A Look at Advanced Pediatric Interventional Radiology

Apr 11, 2016 at 11:27 am by Staff

When people think of interventional radiology (IR), they often think of tiny tubes snaked into the heart or brain by an interventional radiologist subspecialized in one area or the other. That's typical of adult IR, but pediatric IR is a whole-body specialty providing access almost anywhere in the body with minimal trauma, relatively low risk and very short recovery times.

Whether we're working on an image-based diagnosis, a biopsy or a therapeutic intervention such as blocking the blood supply to a vascular anomaly, IR is usually the least invasive approach available. At times, a pediatric IR procedure will provide so much new information that the working diagnosis must be revised. My experience at Nemours Children's Hospital (NCH) reinforces the perspective that pediatric IR is a head-to-toe specialty, since it's common to go from a patient with a vascular malformation in the face to one with an anomaly in the leg.

In pediatric IR we work hand-in-hand with our referring physicians to discuss IR alternatives when there's a need to collect diagnostic information or apply treatment. Which IR techniques might benefit a pediatric patient may not be immediately obvious; the possibilities vary on a case-by-case basis and change as technology evolves, so we welcome inquiries.

The management of a deep vein thrombosis (DVT) in the leg or thigh of a teenager is a great example. It's common to treat with anticoagulant drugs only, but while waiting for the drugs to take effect and dissolve the clot, swelling may continue and cause tissue damage. If the clot lasts long enough, it may prompt the development of collateral circulation, which may produce swelling and chronic pain after the clot has dissolved. IR techniques can improve the chances for a good, long-term outcome. We can place a filter in the inferior vena cava to protect the heart and lungs from clot movement, and then advance a catheter into the clot and perfuse it with a thrombolytic agent, or use a saline jet or ultrasound to disintegrate the clot while suctioning away the debris.

The procedure and equipment costs are greater than anticoagulation therapy alone, but quick removal of the thrombus can reduce the length of hospital stay and the potential for future problems requiring ongoing treatment. Recovery times are negligible, and patients and parents love that! We don't stop there, though. We work and interact in a multidisciplinary environment. In the case of an unexplained DVT, we'll work with our colleagues in hematology to determine the cause and the best practice for prevention.

Even for routine procedures like line placements, the potential for IR techniques to make things easier on patients is very significant. We frequently use these techniques to insert vascular access ports and tunneled lines, and use similar techniques for lumbar punctures for CNS chemotherapy access. Without pediatric IR, central line placements like those we've performed on 900-gram premature babies would be possible only with surgical dissection.

In addition to offering many alternatives, pediatric IR can also change outcomes. For patients with osteoid osteomas, surgical excision often results in considerable pain and weakened bone structure. In IR, we can overheat the osteoma with a radiofrequency ablation tool, or freeze it with a cryogenic one -- both modalities kill and shrink the osteoma. The patient typically goes home the same day and has only mild discomfort for a couple of days.

Because pediatric IR can offer advantages in treating many different kinds of tumors, we participate in multidisciplinary tumor board conferences. Even when IR techniques are not curative, they can still be very helpful. For palliative treatment of malignancies in non-surgical candidates, cryoablation is often an effective and much appreciated tool.

We can do a lot for cystic fibrosis patients too. For a patient with a bronchial artery hemorrhage, bleeding can be extensive. Coughing up blood is especially unsettling to the patient and family. Rather than waiting for the natural clotting process to stop the bleeding, we use IR techniques to locate and plug the bleeding vessel. The treatment offers the patient and family a prompt resolution of the problem and reduces the duration of the patient's and family's anxiety and concern.

As the number of options and applications for interventional radiology in children is growing, the associated levels of radiation exposure are falling. We recently upgraded our fluoroscopy equipment so it can support new protocols that reduce radiation doses by 50-75 percent of the previously required exposure. In all of our techniques, we maintain the ALARA principle of radiation dosing: As low as reasonably achievable.

Despite all the great IR technology available, ranging from coils to lasers, we never forget that the equipment is just expensive gear if it's not used as part of a plan focused on what's best for the patient. To better answer the questions of what techniques to use, when to use them and for which patients, we continue research.

I'm interested in sclerotherapy agents and work to determine which of the commonly used agents (doxycycline, metal coils, detergent or cyanoacrylate glue) works best, alone or in combination. Through our research and that of others, we're always learning. We've learned, for example, that a fibro-adipose venous anomaly (FAVA) is particularly resistant to sclerotherapy. Surgical removal of FAVAs requires removal of muscle, so we're still looking for better IR tools to help treat FAVAs. Recent research indicates some FAVAs may be susceptible to cryoablation, so this offers a new option to consider for our patients who have these complex and often painful vascular anomalies.

NCH has the only two dual-trained board-certified pediatric diagnostic and interventional radiologists in the state. We are leading Central Florida in maximizing the opportunities for better patient care using IR, while reducing the risks of radiation exposure and invasive interventions. Other hospitals in the region have recognized the value of our expertise and have helped us extend our reach to their patients by granting emergency privileges to us. Through sustained teamwork, research and care, we're improving the lives and futures of children throughout the region.

Fabiola C. Weber-Guzman, MD, is a pediatric interventional radiologist who earned her medical degree at the Ponce School of Medicine and Health Sciences and completed an internship and residency at University Hospitals Richmond Medical Center and a diagnostic radiology residency at the Medical College of Georgia. She completed fellowships in pediatric radiology and pediatric interventional radiology at Boston Children's Hospital. Dr. Weber-Guzman is board-certified by the American Board of Radiology.

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