Exploring Pediatric Interventional Radiology:

How far can we go?

A pictorial essay

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Mu Sook Lee, Young Hwan Kim, Eun Taeg Hwang

Department of Diagnostic Radiology, Keimyung University Dongsan Hospital, Daegu, Republic of Korea

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Introduction

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Pediatric Interventional Radiology (PIR)

• Using minimally invasive techniques to diagnose and treat various conditions in children
• Enabling targeted therapies -> reduce invasiveness and patient morbidity

promote quicker recovery

improve quality of care and outcomes of pediatric patients

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Introduction

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Special consideration of Pediatric Interventional Radiology (PIR)

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Anesthesia Support

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Devices and Equipment

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Radiation exposure

ALARA principle must be followed

From Principles to Practice : our experience of PIR

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From Jan. 2010 to May 2025, our institution has performed 350 pediatric interventional procedures, which includes 178 vascular interventional procedures and 172 non-vascular procedures.

From Principles to Practice : our experience of PIR

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Non-vascular interventional procedures (172)

Percutaneous drainage of body fluid (PCD) : 39

Percutaneous nephrostomy (PCN) : 21

Gastrointestinal (GI) tract related procedures : 27

Biopsy : 20

Tubography : 18

Catheter exchange : 27

Aspiration : 9

Percutaneous transhepatic biliary drainage (PTBD): 9

Urethral dilatation :1

Sclerotherapy :1

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From Principles to Practice : our experience of PIR

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Vascular interventional procedures (178)

Central venous access : 141

Arterial line access : 1

Diagnostic angiography (15): Venography (7), Arteriography (8)

Embolization : 17

Intravascular foreign body removal : 1

Central venous catheter removal : 2

Percutaneous transluminal angioplasty (PTA) : 1

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From Principles to Practice : Non-vascular PIR

From Principles to Practice : Non-vascular PIR

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Biopsy

• Indication : diagnosis of underlying inflammatory / malignant pathology, tumor staging, or etc.
• Contraindication : uncorrectable coagulation abnormalities

non-availability of safe pathway to reach the target

ascites for abdominal lesion

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• Ultrasound (US) guidance is more preferred over computed tomography (CT) guidance.
• 22-23 gauge (G) needle for fine needle aspiration (FNA)

18-20 G automated or semi-automated biopsy guns, or coaxial system

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Figure 1. Representative examples of US-guided biopsies.

1. The image of US-guided liver biopsy of an 1-month-year old boy with cholestasis, confirmed paucity of intrahepatic bile duct.
2. 1) T2-weighted MR image of a 8-year-old girl with a 4.8-cm the left hepatic mass, and 2) US-guided biopsy; confirmed hepatoblastoma.
3. 1) T2-weighted MR image of a 13-year-old girl of a 5.4-cm the left thigh mass, and 2) US-guided biopsy; confirmed the schwannoma.

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- Yellow arrows indicate the pathway of the biopsy needle.

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From Principles to Practice : Non-vascular PIR

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Aspiration

• Image guided aspiration of fluid for diagnostic or therapeutic purposes.
• Ultrasound (US) guidance is more preferred over other imaging modalities.
• 18-20 G spinal needle or Chiba needle is frequently used for aspiration.

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Figure 2. US-guided aspiration of a periappendiceal abscess.

1. Contrast-enhanced CT image of a 10-year-year old boy shows an abscess (arrow) in the right pelvic cavity. The abscess is surrounded by bowel loops (dashed line), making percutaneous catheter drainage infeasible.
2. US-guided aspiration image demonstrates the pathway of the echogenic needle (arrow) traversing the anechoic abscess (asterisk); 23mL pus was aspirated.
3. CT image obtained one week after US-guided aspirations shows no residual abscess.

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From principles to Practice : Non-vascular PIR

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Percutaneous Catheter Drainage (PCD)

• Percutaneous catheter drainage (PCD) is a minimally invasive procedure, in which a catheter inserted through the skin into a targeted fluid collection.

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• Trocar technique : Direct insertion of the catheter, as a one-step procedure.

Seldinger technique : 21-22 G needle is used for initial puncture under US guidance and a guidewire is

introduced into the target via this needle. Then, the catheter is placed via guide wire.

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- Appropriate catheter selection based on patient size and fluid characteristics.

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Figure 3. Representative examples of PCD.

1. 1) Chest x-ray image of an 11-month-year old girl with Ebstein anomaly shows the left pleural effusion. 2) A 7F pig tail catheter (arrow) is placed at the left pleural cavity for effusion drainage.
2. 1) Contrast-enhanced CT image and 2) US image of an 1-month-year old boy demonstrate an abscess with air-fluid level (asterisk) in the left lung. 3) A 5F pig tail catheter (arrow) is placed at the left lung abscess (asterisk).

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From Principles to Practice : Non-vascular PIR

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Percutaneous Transhepatic Biliary Drainage (PTBD)

• An effective non-surgical alternative when endoscopic retrograde cholangiopancreatography (ERCP) is not feasible - for examples, in patients with hepaticojejunostomy, Roux-en-Y bilio-enteric anastomosis after liver transplantation.

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• External percutaneous biliary drainage

Internal – External percutaneous biliary drainage

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Figure 4. PTBD, cholangioplasty, and a large-bore catheter stenting for the hepaticojejunostomy stricture.

1. T2-weighted MR image of a 5-month-year old boy with Choledochal cyst.
2. US image obtained one month after surgery demonstrates an intrahepatic biliary dilatation (arrow). The boy presented with symptoms of cholangitis: fever, hyperbilirubinemia, and neutrophilia.
3. 1) A percutaneous transhepatic cholangiogram (PTC) was obtained by accessing a left intrahepatic bile duct under US guidance using a 22-G needle. 2) The PTC demonstrates a severe stricture at the hepaticojejunostomy site (arrow). 3) A 5F pig-tail catheter (arrow) was placed across the hepaticojejunostomy stricture and into the jejunum, achieving Internal-External biliary drainage.

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Figure 4. continued.

d. One month after PTBD, percutaneous transhepatic cholangioplasty was performed. An 8-mm balloon catheter was advanced over the wire

and positioned across the hepaticojejunostomy stricture. The “waist” (arrow) is seen in the balloon catheter as the stricture dilated.

5. Following cholangioplasty, a large-bore catheter (12F) was placed across the hepaticojejunostomy stricture, and then left in place for two months, as an attempt at catheter stenting.
6. A follow-up US image after percutaneous transhepatic cholangioplasty and catheter stenting illustrates the resolution of intrahepatic bile duct dilatation.

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From Principles to Practice : Non-vascular PIR

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Percutaneous Cholecystostomy

• a safe and effective minimally invasive procedure
• serve as a method to decompress the gallbladder (GB) prior to cholecystectomy, or a treatment for acalculous cholecystitis in patients who are not good surgical candidates.

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- Transhepatic approach : traversing a segment of the liver to assess the GB

- prevents the risk of bile leak, which is contained by hepatic parenchyma at the site of GB puncture

- reduces the chance of inadvertent catheter removal or dislodgement.

- Transperitoneal approach : direct puncture of the gallbladder through the abdominal cavity

Figure 5. Percutaneous transhepatic cholecystostomy for acalculous cholecystitis.

1. T2-weighted MR image of a 5-year-year old girl with a Choledochal cyst (asterisk).
2. US image demonstrates a distended gallbladder with wall thickening (arrow) and sludge (asterisk), consistent with acalculous cholecystitis.
3. After US-guided puncture of the gallbladder using a 22-G needle (arrow), 1) contrast medium was injected to confirm the gallbladder lumen (asterisk). 2) A 5-F pig-tail catheter was placed within the gallbladder lumen.

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From Principles to Practice : Non-vascular PIR

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Percutaneous Nephrostomy (PCN)

• used as temporary drainage for urinary obstruction or diversion, and a bridging procedure before definitive corrective surgery.
• has advantage of preserving renal parenchyma, minimizing deterioration of renal functions, or control infection and sepsis until corrective surgery.

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Figure 6. Percutaneous nephrostomy for the left hydronephrosis with ureter stone.

1. 1) Non-contrast CT image of a 4-year-year old boy shows a radio-opaque stone in the left ureter (arrow). 2) Contrast-enhanced coronal CT image shows left-sided hydronephrosis.
2. 1) After US-guided puncture of the left renal calyx using a 22-G needle (arrow), 2) a 0.018-inch guide wire (arrow) was introduced through the needle. 3) A 8.5F double pig-tail catheter (arrow) was placed within left renal calyx and pelvis.

Note. The radio-opaque ureteral stone (asterisk) obstructs contrast medium from left renal pelvis to distal ureter.

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From Principles to Practice : Non-vascular PIR

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Esophageal Balloon Dilatation

• Treatment options for esophageal stricture in children has evolved from surgical revision, to esophageal bougienage, and to the currently used esophageal balloon dilatation.

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• Esophageal balloon dilatation for stricture is a safe and effective procedure with excellent long-term results in pediatric patients. It is associated with fewer dilatation sessions and a lower complication rate compared to bougienage.
• Older age and an eccentric shape of the stricture have been reported as factors associated with a poor response to balloon dilatation.

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Figure 7. Esophageal balloon dilatation for anastomotic stricture secondary to surgical repair of esophageal atresia (EA).

1. 1) An infantogram at the birth and 2) on day 3 after birth demonstrate a coiled nasogastric tube (arrow). The absence of stomach gas on both infantogram suggests type A EA without trachea-esophageal fistula.
2. Follow-up esophagogram obtained 3-months after the corrective surgery shows severe stricture (arrow) at the anastomosis site.
3. A 10-mm balloon catheter was advanced over the wire and positioned across the esophageal anastomotic stricture. The “waist” (arrow) is noted on the balloon catheter as the stricture dilated.
4. Follow-up esophagogram at 10 months of age demonstrates improvement of the stricture (arrow).

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From Principles to Practice : Non-vascular PIR

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Fluoroscopic Stomach Pylorus Balloon Dilatation

• Stomach pyloric balloon dilatation is a less invasive treatment improving gastric drainage in children with symptoms associated with delayed gastric emptying who were no respond to medical treatment.
• Pyloric balloon dilatation may facilitate a larger pyloric channel opening with lower resistance to flow at the time of pyloric relaxation. This leads to improved gastric emptying, regardless of the mechanism responsible for the delay.

Figure 8. Fluoroscopic stomach pyloric balloon dilatation.

1. A fluoroscopic upper gastrointestinal (GI) series of an one-month-old girl demonstrates severely delayed gastric emptying. She was born prematurely at 30 weeks of gestation and presented with frequent vomiting and failure to thrive. No evidence of mechanical gastric outlet obstruction was observed on ultrasonography.
2. An 10-mm balloon catheter (arrow) was advanced over the wire and positioned across the stomach pylorus.

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From Principles to Practice : Non-vascular PIR

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Naso-Enteric (nasoduodenal or nasojejunal) Feeding Tube Insertion

• Nutritional support is important for children with inadequate nutrition intake or manifestation of wasting and stunting. Enteral feeding is more favorable than parenteral feeding, since enteral feeding maintains gut integrity and prevent bacterial translocation.
• Enteral tube feeding involves the artificial delivery of nutrition directly to gastrointestinal tract.
• Post-pyloric access, nasoenteric tube insertion into the proximal small bowel, may be necessary in specific circumstances, including a severe gastrointestinal reflux disease (GERD) with risk of aspiration, gastric emptying dysfunction, gastric outlet obstruction, acute pancreatitis, or early postoperative feeding after major abdominal surgery.

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Figure 9. Fluoroscopic nasoenteric feeding tube insertion.

1. A contrast-enhanced CT image of an 11-year-old girl shows diffuse pancreas swelling and peripancreatic fluid collection (arrow). It suggests acute pancreatitis.
2. A 8F feeding tube (arrow) was advanced over the wire until it reaches the 3^rd. portion of the duodenum. The side hole of the tube is located along the1^st. to 3^rd. portions of the duodenum, thus contrast material is seen in the duodenum through these side holes.

From Principles to Practice : Non-vascular PIR

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Urethral Balloon Dilatation

• Pediatric anterior urethral strictures can be iatrogenic (associated with hypospadias or catheterization), traumatic, inflammatory (associated with lichen sclerosis), post-infectious, or congenital.
• Endoscopic visual internal urethrotomy (EVIU) may be a safe and useful first-line treatment option regardless of the stricture site and etiology. However, if the guide wire cannot pass through the stricture point during EVIU, the operation is often converted from EVIU to open urethroplasty. In such cases, interventional urethral balloon dilatation is helpful to secure the urethral route prior to subsequent EVIU

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Figure 10. Urethral balloon dilatation.

1. 1) A retrograde urethrography of a 12-year-old boy with straddle injury demonstrates partial rupture of the bulbous urethra (arrow). 2) An antegrade urethrography three weeks after the injury shows a severe stricture of the bulbous urethra (arrow).
2. An 5-mm balloon catheter (arrow) was advanced over the wire and positioned across the urethral stricture. The “waist” (arrow) is seen in the balloon catheter as the stricture dilated.

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From Principles to Practice : Non-vascular PIR

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Sclerotherapy

• Lymphatic malformations are one type of vascular malformations and consist of masses of abnormal lymphatic vessels.
• OK-432 (Picibanil) was considered to induce direct inhibition of RNA synthesis in tumor cells. The mechanism of OK-432 remains confined within the malformations after injection and stimulates lymphatic endothelial cells, resulting in obliteration of lymphatic channels with minimal local fibrosis.
• Sclerotherapy of lymphatic malformations with OK-432 achieves excellent to good clinical response in the majority of patients. Swelling, redness at the injection site, low-grade fever and pain are to be expected after the therapy with OK-432.

Figure 11. Sclerotherapy of a cystic lymphangioma with OK-432.

1. T2-weighted MR image of a 16-year-old girl demonstrates a 4.2x2.5x2.6-cm cystic mass (arrow) with fluid-fluid level at around the elbow. It was confirmed to be a cystic lymphangioma.
2. 1) An US image obtained on the day of the procedure shows a hyperechoic cystic mass. After puncturing the mass, 13 mL of hemorrhagic fluid was drained, suggesting that the cystic lymphangioma may has been complicated by hemorrhage. 2) Contrast material was then injected to confirm the absence of leakage from the mass. Finally, 10mL of OK-432 (1 KE in 9 mL normal saline solution) was administrated.
5. A follow-up US image obtained 5 months after sclerotherapy illustrates a markedly decreased size of the lymphangioma (arrow).

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From Principles to Practice : Vascular PIR

From Principles to Practice : Vascular PIR

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Central Venous Access

• Central access refers to the distal tip of the line landing in the larger veins of the central venous system.
• The indications for central venous access are broad and can include administration of large volume fluids, parenteral nutrition, vasoactive or peripherally caustic medications; pressure monitoring; hemodialysis or apheresis; bone marrow transplant; or repeated blood draws for laboratory studies.

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• Considerations : the catheter diameter, length, type of material of catheters, number of catheter lumen.

non-tunneled (for temporary short-term use) vs. tunneled (for long-term use)

site of access – percutaneous vs. open

Figure 12. Representative examples of central venous access.

1. A 4F central venous catheter (arrow) inserted through the right internal jugular vein in a 20-day-old girl.
2. A 3F peripheral inserted central catheter (PICC, arrow) inserted through the right basilic vein in a 3-year-old girl.
3. A 5F Powerline catheter (tunneled catheter, arrow) inserted through the right internal jugular vein in an 11-year-old girl.
4. A 7F Hickman catheter (tunneled catheter, arrow) inserted through the right internal jugular vein in a 9-year-old boy.

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Figure 12. continued.

5. A 12F long-term tunneled dialysis catheter (tunneled catheter, arrow) inserted through the right internal jugular vein in a 12-year-old girl.
6. 8F vascular sheaths were inserted separately via the 1) left internal jugular vein and 2) the right common femoral vein in a 4-year-old girl with leukemia preparing for hematopoietic stem cell transplantation. According to guidelines, the same lumen should not be used for both infusion and blood sampling during stem sell administration to prevent inadvertent loss of infused cells.

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From Principles to Practice : Vascular PIR

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Diagnostic Angiography

- Recent trends in noninvasive imaging have resulted in a dramatic decrease in the need for conventional diagnostic angiography. However, it is still necessary for detailed examination of internal organs such as the heart and kidneys, and for diagnosing diseases.

Figure 13. Diagnostic angiography.

a. Venography of an 8-year-old girl with progressive swelling of the right neck and face demonstrates complete occlusion of the right subclavian vein.

A collateral vein (dashed line) is observed between the right axillary vein and superior vena cava.

b. 1) Inferior mesenteric and 2) superior mesenteric arteriographies in a 3-year-old girl with hematochezia unresponsive to medical treatment

shows no definite evidence of contrast extravasation.

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From Principles to Practice : Vascular PIR

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Percutaneous transcatheter embolization

• Indications : bleeding – traumatic, iatrogenic, spontaneous, or disease related.

preoperative or palliative embolization of tumor

pulmonary arteriovenous malformation

bronchial artery embolization for hemoptysis

congenital and acquired cardiovascular disease

venous disease - varix, or varicocele.

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From Principles to Practice : Vascular PIR

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Percutaneous transcatheter embolization

• Embolic materials
• Gelatin foam (Gelfoam) : temporary vessel occlusion, allowing for recanalization in a few weeks.
• Particles : permanent occlusion by adherence to the vessel wall, causing stagnation of flow.

Polyvinyl alcohol (PVA), Tris-acryl gelatin microsphere (Embosphere)

3) N-Butyl Cyanoacrylate (NBCA) : permanent liquid embolizing agent popularly known as glue.

4. Coils : permanent mechanical embolizing agents.
5. Vascular plugs : occlusive devices of nitinol, intended for permanent occlusions.
6. Ethanol :most powerful sclerosing agent, used in treatment of arteriovenous malformations.

From Principles to Practice : Vascular PIR

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Percutaneous transcatheter embolization for traumatic injury

• Post-traumatic hemorrhage can be due to either a blunt trauma or a penetrating injury to a vessel. Solid organs like liver, spleen and kidneys are commonly involved in patients with blunt trauma.
• Transcatheter arterial embolization may precede or follow laparotomy to achieve complete hemostasis.
• In the case of bleeding, embolization is almost always performed with an endovascular approach via the common femoral artery catheterization. To achieve superselective target embolization and avoid non-target organ ischemia, microcatheters are used to navigate as close as possible to the bleeding site.

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Figure 14. Hepatic artery (HA) embolization for traumatic liver injury.

1. Contrast–enhanced CT image of a 2-year-old girl after a traffic accident (TA) reveals an AAST grade IV liver injury. A small pseudoaneurysm (arrow) is suspected at the injury site. An hypervascular lesion (dashed line) is also observed at the left liver (S2).
2. Follow-up CT after 5 days shows an increased size of the pseudoaneurysm (arrow) at the liver.
3. Selective proper hepatic arteriography using a 1.5 F microcatheter (dashed line) confirms the presence of a pseudoaneurysm (arrow) arising from the left HA.
4. After superselective embolization of the left HA with Gelfoam, the pseudoaneurysm disappears, while the remaining HA branches show patent.

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Figure 14. continued.

e. Follow-up CT image obtained at 7 days after HA embolization demonstrates complete resolution of the pseudoaneurysm within the hypodense injury area (arrow) of the liver.

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Figure 15. Splenic artery embolization for traumatic spleen injury.

1. Contrast–enhanced CT image of a 7-year-old boy after a TA reveals an AAST grade IV spleen injury and contrast leakage (arrow). There is also hemoperitoneum (asterisk) around the liver and spleen.
2. Celiac arteriography using a 4F catheter (dashed arrow) demonstrates the a pseudoaneurysm with contrast leakage (arrow) and splenic laceration (asterisk).
3. After superselective embolization of the branches of splenic artery with Gelfoam and Particles, the pseudoaneurysm disappears, achieving hemostasis while preserving perfusion to the inferior splenic parenchyma.

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Figure 15. continued.

d. Follow-up CT images obtained at 1) 3 weeks, and 2) 3 months after the splenic artery embolization demonstrate a progressive decreasing in the extent of splenic laceration (asterisk), while the remaining splenic parenchyma is preserved.

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Figure 16. Renal artery embolization for traumatic kidney injury.

1. Contrast–enhanced CT image of a 13-year-old boy after a TA reveals an AAST grade V kidney injury, with perirenal hematoma (asterisk).
2. Selective left renal arteriography using a 4 F catheter (dashed line) demonstrates laceration (asterisk) of the left kidney and a pseudoaneurysm (arrow) arising from the left renal artery.
3. After superselective embolization of the left renal artery with Gelfoam and coils (arrow), the pseudoaneurysm disappears, achieving hemostasis

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Figure 16. continued.

4. Follow-up CT image obtained at 3 months after the renal artery embolization demonstrate the positioned coils (arrow), with devascularization of injured portions (asterisk) of the left kidney, while preserving the remaining parenchyma of the left kidney.
5. Tc-99M dimercaptosuccinic acid (DMSA) scintigraphy shows preserved cortical integrity (arrow) in the lower pole of the left kidney.

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Figure 17. Inferior epigastric artery embolization for traumatic abdominal muscle injury.

1. Contrast–enhanced CT image of a 7-year-old boy who fell on a bicycle shows a large hematoma (asterisk) in his left anterior abdominal wall with contrast extravasation (arrow).
2. Selective left inferior epigastric arteriography using a 4 F catheter (dashed line) demonstrates a pseudoaneurysm (arrow).
3. After superselective embolization of the left inferior epigastric artery with Gelfoam, the pseudoaneurysm disappears, achieving hemostasis.

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Figure 17. continued.

d. US image obtained 1 month after embolization of the left inferior epigastric artery demonstrates a small residual chronic hematoma (asterisk ) in the abdominal wall.

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From Principles to Practice : Vascular PIR

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Preoperative or Palliative Embolization of Tumor

• to reduce the blood loss during surgery.

preferred to do preoperative embolization 24–48 hours prior to surgery.

- to alleviate symptoms and to increase the sensitivity of tumor to other treatment modalities.

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• Organ embolization : Embolization of spleen can be performed as a part of preoperative management or as an alternative to surgical splenectomy. Patients requiring unilateral nephrectomy because of end stage renal disease or renovascular hypertension can be managed with renal embolization.

Figure 18. Preoperative splenic artery embolization.

1. Contrast–enhanced MR image of a 9-year-old boy demonstrates a 4-cm splenic mass (asterisk), biopsy-proven as sclerosing angiomatoid nodular transformation. Splenic artery embolization was requested prior to partial splenectomy due to concern about intraoperative blood loss.
2. 1) Selective splenic arteriography using a 4 F catheter (dashed line) and 2) C-arm CT reveals a mass in the spleen (asterisk). The automated vessel tracking system on C-arm CT identified the mass-feeding branches of the splenic artery.
3. After superselective embolization of these feeding arteries with Coils (arrow) and Gelfoam, the portion of spleen containing the mass (asterisk) was successfully devascularized.

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From Principles to Practice : Vascular PIR

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Pulmonary ArterioVenous Malformation (AVM)

• classically characterized by a tangle (i.e., nidus) of anomalous, poorly formed vessels, resulting in abnormal communication between pulmonary arteries and veins, that bypass lung capillary bed, causing right-to-left shunts.
• may results in several serious complications may present as consequences of distal thrombosis and embolization by paradoxical mechanism, or malformations rupture, i.e., cerebrovascular stroke or transient ischemic attack, abscesses, splanchnic vessels embolization, hemoptysis, and hemothorax.
• congenital (80%), and an association with hereditary hemorrhagic telangiectasia (HHT) is reported.
• can grow during puberty, with a rate of approximately 10% per year, and double in size every 5–6 years.

From Principles to Practice : Vascular PIR

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Pulmonary ArterioVenous Malformation (AVM)

• indications for treatment include any solitary or multiple PAVMs with a feeding artery diameter higher than 2–3 mm, evidence of growth, paradoxical emboli, symptomatic hypoxemia, or any of the other aforementioned serious complications.
• endovascular treatment, that is, selective embolization of the pulmonary artery feeding the nidus of the AVMs, the nidus, or the draining vein, has become a first-line treatment, with advances in interventional devices

Figure 19. Pulmonary AVM embolization.

1. Contrast–enhanced CT image of a 2-year-old boy presenting with hypoxemia demonstrates a large pulmonary AVM (arrow) in the right lung.

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Figure 19. continued.

2. Pulmonary arteriography reveals the pulmonary artery (arrow) feeding a large pulmonary AVM nidus (asterisk) and draining vein (dashed line).

He underwent multiple sessions of coil embolization at the age of 2, 5, and 10 years due to recurrent hemoptysis requiring frequent hospital

admission.

3. 15 months after the third coil embolization for pulmonary AVM, he was readmitted with hemoptysis and hypoxemia. 1) Angiography shows a

markedly hypertrophied bronchial artery (arrow) with persistent flow (arrow head) into the previously treated pulmonary AVM with coil

packing (asterisk). 2) After superselective embolization of bronchial artery using Gelfoam and Embosphere, the flow to the AVM disappeared.

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From Principles to Practice : Vascular PIR

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Major AortoPulmonary Collateral Arteries (MAPCA) in congenital heart disease

• the vascular channels that arise from systemic arteries and supply the pulmonary parenchyma in congenital heart diseases associated with reduced pulmonary blood flow.
• commonly arise from the descending thoracic aorta and less frequently from the arch of aorta, branches of subclavian arteries, and abdominal aorta and its branches.
• result in pulmonary hyperperfusion by inducing overflow of blood into the pulmonary arteries, leading to pulmonary arterial hypertension and a further pressure overload on an already overburdened right ventricle in case of pulmonary stenosis.
• Preoperative embolization of MAPCA is important to augment growth of native pulmonary artery and reduce symptoms of cyanosis.

Figure 20. Embolization of MAPCA

1. Contrast–enhanced CT image of a 3-year-old girl with a history of transposition of the great arteries (TGA) with pulmonary atresia, who underwent Blalock-Taussig (BT) shunt and bidirectional cavopulmonary shunt (BCPS), demonstrates multiple MAPCAs (arrow) arising from descending thoracic aorta, bronchial artery, and subclavian artery.

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Figure 20. continued.

2. Angiography demonstrates multiple MAPCAs (arrow) arising from 1) descending thoracic aorta, 2) the right subclavian artery, and 3) the left

common carotid artery.

3. Thoracic aortography after embolization of MAPCAs using coils (arrow) and Gelfoam reveals no residual flow through the embolized segments of

MAPCAs.

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Figure 20. continued.

4. Contrast-enhanced CT of this girl also shows a severe stenosis of the left pulmonary artery (arrow).
5. 1) Pulmonary arteriography demonstrates a severe stenosis (arrow) at the left proximal pulmonary artery. 2) A 5-mm balloon catheter (arrow) was advanced over the wire and positioned across the stenosis, followed by balloon dilatation of the stricture.
6. Follow-up pulmonary arteriography demonstrates resolution of the left pulmonary artery stenosis.

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From Principles to Practice : Vascular PIR

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Percutaneous Umbilical Varix Embolization

• Ectopic varices are defined as any dilated portosystemic collateral veins outside the typical gastro esophageal region. The most common sites for ectopic varices are throughout the small intestine (mainly duodenum), colon and rectum, and peritoneum. Less frequently they may be found in the umbilicus, right diaphragm, vagina, and ovaries.
• Cutaneous umbilical variceal bleeding is a rare complication of portal hypertension.
• Reported treatment approaches include local umbilical vein ligation, embolization of paraumbilical veins, TIPS, and laparoscopic clipping of the umbilical vein.

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Figure 21. Percutaneous umbilical varix embolization.

1. CT images of a 15-year-old boy, a long-term native liver survivor after Kasai operation, demonstrates an umbilical varix (yellow arrow) with recanalized paraumbilical veins (white arrow).
2. Color Doppler US image reveals turbulent blood flow within the umbilical varix.
3. Under US guidance, the umbilical varix was directly punctured, and a 4 F catheter was advanced into the umbilical varix. 1) After confirming opacification of the umbilical varix (asterisk) and paraumbilical veins (white arrow), 2) embolization was performed using NBCA mixed with Lipiodol at a 1:3 ratio.

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From Principles to Practice : Vascular PIR

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Endovascular retrieval of intravascular foreign body

• An intravascular foreign body may be an iatrogenic complication that occurs during arterial or

venous catheterization or interventional procedures. The foreign body could either be a catheter

fragment, a dislodged coil, or a steel guide wire.

• While surgical approaches were traditionally favored, recent years have seen a shift towards

percutaneous endovascular retrieval techniques.

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• Snares, deflectable guidewires, wire baskets, and intravascular forceps (bioptomes) may be used to

retrieve these objects

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Figure 22. Endovascular retrieval of a broken guide wire.

1. Abdominal X-ray image of an 1-year-old boy demonstrates a broken guide wire (arrow) retained in the left femoral vein and inferior vena cava. The guide wire left in place while attempting to insert a central venous catheter via the left femoral vein by his pediatrician.
2. 1) The snare (arrow) entrapped the broken guide wire (dashed line) at the level of the right iliac vein, and 2) the guide wire was captured and withdrawn into the introducer sheath until it was completely removed.
3. A new central venous catheter (arrow) was inserted through the right femoral vein.

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Conclusion

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• Pediatric interventional radiology (PIR) represents a significant advancement in pediatric care, offering minimally invasive solutions for a wide range of conditions.
• While most interventional radiology techniques performed in adults can also be applied to pediatric patients, unique considerations such as patient size, developmental physiology, radiation sensitivity, and the need for sedation or anesthesia necessitate specialized approaches.
• Technological innovation and adaptability—such as modifying adult-sized devices for infants and using hybrid operating rooms—are critical to ensuring success in pediatric cases.

References

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• Paediatric interventional radiology; Radiography (2014) 1-7
• Update on Pediatric Interventional Radiology; Radiographics (2022); 42:1580-1597
• Challenges and Opportunities for Continued Success and Growth of Pediatric Interventional Radiology: A Communiqué From the Society for Pediatric Interventional Radiology; AJR (2018); 211:740-743
• Pediatric Interventional Imaging: Advancements and Considerations; Interve. Pedia. Rese. (2023) 6(4), 98–100
• Developing a Clinical Pediatric Interventional Practice: A Joint Clinical Practice Guideline from the Society of Interventional Radiology and the Society for Pediatric Radiology; JVIR (2011);22:1647-1655
• Embolization in Pediatric Patients: A Comprehensive Review of Indications, Procedures, and Clinical Outcomes; J. Clin. Med. (2022), 11, 6626
• Factors influencing outcomes of esophageal balloon dilatation for anastomosis site stenosis after esophageal atresia surgery; Pediatric Radiology (2023) 53:349–357