Publications by authors named "Bairbre L Connolly"

65 Publications

Image-guided chest tube drainage in the management of chylothorax post cardiac surgery in children: a single-center case series.

Pediatr Radiol 2021 Jan 30. Epub 2021 Jan 30.

Image Guided Therapy, Diagnostic Imaging, The Hospital for Sick Children, 555 University Ave., Toronto, ON, M5G 1X8, Canada.

Background: In children, chylothorax post cardiac surgery can be difficult to treat, may run a protracted course, and remains a source of morbidity and mortality.

Objective: To analyze the experience with percutaneous image-guided chest-tube drainage in the management of post-cardiac-surgery chylothoraces in children.

Materials And Methods: We conducted a single-center retrospective case series of 37 post-cardiac-surgery chylothoraces in 34 children (20 boys; 59%), requiring 48 drainage procedures with placement of 53 image-guided chest tubes over the time period 2004 to 2015. We analyzed clinical and procedural details, adverse events and outcomes. Median age was 0.6 years, median weight 7.2 kg.

Results: Attempted treatments of chylothoraces prior to image-guided chest tubes included dietary restrictions (32/37, 86%), octreotide (12/37, 32%), steroids (7/37, 19%) and thoracic duct ligation (5/37, 14%). Image-guided chest tubes (n=43/53, 81%) were single unilateral in 29 children, bilateral in 4 (n=8/53, 15%), and there were two ipsilateral tubes in one (2/53, 4%). Effusions were isolated, walled-off, in 33/53 (62%). In 20/48 procedures (42%) effusions were septated/complex. The mean drainage through image-guided chest tubes was 17.3 mL/kg in the first 24 h, and 13.4 mL/kg/day from diagnosis to chest tube removal; total mean drainage from all chest tubes was 19.6 mL/kg/day. Nine major and 27 minor maintenance procedures were required during 1,207 tube-days (rate: 30 maintenance/1,000 tube-days). Median tube dwell time was 21 days (range 4-57 days). There were eight mild adverse events, three moderate adverse events and no severe adverse events related to image-guided chest tubes. Radiologic resolution was achieved in 26/37 (70%). Twenty-three children (68%) survived to discharge; 11 children (32%) died from underlying cardiac disease.

Conclusion: Management of chylothorax post-cardiac-surgery in children is multidisciplinary, requiring concomitant multipronged approaches, often through a protracted course. Multiple image-guided chest tube drainages can help achieve resolution with few complications. Interventional radiology involvement in tube care and maintenance is required. Overall, mortality remains high.
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http://dx.doi.org/10.1007/s00247-020-04928-2DOI Listing
January 2021

Society of Interventional Radiology Quality Improvement Standards on Percutaneous Needle Biopsy in Adult and Pediatric Patients.

J Vasc Interv Radiol 2020 11 1;31(11):1840-1848. Epub 2020 Oct 1.

Department of Interventional Radiology, MD Anderson Cancer Center, Houston, Texas.

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http://dx.doi.org/10.1016/j.jvir.2020.07.012DOI Listing
November 2020

Use of Tissue Plasminogen Activator in Abdominal Abscesses in Children-A Single-Center Randomized Control Trial.

Can Assoc Radiol J 2020 Apr 13:846537120914263. Epub 2020 Apr 13.

Image Guided Therapy, Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada.

Purpose: To establish the efficacy of once-per-day intracavitary tissue plasminogen activator (tPA) in the treatment of pediatric intra-abdominal abscesses.

Methods: A single-center prospective, double-blinded, randomized controlled trial of the use of intracavitary tPA in abdominal abscesses in children. Patients were randomized to either tPA-treatment or saline-treatment groups. Primary outcome was drainage catheter dwell (hours). Secondary outcomes were length of hospital stay, times to discharge, clinical and sonographic resolution, and adverse events (AEs).

Results: Twenty-eight children were randomized to either group (n = 14 each). Demographics between groups were not significantly different (age = .28; weight = .40; gender = .44). There were significantly more abscesses in the tPA-treated group ( = .03). Abscesses were secondary to perforated appendicitis (n = 25) or postappendectomy (n = 3). Thirty-four abscesses were drained, 4 aspirated, 3 neither drained/aspirated. There was no significant difference in number of drains ( = .14), drain size ( = .19), primary outcome ( = .077), or secondary outcomes found. No procedural or intervention drug-related AEs occurred. No patient in the saline-treated group required to be switched/treated with tPA.

Conclusion: No significant difference in the length of catheter dwell time, procedure time to discharge, or time to resolution was found. Intracavitary tPA was not associated with morbidity or mortality. The results neither support nor negate routine use of tPA in the drainage of intra-abdominal abscess in children. It is possible that a multicentre study with a larger number of patients may answer this question more definitively.
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http://dx.doi.org/10.1177/0846537120914263DOI Listing
April 2020

Dosimetric Feasibility of Cone-Beam CT in Pediatric Image-Guided Retrograde Gastrostomy Tube Insertions.

Can Assoc Radiol J 2020 Feb 22;71(1):68-74. Epub 2020 Jan 22.

Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada.

Purpose: Cone-beam computed tomography (CBCT) in interventional radiology allows volumetric imaging with open patient access. This work aimed to assess radiation dose metrics of CBCT in simulated image-guided retrograde gastrostomy (IGRG) tube insertions in pediatric anthropomorphic phantoms and to compare them to measured radiation dose metrics obtained using fluoroscopy during clinical IGRG tube insertions in children.

Methods: Radiation dose indices obtained from radiation dose structured reports of fluoroscopic IGRG tube insertions were retrospectively evaluated in a consecutive cohort of 30 children. Dose indices were fractionated into 3 clinical stages for each procedure (, , and ). These 3 stages in 30 patients (3 × 30 = 90 patient stages) were compared to dose indices measured from 4 CBCT acquisition protocols acquired in pediatric phantoms.

Results: The mean proportion of radiation dose during planning, insertion, and confirmation was 35%, 38% and 27%, with mean reference-point air kerma (range) measured to be 1.0 (0.02-6.0) mGy, 0.9 (0.03-4.1) mGy, and 0.7 (0.04-3.7) mGy, respectively. Cone-beam computed tomography dose varied greatly depending on technical parameters and protocol selection, ranging from 0.7 to 39.3 mGy. In 19% of patient stages, the most dose-sparing CBCT protocol evaluated on phantoms delivered less radiation than the radiation dose indices recorded from patient's fluoroscopy.

Conclusions: From a dosimetric perspective, radiation delivered in CBCT can vary widely, yet can be appreciably low. With appropriate CBCT protocol selection, the radiation dose delivered may be sufficiently low to warrant consideration for use, if clinically needed during difficult IGRG tube insertions, and satisfy the interventionalist's benefit-risk assessment.
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http://dx.doi.org/10.1177/0846537119885680DOI Listing
February 2020

Evaluation of implanted venous port-a-caths in children with medical complexity and neurologic impairment.

Pediatr Radiol 2019 09 13;49(10):1354-1361. Epub 2019 Jul 13.

Image Guided Therapy Centre, Diagnostic Imaging Department, The Hospital for Sick Children, 555 University Ave., Toronto, ON, M5G 1X8, Canada.

Background: Children with medical complexity and associated neurologic impairment frequently face difficulties with venous access. Intermittently they require urgent intravenous administration of fluids and medication.

Objective: To analyze the use of implanted port-a-caths in children with medical complexity who have neurologic impairment and difficult venous access.

Materials And Methods: We performed a single-center observational study of port-a-caths placed by interventional radiologists in children with medical complexity with neurologic impairment. We analyzed peripheral intravenous access attempts, peripheral intravenous starts, peripheral intravenous complications, alternative temporary central venous access devices, port-a-cath insertions, catheter days, access days, port-a-cath-related complications, hospital admissions and emergency department visits. We compared the year pre port-a-cath to the year post port-a-cath.

Results: Twenty-one children with medical complexity with neurologic impairment (10 boys, 11 girls; median age 4.1 years; median weight 13.7 kg) underwent 26 port-a-cath insertions (median catheter days 787). In the year post port-a-cath compared to pre port-a-cath there was a highly significant reduction (P<0.001) in numbers of peripheral intravenous attempts, peripheral intravenous starts and skin punctures; and a significant reduction (P<0.05) in need for other devices, number of emergency department visits, emergency department visits resulting in hospital admissions, and total admissions. Adverse events were graded as mild (n=18), moderate (n=6) and severe (n=0).

Conclusion: Port-a-cath placement in children with medical complexity with neurologic impairment significantly reduced all peripheral intravenous attempts, peripheral intravenous starts, skin punctures, total number of emergency department visits, visits culminating in admission, and total number of inpatient admissions. Advantages must be considered against potential port-a-cath-related adverse events.
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http://dx.doi.org/10.1007/s00247-019-04470-wDOI Listing
September 2019

Use of the Transrectal Ultrasound Probe in Aspiration and Drainage in Pediatric Patients: A Retrospective Observational Study.

J Vasc Interv Radiol 2019 Jun 5;30(6):908-914. Epub 2019 Apr 5.

Division of Image Guided Therapy, Diagnostic Imaging, The Hospital for Sick Children, Department of Medical Imaging, University of Toronto, 555 University Avenue, 2810B, Toronto, Canada M5G 1X8.

Purpose: To retrospectively evaluate the safety and efficacy of transrectal ultrasound (TRUS) probe use for aspiration and drainage of pelvic abscesses in children.

Materials And Methods: Patient demographics, procedural details, technical success, safety, and clinical course of TRUS procedures were retrospectively analyzed. Between 2007 and 2016, 118 TRUS-guided procedures were performed in 115 children (60 males, 55 females); median age was 12.4 years (range, 2.4-17.9 years) and median weight was 45 kg (range, 12.6-112 kg). Ten children were 5 years of age or younger.

Results: In total, 113/118 procedures were performed under general anesthesia. The rectum accommodated the probe and needle guide without resistance in all children (technical feasibility, 100%). Abscesses were anterior to the rectum in 116/118 and posterior in 2/118. One hundred twelve collections were drained, 4 were aspirated, and 2 procedures were aborted, both subsequently successfully drained (2 and 3 days later). One patient underwent repeat drainage after 28 months. No major complications were reported. Median times to temperature normalization was 0 days (mean, 1.2; range, 0-13 days), catheter dwell time 5 days (mean, 6; range, 2-21 days), drain removal to discharge 1 day (mean, 2; range, 0-41 days), and follow-up 117 days (mean, 195; range, 5-2,690 days).

Conclusions: TRUS-guided drainage using the TRUS probe and needle guide is a safe and effective method for aspiration and drainage of pelvic abscesses in children as young as 2 years.
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http://dx.doi.org/10.1016/j.jvir.2018.09.023DOI Listing
June 2019

Increased risk of symptomatic upper-extremity venous thrombosis with multiple peripherally inserted central catheter insertions in pediatric patients.

Pediatr Radiol 2018 07 27;48(7):1013-1020. Epub 2018 Feb 27.

Image Guided Therapy, Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.

Background: Peripherally inserted central catheters (PICCs) are associated with superficial and deep venous thrombosis of the arm.

Objective: The purpose of this study was to analyze the sequelae of repeated upper limb PICC insertions in children, in terms of the frequency of upper limb thrombosis in this patient group.

Materials And Methods: The study population included all children who underwent their first successful arm PICC insertion between January 2010 and December 2015. We included subsequent ipsilateral arm PICCs in the analysis. Patients were followed until March 2016 or until any alternative central venous line insertion. For each PICC insertion, we collected demographic variables and line characteristics. We correlated all symptomatic deep and superficial thromboses of the arm with the PICC database.

Results: Applying inclusion and exclusion criteria, 2,180 PICCs remained for analysis. We identified first, second, third and fourth PICC insertions in the same arm in 1,955, 181, 38 and 6 patients, respectively. In total there were 57 upper body deep symptomatic thrombotic events. An increasing odds ratio was seen with higher numbers of PICC insertions, which was significant when comparing the first with the third and fourth PICC insertions in the same arm (odds ratio [OR] 6.00, 95% confidence interval [CI] 2.25-16.04, P=0.0004). Double-lumen PICCs were associated with a significantly higher risk of thrombosis than single lumen (OR 2.77, 95% CI 1.72-4.47, P=0.0003).

Conclusion: Repetitive PICC insertions in the same arm are associated with an increased risk of symptomatic thrombosis. Double-lumen PICCs are associated with a higher risk of thrombosis compared to single-lumen lines.
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http://dx.doi.org/10.1007/s00247-018-4096-xDOI Listing
July 2018

Serial Balloon Dilation to Relieve Gastric Outlet Obstruction Induced by the Ingestion of Toilet Cleaner.

J Pediatr Gastroenterol Nutr 2018 02;66(2):e56

Department of Pediatric Gastroenterology, Hepatology and Nutrition.

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http://dx.doi.org/10.1097/MPG.0000000000001126DOI Listing
February 2018

COST ANALYSIS OF PERIPHERALLY INSERTED CENTRAL CATHETER IN PEDIATRIC PATIENTS.

Int J Technol Assess Health Care 2018 Jan 20;34(1):38-45. Epub 2017 Dec 20.

Institute of Health Policy,Management and

Purpose: A peripherally inserted central catheter (PICC) is a useful option in providing secure venous access, which enables patients to be discharged earlier with the provision of home care. The objective was to identify the costs associated with having a PICC from a societal perspective, and to identify factors that are associated with total PICC costs.

Methods: Data were obtained from a retrospective cohort of 469 hospitalized pediatric patients with PICCs inserted. Both direct and indirect costs were estimated from a societal perspective. Insertion costs, complication costs, nurse and physician assessment costs, inpatient ward costs, catheter removal costs, home care costs, travel costs, and the cost associated with productivity losses incurred by parents were included in this study.

Results: Based on catheter dwell time, the median total cost associated with a PICC per patient per day (including inpatient hospital costs) was $3,133.5 ($2,210.7-$9,627.0) in 2017 Canadian dollars ($1.00USD = $1.25CAD in 2017). The adjusted mean cost per patient per day was $2,648.2 ($2,402.4-$2,920.4). Excluding inpatient ward costs, the median total and adjusted costs per patient per day were $198.8 ($91.8-$2,475.8) and $362.7($341.0-$386.0), respectively. Younger age, occurrence of complications, more catheter dwell days, wards with more intensive care, and the absence of home care were significant factors associated with higher total PICC costs.

Conclusions: This study has demonstrated the costs associated with PICCs. This information may be helpful for healthcare providers to understand PICC related cost in children and resource implications.
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http://dx.doi.org/10.1017/S026646231700109XDOI Listing
January 2018

Perforations associated with peripherally inserted central catheters in a neonatal population.

Pediatr Radiol 2018 01 6;48(1):109-119. Epub 2017 Oct 6.

Division of Neonatology, Department of Pediatrics, The Hospital for Sick Children, 555 University Ave., Toronto, ON, M5G 1X8, Canada.

Background: Peripherally inserted central catheters (PICCs) are increasingly used in neonates but perforations can result in devastating complications such as pericardial and pleural effusions. Identifying risk factors may guide surveillance and reduce morbidity and mortality.

Objective: To determine the risk factors for PICC perforation in neonates.

Materials And Methods: Retrospective case:control (1:2) study of neonates admitted between 2004-2014. Charts and imaging were reviewed for clinical and therapeutic risk factors.

Results: Among 3,454 PICCs, 15 cases of perforation (incidence 0.4%, 5 pericardial effusions, 10 pleural effusions) were matched to 30 controls, based on gestation and insertion date. Timing of perforations post-insertion was median 4 days for pericardial effusions and 21.5 days for pleural effusions. A risk factor for pericardial effusion was lower weight at PICC insertion compared with controls. There were no statistically significant differences between cases and controls in catheter material, insertion site, PICC size and lumen number. Among upper limb PICCs, pericardial effusions were associated with tip positions more proximal to the heart at insertion (P=0.005) and at perforation (P=0.008), compared with controls. Pleural effusions were associated with tip positions more distal from the heart at perforation (P=0.008). Within 48 h before perforation, high/medium risk infusions included total parenteral nutrition (100% cases vs. 56.7% controls, P=0.002) and vancomycin (60% cases vs. 23.3% controls, P=0.02).

Conclusion: PICC-associated pericardial effusions and pleural effusions are rare but inherent risks and can occur at any time after insertion. Risk factors and etiologies are multifactorial, but PICC tip position may be a modifiable risk factor. To mitigate this risk, we have developed and disseminated guidelines for target PICC positions and routinely do radiographs to monitor PICCs for migration and malposition in our NICU. The increased knowledge of risk profiles from this study has helped focus surveillance efforts and facilitate early recognition and treatment.
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http://dx.doi.org/10.1007/s00247-017-3983-xDOI Listing
January 2018

Technique, Safety, and Yield of Bone Biopsies for Histomorphometry in Children.

J Vasc Interv Radiol 2017 Nov 18;28(11):1577-1583. Epub 2017 Aug 18.

Division of Image Guided Therapy, Diagnostic Imaging, Department of Medical Imaging, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8 Canada.

Purpose: To evaluate image-guided bone biopsy for bone histomorphometry to assess osteoporosis in children with respect to safety and yield.

Materials And Methods: A single-center retrospective review was performed of 79 bone biopsies in 73 patients performed between 2007 and 2015. Biopsies of the iliac bone were performed under general anesthesia, after tetracycline labeling, using a Rochester needle (Medical Innovations International, Inc, Rochester, Minnesota). Ultrasound and fluoroscopic guidance were used in all procedures. Biopsy technique, technical success, safety, and histomorphometry results (complete, incomplete, none) were analyzed.

Results: There were 41 male patients (51.8%). Technical success was achieved in 76/79 (96%) procedures. Of 79 biopsies, 75 (95%) were uneventful. Unplanned overnight observation was required in 3 (minor SIR grade B), and prolonged hospital stay owing to hematoma causing nerve compression pain was required in 1 (major SIR grade D). Complete histomorphometric reports were obtained in 69 (87%) procedures, incomplete reports were obtained in 7 (9%), and no reports were obtained in 3(4%). Incomplete reports were insufficient to provide a definitive diagnosis or guide treatment. Histomorphometry impacted subsequent therapy in 69 (87%) biopsies.

Conclusions: Image-guided bone biopsy for osteoporosis using the Rochester needle is a valuable and safe technique for establishing the diagnosis of osteoporosis and directing treatment based on histomorphometry results.
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http://dx.doi.org/10.1016/j.jvir.2017.07.003DOI Listing
November 2017

Proposal of a New Adverse Event Classification by the Society of Interventional Radiology Standards of Practice Committee.

J Vasc Interv Radiol 2017 Oct 27;28(10):1432-1437.e3. Epub 2017 Jul 27.

Department of Radiology, Stratton Medical Center, 113 Holland Ave., Albany, NY 12208. Electronic address:

Purpose: To develop a new adverse event (AE) classification for the interventional radiology (IR) procedures and evaluate its clinical, research, and educational value compared with the existing Society of Interventional Radiology (SIR) classification via an SIR member survey.

Materials And Methods: A new AE classification was developed by members of the Standards of Practice Committee of the SIR. Subsequently, a survey was created by a group of 18 members from the SIR Standards of Practice Committee and Service Lines. Twelve clinical AE case scenarios were generated that encompassed a broad spectrum of IR procedures and potential AEs. Survey questions were designed to evaluate the following domains: educational and research values, accountability for intraprocedural challenges, consistency of AE reporting, unambiguity, and potential for incorporation into existing quality-assurance framework. For each AE scenario, the survey participants were instructed to answer questions about the proposed and existing SIR classifications. SIR members were invited via online survey links, and 68 members participated among 140 surveyed. Answers on new and existing classifications were evaluated and compared statistically. Overall comparison between the two surveys was performed by generalized linear modeling.

Results: The proposed AE classification received superior evaluations in terms of consistency of reporting (P < .05) and potential for incorporation into existing quality-assurance framework (P < .05). Respondents gave a higher overall rating to the educational and research value of the new compared with the existing classification (P < .05).

Conclusions: This study proposed an AE classification system that outperformed the existing SIR classification in the studied domains.
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http://dx.doi.org/10.1016/j.jvir.2017.06.019DOI Listing
October 2017

Intrapleural Dornase and Tissue Plasminogen Activator in pediatric empyema (DTPA): a study protocol for a randomized controlled trial.

Trials 2017 06 24;18(1):293. Epub 2017 Jun 24.

The Hospital for Sick Children, Department of Pediatrics, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.

Background: A randomized controlled trial of adults with empyema recently demonstrated decreased length of stay in hospital in patients treated with intrapleurally administered dornase alfa and fibrinolytics compared to fibrinolytics alone. Whether this treatment strategy is safe and effective in children remains unknown.

Methods/design: This study protocol is for a superiority, placebo-controlled, parallel-design, multicenter randomized controlled trial. The participants are previously well children admitted to a children's hospital with a diagnosis of empyema requiring chest tube insertion and fibrinolytics administered intrapleurally. Children will be randomized after the treating physician has decided that pleural drainage is required but prior to chest tube insertion. After chest tube insertion, participants in the treatment group will receive intrapleurally administered tissue plasminogen activator (tPA) 4 mg followed by dornase alfa 5 mg. Participants in the placebo group will receive tPA 4 mg followed by normal saline. Study treatments will be administered once daily for 3 days. All participants, parents or caregivers, clinicians, and research personnel will remain blinded. The primary outcome is length of stay from chest tube insertion to discharge from hospital. Secondary outcomes include time to meeting discharge criteria, chest tube duration, fever duration, need for additional procedures, adverse events, hospital readmission, cost of hospitalization, and mortality.

Discussion: This multicenter randomized controlled trial will assess the safety, effectiveness, and cost-effectiveness of combined treatment with dornase alfa and fibrinolytics compared to fibrinolytics alone for the treatment of empyema in children.

Trial Registration: ClinicalTrials.gov: NCT01717742 . Registered on 8 October 2012.
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http://dx.doi.org/10.1186/s13063-017-2026-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5482972PMC
June 2017

Ultrasound-guided steroid tendon sheath injections in juvenile idiopathic arthritis: a 10-year single-center retrospective study.

Pediatr Rheumatol Online J 2017 Apr 11;15(1):22. Epub 2017 Apr 11.

Image Guided Therapy, Department of Diagnostic Imaging, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada.

Background: The aims of this study were to: (a) Identify tendon sheaths most commonly treated with steroid injections in a pediatric patient population with Juvenile Idiopathic Arthritis (JIA); (b) Describe technical aspects of the procedure; (c) Characterize sonographic appearance of tenosynovitis in JIA; (d) Assess agreement between clinical request and sites injected.

Methods: This was a 10 year single-center retrospective study (May 2006-April 2016) of patients with JIA referred by Rheumatology for ultrasound-guided tendon sheath injections. Patient demographics, clinical referral information, sonographic appearance of the tendon sheaths and technical aspects of the procedure were analyzed.

Results: There were 308 procedures of 244 patients (75% female, mean age 9.6 years) who underwent a total of 926 tendon sheath injections. Ankle tendons were most commonly injected (84.9%), specifically the tendon sheaths of tibialis posterior (22.3%), peroneus longus (20%) and brevis (19.7%). The majority of treated sites (91.9%) showed peritendinous fluid and sheath thickening on ultrasound. There were 2 minor intra-procedure complications without sequelae. A good agreement between clinical request and sites injected was observed.

Conclusions: Ultrasound-guided tendon sheath injections with steroids are used frequently to treat patients with JIA. It is a safe intervention with a high technical success rate. The ankle region, specifically the medial compartment, is the site most commonly injected in this group of patients. The most common sonographic finding is peritendinous fluid and sheath thickening. These findings might assist clinicians and radiologists to characterize and more effectively manage tenosynovitis in patients with JIA.
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http://dx.doi.org/10.1186/s12969-017-0155-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5387283PMC
April 2017

Pediatric interventional radiology workforce survey: 10-year follow-up.

Pediatr Radiol 2017 May 6;47(6):651-656. Epub 2017 Mar 6.

Seattle Radiologists and Foundry10, Seattle, WA, USA.

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.
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http://dx.doi.org/10.1007/s00247-017-3796-yDOI Listing
May 2017

Variables decreasing tip movement of peripherally inserted central catheters in pediatric patients.

Pediatr Radiol 2016 Oct 7;46(11):1532-8. Epub 2016 Jun 7.

Image Guided Therapy, Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, 555 University Ave., Toronto, ON, M5G 1X8, Canada.

Background: The position of the tip of a peripherally inserted central catheter (PICC) is crucial; malposition can lead to malfunction of the line or life-threatening events (e.g., arrhythmias, perforation).

Objective: To determine what factors other than arm position and accessed vein might influence the tip position of a PICC.

Materials And Methods: Inclusion criteria were upper limb PICC placement, body weight <20 kg, intraoperative imaging with the arm in 0°, 45° and 90° abduction and an arm view marking the skin entry site relative to the shoulder. Evaluated variables included patient demographics, and PICC and insertion site characteristics. We measured central tip movement in rib units.

Results: We included 112 children who received a PICC (42 girls/70 boys, mean age 31±13 months, mean weight 6.5±4.9 kg). The overall range of central tip movement was -1 to +4 rib units (mean +0.8±0.7 rib units). Silicone PICCs moved significantly less than polyurethane PICCs (P<0.05). PICCs placed in the cephalic vein moved significantly less than those placed in other veins (P<0.05). Patient demographics and PICC characteristics (size, number of lumens, left or right arm accessed, length of the line) did not influence the range of central tip movement of a PICC (P>0.05).

Conclusion: Silicone PICCs and PICCs inserted into the cephalic vein move less than PICCs made of polyurethane and PICCs inserted into the brachial and basilic veins. These findings might assist operators in deciding which PICC to place in children in a given clinical context.
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http://dx.doi.org/10.1007/s00247-016-3648-1DOI Listing
October 2016

Peritonitis following percutaneous gastrostomy tube insertions in children.

Pediatr Radiol 2016 Sep 12;46(10):1444-50. Epub 2016 May 12.

Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada.

Background: Percutaneous retrograde gastrostomy has a high success rate, low morbidity, and can be performed under different levels of sedation or local anesthesia in children. Despite its favourable safety profile, major complications can occur. Few studies have examined peritonitis following percutaneous retrograde gastrostomy in children.

Objective: To identify potential risk factors and variables influencing the development and early diagnosis of peritonitis following percutaneous retrograde gastrostomy.

Materials And Methods: We conducted a retrospective case-control study of children who developed peritonitis within 7 days of percutaneous retrograde gastrostomy between 2003 and 2012. From the 1,504 patients who underwent percutaneous retrograde gastrostomy, patients who developed peritonitis (group 1) were matched by closest date of procedure to those without peritonitis (group 2). Peritonitis was defined according to recognized clinical criteria. Demographic, clinical, procedural, management and outcomes data were collected.

Results: Thirty-eight of 1,504 children (2.5%; 95% confidence interval, 1.8-3.5) who underwent percutaneous retrograde gastrostomy developed peritonitis ≤7 days post procedure (group 1). Fever (89%), irritability (63%) and abdominal pain (55%) occurred on presentation of peritonitis. Group 1 patients were all treated with antibiotics; 41% underwent additional interventions: tube readjustments (8%), aspiration of pneumoperitoneum (23%), laparotomy (10%) and intensive care unit admission (10%). In group 1, enteral feeds started on average 3 days later and patients were discharged 5 days later than patients in group 2. There were two deaths not directly related to peritonitis. Neither age, gender, weight, underlying diagnoses nor operator was identified as a risk factor.

Conclusion: Peritonitis following percutaneous retrograde gastrostomy in children occurs in approximately 2.5% of cases. No risk factors for its development were identified. Medical management is usually sufficient for a good outcome. Patients with peritonitis are delayed starting feeds and have a hospital stay that is an average of 5 days longer than those without.
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http://dx.doi.org/10.1007/s00247-016-3628-5DOI Listing
September 2016

IR Approaches to Difficult Removals of Totally Implanted Venous Access Port Catheters in Children: A Single-Center Experience.

J Vasc Interv Radiol 2016 Jun 19;27(6):876-81. Epub 2016 Apr 19.

Division of Image Guided Therapy, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada. Electronic address:

Purpose: To identify factors associated with adherence of implanted venous access port catheters in children and describe technical strategies for removing "stuck" ports.

Materials And Methods: A retrospective single-center review of port removals was conducted between 2003 and 2012. Cases were identified through radiology reports. Clinical details (eg, demographics, disease, port dwell time, interventional techniques) were obtained through patient charts. Cases were classified as difficult removals if there was documented adherence to soft tissues or vein, or simple removals if no difficulty was recorded. Difficult removals were categorized and graded on increasing invasiveness of techniques required. Successful removal was defined as complete removal of the port catheter. Difficult removals were compared with simple removals for factors associated with difficult removal. Of all removals (N = 1,306), 58 were classified as difficult removals (4%).

Results: Using various techniques, 57 of 58 (98%) adherent port catheters were successfully removed. Factors identified with difficult removals included primary diagnosis of acute lymphoblastic leukemia (ALL) (78% vs 37%, P < .0001), age at insertion (3.7 y vs 5.4 y, P = .0019), and port dwell time (median 1,087 d vs 616 d, P < .0001).

Conclusions: Difficulty removing port catheters in children is uncommon. Port catheters can usually be removed successfully using various IR techniques ranging in invasiveness. There is an association of difficult removal with early age at insertion, ALL diagnosis, and long port dwell time. Awareness of these factors may help physicians inform parents of potential difficulties and plan the removal procedure.
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http://dx.doi.org/10.1016/j.jvir.2016.02.021DOI Listing
June 2016

Pediatric interventional radiology clinic - how are we doing?

Pediatr Radiol 2016 Jul 6;46(8):1165-72. Epub 2016 Apr 6.

Image Guided Therapy, Diagnostic Imaging, The Hospital for Sick Children & University of Toronto, 555 University Ave., Toronto, ON, M5G 1X8, Canada.

Background: Development of a pediatric interventional radiology clinic is a necessary component of providing a pediatric interventional radiology service. Patient satisfaction is important when providing efficient, high-quality care.

Objective: To analyze the care provided by a pediatric interventional radiology clinic from the perspective of efficiency and parent satisfaction, so as to identify areas for improvement.

Materials And Methods: The prospective study was both quantitative and qualitative. The quantitative component measured clinic efficiency (waiting times, duration of clinic visit, nurse/physician time allocation and assessments performed; n = 91). The qualitative component assessed parental satisfaction with their experience with the pediatric interventional radiology clinic, using a questionnaire (5-point Likert scale) and optional free text section for feedback (n = 80). Questions explored the family's perception of relevance of information provided, consent process and overall satisfaction with their pediatric interventional radiology clinic experience.

Results: Families waited a mean of 11 and 10 min to meet the physician and nurse, respectively. Nurses and physicians spent a mean of 28 and 21 min with the families, respectively. The average duration of the pediatric interventional radiology clinic consultation was 56 min. Of 80 survey participants, 83% were satisfied with their experience and 94% said they believed providing consent before the day of the procedure was helpful. Only 5% of respondents were not satisfied with the time-efficiency of the interventional radiology clinic.

Conclusion: Results show the majority of patients/parents are very satisfied with the pediatric interventional radiology clinic visit. The efficiency of the pediatric interventional radiology clinic is satisfactory; however, adherence to stricter scheduling can be improved.
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http://dx.doi.org/10.1007/s00247-016-3593-zDOI Listing
July 2016

Ultrasound-Guided Thrombin Injection for the Treatment of Femoral Pseudoaneurysm in Pediatric Patients.

J Vasc Interv Radiol 2016 Apr;27(4):519-23

Division of Imaging Guided Therapy, Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, 555 University Ave., Toronto, ON, Canada M5G 1X8. Electronic address:

Eight patients with nine femoral pseudoaneurysms were treated with 13 ultrasound-guided thrombin injections. Mean patient age was 3.3 years (range, 5 mo to 13.6 y), mean pseudoaneurysm diameter was 2.0 cm ± 0.6, and mean thrombin dose was 119 IU (500 IU/mL ± 116; 0.95 CI). Mean follow-up was 27 days (range, 7-120 d). Eight pseudoaneurysms were successfully treated, and one failed to close as a result of arterial wall disease. No complications were observed. The approach used at the authors' pediatric institution resulted in safe and effective treatment of femoral pseudoaneurysms.
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http://dx.doi.org/10.1016/j.jvir.2015.12.756DOI Listing
April 2016

MR cone-beam CT fusion image overlay for fluoroscopically guided percutaneous biopsies in pediatric patients.

Pediatr Radiol 2016 Mar 13;46(3):407-12. Epub 2015 Nov 13.

Image Guided Therapy, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.

Lesions only visible on magnetic resonance (MR) imaging cannot easily be targeted for image-guided biopsy using ultrasound or X-rays but instead require MR guidance with MR-compatible needles and long procedure times (acquisition of multiple MR sequences). We developed an alternative method for performing these difficult biopsies in a standard interventional suite, by fusing MR with cone-beam CT images. The MR cone-beam CT fusion image is then used as an overlay to guide a biopsy needle to the target area under live fluoroscopic guidance. Advantages of this technique include (i) the ability for it to be performed in a conventional interventional suite, (ii) three-dimensional planning of the needle trajectory using cross-sectional imaging, (iii) real-time fluoroscopic guidance for needle trajectory correction and (iv) targeting within heterogeneous lesions based on MR signal characteristics to maximize the potential biopsy yield.
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http://dx.doi.org/10.1007/s00247-015-3479-5DOI Listing
March 2016

Long-term burden of care and radiation exposure in survivors of esophageal atresia.

J Pediatr Surg 2015 Oct 28;50(10):1686-90. Epub 2015 May 28.

Division of Pediatric General and Thoracic Surgery, The Hospital for Sick Children, 555 University Ave., Toronto, Ontario, Canada M5G 1X8. Electronic address:

Background: Patients with esophageal atresia with or without tracheoesophageal fistula (EA/TEF) historically have had a high risk of neonatal mortality but the majority of patients are now expected to live into adulthood. However, the long-term burden of care among recent EA/TEF survivors has not been documented.

Methods: A single-institution retrospective review of newborns with EA/TEF treated from 2001-2005 was conducted, including initial and total hospitalization length of stay, and number of clinic visits and procedures requiring general anesthesia in the first three years of life. Exposure to and number of radiological studies involving ionizing radiation (IR) were recorded.

Results: Seventy-one of 78 (91%) patients survived to discharge and 69 were included for analysis. Mean length of initial hospital stay was 51.3 (range 9-390) days. By age 3 years, patients required 4.5 (mean, range 1-23) procedures performed under general anesthesia, attended 13.5 (mean, range 3-40) outpatient visits and were exposed to 17.4 mSv (mean, range 3.0-59.9) of IR from 40 (mean, range 5-165) radiological studies.

Conclusion: Patients with EA/TEF need complex and frequent hospital-based care from infancy to early childhood. Opportunities to critically review clinical services and imaging needs should be explored to improve the experience of patients and their families.
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http://dx.doi.org/10.1016/j.jpedsurg.2015.05.006DOI Listing
October 2015

The percutaneous cecostomy tube in the management of fecal incontinence in children.

J Vasc Interv Radiol 2015 Feb 17;26(2):189-95. Epub 2014 Dec 17.

Department of Diagnostic Imaging, Hospital for Sick Children. Electronic address:

Purpose: To retrospectively evaluate experience with percutaneous cecostomies and their long-term outcomes.

Materials And Methods: Between June 1994 and March 2009, 290 patients (mean age, 10.1 y) with fecal incontinence underwent percutaneous cecostomy tube placement and subsequent tube management. Technical success, procedural complications, and long-term follow-up until March 2012 were evaluated.

Results: A cecostomy was successfully placed in 284 patients (98%), and 257 of 280 patients (92%) underwent a successful exchange to a low-profile tube. A total of 1,431 routine exchanges to low-profile tubes were reviewed in 258 patients (mean, 1.6 ± 1.3 routine tube changes per 1,000 days). Eighty-five patients (29%) experienced one or more early problems after cecostomy, and 10 (3%) had major complications. In the total 463,507 tube-days, 938 late problems were noted: 917 (98%) minor and 22 (2%) major. Forty patients had the cecostomy catheter removed and 141 "graduated" to an adult health care facility.

Conclusions: The percutaneous cecostomy procedure provides a safe management option for fecal incontinence in the pediatric population.
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http://dx.doi.org/10.1016/j.jvir.2014.10.015DOI Listing
February 2015

Effective doses in children: association with common complex imaging techniques used during interventional radiology procedures.

AJR Am J Roentgenol 2014 Dec;203(6):1336-44

1 Department of Medical Physics and Applied Radiation Sciences, McMaster University, Hamilton, ON, Canada.

Objective: The purpose of this study was to determine the range of effective doses associated with imaging techniques used during interventional radiology procedures on children.

Materials And Methods: A pediatric phantom set (1, 5, and 10 years) coupled with high-sensitivity metal oxide semiconductor field effect transistor (MOSFET) dosimeters was used to calculate effective doses. Twenty MOSFETs were inserted into each phantom at radiosensitive organ locations. The phantoms were exposed to mock head, chest, and abdominal interventional radiology procedures performed with different geometries and magnifications. Fluoroscopy, digital subtraction angiography (DSA), and spin angiography were simulated on each phantom. Road mapping was conducted only on the 5-year-old phantom. International Commission on Radiological Protection publication 103 tissue weights were applied to the organ doses recorded with the MOSFETs to determine effective dose. For easy application to clinical cases, doses were normalized per minute of fluoroscopy and per 10 frames of DSA or spin angiography.

Results: Effective doses from DSA, angiography, and fluoroscopy were higher for younger ages because of magnification use and were largest for abdominal procedures. DSA of the head, chest, and abdomen (normalized per 10 frames) imparted doses 2-3 times as high as corresponding doses per minute of fluoroscopy while all other factors remained unchanged (age, projection, collimation, magnification). Three to five frames of DSA imparted an effective dose equal to doses from 1 minute of fluoroscopy. Doses from spin angiography were almost one-half the doses received from an equivalent number of frames of DSA.

Conclusion: Patient effective doses during interventional procedures vary substantially depending on procedure type but tend to be higher because of magnification use in younger children and higher in the abdomen.
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http://dx.doi.org/10.2214/AJR.13.11445DOI Listing
December 2014

Placement of an internal-external biliary drain through a bilio-enteric fistula in a neonate to re-establish antegrade bile flow after liver transplantation.

Pediatr Transplant 2014 Nov 19;18(7):E236-9. Epub 2014 Aug 19.

Image Guided Therapy, Department of Diagnostic Imaging, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada.

Three-month-old baby girl with history of post-liver transplant hepatic artery dissection treated with ligation after take down of the biliary anastomosis and placement of a surgical external common bile duct drain. There was persistent malfunction of this drain. A bilio-enteric fistula was noted during the later placement of an image guided percutaneous external drain. Subsequently, an internal-external biliary drain was successfully placed through this fistula. An excellent clinical and functional result was achieved.
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http://dx.doi.org/10.1111/petr.12336DOI Listing
November 2014

Variations in blood glucose levels following gastrostomy tube insertion in a paediatric population.

Pediatr Radiol 2014 Jul 18;44(7):863-70. Epub 2014 Feb 18.

Division of Paediatric Medicine, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada.

Background: Radiologic insertion of a gastrostomy or gastrojejunostomy tube is a common procedure in children. Glucagon is used to create gastric hypotonia, permitting gastric distension and facilitating percutaneous puncture. Glucagon can cause hyperglycaemia and potentially rebound hypoglycaemia. The safety of glucagon and incidence of hypoglycaemia has not been studied following gastrostomy or gastrojejunostomy tube insertion.

Objective: To determine variations in blood glucose in children post gastrostomy or gastrojejunostomy tube insertion. Secondarily, to determine the frequency of hypoglycaemia and hyperglycaemia in children who did or did not receive glucagon.

Materials And Methods: This is a retrospective observational study of 210 children undergoing percutaneous gastrostomy or gastrojejunostomy tube insertion over a 2-year period. We studied the children's clinical and laboratory parameters. Abnormal blood glucose levels were defined according to age-established norms. We used descriptive statistics and ANOVA.

Results: We analysed 210 children with recorded blood glucose levels. More than 50% of the children were less than the third percentile for weight. In the glucagon group (n = 187) hyperglycaemia occurred in 82.3% and hypoglycaemia in 2.7% (n = 5). In the no glucagon group (n = 23), hyperglycaemia occurred in 43.5% and there were no cases of hypoglycaemia. The peak blood glucose occurred within 2 h, with normalization by 6 h post-procedure. Five children became hypoglycaemic, all received glucagon; 4/5 had weights <3rd percentile. Logistic regression analysis revealed no factors significantly associated with hypoglycaemia.

Conclusion: Greatest blood glucose variability occurs between 1 h and 3 h post-procedure. Hyperglycaemia is common and more severe with glucagon, and hypoglycaemia rarely occurs. These findings have assisted in developing clinical guidelines for post-percutaneous gastrostomy/gastrojejunostomy tube insertion.
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http://dx.doi.org/10.1007/s00247-014-2891-6DOI Listing
July 2014

Successful use of indwelling tunneled catheters for the management of effusions in children with advanced cancer.

Pediatr Blood Cancer 2014 Jun 23;61(6):1007-12. Epub 2013 Dec 23.

Division of Haematology/Oncology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Department of Pediatric Oncology/Haematology, Erasmus MC-Sophia Children's Hospital, University of Rotterdam, Rotterdam, The Netherlands.

Background: Malignant pleural effusion (MPE) and ascites (MA) negatively impact quality of life of palliative patients. Treatment options are limited. This study's purpose is to examine the experience with indwelling tunneled catheters (ITCs) for management of MPE/MA in children with advanced cancer.

Methods: Children with MPE/MA who underwent ITC insertion (2007-2012) were retrospectively reviewed. Clinical, procedural, complication and outcome details were analyzed.

Results: PleurX® ITCs (n = 12) were inserted in eight patients (5-18 years) with sarcoma (11 MPE, 1 MA), achieving symptom relief and facilitating discharge home post ITC (median 2 days). Median survival following ITC was 51 days. There were two major complications: pain (n = 1), late site infection (n = 1), and five minor complications. Drainage ceased in four patients (pleurodesis/tumor progression). At time of death, six ITCs (five patients) were still in situ.

Conclusions: ITC appears to be a safe, effective treatment for MPE/MA in advanced pediatric cancer, achieving symptomatic relief and discharge home.
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http://dx.doi.org/10.1002/pbc.24902DOI Listing
June 2014