syndromic renal artery stenosis and arteritis). These patients are often treated surgically. The development of the cutting balloon may provide a minimally invasive alternative to surgery in these individuals. Associated adverse events may include recurrent stenosis, arterial occlusion with renal loss, and arterial rupture with extravasation and pseudoaneurysm formation. Some of these adverse events can be successfully treated with percutaneous interventional techniques. The authors present four cases of cutting balloon angioplasty performed at two large metropolitan children's hospitals in children with resistant renal artery stenosis.
Journal of Vascular and Interventional Radiology 06/2007; 18(5):663-9. · 2.08 Impact Factor
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ABSTRACT: Children with arthritis may endure a lifetime of disfigurement, dysfunction, and pain if acute inflammation progresses to chronic changes in the joint cartilage and underlying bone. Intraarticular steroids have become an integral component of treatment, but at times are difficult to deliver to joints, such as the subtalar joint, that have complex anatomies.
We describe our technique and outcomes using fluoroscopically guided intraarticular subtalar steroid injection in patients with active symptoms of juvenile idiopathic arthritis (JIA).
Fluoroscopically guided subtalar joint injections were performed in 38 children (mean age 6.7 years). Medical records were reviewed retrospectively and improvement was evaluated clinically by the degree of foot movement in eversion and inversion.
Subtalar joint injection was technically successful in 100% of the JIA patients with improvement in physical symptoms in 34/38 (89%). Of the 38 children, 32 were followed up within 13 weeks of the initial injection and, therefore, satisfied the eligibility criteria for resolution of arthritis. Of these 32 children, 14 showed clinical resolution (44%). The mean duration of improvement was 1.2 +/- 0.9 years. Children with a longer interval (>1 year) from diagnosis to treatment had significantly less resolution (P = 0.04). Local subcutaneous atrophy or hypopigmentation were observed in 53% of the children after steroid injection (20/38). These minor complications were associated with a greater volume of steroid injected into the site per child (P = 0.02).
Fluoroscopically guided subtalar joint injection is an effective treatment for subtalar arthropathy. Prompt referral for intraarticular steroid treatment in the acute phase improves response. Skin changes often occur at the injection site, and specific precautions should be employed to reduce this risk. Prospective study is indicated to determine the most effective treatment strategy to prevent long-term pain and disability.
Pediatric Radiology 06/2007; 37(6):544-8. · 1.67 Impact Factor
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ABSTRACT: Priapism is defined as involuntary, prolonged penile erection caused by factors other than sexual arousal, and is classified as either low-flow or high-flow. Embolotherapy is an accepted form of therapy in adults with high-flow priapism. Because the differences in etiology, management and outcome are significant, accurate and timely diagnosis is imperative.
The purpose of this report is to present our experience with embolotherapy for treatment of high-flow priapism in three children.
This was a retrospective study. During an 18-month period, three boys ranging in age from 6 to 15 years presented with priapism. All three children were treated with embolotherapy.
All three children were successfully treated with angiography and embolotherapy. One boy had a presentation that initially raised the possibility of low-flow priapism. No complications occurred, and to date all children are able to maintain normal erections.
Subselective transcatheter embolization is the procedure of choice for high-flow priapism. In cases where priapism persists despite adequate therapy, angiography might be useful to exclude high-flow disease. In children with high-flow priapism, selective occlusion of the penile arteriovenous fistula led to detumescence and normal erectile function.
Pediatric Radiology 06/2007; 37(5):483-7. · 1.67 Impact Factor
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ABSTRACT: OBJECTIVE: The purposes of this study were to retrospectively review an injection technique, to develop a grading system for evaluation of imaging findings, and to report preliminary outcome related to percutaneous CT-guided steroid injection into the temporomandibular joints of children with inflammatory arthropathy. CONCLUSION: CT-guided steroid injection into the temporomandibular joint of children with inflammatory arthropathy results in clinical and imaging improvement in a substantial proportion of children treated.
American Journal of Roentgenology 02/2007; 188(1):182-6. · 2.78 Impact Factor
