Anne E. Gill

Quality Improvement Guidelines for Diagnostic Arteriography

PREAMBLE The membership of the Society of Interventional Radiology (SIR) Standards of Practice Committee represents experts in a broad spectrum of interventional procedures from the private and academic sectors of medicine. Generally, Standards of Practice Committee member dedicate the vast majority of their professional time to performing interventional procedures; as such, they represent a valid, broad expert constituency of the subject matter under consideration for standards production.

Role of interventional radiology in managing pediatric liver tumors

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

Retrograde Thoracic Duct Embolization in a Pediatric Patient with Total Cavopulmonary Connection and Plastic Bronchitis

review in general surgery, the frequency and the type of errors in the operating theater were estimated. Reviewing 28 quantitative articles, the authors demonstrated a median of 15.5 errors per operation, 23.5% of which were equipment related (7). Surgical techniques that relied more on new technologies had a higher proportion of equipment-related errors. Our search retrieved three studies assessing the frequency of errors before and after a suggested intervention. The paucity of data analyzed makes it difficult to draw any generalizable conclusions and calls for more research into safety in IR. Nontechnical, preventable failures account for two-thirds of intraprocedural errors in the angiography suite. These errors are due at least in part to suboptimal communication among the IR team. The unavailability of equipment is common and is due to inadequate planning and lack of communication between the operator and individuals responsible for equipment stock. None of the studies assessed the entire journey of the patient, highlighting the need for a more comprehensive study of the IR care pathway from admission to discharge. Morbi et al (4) reported 2,040 errors in 55 IR procedures in the period before intervention. In contrast, Koetser et al (5) identified only 67 errors during a similar period in 94 IR procedures, whereas Lutjeboer et al (6) reported 50 errors in 220 procedures. The difference may be due to many reasons, including different thresholds for recording medical errors. The predefined nature of the recorded errors may also explain the discrepancy. In addition, only Morbi et al (4) addressed the intraprocedure period, when most errors are likely to occur. The complex intraprocedure interactions among the different team members and continuously developing equipment technologies create a fertile environment for medical errors to occur. The lack of standardization in medical error reporting is a major shortcoming in current and future studies concerned with errors in IR. Standardized error reporting and a complications registry would facilitate larger multicenter studies, which would help identify the most common errors and vulnerabilities in the IR care pathway. Identifying vulnerabilities will, in turn, help develop strategies for error prevention. In conclusion, in the studies retrieved, it appears that the frequency of medical errors in IR is comparable to surgical disciplines and that errors can be reduced with improvement strategies. Overall, however, IR literature lacks research concerned with medical errors and patient safety outcomes. It is paramount for the IR community to react to this and investigate the incidence of medical errors at all phases of the IR pathway. In addition, it is crucial to devise strategies to reduce these failures and maintain a safe IR practice.

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

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

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

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

Percutaneous Image-Guided Treatment of Benign Musculoskeletal Tumors in Children

Abstract Percutaneous ablation of benign musculoskeletal tumors in children has become an area of significant clinical growth over the last decade. With growing research interest, the technologies available and techniques used are becoming increasingly safe and effective. We review some of the more common ablation technologies and their utility in several common benign bone and soft tissue tumors that occur in children and young adults.

Transsplenic splenoportography and portal venous interventions in pediatric patients

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

Thrombogenic superior vena cava syndrome from long-standing central venous access in a 5-year-old patient treated with balloon-expandable stents

Thrombogenic superior vena cava syndrome is an uncommon, dangerous complication of long-standing central venous catheter use. The increased use of central venous catheters has resulted in more non-malignant cases of superior vena cava syndrome across all age groups. We present a 5-year-old male with superior vena cava syndrome associated with acute onset of severe upper extremity and facial swelling, dyspnea, and a right subclavian central venous catheter malfunction. The patient was ultimately treated with percutaneous stenting of the superior vena cava with balloon-expandable Palmaz stents following unsuccessful angioplasty, catheter-directed thrombolysis, and percutaneous thrombectomy. This case highlights a relatively uncommon complication in children from long-term central venous catheter access and describes an emerging, minimally-invasive therapeutic alternative that allows for preservation of age-appropriate superior vena cava luminal diameter as patients grow.

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

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