FUTURE-DIRECTIONS IN INTERVENTIONAL PEDIATRIC RADIOLOGY

The origins of interventional radiology are in the Seldinger technique described in the early 1950s by Seldinger.(78) This system allowed ac cess to an artery with a needle followed by a wire and catheter placem ent. The performance of percutaneous interventional procedures has pro gressed substantially with the development of cross-sectional imaging including ultrasound, computed tomography (CT), and magnetic resonance (MR) imaging, as well as the development of high-resolution image-int ensified fluoroscopy. At the same time there also has been significant development in materials and technology, with numerous needles, wires , balloons, stents, and embolic materials becoming available. There al so has been a significant improvement in the care of the pediatric pat ient, with better anesthesia and sedation and improved monitoring.(11, 22) The spectrum of available interventional procedures is shown in Fi gure 1. Access to a system, conduit, or mass is achieved either throug h imaging using ultrasound, CT, fluoroscopy, or MR imaging, by palpati on (e.g., of the femoral artery), or by anatomic landmarks (e.g., femo ral vein medial to the femoral artery). Once access has been obtained with a needle, the needle can be used for biopsy or aspiration or a wi re can be placed followed by numerous interventional or diagnostic pro cedures. These include arteriogram, venogram, stent placement, dilatat ion, filter placement, stent removal, and embolization. The growth of pediatric interventional radiology has lagged behind the adult interve ntional programs. The disease processes-seen in the pediatric populati on are significantly different from those of adults and techniques and use of imaging therefore is different.(82,85) As children are general ly not cooperative, sedation or general anesthesia often is required. Additionally, if the pediatric interventional radiologist is going to be performing procedures on patients under sedation with the assistanc e of a nurse clinician, a good knowledge of the drugs and combination of drugs for sedation and analgesia, as well as the treatment of compl ications from the use of these drugs, is required.(11) The decision to do a procedure under general anesthesia is the choice of the interven tional radiologist, and this also requires some knowledge not only of the disease process but of the patient, requiring consultation with th e referring service and physician. General anesthesia is used for proc edures that require complete patient cooperation, painful or lengthy p rocedures, procedures that are risky in terms of closeness to vital or gans, or patients who have failed sedation previously.