Malavia Mira,  Rivard Douglas

Final Pr. ID: Poster #: EDU-068

Ischial tuberosity avulsion fractures, though not uncommon in adolescent athletes, are often overlooked or misdiagnosed. These fractures occur more frequently in males than females. Primary cause of this fracture type is usually a sudden eccentric load on the proximal hamstrings, typically seen during a kicking action in dance, football, or soccer. Due to the limited use of imaging in the evaluation of such injuries, these fractures often are misdiagnosed or underdiagnosed. Recent injuries warrant more conservative management, including rest and relative immobilization. In cases of late diagnosis, delayed healing, or persistent symptomatology, surgical intervention can be undertaken to restore normal anatomy, alleviate symptoms, and facilitate healing. Minimally invasive CT-guided percutaneous needle fenestration has been introduced for symptomatic delayed union ischial tuberosity fractures in adolescents. This percutaneous procedure involves the creation of multiple channels into the bone at the fracture site with an 18 gauge Chiba needle via image guided needle fenestration to enhance blood flow and promote healing of the target area. Following this, a tailored physical therapy program is implemented based on patient symptomatology, individual tissue healing rates, and the current literature related to proximal hamstring injuries. Outcomes to this minimally invasive approach have been promising including cases of complete pain relief, full functional recovery, and a return to sports without limitations.

Outline of Teaching Points:
Ischial tuberosity avulsion fractures are common in adolescent athletes, with a higher incidence in males, caused by sudden eccentric loads on proximal hamstrings during activities like dance, football, or soccer.
Due to limited imaging use, these fractures are often overlooked or misdiagnosed, leading to delayed healing or persistent symptoms.
Recent injuries may benefit from conservative management, involving rest and relative immobilization.
Surgical intervention becomes necessary for late diagnoses, delayed healing, or persistent symptoms to restore normal anatomy and alleviate symptoms.
Minimally invasive CT-guided percutaneous needle fenestration has shown promising outcomes, facilitating healing with complete pain relief and a return to sports without limitations. Read More

Authors:  Malavia Mira , Rivard Douglas

Keywords:  fracture, interventional radiology

Tran Patrick,  Kang Lisa,  Gundeti Mohan,  Long Jessica,  Brown Colin

Final Pr. ID: Poster #: CR-029

Congenital adrenal hyperplasia (CAH) is an autosomal recessive disorder resulting from mutations in genes encoding enzymes essential for adrenal hormone synthesis. It affects roughly 1 in 15,000 individuals and can present with ambiguous genitalia, salt-wasting, and virilization.

An 8-year-old girl with history of CAH and genitoplasty at age 2 presented with abdominal pain, brown perineal discharge, and fever (39°C). Labs were notable for leukocytosis (15 x 10^9/L).

Transabdominal ultrasound (TAUS) revealed a fluid-filled uterus and vagina with layering echoes. MRI confirmed a distended, fluid-filled uterus and vagina with layering debris. The ovaries were normal. Differential included imperforate or microperforate hymen, lower vaginal atresia, transverse vaginal septum, and vaginal outlet obstruction due to scarring.
On initial exam under anesthesia (EUA) findings of imperforate hymen were not present and placement of a speculum into an apparent narrowed vaginal introitus produced efflux of urine. Subsequent cystoscopy revealed that this channel led to the urinary bladder and a bladder catheter was placed.

Following discussion among pediatric gynecology, pediatric urology, and interventional radiology (IR), a joint EUA and drainage procedure was performed in the IR suite. A diminutive vaginal opening was identified and a cystoscope was advanced into the vagina under TAUS. The cystoscope was exchanged for a catheter and a fluoroscopic contrast vaginogram was performed, showing stricture of the vaginal introitus. Balloon stricturoplasty was performed, a Foley catheter was placed into the vagina, and the vaginal fluid was drained. The urinary bladder catheter was replaced and the bladder was decompressed.

After the procedure the patient's symptoms improved. Vaginal fluid culture grew E. faecalis. The patient was discharged with vaginal and bladder catheters in place and a 14-day antibiotic course.

Subsequent EUA by pediatric urology confirmed a single urogenital orifice with urethrovaginal communication, consistent with urogenital sinus anomaly and urethrovaginal fistula. Definitive surgery was deferred due to the patient’s age.

This case highlights the complexities of evaluating and treating children with urogenital anomalies and the importance of multidisciplinary collaboration in their management.

Final diagnosis: Vaginal outlet obstruction due to stricture managed with balloon dilation; urogenital sinus anomaly and urethrovaginal fistula secondary to CAH. Read More

Authors:  Tran Patrick , Kang Lisa , Gundeti Mohan , Long Jessica , Brown Colin

Keywords:  Interventional Radiology, Genitourinary, Urogenital Sinus

Arshad Wajiha

Final Pr. ID: Poster #: EDU-051

Introduction:
Gastrostomy insertion provides essential long-term nutritional support for patients due to neurological or congenital conditions. While common in both adults and children, pediatric patients present unique challenges requiring specialized techniques. This article highlights the differences between pediatric and adult gastrostomy procedures and explores how to optimize outcomes .
Anatomical Considerations:
Pediatric patients have smaller abdominal cavities, thinner abdominal walls, and smaller stomachs, increasing the risk of injury during gastrostomy. These factors necessitate smaller instruments and specialized techniques. The pliability of the pediatric abdominal wall makes securing the gastrostomy tube crucial to prevent dislodgement or leakage. Ensuring accurate tube placement is essential to avoid trauma and complications.
Physiological Differences:
Children have higher metabolic rates and rapid growth, affecting their nutritional needs and healing after surgery. Considerations include complications such as reflux or poor feed tolerance. Smaller stomach volume also requires careful tube size and placement.
Technique Modifications:

Percutaneous Endoscopic Gastrostomy (PEG): Adjusted for smaller anatomy.
Radiologically Inserted Gastrostomy (RIG): Ideal for children with complex surgical histories; guided placement reduces injury risk, though minimizing radiation exposure is vital.
Laparoscopic Gastrostomy: Used when direct visualization is needed, particularly for complex cases.
Radiological considerations include fluoroscopic visualization of the stomach bubble and liver ultrasound to assess organ positioning.
Postoperative Considerations:
Children are more prone to complications such as infection, leakage, and tube dislodgement. Educating caregivers on tube care and recognizing complications is critical to ensure proper nutrition and tube functionality.
Optimizing Outcomes:
A multidisciplinary approach involving pediatric surgeons, gastroenterologists, and radiologists is essential. Preoperative planning must address anatomical and medical complexities, while postoperative care should include ongoing monitoring and adjustments as the child grows.
Conclusion:
Pediatric gastrostomy requires adaptations of adult techniques to account for children’s anatomical and physiological differences. A multidisciplinary approach with careful planning and specialized care is vital for minimizing complications and ensuring successful outcomes. Read More

Authors:  Arshad Wajiha

Keywords:  Interventional Radiology

Kleedehn Mark,  Witt Jessica,  Laeseke Paul,  Woods Michael,  Monroe Eric

Final Pr. ID: Poster #: SCI-009

To evaluate patient and procedural variables for association with clinical outcomes in pediatric patients receiving IR drains. Read More

Authors:  Kleedehn Mark , Witt Jessica , Laeseke Paul , Woods Michael , Monroe Eric

Keywords:  Abscess, Interventional Radiology

Acord Michael,  Termine Carl,  Cahill Anne Marie,  Escobar Fernando

Final Pr. ID: Poster #: SCI-037

To assess the rate of dislodgement of posteriorly tunneled central lines, over-the-shoulder, in children. Read More

Authors:  Acord Michael , Termine Carl , Cahill Anne Marie , Escobar Fernando

Keywords:  venous access, back, interventional radiology

Hampton Erica,  Fuentealba Cargill Andrea,  Trenbeath Zachary,  Alazraki Adina,  Stence Nicholas,  Milla Sarah

Final Pr. ID: Poster #: EDU-076

Brain death, also known as death by neurologic criteria, (BD/DNC) is the permanent loss of total brain function in individuals who have sustained catastrophic brain injuries. Accounting for approximately 5% of pediatric deaths, BD/DNC remains a clinical diagnosis, which is often emotionally laden and not always straightforward. When results are equivocal or there exist limitations to the safe completion of the clinical assessment, clinicians rely on ancillary testing to make informed decisions. In October 2023, updated adult and pediatric BD/DNC consensus guidelines were published which reinforce differences in the recommendations for testing between the adult and pediatric populations. It is, therefore, crucial for Pediatric Radiologists to understand these guidelines and the critical role radiology plays in supporting this important diagnosis.
In this educational exhibit, we will review the recent consensus guidelines and clinical indications for the use of imaging in BD/DNC evaluation. We will provide a step-by-step guide which will include patient preparation, radionuclide or contrast administration, image acquisition, and image interpretation for the two validated methods of pediatric BD/DNC ancillary testing: Radionuclide Perfusion Scintigraphy and 4-Vessel Catheter Angiography.
Although 4 vessel catheter angiography is considered the gold standard in ancillary BD/DNC testing, as it is believed to be both 100% sensitive and 100% specific, radionuclide scintigraphy is the more widely used modality in the pediatric population, owing to the less invasive nature of the exam. Neither exam is without challenges related to limited availability and technical skill required yet are currently the only validated radiologic tools recommended for use in brain death diagnosis. Our exhibit will review multiple cases of evaluation for BD/DNC, accentuating imaging findings and pearls/pitfalls of acquisition and interpretation. Opportunities for investigation of other available imaging techniques will also be highlighted. Read More

Authors:  Hampton Erica , Fuentealba Cargill Andrea , Trenbeath Zachary , Alazraki Adina , Stence Nicholas , Milla Sarah

Keywords:  Nuclear Medicine, Interventional Radiology

Yen Christopher,  Kukreja Kamlesh,  Masand Prakash

Final Pr. ID: Poster #: CR-010

Female conjoined throraco-omphalopagus twins were delivered via cesarean section at 35 weeks 5 days gestational age to a 38-year-old mother who received standard prenatal care. After resuscitation, the twins were transferred to the neonatal ICU, where they remained for monitoring and growth as they were assessed for potential separation.
CT angiography was performed at 3-4 months of life using a staged approach. Selective IV and oral contrast administration was used over two visits to delineate shared and non-shared structures. Most significantly, there was a single shared liver with anomalous hepatic venous drainage. Twin A had three normal caliber hepatic veins draining into a normal IVC, but a large branch of the middle hepatic vein traversed midline into Twin B and received hepatic venous drainage from Twin B via numerous anomalous vessels. Twin B had a normal IVC but three diminutive hepatic veins, thought to be due to reduced venous drainage as a result of the anomalous shared vasculature.
After multidisciplinary discussion, interventional radiology was consulted for hepatic venogram and intervention as needed. The anomalous communicating vessels were identified on hepatic venogram via Twin A femoral approach. Occlusion of the anomalous branches was achieved with serial embolization of the primary draining vessel on the Twin A side using Amplatzer vascular plugs. Successful occlusion was confirmed on venography after the final embolization procedure.
Follow-up Doppler ultrasound exams confirmed improved hepatic venous outflow in Twin B, initially with reversal of flow in the anomalous veins back toward the IVC of Twin B, followed by nonvisualization of the anomalous veins on later exams. CT angiography later showed enlarged caliber of the native Twin B hepatic veins. Following the optimization of hepatic venous outflow, the multispecialty surgical team proceeded with separation. The twins were separated at 13 months of age without complication. In addition to restoring venous outflow to allow for a successful surgical outcome, it was noted that the Amplatzer devices were used as surgical landmarks during separation for identification of shared anatomy. Through careful planning and execution, diagnostic and interventional radiology techniques played a critical role in this successful outcome. Read More

Authors:  Yen Christopher , Kukreja Kamlesh , Masand Prakash

Keywords:  Conjoined twins, Interventional Radiology, CT Angiography

Hailu Tigist,  Ginader Abigail,  Bodo Nicole,  Sze Alyssa,  Corder William,  Thompson Lynn,  Escobar Fernando,  Sze Raymond,  Balmer Dorene

Final Pr. ID: Paper #: 144

Little is known about how families of children undergoing interventional radiology (IR) procedures experience their interactions with IR teams; therefore, we conducted a qualitative study to explore and learn from families experience with IR teams in order to educate pediatric IR staff and ultimately improve delivery of care. Read More

Authors:  Hailu Tigist , Ginader Abigail , Bodo Nicole , Sze Alyssa , Corder William , Thompson Lynn , Escobar Fernando , Sze Raymond , Balmer Dorene

Keywords:  Interventional Radiology, patient experience

Arshad Wajiha

Final Pr. ID: Poster #: EDU-001

Introduction:
Artificial intelligence (AI) is set to transform pediatric interventional radiology (PIR) by enhancing precision, improving diagnostics, and streamlining workflows. Given the complexities of smaller anatomy and higher risks in pediatric patients, AI's integration into imaging and procedural planning will significantly support growth and improve outcomes in the next decade. This abstract outlines key areas where AI will impact PIR.
Key Areas:
Enhanced Imaging and Diagnosis:
AI algorithms will enable faster and more accurate identification of anatomical structures and abnormalities in pediatric patients. Automated image processing can highlight critical features, assisting interventional radiologists in making informed decisions. This technology will provide detailed anatomical maps to guide minimally invasive interventions.
Procedure Optimization:
AI will enhance procedure planning and execution by predicting complications and recommending optimal techniques. AI-powered navigation systems integrated with real-time imaging will assist radiologists in navigating complex anatomical pathways, reducing procedure times and minimizing radiation exposure. Automated measurement tools will further personalize treatment.
Improved Decision-Making:
AI can analyze data from previous procedures to support decision-making, helping radiologists choose the best treatment based on predictive analytics. Machine learning models can identify trends and suggest personalized interventions, standardizing best practices and improving success rates in pediatric interventions.
Workflow Efficiency:
AI-driven automation will streamline tasks such as scheduling, imaging analysis, and report generation, allowing radiologists to focus more on patient care. By predicting resource needs and optimizing timing, AI will enhance workflow efficiency and facilitate multidisciplinary collaboration.
Education and Training:
AI will revolutionize education in pediatric interventional radiology. Virtual reality (VR) and AI-based simulation platforms will enable trainees to practice complex procedures in realistic environments, providing real-time feedback and personalized learning pathways.
Conclusion:
AI’s integration into pediatric interventional radiology will enhance imaging, optimize procedures, and streamline workflows. By leveraging AI’s capabilities, PIR can achieve greater precision, reduce risks, and improve outcomes for pediatric patients, driving growth and advancement in the field. Read More

Authors:  Arshad Wajiha

Keywords:  Interventional Radiology

Cregg Allison,  Nguyen Theo,  Holm Tara,  Flanagan Siobhan

Final Pr. ID: Poster #: CR-059

Portal hypertension in pediatric patients is rare, most commonly caused by extrahepatic portal vein (PV) occlusion. Complications include gastrointestinal bleeding. If obstruction recanalization or surgical shunt is not feasible, a transjugular intrahepatic portosystemic shunt (TIPS) can be placed. Risks of TIPS include encephalopathy, shunt stenosis, or thrombosis. Tipsitis is rare, occurring in less than 1% of TIPS patients, but is serious, with a mortality of 32%. Early diagnosis and treatment are key to preventing the need for liver transplantation, and imaging plays a key role in early detection. We present a case of tipsitis identified with FDG-PET/CT imaging.
A 16 year-old-male with prematurity, umbilical vein catheter, and heterozygous prothrombin mutation presented with hematemesis. Imaging identified chronic PV thrombosis. Due to the occlusion involving both the right and left PV, TIPS was placed. 5.5 months post-TIPS, he presented with fever and body aches. Investigations revealed Methicillin-Sensitive Staphylococcus aureus (MSSA) bacteremia and thrombosed TIPS. He completed a 6-week course of IV antibiotics, and the TIPS was revised.
Two weeks later, he was readmitted with recurrent MSSA bacteremia. FDG-PET/CT scan was performed, showing increased TIPS uptake, consistent with tipsitis. He completed an additional 8-week IV antibiotic course. Repeat FDG-PET/CT showed decreased but persistent TIPS uptake. IV antibiotics were extended, and he was placed on suppressive oral antibiotics with a plan for FDG-PET/CT in 3 months.
Tipsitis is rare, and early infection (<120 days) is associated with gram-positive bacteria caused by seeding during placement. In this case, later infection was suspected to be caused by Staph aureus superinfection during influenza. Low-grade symptoms include malaise, and high-grade symptoms include fever and rigors. Suspicious CT findings include peri-graft gas or fluid. Radiolabeled leukocyte uptake is specific to infection, but spatial resolution is limited. FDG-PET/CT with focal TIPS metabolic activity (SUV > 8.0) correlates with infection source (sensitivity 91-98%, specificity 64–91%).
Antibiotic therapy is successful in 53% of cases, and FDG-PET/CT can determine the degree of treatment success. Residual hypermetabolic activity signifies partial response. Aggressive antibiotics are recommended to prevent resistance and the need for liver transplant. FDG-PET/CT plays a vital role in diagnosis and management of tipsitis. Read More

Authors:  Cregg Allison , Nguyen Theo , Holm Tara , Flanagan Siobhan

Keywords:  Portal Vein Thrombosis, FDG PET, Interventional Radiology