López Diana,  Arrate Antonia,  Leal Camilo,  Méndez Daniela,  Pérez-marrero Lizbet

Final Pr. ID: Poster #: CR-043

Case report: Congenital bronchobiliary fistula is a rare congenital malformation, with high morbidity and mortality. It is characterized by a communication between the respiratory and digestive tracts, between a bronchus and the bile duct.
This is a full-term female newborn patient, appropriate for gestational age, who from the third day of life presents with progressive respiratory difficulty associated with abundant waste through a nasogastric tube. She evolved with greater respiratory difficulty, so she was kept on a complete bowel rest and with a nasogastric tube, which increased his output. Airway aspiration was suspected, and an esophagus-stomach-duodenum study was performed to evaluate gastroesophageal reflux, which was normal. The study continued with abdominal ultrasound, showing aerobilia.
The patient evolves with severe respiratory distress and requires mechanical ventilation on day 15, so a chest tomography is performed, which shows aerobilia and a communicating tract between the right main bronchus and the bile duct.
Surgical management was performed with closure of the proximal end of the fistula at the supradiaphragmatic level, without intervening the intrahepatic tract.
The newborn later develops cholestatic syndrome, which is studied with cholangiopancreatography magnetic resonance (MRCP) that reports atresia of the extrahepatic bile ducts, performing an entero-biliary anastomosis in a second surgical procedure.
During her childhood after being discharged, she was diagnosed with several obstructive bronchial syndromes, cholangitis and malnutrition, remaining stable at the outpatient level. She is currently 15 years of age, her only chronic illness being with chronic liver disease, without evidence of clinical or elastographic fibrosis.
Bronchobiliary fistula presents as bronchitis and repeated bronchopneumonia, bilioptysis, cholangitis and sepsis in some cases. Proposed etiologies are either union of an accessory bronchus with an aberrant bile duct or duplication of the foregut. This diagnosis can be associated with other malformations such as bile duct atresia and right diaphragmatic hernia. Computed tomography with 2D and 3D reconstructions and MRCP are recommended for diagnostic workup. Read More

Authors:  López Diana , Arrate Antonia , Leal Camilo , Méndez Daniela , Pérez-marrero Lizbet

Keywords:  Bronchobiliary fistula, Congenital malformation, Bilioptysis

Patel Parth,  Shepp Kasey,  Aribindi Haritha,  Ibrahim Muaz

Final Pr. ID: Poster #: CR-011

The ingestions of magnetic foreign objects are a common occurrence in the pediatric population. The American Association of Poison Control has documented 95,700 incidents of foreign-body ingestion in the year 2011 alone with most cases occurring in children younger than 5 years of age. In this case, we present a two-year-old male who presented to the emergency department with a four-day history of bilious vomiting. Read More

Authors:  Patel Parth , Shepp Kasey , Aribindi Haritha , Ibrahim Muaz

Keywords:  jejuno-jejunal, fistula, small bowel obstruction

Maller Vijetha,  Maller Vinod

Final Pr. ID: Poster #: CR-004

10-year-old male presented with intermittent fever, cough, shortness of breath, and weight loss. Contrast CT chest performed showed pulmonary thrombus in the right lower lobe branch with necrotizing cavitary pneumonia of the right lower lobe. Dilation of the left coronary artery (LCA) was noted on the chest CT and hence dedicated CT coronary angiography was performed. On CT coronary angiography, there was dilation of the proximal LCA with a wide caliber fistula arising from the LCA, proximal to its bifurcation. The fistula coursed in a retroaortic manner, draining into the right atrium posteriorly at the superior cava-atrial junction. Blood culture showed HACEK organism which is known to be associated with endocarditis. The echocardiogram showed possible vegetation attached to the left side of the atrial septum. After the patient was medically treated with intravenous antibiotics, successful ligation of the fistula was performed at its insertion to the right atrium.
We will discuss in detail as well as illustrate the CT coronary angiography findings in this patient using MIP and 3D reconstructions. We will also describe the types of coronary cameral fistula in detail Read More

Authors:  Maller Vijetha , Maller Vinod

Keywords:  coronary cameral fistula

Johnson Brittany,  Desai Sudhen,  Minifee Paul

Final Pr. ID: Poster #: CR-011

Introduction: The management of gastrobronchial fistula (GBF) is not well defined in the literature. First line management is non-operative, allowing time for the fistula to close naturally. Surgical intervention is implemented when non-operative management fails. In medically complex patients, who often fail non-operative management, surgical procedures for closure remain high risk for complications.

Case: We present a 2 year-old female with congenital esophageal atresia, duodenal atresia and annular pancreas. Beginning October 2015, she underwent multiple surgical procedures resulting in a multitude of complications. In August 2017, she transferred to our institution for management. Additional immediate operative intervention was pursued given the presence of the GBF. Despite two attempts at operative repair, the fistula recurred. Interventional radiology, consulted March 2018, developed a plan to place a percutaneous pigtail catheter in the esophagus through the dehiscent stomach wall from an external chest tube entry site, creating an iatrogenic enterocutaneous fistula (ECF). Diversion of flow from the GBF to the ECF was hypothesized to allow a conservative alternative for closure and tissue healing to occur. Initially, a 12 French (F) pigtail catheter was placed through the gastric wall into the esophageal pouch allowing the formation of the ECF tract. The patient returned for catheter downsizing to 8F three weeks later. A third intervention was performed to reposition the catheter to ensure that the tissues remained as dehydrated as possible. In May 2018, a 7 mm Cook Biodesign SIS fistula plug was placed. The 8F catheter was used to place a guide wire through the tract, then removed. The AFP bioplug, soaked in contrast to facilitate use of fluoroscopy, was placed through the mouth to seal the gastric wall. Placement was confirmed with a rigid esophagoscope and fluoroscopy. One week later, esophogram confirmed no leak. At 1 month follow-up the patient had no evidence of right pleural fluid and remains without evidence of fistula at five months. The skin site is well-healed.

Discussion: In this case, an ECF was closed with a Cook Biodesign SIS fistula plug allowing for a successful non-operative strategy after multiple failed operative revisions. The plug has FDA approval for the treatment of anal fistula, but given the positive outcome in this case, its use in esophagocutaneous fistulas may be a viable off-label option for other patients.

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Authors:  Johnson Brittany , Desai Sudhen , Minifee Paul

Keywords:  Gastrobronchial Fistula, SIS Fistula Plug

Jordan Gregory,  Hampton Erica,  Stence Nicholas,  Milla Sarah,  Callen Andrew

Final Pr. ID: Poster #: EDU-078

Intracranial hypotension is a condition caused by the loss of cerebrospinal fluid through either a dural defect, ruptured meningeal diverticulum, or CSF-venous fistula. In the past decade, this condition has been increasingly diagnosed in individuals suffering from orthostatic headaches. In adults, CSF leaks are commonly caused by dural defects due to a degenerative disc osteophyte violating the ventral dura. In the pediatric population, spontaneous leaks may occur in individuals with underlying connective tissue disease, or from venous/lymphatic malformations which approximate the spinal subarachnoid space. Most commonly, a CSF leak results in an “orthostatic headache” characterized by head pain which worsens upon sitting or standing and improves when lying flat. In addition to headache, patients can experience vestibulocochlear symptoms, changes in vision, forgetfulness, or personality changes. CSF leak localization usually requires dynamic myelography, performed using either digital subtraction or CT techniques. However, specific tailored MRI protocols can aid in the detection and characterization of leaks. Treatment options include percutaneous injection of autologous blood or fibrin sealant into the epidural space, embolization of draining veins, or primary surgical repair. The goal of this exhibit is to provide an illustrative review of the various pathologies that can cause CSF leak in the pediatric population. A review of anatomy and pathophysiology followed by a case-based presentation including congenital, iatrogenic, traumatic, and idiopathic causes will be presented. Both noninvasive and invasive imaging protocols will be discussed with a focus on minimizing radiation dose in the pediatric population. Read More

Authors:  Jordan Gregory , Hampton Erica , Stence Nicholas , Milla Sarah , Callen Andrew

Keywords:  CSF Leak, Intracranial hypotension, CSF-venous fistula

Maller Vijetha,  Boston Umar,  Knott-craig Christopher

Final Pr. ID: Poster #: CR-003

Transseptal course is defined as the anomalous course of left coronary artery (LCA) after its anomalous origin from the opposite sinus, when the coronary artery takes a sharp turn to dip into the basal interventricular septum behind the right ventricular outflow tract (RVOT) and emerge laterally to the epicardial surface. Transseptal course is generally considered by some as benign entity. However, case reports of severe cardiac symptoms such as myocardial ischemia, arrhythmia, and even sudden cardiac death have been sporadically reported. Surgical management in symptomatic patients can be challenging. One of the latest surgical approach to this anomaly is transection of the RVOT, unroofing the septal course of the LCA, followed repair of the posterior wall of the RVOT by placement of rectangular strip of autologous pericardium.
We present a 17-year-old male who was noted to have an anomalous left coronary artery on screening echocardiography. CT coronary angiography revealed anomalous origin of left anterior descending artery (LAD) from the right sinus of Valsalva with a long intraconal/transseptal course that measured 43mm in length. The left circumflex artery (LCx) also had anomalous origin from the right sinus of Valsalva with retroaortic course and a fistula with pulmonary artery. This patient had 5 ostia at the right sinus of Valsalva with separate origins of two conus arteries. This patient had successful transconal unroofing of the anomalous LAD and ligation of the LCX to pulmonary artery fistula.
We will discuss the preoperative as well as postoperative CT coronary angiography using multiplanar views, 3D hollow reconstructions, as well as virtual endoluminal views. The CT coronary angiography characteristics of transeptal course of anomalous coronary artery will be discussed in detail. Illustrations with 3D reconstructions which helped our cardiothoracic surgeons to plan the transconal unroofing of the anomalous LAD will be discussed. Recognition of transeptal course of the coronary artery and describing its course and relation to the RVOT including the assessment of the overlying conal septal myocardial thickness with the help of multiplanar views and 3D views can help better surgical planning. Read More

Authors:  Maller Vijetha , Boston Umar , Knott-craig Christopher

Keywords:  Transseptal course, coronary fistula, transconal unroofing

Chughtai Komal,  Saul David,  Chaturvedi Apeksha

Final Pr. ID: Poster #: EDU-002

Congenital hepatic vascular shunts occur secondary to abnormal formation and aberrant communication of blood vessels during fetal development. This spectrum of anomalies can be challenging to diagnose without a strong understanding of their embryology and clinical and imaging manifestations. Ultrasound is among the most widely used modalities in pediatric imaging, given its real-time nature, easy portability and lack of radiation exposure. This case-based exhibit reviews ultrasound and doppler imaging findings of congenital vascular shunts in the pediatric liver.

The broad categories of congenital hepatic vascular shunts include: arteriovenous (hepatic artery to hepatic vein), arterioportal (hepatic artery to portal vein), and portovenous (portal vein to hepatic vein). This exhibit starts by demonstrating the formation of normal hepatic vasculature during fetal development. This is followed by a discussion of embryological aberrations which lead to vascular shunts, clinical context of each anomaly (when to wait, worry or intervene), and the role of imaging in detection, quantification, prognostication and treatment of these anomalies.

There are case presentations and discussion of the following vascular anomalies: extrahepatic portosystemic shunt (also known as Abernethy Malformation), intrahepatic portosystemic shunt, arterioportal fistula, intrahepatic arteriovenous malformation, patent ductus venosus, infradiaphragmatic total anomalous pulmonary venous return, and hepatic hemangioma. Illustrations and ultrasound/Doppler images are included for most of these cases.

Besides providing a clinical and imaging review of anomalous hepatic vascular communications, this exhibit will reinforce an understanding of physiologic hepatic vascular shunts in fetal life and describe the sequence of successful transition to neonatal circulation. This understanding can be applied to clinical decision making.

Supplemental Files- legends:
1. File 1: Hepatic vascular shunts.
2. File 2: Portosystemic shunt. Turbulent flow within an aberrant vessel connecting left portal to left hepatic vein. Flow pulsatility/triphasicity within the portal vein.
3. File 3: Intrahepatic Arteriovenous Malformation. Tangle of enlarged vessels within left liver lobe. High velocity, low resistance arterial waveforms and pulsatile venous flow. Read More

Authors:  Chughtai Komal , Saul David , Chaturvedi Apeksha

Keywords:  Arteriovenous malformation, Patent ductus venosus, Arterioportal fistula