So first we're gonna talk about workflow variations. So, in pediatrics, for the most part, there are some institutional differences but, I think almost all of us do our cases with general anesthesia. And so what does that mean for workflow variation
on the room? It means that we have an anesthesiology team dedicated to us every single day. They have a general anesthesiologist and either a CRNA or a PA that assists them. And we don't have a sedation nurse.
So really, anesthesia monitors all of our vital signs and then our techs and myself are left to do the cases, which is really nice, because some of the patients are very critically ill and then also on the peds side is that you have to weight base dose all of your medications
and so that could be pretty cumbersome. Also, we work for parental consent. And so we have different forms that you have to sign so very rarely are you ever getting consent from the actual patient themselves.
I like working with parents. They ask lots of really good questions. I like their conscientiousness because they really care about what's happening with their child, for the most part. And then on first, pre-procedure labs,
we sort of run with the normal cutoffs that adult IRs, platelets great than 59 or less than 1.5. But sometimes even when you put abcess drains in or you know, just a small picc line, sometimes we don't even check labs
because in the peds world, it's not like the adult world. You don't get labs every single day. And so we may be working with labs that might be a week, they might be two weeks, they might even be a month old. And as long as they're relatively normal
and the child doesn't have any concerns for a thrombo failure or coagulopathy then we just sort of roll with it. Post-procedurely you have to be very specific with children and so fortunately I work with wonderful techs and nurses
and sometimes they are the ones that end up answering the questions for me when I'm not available. But you have to be very specific because that kid will go jump on a trampoline, you know. You've told them limited physical activity and the parents are like well, that'd be okay.
It's just jumping. They've just had a liver biopsy. They dislodge the clot. They end up bleeding. So, you have to be very specific with them. Also, a lot of notes that need to go out
and information that needs to go out back to their school so they're not participating in PE or sport type of activities. And then also, medications are weight based again. One of the other really wonderful thing about working with pediatrics is that their
compliance is top notch for the most part. The parents are really invested in making sure that that medication is given every six hours or they're wearing that elastic wrap for four days. And they'll even text you like it's been
four and a half days, can I take the elastic wrap off? And you're like, yes, you can take it off. So compliance is actually really easy with kids because they have an adult supervising them.
So this is probably interesting to you guys. So the radiation reduction that we use.
I think we're all sort of familiar with the topics on this slide but there's two different things here that you can work with and then the other part is the operator management. But in looking at your machine, you can focus on the exposure rate or
how often you're imaging. You can focus on how long you image and the number of recorded images. And all of that is going to play into the total patient dose. And so this has really been a big focus in the
pediatric world because of the concern for lifelong exposure for radiation. And they have the ALARA criteria but they also have the Step Lightly Campaign which is to remind all of us when we're using fluoro, to use it as sparingly as possible
and to not image when you don't have to or think of other modalities that can help you image. And so, sometimes I'll go a full day with only doing one fluoro case and everything else I'm doing under ultrasound guidance. We even do, you know, tiny baby NICU pics if we need to
get central venous access for them up at the bedside with ultrasound. Because you can literally see through an abdomen with a linear probe. And I mean, you're talking about a depth of three to four centimeters that's seen clear from
the percutaneous access at the skin clear to their spine. And you can very easily see that caval atrial junction under ultrasound guidance. And so what we'll do there, often it's a groin picc that we'd be putting in there.
We just go through the common femoral vein, watch our wire as it advances. You can watch it through the iliacus, in through the IVC, and then terminating at the caval atrial junction from below. Mark that wire length, cut your picc,
put it in over the wire. You can see the catheter tip and the wire come out. And so we really use ultrasound a lot in pediatrics.
Here are some other strategies. And I've highlighted a few here that are particularly important.
So we really try to minimize the use of magnification modes because when you are magnifying, if you watch on your little dose meter or your recording for the patient, it just amplifies everything and so a lot of tendency in peds is to magnify
because you're working on a, you know, sometimes you're working on a two kilo baby. That's really, really small. And so if you look on your machines there are these things called digital zoom or live action zoom or that type of thing
which is just a magnification of the image that the operator is seeing on the screen without magnifying the actual acquisition of the image. And so those are particularly helpful when we put in piccs under fluoroscopy. Obviously you wanna use a very low frame rate.
So when I was training in adult IR we used a frame rate of around seven, sometimes fifteen, but usually seven frames per second. In peds we really never go above three and very often we're operating at two frames per second. Always want to keep the image receptor close to
the patient collimate. So, when we're working like an arterial venous fistula in the liver, we literally collimate down to this little teeny tiny square, just right over their liver, right over the vessels that we're embolizing and then we'll do that
live action zoom and that way also helps really reduce the dose. And then as far as the operator, you wanna stand obviously as far away as possible and wear all of your personal protective gear. That's pretty much it.
There are some other advances for dose reduction that have come up in the last few years. There's software enhancements that are available on a lot of machines. We have Philips and Toshiba machines at my institution. Those are the ones I'm most familiar with.
But there's Clarity and it sort of makes the image like a little bit more pixilated, if you will, or stippled. You sort of get used to that after a while and the dose reduction is profound because just recently we had an upgrade on our machine
and the person that came in to fix it that was doing the upgrade forgot to turn the clarity back on and that was unfortunate. And so I was doing an angio on a child that was bleeding into the pancreatic pseudocyst and I'd done like to or three runs, not magged up,
you know DSAs, and my dose was already over 500 milligray and I was freaking out. I was like what is going on? Called them immediately. They told us what we needed to do. We finished the case.
But then the next day, I had another GI bleed in a child and I did like seven runs and our dose was 167 milligray. So these types of software reductions really make a big difference when you're working on kids. They do cost additional money.
But if you're in a peds heavy practice like I am, it makes sense. Monitoring. We don't use patient monitors but we do use our own personal monitors so we have different ones for ourselves.
And then we always are very cognizant of the patient monitor dose that comes up on our screen. As far as contrast, we always dilute our contrast because our patients are very small. And so we never use above 50% contrast.
We always are very cognizant of how much contrast we're using, four to six ml's per kilo. So when you're talking about doing an angio on a three kilo baby, you are literally talking about 12 cc's of contrast total. You have to be very judicious with it.
And then like I said, the other modalities that we use.
So this is part of the creative part of peds IR, is the equipment. And really where the huge jump in us being able to do complex cases has come is from the neuro IR world. So now we have these wonderful, like, 1.6, 1.9, 2.3
French micro-catheters that allow us to get out in these little tiny baby vessels and the wires to support them. And so, for all of our arterial cases, unless it's just a very big adolescent patient, we tend to use four French arterial sheaths.
Through that we use various four French catheters. A lot of times, though, you can even use a micropuncture. So we'll use a four French micropuncture device to gain access into the vessel, take out the inner obturator and then through the outer obturator of the transitional catheter, you can put a check flow
on the back of it to turn it into a sheath, and then you can work either with a three French diagnostic catheter or you can do like a microcatheter through that. And it works as a really great sheath. You just have to watch the length because a lot of times
those transitional catheters for micropunctures are 10 centimeters and if you're working in their arterial system you're gonna be halfway up the aorta. You just have to be careful. And so this is a case that we had when I was a peds IR fellow of a two year old that came in
with a traumatic injury. Just kept having this hemoperitoneum after a gunshot wound and we couldn't figure out why. And so we finally did an angio on him and it shows this stretch injury of the inferior mesenteric artery here and you can see
as it divides into the sigmoid colon branches with the arrow pointing at the region of narrowing. So this was an active extravasation but the irregularity of the lumens suggests that there's vessel damage here. And so when we're talking about sizes, this is a magged up image, but it was again,
on the digital zoom. This is a microcatheter that's selecting that vessel. This vessel probably is around one and a half to two millimeters. And so going in there with a microcatheter is safe. And then we did the run.
We placed the coils so that's another fun thing that we get to do is we use a lot of neurocoils in peds IR because they are so small. And then we had excellent occlusion and the child did very well. A lot of balloon sizes are starting now to become
very, very small as well. And so we have a large balloon stock that go anywhere from 1.5 millimeters to 20 millimeters. Obviously the larger size of stents we would use in the venous system, not the arterial system. And we use anything from cutting balloons.
We've used Lutonix balloons. There's just sort of a vast array of things that you can do. Enteric access, we provide a lot of G-J tubes for our patients and there's both 16 French and 14 French for those. We put almost all low profile enteric access
in our patients because it's just so much easier with how active they are to move around. They don't like having those big tubes hanging out. For tunneled catheters for like tunneled small bore catheters we use as small as three French and MedComp has now come up with a
cuffed three French catheter which is great. So these can be put in on your transplant pedi patients that are gonna have the catheter for like over four weeks. And they work really, really well. Permcath and Vascaths also come in smaller sizes. So a lot of our babies that have to go on dialysis
or have Plasmapheresis, we'll put an eight French catheter in. And so all of these are sized to the child based on their weight. So less than 10 kilos, we put in an eight French. 10 to 30 kilos, we put in 10.
And then greater than 30 kilos we put in 12s or 14s. And it all depends on the flows that the nephrologists are trying to attain with the apheresis or the hemodialysis. stents, stents are a controversial topic in peds. We do quite a bit of veno-stenting in my practice
because these are kids that are coming to us with either agenesis of their central venous system that we have to reconstitute and recanalize. Or also, with chronic catheter dwelling and they come with occlusion and so we're recanalizing them. We work very closely with our hematologist team
and so we're partnering with them to come with different protocols as far as like antiplatelet and anticoagulation monitoring in those patients that receive stents. And then we do a lot of work with our C-arm Cone beam CT.
So we do a not of bone ablations with cryoablation or microwave ablation. And we use C-arm Cone beam CT for all of that targeting.
And so finally, this is the fun part. This is where I get to show you some of our cool cases. So in Atlanta, we have a very large
vascular malformations clinic. I think over the last year we saw over 650 patients in it. Not all of them are IR patients but a vast majority of them are. And so when we talk about vascular malformations, I don't know how many of you all treat them,
but you can really separate them out into three groups. So low flow, high flow, and vascular tumors. The low flow are typically your venous and your lymphatic malformations. And then lymphatic malformations can break out into macrocystic and microcystic.
Your high flow are gonna be your arterial venous malformations and then your vascular tumors are gonna be things like hemangiomas, PTEN hamartomas, that type of thing. And so really what we focus on in IR for the most part are the low flow and the high flow vascular malformations.
Here's one of my favorite cases that I did as a fellow. This was a deeper intramuscular venous malformation in a patient. Her initial complaint was just pain and swelling that she had in her leg when she was standing in line
at a movie theater. And then slowly but surely the leg started to swell. She started to have these sort of bluish blubs on her skin. They had no idea what was going on. They got an MRI and low and behold she has this very large venous malformation in her system.
Traditionally these were treated with ethanol and really the majority of the peds IRs are now getting away from ethanol because it carried so much risk and damage to the child when you were injecting it. It's very hard to control your ethanol when you're injecting it and it's very caustic to whatever you
inject it into. So, if you had happened to be extra vascular or if you had extraved some from a really brisk injection it's going to kill whatever it touches. And then also if you think about a vessel. You think about it being round.
When you inject fluid into a vessel, it's gonna layer dependently, so however the patient's laying. If they're laying on their tummy it goes on that surface. If they're laying on their back,
it goes on the other surface. It has a very difficult time filling the entire vessel. And that's what you need to do. You need to destroy the endothelium because the endothelium is really where the mutation has occurred and where the problem is.
So we've now moved on to much safer medication and much more effective, in my opinion, is a Sotradecol foam, STS. There's two intensities of it. There's a 1% and a 3% concentration which you can use based on the area that you're working in.
For the most part we use 3% in all of our chest wall abdominal and extremity malformations. You can use the lesser concentration around the mouth or the eyes in sort of higher real estate type of things. And so it's just a 3-2-1 concentration. three ml's of air, two ml's of the Sotradecol
and one ml of the Lipiodol. And you get it in your two syringes with the three-way stop cock and you mix it back and forth and it literally creates millions and millions of bubbles. It looks just white, opaque. But it's bubbles.
And why that works so well for venous malformations is you image those millions and millions of bubbles being injected into the vessel. Well first of all, it has volume. So it's gonna push the blood out of the vessel. And secondly, those bubbles, they fill that vessel.
So they are touching the wall of that endothelium and scarring it down, wherever it touches. It's a foam so it's also easier to control. It has Lipiodol mixed in it so you can watch under fluoroscopic guidance when you're injecting it, which is really helpful because alcohol,
you could never watch unless you diluted it some and mixed it with contrast. So this is really great when you're looking at these to see if you have outflow into your normal deep venous structures and make sure that you're careful of not getting foam in those.
The other medication we use is Bleomycin. It's actually a low risk chemotherapy agent. Again, works to shut down the endothelium cells. Some people foam their Bleomycen for that same benefit of really filling the vessel and destroying the endothelium. And Bleomycen is great but it has some risks with it
as far as Pulmonary Fibrosis. And it has a lifetime dose that you have to be careful of. You can't get more than 400 units of it. And so what we're hoping to do with this sclero therapy is get the blood out of the vessel, scar the endothelium down, sets off a massive
inflammatory reaction. The vessels scar down, no longer fill with blood, and then you just sort of march yourself through with a plan of course, the venous malformation and destroying it. This is another child that I worked on.
You can see his lesion is very superficial and so this brings up a good point that they can be in the dermis. They can be right in the skin layers. They can be subcutaneous like his is, in that fatty layer of tissue.
They can be intramuscular like in the patient I showed you previously and the picture in the middle is just our MRV which shows that contrast filling of all those abnormal veins. You can see he has a normal vein that's coursing along
the medial aspect of the leg but that normal vein is actually feeding all those abnormal ones. And so when I was treating him I put a tourniquet up to block that outflow of that normal vein in order to try and preserve it and then just
injected the medicine within the abnormal portions of the venous malformation. We get access with our angiocatheters and then just foam the medication on the back table and then inject it through those. So just lots of little IVs.
Lymphatic malformations, we treat these predominately when they're macrocystic. The microcystic are really hard for us to treat with a procedure unless you're able to get your needle or your access into those tiny channels that are communicating between the cyst.
And typically what we use for macrocystic lymphatic malformations is Doxycycline. Sometimes we can also use Bleomycin again. But really, what you're trying to do again, is just get that medication to touch all the walls and scar it down.
Doxycycline works on the VEGF pathway which is a protein signaling pathway of the endothelium cells and that's the pathway that's continuing to have those cells produce fluid. So, very effective treatment. And these we typically do it with ultrasound guidance.
So here we have like a micropuncture needle or an 18 gauge Chiba needle, giving access into one of these macrocystic fluid cavities. You place a small wire into it and then you place a drain which you can see the two echogenic reflectors here of my drain.
You suck the fluid out, infuse the Doxycycline in. Let it dwell for about 45 minutes to be completely reactive with the cell. And then aspirate out the Doxycycline, pull the drain at the end of the case, and done. There's the Doxycycline going in.
It has these nice little white bubbles in it that you can see really well under ultrasound.
Arteriovenous malformations are probably the most difficult vascular malformation that we treat. This is a patient that had a forehead lesion and so to orient you on the image,
the vessels going to the left of the screen, that's her nose. And then obviously that's the external carotid artery that's going up and has that large feeder to the AVM. And so with AVMs what you see here, so this is the initial injection in the arterial phase
and this is the later injection where you see these early draining veins. But you see, we're still really in the arterial phase here, so what an arteriovenous malformation is is that basically is this anomalous connection between an artery and a vein and there's no capillary bed to assume that flow
so it's a very high flow lesion. It causes a lot of ischemic steal from the normal surrounding tissues. And it's very painful. And so, because it is such high flow, we don't have time for the foam to really set up
in the vessel. It would just be whisked away to the venous side. So really the only medication that we have left to treat these is ethanol and this is where we still use alcohol. And the theory is is that you do your first injection
with your contrast and you prove, so like here, we have worked a microcatheter clear up to the very top of that feeding vessel, right until we're at the nidus. You do a contrast injection to plan your rate and your volume of what you're injecting in. And then you just mimic that same rate and that same volume
when you're injecting the ethanol because again, you can't see exactly where you're injecting. And then this is an after on this patient so this is after we've injected the ethanol. You can see it just sort of disappears. This was a very good result.
This was after maybe three or four treatments. They do not always look like this. In fact, the majority of them don't look like this. I just put this in so that you guys have an idea of what the goal is. Because these are so hard to treat,
sometimes they have to be surgically resected because of the ischemic and the ulcerations that patients can withstand from having them. And so in those types of cases, the surgeons are not real excited about going in and resecting a highly vascular lesion
with high flow so they'll ask us to go in and embolize it first. Well, we can't embolize it with the particles. Those would just be shunted to other places of the body which is scary. So what we try to either do is Onyx or endovascular glue.
I like working with Onyx 'cause it's a little bit slower, little bit easier to work with than glue. But it's really up to the operator.
Both do the same thing. Vascular tumors, they can be benign, they can be malignant. For the most part in kids, they're benign.
And so a lot of times again, surgeons do not want to resect these without a pre-op embolization and so that's sort of our role. This is a case that we did with Onxy. Again, we worked out with a tiny microcatheter out to the main feeder vessel of the mass.
Embolized it with Onyx, which is the center picture here. And then this is our post embo run.
Some of the other things we do, so leaving the world of vascular malformations, is embolization. So, varicocele embolization in kids,
pelvic congestion syndrome, so basically getting access through the renal veins into the gonadal veins. We used Sotradecol foam and coils for embolization materials.
We do a lot of transplant interventions in peds IR
so it's a lot easier for kids to get transplants than it is for adults so they transplant them very quickly. So tips really, they happen, but not that often for us. It's more so the post-transplant complications. So, we see a lot of kids with portal vein anastomo stenosis.
So this is this case here. See high flows on doppler with potentially areas of narrowing. They ask us. We get transhepatic access into the portal vein, do a contrast injection,
see the area of narrowing, and then we angioplasty it. Kids do remarkably well with the angioplasty. So this would never be something that you would go in and stent because you're thereby limiting the surgeon from how much vein they would have for a future transplant to transplant to.
And so here we would just do an angioplasty. Also with liver transplants, sometimes there's been a misplaced clip or some type of stenosis with the artery and these tend to come to us very quickly after the liver transplants,
within one to two, maybe three days. This isn't something that we can intervene on but it's something that we can provide a diagnosis for for the liver surgeon and so they'll come for a hepatic angiogram. We do the diagnostic angiogram.
This one, there was complete occlusion at the area of anastomosis of the hepatic artery and so the child had to be taken right back to surgery and not retransplanted but arterial revascularization performed. The other thing we do for liver transplants
is biliary interventions. Over time, the biliary anastomosis can become stenotic and scarred down and so we just do it like you do any other PTC. The only hard part is that you never have a gall bladder if you're really having a difficult time
getting access and you know, on patients that haven't had transplants you could always stick the gall bladder and inject contrast or reflex it into your system so you have a target. Transplant patients, you don't have that option 'cause the gall bladder's gone so we really do
everything under ultrasound guidance, get access into the biliary system, wire down, aplasty it, put a drain in, and manage them that way.
We do other pre-op embolizations. So this was a patient that came in with a very large JNA
and the surgeons were again, not wild about operating on this and trying to excise the tumor without some backup embo so, we used Onyx again in this case and you can see how profoundly vascular it was on the first angiogram and then the follow up post-embolization angiogram, we had very good control.
And patients can actually die from having these resected without embolization because they are so highly vascular.
We're gonna talk really briefly about May-Thurner because we see a lot of these kids as adolescents when they present.
So here you see the MRV with the expanded left iliac vein that's clotted and rim enhancing which is the vessel wall. We use intravascular ultrasound for a lot of our venous cases. And so, I think it's a great tool.
You're able to see pretty much everything you can see on an ultrasound which just is showing on this picture. The calcium is gonna shadow your image out. Your transducer is gonna be in the middle of the screen. You can see your vessel wall lumen and then beyond that you can't see too much.
But really helpful when you're looking at, ooh, hi. Does that mean I'm out of time? No? Okay. So, really helpful when you're looking at and confirming the diagnosis of May-Thurner though,
because you're actually able to see what's happening in the vessel at that moment. So here we're starting in the IVC. My catheter is in the IVC at that little hash mark. And then you have the aorta right next to it. As we come down, so we're doing a pull back from the
IVC into the left common iliac vein. And you have the right common iliac artery overriding that left iliac vein. And you can see really how squashed that vein is. I wish I had a pointer. But it is absolutely pancaked in between that iliac artery
and the spine. And then there's the clot below it. So the clot very rarely, it has happened before, but very rarely does the clot migrate from the left common iliac vein into the IVC with May-Thurner.
It's kind of a blessing because that occlusion is so tight that it's blocking the clot from migrating and really then you'll just have the clot all throughout the leg and the pelvis. So this was the venogram on the same patient. After we did angiojet and balloon maceration,
we go ahead and stent on the first day in my practice. We feel that that provides excellent outflow for any residual clot and solves the underlying problem which is the external compression. So there's the stent that we placed and then here is our IVUS, immediately after
stent placement, over here in the IVC. You want that stent to land just right at the bifurcation there. You see the aorta crossing next to it. Here now you see the right common iliac artery as it crossed over that right common iliac vein
and you can see how much more of a lumen you have now with that stent in place. And then distally, there's no more clot.
We do De-Novo G-J tubes on even teeny tiny babies. So I think the smallest baby I've put a De-Novo in is 2.3 kilos, which is very small.
And we just do the two t-tacks, insufflate the stomach, put our access in. We use a working wire because that's what you see looped here in the fundus of the stomach because it is really easy to lose access on these.
You're working with a stomach that's about three to five centimeters in length. And so, very easy for a wire to flip out. That maintains our access as we get across the pylorus and down and then we put the G-J tube in. This is a paper that we just published on our
experience with it. And we had 100% technical success with very few complications.
Finally, we use ultrasound like I said in a various number of ways, whether placing bedside catheters
or even doing bedside lumbar punctures. So in kids, up until about the age of four, you can really use an ultrasound to do a lumbar puncture. You're gonna be able to see in between the muscular tissues. You're gonna be able to see in between your vetebral discs. And here you see, that's the spinal canal
with some of the nerve roots over on the left side of the screen. I left up the calibers so you can see how deep we are. So this is two centimeters. So think about two centimeters in relative to your thumb. That's on a tiny baby.
That's how deep their little spinal canal is. So not very deep at all. This is just a micropuncture needle that's coming in to the spinal canal for us to do our lumbar puncture.
We do a lot of bone ablations. We use CR navigational overlay for those
and we use cryoablation as far as ablating the lesions. And then finally, we do also cryoablation with aneurysmal bone cyst and have really good luck with those. And that's it. Thank you so much. (audience applause)
Does anyone have...
Okay, thank you. Oh, yeah? (audience member mumbles) Right, so we'd never stent a child that isn't in puberty. So I think the youngest was a boy that was 14 that had
definitely achieved puberty. So that's really a concern. I have had a patient that was nine that presented with May-Thurner so I just did her thrombolysis. I'm following her in clinic. She's on prophylactic anticoagulation
so that she doesn't form another clot. And like I said, we partner very closely with our hematology group and we would never stent with somebody that hadn't gone through puberty. (audience member mumbles) No, we use wall stents because we need the radial force.
It is impressive how much force that overriding artery has. We've had silver stents that actually kinked because of it. And so, you really need the maximal radial force that you can have. Mm-hmm. Anyone else?
Alright, thank you.
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