Percutaneous Drainage of Pediatric Pulmonary Abscesses: An Effective Therapy.

INTRODUCTION: Pulmonary abscess is a complication of lung infection with localized necrosis and purulent cavity formation. Pulmonary abscesses are typically managed using antibiotic therapy with anatomic surgical resection reserved as a rescue. Percutaneous drainage is considered relatively contraindicated in some centers due to perceived risk of bronchopleural fistula. However, drain placement has been frequently employed at our institution. The purpose of this study was to review and describe our longitudinal experience. METHODS: Medical records of children diagnosed with lung abscess and treated with percutaneous drainage from 2005 through 2023 were reviewed. Patient clinical parameters, follow-up imaging, and clinical outcomes were evaluated. RESULTS: Percutaneous drainage (n = 24) or aspiration alone (n = 4) under imaging guidance was performed by interventional radiologists for 28 children with lung abscesses. A single catheter (8-12 Fr) was deployed in the pulmonary abscess cavity and remained for a median of 6 days (IQR: 6-8 days). The median hospital stay was 10 days (IQR: 8.8-14.8 days). The technical success rate for percutaneous drainage or aspiration of primary pulmonary abscesses was 100% (26/26). Two children were later diagnosed with secondarily infected congenital pulmonary airway malformations that were both successfully drained and ultimately surgically resected. The abscess cavities resolved in all patients and catheters were removed upon clinical, radiographic, and laboratory improvement. Complications included the presence of two bronchopleural fistula, both of which were treated with immediate pleural drain placement. CONCLUSION: Percutaneous drainage of pulmonary abscesses is an effective therapeutic option in children and can be considered alongside antibiotics as part of the initial treatment for pulmonary abscesses. Bronchopleural fistula can occur, but at a lower frequency than previously reported. LEVEL OF EVIDENCE: Level V.

Use of regional anesthesia within a pediatric interventional radiology suite reduced periprocedural opioid use without delaying the overall workflow: a retrospective study.

BACKGROUND: Nerve block utility has been extensively described in the operating room, however, there is a paucity of evidence regarding blocks in the interventional radiology (IR) suite, with no studies examining its safety and efficacy in children. METHODS: A retrospective study was conducted at a single tertiary-care children's hospital to evaluate the analgesic utility of nerve blocks during IR-performed sclerotherapy for bone cysts, venous malformations, and lymphatic malformations. Lymphatic and venous malformations were combined for final analysis. Patients between January 2016 and September 2022 had their medical records reviewed for procedural data, postprocedural pain scores, and analgesic administration data. RESULTS: 309 patients were included in the final analysis. Opioids were required significantly less frequently intraprocedurally and postprocedurally across subgroups. The proportion of patients who received opioids during their hospital course was significant between block and non-block patients, respectively: bone cyst: 62.7% vs 100% (p<0.001); venous and lymphatic malformation: 65.7% vs 97.4% (p<0.001). Average maximum postanesthesia care unit (PACU) pain scores were significantly lower in bone cyst patients with no significant difference seen in pain scores among venous and lymphatic malformation patients. There were no reported nerve block-related complications. DISCUSSION: Nerve blocks demonstrated an opioid-sparing effect intraprocedurally and postprocedurally for all subgroups. Their use among bone cyst patients was associated with significant reductions in average maximum PACU pain scores. Nerve blocks may constitute an effective opioid-sparing component of multimodal analgesia in pediatric patients undergoing IR sclerosis procedures. Prospective data are needed to establish the optimal utility of nerve blocks in the IR setting.

Treatment of Unicameral Bone Cysts Utilizing the Sclerograft™ Technique.

PURPOSE: To evaluate the Sclerograft™ procedure, which is an image-guided, minimally invasive approach of chemical sclerotherapy followed by bone grafting of unicameral bone cysts (UBC). MATERIALS AND METHODS: A retrospective evaluation from August 2018 through August 2023 was performed at a single institution on patients that underwent the Sclerograft™ procedure for UBCs. Radiographic healing was evaluated utilizing the Modified Neer Classification. Two different regenerative grafts, CaSO4-CaPO4 and HA-CaSO4 were utilized. A total of 50 patients were evaluated with 41 patients grafted with CaSO4-CaPO4 and 9 patients grafted with HA-CaSO4. RESULTS: The average age of the patient was 12.1 years with an average radiographic follow-up of 14.5 months. Average cyst size was 5.5 cm in the largest dimension and average cyst volume was 20.2 cc. 42 out of 50 (84%) showed healed cysts (Modified Neer Class 1) on the most recent radiograph or MRI. Recurrences occurred on average at 7.2 months. Activity restrictions were lifted at 3-4.5 months post-procedure. Cyst stratification by size did not show a difference in recurrence rates (p = 0.707). There was no significant difference in recurrence rate between lesions abutting the physis compared to those that were not abutting the physis (p = 0.643). There were no major complications. CONCLUSIONS: The Sclerograft™ procedure is an image-guided approach to treating unicameral bone cysts, utilizing chemical sclerosis and regenerative bone grafting. The radiographic healing of cysts compares favorably to open curettage and grafting as determined utilizing previously published trials.

New-Onset Paralysis following Biopsy of a Retroperitoneal Mass with Intraspinal Extension in a Pediatric Patient.

Image-guided percutaneous biopsies are routine, safe procedures and complications are infrequent and usually directly related to the biopsy itself. This report describes a biopsy of a retroperitoneal mass with extension into the spinal canal, following which the patient developed paralysis unrelated to the biopsy itself but secondary to spinal cord ischemia during the procedure. Multiple factors contributed to the ischemia, including prone positioning, compression of spinal vasculature by the mass, low arterial pressures, and an extended duration of anesthesia. While the patient eventually recovered neurologic function, it is an important reminder to consider individual patient factors that may complicate typically routine procedures. In masses with intraspinal extension, patient positioning is critical to prevent positional ischemia, and maintaining elevated mean arterial pressures is crucial for ensuring adequate spinal perfusion throughout the procedure.

Diagnosis and Treatment of a Nonhealing Wound Secondary to a Reepithelialized Hair Tourniquet With Ultrasound.

A 9-month-old girl presented with a chronic wound on the dorsal surface of her toe that failed 6 months of medical management. Due to the prolonged clinical course, there was a concern for a foreign body. Intraoperative ultrasound was utilized to identify linear echogenic structures, which were excised and consistent with reepithelialized hairs secondary to hair-thread tourniquet syndrome. There were also erosive changes to the underlying phalanx. Intraoperative ultrasound was also used to guide the incision size and confirm the complete removal of the hairs.

Management of a Gluteal Noninvoluting Hemangioma With Glue Embolization and Excision.

Noninvoluting congenital hemangiomas (NICHs) persist in a high-flow state into childhood and often require surgical excision. The inherent vascular nature of these tumors make effective surgical treatment challenging. Here we report on a patient that underwent intraoperative glue embolization and complete excision of a large gluteal NICH. Concurrent glue embolization followed by complete excision allows for decreased intraoperative blood loss and easier discrimination between the tumor and surrounding structures. Treating difficult vascular tumors with a multidisciplinary approach and subsequent intraoperative glue embolization with surgical excision allows for an effective, single-stage approach to NICHs.

How Endoscopic Guidance Augments Nonvascular Image-guided Interventions.

Endoscopy can improve guidance in nonvascular procedures performed by interventional radiologists (IRs). Historically, the major limiting factors preventing the widespread use of endoscopic tools by IRs were the large diameter (>20F) and length of the endoscopes. IRs had to significantly upsize their access into vascular organs such as the kidney and liver to allow endoscope placement. With the advent of newer endoscopes with sizes smaller than 11F (approximately 4 mm in diameter), percutaneous endoscopy has become more feasible than before. IRs routinely place percutaneous drains (eg, abscess drains, biliary drains, percutaneous nephrostomies, and percutaneous cholecystostomies). Once the drain is in position and the acute infection (if present) has resolved, the IR can use the percutaneous access to perform image-guided and endoscopically guided procedures, depending on the clinical situation. Most percutaneous image- and endoscopically guided interventions performed by IRs involve procedures for biliary and gallbladder pathologic conditions. Image-guided procedures with additional endoscopic guidance can also be used to manage urinary, gastrointestinal, and gynecologic pathologic conditions. The authors review the current applications and techniques of percutaneous endoscopy in interventional radiology. In unique situations, IRs can also perform endoscopy through natural orifices (eg, the urethra) or surgically created orifices (eg, urostomies). The authors also discuss the adjunctive techniques that are enhanced or made possible because of endoscopy in interventional radiology, including but not limited to endoscopic forceps biopsies, endobiliary ablation, laser stricturotomy, lithotripsy, and stone extraction. An invited commentary by Srinivasa is available online. Online supplemental material is available for this article. ©RSNA, 2022.

Minimally Invasive Treatment for Unicameral Bone Cysts with Chemical Sclerosis and Bone Graft Substitute: A Preliminary Report.

PURPOSE: Unicameral bone cysts (UBCs) are benign lesions that primarily occur in childhood and can present with pain, pathologic fracture and growth disturbances. Existing treatment approaches for the management of UBCs are highly variable and recurrence is not uncommon. This study seeks to evaluate near-term outcomes of an image-guided, minimally invasive combination of chemical sclerotherapy and synthetic grafting as a novel outpatient management treatment option for UBCs. MATERIALS AND METHODS: Retrospective evaluation from August 2018 to July 2020 of fourteen pediatric patients, ages 5-14 years, undergoing treatment for a UBC, at a single institution. All UBCs were treated in a single, minimally invasive, image-guided procedure using percutaneous needle access into the UBC followed by chemical sclerotherapy and injection of regenerative synthetic graft. Patients were followed clinically and with serial radiographs to evaluate for healing and complications, with an average follow-up of 13.7 months. Descriptive statistics were performed. RESULTS: Twelve of 14 (85.7%) patients showed Modified Neer classification class 1 or 2 healed cysts at their most recent follow-up. There were two recurrences. All patients were pain-free and returned to normal physical activity on average within 2.0 months, and all patients with healed cysts remained asymptomatic at the most recent follow-up. There were no complications related to the procedures. CONCLUSIONS: Image-guided chemical sclerosis and bone grafting is a minimally invasive treatment option for unicameral bone cysts and compares favorably to other existing treatment options. The preliminary findings of this technique are promising as an alternative management option for UBCs.

Pediatric Vascular Malformations: Imaging Guidelines and Recommendations.

Vascular malformations are commonly encountered in the pediatric population. This article reviews the imaging appearances of simple and syndromic vascular malformations in infants and children that radiologists should know and provides imaging guidelines based on an evidence-based approach. Malformations are discussed within the framework of the International Society for the Study of Vascular Anomalies classification system.

Role of Interventional Radiology in Children with Biliary and Gallbladder Diseases.

Biliary and gallbladder diseases in infants and children often present unique diagnostic and therapeutic challenges that require a fundamental understanding of notable biliary diseases and anatomical variations. Surgical and endoscopic approaches that are often the gold standard in adult biliary treatment may be technically challenging and are associated with a high morbidity that may warrant a multidisciplinary treatment approach. This article will provide a comprehensive overview of the biliary conditions where interventional radiology can play a vital role in the diagnosis, management, and treatment. Differences in approach or technique between children and adults will be highlighted.

Abernethy Malformations: Evaluation and Management of Congenital Portosystemic Shunts.

PURPOSE: To assess the utility of preoperative venography in evaluating and managing patients with congenital portosystemic shunts (CPSSs). MATERIALS AND METHODS: A retrospective study was performed of 42 patients (62% female; median age, 4.1 years) diagnosed with a CPSS from 2005 to 2018. Preoperative venography (n = 39) and balloon occlusive pressure measurements (n = 33) within the mesenteric venous system guided treatment. Primary outcome was serum ammonia levels at 1 month after shunt closure. Management strategies included single (n = 12) or staged (n = 18) operative ligation, endovascular occlusion (n = 8), combined surgical and endovascular closure (n = 2), and observation (n = 2). RESULTS: At 1 month, serum ammonia levels decreased from 82.5 ± 10.3 µmol/L to 38.4 ± 4.6 µmol/L (P < .001). No difference was observed in the decrease between patients treated surgically or endovascularly (P = .91). Mean occluded to non-occluded pressure gradients were significantly lower for endovascular closure (5.3 ± 1.8 mmHg) than for surgical closure (12.3 ± 3.3 mmHg, P = .02). Shunts were classified as extrahepatic in 29 patients and as intrahepatic in 13 patients; all shunts demonstrated filling of the portal system with occlusive venography. Broad and short shunts were closed surgically; narrow and long shunts were closed endovascularly. Shunts were closed in a single session (n = 20) if the pressure gradient was less than 10 mmHg and the occluded mesenteric pressure was less than 25 mmHg. CONCLUSIONS: Preoperative venography delineates shunt morphology, and balloon occlusion simulates closure hemodynamics. This information is necessary to determine whether definitive closure should be performed through endovascular or surgical methods and whether closure should be performed in a single or staged setting.

Deep Vein Thrombosis Due to Fecal Impaction.

BACKGROUND: Deep vein thrombosis (DVT) can occasionally be secondary to mechanical compressions, such as in May-Thurner syndrome. To our knowledge, no cases of DVT associated with mechanical compression by fecal impaction in a pediatric patient have been previously reported. CASE PRESENTATION: An 18-year-old developmentally delayed female presented to the emergency department with swelling involving her left lower extremity. Cross-sectional imaging revealed a significant stool burden in the rectosigmoid colon compressing the left external iliac vein and causing secondary thrombosis. Thrombectomy successfully alleviated the clot burden. CONCLUSION: This case underscores the potentially serious implications of severe fecal impaction in the pediatric and adolescent populations.

MR angiography and 2-D phase-contrast imaging for evaluation of meso-rex bypass function.

BACKGROUND: The meso-Rex bypass restores blood flow to the liver in patients with extrahepatic portal vein thrombosis. Stenosis occurs in some cases, causing the reappearance of portal hypertension. Complications such as thrombocytopenia present on a spectrum and there are currently no guidelines regarding a threshold for endovascular intervention. While Doppler ultrasound (US) is common for routine evaluation, magnetic resonance (MR) angiography with two-dimensional phase-contrast MRI (2-D PC-MRI) may improve the assessment of meso-Rex bypass function. OBJECTIVES: To determine the feasibility and utility of MR angiography with 2-D PC-MRI in evaluating children with meso-Rex bypass and to correlate meso-Rex bypass blood flow to markers of portal hypertension. MATERIALS AND METHODS: MR angiography and 2-D PC-MRI in meso-Rex bypass patients were retrospectively analyzed. Minimum bypass diameter was measured on MR angiography and used to calculate cross-sectional area. Meso-Rex bypass blood flow was measured using 2-D PC-MRI and divided by ascending aortic flow to quantify bypass flow relative to systemic circulation. Platelet and white blood cell counts were recorded. Correlation was performed between minimum bypass area, blood flow and clinical data. RESULTS: Twenty-five children (median age: 9.5 years) with meso-Rex bypass underwent MR angiography and 2-D PC-MRI. The majority of patients were referred to imaging given clinical concern for complications. Eighteen of the 25 patients demonstrated >50% narrowing of the bypass cross-sectional area. The mean platelet count in 19 patients was 127 K/µL. There was a significant correlation between minimum cross-sectional bypass area and bypass flow (rho=0.469, P=0.018) and between bypass flow and platelet counts (r=0.525, P=0.021). CONCLUSION: Two-dimensional PC-MRI can quantify meso-Rex bypass blood flow relative to total systemic flow. In a cohort of 25 children, bypass flow correlated to minimum bypass area and platelet count. Two-dimensional PC-MRI may be valuable alongside MR angiography to assess bypass integrity.

Management of Portal Hypertension in the Pediatric Population: A Primer for the Interventional Radiologist.

Interventional radiology's role in the management of portal hypertension in the pediatric population differs from the management of adult portal hypertension. In the pediatric population, portal hypertension is frequently secondary to thrombosis and cavernous transformation of the extrahepatic portion of the portal vein. Transjugular intrahepatic portosystemic shunt can be utilized to manage portal hypertension in children with intrinsic liver disease that results in cirrhosis and portal hypertension, and is often used as a bridge to transplant. While technically feasible in extrahepatic portal vein occlusion, the sequelae of portosystemic shunting are less desirable in a child. The Meso-Rex bypass procedure, which represents the mainstay of management for pediatric portal hypertension, provides surgical relief of extrahepatic portal vein obstruction and restores mesenteric venous blood flow to the liver. This article aims to review management of portal hypertension in children as it pertains to the interventional radiologist, including preoperative assessment, postoperative evaluation, and the management of complications of the Meso-Rex bypass.

A Comparison of Retrievability: Celect versus Option Filter.

PURPOSE: To compare the retrievability of 2 potentially retrievable inferior vena cava filter devices. MATERIALS AND METHODS: A retrospective, institutional review board-approved study of Celect (Cook, Inc, Bloomington, Indiana) and Option (Rex Medical, Conshohocken, Pennsylvania) filters was conducted over a 33-month period at a single institution. Fluoroscopy time, significant filter tilt, use of adjunctive retrieval technique, and strut perforation in the inferior vena cava were recorded on retrieval. Fisher exact test and Mann-Whitney-Wilcoxon test were used for comparison. RESULTS: There were 99 Celect and 86 Option filters deployed. After an average of 2.09 months (range, 0.3-7.6 mo) and 1.94 months (range, 0.47-9.13 mo), respectively, 59% (n = 58) of patients with Celect filters and 74.7% (n = 65) of patients with Option filters presented for filter retrieval. Retrieval failure rates were 3.4% for Celect filters versus 7.7% for Option filters (P = .45). Median fluoroscopy retrieval times were 4.25 minutes for Celect filters versus 6 minutes for Option filters (P = .006). Adjunctive retrieval techniques were used in 5.4% of Celect filter retrievals versus 18.3% of Option filter retrievals (P = .045). The incidence of significant tilting was 8.9% for Celect filters versus 16.7% for Option filters (P = .27). The incidence of strut perforation was 43% for Celect filters versus 0% for Option filters (P < .0001). CONCLUSIONS: Retrieval rates for the Celect and Option filters were not significantly different. However, retrieval of the Option filter required a significantly increased amount of fluoroscopy time compared with the Celect filter, and there was a significantly greater usage of adjunctive retrieval techniques for the Option filter. The Celect filter had a significantly higher rate of strut perforation.

Peroral esophageal myotomy (POEM) and laparoscopic Heller myotomy produce a similar short-term anatomic and functional effect.

BACKGROUND: Peroral esophageal myotomy (POEM) differs from laparoscopic Heller myotomy (LHM) in that only the circular muscle layer of the esophagus is divided, the hiatus is not mobilized, and an antireflux procedure is not performed. The effect of these differences on anatomic and functional outcomes is unknown. METHODS: Patients who underwent LHM or POEM and had both a pre- and postoperative timed barium esophagogram were selected for analysis. Timed barium esophagograms were performed with 200 mL of contrast, with radiographs taken at 1, 2, and 5 minutes. RESULTS: A total o f 17 LHM and 12 POEM patients had undergone pre- and postoperative timed barium esophagograms. Both groups had decreased column heights postoperatively at 1, 2, and 5 minutes (LHM: pre, 15.6, 12.7, 11.3 cm vs post, 3.6, 2.5, 1.8 cm; P < .001 and POEM: pre, 14.7, 11, 9.4 cm vs post, 4.4, 2.5, 1.2 cm; P < .001). There was no difference between procedures in changes from baseline column height. Both operations resulted in decreased esophageal width and less angulation between the esophageal body and esophagogastric junction. CONCLUSION: POEM and LHM produce a similar short-term anatomic and functional result at the esophagogastric junction. POEM results in a similar narrowing and straightening of the esophagus despite the fact that POEM does not involve hiatal mobilization.

Cirrhotic right and left portal veins: how slow do they go? Identification of threshold velocities associated with subsequent development of hepatofugal flow.

OBJECTIVE: The purpose of this study was to identify threshold right and left portal vein sonographic velocities that are correlated with subsequent development of hepatofugal flow in the main portal vein (MPV), a marker of portal hypertension. METHODS: A database containing 6019 Doppler liver ultrasound reports from an academic hospital was parsed using a Visual Basic computer algorithm. Right and left portal vein velocities were identified from 65 patients who developed hepatofugal MPV flow. Patients with a liver transplant or transjugular intrahepatic portosystemic shunt were excluded. Similarly, right and left portal vein velocities were identified from 195 patients free of chronic hepatic disease. The right and left portal vein velocities of these 2 groups were analyzed using a receiver operating characteristic curve to identify threshold velocities with the optimal sensitivity and specificity for patients who will develop hepatofugal flow in the MPV. RESULTS: A threshold velocity of 11 cm/s in the right portal vein is associated with 81.8% sensitivity and 93.5% specificity in distinguishing patients who develop hepatofugal flow from otherwise healthy control subjects. Likewise, a threshold velocity of 8 cm/s in the left portal vein is associated with a 62.3% sensitivity and a 94.5% specificity. CONCLUSIONS: A threshold right portal vein velocity of 11 cm/s can be used with high sensitivity and specificity to identify patients who may develop hepatofugal flow in the MPV. A left portal vein velocity less than 8 cm/s is 94.5% specific for the development of hepatofugal flow.

A comparison of symptom severity and bolus retention with Chicago classification esophageal pressure topography metrics in patients with achalasia.

BACKGROUND & AIMS: We compared findings from timed barium esophagrams (TBEs) and esophageal pressure topography studies among achalasia subtypes and in relation to symptom severity. METHODS: We analyzed data from 50 patients with achalasia (31 men; age, 20-79 y) who underwent high-resolution manometry (HRM), had TBE after a 200-mL barium swallow, and completed questionnaires that determined Eckardt Scores. Twenty-five patients were not treated, and 25 patients were treated (11 by pneumatic dilation, 14 by myotomy). Nonparametric testing was used to assess differences among groups of treated patients (10 had type 1 achalasia and 15 had type 2 achalasia), and the Pearson correlation was used to assess their relationship. RESULTS: There were no significant differences in TBE measurements between patient groups. Of the 25 patients who received treatment, 10 had a manometric pattern consistent with persistent achalasia after treatment (6 patients with type 1 and 4 patients with type 2 achalasia), whereas 15 appeared to have resolved the achalasia pattern (peristalsis was absent in 8 patients and weak in 7 patients). The height of the barium column at 5 minutes and Eckardt Scores were reduced significantly in patients who had resolved their achalasia pattern, based on HRM. The integrated relaxation pressure and the TBE column height correlated at 5 minutes (r = 0.422; P < .05). CONCLUSIONS: Patients who resolved their achalasia pattern, based on HRM, showed improved emptying based on TBE measurements and improved symptom scores. There was no significant difference between patients with type 1 or type 2 achalasia in TBEs. These findings indicate that normalization of the integrated relaxation pressure on HRM is a clinically relevant objective of treatment for achalasia.