Mary Landrigan-Ossar

Intranodal Lymphangiography: Feasibility and Preliminary Experience in Children

PURPOSE To review an initial experience studying the lymphatic system using direct injection of ethiodized oil contrast medium into lymph nodes (ie, intranodal lymphangiography) in children with chylous disorders. MATERIALS AND METHODS Children with chylous disorders who underwent intranodal lymphangiography were included in this retrospective study. Under general anesthesia, ultrasonography was used to guide the placement of a small-bore (22-25-gauge) needle into an inguinal lymph node. Ethiodized oil contrast medium was very slowly injected into the node. Opacification of the lymphatic system was documented with fluoroscopic and digital substraction imaging and videofluoroscopic clips. RESULTS Five children (age range, 6 wk to 17 y) with chylous vaginorrhea (n = 1), postoperative chylothorax (n = 2), or spontaneous chylothorax (n = 2) underwent intranodal lymphangiography. The amount of ethiodized oil injected was 0.5-4.5 mL. Intranodal lymphangiography was successfully completed in four patients. One procedure was terminated because of patient motion and extravasation of contrast medium. Lymphangiographic findings included a spectrum of lymphatic channel disorders including incompetence, obstruction, collateralization, chylous reflux, and chylous leak. There were no complications. CONCLUSIONS The simplified technique of injecting contrast medium into a lymph node to opacify the lymphatic system in children can be an alternative to the more elaborate conventional lymphangiography.

Fibro-adipose vascular anomaly: clinical-radiologic-pathologic features of a newly delineated disorder of the extremity.

Background: The diagnosis and management of vascular anomalies of the extremities can be challenging as these disorders are uncommon and may clinically overlap. The aim of this paper is to describe the clinical, radiologic, and histopathologic features of fibro-adipose vascular anomaly (FAVA), a previously unrecognized disorder of the limb. Methods: The clinical, imaging, operative, and histopathologic data from patients with a unique intramuscular lesion of the extremities comprising dense fibrofatty tissue and slow-flow vascular malformations were retrospectively reviewed. Results: Sixteen patients diagnosed with FAVA of the extremity (3 male and 13 female individuals) met the clinical, radiologic, and histopathologic inclusion criteria. The age at presentation ranged from the time of birth to 28 years. The locations of the lesions were: calf (n=10), forearm/wrist (n=3), and thigh (n=3). Fourteen patients presented with severe pain. Seven of the patients with calf lesions had limited ankle dorsiflexion. On imaging, the complex intramuscular lesions replaced muscle fibers with fibrofatty overgrowth and phlebectasia (dilation of the veins). The extrafascial component comprised fatty overgrowth, phlebectasia, and an occasional lymphatic malformation. The histopathologic features comprised dense fibrous tissue, fat, and lymphoplasmacytic aggregates within atrophied skeletal muscle. Adipose tissue also infiltrated skeletal muscle at the periphery of the lesion. There were large, irregular, and sometimes excessively muscularized venous channels and smaller, clustered channels. Other findings include organizing thrombi, a lymphatic component, and dense fibrous tissue–encircled nerves. Conclusions: The constellation of clinical, radiologic, and histopathologic features constitutes a distinct entity comprising fibrofatty infiltration of muscle, unusual phlebectasia with pain, and contracture of the affected extremity. The clinical and radiologic findings permit the diagnosis of FAVA with major therapeutic implications. Level of Evidence: Level III.

Sonography-guided percutaneous liver biopsies in children.

OBJECTIVE The purpose of this study was to evaluate the safety and efficacy of sonography-guided percutaneous core needle liver biopsy in infants and children. MATERIALS AND METHODS We conducted a retrospective analysis of all patients who underwent sonography-guided percutaneous core needle liver biopsies over a 7.5-year period by pediatric interventionalists at a single tertiary center. RESULTS A total of 597 procedures were performed in 470 patients (270 male and 200 female), with a mean age of 10.5 years (age range, 1 month-21 years). The main indications for biopsies were abnormal liver enzymes (n=129, 21.6%), grading and staging of chronic hepatitis B or C (n=105, 17.6%), evaluation of transplanted liver (n=111, 18.6%), iron overload (n=73, 12.2%), miscellaneous other diffuse parenchymal abnormalities (n=124, 20.7%), and focal hepatic lesions (n=55, 9.2%). The procedures were performed either under sedation (n=311, 52.1%) or general anesthesia (n=286, 47.9%). Diagnostic yield was obtained in 596 biopsies (99.8%) from an average of 2.4 cores in patients with diffuse disease (n=541, 90.6%) and 6.5 cores in patients with focal disease (n=55, 9.2%). Ten patients (1.7%) experienced a major complication, including pneumothorax (n=1, 0.2%), abdominal wall pseudoaneurysm (n=1, 0.2%), and symptomatic bleeding (n=8, 1.3%). Five of these children required transfusion, two were only admitted for observation, and one required surgical evacuation. There were no procedure-related deaths. Minor complications (n=49, 8.2%) included a symptomatic subcapsular hematoma (n=35) and stable small hemoperitoneum (n=9). CONCLUSION Sonography-guided percutaneous core liver biopsy is a safe and effective procedure in children that has a high diagnostic yield and very low complication rate.

Gross Hemoglobinuria and Oliguria Are Common Transient Complications of Sclerotherapy for Venous Malformations: Review of 475 Procedures

OBJECTIVE The purpose of this article is to study the incidence, risk factors, and treatment of gross hemoglobinuria and oliguria following sclerotherapy for venous malformations. MATERIALS AND METHODS The clinical records and imaging studies of 131 patients with venous malformations (57 male and 74 female patients; age range, 2-58 years) who underwent sclerotherapy at our institution between July 1993 and August 2007 were reviewed. Demographic data, the location and estimated size of the malformation, the type and dose of the sclerosing agents, development of postprocedural hemoglobinuria and oliguria, and the treatment given were documented and analyzed. RESULTS Four hundred seventy-five sclerotherapy procedures were performed on 131 patients, with the number of procedures per patient ranging from 1 to 21 (mean, 3.6 procedures). Sodium tetradecyl sulfate was used in 47% of the procedures, ethanol in 27%, and both agents in 26%. Transient hemoglobinuria occurred after 34% of the sclerotherapy procedures, and 57% of these were associated with transient oliguria, with increased risk with higher adjusted doses (sclerosant volume/weight of patient) for both agents. Resolution of the hemoglobinuria and oliguria with hydration, alkalinization, and diuretics occurred in all patients. The risk of hemoglobinuria increased with higher adjusted dose (sclerosant volume/weight of patient) for both agents and with sclerotherapy of venous malformations affecting the lower extremities and multiple locations. CONCLUSION Transient hemoglobinuria and oliguria are common complications of sclerotherapy for venous malformation. Nevertheless, with proper fluid management, all the patients promptly recovered. The risk correlates with the volume of sclerosant (adjusted to patients weight) and is higher for lower extremity and multiple locations.

The Use of Endovenous Laser Treatment in Toddlers

The use of endovenous laser ablation therapy in children is limited. Klippel-Trenaunay syndrome (KTS) is associated with persistent ectatic anomalous veins within the affected extremity, with increased risk of thromboembolism. The present report describes four toddlers (<20 kg) with KTS of the lower extremity who underwent a total of five endovenous laser procedures for treatment of ectatic anomalous marginal venous system, without complications.

Anesthesia for interventional radiology

Pediatric patients in the neurointerventional radiology setting pose the dual challenges of caring for relatively sick patients in the outfield environment. For safe and successful practice, the anesthesiologist must not only understand the nuances of pediatric anesthesia and the physiologic demands of the cerebral lesions. They must also help maintain a team‐based approach to safe, compassionate care of the child in this challenging setting. In this review article, we summarize key aspects of success for several of these topics.

Challenges in Pediatric Neuroanesthesia: Awake Craniotomy, Intraoperative Magnetic Resonance Imaging, and Interventional Neuroradiology

This article gives a review of 3 challenges in caring for children undergoing neurosurgical and neurointerventional procedures. Anesthesiologists may have experience with certain aspects of these situations but may not have extensive experience with each clinical setting. This review addresses issues with awake craniotomy, intraoperative magnetic resonance imaging, and neurointerventional procedures in children with neurologic disease. Familiarization with these complex clinical scenarios and their unique considerations allows the anesthesiologist to deliver optimal care and helps facilitate the best possible outcome for these patients.

Common procedures and strategies for anaesthesia in interventional radiology.

Purpose of review This review describes the range of cases now available in the interventional radiology suite and summarizes suggestions for their anaesthetic and perioperative management. Recent findings The type and complexity of interventional radiology cases being performed increases from year to year. Anaesthesiologists’ presence in interventional radiology is increasing in turn, due to increasingly ill patients and intricate procedures requiring more than local anaesthesia for well tolerated completion. The literature available describing this is largely written by radiologists, with little attention paid to anaesthetic considerations. Summary Cases in interventional radiology are complex in terms of the logistics of working in an unfamiliar area, frequency of patient comorbidity and unfamiliar procedures. Ensuring familiarity with the variety of interventional radiology procedures and their periprocedure requirements can increase anaesthesiologists’ comfort in interventional radiology.

Individualized remediation during fellowship training

The Accreditation Council for Graduate Medical Education requires medical training programs to monitor, track, and formally document a fellows performance. If deficiencies are found, programs are expected to prepare and implement an effective plan of action for improvement and to ensure that graduates acquire the personal and professional attributes of an independent physician. We revised our evaluation policy and instituted a remediation protocol in 2008. Since that time, 130 pediatric anesthesia fellows have graduated. Seven fellows (5%) underwent departmental formal consultation for deficient behavior or poor performance. Of these 7 fellows, 4 underwent an individualized remediation program (IRP). A formal performance review and written contract, with specifically identified problems and general themes, recommendations for time-based successful behaviors, and clearly identified consequences for unsuccessful behaviors, was initiated for each fellow undergoing an IRP. All fellows who participated in this program completed their subspecialty training in pediatric anesthesia, and all eligible fellows have successfully achieved their subspecialty board certification. Our approach has the advantage of multimodality, time-based daily evaluations, and group discussions in the context of a Clinical Competency Committee. Utilization of an IRP as a metric for progress has features similar to effective cognitive behavioral therapy contracts and has ensured that our graduates are held to clearly delineated and specified skills and behaviors that allow them to work independently in the field of pediatric anesthesiology.

Exsanguination by intent: controlled phlebotomy during resection of a giant vascular malformation in a 22-month-old child

Resection of large vascular malformations may require transection across the lesion, resulting in uncontrollable bleeding with the risk of exsanguination or massive transfusion‐related complications such as hyperkalemic cardiac arrest. We present the anesthetic management of a 22‐month‐old child with a giant vascular malformation who required surgical intervention because of increasing pain and bleeding from the lesion. As a standard resection carried a high risk of mortality for the patient, a novel surgical approach was performed, consisting of gradual compression of the lesion, reducing its base to allow transection across the smallest possible area. This compression resulted in acute massive autotransfusion managed by therapeutic phlebotomy of more than twice the circulating blood volume of the patient, guided by CVP and blood pressure. Although subsequent resection was still associated with large blood loss, the hemodynamic course of the patient was stable, and both bleeding and massive transfusion occurred in a controlled fashion allowing safe and successful resection of the malformation.