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We evaluated therapeutic microcoil embolization in a group of patients with severe colonic hemorrhage.Twenty-seven patients with severe colonic bleeding due to diverticular disease (n = 19), angiodysplasia (n = 6), cecal ulcer (n = 1), or unknown cause (n = 1) underwent attempted microcoil embolization (n = 25). Microcatheters were used in all procedures, and embolization was performed at the level of the vasa recta or the marginal artery of Drummond. Branches of the superior mesenteric artery were embolized in 12 patients, branches of the inferior mesenteric artery were embolized in 12 patients, and branches of both the superior and inferior mesenteric arteries were embolized in one patient.Technical success was achieved in 93% (25/27) of the procedures. However, immediate hemostasis occurred in 96% (26/27) of patients because in one failed procedure, an occlusive dissection of the inferior mesenteric artery arrested bleeding. Three patients rebled within 24 hr. One patient was treated with endoscopic cauterization, and two patients underwent right hemicolectomy. One patient who underwent right hemicolectomy for rebleeding had ischemic changes found on pathologic analysis of the resected specimen, and a second patient who underwent embolization of branches of the superior and inferior mesenteric arteries developed bowel infarction requiring left hemicolectomy. Prolonged clinical success occurred in 81% (22/27) of patients.Therapeutic microcoil embolization for severe colonic hemorrhage is an effective and well-tolerated procedure.

To evaluate feasibility and benefits of sonographic guidance of percutaneous transhepatic cholangiography (PTC) in children with liver transplants.The authors prospectively followed 24 PTC procedures in 19 pediatric patients (11 females, 8 males; age 3 months to 17 years) randomized to fluoroscopic or sonographic guidance. The number of needle passes, the contrast material dose, fluoroscopy time, and procedure time for each procedure were recorded. All patients were transplant recipients-six whole and 13 reduced-size grafts. Cases were randomly assigned to two groups: group I, fluoroscopically guided PTC (12 procedures); group II, sonographically guided PTC (12 procedures).The technical success rate was 92% (11 of 12) for each group. In group I, there were two procedure-related complications: postprocedural fever caused by biliary to portal vein fistula, and peritoneal bleeding requiring surgery. In group II, there were no procedure-related complications. A mean of 8.2 +/- 3.7 needle passes were required in group I compared to only 2.0 +/- 1.3 in group II (P.0001). A mean contrast material dose of 19.5 mL +/- 13.4 was required in group I compared to only 2.5 mL +/- 1.9 in group II (P.001). A mean procedure time of 15.7 minutes +/- 7.4 was required in group I compared to only 6.1 minutes +/- 4.5 in group II (P.001). A mean fluoroscopy time of 10.4 minutes +/- 5.0 was required in group I compared to only 1.0 minutes +/- 0.7 in group II (P.0001).In pediatric patients who have undergone liver transplantation, sonographic guidance significantly decreases the number of needle passes, contrast material dose, and fluoroscopy time required for PTC.

In children with liver transplants, percutaneous transhepatic cholangiography has a critical role in evaluation and treatment of biliary complications. The purpose of this study was to evaluate the technical success and complication rates of percutaneous transhepatic cholangiography and biliary drain placement in children who underwent liver transplantation.Between January 1, 1995 and July 1, 1999, 120 pediatric percutaneous transhepatic cholangiography procedures were performed in 76 patients (34 boys, 42 girls; age range, 5 months to 18 years; mean age, 5.3 years). Patients had received left lateral segment, whole-liver, or split-liver transplant grafts. Retrospective review of all pertinent radiology studies and electronic chart review were performed.A diagnostic cholangiogram was obtained in 96% (115/120) of all procedures and drainage catheter placement was successful in 89% (88/99) of attempts. In patients with nondilated intrahepatic bile ducts, a diagnostic cholangiogram was obtained in 92% (46/50) of procedures, and drainage catheter placement was successful in 76% (19/25) of attempts. Minor complications occurred in 10.8% (13/120) of procedures and included transient hemobilia with mild drop in hematocrit level (n = 2), mild pancreatitis (n = 1), fever with bacteremia (n = 5), and fever with negative blood cultures (n = 5). Major complications occurred in 1.7% (2/120) of procedures and included sepsis (n = 1) and hemoperitoneum requiring immediate surgery (n = 1).Percutaneous transhepatic cholangiography and biliary drainage can be performed with high technical success and low complication rates in pediatric liver transplant patients, even in those with nondilated intrahepatic ducts.

To evaluate the long-term effectiveness of the percutaneous treatment of portal venous stenoses in children and adolescents with reduced-size hepatic transplants.During the past 5 years, percutaneous transhepatic balloon venoplasty was attempted in 25 children and adolescents with anastomotic portal venous stenoses that occurred after reduced-size hepatic transplantation. All procedures were performed with direct puncture of the intrahepatic portal vein and with subsequent balloon dilation. Intravascular stents were deployed in patients with suboptimal results after dilation or with recurrent stenoses.Percutaneous venoplasty was technically successful in 19 of 25 patients. In the remaining six patients, portal venous occlusion precluded access to the extrahepatic portal vein. Intravascular stents were deployed in 12 patients for "elastic" (n = 5) or recurrent (n = 7) stenoses. Seven patients who underwent successful venoplasty without stent placement have required no further intervention. All stents have remained patent without further intervention. Portal venous patency has been maintained for 5-61 months (mean time, 46 months) in all 19 patients.Percutaneous treatment of portal venous stenoses is effective and long lasting in children with reduced-size hepatic transplants. In patients with elastic or recurrent lesions, portal venous stents have excellent long-term primary patency despite continued patient growth. Successful, percutaneous transhepatic venoplasty eliminates the need for surgical revision, portacaval shunting, or repeat transplantation.

The usefulness of exchanging poorly functioning tunneled permanent hemodialysis catheters in patients with end-stage renal disease was evaluated.We retrospectively reviewed case histories of 51 consecutive patients who underwent 88 catheter exchanges because of poor flow rates. All hemodialysis catheters were initially placed by the radiology service using image guidance. Catheter exchanges were performed through the existing subcutaneous tract over two stiff hydrophilic guidewires and without additional interventions such as fibrin sheath stripping or venoplasty. Life table analysis was performed to evaluate catheter patency rates after initial placement (primary patency) and after multiple exchanges (secondary patency).The technical success rate for hemodialysis catheter exchange was 100%. Primary catheter patency was 42% at 60 days and 16% at 120 days. Secondary patency was 92% at 60 days and 82% at 120 days. The cumulative infection rate was 1.1 per 1000 catheter days. No complications from the procedure occurred.Catheter exchange is an effective means of prolonging catheter patency in patients with end-stage renal disease and limited central venous access.

We studied the effectiveness of Wallstent deployment to treat elastic femoral and iliac vein stenoses in patients with lower extremity hemodialysis grafts.Between August 31, 1992, and October 13, 1997, 44 metallic stents were deployed in 20 patients to treat stenoses exhibiting immediate, significant elastic recoil after angioplasty. Twenty-four stents were placed in the femoral and saphenous veins, and the remaining 20 stents were placed in the iliac veins. Follow-up was provided by the nephrology and surgical service at our institution and by electronic review of patients' charts. The follow-up period was from August 31, 1992, until October 1, 1998.Stents were successfully inserted and stenotic lesions dilated in 100% of procedures. Each patient successfully completed at least one session of dialysis after the procedure. The primary patency rate of stents was 87% 60 days after the procedure, 51% 180 days after, 39% 1 year after, and 20% 2 years after. The secondary patency rate was 95% 60 days after the procedure, 92% 180 days after, 81% 1 year after, and 62% 2 years after. Complications were limited to two graft infections that developed 5 and 7 days after stent placement.Treatment of elastic venous stenoses is effective in patients with lower extremity dialysis grafts using metallic stents. The patency rates of these devices placed in the iliac and femoral veins are comparable with those of metallic stents placed in upper extremity and central veins.

Lorenz JM, Funaki B, Denison G ransjugular portosystemic shunt (TIPS) placement has become a standard treatment for children with portal hypertension caused by chronic liver disease. However, in the setting of portal hypertension due to chronic occlusion of the portal vein, TIPS may not be technically feasible, and surgical placement of a distal splenorenal shunt may be necessary. To our knowledge, percutaneous balloon dilatation of a distal splenorenal shunt in a child has not been reported in the radiology literature. Limited reports describe shunt dilatation in adults [1–3]. We present a case of successful balloon dilatation of a distal splenorenal shunt in a child, requiring repeated dilatation procedures to maintain long-term patency.

Purpose The informed consent process is part of the legal and ethical duty of physicians to involve patients in choices about their health care. IR procedures are often poorly understood by patients and referring physicians alike. We postulated that utilization of multimedia could improve patient understanding. We elected to determine if presenting a short slide presentation on an iPad as part of the informed consent process would result in improved patient understanding and satisfaction. Materials and Methods Eight common IR procedures were identified (abscess drainage, tunneled central venous catheter placement, gastrostomy tube placement, port catheter placement, percutaneous lung biopsy, vena cava filter placement, nephrostomy tube insertion, and percutaneous biliary drainage). Informed consent was then obtained without the iPad in 100 consecutive patients undergoing these procedures. These patients completed a 2 item questionnaire asking them to indicate their understanding of the procedure and if they had their questions answered. Then, informed consent was obtained in 100 patients where a short iPad presentation was included. These patients completed a 3 item questionnaire asking them to indicate their understanding of the procedure and if they had their questions answered. The additional question asked the patient if the iPad improved their understanding of the procedure. Results Without the iPad, the average score was 9.6 (range 7-10). One of 100 patients felt that more information was needed. With the use of the iPad, the average score was 9.5 (7-10). One of 100 patients felt that more information was needed. 99 of 100 (98%) thought the iPad was useful for the consent process. Conclusion Using an iPad during the informed consent process resulted in no statistically significant difference in patient perceived understanding. However, use of the iPad was deemed helpful by almost all patients. In this study, patient understanding was self-assessed. Future studies can consider formal testing mechanisms to objectively measure patient understanding. Nonetheless, multimedia devices such as the iPad may be a reasonable complement to standard verbal and written practices in the informed consent process.

To determine the frequency of focal hepatic vein stenosis in diffuse liver disease and to study the relationship of stenosis to abnormal hepatic venous Doppler waveforms, 92 patients being evaluated for liver transplantation or transjugular intrahepatic portosystemic shunt were prospectively studied with color flow and pulsed Doppler sonography for the presence of focal hepatic vein stenoses and waveform abnormalities. Thirty-six patients had no focal stenoses with normal curves, 26 of 38 patients with Bolondi type I curves had focal stenoses, and 10 of 18 patients with damped type II curves had focal stenoses. Damped hepatic venous velocity curves associated with liver disease probably are caused by increased resistance in the hepatic venous circulation produced by focal stenoses.

8526 Background: CD30 expression by Reed-Sternberg cells is a defining feature of Hodgkin lymphoma (HL). The ADC SGN-35 comprises an anti-CD30 antibody conjugated to monomethyl auristatin E (MMAE). SGN-35 mechanism of action involves binding to CD30 on the tumor cell surface, ADC internalization, MMAE release and binding to tubulin, prompting cell cycle arrest and apoptosis. Methods: A multicenter phase I dose escalation study was conducted in patients with refractory or recurrent CD30-positive hematologic malignancies. Twenty-nine patients (pts) were enrolled; 26 with HL, 3 with other CD30+ malignancies. Median age was 32 (range 22–87) and pts received a median of 5 prior therapies; 76% previously received an autologous stem cell transplant. Most (89%) pts had an ECOG performance status of 0/1. SGN-35 dose levels were 0.1, 0.2, 0.4, 0.6, 0.8, 1.2, 1.8 and 2.7 mg/kg (2-hr outpatient IV infusion, premedications not required) every 3 weeks (wks). Pts with stable disease or better after 2 doses were eligible...

Hakansson et al1 report in this issue of Pediatrics a population-based retrospective cohort study of mortality and morbidity during the first year of life in Swedish infants 22 to 27 weeks’ gestation with 2 different perinatal management strategies in the 1990s. In the southern region of the country, active obstetric intervention at ≤25 weeks’ gestation for fetal indications was restricted, and the approach to resuscitation of these infants was individualized. In the northern region, the approach to births ≤25 weeks’ gestation was proactive: a greater proportion of these births were managed in level III perinatal centers and delivered by cesarean section, a smaller proportion of infants had 1- and 5-minute Apgar scores