Pediatric Interventional Radiology

Peds IR Basics - Tiny Patients, Big Care

• Consent & Assent:
  • Parental/guardian consent mandatory.
  • Assent from capable children (often >7 years), explained simply.
• Sedation Spectrum & Monitoring:
  • Minimal (anxiolysis) → Moderate → Deep → General Anesthesia (GA).
  • Agents: Midazolam, Fentanyl, Ketamine, Propofol.
  • Monitoring: ECG, $SpO_2$, BP, $EtCO_2$.
  • 📌 Reversals: Flumazenil (Benzos), Naloxone (Opioids).
• Radiation Safety (ALARA):
  • "As Low As Reasonably Achievable."
  • Dose reduction: Pulsed fluoro, collimation, shielding, ↑kVp/↓mAs.
  • Use pediatric Dose Reference Levels (DRLs).

⭐ The 'Image Gently' campaign advocates for radiation safety in pediatric imaging, emphasizing dose reduction.

Peds Vascular IR - Navigating Tiny Tubes

• Central Venous Access (CVA)
  • Indications: TPN, chemotherapy, long-term antibiotics.
  • Types:
    • Non-tunneled: Short-term (IJ, femoral, subclavian).
    • Tunneled (e.g., Hickman): Long-term, cuffed (IJ, subclavian).
    • PICCs: Intermediate-term (basilic, cephalic veins).
    • Ports: Longest-term, intermittent access (chest, arm).
  • Complications: 📌 TIMP - Thrombosis, Infection, Malposition, Pneumothorax/Catheter fracture.
• Angiography
  • Indications: Peds trauma (e.g., active bleed), vascular anomalies (AVMs, hemangiomas).
• Embolization
  • Agents: Coils, Gelfoam, particles (PVA), glue (NBCA).
  • Applications: Trauma, AVMs, tumor devascularization, GI bleeds, varicocele.
• Angioplasty/Stenting
  • Indications: Renal artery stenosis (RAS), coarctation of aorta, other congenital/acquired stenoses.
  • Challenges: Small vessel size, patient growth, restenosis.

⭐ In infants, the Right Internal Jugular (RIJ) vein is preferred for tunneled CVCs to minimize risk of thoracic duct injury (left-sided structure).

Peds Non-Vascular IR - Drains, Biopsies & Beyond

• Image-Guided Biopsy:
  • Modalities: US (commonest), CT, fluoro.
  • Targets: Liver, kidney, lung, bone, LNs. High diagnostic yield.
  • Needles: FNA (cytology), Core (histology).
  • Complications: Bleeding, pneumothorax (lung), infection.
• Drainage Procedures:
  • Targets: Abscess, collections (urinoma, biloma), pleural effusion/empyema.
  • Techniques: Seldinger (preferred), trocar. High success rates.
  • Catheters: 6-12F common; pigtail, Malecot.
• GI Interventions:
  • Gastrostomy/Gastrojejunostomy (G/GJ tubes):
    • Indications: Feeding difficulties, GERD (GJ).
    • Technique: Percutaneous radiologic.
    • Complications: Leakage, infection, dislodgement, buried bumper.
  • Foreign body retrieval: Esophageal (coins), gastric.
• Biliary Interventions:
  • PTBD (Percutaneous Transhepatic Biliary Drainage)/Cholecystostomy: For biliary obstruction, cholangitis, post-Kasai complications.
  • Complications: Bleeding, bile leak, sepsis.

⭐ Most common indication for percutaneous gastrostomy in children: Neurological impairment leading to feeding difficulties.

Peds IR for Specific Pathologies - Tiny Heroes, Big Fights

• Oncology IR:

  • Hepatoblastoma: TACE for unresectable tumors (Doxorubicin, Cisplatin).
  • Wilms'/Neuroblastoma: Image-guided biopsy, pre-op embolization, venous access.

• Vascular Malformations (VMs): 📌 Mnemonic: "Low flow, Lymphatics & Veins, Slowly Swell; High flow, Arteries, Fast Feel."

  Type	Flow	Examples	IR Treatment	Sclerosants
  Low-Flow	Venous	Venous Malf.	Sclerotherapy	Bleomycin, Doxycycline, Ethanol
  	Lymphatic	Lymphatic Malf.	Sclerotherapy	Bleomycin, Doxycycline
  High-Flow	Arterial	AVMs, AVFs	Embolization	N/A

• Portal Hypertension:

  • Causes: EHPVO (Extrahepatic Portal Vein Obstruction), biliary atresia.
  • IR: BRTO, variceal embolization, TIPS (older children, select cases).

• Musculoskeletal IR:

  • Biopsies: Bone/soft tissue (infection/tumor).
  • Ablation: Osteoid osteoma (RFA/Cryo).

  ⭐ RFA is first-line IR for symptomatic osteoid osteoma; success >90%.

High‑Yield Points - ⚡ Biggest Takeaways

• Sclerotherapy is key for low-flow vascular malformations (lymphatic, venous).
• Image-guided biopsies and drainage (abscess, nephrostomy, biliary) are fundamental.
• Central venous access (PICC lines, tunnelled catheters) is a common pediatric IR procedure.
• Embolization is crucial for trauma, AVMs, and pre-op tumor devascularization.
• Intussusception reduction via air/contrast enema is a hallmark intervention.
• Thermal ablation (RFA) effectively treats osteoid osteomas and select tumors.