Faculty Bibliography

BACKGROUND:Reports of child and young adult superior vena cava (SVC) stent placement, safety, and long-term patency are limited, particularly in children without congenital heart defects (CHDs). OBJECTIVE:To characterize technical success, safety, and long-term outcomes of SVC stent placement in children and young adults without co-existing congenital heart defects. Additionally, to demonstrate the ability of SVC stent placement to maintain central venous access in patients with difficult access. MATERIALS AND METHODS/METHODS:Institutional Review Board (IRB) approved retrospective review of children and young adults without CHDs who underwent SVC stent placement between 2014 and 2024 was performed. SVC stenosis/occlusion was determined by pre-procedure imaging (chest computed tomography (CT) or magnetic resonance imaging (MRI)), and confirmed with venography and intravascular ultrasound. Symptomatic patients were defined as patients with facial or neck swelling, bulging neck or chest wall collaterals, and dependence on central venous access with narrowed or occluded central venous pathways. RESULTS:Nineteen patients (n = 11 F, n = 8 M) without CHDs had SVC stents placed. All had SVC stenosis or occlusion secondary to chronic central venous access. Mean age was 16.5 years (3 - 20 years, interquartile range 7.375 years) and mean weight was 50 kg (15.8 - 115.2 kg, interquartile range 32.6 kg). Ten percent (2/19) presented with acute SVC syndrome. In total, 21% (4/19) required sharp recanalization. Twenty-four total stents were placed; 21 (88%) were bare metal and three were covered. One major complication of SVC tearing occurred during sharp recanalization, which led to hemopericardium/cardiac tamponade. This complication was successfully treated with a pericardial drain and deployment of a second stent across the vessel injury. Median patient follow-up time was 15 months (0.5-88 months, interquartile range 53 months). Seventy-four percent (15/19) had imaging follow-up (chest CT or venography) to assess stent patency, with a mean imaging follow-up of 11 months (3 days-86 months, interquartile range 11 months). Three patients required re-intervention(s): two required venoplasty to allow for catheter exchange, and one required venoplasty for recurrent facial and upper extremity swelling. The mean time to re-intervention was 16 months (2-28). There were no complications during repeat interventions. All patients maintained central venous access for the duration of required treatment or throughout the entire study period. CONCLUSION/CONCLUSIONS:SVC stent placement in children and young adults without CHDs has a favorable safety profile and is an effective solution for preserving critical central venous access for necessary therapy in chronically ill children.

BACKGROUND:Fistulous and cystic neck lesions that cannot be categorized into traditional classification schemes at presentation are challenging to manage and often manifest as recurrently draining fistulas after primary surgery. Work up with traditional cross-sectional imaging techniques with computed tomography (CT) or magnetic resonance imaging (MRI) may not provide adequate fine details of small channels. Characterization of fistula tracts is necessary for identification and definitive management of atypical or recurrent congenital neck anomalies. METHODS:A retrospective review of the electronic medical record from 2 institutions between 2016 and 2023 identifying cases of atypical or recurrent congenital neck anomalies for which CT and MR fistulogram, a novel interventional imaging technique, identified and characterized atypical fistula tracts. Imaging protocol, fistulogram technique, imaging-anatomic correlation, and follow up are reported. RESULTS:We identified 5 patients aged 8-14 years who presented with a draining pit in the head and neck who underwent CT or MRI fistulograms. Diagnoses include first branchial cleft anomalies (n = 3), deep branchial cleft fistula containing ectopic salivary tissue (n = 1), and a recurrent thyroglossal duct cyst (n = 1). Three patients had prior surgery to address these anomalies with recurrences, and one patient had an associated Kabuki syndrome. Complete resection was performed in all cases, with no recurrence to date. CONCLUSION/CONCLUSIONS:CT and MRI fistulograms are minimally invasive, safe, efficacious, and feasible techniques that can be performed before surgery and facilitated on the same day in a single anesthesia encounter. The technique allows for complete visualization of atypical and/or recurrent cystic and fistulous neck anomalies. It facilitates preoperative planning and aids in the characterization of the lesion so that a complete surgical excision can be executed.

Pediatric renovascular hypertension (RVHTN) results from flow-limiting disease of the renal arterial vasculature and is a potentially treatable cause of pediatric hypertension. Causes of pediatric RVHTN include idiopathic causes, fibromuscular dysplasia, neurofibromatosis, vasculitis, traumatic vascular injury, aneurysms, and aberrant renal arterial supply. Diagnostic imaging allows screening for and confirmation of pediatric RVHTN. Renal sonography with Doppler evaluation is the initial test of choice, followed by CT angiography and MR angiography. However, these modalities may not demonstrate intrarenal segmental or subsegmental branch disease. Therefore, conventional angiography maintains a significant role in diagnosis of pediatric RVHTN. Once diagnosed, pediatric RVHTN is initially treated with antihypertensive medications. Minimally invasive procedures, including angioplasty and embolization, may temporize or cure RVHTN. Surgical intervention-including renal artery reconstruction or reimplantation, aortorenal bypass grafting, or even nephrectomy-may be required for flow-limiting pathologic conditions, which often require endovascular strategies for maintenance. Renal artery stent placement is generally avoided due to limited data and risk of occlusion, although it can be considered in cases of iatrogenic dissection or severe elastic recoil refractory to angioplasty. Having appropriately sized covered stent-grafts nearby as a safety precaution is encouraged when performing these interventions. Radiologists play an invaluable role in the care of patients with pediatric RVHTN through multimodality diagnostic tools, both noninvasive and minimally invasive. The authors review medical management, diagnostic imaging, and endovascular interventions involved in caring for patients with pediatric RVHTN, to optimize diagnostic and interventional radiologist participation in multidisciplinary care with pediatric nephrologists and vascular surgeons. ^©RSNA, 2025 Supplemental material is available for this article.

Patients with pancreatic ductal adenocarcinoma (PDAC) frequently present with liver metastases, which severely limit treatment options and prognosis. In other cancers, treatment of liver disease can improve outcomes and similar approaches are being explored in PDAC. Clinical data for locoregional control of pancreatic cancer liver metastases (PCLM) are limited, and histotripsy offers a new noninvasive tool for disease control. This study evaluates the preliminary safety, efficacy, and imaging findings of histotripsy in patients with PCLM.

PURPOSE/OBJECTIVE:The Protrieve Sheath (Inari Medical; Irvine, CA) is designed for embolic protection during venous thrombectomy. This report describes experience with its use. MATERIALS AND METHODS/METHODS:Between November 2022 and December 2023 (13 months), seventeen patients, including nine (52.9%) females and eight (47.1%) males (mean age 58.8 ± 13.3 years, range 37-81 years), underwent deep venous thrombectomy following the Protrieve Sheath placement for embolic protection. Gender, age, presenting symptoms, procedural indications, obstructed venous segments, the Protrieve Sheath access and deployment sites, thrombectomy devices utilized, need for stent reconstruction, technical success, clinical success, adverse events (the Protrieve Sheath maldeployment or clinically significant embolic events), removed thrombi analyses, and mortality were recorded. Technical success was defined as successful deployment of the Protrieve Sheath funnel central to the thrombectomy site. Clinical success was defined as improvement in presenting venous occlusive symptoms without procedure-related venous thromboembolism. RESULTS:The most common presenting symptom was extremity swelling (n = 15; 88.2%). Nine (52.9%) patients had malignant and eight (47.1%) had benign etiologies of venous obstruction. Obstructed venous segments included the inferior vena cava (IVC) and lower extremity (n = 9; 52.9%), isolated lower extremity (n = 4; 23.5%), isolated IVC (n = 2; 11.8%), thoracic central veins and superior vena cava (n = 1; 5.9%), and isolated thoracic central vein (n = 1; 5.9%). The Protrieve Sheath access sites included the right internal jugular vein (n = 15; 88.2%) for IVC and lower extremity obstructions and the right common femoral vein (n = 2; 11.8%) for thoracic central vein and superior vena cava obstructions. The Protrieve sheath funnel deployment locations included intrahepatic IVC in 13 patients (n = 13; 76.5%), suprarenal IVC in two (n = 2; 11.8%), and inferior cavoatrial junction in two (n = 2; 11.8%). Thrombectomy devices used included the ClotTriever System (Inari Medical) (n = 15; 88.2%), the InThrill Thrombectomy System (Inari Medical) (n = 4; 23.5%), the FlowTriever System (Inari Medical) (n = 2; 11.8%), the Lightning Flash 16 Aspiration System (Penumbra; Salt Lake City, UT) (n = 2; 11.8%), the Cleaner Rotational Thrombectomy System (Argon; Plano, TX) (n = 1; 5.9%), and the RevCore Thrombectomy System (Inari Medical) (n = 1; 5.9%). Ten (58.8%) patients required stent reconstruction following thrombectomy. Technical success was achieved in all patients. Clinical success was achieved in 16 (94.1%) patients. No immediate adverse events, including the Protrieve Sheath maldeployment or clinically significant embolic events, occurred. CONCLUSION/CONCLUSIONS:Use of the Protrieve Sheath during large-bore venous mechanical thrombectomy resulted in favorable technical and clinical outcomes without device-related adverse events or clinically significant thromboembolic events.

PURPOSE/OBJECTIVE:To report technical feasibility and clinical efficacy of iliac vein stent placement in adolescent patients with May-Thurner Syndrome (MTS). MATERIALS AND METHODS/METHODS:Single-institution retrospective review of the medical record between 2014 and 2021 found 63 symptomatic patients (F = 40/63; mean age 16.1 years, 12-20 years) who underwent left common iliac vein (LCIV) stent placement for treatment of LCIV compression from an overriding right common iliac artery, or equivalent (n = 1, left IVC). 32/63 (50.7%) patients presented with non-thrombotic iliac vein lesions (NIVL). 31/63 (49.2%) patients presented with deep vein thrombosis of the lower extremity and required catheter-directed thrombolysis after stent placement (tMTS). Outcomes include technically successful stent placement with resolution of anatomic compression and symptom improvement. Stent patency was monitored with Kaplan-Meier analysis at 3, 6, 12, 24, and 36 months. Anticoagulation and antiplatelet (AC/AP) regimens were reported. RESULTS:Technical success rate was 98.4%. 74 bare-metal self-expanding stents were placed in 63 patients. Primary patency at 12, and 24-months was 93.5%, and 88.9% for the NIVL group and 84.4% and 84.4% for the tMTS group for the same period. Overall patency for the same time intervals was 100%, and 95.4% for the NIVL group and 96.9%, and 96.9% for the tMTS group. Procedural complication rate was 3.2% (2/63) with no thrombolysis-related bleeding complications. Clinical success was achieved in 30/32 (93.8%) and 29/31 (93.5%) patients with tMTS and NIVL groups, respectively. CONCLUSION/CONCLUSIONS:CIV stent placement in the setting of tMTS and NIVL is technically feasible and clinically efficacious in young patients with excellent patency rates and a favorable safety profile.

The field of pediatric organ transplantation has grown significantly in recent decades, with interventional radiology (IR) playing an essential role in managing pre and post-transplant complications. Pediatric transplant patients face unique challenges compared to adults, including donor-recipient size mismatch, and complications of a growing child with changing physiology. Interventional radiologists play a major role in pediatric renal and liver transplant. IR interventions begin early in the child's pretransplant journey, with diagnostic procedures such as biopsies, angiograms, and cholangiograms. These procedures are essential for understanding the etiology of organ failure and identifying potential transplant candidates. Minimally invasive therapeutic procedures may serve as bridges to transplant and may include vascular access optimization for hemodialysis, transjugular intrahepatic portosystemic shunts (TIPS) creation, and tumor embolization or ablation. After transplant, image-guided biopsies for the surveillance of graft rejection and treatment of vascular or luminal stenoses, pseudoaneurysms, and anastomotic leaks can maintain the function and longevity of the transplant organ. Careful consideration must be given to patient size and evolving anatomy, radiation exposure, and the need for deeper sedation for pediatric patients. Despite these challenges, the integration of IR in pediatric transplant care has proven beneficial, offering minimally invasive alternatives to surgery, faster recovery times, and improved outcomes.

Vascular malformations are congenital vascular anomalies that originate because of disorganized angiogenesis, most commonly from spontaneous somatic genetic mutations. The modern management of vascular malformations requires a multidisciplinary team that offers patients the gamut of medical, surgical, and percutaneous treatment options with supportive care. This manuscript discusses the standard and contemporary management strategies surrounding extracranial vascular malformations and overgrowth syndromes.