Ganesh Krishnamurthy

Angioplasty for Renal Artery Stenosis in Pediatric Patients: An 11-year Retrospective Experience

PURPOSE 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. MATERIALS AND METHODS 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. RESULTS 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. CONCLUSIONS 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.

Percutaneous Thoracic Duct Embolization as a Treatment for Intrathoracic Chyle Leaks in Infants

Chylothorax is an uncommon complication of cardiothoracic surgery in children that is traditionally treated with either conservative (diet modification, octreotide administration, and percutaneous drainage) or surgical (thoracic duct ligation, pleurodesis, and pleuroperitoneal shunt) approaches. We report here the cases of 2 children (a 6-month-old and a 1-month-old) with postoperative chylous leaks who were treated successfully by percutaneous thoracic duct embolization.

Vascular Access in Children

Establishment of stable vascular access is one of the essential and most challenging procedures in a pediatric hospital. Many clinical specialties provide vascular service in a pediatric hospital. At the top of the “expert procedural pyramid” is the pediatric interventional radiologist, who is best suited and trained to deliver this service. Growing awareness regarding the safety and high success rate of vascular access using image guidance has led to increased demand from clinicians to provide around-the-clock vascular access service by pediatric interventional radiologists. Hence, the success of a vascular access program, with the pediatric interventional radiologist as the key provider, is challenging, and a coordinated multidisciplinary team effort is essential for success. However, there are few dedicated pediatric interventional radiologists across the globe, and also only a couple of training programs exist for pediatric interventions. This article gives an overview of the technical aspects of pediatric vascular access and provides useful tips for obtaining vascular access in children safely and successfully using image guidance.

Imaging findings in external snapping hip syndrome

We describe a case of external snapping hip diagnosed by dynamic sonography. The case prompted us to retrospectively review the imaging findings of children who clinically had presented with snapping hip. From this review we identified the features on MRI and CT of either thickening of the iliotibial band or thickening of the anterior edge of the gluteus maximus muscle as the cause of snapping and atrophy of the bulk of gluteus maximus muscle as an important secondary sign associated with snapping.

Intraoperative cerebral angiography in arteriovenous malformation resection in children: a single institutional experience.

OBJECT The use of cerebral intraoperative angiography has been described in resection of arteriovenous malformations (AVMs) in adults. More recently, studies have described experiences with intraoperative angiography in a small number of children. However, data on the safety and clinical utility of intraoperative angiography in the pediatric population remains limited in comparison with available data in adults. The aim of the study was to evaluate the use of cerebral intraoperative angiography in children undergoing AVM resection. The clinical utility of intraoperative angiography and procedure-related complications were evaluated. METHODS A retrospective review was performed for all patients undergoing cerebral AVM resection with intraoperative angiography at The Childrens Hospital of Philadelphia between 2008 and 2012. Patient imaging and operative and medical notes were reviewed to evaluate for end points of the study. A total of 17 patients (8 males, 9 females) were identified, with a median age of 12.1 years (range 1.2-17.9 years) and median weight of 45.5 kg (range 12.1-78.9 kg). RESULTS A total of 21 intraoperative angiography procedures were performed for 18 AVM resections in 17 patients. The technical success rate was 94%. In 2 cases (11%), intraoperative angiography demonstrated a residual AVM, and repeat resections were performed. In both cases, no recurrent disease was noted on postoperative follow-up. One procedure-related complication (4.8%) occurred in 1 patient who was positioned prone. Recurrence to date was noted in 2 (14%) of the 14 cases with available postoperative follow-up at 3.5 and 4.7 months following resection with intraoperative angiography. The median follow-up time from intraoperative angiography to the most recent postoperative angiography was 1.1 years (range 4.3 months to 3.8 years). CONCLUSIONS Intraoperative angiography is an effective and safe adjunct for surgical management of cerebral AVMs in the pediatric population.

Upper Gastrointestinal Access in Children: Techniques and Outcomes

This article describes the radiologic techniques to obtain upper gastrointestinal access in children with poor oral intake and inadequate nutrition. Our goal is to provide a simple guide of radiologic gastrostomy and gastrojejunostomy procedures, their technical success, and long-term outcomes. Potential complications will be discussed as well as their management. It is important to emphasize that a multidisciplinary approach (pediatrician, dietitian, interventional radiologist, pediatric surgeon) is paramount for appropriate indications and management of patients with gastrostomies and gastrojejunostomies.

Endovascular Thrombolysis in the Management of Iliofemoral Thrombosis in Children: A Multi-Institutional Experience.

PURPOSE To evaluate technical feasibility, complications, and clinical outcomes of endovascular thrombolysis for iliofemoral thrombosis at two tertiary-care childrens hospitals. MATERIALS AND METHODS Institutional review board-approved retrospective review from March 2003 through June 2013 showed that venous thrombolysis for iliofemoral thrombosis was performed in 57 children (64 limbs) with a median age of 16.1 years (mean age, 14.5 y; range, 1.0-17.8 y). Techniques included catheter-directed thrombolysis (CDT), percutaneous mechanical thrombectomy (PMT), and pharmacomechanical catheter-directed thrombolysis (PCDT) with adjunctive angioplasty and/or stent placement. Villalta and modified Villalta scales were applied retrospectively to follow-up data to assess postthrombotic syndrome (PTS). RESULTS Technical success (≥ 50% thrombolysis) rate was 93.7%: grade III (100%) in 19 limbs, grade II (50%-99%) in 41 limbs, and grade I (< 50%) in four limbs. Techniques included CDT with PCDT (32.8%) or PMT (35.9%), CDT alone (26.6%), PCDT alone (4.7%) or with adjunctive angioplasty (54.7%), and stent placement (6.3%). Mean duration of CDT was 36.5 hours (range, 2.9-89.6 h). There was one major complication (1.8%) of bleeding requiring transfusion. Minor complications (ie, bleeding) occurred in seven patients (12.2%). Median follow-up was 1.5 years (range, 30 d to 7 y). Seven patients underwent repeat thrombolysis for recurrent thrombosis. The PTS rate was 59.3% per modified Villalta scale but only 2.1% per Villalta scale. CONCLUSIONS Endovascular thrombolysis is technically feasible and safe for iliofemoral thrombosis in children. Variable results were seen with two scales to assess PTS, suggesting an acute need for standardization of outcome measurement in children.

Ectopic drainage of the common bile duct into the lesser curvature of the gastric antrum in a newborn with pyloric atresia, annular pancreas and congenital short bowel syndrome

We report a newborn with bilious vomiting and the rare combination of pyloric atresia, annular pancreas and ectopic drainage of the common bile duct into the lesser curvature of the gastric antrum. Radiologic, sonographic and percutaneous transhepatic transcholecystic cholangiographic (PTTC) findings, with surgical correlation, are presented.

US-Guided Placement and Tip Position Confirmation for Lower-Extremity Central Venous Access in Neonates and Infants with Comparison versus Conventional Insertion

PURPOSE To describe experience with the use of ultrasound (US)-guided placement and tip position confirmation for direct saphenous and single-incision tunneled femoral noncuffed central venous catheters (CVCs) placed in neonates and infants at the bedside. MATERIALS AND METHODS A retrospective review of the interventional radiology (IR) database and electronic medical records was performed for 68 neonates and infants who received a CVC at the bedside and for 70 age- and weight-matched patients with CVCs placed in the IR suite between 2007 and 2012. Technical success, complications, and outcomes of CVCs placed at the bedside were compared with those in an age- and weight-matched sample of children with CVCs placed in the IR suite. RESULTS A total of 150 primary insertions were performed, with a technical success rate of 100%. Total catheter lives for CVCs placed at the bedside and in the IR suite were 2,030 catheter-days (mean, 27.1 d) and 2,043 catheter-days (mean, 27.2 d), respectively. No significant difference was appreciated between intraprocedural complications, mechanical complications (bedside, 1.53 per 100 catheter-days; IR, 1.76 per 100 catheter-days), or infectious complications (bedside, 0.39 per 100 catheter-days; IR, 0.34 per 100 catheter-days) between groups. CONCLUSIONS US-guided placement and tip position confirmation of lower-extremity CVCs at bedside for critically ill neonates and infants is a safe and feasible method for central venous access, with similar complications and catheter outcomes in comparison with CVCs placed by using fluoroscopic guidance in the IR suite.

Radiologically Placed Tunneled Hemodialysis Catheters: A Single Pediatric Institutional Experience of 120 Patients

PURPOSE To report the outcome of tunneled dialysis catheter insertion in 120 patients. MATERIALS AND METHODS 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. RESULTS 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). CONCLUSIONS 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.