Background Biliary atresia (BA) is one of the causes of conjugated hyperbilirubinemia in infants which if untreated leads to end-stage liver disease and death. Percutaneous Trans-hepatic Cholecysto-Cholangiography (PTCC) is a minimally invasive study which can be utilized in the diagnostic work-up of these patients. This study’s purpose is to describe the experience with PTCC in neonates, the imaging findings encountered, and the abnormal patterns which warrant further investigation. Methods A 16-year single-center retrospective study of patients with persistent neonatal cholestasis (suspected BA) undergoing PTCC. Patient demographics, laboratory values, PTCC images, pathology and surgical reports were reviewed. Results 73 patients underwent PTCC (68% male, mean age 8.7 weeks, mean weight 4.0 Kg). The majority of studies were normal (55%). Abnormal patterns were identified in 33 cases, 79% were diagnosed with BA and 12% with Alagille syndrome. Non-opacification of the common hepatic duct with a narrowed common bile duct (42%) and isolated small gallbladder (38%) were the most common patterns in BA. Conclusion PTCC is a minimally invasive study in the diagnostic work-up of infants presenting with conjugated hyperbilirubinemia (suspected BA). Further invasive investigations or surgery can be avoided when results are normal.

Intra‐operative arterial vasospasm during pediatric renal transplantation is an urgent clinical situation resulting in end‐organ ischemia, associated changes in parenchymal turgor and color, diminished flow on ultrasound, and if left untreated, allograft loss. We hypothesized that intra‐operative intra‐arterial injection of nitroglycerin would reverse vasospasm and improve renal perfusion. A three‐yr‐old girl with end‐stage renal disease due to autosomal recessive polycystic kidney disease on peritoneal dialysis underwent deceased donor renal transplantation. After optimal immediate reperfusion and hemodynamic parameters, the kidney lost turgor and became mottled in appearance despite adequate hilar arterial and venous Doppler waveforms. Two aliquots of 40 μg (0.4 mL of a 100 μg/mL) nitroglycerin solution were injected directly into the renal artery 10 min apart. Nitroglycerin resulted in dramatic change in the consistency and appearance of the allograft. An improvement in renal blood flow was demonstrated by ultrasound after the second intra‐arterial nitroglycerin injection with only a transient decrease in systemic arterial blood pressure. The child experienced normal allograft perfusion on serial postoperative ultrasounds, with a prompt decrease in serum creatinine and excellent diuresis. Intra‐arterial nitroglycerin is a promising option for intra‐operative arterial vasospasm during pediatric renal transplantation with objective improvement in blood flow and perfusion.

Lymphatic malformations (LMs) are congenital lesions of the lymphatic system and consist of lymphatic channels and cystic spaces of varying sizes. Recent evidence has shown that LMs respond well to intralesional sclerotherapy.

PURPOSE:To assess the effects of repeated placements of peripherally inserted central catheters (PICCs) on the venous system in children.MATERIALS AND METHODS:Children who underwent successful first-time PICC placements between 2005 and 2007 were retrospectively evaluated. Patient demographics, procedural data, and complications were obtained from hospital databases. Data from subsequent PICC insertions were compared with those from previous PICC insertions. A generalized estimating equation was used with appropriate statistical tests for data analysis.RESULTS:PICCs were grouped into four groups: first PICCs (n = 1,274), second PICCs (n = 167), third PICCs (n = 52), and fourth to seventh PICCs (n = 32). Successive PICCs were associated with progressively increased difficulty of access compared with earlier PICCs, as demonstrated by significant increases in procedural duration (P = .01) and fluoroscopy time (P = .005). Increased complexity was also evident through significant increases in the percentages of cases that required venography/digital subtraction angiography (P <.0001), multiple attempts to gain venous access (P <.0001), and a switch to another limb for venous access (P <.0001) between subsequent and first PICCs. In addition, rates of procedural complications also increased for subsequent PICCs compared with first PICCs (P <.0001). Furthermore use of the most preferred vein for vascular access significantly decreased in subsequent versus first PICC insertions (P <.0001).CONCLUSIONS:Increased procedural complexity and complications were found with successive PICC insertions. These results confirm the need for a prospective study to directly assess the long-term effects of PICCs on venous patency.

Children with Pierre Robin sequence (PRS) have significant oropharyngeal abnormalities, with respiratory and feeding difficulties. Gastrostomy tubes (G-tube) provide a means for nutrition.

Hepatic vein stenoses are a rare but serious complication of liver transplants in children. Restoration of flow by radiological methods often provides a viable treatment option. This technique relies on the interventional radiologist's ability to advance a guide wire across the obstruction, thus allowing for balloon dilatation and other necessary interventions. Failure to cross the stenosis reduces graft survival and increases patient morbidity. We report two cases with tight hepatic vein stenosis where the guide wire could not be advanced in a conventional approach across the upper end of the stenosis. Utilizing prominent intrahepatic collateral vessels, the stenoses were able to be crossed, facilitating successful PTA with good clinical outcome.

Anterior mediastinal masses in children are clinically challenging, requiring prompt histological diagnosis.

PURPOSE:To retrospectively evaluate the technical success, safety, and outcomes of radiologically guided retrograde percutaneous gastrostomy and gastrojejunostomy tube placements in terms of weight gain and growth in children with gastroschisis, omphalocele, and/or congenital diaphragmatic hernia (CDH).MATERIALS AND METHODS:Research ethics board approval, with waived informed patient consent, was obtained for review of the data of 37 children (17 male, 20 female; age range, 1-20 months; mean age, 4.3 months) in whom gastrostomy or gastrojejunostomy tubes were inserted between 1995 and 2004. Twenty-two patients had CDH, eight had gastroschisis, five had omphalocele, and two had both CDH and omphalocele. The technical success and complications of the procedures were recorded. Tube maintenance problems were analyzed separately from postprocedural complications. Initial and final patient growth percentiles were compared by using a one-sided paired Student t test.RESULTS:Thirty-six of the 38 procedures performed in the 37 patients were successful. There were three intraprocedural complications (two cases of access difficulty, one case of bleeding) and three major complications (one skin and prosthetic material infection, one track loss during tube replacement, one delayed gastrostomy track closure necessitating surgery). Sixteen patients had at least one minor complication (cellulitis, feeding intolerance, skin-site bleeding, intussusception). Twenty-two patients had at least one tube maintenance problem. All patients gained weight (mean weight gain, 4.7 kg) after the procedure, with a significant increase in growth percentile (average increase, 6.5%; P = .029).CONCLUSION:Radiologically guided percutaneous gastrostomy and gastrojejunostomy tube placements in children with gastroschisis, omphalocele, and/or CDH are associated with high success rates and low major complication rates. Although tube maintenance problems and minor complications are common, use of gastrostomy and gastrojejunostomy tubes effectively improves nutritional support.

OBJECTIVE:The purpose of our study was to evaluate the safety and effectiveness of radiologic percutaneous gastrostomy and gastrojejunostomy for providing nutritional support in children with cardiac disease.MATERIALS AND METHODS:Retrospective chart review of 58 children with cardiac disease who underwent radiologic percutaneous gastrostomy from November 2001 to June 2005 was conducted. Patient data were collected until January 2007. The patients' weights were collected at the time of insertion and 6, 12, 18, and 24 months after insertion, and weight-for-age z-scores were calculated.RESULTS:The mean weight-for-age z-score increased from -2.79 at the time of radiologic percutaneous gastrostomy insertion to -2.33 (p = 0.05) at 6 months after insertion, -1.89 (p = 0.001) at 12 months, -1.65 (p = 0.0002) at 18 months, and -1.40 (p = 0.0004) at 24 months. Repeated measures regression analysis showed a significant increase in weight-for-age z-score over time (p < 0.0001), with an estimated mean increase in weight-for-age z-score of 0.055 per month. No mortality was associated with the insertion or usage of radiologic percutaneous gastrostomy. Major complications included intestinal perforation (3.4%) and aspiration pneumonia (12.1%).CONCLUSION:Radiologic percutaneous gastrostomy is a safe method for providing long-term nutritional support in children with cardiac disease and is effective for improving growth and nutrition in this group of patients.

OBJECTIVE:The purpose of our study was to assess the technical success and complication rate of sonographically guided percutaneous liver biopsies performed in infants under 1 year old at a tertiary pediatric center.MATERIALS AND METHODS:Retrospective analysis of 65 biopsies performed in 61 infants between January 1999 and December 2003 was conducted. Data collected included patient demographics; details of the biopsy procedure including indication, needle type and size, number of passes, and samples; pathology results; and procedure-related complications.RESULTS:The 61 infants studied included 37 males and 24 females with a mean age of 119 days (age range, 7-348 days; median age, 83 days) and a mean weight of 4.5 kg (1.9-8.3 kg). A total of 65 biopsies were performed in these 61 infants. General anesthesia was used in 66.1% of procedures. An 18-gauge needle was used in 47 (72.3%) procedures. Coaxial technique was used in seven procedures, and five biopsy tracts were embolized. In 63 of 65 procedures, the mean number of passes was 1.8. In two procedures, using a coaxial technique, 11 and 12 passes were made. One biopsy was considered technically unsuccessful, and 64 of 65 (98.5%) of the biopsies provided adequate tissue for pathologic analysis. There were three (4.6%) major complications related to bleeding: one requiring a blood transfusion, one requiring surgery, and one arteriobiliary fistula requiring transarterial embolization. Three (4.6%) minor complications also occurred. There were no deaths.CONCLUSION:Sonographically guided percutaneous liver biopsy in infants is a good and effective diagnostic tool. The complication rate, however, even when performed by an experienced physician, is not insignificant in this age group of patients.