What types of treatments does interventional radiology offer?
While we occasionally provide interventions to children with vascular tumors, the majority of our patients have vascular malformations. For example, one of the most common indications is sclerotherapy for venous malformations. Diode laser can also be used for some types of venous malformations. For a lymphatic malformation, sclerotherapy is effective to shrink deep lesions. CO2 laser evaporation is used to treat lymphatic skin disease.
In some patients who have unusual or atypical malformation, tissue biopsy can be done with image guidance.
We also can do some prophylactic work in these patients to prevent problems that can occur during or after other interventions. For pre-operative work prior to surgical resection, for example, an IVC filter can be placed to prevent clots from moving into the lungs. We can also do angiography, which is mapping out the blood vessels anywhere in the body. Arteriovenous malformations are abnormal connections between arteries and veins and can be very challenging to treat. Embolization, which means closing those abnormal connections between the arteries and veins, is the initial treatment of choice for most lesions. It is done by navigating through the blood vessels using small microcatheters and other small tools to close the connections.
The advantage of the interventional therapy is mainly its minimally-invasive nature without surgical cutdowns and faster recovery.
Ahmad Alomari, MD, MSc, FSIR
How do you decide what treatment to recommend?
There are many factors to consider here. The type, severity and location of the malformation as well as the age are major factors which guide the approach, type of intervention, how many times we need to do it, and the tools we’re going to use. Different malformations respond differently and not all the malformations will benefit equally from the same approach. The approach is tailored based on the need of the patient, efficacy and risk. Some malformations are simpler to treat with minimal risk while other ones may require sophisticated plans, multiple teams with combined operative approach or may carry some higher risk.
Ahmad Alomari, MD, MSc, FSIR
How do you decide what symptoms to treat?
The child’s perspective is crucial. Massive parts of the malformation could be initially less pressing than a tiny spot at the bottom of the foot that hurts each time the child walks. “That big deformity of my spine has been there since birth, but I can walk now.” One may not see the perspective of the child and the family without talking to them in comfortable environment and provide them with enough time to express their concerns. That’s how we prioritize treatment; then a consensus is made as to how address the other issues that can carry risk or morbidity if they are left untreated. Families understand and appreciate this approach remarkably quickly.
Ahmad Alomari, MD, MSc, FSIR
What is sclerotherapy?
Generally speaking, for the slow-flow malformations such as venous and lymphatic malformations, the treatment of choice to start is something called sclerotherapy. We inject a sclerosant, which is something that induces scarring, essentially, over time. It initially can cause a lot of swelling, but then eventually we try to convert the lesion from a fluid-filled structure (filled with either blood or lymph) into a scar. That usually takes down its volume, and it almost always improves the symptoms. Sometimes that may be followed by surgery to actually resect it or do some plastic surgical type of improvement, sometimes not.
Darren Orbach, MD, PhD
What do you do during sclerotherapy?
What we effectively do is to put a small needle into the channels under ultrasound. We’ll inject contrast to confirm our position using a combination of ultrasound and fluoroscopy, and then with the same needle or catheter we inject our sclerosant, which is predominantly ethanol or sodium tetradecyl sulfate. We inject those directly into the channel and we try to keep the sclerosant in the malformation without it draining out. … The aim is to try and reduce it and scar it and reduce it in size… It’s chemical irritation. It’s chemical inflammation of the endothelium, which is the cells lining the malformation and causing a lot of inflammation which then causes it to scar.
Gulraiz Chaudry, MB, ChB, MRCP, FRCR
How does sclerotherapy work?
We’re basically invoking the body’s mechanisms to form scar by injecting these malformations. It irritates the insides of the malformations; it irritates the blood vessels and channels, and that triggers the body’s inflammatory reaction of which the end point is formation of scar. What happens then is scar tissue forms which will basically glue these abnormal channels together so they don’t fill with lymph, they don’t fill with blood, and it just diverts into the normal vessels.
That being said, the body doesn’t work instantaneously with these things. You start the reaction, but then you have to give the body a chance to create the reaction and form the scar tissue. That takes time. And sometimes you have to be repetitive because we can only treat what we can see. Sometimes what happens is you treat one area that you can see, then that blood and fluid divert into the areas that you can’t see and you have to treat that again.
Horacio Padua, MD
How do you decide when to do sclerotherapy?
The treatment is dictated more by the type of malformation rather than the location… [We mostly sclerose] venous and lymphatic malformations. The lymphatic, in particular the large macrocystic lymphatic, respond wonderfully well to sclerotherapy; they’re easy basically because you can drain those out, it’s like a big sac you put those in. Microcystic lymphatic don’t tend to respond very well, unfortunately, and those are still slightly quite challenging.
Gulraiz Chaudry, MB, ChB, MRCP, FRCR
What are the most common questions around sclerotherapy?
Parents want to know, “How long is my child going to be out of school?” A lot of times, patients can be back in school within 48 hours. This is about as minimally invasive as you can get in terms of procedure, and what I tell parents is you can really just ad-lib it. If they don’t feel like going to school after about 48 hours, I’d probably keep them out of school, but anything beyond that you should give me a call because our experience is most kids can literally, within 24 hours, get back into their normal routine. So that tends to be a common question.
“How long is this going to take?” Usually most procedures are day surgery procedures and if they’re of average complexity, probably about two hours. If they’re really complex, it could be around five or six hours, but usually those patients stay in the hospital after, so those patients can plan on staying, and we’ll continue tomorrow, even after a long procedure.
Horacio Padua, MD
What happens before an IR procedure?
There’s an interventional radiologist who’ll evaluate you if there’s going to be an interventional treatment. You’ll probably be scheduled for treatment at that point. On the elective list, the wait can be long depending on how complex your lesion is and who’s treating it. Certain physicians have their own niche of what they treat so that dictates how long you’ll have to wait to get into treatment.
If we’re intending to admit you after the procedure, you’ll have to come into the hospital to do a pre-op visit where you’ll see the anesthesiologist, and you’ll meet the nurse practitioners as well. You’ll be evaluated at that point prior to the appointment time for the procedure. Occasionally we can do the procedure as a same-day procedure where you’ll come in, get your evaluation that day, your anesthesia workup that day, and then have your procedure that day, but that’s usually when you’re also going to go home that day, which I would say is about 60-70% of the time. It’s going to be what we call a day-surgery procedure, so you get your entire workup and everything gets done in one day. If it’s a more complex procedure and it looks like you’re going to have to come into the hospital at least for observation, then you’ll probably have a separate appointment for a pre-op visit prior to coming in for the actual procedure itself.
Horacio Padua, MD
What happens on the day of the procedure?
On day of procedure, you come in and meet the staff you’ll be working with (the treating physician, anesthesiologist, all the house staff, the nurse practitioners who’ll be following you up after, the nurses who’ll be managing you while you’re in the procedure room)… After that you get your workup, we explain the procedure to you, and then we’ll have you sign a consent form. From there you’ll move into our treatment room, you’ll be put under the anesthetic, and you’ll have your procedure done. You’ll wake up in the recovery room, and then depending on how we protocol the procedure, you’ll stay until you’re awake enough and you’ll either go home that day or else you’ll be transferred up to the floor for your 24-hour observation.
If you have lesions in particular areas, particularly around the airway, we may admit you to the intensive care unit, and that’s so we’ll have good one-on-one, 24/7 monitoring because we want to make sure the airway stays open and stays under control. That’s the one category of lesions that we’re very careful with, lesions that are in the neck and involve the airway. Neural cases, cases in the head and neck and in the brain itself are the other categories of these lesions that usually end up in the ICU rather than the floor.
Horacio Padua, MD
What happens after a procedure?
Once you get past the periprocedural point and you’re discharged from the hospital, we typically see patients in clinic about 6-8 weeks after the procedure. At that time, we’ll do ultrasounds and/or more advanced imaging on top of that, and then we’ll say, “Are things going in the right direction? Are the symptoms resolving? Are things getting better? Are things getting worse?” We then decide if we need to schedule another procedure or if we need to monitor for a longer period of time, or we can just say, “You’ve got good control right now, see you next time when you have a problem.” That’s the usual case. Sometimes once a patient gets beyond that point, they’ll call me in a month saying, “Oh, I’m having problems again.” Sometimes I’ll see a patient that I haven’t seen in several years. It’s something of an open-door policy, because once we’ve seen a lesion, we’ve sort of gotten a handle on what that particular lesion is going to do, how it’s going to respond. We know the inherent nature of these things is for them to grow back and recur, so we always leave the door open.
Horacio Padua, MD