Pediatric Interventional Procedures Research Articles

Medical staff dose estimation during pediatric cardiac interventional procedures.

The purpose of this study is to evaluate the occupational doses (eye lens, extremities and whole body) in paediatric cardiac interventional and diagnostic catheterization procedures performed in a paediatric reference hospital located in Recife, Pernambuco. For eye lens dosimetry, the results show that the left eye receives a higher dose than the right eye, and there is a small difference between the doses received during diagnostic (D) and therapeutic (T) procedures. The extrapolated annual values for the most exposed eye are close to the annual limit. For doses to the hands, it was observed that in a significant number of procedures (37 out of 45 therapeutic procedures, or 82%) at least one hand of the physician was exposed to the primary beam. During diagnostic procedures, the physician's hand was in the radiation field in 11 of the 17 catheterization procedures (65%). This resulted in a 10-fold increase in dose to the hands. The results underscore the need for optimization of radiation safety and continued efforts to engage staff in a radiation safety culture.&#xD.

Establishment of local diagnostic reference levels for radiation dose in paediatric interventional cardiology procedures in Brazil

Diagnostic and therapeutic interventional cardiology procedures are essential tools for evaluating congenital pathologies in paediatric patients. However, these procedures may expose patients to high levels of ionizing radiation. In this paper, we present the results of the radiation doses received by patients undergoing interventional cardiac procedures at a paediatric hospital in Brazil, aiming to establish local Diagnostic Reference Levels (DRL). The data were collected over a period of three years (2019–2022), and 148 procedures were analyzed, comprising 53% male (78) and 47% female (70) patients. These procedures included both diagnostic (59%) and therapeutic (41%) cardiac catheterization interventions. The average patient weight was 21.4 ± 1.7 kg (2.0–112.0 kg), with an average age of 5.3 ± 0.4 years (0.0–17.1 years). Comprehensive data for each procedure were extracted from Radiation Dose Structure Reports generated by the equipment. The results showed significant differences between diagnostic and therapeutic procedures, and the DRL values were estimated considering the age and weight of the patients. The DRL values correspond to the 3rd quartile of the dose distribution for each group. The following local DRL values were estimated, considering the patient's ages. For diagnostic procedures, the PKA defined according to the age groups <1, 1–5, 5–10, 10–15, and >15 years were respectively: 1.4, 2.8, 3.1, 4.3 and 12.0 Gy cm2. For therapeutic procedures, the DRL values for patients with the same ages were: 2.0, 3.7, 5.4, 7.4, and 30.9 Gy cm2. For the total procedures, the PKA values were 1.7, 3.2, 4.9, 6.6, and 24.5 Gy cm2, respectively. The suggested local DRL values for weight groups (<5, 5–15, 15–30, 30–50, and 50–80 kg) for PKA in diagnostic procedures were: 1.3, 2.2, 3.2, 4.1, and 7.9 Gy cm2, respectively. For therapeutic procedures, the PKA values were 1.1, 2.7, 5.4, 5.5, and 30.9 Gy cm2, respectively. For the total procedures, the PKA values were 1.25, 2.5, 4.6, 4.2, and 18.3 Gy cm2, respectively. For establishing PKA DRL, patient weight was found to be preferable over age, whereas for Ka,r, both approaches yielded nearly identical results.

An Approach to Establishing Diagnostic Reference Levels in Interventional Pediatric Cardiology from Different Regions of Brazil.

Diagnostic reference levels (DRLs) are a pivotal strategy to be implemented since pediatric interventional cardiology procedures are increasing. This work aimed to propose an initial set of Brazilian DRLs for pediatric interventional diagnostic and therapeutic (D&T) procedures. A retrospective study was carried out in four Brazilian states, distributed across the three regions of the country. Data were collected from pediatric patients undergoing cardiac interventional procedures (CIPs), including their age and anthropometric characteristics, and at least four parameters (number of images, exposure time, air kerma-area product-PKA, and cumulative air kerma). Data from 279 patients undergoing CIPs were gathered (147 diagnostic and 132 therapeutic procedures). There were no significant differences in exposure time and the number of images between the D&T procedures. A wide range of PKA was observed when the therapeutic procedures were compared to diagnostics for all age groups. There were significant differences between the D&T procedures, whether grouping data by patient weight or age. In terms of cumulative air kerma, it was noted that no value exceeded the level to trigger a monitoring process for patients. This study shows that it is possible to adopt them as the first proposal to establish national DRLs considering pediatric patient groups.

First record of pediatric cardiovascular interventional procedures performed in a state pediatric catheterization laboratory in El Salvador

First record of pediatric cardiovascular interventional procedures performed in a state pediatric catheterization laboratory in El Salvador

Local Diagnostic Reference Levels for Pediatric Interventional Cardiology Procedures in Argentina.

The aim of this work was to propose a preliminary local diagnostic reference levels (DRL) for pediatric interventional cardiology (PIC) procedures in Argentina, for different ranges of age and weight. This work has been conducted in the framework of the "Optimization of Protection in Pediatric Interventional Radiology in Latin America and the Caribbean" (OPRIPALC) program coordinated by the World Health Organization and the Pan American Health Organization in cooperation with the International Atomic Energy Agency to ensuring that radiation exposures of pediatric patients are the minimum necessary during fluoroscopy-guided interventional procedures. The local DRL values presented in this paper by weight group and age group were 7.1 Gy·cm2 (<5 kg), 10.7 Gy·cm2 (5-15 kg), 18.0 Gy·cm2 (15-30 kg), 15.9 Gy·cm2 (30-50 kg), and 28.2 Gy·cm2 (50-80 kg) and 5.3 Gy·cm2 (<1), 11.2 Gy·cm2 (1 to 5<), 19.6 Gy·cm2 (5 to 10<), and 21.4 Gy·cm2 (10 to 16<), respectively. Our dose results are among the values found in other international studies; however, there is great potential for dose optimization.

Physical Image Quality Metrics for the Characterization of X-ray Systems Used in Fluoroscopy-Guided Pediatric Cardiac Interventional Procedures: A Systematic Review.

Pediatric interventional cardiology procedures are essential in diagnosing and treating congenital heart disease in children; however, they raise concerns about potential radiation exposure. Managing radiation doses and assessing image quality in angiographs becomes imperative for safe and effective interventions. This systematic review aims to comprehensively analyze the current understanding of physical image quality metrics relevant for characterizing X-ray systems used in fluoroscopy-guided pediatric cardiac interventional procedures, considering the main factors reported in the literature that influence this outcome. A search in Scopus and Web of Science, using relevant keywords and inclusion/exclusion criteria, yielded 14 relevant articles published between 2000 and 2022. The physical image quality metrics reported were noise, signal-to-noise ratio, contrast, contrast-to-noise ratio, and high-contrast spatial resolution. Various factors influencing image quality were investigated, such as polymethyl methacrylate thickness (often used to simulate water equivalent tissue thickness), operation mode, anti-scatter grid presence, and tube voltage. Objective evaluations using these metrics ensured impartial assessments for main factors affecting image quality, improving the characterization of fluoroscopic X-ray systems, and aiding informed decision making to safeguard pediatric patients during procedures.

Local reference and achievable dose levels for vascular and enterostomy access procedures in pediatric interventional radiology.

Knowledge of radiation quantities delivered in routine practice is an essential responsibility of a pediatric interventional radiology department. To review radiation indices in frequently performed vascular and enterostomy access procedures at a quaternary pediatric hospital to formulate dosimetric reference levels and achievable levels. A retrospective review of patient demographics, procedure information and quantitative dose metrics over a 2-year period was performed. Dosimetric details forcommon procedures (central line insertions, gastrostomy/gastrojejunostomy insertions and maintenance) were evaluated, correlated with demographic data and stratified acrossfive weight groups (0-5kg, 5-15kg, 15-30kg, 30-50kg, 50-80kg).Achievable (50th percentile) and reference (75thpercentile)levels with confidence intervals were established for each procedure. Within the evaluation period, 3,165 studies satisfied the inclusion criteria. Five were classified as device insertions (peripherally inserted central catheter, n=1,145; port-a-catheter, n=321; central venous line, n=285; gastrostomy-tube [G-tube], n=262, and gastrojejunostomy-tube [GJ-tube], n=66),and two were classified as maintenance procedures (G-tube, n=358, and GJ-tube, n=728, checks, exchanges and reinsertions). Representative reference and achievable levels were calculated for each procedure category and weight group. This work highlights the creation of local reference and achievable levels for common pediatric interventional procedures. These data establish a dosimetric reference to understand the quantity of radiation routinely applied, allowing for improved relative radiation risk assessment and enriched communication to interventionalists, health care providers, parents and patients.

Contribution of the fluoroscopy and cine modes to patient exposure in paediatric interventional cardiology procedures

IntroductionPaediatric interventional cardiology procedures have grown in recent years. The main disadvantage of these procedures is the high dose of radiation that patients receive. Such methods include the fluoroscopy mode, which allows real-time visualization, and the cine mode, which allows the documentation of images. The dosimetric quantities recommended currently for these procedures are: kerma-area product (PKA), air kerma at the patient entrance reference point (Ka,r), fluoroscopy time (tFl) and number of acquired images (IN). While PKA and Ka,r characterize total irradiation during the examination, IN and tFl describe the contribution of fluoroscopy and cine modes separately. These characteristics are indirect and presume that the radiation exposure is proportional to them. Such a choice is made because most of the equipment do not supply information about the contribution of fluoroscopy and cine modes to the PKA or Ka,r separately. ObjectivesThe primary objective of this work is to evaluate the contribution of the fluoroscopy and cine modes to the total exposure; we study to what extent these contributions can be characterized by fluoroscopy and cine time and number of acquired images. We also propose local diagnostic reference levels for quantities that separately describe the contribution of fluoroscopy and cine modes. MethodsIn a period of 3 years (2019–2021), data on 135 procedures were evaluated; the study included 53% of male patients (72) and 47% of female patients (63). Cardiac catheterization procedures were considered for diagnostic (59%) and therapeutic (41%) purposes. The average weight of patients was 21.4 ± 1.7 kg (2.0–112.0 kg), and the average age was 5.3 ± 0.4 years (0.0–17.1 years). Interventional cardiology procedures were performed using a GE Innova IGS 530 equipment (GE Healthcare, Milwaukee, WI, USA), manufactured in 2016 and installed in 2017, dedicated to the paediatric population. The necessary data on each procedure was extracted from the Radiation Dose Structure Reports, generated by the equipment at the end of the procedure. This report presents the PKA values for the fluoroscopy mode and the cine mode, total PKA, the fluoroscopy time, the cine time, and IN, as well as other data related to the procedure. The diagnostic reference levels (DRLs) proposed in this study were calculated as the 3-rd quartile of the corresponding distribution. ResultsThe contribution of the cine mode to the total kerma-area product is, on average, 50% though this mode lasted about 4% of the procedure time. Only the fluoroscopy time may be used among the indirect quantities to characterize the contribution of the fluoroscopy and cine modes. ConclusionsThe following local DRLs values are proposed: 2.0 Gy⋅cm2 for kerma-area product in fluoroscopy mode, 1.9 Gy⋅cm2 for kerma-area product in cine mode and 22 min (26 min for therapeutic procedures) for fluoroscopy time. For diagnostic and therapeutic procedures, the local DRLs values may be chosen as 1.5 Gy⋅cm2 and 2.5 Gy⋅cm2 correspondingly in both modes.

Local Diagnostic Reference Levels in Paediatric Interventional Cardiology Procedures in Brazil

Local Diagnostic Reference Levels in Paediatric Interventional Cardiology Procedures in Brazil

Contribution of the Fluoroscopy and Cine Modes to Patient Exposure in Paediatric Interventional Cardiology Procedures

Contribution of the Fluoroscopy and Cine Modes to Patient Exposure in Paediatric Interventional Cardiology Procedures

Radiation Exposure in Pediatric Interventional Procedures.

The article is part of the series of articles on radiation protection. You can find further articles in the special section of the CVIR issue. The expanding applications of interventional procedures coupled with the potential harmful effects of ionizing radiation highlight the need to assess the delivered radiation dose and establish an effective radiation protection program, particularly in the radiosensitive pediatric population. Given the complexity and heterogeneity of interventional procedures as well as the unique characteristics of children, the management of radiation dose is proving to be quite challenging. The aim of the current article is to provide an overview of the radiation exposure in pediatric patients during interventional procedures focusing on the importance of radiation protection in the pediatric population, the reported radiation doses and the techniques of minimizing radiation dose.

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.

Occupational doses to the eye lens in pediatric and adult noncardiac interventional radiology procedures.

To assess occupational lens exposure in a mixed interventional radiology department, comparing pediatric and adult procedures. To analyze the correlation between the lens dose and the doses measured at the chest and collar level and the kerma-area product (PKA ). For 17months, three radiologists performing both pediatric and adult interventions were monitored by means of 14 dosimeters per worker: 12 single-point optically stimulated luminescent (OSL) dosimeters calibrated in terms of Hp (0.07) were placed on the inside and outside of two pairs of lead glasses, one for pediatric procedures and one for adult interventions; another whole-body OSL dosimeter calibrated in terms of Hp (10) was placed over the thyroid shield; finally, an additional active solid-state dosimeter, also calibrated for Hp (10), was worn on the chest, over the apron. Furthermore, a database was created to register the demographic and dosimetric data of the procedures, as well as the name of the radiologist acting as first operator. For the three radiologists, who performed 276-338 procedures/year (20% pediatric), cumulative annual doses to the left bare eye exceeded 20mSv (21-61mSv). Considering the glasses' protection, annual doses exceeded 6mSv (13-48mSv) for both eyes. No important differences were observed in lens dose per procedure between pediatric and adult interventions (0.16 vs 0.18, 0.12 vs 0.09, and 0.07 vs 0.07mSv), although lens dose per PKA was 4.1-4.5 times higher in pediatrics (5.8 vs 1.3, 3.3 vs 0.8, and 2.6 vs 0.6µSv/Gy·cm2 ) despite a similar use of the ceiling-suspended screen. Lens doses were highly correlated with collar readings (with Pearson coefficients [r] ranging from 0.86 to 0.98) and with chest readings (with r ranging from 0.75 to 0.93). However, slopes of the linear regressions varied greatly among radiologists. There is real risk of exceeding the occupational dose limit to the eye lens in mixed interventional radiology rooms if radiation protection tools are not used properly. Regular monitoring of the lens dose is recommended, given lens exposure might easily exceed 6mSv/yr. Using a collar dosimeter for this purpose might be suitable if it is preceded by an individualized regression analysis. The same radiation protection measures should be applied to interventional radiologists regardless of whether they are treating pediatric or adult patients.

The Perioperative Services Response at a Major Children's Hospital During the Peak of the COVID-19 Pandemic in New York City.

The Perioperative Services Response at a Major Children's Hospital During the Peak of the COVID-19 Pandemic in New York City.

Diagnostic Reference Levels, Deterministic and Stochastic Risks in Pediatric Interventional Cardiology Procedures.

To establish diagnostic reference levels (DRLs) and investigate deterministic and stochastic risks in pediatric interventional cardiology (IC) procedures. Exposure parameters were retrospectively reviewed for 373 patients treated between May 2016 and November 2018 at a single specialized hospital. Weight specific DRLs were derived for pediatric IC procedures. Additionally, peak skin dose (Dskin,max) was measured using thermoluminescent dosimeters for a sample of 7 diagnostic and 43 therapeutic procedures. Finally, using PCXMC software, organ doses were computed and the risk of exposure-induced cancer death (REID) was estimated using the risk models of the Biological Effects of Ionizing Radiation VII committee. DRLs for ventricular septal defect (VSD) occlusions, lacking in the literature, in terms of air kerma at patient entrance reference point (388 and 629 mGy) and total air kerma-area product (28 and 61 Gycm) were proposed for patients weight-groups 5 - < 15 kg and 15 - < 30 kg, respectively. The mean (range) Dskin,max was 15 (1-30) mGy and 94 (1-491) mGy for diagnostic and therapeutic procedures, respectively. Meanwhile, VSD occlusion involved the highest organ doses where the lungs, liver, stomach, and breasts mean doses were 57, 37, 6, and 10 mGy, respectively, and the associated REID were 0.5% and 0.3% in female and male patients, respectively. DRLs were proposed for pediatric IC procedures; these will help optimize patient exposure. Dskin,max values were lower than the 2 Gy threshold for skin injuries. Pediatric organ doses and the REID were the highest during VSD occlusion and may be critical for repetitive procedures.

Patient radiation doses in paediatric interventional cardiology and optimization actions

This work presents patient radiation dose data for paediatric interventional cardiology procedures in a large paediatric hospital in Chile. This will contribute to setting national diagnostic reference levels (DRLs) for Chile in the near future. The dosimetric data collection period was from January 2018 to December 2018. The local DRLs were calculated as the 3rd quartile of patient dose data distributions for kerma area-product (Pka) values. The sample of collected clinical procedures (261) was divided into diagnostic and therapeutic procedures and grouped into five weight bands. The Pka differences found between diagnostic and therapeutic procedures were not statistically significant when comparing the same weight bands, as a result of which we propose a single DRL value for both types of procedure. The local DRLs were 4.9 Gy cm2 (<5 kg), 6.6 Gy cm2 (5-<15 kg), 13.7 Gy cm2 (15-<30 kg), 30.7 Gy cm2 (30-<50 kg) and 29.7 Gy cm2 (50-<80 kg), respectively. The conclusion from comparing our results with other existing DRL values is that there is ample scope to continue optimizing by reducing patient dose values. Equipment performance, settings used and examination protocols should be reviewed as corrective actions and adapted to patient weight.

Experience with Compressed Gelfoam Plugs inChildren during Liver Biopsies and Other IR Procedures: A Retrospective Single-Center Case Series.

To analyze the experience using compressed gelfoam plugs (CGPs) in children during liver biopsies and other interventional procedures. This was a single-center, retrospective, consecutive case series of 477 various pediatric interventional radiology procedures using CGPs (January 2012 to December 2016) performed on 397 children (209 males, 188 females; median age, 7 years [range, 9 days-17.8 years]; median weight, 18 kg [range, 2.7-141 kg]). Of 477 procedures, most (n= 371) were liver biopsies, 98 were biopsies of other organs, and 8 were non-biopsy procedures. Analysis focused on liver biopsies. Of liver biopsies, a median of 2 CGPs were used per procedure, and the mean drop in hemoglobin was -0.36 g/dl (-3.0% change). Thirty-seven mild, 8 moderate, 2 severe, and 1 life-threatening (an anaphylaxis to CGP) adverse events (AEs) occurred. Analysis of liver biopsies with AEs showed significant association between number of passes, cores, and focal-type lesions (unadjusted logistic regression: P= .007, P= .022, P= .028, respectively) and age, weight, and number of passes (adjusted multiple logistic regression: P=.006, P= .032, P= .046, respectively). Technical problems relating to CGP deployment were noted in 5 (1%), without any AEs. CGPs were used in a wide variety of procedures and organs in children. There was 1 life-threatening AE resulting from the rare risk of anaphylaxis caused by the gelfoam-containing plug. After liver biopsies, transfusion was required in 2/371 (0.5%) procedures, 1 related to pre-biopsy anemia (0.25%).

Pediatric Traumas and Paradigm Shifts: The Necessary Adaption of the Steerable Microcatheter in Pediatric Interventional Radiology.

The use of traditionally available intra-arterial devices have historically been designed with the adult patient population in mind. Currently, there are not manufactured devices specifically tailored for use during pediatric interventional procedures, pressuring interventional operators to adapt commonplace and readily available devices for interventional management. Experienced interventional operators understand that pediatric and adult interventions can entail vastly different management, affecting patient care and outcomes. To address the pitfalls in pediatric interventional management, an accredited fellowship specifically for pediatric interventional radiology is available. However, devices must equally evolve with the training available in order to adequately address interventional management of the pediatric patient population. Interventional device innovation can be considered the initial step towards bridging the technical and procedural gaps necessary for refining pediatric intervention. The introduction of steerable microcatheters in interventional radiology has innovated procedural protocols, but has never been documented in pediatric patients until this time.

Cone-beam computed tomography guidance with navigational overlay for percutaneous lung nodule biopsy.

Cone-beam CT is increasingly used in pediatric interventional radiology procedures. However, the feasibility or safety of using this mode of imaging guidance for percutaneous lung nodule biopsy in children has not been assessed. To retrospectively evaluate safety and diagnostic accuracy of percutaneous lung nodule biopsy in people treated at a pediatric hospital using cone-beam CT with navigational overlay. Thirty-six consecutive patients from two large tertiary-care children's hospitals with lung nodules of 48mm or smaller underwent percutaneous lung nodule biopsy using cone-beam CT with navigational overlay. We evaluated patient demographics, pre- and post-biopsy diagnoses, number of biopsy passes, complications, radiation exposure and technical success. Percutaneous lung nodule biopsy was performed for 37 nodules in 36 patients (23 males, 13 females, median age 15.5years, range 8months to 23years). One patient underwent biopsy of two nodules at a single procedure. Median patient weight was 55kg (range 8-97kg). Pre-biopsy diagnoses included metastatic sarcoma or other solid tumor (n=11), leukemia/lymphoma (n=13), infection (n=10), chronic granulomatous disease (n=2) and post-transplant lymphoproliferative disorder (PTLD; n=1). Mean number of passes was 5 (range 2-15). Mean pre-procedure international normalized ratio (INR) was 1.1 and platelet count 193 × 109/L. Diagnostic specimens were obtained in 32 of 36 patients (89%). Thirteen complications were encountered in 12 patients (33% of cohort), including 9 pneumothoraces (4 requiring chest tubes); 1 hemothorax, which required a chest tube; and 3 self-limited pulmonary hemorrhages. Mean and median radiation doses were as follows: fluoroscopy time 3min and 2.4min, dose-area product (DAP) (recorded in 31 patients) 23,402 Gy·cm2 and 12,453 Gy·cm2, and air kerma 88 mGy and 58 mGy. Percutaneous lung nodule needle biopsy can be performed accurately using cone-beam CT with navigational overlay.

OA100] Skin and organ doses in pediatric interventional cardiology procedures

Purpose Recent reports on radiation accidents and injuries in interventional cardiology (IC) raised the issue of radiation protection, especially for pediatric patients. This work hence focused on the measurement of skin dose in diagnostic and therapeutic pediatric IC procedures and the estimation of organ doses. Methods Exposures parameters including Dose Area Product (DAP), Cumulative Dose (CD), etc. were retrospectively reviewed for 263 patients undergoing diagnostic or therapeutic IC procedures for a congenital heart disease. These were all taken from a large pediatric hospital responsible for approximately 50% of all pediatric IC activity in the country. Patient age and weight were also collected. Additionally, Peak Skin Dose (PSD) was measured using thermoluminescent dosemeters for a sample of 50 children, 7 diagnostic (DP) and 43 therapeutic procedures (TP). Finally, breasts, lungs, esophagus and thyroid doses were estimated based on DAP-to-organ doses conversion factors available in literature. Results The study included 263 patients divided into 4 groups according to weight: 5 kg with 5 DP and 31 TP, 5– Conclusions Exposures parameters and measured PSD values were very low excluding the risk of skin injuries. The lungs and esophagus involved highest estimated organ doses for both neonate and infant. For patients requiring repeated procedures, accumulated doses will increase the cancer risk in specific organ.