Pediatric IR in a snapshot:

lots of venous access catheters and low profile GJ tube insertions

also AV malformation embolization / sclerotherapy

renal artery stenosis angioplasty

cases are complicated by needs of pediatric patient

pediatric anesthesiologist is nescessity

size of patient esp < 2 yrs age can be difficult barrier to cross

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Pediatric Small Bore Tunnelled Venous Access:

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RIJ tunnelled single lumen 3-4F catheter insertion is preferred

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In patients < 2, use a special shoulder single stick techinque (MH)

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On table, have micropuncture kit

3F single lumen noncuffed or cuffed catheter, bard

to access the RIJ

use hockey stick probe

enter needle at shoulder level and watch needle in real time as it enters RIJ or just below at BCV region, can angle needle

advance micro

be careful as just due to size, the floppy end may be all that can advance

try to get down to IVC
get accruate measurement of catheter length, use back end of wire for measurement (45 cm wire, peel away sheath complex length is usually 4-5 cm

once have length, trim catheter and advance through peelaway

basically done

suture both aspects of the hub down

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Permacath placement with SVC angioplasty

in young patient with may repeat permacath placement

will likely have SVC narrowing that will show itself as diffculty advancing microwire into svc / ivc

if this happens, do the following to open

do a run to provide roadmapping

advance glide or other wire to cross lesion

switch over for aplatz

baloon the stenosis

be careful because balooning can cause SVC rupture or pericardial effusion and to prevent this, going small is best

baloon sizes can be 6 mm, 8 mm, 10 mm x 40 mm

do a post run through a sheath

afterwards, placing the catheter is usually straightforward

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Venous Malformation Sclerotherapy

 

Slow flow malformations, usually lumpy and in the arms, hands, feet, legs, face/ neck region

overall goal is to stick with thin needles under US and then infuse sclerosant, sotradecol foam

 

get ped anesthesia

prep drape area

use hockeystick probe or other high freq transducer

find VM usually in subdermis level, lumpy

use 22 G angiocath to access under US guidance

one see needle in vessel, advance cath

should see blood return into angiocath if not can pull cath back under US

when see blood return, hook up tubing and contrast and do angio run

look at VM and draining veins which can be normal

make sclerosant, 321 mix of air, 3% sotradecol, lipiodol, tessari method

infuse sclerosant very slowly under roadmap guidance

do spot images at timepoints to track progress

want to see filling of VM without too much embolization to normal draining veins

want to fill out edges of VM

reset roadmpa from time to time

can choose addt'l access sites using US and do same as above

when finished, remove all instruments, hold pressure

apply ace bandage wrap

recommendations to continue ace wrap x24 hrs and at bedtime for 1 wk to complete sclerossant

use NSAIDS for pain control

 

Treatment of a high flow AVM with alcohol embolziation:

overall goal is to infuse 3 ml of dehyrated alcohol into a nidus over course of 15 minute.  if infuse too fast, can cause pulmonary edema by systemic venous nontarget embolization

example is for R humeral head AVM

check prior studies, look for early shunting of blood to veins

remember that etoh has high rate of bad compliations, approx 10%

get base catheter (4F kumpe or simliar) to level of nidus

try to subselect nidus

get deep in nidus using micro catheter, can use 1.7F Headway catheter - Terumo

When you know you arein nidus, can infuse etoh

draw up 3 cc carefully and infuse ratheter quickly into lesion

chase with 1.5 cc of flush

keep etoh seperate from other syringes, disastrous to infuse alcohol into systemic ciruclation

treat 3 cc x3 over 15 minutes

when done, do postembolization imaging

then remove all instruemnts and case done

 

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pediatric liver biopsy

want to image liver either R subcostal or R intercostal lower ribcage approach

MH approach

use 16 gauge Bard Monopty device, why, gets better tissue per in house path and GI docs

use 15 gauge introducer

advance introducer to liver, pop into liver capsule, advance approx one cm

remove stylet

advance biopsy gun

take 3 cores, save each US image

use saline to fill cannula after taking stylet out- not sure why

when done, use 1 cc syringe with rolled gelfoam "pleget" to embolize tract

place one at bipsy site

place one at capsule

remove all instruments hold pressure and place dressing

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Peds renal biopsy

main point is to image lowerpole kidney on L side, prone, start long and then shift to transverse and should only see parenchyma

then biopsy as per usual, 18g biopince device

do simliar saline infusion and gelfoam pleget thing

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peds facial AVM embo

goal is to cannulate ECA territory

use 4F kumpe or berenstein to catheterize ECA

use headway catheter to select vessels

when doing angiograms, look for opacification of nidal vessels:  abnormal tangle with early draining vein

if see normal tapered vessels do not embolize

when see nidal vessels, position intranidal using 1.7F headway catheter

can now sclerose with alcohol

use 3 cc at a time, wait 5 minutes between infusions

goal is to replace existing blood with alcohol to destroy tissue endothelium

during case i saw, did 3 x 3 cc infusions and then ended case

advise pts of pain after procedure

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peds biposy MH revised

for 18 g biopince

use 17g introducer

lido at site

enter liver approx 1 cm, angle shallow

drip saline when removed stylet

advance bipsy gun and take bipsy

drip saline and replace stylet

take biopsy on wet telfa

repeat x2 or 3

for gelfoam

remove air from syringe

place pleget at site

retract needle to capsule

place pleget there

remove all and hold pressure till hemostatic

dressing and done

use capped needle to handle specimens

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of note for renal biopsy, don't access through capsule with introducer

with liver, go 1 cm below capsule with access/introducer needle

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