Construction of Femoral Vessel Nomograms for Planning Cardiac Interventional Procedures in Children 0-4 Years Old

Best Practices for Vessel Management in Pediatric Extracorporeal Membrane Oxygenation Cannulation, Decannulation, and Follow-up: A Narrative Review

Extracorporeal membrane oxygenation (ECMO) to support neonates and children with cardiopulmonary failure was first described in the 1970s, since which time its use has expanded to an increasingly complex and heterogenous pediatric population. Despite preserved survival outcomes, complications of ECMO use, including iatrogenic vascular injury, are common. Here, we provide a brief overview of the epidemiology of pediatric ECMO and associated vascular complications; describe common peripheral cannulation equipment and techniques, trends in cannulation and decannulation strategies, and respective incidence of vascular complications; and review existing evidence for best practices in cannula site selection, cannulation technique, decannulation strategies, and management of vascular complications, with the goal of providing a comprehensive review for interventionalists involved in the care of pediatric ECMO patients. Areas of wide practice variation in vessel management-application of vessel-sparing cervical venoarterial cannulation, the use of distal perfusion catheters in femoral arterial cannulation, and best practices for percutaneous single-lumen venovenous cannulation, as examples-areas of focus for future research, and the potential role of vascular surgeons and other subspecialty proceduralists in the care of pediatric ECMO patients are highlighted. LEVEL OF EVIDENCE: V.

Off-label uses of the Amplatzer Piccolo Occluder in children with congenital and acquired heart diseases

Aim: The Amplatzer Piccolo Occluder (APO) is approved for patent ductus arteriosus (PDA) occlusion in infants weighing >700 g but could offer versatility to treat other lesions.Methods: Retrospective review of children in whom APO was utilized for defects other than PDA between January 2022 and June 2023.Results: The APO was used in nine patients; three for ventricular septal defects, four with coronary fistulas, one for a ventricular pseudoaneurysm and one where APO deployed within a fenestration of a previously placed Amplatzer Septal Occluder. All nine patients had successful occlusions without complications.Conclusion: The APO is a versatile device that can be used to treat various small diameter lesions in children besides the PDA for which it is currently approved for.

Patent Ductus Arteriosus Occlusion in Premature Infants

Transcatheter ductal closure has proven to be safe and effective to occlude the patent ductus arteriosus (PDA) in premature infants. We have developed a robust multidisciplinary PDA program. After gaining experience performing transcatheter ductal closure in the cardiac catheterization laboratory, we transitioned to performing the procedure at the patient's bedside in the neonatal intensive care unit using echocardiographic guidance. The bedside approach has the potential to expand this therapy to patients who currently undergo expectant PDA management because of lack of availability of this therapy, and allow for earlier referral, which will reduce time of exposure to this pathologic shunt.

Pediatric Interventional Neuroradiology: "How I Do It" v. I - Diagnostic Angiography

Pediatric neurointervention differs from the adult in several important respects. Here we describe a modern approach to readily acquire diagnostic quality images of children. Preparation, access, angiogragraphy and closure have evolved along with new knowledge and technology. This timely "how I do it" series addresses each topic utilizing literature review and our own experience over 35 years.

Endovascular treatment of acute ischemic stroke in childhood: A comprehensive literature review based on the experience of a single center

Acute ischemic stroke (AIS) in childhood is a relatively rare but significant condition that can result in long-term disabilities. There is a lack of standardized strategies for diagnosing and treating pediatric AIS due to limited evidence-based data on thrombolytic and endovascular treatments in children. This comprehensive literature review focuses on the experience of a single center in Italy and aims to highlight the main peculiarities of endovascular treatment (EVT) for AIS in childhood. The review covers the diagnostic workup, the endovascular procedures, and the need for a specific thrombectomy program for pediatric AIS. The review discusses the indications and considerations for thrombectomy in children, including the risk of complications and the challenges of extrapolating results from adult studies. The diagnostic protocols for pediatric AIS are also discussed, emphasizing the use of MRI to avoid X-ray and contrast medium exposure in children. The combination of intravenous thrombolysis and mechanical thrombectomy has been examined, considering the differences between pediatric and adult thrombi. Technical considerations related to the size of pediatric patients are addressed, including the use of large bore catheters and potential concerns with access points. The organization of a thrombectomy program for pediatric AIS is discussed, emphasizing the need for specialized facilities and expertise. Although evidence for EVT in the pediatric population is based on case series, the importance of specialized centers and the lack of validated guidelines are evident.

Percutaneous treatment of symptomatic deep vein thrombosis in adolescents using large-bore thrombectomy systems

BACKGROUND

While large-bore mechanical thrombectomy provides effective venous thrombus removal, often with avoidance of thrombolytics, literature surrounding the application of these devices in pediatric patients is sparse.

OBJECTIVE

To report technical success and outcomes following large-bore thrombectomy systems in adolescent patients with deep venous thrombosis.

MATERIALS AND METHODS

A retrospective review identified all patients less than 18 years of age undergoing mechanical venous thrombectomy at a single institution between 2018 and 2022. No patients were excluded. Technical success was defined as extraction of thrombus sufficient to restore unimpeded flow in affected segments. Clinical success was defined as resolution of presenting symptoms.

RESULTS

Nine consecutive patients (6 females, 3 males; age range 15-17 years) underwent 10 thrombectomy procedures using ClotTriever (n=6; 60%), FlowTriever (n=2; 20%), or both (n=2; 20%). Chronicity of thrombus was categorized as acute (<2 weeks) in 6 (60%), subacute (2-6 weeks) in 1 (10%), and chronic (>6 weeks) in 3 (30%). Distribution of thrombus was lower extremity and/or inferior vena cava (IVC) in 9 (90%) and unilateral axillo-subclavian in 1 (10%). Technical success was achieved in 9 interventions (90%). Clinical success was achieved in 8 patients (88.9%). No patients received thrombolytics. There were no intraprocedural adverse events (AE). Minor complications (Society of Interventional Radiology mild adverse events) were observed in a delayed fashion following 2 interventions (20%).

CONCLUSIONS

This preliminary experience demonstrated high rates of technical and clinical success with large-bore deep venous thrombectomy in adolescent patients across a range of thrombus chronicity and locations.

A Global Perspective on PDA Management in the Extremely Premature: Shifting Trend Toward Transcatheter Closure

Patent ductus arteriosus (PDA) is a frequently encountered defect in infants born extremely premature (≤26 weeks' gestation). Historically, closure of the PDA was performed using cyclooxygenase inhibitor medications or by surgical ligations. However, the benefits of PDA closure using these therapies have never been demonstrated, albeit studies have previously not focused on the extremely premature infants. Therefore, there was a worldwide trend toward conservative management of the PDA. With improved survival of extremely premature infants, comorbidities associated with the PDA has increased, resulting in finding alternate treatments such as transcatheter patent ductus arteriosus closure (TCPC) for this population. Currently, there is a renewed interest toward selective treatment of the PDA in this high-risk cohort of small infants. This Comprehensive Review article inspects the globally changing trends in the management of the PDA in premature infants, with a special focus on the rising adoption of TCPC. Moreover, this article compiles data from several neonatal networks worldwide to help understand the problem at hand. Understanding the current management of premature infants and their outcomes is fundamentally essential if pediatric cardiologists are to offer TCPC as a viable therapeutic option for this population. This article aims to serve as a guide for pediatric cardiologists on this topic by compiling the results on landmark clinical trials on PDA management and the controversies that arise from these trials. Comparative outcomes from several countries are presented, including interpretations and opinions of the data from experts globally. This is a step toward coming to a global consensus in PDA management in premature infants.

Ultrasonographic measurements of femoral vessel diameter in neonates weighing less than 2.5 kg

BACKGROUND

Cannulation in low birth weight (LBW) neonates using larger sheaths could increase the risk of vascular injury. This study investigated the relationship between body weight (BW) and diameter of femoral vessels in LBW neonates and whether BW can be used to predict femoral vessel diameter.

METHODS

The cohort included 100 neonates weighing < 2.5 kg (.57-2.42 kg) with a gestational age of 24-39 weeks. Vascular ultrasonography was used to measure diameters of the bilateral femoral arteries (FA) and veins (FV). The cohort was divided into four groups according to weight: group-A, 2-2.49 kg (n = 28); group-B, 1.5-1.99 kg (n = 38); group-C, 1-1.49 kg (n = 21); and group-D, < 1 kg (n = 13); or according to BSA: group-A, BSA > .16 m² (n = 25); group-B, .13-.16 m² (n = 40); group-C, .1-.13 m² (n = 22); and group-D, < .1 m² (n = 13).

RESULTS

The median vessel diameters (mm) in groups A-D according to weight were FA, 1.96, 1.86, 1.78, and 1.53, and FV, 2.30, 2.28, 2.13, and 1.87, respectively. The median vessel diameters (mm) in groups A-D according to BSA were FA, 1.96, 1.86, 1.76, and 1.53, and FV, 2.30, 2.28, 2.05, and 1.87, respectively. There were positive correlations between BW and femoral vessel diameter (correlation coefficient: .56 and .55 between BW and FA and FV, respectively) (p < 0.001), and between BSA and femoral vessel diameter (correlation coefficient: .56 and .55 between BSA and FA and FV, respectively) (p < 0.001).

CONCLUSIONS

BW is a predictor of femoral vessel diameter in LBW newborns. This finding may help to avoid using larger sheath in smaller vessels.

Management of Patent Ductus Arteriosus in Premature Infants in 2020

The patent ductus arteriosus (PDA) is the most commonly found cardiac condition in neonates. While there have been several studies and thousands of publications on the topic, the decision to treat the PDA is still strongly debated among cardiologists, surgeons, and neonatologists. This is in part due to the shortage of long-term benefits with the interventions studied. Practice variations still exist within sub-specialties and centers. This article briefly summarizes the history, embryology and histology of the PDA. It also succinctly discusses the hemodynamic significance of a PDA which builds the framework to review all the available literature on PDA closure in premature infants, though not a paradigm shift just yet; it introduces transcatheter PDA closure (TCPC) as a possible armament to the clinician for this age-old problem.

Consensus Guidelines for the Prevention and Management of Periprocedural Complications of Transcatheter Patent Ductus Arteriosus Closure with the Amplatzer Piccolo Occluder in Extremely Low Birth Weight Infants

Transcatheter closure of patent ductus arteriosus (PDA) in premature infants is a feasible, safe, and an effective alternative to surgical ligation and may be performed with an implant success rate of 97%. Major procedural complications related to transcatheter PDA closure in extremely low birth weight (ELBW) infants are relatively infrequent (< 3%) ,but may be associated with a fatality if not optimally managed. Operators performing transcatheter PDA closures should be knowledgeable about these potential complications and management options. Prompt recognition and treatment are often necessary to avoid serious consequences. With strict guidelines on operator training, proctoring requirements, and technical refinements, transcatheter PDA closure in ELBW infants can be performed safely with low complication rates. This article summarizes the consensus guidelines put forward by a panel of physicians for the prevention and management of periprocedural complications of transcatheter PDA closure with the Amplatzer Piccolo Occluder in ELBW infants.