Paediatric interventional radiology: it's not child's play

Pediatric interventional radiology is a dynamic and growing subspecialty. The new training pathways in interventional radiology, the maintenance of skills with a small volume of cases or complex procedures, the limited availability of specific pediatric equipment and materials pose significant challenges and opportunities.

Pediatric Transplant Interventions

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.

Is There Really No Kit for Kids? Quantification of Manufacturer Recommendations Regarding Paediatric Use For High-Volume IR Devices

AIMS

The development of paediatric specific devices appears to lag behind advancements in our specialty. Children could therefore be limited in the number of procedures available to them unless we continue to use and modify adult devices 'off-label'. This study quantifies the proportion of IR devices in which paediatric use is indicated by the manufacturer.

MATERIALS & METHODS

Cross-sectional analysis of device instructions for use (IFU), assessing inclusion of children was performed. Vascular access, biopsy, drainage, and enteral feeding devices, from 28 companies who sponsored BSIR, CIRSE and SIR (2019-2020) as determined by the meeting websites, were included. Devices for which the IFU was not available were excluded.

RESULTS

190 (106 vascular access, 40 biopsy, 39 drainage and 5 feeding) devices with IFU's from 18 medical device manufacturers were assessed. 49/190 (26%) IFU's referenced children. 6/190 (3%) explicitly stated the device could be used in children and 1/190 (0.5%) explicitly stated the device was not for use in children. 55/190 (29%) implied they could be used in children through caution notes. The most common caution was a reference to the size of the device that could be accommodated in a child (26/190, 14%).

CONCLUSIONS

This data identifies an unmet need for paediatric IR devices and could be used to support the future development of devices intended for the children we treat. There is potentially a larger proportion (29%) of devices suitable for paediatric use, but which lack manufacturer explicit support.

LEVEL OF EVIDENCE

Level 2c, Cross-Sectional study.

Pediatric Interventional Neuroradiology: Opportunities and Challenges

Pediatric interventional neuroradiology (PINR) is a relatively new field of diagnostic and therapeutic care in the pediatric population that has seen considerable advances in recent decades. However, it is still lagging behind adult interventional neuroradiology due to a variety of reasons, including the lack of evidence validating pediatric-specific procedures, the relative absence of pediatric-specific equipment, and the challenges in establishing and maintaining PINR competencies in a relatively small number of cases. Despite these challenges, the number and variety of PINR procedures are expanding for a variety of indications, including unique pediatric conditions, and are associated with reduced morbidity and psychological stigma. Continued technological advances, such as improved catheter and microwire designs and novel embolic agents, are also contributing to the growth of the field. This review aims to increase awareness of PINR and provide an overview of the current evidence base for minimally invasive neurological interventions in children. Important considerations, such as sedation, contrast agent use, and radiation protection, will also be discussed, taking into account the distinct characteristics of the pediatric population. The review highlights the usefulness and benefits of PINR and emphasizes the need for ongoing research and development to further advance this field.

Pediatric interventional radiology - does it add value?

Although attempts have been made to show that pediatric interventional radiology adds value in children's hospitals, none has been particularly persuasive. An analysis of individual procedures would seem to be the most scientific approach, but there are numerous problems, including the effects that different health care systems have on clinical practice and the difficulty of generalizing the results of a single-center study to other hospitals, even within the same type of health care system. It is unsurprising that there are no published randomized controlled trials comparing both the costs and outcomes of specific pediatric interventional radiology procedures with surgical alternatives, and in fact these may not be feasible. There is only anecdotal evidence of the value of pediatric interventional radiology in multidisciplinary teams in children's hospitals. Currently, the best justification may be the counterfactual: demonstrating what can go wrong if pediatric interventional radiology expertise is not available.

Vascular and Interventional Radiology Training; International Perspectives and Challenges

PURPOSE

Assess international interventional radiology (IR) training standards and trainee satisfaction to identify challenges and drive positive change.

MATERIALS AND METHODS

An anonymous survey was created using Survey Monkey and distributed as a single-use web link via eight IR national and international societies around the world. It consisted of two parts: the first assessed the general exposure of radiology trainees to IR and whether this influenced their decision to pursue a career in IR; the second focussed on satisfaction and quality of training by those who are in training or have recently completed an IR training program.

RESULTS

There were 496 participants of which 274 were eligible to complete part one of the survey and 222 were eligible to complete the whole survey. UK and Europe contributed 52% of the responses. The USA and Middle East contributed 23%, and the rest of the world 9%. Over half of responders expressed that exposure early in their career was the main inspiration to pursue a career in IR. Overall satisfaction with training was high across all regions; however, satisfaction regarding vascular training varied. The negative impact of competition from other specialities ranged from 9% (USA) to 61% (UK). Great variability was reported regarding the amount of time spent dedicated to IR and IR on call.

CONCLUSION

Despite significant progress in creating structured and comprehensive IR training, there is still room for improvement. Early promotion of IR is essential for on-going high-quality recruitment. Monitoring and standardization of the training environment at a national and international level are necessary to equip IR trainees and to consolidate IR's speciality status in the medical field.