Interventional Radiology for Improved Outcomes in the Neonatal Period

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1 Interventional Radiology for Improved Outcomes in the Neonatal Period Mark J. Hogan, MD Nationwide Children s Hospital The Ohio State University mark.hogan@nationwidechildrens.org

2 No financial disclosures Lots of FDA off-label uses

3 Interventional Radiology Basically, using imaging to do a diagnostic or therapeutic procedure. Fluoroscopy Ultrasound CT, MR, and others less common

4 Interventional Radiology Improved outcomes and IR It was the driving factor for IR to be created! Continuous innovation Fewer complications Better or equivalent results

5 Interventional Radiology and Neonatal Care Vascular Access GI Access Other GI issues Drainage procedures Lumbar puncture Biliary disease Biopsy Chest interventions Angiography and treatments GU

6 Vascular Access Types of devices PICC s Tunneled catheters Totally implanted port devices

7 Vascular Access When is IR needed? Failed attempt at placement Higher risk patients Specific indications (Dialysis, etc)

8 Vascular Access How does IR help? Ultrasound guidance: The vein gets punctured Fluoroscopic guidance: The catheter gets into the right spot Can make a diagnosis if a problem is encountered

9 Vascular Access

10 Vascular Access

11 Vascular Access

12 Vascular Access

13 Vascular Access

14 Vascular Access

15 Vascular Access

16 Vascular Access

17 Vascular Access

18 Vascular Access

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21 Shortcomings Equipment limitations Small introducers are too short to easily see with ultrasound Larger introducers are too long

22 Shortcomings Equipment limitations Ultrasound probes are large WRT premmies

23 Infection Prevention CDC Guidelines To reduce catheter related infections August 2002 CCH Vascular Access Task Force, 2003-present Evaluate all aspects of vascular access

24 NCH Actions Related to CVL Insertion All CVL s will be placed with OR protocol Hand Hygiene: Surgical scrub Barriers Skin antisepsis: Chlorhexidine 2% Dressing: Transparent, semipermeable Biopatch Insertion Bundles

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26 GI Access Percutaneous gastrostomy Feeding tube maintenance

27 GI Access Primary gastrostomy Open surgical placement Endoscopic placement (PEG) Image guided placement Uses ultrasound to identify solid organs Barium allows visualization of the colon Immediate conversion to GJ Easier conversion to GJ

28 GI Access

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34 G and GJ tube Replacement GJ replacement Tubes can be sticky May need lubricant (Water soluble or Pam)

35 GI Dilation Stenoses of esophagus after repair for TEF Colonic stenoses from NEC or post op

36 GI Dilation

37 GI Dilation

38 GI Dilation

39 GI Dilation

40 Drainage Procedures Basically in any organ system or body area Abdominal Chest/pleural Extremities Head and neck May be definitive care (Avoids surgery)

41 Drainage Procedures

42 Drainage Procedures

43 Drainage Procedures

44 Drainage Procedures

45 Drainage Procedures

46 Drainage Procedures

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50 Drainage Procedures

51 Drainage Procedures

52 Drainage Procedures

53 Lumbar Puncture Show if fluid is present Guides and confirms needle placement Infants with incomplete ossification

54 Lumbar Puncture: Gravity Effect

55 Biliary Interventions Neonatal Jaundice DDX Biliary atresia Neonatal hepatitis Bile plug syndrome Conventional treatment Watch and hope it goes away If it persists, NM to see if there is bile excretion If no definite bile excretion, surgery with open cholangiogram and biopsy

56 Biliary Interventions Neonatal Jaundice DDX Biliary atresia Neonatal hepatitis Bile plug syndrome Conventional treatment Watch and hope it goes away If it persists, NM to see if there is bile excretion If no definite bile excretion, surgery with open cholangiogram and biopsy

57 Biliary Interventions Alternative Percutaneous cholecystogram Percutaneous biopsy

58 Biliary Interventions

59 Biopsy Liver biopsies Tumor biopsies Alternative is surgical biopsy

60 Biopsy

61 Angiography Rarely indicated Roles Make diagnosis Open up a blood vessel (Lysis or plasty) Close a blood vessel (Embolization)

62 Angiography

63 Angiography

64 Angiography

65 Angiography

66 Angiography

67 Genitourinary Urinary diversions for obstruction Nephrostomy/stents UPJ UVJ PUV Suprapubic drainage catheters PUV Urethral injury

68 Genitourinary

69 Genitourinary

70 Genitourinary

71 Summary IR techniques can be used to improve outcomes in neonates Almost any organ system can be treated Innovation still needed