Pediatric Interventional Radiology

Continue Continue Continue Continue Continue Continue Continue Continue Restricted © Siemens Healthcare Diagnostics Inc., 2019 Continue Continue Continue Continue Continue Pediatric Interventional Radiology Objective 1 Objective 1 Objective 1 Objective 1 Objective 4 Objective 4 Objective 4 Objective 4 Objective 4 Objective 2 Objective 2 Objective 2 Objective 2 Objective 2 Objective 3 Objective 3 Objective 3 Objective 3 Objective 3 Select each button to learn more. Pediatric Interventional Imaging Online Training Welcome Welcome to Pediatric interventional imaging online training. Select each button to review the course objectives before starting the training. Objective four Best practices for imaging pediatric patients. 4 4 4 4 Objective three Review considerations to take in the IR lab. 3 3 3 3 A doctor holding a baby Description automatically generated Objective two Discuss Interventional Radiography Procedures 2 2 2 2 Developers – second color option for image/content. align all objectives to be the same Objective One Evaluate pediatric anatomy and pathologies. 1 1 1 1 ? When it comes to Pediatrics… Branch of medicine serving infants all the way into young adulthood 0-18 years old Sometimes older depending on pathology and hospital policy Pediatric patients are: Developing and delicate Leads to added precautions and increased need for precision Lower dose and lower profile equipment Catheter based treatments are becoming more relevant: Increased risk of post-embolization syndrome in peds Increased risk of arterial spasm/dissection Increased demand of anesthesia, body temperature control and aggressive pain control Introduction Pediatrics is the branch of medicine that deals with children from infancy up to 18 years old… Pediatrics at first sounds very intimidating. THere is a broad range of patients, from newborns all the way up to possibly their 20s, depending upon the hospital, the type of pathology present, or the possibly something cognitive. Key things to keep in mind when working with pediatric patients, is that they are developing and delicate. This means increased need for precautions along with precision in performing procedures. Keeping dose minimal while working with lower profile equipment, and very small instruments, elevates the physician and other providers need for precaution and precision to a very high level. When it comes to treating these patients, via catheter based treatments, there is an increased risk of post embolization syndrome. When they have come off of anesthesia, the effects of these procedures will be very high… dealing with very small, and fragile vessels, comes with increased risk of spasm and dissection.. ? Anatomy Anatomy – unique physiology often requiring a multidisciplinary approach Majority of peds IR centers around treatment of congenital pathologies/lesion. Anatomy Because children are developing their anatomy and Physiology is very unique and will often require a multidisciplinary approach… in the PEDs lab, there will be a specific branch of anesthesia, surgeons and other providers who are very closely tied to these patients. Drag the dial to see information for each section Pathologies ? Pathologies Drag the dial to review some vascular malformations that can be seen in the pediatric I-R lab. Vascular layer the lymphatic system, is a very huge part of our immune system.. it's responsible for delivering nutrients to tissues..... Also helps with filtering out interstitial fluid, that usually leaks out at the capillary level,, It plays a key role in grabbing and destroying harmful substances,, such as cancerous cells, bacteria, and viruses.... with lymphatic malformations,, usually these children are dealing with just abnormal development, of these lymphatic vessels.... Usually there is no direct cause as to why this happens.... This is Something that happens during embryonic development of these children.., and is usually very noticeable, because they protrude outside of the body..... They are giant pockets of soft compressible masses, appearing blue purplish in appearance..... THey are most common in the head and neck area, and usually are classified by size,. A macrocyst, being just a large singular collection,,,, microcyst being just a a focal collection of a bunch of different little cysts, and then where they are in the body, are they superficial or are they deep??... Usually these are spotted, either they're visible or for the deeper malformations, something like an M-R lymph angiogram, helps spot the locatin of. They are treated by draining the lymph fluid, and sclerosing the cyst, either with doxycycline, or bleomycin.... With the overall goal to decrease the size.... chylothorax........ THis can occur on a child who had a recent heart surgery, due to some sort of congenital defect,.... WHile performing surgery on the child, sometimes a lymphatic vessel can be cut, and then these giant collections of lymph are seen in the thoracic cavity..... These are usually diagnosed by fluoro, or M-r lymph angiogram, with li-pi-adol, to identify the leak... Then this can be repaired with coils, and glue, to go ahead and stop the leak, or it may have to be passed off to surgery..... Venous malformations glomulo -venous mal formations or G-V-Ms... They appear on the patient, as a bunch of little, Pebble like, protrusions on their skin, and are pretty hard to the touch, like rocks..... the glomulus or glomulus cells in the veins, develop abnormally and protrude out.... In the pediatric neuro I-R, there are a good deal of cerebral cavernous malformations seen..... These are abnormal bundles of veins, and capillaries, usually in the brain.... These are definitely a concern, because they often bleed and grow, which creates other issues with, compressing other pertinent anatomy, in these children... ... Patients that have this malformation, also have a pretty decent risk of developing other skin venous malformations. Blue rubber bleb. Nevis syndrome, is venous malformations all over the patient. ... It can be superficial or deep,.... And then Ma-fucci syndrome, deals with venous malformations at the skin, as well as multiple benign tumors on the bone of these patients.... AV malformations arterial venous malformations, or A-V-M for short, are also very pertinent in these children.... abnormal bundles of capillaries, between the arteries and the veins, and these are very dangerous..... While they are rare, there's a high risk of rupture.... So definitely want to spot these, and treat them as soon as possible, before having to deal with a hemorrhage..... These are most common in the brain, and spine, but can be seen anywhere in the body..... Usually these are graded depending on size, location and pattern..... the lower the number, the easier they are to treat... The higher the number, the more difficult treatment will be, and the the higher risk of neurological impairment.... Usually these can be handled by embolization, for larger ones, usually in combo with neurosurgery, or surgery.,,, In general, when you're treating these, it id just trying to make it more resectable for the surgeon... And then obviously, the smaller the better.... Usually, the symptoms for these before they rupture, patients might have seizures, weakness, or numbness in the extremities, headaches.... children might complain of a pulsing sound, that they might feel in their head, or they might be hearing in their ear... And then when they rupture, they're they're similar to a stroke.... So then symptoms of headache, vision loss, difficulties speaking, confusion will be present. Select and drag the pointer to each circle to view content. Abnormal shunting of arteries and veins (tangles) outside of capillary beds Rare condition in peds but higher risk of rupture Most common in brain and spine but can occur anywhere Graded on a sliding scale (1-5) based on size, location, and pattern of venous drainage (Spetzler Martin Scale) Higher the number, greater to risk of neurological impairment Embolization is used to manage larger AVMs for radiosurgery or surgical resection (Glue/Onyx) Better outcomes with smaller AVMs Symptoms Pre-rupture: Seizures Weakness or numbness Headaches, pulsing sound in head Post rupture: Similar to a stroke Sudden, severe headache Vision loss Difficulty speaking Difficulty understanding others Arteriovenous malformations Diagram showing normal veins and the larger, more tangled veins that happen with a venous malformation. Glomuvenous malformation (GVM) Glomus cells are smooth muscle cells that are believed to regulate blood flow Glomus cells in GVMs are shaped abnormally Pebble like appearance  Cerebral-cavernous malformation (CCM) Familial disorder characterized by the formation of multiple VMs in the brain Often bleed and expand ~10 percent of kids with this disorder develop skin VMs Blue rubber bleb nevus syndrome (BRBNS) Multiple VMs of the skin and internal organs Maffucci syndrome Multiple benign bone tumors (enchondromas) and VM-like lesions of the skin Venous malformations cont. Venous malformations Soft tissue venous malformations | Radiology Reference Article ... Diagram showing normal veins and the larger, more tangled veins that happen with a venous malformation. Abnormal development of veins during embryonic phase (may be diagnosed at any stage in life) Blueish color, soft/compressible, superficial or deep (parenchymal), focal or widespread Common symptoms are pain, swelling, and psychological/social issues related to appearance Abnormal development of lymphatic vessels that carry lymph from nodes to blood vessels Most common in head/neck area, categorized by size (macrocysts/microcysts), superficial or deep Usually treated with aspiration/drainage and doxycycline/bleomycin, goal is to scar down lymph vessels (decrease size) Chylothorax Lymphatic collections may be a result of disruption due to cardiothoracic surgery while treating congenital cardiac defects Leaks (chylothorax) are diagnosed with FL or MR using lipiodol. Used to locate leak for interventional (coils/glue) or surgical treatment Lymphatic malformations Pediatric malignancies Cancer in children is rare overall. American Cancer Society predicts ~9620 new cases of cancer in patients 15 years old and younger. 2nd leading cause of death in children 1-14 years old 1040 mortalities in children Due to recent treatment advancement, 85% of children with cancer live 5 or more years past diagnosis. Risk Factors: Lifestyle and environmental factors HIGHLY unlikely Genetic mutations Inherited Pre or post partum https://www.cancer.org/cancer/types/cancer-in-children/key-statistics.html While adult cancer is classified by primary tumor location, pediatric cancer is classified by histology (tissue type) in 12 major groups. Most common being leukemia, brain/spinal tumors, and lymphoma. ? Pediatric malignancies GI A diagram of a child's stomach Description automatically generated Gastroesophageal reflux or aspiration Inadequate nutrition due to congenital heart disease Gastric outlet obstruction Small bowel dysmotility GJ tube placements/exchanges are common peds procedures to provide nutritional support Bone tumors Osteoid Osteoma Benign bone tumor characterized by dense sclerotic central nidus presenting with: Pain that worsens at night and is treated with NSAIDS Growth disturbances Scoliosis, bowing deformity and sciatica 10% of all benign tumors in peds treated with RFA or Cryoablation Wilms tumor | Radiology Reference Article | Radiopaedia.org Wilms Tumor (nephroblastoma) Most common pediatric renal cancer and abdominal cancer 9-10% of peds malignancies No specific cause, genetic alterations dealing with embryological develop of genitourinary tract Hereditary gene, mainly effects African Americans and women. Commonly affects 3–5-year-olds Symptoms: Painless palpable mass, loss of appetite, fever, nausea/vomiting, hematuria, etc. Depending on size, pre-op TACE can be performed to shrink for resection. Bland embo can be used to control hematuria and pre-op bleeding. Renal tumors Biliary atresia causes, symptoms, prognosis and biliary atresia treatment Progressive cholangiopathy involving destruction of biliary ducts and fibrosis If not treated surgically, then advanced cirrhosis develops, and liver transplant is needed Usually spotted by elevated bilirubin in blood with no signs of obstruction Diagnosed with liver biopsy or cholangiogram showing small caliber biliary ducts Biliary Atresia Portosystemic Shunt Abnormal shunting on portal venous blood (intra or extrahepatic) into hepatic veins or IVC. Congenital extrahepatic portosystemic shunt (CEPS), also termed as Abernethy malformation, are classified into two types: Type 1 being complete shunting into IVC with no portal blood reaching liver (leads to transplant) Type 2 being partial shunting into IVC with partial intrahepatic perfusion (leads to shunt closure) Hepatoblastoma is the predominant childhood liver cancer. Hepatocellular Carcinoma is less likely in children but possible. 1% of childhood cancer Abnormal proliferation of liver cell Symptoms: Lump in abdomen Swollen abdomen Pain in abdomen Nausea/vomiting/loss of appetite Ruptured hepatoblastoma in a 2-year-old boy with significant hemoperitoneum. (A) Coronal contrast-enhanced CT image shows a large liver lesion (arrowhead) and free fluid. (B) Subselective right hepatic arteriogram shows significant neovascularity and multifocal arterial aneurysms (arrowhead) without obvious extravasation. Transarterial embolization was performed by injecting 300–500-μm embospheres into two large branches supplying the tumor. Progressive heart failure due to focal congenital hepatic hemangioma in a 22-day-old boy born at 36 weeks of gestation. (A) Axial CT image at the level of a dilated left hepatic vein (arrowhead). (B) Axial CT image shows typical peripheral enhancement (arrowhead) and central low attenuation of a congenital hepatic hemangioma. (C) Celiac angiogram after partial embolization of the lesion with N-butyl-cyanoacrylate glue shows a hypervascular left hepatic tumor supplied by multiple celiac artery branches, including hypertrophied left hepatic artery branches, with a minor supply from branches recruited from the splenic artery and inferior phrenic arteries. (D) Venous phase angiogram shows a dilated draining left hepatic vein (arrowhead). Hepatic Hemangiomas (10% of population) Benign mass of liver vessels (focal or diffuse) Present at birth, rarely cause symptoms Large HH presents in: Compression of hepatic veins (Budd Chiari Syndrome) Hemorrhage Low platelet count (Kasabach–Merritt Syndrome) Bland embos, TACE and TARE are becoming more commonplace in peds IR. Liver malignancies Starts in lymphatic system, specifically WBC’s called lymphocytes Presents itself in mediastinal adenopathy/mass that continually grow putting children at-risk of mass effect, compression of airway and vasculature  Hodgkin's and Non-Hodgkin's A diagram of lymphomas Description automatically generated Signs/Symptoms: Painless swollen lymph nodes (neck, collarbone, underarm, groin) Fatigue Respiratory issues Idiopathic fever Night sweats Unintended weight loss Mediastinal mass leads to>cardiac and airway compression Lymphoma Pediatric malignancies Image result for Renal Angiomyolipoma Surgery Renal Angiomyolipomas Predominant benign renal tumor 50% risk of rupture / hemorrhage at 4cm and greater Symptoms: Flank pain Gross hematuria, or, Severe retroperitoneal hemorrhage Renal artery embos help control bleeding and potentially decrease size. Renal angiomyolipomas ? Pediatric malignancies Osteoblastoma Attacks healthy bone and replaces it with osteoid Larger version of osteoid osteoma More common in spine, hands, and legs Increases risk of fracture Aneurysmal Bone Cyst Aggressive bone tumor in metaphysis of long bones, the pelvis, or the posterior spinal elements Usually biopsied and treated with sclerotherapy, transarterial embo or cryoablation Aneurysmal Bone Cyst | Basicmedical Key Lightbox bone malignancies A picture containing text, person, standing, suit Description automatically generated Venous Access . Angiography IR GI Click on each icon to learn more about the types of procedures that can be seen in the pediatric IR lab. Procedures Procedures Venous Access Procedures Venous Access Procedures PICC Lines Tunnel Dialysis Catheter (TDC) Tunnel Central Line (TCL) Temp Central Line Indication for Venous Access Procedures Cystic Fibrosis (CF) Congenital Kidney Disease (CKD) Volume resuscitation Emergency venous access Nutritional support Administration of medications Hemodialysis Limited peripheral access Chemotherapy Long term antibiotics Frequent blood draws A close-up of a medical equipment Description automatically generated Venous Access Procedures Angiography IR Procedures Angiography IR Procedures Trans jugular intrahepatic portosystemic shunt (TIPS) Percutaneous transluminal angioplasty (PTA) Indication for Angiography IR Procedures Deep Vein Thrombosis (DVT) Paget Schroetter Syndrome (PSS) May-Thurner Syndrome Stroke Tumors Bleeding Vascular Malformations Arteriovenous Malformation (AVM) Stenosis Aneurysm A close-up of a doctor's hands Description automatically generated Angiography IR Procedures https://radiologykey.com/14-may-thurner-syndrome/ https://www.jpeds.com/article/S0022-3476(18)31606-8/abstract GI Procedures GI Procedures GJ change G to GJ change Percutaneous Gastrostomy Tube (PGT) placement NG NJ Indication for GI Procedures Clogged GJ or NJ tube Dislodged GJ or NJ tube Tube coiled in stomach Balloon Burst (GJ) A close-up of a medical tube Description automatically generated GI Procedures 3 3 3 3 Tips & tricks 2 2 2 2 Other considerations 1 1 1 1 Dose saving Best practices Best practices Use laser (when applicable) to center over ROI​ Use Care Position after initial fluoro​ Limit the use of fluoro as a centering tool​ Collimation​ Air Gap technique (when applicable)​ Try not to mag unless necessary​ Low dose FL and 3 P/S​ Have patient information and room set up prior to patient in the room (especially for toddlers)​ Try distracting patient (keeping them from focusing on procedure)​ Allow parent in the room when necessary (most parents are good at keeping child calm)​ Tips & Tricks Roadmap / iFlow / 3D / Needle Guidance Roadmap Overlay reference will serve as means to reduce contrast given 3D Anesthesia will reduce risk of patient movement during spins, cutting down on repeating Needle Guidance Use for Focal Lesions (mostly bone) Soft Tissue Lesions done under US Guidance iFlow Helps with pre and post assessment on AVM or Fistula treatments A diagram of a patient detector Description automatically generated Air Gap technique Air Gap technique: removal of grid and raising of FD  Children Saves X-ray attenuation from grid, scatter reduction measure  Focus on:  Isocenter Remove grid Max SID Pick OGP Collimate Microfocus Zoom out (Zoom dose factor)  A.J. Hicks RT(R)(VI) & Mike Snyder RT(R) Clinical Education Specialists Siemens Healthineers Thank you for this informative online training! Conclusion Disclaimer The information presented in this session is for educational purposes only. The accrediting agency is responsible for determining the number of CE credits awarded for this course. For the proper use of the software or hardware, please always use the Operator Manual or Instructions for Use (hereinafter collectively “Operator Manual”) issued by Siemens Healthineers. This material is to be used as training material only and shall by no means substitute the Operator Manual. Any material used in this training will not be updated on a regular basis and does not necessarily reflect the latest version of the software and hardware available at the time of the training. The Operator Manual shall be used as your main reference, in particular for relevant safety information like warnings and cautions. 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NJ PGT Question 2 of 6 Which one of the following is the most common procedures in the pediatric IR lab? NG tube GJ tube change Multiple Choice Select the best answer. ? medial none of the above Question 3 of 6 Benign bone tumor characterized by dense sclerotic _______ nidus. peripheral central Multiple Choice Select the best answer. ? True Question 4 of 6 Pediatric physiology is unique often requiring a multidisciplinary approach. False Multiple Choice ? Select all that apply. Question 5 of 6 Which of the following are increased risks with catheter based treatments? body temperature control and aggressive pain control arterial spasm/dissection post-embolization syndrome attenuate scatter Multiple Answer Glomuvenous malformation (GVM) Pebble like appearance  Cerebral-cavernous malformation (CCM) Often bleed and expand Arteriovenous malformations Graded on a sliding scale (1-5) based on size, location, and pattern of venous drainage Drag each response from the right column to its corresponding item in the left column. Align the characteristic to the malformation. Chylothorax ? Question 6 of 6 Lymphatic collections may be a result of disruption due to cardiothoracic surgery while treating congential cardiac defects. Matching Retry Assessment Results %Quiz1.ScorePercent%% %Quiz1.PassPercent%% Continue YOUR SCORE: PASSING SCORE: Results Slide You have exceeded your number of assessment attempts. Exit You did not pass the course. Select Retry to continue. Congratulations. You passed the course. Exit To access your Certificate of Completion, select the Certificates tab from the learning activity overview page. You can also access the certificate from your PEPconnect transcript. You have completed the Pediatric Interventional Radiology online training. Completion Help slides Select the X to close the pop-up. Click Next to continue. Next Layer Slide The timeline displays the slide progression. Slide the orange bar backwards to rewind the timeline. Click Next to continue. Next Tmeline Select the buttons to learn more about a topic. Be sure to review all topics before navigating to the next slide. Click Next to continue. Next Tab Arrow Slide Select the X to close the pop-up. Click Next to continue. Next Layer Slide Some images may have a magnifier icon. Select the image to see an enlarged view. Select it again to return to the normal view. Click Next to continue. Next Zoom Slide Some images have a magnifier icon in the bottom-left corner. Select these image to see an enlarged view of the image. Select the image again to return to the normal view. Select Submit to record your response. Click the X in the upper right corner to exit the navigation help. Assessment Slide Question Bank 1 Pediatric Interventional Radiology