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8 - Vascular interventions
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- By Richard Towbin, University of Arizona, Kevin M. Baskin, University of Pittsburgh Medical Center, David Aria, Phoenix Children's Hospital, Carrie Schaefer, University of Arizona
- Edited by Richard Towbin, Kevin Baskin
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- Book:
- Pediatric Interventional Radiology
- Published online:
- 05 June 2015
- Print publication:
- 18 June 2015, pp 404-476
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Summary
General angiographic considerations
Introduction
Most vascular interventional techniques that were initially developed for the treatment of adult vascular disease can be applied to the pediatric patient, providing appropriate technical modifications are made. There are issues specific to pediatric patients that require consideration in order to safely and successfully use vascular interventional techniques in this population. The problems that need to be overcome include the small patient size, the child's inability to cooperate, vulnerability to hypothermia and blood loss, volume limits for fluids and contrast media, the small size and fragility of access vessels, and, in the neonate, physiological differences related to fetal circulation. The wide range of patient sizes and clinical indications require that the operator be familiar with the vascular problems affecting children and techniques required to treat them. In addition, the interventionalist should be experienced with pediatric sedation and resuscitation, fluid administration, drug dosages, and contrast injection volumes for children of all ages and sizes. Catheterization supplies including needles, guide wires, sheaths, and other materials must be available in a range of sizes appropriate to the child being treated, and the operator should be familiar with the technique of custom shaping of catheters.
Indications
A large proportion of angiographic studies in the pediatric population are performed in conjunction with endovascular therapies (Table 8.1).
Current indications for diagnostic cerebral angiography include central nervous system (CNS) vasculitis, hemorrhage, cerebral ischemia, trauma, and investigation of vascular malformations, strokes, and vasospasm prior to endovascular therapy. Visceral angiography is most commonly indicated to investigate and treat hypertension, ischemia or occlusion related to organ transplantation, gastrointestinal bleeding, hemorrhage after penetrating or blunt trauma, varicoceles, and vascular malformations. Indications for extremity angiography include vascular mapping prior to surgical reconstruction of complex hand and foot anomalies, following penetrating injury and to investigate ischemic vasculopathy. In addition to the investigation of congenital heart disease, thoracic angiography is needed to study and treat hemoptysis, cyanosis (e.g., pulmonary AV malformations), and pulmonary embolism.
3 - Thoracic interventions
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- By Richard Towbin, University of Arizona, Kevin M. Baskin, University of Pittsburgh Medical Center, David Aria, Phoenix Children's Hospital, Carrie Schaefer, University of Arizona
- Edited by Richard Towbin, Kevin Baskin
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- Book:
- Pediatric Interventional Radiology
- Published online:
- 05 June 2015
- Print publication:
- 18 June 2015, pp 97-150
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Summary
History
In the past, relatively few thoracic interventional procedures were performed in the pediatric population. The majority of thoracic procedures have been performed by physicians and surgeons in their offices, on the wards, in emergency rooms, and in the clinics. This appears to be changing. Interventionalists, using image guidance, are now performing an increasing number of diagnostic and therapeutic procedures. Traditionally, most thoracic procedures involved diagnostic aspiration (thoracentesis), drainage of pleural fluid, or biopsy of pulmonary lesions. Recently, more complex interventions involving the tracheobronchial tree have become possible. The availability of high-quality ultrasound (US), computed tomography (CT), and to a lesser extent magnetic resonance imaging (MRI), has led to a wider range and larger number of procedures being performed each year.
Interventional radiology and thoracic interventions
To achieve maximal involvement, the interventionalist needs to play an active role in the patient care team. It is important to work closely with pediatricians, oncologists, cardiologists, pulmonologists, general and cardiovascular surgeons, and others, to clearly define the goals of each procedure and develop a treatment plan. As the treatment plan is tailored to each child's needs, attention to detail is critical for a successful outcome.
Three important features of the thoracic region bear directly on management decisions for image-guided therapy. First, the bony thorax may limit the use of US. Therefore transducer selection is important. Whenever possible, use of a higher frequency transducer with a small footprint is recommended. Second, air-filled lung also limits sonographic visualization. Thus the risks associated with transgression of pleura and lung parenchyma may not be predicted with US guidance. However, there are situations where US can be useful, such as for visualization of pleural and subpleural lesions and mediastinal pathology, and for evaluation of pulmonary masses or other pathology when non-aerated lung is interposed between the target and the pleura.
7 - Musculoskeletal and soft tissue interventions
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- By Kevin M. Baskin, University of Pittsburgh Medical Center, Richard Towbin, University of Arizona, David Aria, Phoenix Children's Hospital, Carrie Schaefer, University of Arizona
- Edited by Richard Towbin, Kevin Baskin
-
- Book:
- Pediatric Interventional Radiology
- Published online:
- 05 June 2015
- Print publication:
- 18 June 2015, pp 356-403
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- Chapter
- Export citation
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Summary
History
In the past, the primary approach to diagnostic and therapeutic procedures involving the musculoskeletal (MSK) system has been open surgery by orthopedic surgeons, with the exceptions of joint aspiration and arthrography. Over time an increasingly broad range of these procedures are carried out using image-guided approaches, and consequently interventional radiologists are exercising a larger role, both in procedural collaboration with the orthopedic surgeons, neurosurgeons, rheumatologists, and other related proceduralists, as well as a more substantial role in clinical consultation for evaluation and management of relevant patients. It is in the MSK system that the modular approach to procedure development has worked particularly well, and this has led to an increasing diversity of patient problems that fall within the scope of practice of the pediatric interventionalist and an increasingly fertile area for innovation and collegial development of creative solutions. It is likely that this trend will continue and over time there will be fewer open procedures performed and increasing integration of interventional involvement in the care of these patients.
Interventional radiology and musculoskeletal interventions
Team approach
Interventions for problems that involve the MSK system and soft tissues can often be accomplished with improved out-comes, less surgical trauma, and a shorter recovery time if image-guided techniques are used compared to traditional open surgical approaches. For example, traumatic fracture of the pelvis with both anterior and posterior instability has traditionally been treated using a large anterior incision and plating across the reduced sacroiliac (SI) fracture. The same objective, stabilization of the posterior ring instability, can be accomplished through a small posterolateral incision with image-guided placement of one or more screws across the SI fracture after closed reduction of the dislocation. Details and advantages of this procedure are outlined below under “Orthopedic interventions.” Because of the infrequency of this problem, interventionalists seldom have a depth of experience with the required hardware and delivery systems, while orthopedic surgeons usually lack training with sophisticated cross-sectional image guidance.
Collaboration allows optimal application of asymmetric skill sets to optimize high-quality outcomes not easily achieved by either subspecialty in isolation.