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In comparison to adult IR, most of these common procedures require only minor variations in technique and equipment to accommodate the smaller size and more delicate tissues of pediatric patients. However, there are other IR procedures that are more specific to pediatric practice based on the unique physiology of the pediatric patient. Additionally, pediatric IR cases also encompass treatment of a larger proportion of congenital lesions as compared to adults. Sclerotherapy of vascular malformations congenital malformations of lymphatic vessels, veins, and arteries while not specific to pediatrics, is most commonly performed early in life.

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Lymphatic malformations contain serous fluid with varying amounts of internal hemorrhage and are often treated with drainage or aspiration and injection of sclerosant agents such as doxycycline or bleomycin Figure 1. Venous malformations on the other hand are not aspirated and are generally injected with foamed sotradecol. Precise placement of the proper sclerosant agent is essential especially if the malformation is in a critical area such as in the orbit or near the airway.

High flow malformations that involve connections to arterial supply are most commonly treated with precise navigation of a catheter or needle to inject ethanol or embolic agents to occlude the nidus.

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Following sclerotherapy, the vascular malformation often increases in size for a week or two due to inflammation. Follow-up is planned in a few months to give the lesion time to scar down and allow time for new or untreated areas to develop. Larger or more complex vascular malformations frequently require multiple treatments. Newborn male with left axillary lymphatic malformation. T2 MR imaging in neonatal period demonstrates a large multilocular cystic lesion in the left axilla with predominantly high signal and heterogeneous areas of low signal suggesting hemorrhage.

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Flouroscopic image from initial sclerotherapy treatment demonstrates multiple drains white arrows with contrast black arrows in loculated cystic areas. Sclerotherapy was performed through the drains. Ultrasound Image from initial sclerotherapy demonstrates a needle white arrow advancing into the loculated cystic mass.

T2 MR imaging 14 months post multiple sclerotherapy treatments demonstrates decreased cystic areas with residual scar tissue which was subsequently removed at surgical debulking. In addition to congenital lesions, lymphatic collections may also be acquired due to disruption of lymphatic channels, most commonly following thoracic surgery for congenital cardiac anomalies. Lymphatic leaks are notoriously difficult to stop and the first step in treatment is defining the location of the leak.

Recent advancements in fluoroscopic and MR lymphangiography provide excellent detail of the lymphatic system and often define the location of a leak.

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In some cases where the leak arises from small diffuse lymphatic channels, fluoroscopic lymphangiography with lipiodol may even be therapeutic as the viscous and mildly sclerotic contrast agent can occlude small lymphatic channels. Alternatively, after the leak is located, it can be occluded with glue or coils through a catheter placed percutaneously into the thoracic duct. In cases where the duct is too small to cannulate, imaging can help guide an open surgical closure.

There is an ever-increasing role of the pediatric IR physician in the treatment of children with malignancies. This ranges from image guided biopsy procedures to procure necessary tissue for diagnosis to more advanced direct tumor therapies. Pediatric IR physicians also play an important role by placing vascular access devices in children such as PICCs, tunneled lines, and port catheters for oncology therapy.

Pediatric types of cancer such as lymphoma also present unique challenges with opportunities for IR intervention. This presents a challenging clinical scenario in which a diagnostic biopsy is needed prior to treatment and yet treatment would be helpful in decreasing the mass effect to facilitate safer biopsy. Often, biopsy is safely performed prior to treatment with ultrasound guidance, local anesthetic, and minimal sedation Figure 2.

Three year-old female with lymphoma resulting in anterior mediastinal mass. CT of the chest demonstrates a large anterior mediastinal mass resulting in mass effect on the major mediastinal vessels white arrow and mass effect on the left mainstem bronchus black arrow. Ultrasound image from biopsy with minimal sedation to decrease risk of cardiopulmonary compromise demonstrates the biopsy needle white arrow within the mediastinal mass.

Metastatic disease in pediatrics has traditionally been treated with chemotherapy or surgery. However, percutaneous ablation and transarterial chemoembolization which are becoming more common in adult oncology are now being employed in cases of inoperative pediatric metastatic disease.