- Email: [email protected]
Abstract No. 411: Interventional radiologic management of trauma in children−from head to toe
JVIR 䡲 Poster Sessions
S163
S.H. Sabir, S. Govindan, R. Arellano; Radiology, Massachusetts General Hospital, Boston, MA Learning Objectives: Understand the embryology, classification, imaging, clinical effects, and treatment of congenital extrahepatic portosystemic shunts (CEPS). Background: - CEPS is an unusual condition wherein portal blood either completely or partially bypasses the liver and enters a systemic vein. - CEPS develops because of abnormal involution of the vitelline veins that embryologically constitute the portal vein (1). Clinical Findings/Procedure Details: - There are two types of CEPS. Type 1 shunts show complete shunting of blood from the portal system to systemic circulation with absence of the intrahepatic portal vein. Type 2 shunts demonstrate partial shunting of blood from the portal system to systemic circulation with an intact intrahepatic portal vein (1). - MRI is the best imaging modality for evaluating CEPS because of the lack of ionizing radiation, ability to image the vasculature, and demonstration of hepatic parenchymal abnormalities (2). - Clinically, both types of shunts demonstrate liver dysfunction, nodular liver lesions usually regenerative nodules and rarely hepatoblastoma or HCC, and metabolic derangements (1); however, there are several clinical features unique to the two types of shunts for examples Type 1 shunts are predominantly seen in females and often have associated congenital anomalies (1). - Mild metabolic abnormalities can be managed with medical therapy and diet modification. The definitive therapy for Type 1 shunts is liver transplantation and for Type 2 shunts is surgical or endovascular occlusion of the shunt (1). Conclusion and/or Teaching Points: - CEPS is a rare cause of liver dysfunction, liver lesions, and metabolic derangements. - There are 2 types of CEPS, Type 1 with complete shunting and absent intrahepatic portal vein and Type 2 with partial shunting and present intrahepatic portal vein. - Though medical management and diet modification can be tried, definitive management of Type 1 shunts is liver transplantation and of Type 2 shunts is surgical or endovascular occlusion of the shunt. References 1. Stringer MD. The clinical anatomy of congenital portosystemic venous shunts. Clin Anat 2008; 21(2):147–157. 2. Murray CP, Yoo SJ, Babyn PS. Congenital extrahepatic portosystemic shunts. Pediatr Radiol 2003; 33(9):614 – 620.
Abstract No. 410 The use of the patent ductus venosus as an access for portal vascular interventions in children
Purpose: The ductus venosus, a fetal communication between the portal and systemic venous circulations, spontaneously closes early in the neonatal period. The persistence of the ductus venosus is rare and can be primary (congenital) or secondary to abnormal portal hemodynamics. Vascular anomalies of the portal vein can be associated with serious clinical presentation and pose technical challenges at interventions. In such patients, the patent ductus
Educational Exhibit
Abstract No. 411
Interventional radiologic management of trauma in childrenⴚfrom head to toe W.C. Fox1, J. Tisnado1, J. Tisnado2, G.S. Morano1, R.R. Ivatury3; 1Radiology/VIR, MCV Hospitals/VCU Medical Center, Richmond, VA; 2Radiology, Hartford General, Hartford, CT; 3Surgery, MCV Hospitals/VCU Health System, Richmond, VA Learning Objectives: Trauma is the leading cause of death in children and young adults and one of the leading causes of death in USA. It is responsible for about 150,000 deaths a year which is more deaths than in World War II, Vietnam and Korea combined. Trauma in children is a serious cause of morbidity and mortality, yet there is very little mention made in major meetings, congresses and conferences. In a recent largest interventional radiologic meeting in USA, almost nothing was said or discussed about trauma in children. It’s obvious a serious gap in knowledge exists. Many “adult” IR does not deal with pediatric trauma. Most children with traumatic lesions are managed by “adult” IR. Therefore, we must be prepared and ready to take care of children. There is not enough pediatric IR; therefore, we are proposing a “call to arms.” Some of the causes are lack of experience, unfamiliarity with pediatrics, and the emotional attachment of the adult IR when dealing with serious causes of M&M in pediatric trauma. Background: We have been fortunate to deal with the topic for many decades. We have accumulated a vast and varied experience in diagnosis and IR management of traumatic lesions in children from head to toe. We, therefore, present a general revision from
Poster Sessions
R. Shaikh, P.E. Burrows, G. Chaudry, B. Dillon, H.M. Padua, A.I. Alomari; Interventional Radiology, Childrens Hospital of Boston, Boston, MA
venosus provides a safe and valuable alternative access for endovascular treatment. Materials and Methods: 4 children (age: 2 months– 6 years) underwent interventional treatment of vascular anomalies of the portal vein using the patent ductus venosus as a vascular conduit to the portal vein via a transjugular approach. Two patients had arterioportal fistulae; one had a large portosystemic shunt with severe gastrointestinal bleeding and one congenital hemangioma with heart and liver failure. Mesenteric arteriography was initially performed followed by transjugular access of the patent ductus venosus and embolization of the portal anomaly. Results: All the procedures were technically successful using the patent ductus venosus. In patient # 1 with a fistula between the inferior phrenic artery and portal vein, the shunt was embolized with coils. Patient # 2 had a complex arterioportal shunt with a giant portal aneurysm was embolized with an Amplatzer septal occluder and coils. The portosystemic shunt in patient # 3 was closed using an Amplatzer vascular plug. Embolization of the portal feeding tributaries to the liver hemangioma in patient # 4 was done with coils. The procedures were technically successful in the four children without complications. The arterioportal fistula (patient # 1) and the portosystemic shunt (patient # 3) were completely obliterated and clinically successfully. Though technically successful, the response to embolization in patients # 2 and 3 (complex arterioportal fistula and congenital liver hemangioma, respectively) was partial; largely related to other serious comorbidity. Conclusion: Patent ductus venosus provides an invaluable safe access for endovascular portal venous interventions in children.
Poster Sessions 䡲 JVIR
S164
the radiologic diagnosis, including plain film, and all new diagnostic imaging methods to the IR management. We discuss numerous etiologic trauma causes (blunt, penetrating, iatrogenic) and different IR methods to manage those lesions: embolotherapy, stenting and insertion of occlusion balloon catheters. We review diagnostic and IR aspects of trauma in children, including causes, etiologic factors: car accidents, bullets, knives, buck shot injuries, falls, etc. Clinical Findings/Procedure Details: We present successful IR management with three main methods: embolotherapy, placement of stents and stent-grafts, and insertion of balloon occlusion catheters. We also propose algorithms for management. Conclusion and/or Teaching Points: We conclude that the incidence of trauma in children is increasing rapidly in this era of violent behavior, impaired driving, alcohol and drug abuse. The IR management is ideal in these cases.
Peripheral Arterial Interventions Educational Exhibit
Abstract No. 412
MRA as a problem-solving tool for identifying and classifying endoleak after EVAR
Poster Sessions
B.M. Everist1, J. Friese1, M. Kalra2, P.M. Young1; 1 Radiology, Mayo Clinic, Rochester, MN; 2Vascular Surgery, Mayo Clinic, Rochester, MN Learning Objectives: Review indications, imaging findings, and MR techniques to perform magnetic resonance angiography (MRA) for the evaluation of endoleak (EL) after EVAR. Background: Endovascular repair of aortic aneurysms is increasingly common. Lifetime imaging surveillance is recommended, and EL and continued sac growth are potential issues. Although CTA is the mainstay in EVAR surveillance in our practice, MRA is useful for identifying subtle leaks not detected or well-characterized with CTA. Time-resolved (dynamic) MRA further increases diagnostic accuracy when compared to static MRA by frequently enabling EL-type assessment (15 vs 9, n⫽23 [65 vs 40%]). Recently TR-MRA has been shown comparable to gold standard DSA for classification of EL type (97% n⫽30/31), and remains more sensitive than CTA. Clinical Findings/Procedure Details: In our practice, CEMRA is often performed when routine three-phase CTA (noncontrast, arterial, and delayed) fails to demonstrate the etiology of an expanding, excluded aneurysm sac during EVAR surveillance. We will review potential advantages both of view-shared and non-view-shared TR-MRA with newer contrast agents and parallel imaging techniques and highlight successful use of MRA for endoleak detection, characterization, and treatment planning through clinical examples. Conclusion and/or Teaching Points: 1. MRA is extremely helpful for detecting and characterizing endoleaks which are not well seen on CTA. 2. Higher contrast-to-background ratio, very high combined spatial and temporal resolution, and ability to obtain multiple time-points without exposing the patient to increased ionizing radiation are factors which give MRA an advantage over CTA for detecting and characterizing endoleaks.
3. MRA should be considered as a first-line or second-line test for problem solving in patients for whom CTA does not provide a definitive diagnosis.
Educational Exhibit
Abstract No. 413
Catheter directed CT angiography for evaluation of patients preop for EVAR and postop for endoleaks C.J. Francis, B. Zwiebel; Radiology, University of South Florida College of Medicine, Tampa, FL Learning Objectives: Reduce contrast load and contrast induced nephrotoxicity in patients with renal insufficiency who are undergoing preoperative and postoperative evaluation for EVAR. Background: Over the past 2 years, 10 patients were evaluated preop or postop for EVAR that have had renal insufficiency defined as creatinine greater than 2.0. Renal insufficiency usually precludes evaluation of the patient with either conventional CTA or MRA. In the preop patient for EVAR, it is useful to evaluate the presence and degree of mural thrombus and/or calcification in both the abdominal aorta and iliac arteries. In addition, it is helpful to evaluate for iliac artery and renal or visceral stenosis. Postop EVAR patients need evaluation for AAA size and morphology, endoleak, graft migration and graft integrity. In the patient with renal insufficiency, this can be limited with duplex and/or noncontrast CT/MR. In the IR suite, a 4F straight flush catheter is placed in the aorta up to T10. The patient is sent to the CT scanner(Phillips Brilliance 64) for CTA. After a noncontrast CT, 30cc of OptiRay 350 is diluted with saline to a total volume of 80 cc. This mixture is injected via a Optiadvantage injector through the 4F straight flush catheter at a rate of 5cc/sec. A 5 second scan delay is implemented and then the patient is scanned at 0.625 mm slices and a pitch of 0.9. Delayed imaging is also performed at 60 seconds after the arterial phase. Standard reformatting and post processing is performed. Clinical Findings/Procedure Details: Of the 10 patients scanned, all had technically adequate studies. None of the patients had an increase in their creatinine as compared to the pre-scan values. Conclusion and/or Teaching Points: In patients with renal insufficiency that require CTA either for preop or postop evaluation for EVAR, catheter directed CTA is a useful technique that will provide all the necessary diagnostic information without the negative effects of contrast induced nephrotoxicity.
Educational Exhibit
Abstract No. 414
Treatment of pulmonary artery stenosis with stents N. Hendricks, C.L. Anderson, J.F. Angle; Radiology, University of Virginia Health System, Charlottesville, VA Learning Objectives: 1. To become familiar with the causes and clinical presentation of pulmonary artery stenosis. 2. Describe the endovascular treatment for PA stenosis. 3. Develop awareness of the risks and pitfalls of endovascular treatment of the pulmonary artery. Background: Pulmonary artery stenosis is a rare condition that can be a cause of severe hypoxemia, hypotension, and right heart failure. In adults, the most common etiologies of main or
S163
S.H. Sabir, S. Govindan, R. Arellano; Radiology, Massachusetts General Hospital, Boston, MA Learning Objectives: Understand the embryology, classification, imaging, clinical effects, and treatment of congenital extrahepatic portosystemic shunts (CEPS). Background: - CEPS is an unusual condition wherein portal blood either completely or partially bypasses the liver and enters a systemic vein. - CEPS develops because of abnormal involution of the vitelline veins that embryologically constitute the portal vein (1). Clinical Findings/Procedure Details: - There are two types of CEPS. Type 1 shunts show complete shunting of blood from the portal system to systemic circulation with absence of the intrahepatic portal vein. Type 2 shunts demonstrate partial shunting of blood from the portal system to systemic circulation with an intact intrahepatic portal vein (1). - MRI is the best imaging modality for evaluating CEPS because of the lack of ionizing radiation, ability to image the vasculature, and demonstration of hepatic parenchymal abnormalities (2). - Clinically, both types of shunts demonstrate liver dysfunction, nodular liver lesions usually regenerative nodules and rarely hepatoblastoma or HCC, and metabolic derangements (1); however, there are several clinical features unique to the two types of shunts for examples Type 1 shunts are predominantly seen in females and often have associated congenital anomalies (1). - Mild metabolic abnormalities can be managed with medical therapy and diet modification. The definitive therapy for Type 1 shunts is liver transplantation and for Type 2 shunts is surgical or endovascular occlusion of the shunt (1). Conclusion and/or Teaching Points: - CEPS is a rare cause of liver dysfunction, liver lesions, and metabolic derangements. - There are 2 types of CEPS, Type 1 with complete shunting and absent intrahepatic portal vein and Type 2 with partial shunting and present intrahepatic portal vein. - Though medical management and diet modification can be tried, definitive management of Type 1 shunts is liver transplantation and of Type 2 shunts is surgical or endovascular occlusion of the shunt. References 1. Stringer MD. The clinical anatomy of congenital portosystemic venous shunts. Clin Anat 2008; 21(2):147–157. 2. Murray CP, Yoo SJ, Babyn PS. Congenital extrahepatic portosystemic shunts. Pediatr Radiol 2003; 33(9):614 – 620.
Abstract No. 410 The use of the patent ductus venosus as an access for portal vascular interventions in children
Purpose: The ductus venosus, a fetal communication between the portal and systemic venous circulations, spontaneously closes early in the neonatal period. The persistence of the ductus venosus is rare and can be primary (congenital) or secondary to abnormal portal hemodynamics. Vascular anomalies of the portal vein can be associated with serious clinical presentation and pose technical challenges at interventions. In such patients, the patent ductus
Educational Exhibit
Abstract No. 411
Interventional radiologic management of trauma in childrenⴚfrom head to toe W.C. Fox1, J. Tisnado1, J. Tisnado2, G.S. Morano1, R.R. Ivatury3; 1Radiology/VIR, MCV Hospitals/VCU Medical Center, Richmond, VA; 2Radiology, Hartford General, Hartford, CT; 3Surgery, MCV Hospitals/VCU Health System, Richmond, VA Learning Objectives: Trauma is the leading cause of death in children and young adults and one of the leading causes of death in USA. It is responsible for about 150,000 deaths a year which is more deaths than in World War II, Vietnam and Korea combined. Trauma in children is a serious cause of morbidity and mortality, yet there is very little mention made in major meetings, congresses and conferences. In a recent largest interventional radiologic meeting in USA, almost nothing was said or discussed about trauma in children. It’s obvious a serious gap in knowledge exists. Many “adult” IR does not deal with pediatric trauma. Most children with traumatic lesions are managed by “adult” IR. Therefore, we must be prepared and ready to take care of children. There is not enough pediatric IR; therefore, we are proposing a “call to arms.” Some of the causes are lack of experience, unfamiliarity with pediatrics, and the emotional attachment of the adult IR when dealing with serious causes of M&M in pediatric trauma. Background: We have been fortunate to deal with the topic for many decades. We have accumulated a vast and varied experience in diagnosis and IR management of traumatic lesions in children from head to toe. We, therefore, present a general revision from
Poster Sessions
R. Shaikh, P.E. Burrows, G. Chaudry, B. Dillon, H.M. Padua, A.I. Alomari; Interventional Radiology, Childrens Hospital of Boston, Boston, MA
venosus provides a safe and valuable alternative access for endovascular treatment. Materials and Methods: 4 children (age: 2 months– 6 years) underwent interventional treatment of vascular anomalies of the portal vein using the patent ductus venosus as a vascular conduit to the portal vein via a transjugular approach. Two patients had arterioportal fistulae; one had a large portosystemic shunt with severe gastrointestinal bleeding and one congenital hemangioma with heart and liver failure. Mesenteric arteriography was initially performed followed by transjugular access of the patent ductus venosus and embolization of the portal anomaly. Results: All the procedures were technically successful using the patent ductus venosus. In patient # 1 with a fistula between the inferior phrenic artery and portal vein, the shunt was embolized with coils. Patient # 2 had a complex arterioportal shunt with a giant portal aneurysm was embolized with an Amplatzer septal occluder and coils. The portosystemic shunt in patient # 3 was closed using an Amplatzer vascular plug. Embolization of the portal feeding tributaries to the liver hemangioma in patient # 4 was done with coils. The procedures were technically successful in the four children without complications. The arterioportal fistula (patient # 1) and the portosystemic shunt (patient # 3) were completely obliterated and clinically successfully. Though technically successful, the response to embolization in patients # 2 and 3 (complex arterioportal fistula and congenital liver hemangioma, respectively) was partial; largely related to other serious comorbidity. Conclusion: Patent ductus venosus provides an invaluable safe access for endovascular portal venous interventions in children.
Poster Sessions 䡲 JVIR
S164
the radiologic diagnosis, including plain film, and all new diagnostic imaging methods to the IR management. We discuss numerous etiologic trauma causes (blunt, penetrating, iatrogenic) and different IR methods to manage those lesions: embolotherapy, stenting and insertion of occlusion balloon catheters. We review diagnostic and IR aspects of trauma in children, including causes, etiologic factors: car accidents, bullets, knives, buck shot injuries, falls, etc. Clinical Findings/Procedure Details: We present successful IR management with three main methods: embolotherapy, placement of stents and stent-grafts, and insertion of balloon occlusion catheters. We also propose algorithms for management. Conclusion and/or Teaching Points: We conclude that the incidence of trauma in children is increasing rapidly in this era of violent behavior, impaired driving, alcohol and drug abuse. The IR management is ideal in these cases.
Peripheral Arterial Interventions Educational Exhibit
Abstract No. 412
MRA as a problem-solving tool for identifying and classifying endoleak after EVAR
Poster Sessions
B.M. Everist1, J. Friese1, M. Kalra2, P.M. Young1; 1 Radiology, Mayo Clinic, Rochester, MN; 2Vascular Surgery, Mayo Clinic, Rochester, MN Learning Objectives: Review indications, imaging findings, and MR techniques to perform magnetic resonance angiography (MRA) for the evaluation of endoleak (EL) after EVAR. Background: Endovascular repair of aortic aneurysms is increasingly common. Lifetime imaging surveillance is recommended, and EL and continued sac growth are potential issues. Although CTA is the mainstay in EVAR surveillance in our practice, MRA is useful for identifying subtle leaks not detected or well-characterized with CTA. Time-resolved (dynamic) MRA further increases diagnostic accuracy when compared to static MRA by frequently enabling EL-type assessment (15 vs 9, n⫽23 [65 vs 40%]). Recently TR-MRA has been shown comparable to gold standard DSA for classification of EL type (97% n⫽30/31), and remains more sensitive than CTA. Clinical Findings/Procedure Details: In our practice, CEMRA is often performed when routine three-phase CTA (noncontrast, arterial, and delayed) fails to demonstrate the etiology of an expanding, excluded aneurysm sac during EVAR surveillance. We will review potential advantages both of view-shared and non-view-shared TR-MRA with newer contrast agents and parallel imaging techniques and highlight successful use of MRA for endoleak detection, characterization, and treatment planning through clinical examples. Conclusion and/or Teaching Points: 1. MRA is extremely helpful for detecting and characterizing endoleaks which are not well seen on CTA. 2. Higher contrast-to-background ratio, very high combined spatial and temporal resolution, and ability to obtain multiple time-points without exposing the patient to increased ionizing radiation are factors which give MRA an advantage over CTA for detecting and characterizing endoleaks.
3. MRA should be considered as a first-line or second-line test for problem solving in patients for whom CTA does not provide a definitive diagnosis.
Educational Exhibit
Abstract No. 413
Catheter directed CT angiography for evaluation of patients preop for EVAR and postop for endoleaks C.J. Francis, B. Zwiebel; Radiology, University of South Florida College of Medicine, Tampa, FL Learning Objectives: Reduce contrast load and contrast induced nephrotoxicity in patients with renal insufficiency who are undergoing preoperative and postoperative evaluation for EVAR. Background: Over the past 2 years, 10 patients were evaluated preop or postop for EVAR that have had renal insufficiency defined as creatinine greater than 2.0. Renal insufficiency usually precludes evaluation of the patient with either conventional CTA or MRA. In the preop patient for EVAR, it is useful to evaluate the presence and degree of mural thrombus and/or calcification in both the abdominal aorta and iliac arteries. In addition, it is helpful to evaluate for iliac artery and renal or visceral stenosis. Postop EVAR patients need evaluation for AAA size and morphology, endoleak, graft migration and graft integrity. In the patient with renal insufficiency, this can be limited with duplex and/or noncontrast CT/MR. In the IR suite, a 4F straight flush catheter is placed in the aorta up to T10. The patient is sent to the CT scanner(Phillips Brilliance 64) for CTA. After a noncontrast CT, 30cc of OptiRay 350 is diluted with saline to a total volume of 80 cc. This mixture is injected via a Optiadvantage injector through the 4F straight flush catheter at a rate of 5cc/sec. A 5 second scan delay is implemented and then the patient is scanned at 0.625 mm slices and a pitch of 0.9. Delayed imaging is also performed at 60 seconds after the arterial phase. Standard reformatting and post processing is performed. Clinical Findings/Procedure Details: Of the 10 patients scanned, all had technically adequate studies. None of the patients had an increase in their creatinine as compared to the pre-scan values. Conclusion and/or Teaching Points: In patients with renal insufficiency that require CTA either for preop or postop evaluation for EVAR, catheter directed CTA is a useful technique that will provide all the necessary diagnostic information without the negative effects of contrast induced nephrotoxicity.
Educational Exhibit
Abstract No. 414
Treatment of pulmonary artery stenosis with stents N. Hendricks, C.L. Anderson, J.F. Angle; Radiology, University of Virginia Health System, Charlottesville, VA Learning Objectives: 1. To become familiar with the causes and clinical presentation of pulmonary artery stenosis. 2. Describe the endovascular treatment for PA stenosis. 3. Develop awareness of the risks and pitfalls of endovascular treatment of the pulmonary artery. Background: Pulmonary artery stenosis is a rare condition that can be a cause of severe hypoxemia, hypotension, and right heart failure. In adults, the most common etiologies of main or