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Background: A first febrile urinary tract infection (UTI) is a common condition in children, and pathways of management have evolved over time. Objective: To determine the extent to which pediatricians and surgeons differ in their investigation and management of a first febrile UTI, and to evaluate the justifications for any divergence of approach. Materials and methods: A literature search was conducted for papers addressing investigation and/or management following a first febrile UTI in children published between 2011 and 2021. Searches were conducted on Medline, Embase, and the Cochrane Controlled Trials Register. To be eligible for inclusion, a paper was required to provide recommendations on one or more of the following: ultrasound (US) and voiding cystourethrogram (VCUG), the need for continuous antibiotic prophylaxis and surgery when vesicoureteral reflux (VUR) was detected. The authorship required at least one pediatrician or surgeon. Authorship was categorized as medical, surgical, or combined. Results: Pediatricians advocated less imaging and intervention and were more inclined to adopt a "watchful-waiting" approach, confident that any significant abnormality, grades IV–V VUR in particular, should be detected following a second febrile UTI. In contrast, surgeons were more likely to recommend imaging to detect VUR (p<0.00001), and antibiotic prophylaxis (p<0.001) and/or surgical correction (p=0.004) if it was detected, concerned that any delay in diagnosis and treatment could place the child at risk of kidney damage. Papers with combined authorship displayed intermediate results. Conclusion: There are two distinct directions in the literature regarding the investigation of an uncomplicated first febrile UTI in a child. In general, when presented with a first febrile UTI in a child, physicians recommend fewer investigations and less treatment, in contrast to surgeons who advocate extensive investigation and aggressive intervention in the event that imaging detects an abnormality. This has the potential to confuse the carers of affected children. [ABSTRACT FROM AUTHOR]

Background: Traditionally, testicular biopsy is performed using an open surgical approach. Ultrasound-guided percutaneous biopsy is a less invasive alternative and can be performed in children. Objective: The aim of this study is to report our technique and to assess the diagnostic accuracy and safety of ultrasound-guided percutaneous biopsy of testicular masses in children. Materials and methods: This is a 16-year retrospective review of ultrasound-guided percutaneous testicular biopsies at a single pediatric hospital. Results: We performed nine ultrasound-guided testicular biopsies in 9 patients (median age: 3 years, range: 4 months–11 years; median weight: 20.9 kg, range: 8.4–35 kg; median volume of testicular lesion biopsied: 4.4 mL, range: 1.2–17 mL). A percutaneous co-axial technique was used for 5/9 biopsies with absorbable gelatin sponge tract embolization performed in 4 of those biopsies. A non-co-axial technique was used in 4/9 biopsies. A median of three cores, range 2–6, were obtained. The diagnostic yield was 89% with one biopsy yielding material suggestive of, but insufficient for, a definitive diagnosis. The most common histological diagnosis was leukemic infiltration, occurring in 6/9 biopsies. Of the remaining three biopsies, one biopsy was suggestive of, but not confirmatory for, juvenile granulosa cell tumor and two biopsies confirmed normal testicular tissue; the long-term follow-up of which demonstrated normal growth and no lasting damage. There was one (clinically insignificant) complication out of nine biopsies (11%, 95% confidence interval 0–44%): a mild, self-resolving scrotal hematoma. Conclusion: Ultrasound-guided testicular biopsy can be performed safely in children as an alternative to open surgical biopsy, with a high diagnostic yield and low complication rate. [ABSTRACT FROM AUTHOR]

In the case of paediatric renal tumours, high correlation between the ultrasound-guided biopsy tissue diagnosis and the final histological diagnosis has been demonstrated [[3]] and ultrasound-guided biopsy is the protocolised biopsy method, when deemed necessary, for paediatric renal tumours [[4]]. Dear Editor, We are thankful to Verma et al. [[1]] for their letter to the editor [[2]] regarding our published research paper 'Diagnostic yield and safety of ultrasound-guided percutaneous testicular biopsies in children' [[2]]. Verma et al. [[1]] mention both "aspiration" biopsy, which we presume to represent fine needle aspiration and "needle" biopsy, which we presume to represent core needle biopsy. [Extracted from the article]

The letter responds to a suggestion for a "top-down" approach to investigating and treating children with urinary tract infections (UTIs). The authors argue that this approach, which involves early 99mtechnitium-dimercaptosuccinic acid (DMSA) scans, is no longer promoted in medical guidelines and has higher costs and radiation exposure compared to other guidelines. They also highlight that recent research does not support the use of DMSA scans to guide antibiotic prophylaxis and voiding cystourethrography. The authors conclude that there is no strong evidence that recurrent UTIs in childhood lead to significant long-term health issues, making it unnecessary to subject all children with UTIs to radiation-based tests. [Extracted from the article]

Renovascular hypertension in most cases requires endovascular treatment and/or surgery. This is technically much more difficult in small children and there is very limited published knowledge in this age group. We here present treatment and outcome of young children with renovascular hypertension at our institution. Children below 2 years of age, with renovascular hypertension between January 1998 and March 2020 were retrospectively reviewed. Demographics and treatment modalities were noted. Primary outcome was blood pressure within a week after the procedures and at last available visit. Sixty-six angiographies were performed in 34 patients. Median age at time of first angiography was 1.03 (interquartile range (IQR) 0.4-1.4) years and systolic blood pressure at presentation 130 (IQR 130-150) mm Hg. Thirty-eight percent (13/34) of children were incidentally diagnosed and 18% (6/34) presented with heart failure. Twenty-six (76%) children had main renal artery stenosis and 17 (50%) mid-aortic syndrome. Seventeen (50%) children showed intrarenal, six (18%) mesenteric, and three (9%) cerebrovascular involvement. Twenty patients underwent 45 percutaneous transluminal angioplasty procedures and seven children surgeries. In 44% of the 16 patients who underwent only percutaneous transluminal angioplasty blood pressure was normalized, 38% had improvement on same or decreased treatment and 19% showed no improvement. Complications were seen in 7.5% (5/66) of angiographies. In four of the seven (57%) children who underwent surgery blood pressure was normalized, two had improved (29%) and one unchanged (14%) blood pressure.Conclusion: In small children with renovascular hypertension below the age of 2 years, percutaneous transluminal angioplasty caused significant improvement in blood pressure with low complication profile. Surgery can be recommended where percutaneous transluminal angioplasty and medical treatments failed.What Is Known: • Renovascular hypertension is diagnosed in all age groups from a few weeks of life until adulthood. • Both angioplasty and surgery are significantly more difficult to perform in small children and the published information on short and long-term outcome in these children is very scarce.What Is New: • Children below the age of two years can safely and successfully undergo selective renal angiography and also safely be treated with angioplasty. • We here present a large group of babies and infants where angioplasty and in some cases surgery effectively and safely improved their blood pressure. [ABSTRACT FROM AUTHOR]

Purpose: To determine the management and outcomes of patients with gastro-oesophageal reflux (GOR) that requires further intervention following failure of Nissen fundoplication (NF). Methods: After institutional audit department approval, a retrospective review of paediatric patients who had further intervention following failure of primary NF between January 2006 and December 2015 for GOR at our centre was performed. Data are presented as median (range). Results: Of 820 patients who underwent NF, 190 (23%) received further procedures for GOR management at a median of 21 months of age (6–186); 90/190 (47%) had gastro-jejunal feeding (GJ). Of these, 67 (74%) remained on GJ feeds up to a median of 48 months and 23/90 (26%) had a second NF after GJ feeding. 97/190 (51%) had a redo fundoplication without having had a GJ; thus, 120/190 (63%) of patients having a further procedure went on to have a second NF after a median period of 15 months (1–70 months). Three patients (2%) had early emergency wrap revision 4 days after first fundoplication (we classed this as an 'early complication'). Of the seven patients who failed a 3rd NF, 4 continued GJ feeding, 2 of had oesophagogastric dissociation; 2 had 4th NF of which 1 was successful and 1 patient had gastric pacemaker and is successfully feeding orally. Patients who were finally successfully managed with GJ underwent 2 (2–5) tube changes/year. We found patients who had a previous GJ were more likely to have failure of the redo fundoplication than those who had not to have the GJ (16/24 vs. 30/90, p = 0.005). Conclusion: The chance of success decreases with every further attempt at fundoplication. The only factor significantly associated with failure of redo fundoplication was whether the patient previously had a GJ tube. In patients with failed fundoplications, when symptom free on jejunal feedings, further anti-reflux surgical intervention should be avoided. A randomized prospective study is needed for patient selection. [ABSTRACT FROM AUTHOR]

Although attempts have been made to show that pediatric interventional radiology adds value in children's hospitals, none has been particularly persuasive. An analysis of individual procedures would seem to be the most scientific approach, but there are numerous problems, including the effects that different health care systems have on clinical practice and the difficulty of generalizing the results of a single-center study to other hospitals, even within the same type of health care system. It is unsurprising that there are no published randomized controlled trials comparing both the costs and outcomes of specific pediatric interventional radiology procedures with surgical alternatives, and in fact these may not be feasible. There is only anecdotal evidence of the value of pediatric interventional radiology in multidisciplinary teams in children's hospitals. Currently, the best justification may be the counterfactual: demonstrating what can go wrong if pediatric interventional radiology expertise is not available. [ABSTRACT FROM AUTHOR]

Background: Traditionally, ultrasound (US)-guided bowel mass biopsies are avoided in favour of endoscopic or surgical biopsies. However, endoscopy cannot easily reach lesions between the duodenojejunal flexure and the terminal ileum and lesions not involving the mucosa may not be accessible via an endoscopic route.Objective: The aim of this study was to report our technique and to assess the diagnostic accuracy and safety of US-guided biopsy of bowel masses in children.Materials and Methods: We conducted a 14-year retrospective review of US-guided bowel mass biopsies at a single paediatric hospital.Results: Twenty US-guided bowel mass biopsies were performed in 19 patients (median age: 6 years and 6 months, range: 22 months-17 years, median weight: 22 kg, range: 10.2-48.4 kg). For 14 biopsies, there was no other lesion that could potentially be biopsied. A percutaneous coaxial technique was used for 19 biopsies and a transanal non-coaxial biopsy was performed in 1. A median of 9 (range: 2-15) cores of tissue was obtained at each biopsy. The technical success rate and adequacy of diagnostic yield were 100%. The most common diagnosis was lymphoma, which occurred in 16 biopsies. Three biopsies contained mucosa. There was one complication out of 20 biopsies (5%, 95% confidence interval 0-15%): a self-limiting, post biopsy pyrexia. Nineteen procedures were accompanied by a bone marrow aspirate and/or trephine within 2 weeks of the bowel biopsy, only one of which was diagnostic.Conclusion: US-guided bowel mass biopsy can be performed safely in children, with a high diagnostic yield and low complication rate. [ABSTRACT FROM AUTHOR]

Background: Endoscopic ultrasound is seldom available at paediatric centres; therefore drainage of pancreatic pseudocysts in children has traditionally been achieved by surgery.Objective: This study assessed the feasibility and safety of performing image-guided internal drainage of pancreatic pseudocysts with a flanged self-expanding covered nitinol pancreatic pseudocyst drainage stent.Materials and Methods: We conducted a retrospective case note review of children undergoing image-guided cystogastrostomy at two paediatric hospitals. Percutaneous access to the stomach was achieved via an existing gastrostomy tract or image-guided formation of a new tract. Under combined ultrasound, fluoroscopic or cone-beam CT guidance the pancreatic pseudocysts were punctured through the posterior wall of the stomach. A self-expanding covered nitinol stent was deployed to create a cystogastrostomy opening.Results: Image-guided cystogastrostomy was performed in 6 children (4 male; median age 6 years, range 46 months to 15 years; median weight 18 kg, range 13.8-47 kg). Two children had prior failed attempts at surgical or endoscopic drainage. Median maximum cyst diameter was 11.5 cm (range 4.7-15.5 cm) pre-procedure. Technical success was 100%. There were no complications. There was complete pseudocyst resolution in five children and a small (2.1-cm) residual pseudocyst in one. Pseudocyst-related symptoms resolved in all children.Conclusion: Pancreatic pseudocyst drainage can be successfully performed in children by image-guided placement of a cystogastrostomy stent. In this cohort of six children there were no complications. [ABSTRACT FROM AUTHOR]

Background: Arteriovenous fistulae (AVF) provide superior primary vascular access for children on chronic dialysis compared to central venous catheters (CVC). However, AVFs inevitably develop complications and will require some intervention to maintain long-term functional patency.Methods: We report an 'endovascular-first' approach to the maintenance and rescue of paediatric AVFs. Thirty interventions targeting 46 lesions in 18 children (median age 11 years [range 5-17]) were performed. Sixty-eight percent of the AVFs were brachio-cephalic fistulae, 26% brachio-basilic fistulae and 5% radio-cephalic fistulae. Immediate functional success was 86% with good dialysis adequacy (mean urea reduction ratio > 70%) at 3 months post procedure.Results: There was one significant complication, consisting of an AVF rupture which was managed with a covered stent.Conclusions: Repeated interventions may be necessary to maintain AVF patency and avoid central venous catheters. This is the largest series reported to date. [ABSTRACT FROM AUTHOR]

Purpose: Radiologically inserted gastrojejunal tubes (RGJ) and surgical jejunostomy (SJ) are established modes of jejunal feeding. The aim of the study is to review nutritional outcomes, complications and the practical consideration to enable patients and carers to make informed choice.Methods: Retrospective review of patient notes with a RGJ or SJ in 2010, with detailed follow-up and review of the literature.Results: Both RGJ and SJ are reliable modes to provide stable enteral nutrition. Both have complications and their own associated limitations.Conclusions: The choice has to be tailored to the individual patient, the social care available, the inherent medical disease and risk/benefit of repeated anaesthetic and radiation exposure. RGJ and SJ are important tools for nutritional management that achieve and maintain growth in a complex group of children. The risk and benefits should be reviewed for each individual patient. [ABSTRACT FROM AUTHOR]

Imaging is crucial in the assessment of children with a primary hepatic malignancy. Since its inception in 1992, the PRETEXT (PRE-Treatment EXTent of tumor) system has become the primary method of risk stratification for hepatoblastoma and pediatric hepatocellular carcinoma in numerous cooperative group trials across the world. The PRETEXT system is made of two components: the PRETEXT group and the annotation factors. The PRETEXT group describes the extent of tumor within the liver while the annotation factors help to describe associated features such as vascular involvement (either portal vein or hepatic vein/inferior vena cava), extrahepatic disease, multifocality, tumor rupture and metastatic disease (to both the lungs and lymph nodes). This manuscript is written by members of the Children's Oncology Group (COG) in North America, the International Childhood Liver Tumors Strategy Group (SIOPEL) in Europe, and the Japanese Study Group for Pediatric Liver Tumor (JPLT; now part of the Japan Children's Cancer Group) and represents an international consensus update to the 2005 PRETEXT definitions. These definitions will be used in the forthcoming Trial to Pediatric Hepatic International Tumor Trial (PHITT). [ABSTRACT FROM AUTHOR]

Primary liver malignancies are rare in children. Hepatoblastoma and hepatocellular carcinoma (HCC) together represent the overwhelming majority of cases. Overall survival of hepatoblastoma approaches 80% with multimodal treatment approaches that include chemotherapy, surgery and transplantation. However, there remains a subset of children with hepatoblastoma in whom resection or transplantation is not possible. The 5-year survival for children diagnosed with HCC is less than 30% and remains a significant therapeutic challenge. The poor outcomes for children with primary liver tumors motivate investigation of new therapeutic alternatives. Interventional oncology offers a broad scope of percutaneous and transcatheter endovascular cancer therapies that might provide clinical benefits. Minimally invasive approaches are distinct from medical, surgical and radiation oncologic treatments, and in adults these approaches have been established as the fourth pillar of cancer care. Transarterial chemoembolization is a minimally invasive locoregional treatment option performed by interventional radiologists with level-I evidence as standard of care in adults with advanced liver malignancy; transarterial chemoembolization in adults has served to prolong disease-free progression, downstage and bridge patients for surgical and transplant interventions, and improve overall survival. However, while several groups have reported that transarterial chemoembolization is feasible in children, the published experience is limited primarily to small retrospective case series. The lack of prospective trial evidence has in part limited the utilization of transarterial chemoembolization in the pediatric patient population. The purpose of this article is to provide an overview of the role of interventional radiology in the diagnosis and endovascular management of hepatic malignancies in children. [ABSTRACT FROM AUTHOR]

Hepatoblastoma and hepatocellular carcinoma (HCC) are the most common pediatric liver malignancies, with hepatoblastoma occurring more commonly in younger children and HCC occurring more commonly in older children and adolescents. Although surgical resection (including transplant when necessary) and systemic chemotherapy have improved overall survival rate for hepatoblastoma to approximately 80% from 30%, a number of children with this tumor type are not eligible for operative treatment. In contradistinction, pediatric HCC continues to carry a dismal prognosis with an overall 5-year survival rate of 30%. The Paediatric Hepatic International Tumour Trial (PHITT) is an international trial aimed at evaluating both existing and emerging oncologic therapies for primary pediatric liver tumors. Interventional radiology offers a number of minimally invasive procedures that aid in diagnosis and therapy of pediatric liver tumors. For diagnosis, the PHITT biopsy guidelines emphasize and recommend percutaneous image-guided tumor biopsy. Additionally, both percutaneous and endovascular procedures provide therapeutic alternatives that have been, to this point, only minimally utilized in the pediatric population. Specifically, percutaneous ablation offers a number of cytotoxic technologies that can potentially eradicate disease or downstage children with unresectable disease. Percutaneous portal vein embolization is an additional minimally invasive procedure that might be useful to induce remnant liver hypertrophy prior to extended liver resection in the setting of a primary liver tumor. PHITT offers an opportunity to collect data from children treated with these emerging therapeutic options across the world. The purpose of this manuscript is to describe the potential role of minimally invasive percutaneous transhepatic procedures, as well as review the existing data largely stemming from the adult HCC experience. [ABSTRACT FROM AUTHOR]

Achalasia is a rare esophageal motility disorder: its optimal treatment in children is still a matter of debate. Records of children treated for achalasia, over an 18-year period, were reviewed.Forty-eight children (median age at diagnosis 10 years; range 3-17 years) were identified. Twenty-eight patients were initially treated with Heller's myotomy (HM) and 20 with balloon dilatation (BD). At last follow-up (median 3 years; range 1-5.5 years), 43.8% (21/48) of children were symptom free. The number of asymptomatic children was significantly higher among those treated initially with HM compared to BD (HM 15/28, 53.6% BD 6/20, 30%, p < 0.05). All children who underwent BD required HM due to symptom recurrence. The median (range) total number of procedures was significantly higher in the BD group (BD 3 (1-7); HM 1 (1-5); p < 0.05) with a shorter time to the second intervention (BD 14 months, 95%CI 4-24; HM 58 months, 95%CI 38-79; p < 0.05). Of 108 procedures, esophageal perforation occurred in two children after HM (two out of 48 HM procedures in total, 4%) and one child after BD (1/60, 1.7%).Conclusion: Less than half of children with achalasia are symptom free after initial treatment with either BD or HM. HM, however, when performed as first procedure, provided longer symptom-free period and reduced need for subsequent intervention. What is Known: • Balloon dilatation (BD) and Heller's myotomy (HM) are safe and effective treatment options for achalasia. • Controversy, however, exists regarding the most effective initial therapeutic approach. What is New: • HM with or without fundoplication may represent the initial therapeutic approach of choice. • Initial BD may negatively affect the outcome of a subsequent HM. [ABSTRACT FROM AUTHOR]

Background: Pediatric interventional radiology is a distinct subspecialty differing from both pediatric diagnostic radiology and adult interventional radiology. We conducted a workforce survey in 2005 to evaluate the state of pediatric interventional radiology at that time. Since then there have been many advancements to the subspecialty, including the founding of the Society for Pediatric Interventional Radiology (SPIR). Objective: To evaluate the current state of the pediatric interventional radiology workforce and compare findings with those of the initial 2005 workforce survey. Materials and methods: We sent a two-part survey electronically to members of SPIR, the Society for Pediatric Radiology (SPR), the Society of Chairmen of Radiology in Children's Hospitals (SCORCH) and the Society of Interventional Radiology (SIR). Part 1 focused on individual practitioners ( n=177), while part 2 focused on group practices and was answered by a leader from each group ( n=88). We examined descriptive statistics and, when possible, compared the results to the study from 2005. Results: A total of 177 individuals replied (a 331% increase over the first study) and 88 pediatric interventional radiology (IR) service sites responded (a 131.6% increase). Pediatric IR has become a more clinically oriented specialty, with a statistically significant increase in services with admitting privileges, clinics and performance of daily rounds. Pediatric IR remains diverse in training and practice. Many challenges still exist, including anesthesia/hospital support, and the unknown impact of the new IR residency on pediatric IR training, although the workforce shortage has been somewhat alleviated, as demonstrated by the decreased mean call from 165 days/year to 67.2 days/year. Conclusion: Pediatric interventional radiology practitioners and services have grown significantly since 2005, although the profile of this small subspecialty has changed and some challenges remain. [ABSTRACT FROM AUTHOR]

Objectives: Renovascular disease (RVD) is found in about 10 % of secondary childhood hypertension. Digital subtraction angiography (DSA) is the gold standard to diagnose RVD. Non-invasive imaging methods like Doppler ultrasound (US), magnetic resonance angiography (MRA), and computed tomography angiography (CTA) are increasingly used. Our aim was to evaluate the role and accuracy of US, MRA, and CTA compared to DSA in diagnosing RVD in children. Patients and methods: A retrospective review of 127 children with suspected renovascular hypertension was performed in children referred to Great Ormond Street Hospital between 2006 and 2014 due to clinical suspicion of renovascular hypertension and/or findings on US and/or MRA or CTA. Results: Ninety-nine of 127 children (78 %) were diagnosed with renovascular disease and 80 were treated with percutaneous transluminal angioplasty during the same procedure. The median age at presentation was 5.6 (range, 2.5-10.6) years. Thirty-six children had unilateral renal artery stenosis in major extraparenchymal vessels, 47 bilateral stenosis and 16 intrarenal small vessel disease. US had a sensitivity of 63 % and specificity of 95 %. MRA and CTA were performed in 39 and 34 children, respectively. CTA sensitivity was slightly higher than that of MRA, 88 vs. 80 %, and specificity 81 vs. 63 %. Conclusions: The sensitivity of MRA and CTA is still too low to reliably rule out renovascular disease in children with a strong suspicion of this diagnosis. DSA remains the gold standard to diagnose renovascular hypertension and is recommended when clinical and laboratory criteria are highly suggestive of renovascular disease even with normal radiological investigations from non-invasive methods. [ABSTRACT FROM AUTHOR]

Conventionally, xanthogranulomatous pyelonephritis is treated with antibiotics and drainage of abscess followed by nephrectomy for definitive treatment. Surgical excision of the affected kidney carries risk of significant complications. An alternative treatment modality is described in the form of embolization of the renal artery to devascularise the renal parenchyma and ablate the renal tissue, thus avoiding a major surgical procedure and the significant risks involved. [ABSTRACT FROM AUTHOR]

Purpose: Ventriculoatrial (VA) shunts are commonly used as a second-line treatment of hydrocephalus when the peritoneum is an unsuitable site for the distal catheter. Many centres now utilise ultrasound and interventional radiology techniques to aid placement of the distal catheter. The purpose of this study was to conduct a contemporary audit of VA shunting in children using interventional radiology techniques for placement of the distal catheter. Methods: A retrospective analysis of all patients who had VA shunts inserted between June 2000 and June 2010 was conducted using a prospectively updated surgical database and case notes review. Results: Ninety-four VA shunts were inserted in 38 patients. Thirty-seven patients had been treated initially with ventriculoperitoneal (VP) shunts. Twenty-two patients required at least 1 shunt revision (58 %). The 6-month, 1- and 2-year shunt survival rates were 53, 43 and 27 %, respectively. Blockage was the commonest reason for shunt failure (68 %). The site of failure was proximal (ventricular catheter +/− valve) in 32 % and distal (atrial catheter) in 21 % of cases. The overall infection rate was 6 % per procedure and 11 % per patient. There were 7 deaths, of which 3 were shunt related. Conclusions: VA shunting provides a viable second-line option for shunt placement in complex hydrocephalus. The causes of shunt failure (blockage, infection and equipment failure) are similar to VP shunting though shunt survival rates are inferior to VP shunts. Ultrasound guided VA shunt placement provides a relatively safe, second-line alternative to the placement of a ventriculoperitoneal shunt when this route is unsuitable. [ABSTRACT FROM AUTHOR]

Haemorrhagic cystitis is an uncommon and, in its severe form, potentially life-threatening complication of haematopoietic stem cell transplantation or cancer therapy in children. The severe form involves macroscopic haematuria with blood clots, urinary obstruction and/or renal impairment. There are many therapeutic options to treat acute haemorrhage, but only recombinant factor VII has a high level of clinical evidence in children. Supraselective vesical artery embolization (SVAE) is an increasingly used therapeutic procedure for controlling haemorrhage in adults, but is less commonly used in children. This might be due to several factors, such as the invasive nature of the procedure, lack of appropriate medical experience and possible long-term side effects. We present three cases of children successfully treated by means of effective SVAE. [ABSTRACT FROM AUTHOR]

Background: Ablation techniques are widely used for solid malignant tumors in adults. There is no large series assessing the effectiveness of local ablative therapies in the treatment of malignant or aggressive benign lesions in children. Objective: To review the existing evidence on the techniques and results of ablation for pediatric solid malignant or aggressive benign tumors. Materials and methods: We searched MEDLINE for papers published between 1995 and 2012 that reported outcomes of radiofrequency, microwave and cryoablation, interstitial laser therapy, irreversible electroporation and percutaneous ethanol injection for patients younger than 18 years old. Data collection included factors related to the patient, tumor biology, ablation technique and cancer-specific endpoints. Additional series of predominantly adults including data on patients younger than 18 years old were also identified. Results: We identified 28 patients treated by ablation in 29 regions: 5 patients undergoing ablation for liver lesions, 9 patients for lung metastases, 11 patients for bone and/or soft tissue and 4 patients for kidney or pancreas. The ablation was performed to treat primary tumors, local recurrences and metastases. The histology of the tumors was osteosarcoma in 6 patients, Wilms tumor in 3, rhabdomyosarcoma in 3, hepatoblastoma in 3, desmoid tumor in 3, adrenocortical carcinoma in 2 and a single case each of leiomyosarcoma, Ewing sarcoma, paraganglioma, solid-pseudopapillary neoplasm, sacrococcygeal teratoma, hepatic adenoma, juxtaglomerular cell tumor and plantar fibromatosis. Eighteen of the patients (64%) experienced a complication, but only 6 (21%) of these needed treatment other than supportive care. Conclusions: Although ablative techniques are feasible and promising treatments for certain pediatric tumors, large multicenter prospective trials will be needed to establish efficacy. [ABSTRACT FROM AUTHOR]

Various vascular and nonvascular hepatobiliary interventional radiology techniques are now commonly performed in children's hospitals. Although the procedures are broadly similar to interventional practice in adults, there are important differences in indications and technical aspects. This review describes the indications, techniques, and results of liver biopsy, hepatic and portal venous interventions and biliary interventions in children. [ABSTRACT FROM AUTHOR]

Paediatric palliative care is a distinct subspecialty that offers treatment to children with many types of illness, including oncological, neurological and respiratory problems. Paediatric interventional radiologists can make a useful contribution to symptom management as part of a multidisciplinary team. Interventions for pain management include local ablation or other treatment of painful lesions, image-guided nerve blocks and the insertion of devices for the delivery of analgesic drugs. Various techniques are also available for the management of ascites, pleural effusions and other symptomatic complications of the underlying disease process. [ABSTRACT FROM AUTHOR]

Background: Primary yolk sac tumour of the liver is extremely rare, and when it occurs in a young child it can be confused with hepatoblastoma. Objective: To present a retrospective case series of primary hepatic yolk sac tumour from two institutions to highlight the imaging features. Materials and methods: We conducted a retrospective review of pathological and imaging findings in biopsy-proven pure primary yolk sac tumour of the liver. Results: A total of three children (15 months to 6 years) presented between 2006 and 2012 with primary hepatic yolk sac tumour. Two children presented with acute abdomen after minor trauma caused by tumour rupture and haemoperitoneum. We identified five additional paediatric cases of pure hepatic yolk sac tumour with descriptions of imaging findings in the literature. In seven of these eight children, central necrosis was seen on cross-sectional imaging. Conclusion: Primary yolk sac tumour should be considered as an alternative diagnosis to hepatoblastoma in a young child with a large liver mass and significantly raised serum alpha-foetoprotein, but in view of the nonspecific imaging features histological examination is essential for diagnosis. Although there are no specific imaging findings of primary yolk sac tumour, presence of cystic or necrotic areas and a tendency for tumour rupture are suggestive features. [ABSTRACT FROM AUTHOR]

Surgical repair of oesophageal atresia may result in anastomotic strictures. These strictures are often treated by balloon dilatation (BD) and currently balloon dilatation (fluoroscopic or endoscopic) is the preferred primary treatment method. Here we review the current evidence of the outcomes of balloon dilatation of anastomotic strictures secondary to surgical repair of oesophageal atresia. We searched the standard databases (January, 1960-May, 2012) to identify all studies that reported outcomes of balloon dilatation of anastomotic strictures secondary to surgical repair of oesophageal atresia in children. Data, reported as median (range), were analysed and compared. Outcomes were success of BD, number of BD sessions, number of oesophageal perforations, need for other surgical interventions and mortality. Five studies were found to be relevant ( n = 139; 81 [58%] male children). The total number of dilatation sessions was 401 (2.9 dilatations per child patient). General anaesthesia was used in two (40%) studies; sedation in a further two (40%) studies and one (20%) study used a combination of both. The size of balloon catheter ranged from 4 mm to 22 mm. Seven perforations were reported (1.8% per dilatation session), of which only one (14%) required surgery. No deaths were recorded. Balloon dilatation for anastomotic strictures post-EA repair is safe, and associated with a low perforation and mortality rates. Most perforations are amenable to conservative management. [ABSTRACT FROM AUTHOR]

The article offers information on various aspects associated with hypertension including its causes, definitions and role of noninvasive imaging in hypertension. It states that medical cases of high blood pressure in children is increasing in developed nations. It further informs about the three imaging modalities used in the U.S. including nuclear medicine, magnetic resonance imaging and computed tomography.

The article offers information on the quality improvement guidelines for pediatric abscess and fluid drainage. It states that membership of the Society of Interventional Radiology (SIR) Standards of Practice Committee represents experts in a broad spectrum of interventional procedures from the private and academic sectors of medicine.

Background: Children with renovascular hypertension often present with severe hypertension. Some children have severe obstruction of their renal arteries resulting in <10% relative function on [Tc]dimercaptosuccinic acid (DMSA) scan. Conventional treatment of these children has been nephrectomy of the poorly functioning kidney to normalise their blood pressure (BP). Case-Diagnosis/treatment: We describe three children aged 20 months to 9 years with severe renal artery stenosis and severe hypertension who had radionucleotide uptake of 0% in one kidney. In one case, no renal perfusion was demonstrated by duplex ultrasound scan. Significant recovery of relative renal function of 18 to 52% was achieved after revascularisation by percutaneous angioplasty or open surgery of the obstructed renal artery. Conclusion: These cases illustrate that scintigraphy alone cannot be used to predict salvageable function in children with renovascular disease. [ABSTRACT FROM AUTHOR]

Background: Rapidly involuting congenital haemangioma (RICH) is a benign neoplasm that may occur in many locations in the body. When RICH occurs in the liver, it may be confused with other lesions. Objective: To present a case series from a single institution. Materials and methods: Retrospective review of pathological and imaging findings in infants with biopsy-proven hepatic RICH treated at a single hospital. Results: Four children (2 days to 6 weeks of age) presented between 2002 and 2007 with a solitary hepatic lesion. Needle biopsy excluded the alternative possibility of infantile haemangioma by showing negativity for GLUT1. Serial imaging confirmed rapid involution in each child. Conclusion: RICH should be suspected in neonates who present with a solitary liver lesion and normal-for-age serum alpha-fetoprotein. Serial US scans should be used to confirm a progressive shrinkage of the lesion. Corticosteroids and β-adrenergic antagonists have no proven effect in treating RICH. If the lesion grows, percutaneous needle biopsy is recommended to exclude a malignant tumour and to direct further management. Infants with cardiac failure should be treated medically. Embolization (with or without needle biopsy) should only be performed when this strategy fails. [ABSTRACT FROM AUTHOR]

Mid aortic syndrome (MAS) is a rare condition often presenting with severe hypertension. It is characterized by narrowing of the abdominal aorta. We here describe a case of complete occlusion of the abdominal aorta presenting in infancy. This child presented at four months of age with heart failure and hypertension. CT angiogram showed total narrowing of the abdominal aorta. This was initially felt to be too severe for surgical treatment and he was planned for palliative care. We were however able to improve his blood pressure with antihypertensive agents and he underwent succesful angioplasty at five and a half months of age. He has required three further angioplasty procedures and still needs two antihypertensive agents to control his blood pressure. His renal function remains normal and at age six years he has excellent quality of life with normal growth and development. This case illustrates that the combination of medical treatment and angioplasty can give an excellent long-term treatment response even in children with extremely severe MAS. This boy now has normal blood pressure and has experienced normal growth, development and quality of life. [ABSTRACT FROM AUTHOR]

The article discusses the development of a pediatric interventional radiology practice in clinics. It mentions the significance of informed consent such as understanding clinical elements. It conveys that a pediatric life support certification and radiation protection are recommended for pediatric radiology. It also suggest having auxiliary services to help patients and families reduce frustration and anxiety.

Narrowing of the abdominal aorta and renal arteries (mid-aortic syndrome) after treatment for neuroblastoma has been attributed to radiation therapy. We present a child with neuroblastoma, successfully treated without radiation therapy, who developed mid-aortic syndrome and hypertension. MR imaging demonstrated encasement of the aorta at presentation. Following successful treatment, long-segment aortic narrowing and narrowing of the proximal renal arteries were present. Hypertension has improved during a 5-year period although renal artery stenosis persists. The incidence of mid-aortic syndrome in children with neuroblastoma is unknown. Etiologies include vascular injury from radiation or chemotherapy, the effect of catecholamines secreted by the tumor on arterial growth, arterial injury at the time of surgery or a constitutional predisposition to the development of both neuroblastoma and mid-aortic syndrome. [ABSTRACT FROM AUTHOR]

Paediatric interventional uroradiology lies at the intersection of the disciplines of paediatric interventional radiology and paediatric endourology. Interdisciplinary collaboration has led to the development of new techniques and refinement of procedures adopted from adult practice. This article reviews the major procedures used in paediatric interventional uroradiology, with emphasis on nephrostomy, percutaneous nephrolithotomy, balloon-burst pyeloplasty, and antegrade ureteric stenting. [ABSTRACT FROM AUTHOR]

Interventional radiology is a rapidly growing discipline in paediatrics. Many non-vascular interventional techniques may be used in the gastrointestinal tract in children. The technically simpler and more common of these may be adopted by any paediatric radiologist with an interest in interventional radiology. Other rarer and more complex techniques are currently restricted to specialist centres with a higher overall caseload. This review emphasizes the common procedures such as oesophageal dilatation, gastrostomy, insertion of transgastric jejunal feeding tubes and biopsy. Less common salivary, hepatobiliary, pancreatic and intestinal interventions are also described. [ABSTRACT FROM AUTHOR]

Renovascular disease (RVD) is an important cause of hypertension in children, as it often is amenable to potentially curative treatment. Imaging aimed at finding RVD therefore needs to have high sensitivity so as not to miss important findings. Digital subtraction angiography is the gold standard investigation. Doppler ultrasonography, computed tomography (CT) angiography and magnetic resonance (MR) angiography can all be helpful, but none has, at present, high enough sensitivity to rule out RVD in a child with a suggestion of that diagnosis. [ABSTRACT FROM AUTHOR]

Fetal endoscopic tracheal occlusion (FETO) is a promising treatment for severe congenital diaphragmatic hernia, a condition that carries significant morbidity and mortality. It is hypothesised that balloon occlusion of the fetal trachea leads to an improvement in lung growth and development. The major documented complications of FETO to date are related to preterm delivery. To report a series of five infants who developed tracheomegaly following FETO. Review of all children referred with tracheomegaly to the paediatric intensive care and tracheal service at two referral centres. Five neonates presented with features of respiratory distress shortly after birth and were subsequently found to have marked tracheomegaly. Two neonates had tracheomalacia in addition. There are no previous reports in the literature describing tracheomalacia, or more specifically, tracheomegaly, as a consequence of FETO. We propose that the particularly compliant fetal airway is at risk of mechanical damage from in utero balloon occlusion. This observation of a new problem in this cohort suggests a thorough evaluation of the trachea should be performed in children who have had FETO in utero. It may be that balloon occlusion of the trachea earlier in utero (before 26 weeks’ gestation) predisposes to this condition. [ABSTRACT FROM AUTHOR]

The article presents the joint quality improvement guidelines for pediatric arterial access and arteriography by the Societies of International Radiology and Pediatric Radiology that serves as the standard of practice. It notes that the guidelines covers the broad spectrum of interventional procedures from private and academic sectors of medicine. It includes the general considerations in pediatric arteriography, radiation protection and arteriography .

We studied the ability of pre- and postcaptopril renal scintigraphy to predict renovascular disease (RVD) in children. Retrospective review of medical notes and radiology reports of all hypertensive children who had had both pre- and postcaptopril renal scintigraphy with [99mTc] dimercaptosuccinic acid (DMSA) and/or [99mTc] mercaptoacetyltriglycine (MAG3) and digital subtraction angiography (DSA). 81 children aged 1–18 (median 10) years were studied with 62% (51) having a diagnosis of RVD. Main renal artery disease, intrarenal disease, and both main and intrarenal artery disease were present in 25, 14, and 12 patients respectively. The isotope study accurately diagnosed RVD, confirmed by DSA, in 47% (24 of 51) children, with eight false positive studies. The sensitivity, specificity, and positive and negative predictive values of the isotope study to predict RVD were 48%, 73%, 76%, and 51%, respectively. Pre- and postcaptopril renal scintigraphy was unable to predict RVD in children. [ABSTRACT FROM AUTHOR]

The clinical characteristics and outcomes of children with mid-aortic syndrome (MAS) and the effectiveness of different therapeutic approaches in reducing hypertension are still debated. We conducted a single-centre retrospective review of the records of children with MAS over 30 years. Children with angiographic evidence of a narrowed abdominal aorta were included. Therapeutic approaches included medical management, percutaneous transluminal angioplasty and/or surgical intervention. Thirty-six children had presented at a median age of 2.7 years (10 days–10 years). Thirteen (36%) patients had associated syndromes, and 44% had been diagnosed with cerebrovascular disease. All patients had involvement of multiple arteries. The mortality rate was 8% after a median follow-up period of 4.5 (range 1.1–19.7) years. Among the children who survived, 90% had obtained a reduction in their blood pressure (BP). Of the patients, 76% had had a normal estimated glomerular filtration rate (eGFR) at the last follow-up examination. Seventeen percent (six of 36) had renal dysfunction at presentation. Although MAS is a severe and widespread disease, in most cases it can be effectively treated with a combination of medical, angioplasty and surgical interventions. [ABSTRACT FROM AUTHOR]

Rhabdomyosarcoma is a soft-tissue malignancy that represents approximately 4–8% of all solid tumours in children and commonly arises from the head and neck and genitourinary system. Intraperitoneal rhabdomyosarcoma, in particular with omental involvement, has been rarely reported in the literature. Furthermore, reports of omental rhabdomyosarcoma of embryonal origin do not exist, to our knowledge. We report two cases of omental embryonal rhabdomyosarcoma affecting children and illustrate the imaging characteristics of this rare tumour. [ABSTRACT FROM AUTHOR]

The article offers information on the pediatric interventional radiology (PIR). It is stated that PIR is a small but mature subspecialty, which was historically performed by pediatric radiologists with an interest in intervention. It notes that PIR procedures, which are also performed by specialists in other disciplines, depend on local practice and referral patterns. It also mentions several PIR procedure types, which include central venous access, biopsy and angiography.

The article focuses on imaging techniques used to detect focal liver lesions in children. Multiplanar imaging can be used to confirm the organ of origin of a solid liver mass. Colour doppler ultrasonography is considered as the best way to assess the dominant arterial supply of adrenal and renal tumours. Furthermore, biopsy is used to diagnose a soild liver mass on the basis of imaging signs. Computed tomography and magnetic resonance imaging can also help to diagnose undifferentiated sarcoma.

The article explores the role of medical imaging in identifying the cause of hypertension in children. It cites that obesity, family history of high blood pressure (BP), sleep apnoea, low birth weight, and prematurity, and chronic renal disease are the most crucial risk factors for essential hypertension in children. The author stresses that diagnostic imaging such as ultrasound, scintigraphy, and magnetic resonance (MR) angiography may help in determining the cause of hypertension in children.

Central venous access is increasingly becoming the domain of the radiologist, both in terms of the insertion of central venous catheters (CVCs) and in the subsequent management of these lines. This article seeks to provide an overview of the CVC types available for paediatric patients and a more detailed explanation of the spectrum of complications that may lead to catheter malfunction. A standard catheter contrast study or ‘linogram’ technique is described. The normal appearances of such a study and a detailed pictorial review of abnormal catheter studies are provided, together with a brief overview of how information from catheter investigations can guide the management of catheter complications. [ABSTRACT FROM AUTHOR]

Imaging is a crucial part of the evaluation of children with primary liver malignancies. In addition to staging the intrahepatic extent of the tumour, the 2005 revision of the PRETEXT system specifies certain criteria for assessment of extrahepatic disease. This article reviews the imaging findings of two of these criteria: direct extrahepatic extension of the tumour (E1, E1a, E2, E2a) and tumour rupture at diagnosis (H1). [ABSTRACT FROM AUTHOR]

Over the last 15 years, various oncology groups throughout the world have used the PRETEXT system for staging malignant primary liver tumours of childhood. This paper, written by members of the radiology and surgery committees of the International Childhood Liver Tumor Strategy Group (SIOPEL), presents various clarifications and revisions to the original PRETEXT system. [ABSTRACT FROM AUTHOR]