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While pectus excavatum is the most common congenital chest wall deformity in children, indications for surgical repair are still debated among experts. Some centers require demonstration of physiologic criteria prior to repair, even in the face of significant anatomic compression. We present a case of a 16-year-old male with severe pectus excavatum who presented with a 3-year history of a chronic barking cough and exercise-induced shortness of breath. Radiographic imaging demonstrated compression of the trachea and bilateral mainstem bronchi secondary to severe pectus excavatum deformity. Despite his severe pectus deformity, preoperative physiologic testing demonstrated normal to near-normal cardiopulmonary function. Minimally invasive repair of the chest wall defect (modified Nuss procedure) provided rapid alleviation of symptoms, and a significant improvement in quality of life. [ABSTRACT FROM AUTHOR]

Image-guided drainage of abscesses and fluid collections is a valuable tool in the treatment of pediatric patients. It may obviate surgery or optimize the child’s clinical condition for subsequent surgery. Compared with adults, several differences exist in terms of etiology, risks (especially radiation exposure), preprocedural imaging and planning, technical considerations, support issues such as sedation, and complications. Knowledge of these differences is important in the planning and treatment of these patients. In addition, a quality improvement plan can be used to assess practice performance. [ABSTRACT FROM AUTHOR]

Purpose: To review outcomes of ultrasound (US)–guided percutaneous submandibular gland injection of botulinum toxin A (BTX-A) in the treatment of drooling and chronic aspiration. Materials and Methods: A 3-year retrospective review was performed of 220 US-guided salivary gland injections in 36 patients. There were 21 male patients and 15 female patients with an age range of 1.4 to 19.8 years (mean, 8.6 y) and a weight range of 7.8 to 73 kg (mean, 24.4 kg). The mean pretreatment analysis period was 48 months and the mean follow-up period was 21 months. The study group was divided into groups with anterior (n = 9) and posterior (n = 27) drooling, with those with both (n = 10) included in the posterior group. Results: All procedures were technically successful. Bilateral submandibular injections were performed in 34 procedures and bilateral submandibular and parotid injections were performed in 38 procedures. Of the 27 patients with posterior drooling, improvement occurred in 24 patients (88%), no improvement was seen in two (8%), and one (4%) was lost to follow-up. Of the nine patients with anterior drooling, six (66%) showed improvement, there was no response in two (22%), and one (12%) was lost to follow-up. The total number of hospitalizations for respiratory issues and presumed aspiration pneumonia decreased by 56.4% per year in the patients with posterior drooling. There was one procedure-related complication: an episode of self-limited oral bleeding. Conclusion: Salivary gland BTX-A injection for salivary control shows promising results in decreasing saliva production and frequency of respiratory symptoms in children with drooling and chronic aspiration. [Copyright &y& Elsevier]

Purpose: To quantify the anatomic relationships of the cavoatrial junction and propose a system for describing central venous access device tip location on the basis of structures visible on chest radiographs. Materials and Methods: The authors performed a retrospective study of 100 consecutive computed tomographic (CT) studies from a predominantly pediatric population consisting of 52 male and 48 female patients aged 12–28 years (mean age, 16 years). With use of multiplanar and scout images, relevant mediastinal structures were marked, vertebral levels were noted, and measurements were made electronically. Catheter tip positions were recorded in the 26 children who had central catheters. Results: A vertebral body unit was defined as the distance between the inferior endplate of one vertebra to the inferior endplate of the next, with the upper intervertebral disk included. The most reliable estimate of cavoatrial junction position is a point two vertebral body units below the carina; there was no association with patient age or other parameters. Conclusions: A more accurate understanding of the superior vena cava anatomy is essential for the correct interpretation of central venous access device position. The true cavoatrial junction is located more inferiorly than commonly believed and is not accurately estimated with commonly used imaging landmarks. A point two vertebral body units below the carina enables the reliable estimate of the position of the cavoatrial junction. Catheter tip position can be most reliably described in vertebral body units below the carina, with use of the thoracic spine as an internal ruler. [Copyright &y& Elsevier]

Children with systemic hypertension resulting from a renovascular stenosis commonly have fibromuscular dysplasia and respond to percutaneous transluminal renal angioplasty (PTRA). There is a subset of children, however, with conditions that appear to be resistant to PTRA (eg, syndromic renal artery stenosis and arteritis). These patients are often treated surgically. The development of the cutting balloon may provide a minimally invasive alternative to surgery in these individuals. Associated adverse events may include recurrent stenosis, arterial occlusion with renal loss, and arterial rupture with extravasation and pseudoaneurysm formation. Some of these adverse events can be successfully treated with percutaneous interventional techniques. The authors present four cases of cutting balloon angioplasty performed at two large metropolitan children’s hospitals in children with resistant renal artery stenosis. [Copyright &y& Elsevier]

Purpose: To describe techniques and evaluate outcomes of computed tomography (CT)-guided percutaneous lung biopsy in children. Materials and Methods: Between April 1992 and June 2003, 64 patients (32 male, 32 female) with a mean age of 10.8 years (0.6-20 years) were referred for 75 lung biopsies. Most biopsies were performed for suspected malignancy (n = 24; 32%) or to distinguish posttransplantation lymphoproliferative disorder from fungal infection in immunocompromised patients (n = 17; 23%). All children referred to the pediatric interventionalists in two children's hospitals for CT-guided biopsy of parenchymal or pleural-based lesions in the thorax were studied. Prospectively gathered procedural data were reviewed for medical history and indications for procedure, admission status, type of anesthesia, technical approach (core vs aspiration biopsy), procedural modifications, lesion size, number of passes required, and immediate complications. Medical records were retrospectively reviewed for diagnostic outcome, impact on patient management, and delayed complications. Results: Procedures were performed under deep sedation whenever possible (n = 61; 81%) with use of a coaxial core biopsy technique (n = 56; 75%), a fine needle aspiration biopsy technique (n = 15; 20%), or both (n = 4; 5%). Mean lesion diameters were 2.5 cm (range, 1-10 cm) in the core biopsy group and 1.0 cm (range, 0.5-1.7 cm) in the aspiration biopsy group. Sixty-four biopsies (85%) were diagnostic. There was one major complication (1.3%), a tension pneumothorax treated with intraprocedural placement of a chest tube. Conclusion: Percutaneous CT-guided lung biopsy is a safe and accurate diagnostic procedure in children that obviates open surgical biopsy in most patients. [ABSTRACT FROM AUTHOR]

Recently developed endovascular techniques to create percutaneous arteriovenous fistulas are an alternative to surgical arteriovenous fistula creation, although there is currently a lack of high-level evidence regarding their creation, maturation, utilization, and long-term function. Recognizing this, the Society of Interventional Radiology Foundation sponsored a Research Consensus Panel and Summit for the prioritization of a research agenda to identify and address the gaps in current knowledge. [ABSTRACT FROM AUTHOR]

The fetal inflammatory response syndrome (FIRS) is a condition whereby the fetus mounts an inflammatory response to intrauterine infection/inflammation. Clinical consequences include preterm premature rupture of membranes (PPROM), spontaneous preterm delivery, neonatal sepsis, bronchopulmonary dysplasia, and brain and other organ injury. Mechanisms leading to brain injury in FIRS have been investigated in animal and human studies. We review the neuroimaging findings of brain injury in FIRS, which overlap those of hypoxic-ischemic injury, and clinical correlation is necessary for a correct diagnosis. FIRS should be considered the primary diagnosis when neuroimaging findings such as periventricular leukomalacia are identified in preterm children born as a consequence of PPROM and spontaneous preterm labor. Additionally, FIRS should be considered in term infants who do not have the most common features of HIE (e.g. a sentinel event). Systematic histopathologic examination of the placenta and umbilical cord and/or detection of characteristic inflammatory markers in such cases are needed to establish the correct diagnosis. [ABSTRACT FROM AUTHOR]

Fontan associated liver disease (FALD) is attributed to the limitations of the Fontan circulation, resulting in congestive hepatopathy. The technique and outcomes of transjugular liver biopsies (TJLB) in Fontan patients warrant definition as part of a rigorous FALD surveillance program. Four year review of patients with Fontan physiology who underwent a TJLB during surveillance catheterizations. Biopsy site, technique, histology, angiography, hemodynamics, and complications were reviewed to assess correlation of biopsy scores with simultaneously obtained catheterization hemodynamics. 125 patients with a TJLB from 10/1/14 to 5/1/18. Median age 17 years (2–50.5). Technical success 100% (125/125), all samples diagnostic. 17% (21) accessed via the left internal jugular vein, secondary to right IJ occlusion or Heterotaxy syndrome. No patients had superior compartment obstruction preventing transjugular approach. 3.2% complication rate (4/125). Complications were early in the experience, including capsular perforation (2), renal hematoma (1) and hemobilia (1), all without long-term effect and all avoidable. After standardized entry/exit angiography was adopted, no further complications noted. There is a significant correlation between the newly described modified Ishak congestive hepatic fibrosis (ICHF) score with mean Fontan pressure, time from Fontan and cardiac index. TJLB is an alternate method for obtaining critical FALD surveillance data, with lower complication rates that traditional techniques. Vascular anomalies in Fontan physiology appear common and warrant pre-biopsy assessment. There is a significant correlation between biopsy score, time from Fontan, mean Fontan pressure and cardiac index. • Transjugular liver biopsy is an alternate technique when a biopsy is needed for Fontan associated liver disease surveillance. • Complication rates are lower than traditional techniques and can be done during a routine hemodynamics catheterization. • Amalgamation of biopsy and hemodynamic data as a summated risk evaluation has become our institutional practice. [ABSTRACT FROM AUTHOR]