RESULTS: Overall there was an increase of 10,438 proce-dures performed from 1997 to 2001, representing growth of25% within the market. Radiologists performed the greatestnumber of procedures each year. Medical specialties pro-vided the next largest percentage with surgical and all otherspecialties accounting for the remaining procedures. Allspecialty groups saw a rise in the absolute numbers ofprocedures performed. However, Radiologists showed sta-ble or a yearly loss in their market share totaling a five-yeardecrease of 12.2%, while medical and surgical specialtiessaw a yearly gain in market share with a cumulative five-year increase of 7.7% and 3.6%, respectively.

CONCLUSION: Percutaneous peripheral vascular interven-tions are rapidly diffusing within the endovascular market,however, the diffusion has not occurred with equal distri-bution among specialists. There is much speculation regard-ing the market share of these procedures with relativelylittle evidence in the literature to support any claims regard-ing market distribution. Using Medicare data from 1997 to2001, radiology has experienced a relative loss in marketshare, while medical and surgical specialties have seen rapidgrowth. Specifically, Cardiologists and Vascular Surgeonshave realized the largest gains in market share while Radi-ology specialties have experienced declines. The data sug-gest that as clinicians are more willing to broaden andchange their scope of practice, healthcare technology mar-kets will be impacted. Several factors that may play a rolein the expansion of practice are the increase in the providerswilling to supply these procedures, patient referral patternsfor the treatments and managed care reimbursement.

Other: Pediatric Interventions

Abstract No. 447 EE

Complex Interventional Procedures Performed in theNeonatal Intensive Care Unit with a Portable C Arm.P. Stanley, Childrens Hospital Los Angeles, Los Angeles,CA, USA � A. Panigrahy

PURPOSE: To review the experience of performing com-plex invasive procedures with a portable C arm in theneonatal intensive care unit.

MATERIALS AND METHODS: Twelve interventional ra-diological procedures were performed on 7 neonates in theunit using a portable C arm equipped with a vascular soft-ware package. Six were ventilated with high frequencyoscilators and one was on Extra Corporeal Membrane Ox-ygenator. Three diagnostic arteriograms performed for (1)Umbilical arteriovenous fistula in a two day old weighing1348 grams (24 weeks gestational age). (2) Subclavianartery fistula on a five day old weighing 6140 grams whowas on ECMO (3) suspected hepatic artery fistula in a fourmonth old weighing 5715 grams. Therapeutic embolizationsperformed for vascular malformation of the face and scalpat 17 and 18 days of age in a patient weighing 6140 gramsand four times for hepatic hemangioma between 11 and 41days in a patient weighing 4230 grams. Three percutaneousnephrostomy tube placements were performed in two pa-tients (1) Sacrococcygeal teratoma at two days (25 weeksgestational age) weight 1779 grams and twice for cysticrenal disease at three and five days, in a patient weighing2600 grams.

TEACHING POINTS: There were no procedure-relatedcomplications. Four patients were discharged from the hos-pital after further therapy. In patients too fragile to bemoved to an interventional suite, complex procedures can

be performed safley with a portable C arm in the neonatalunit preserving the critical supportive environment.

Abstract No. 448

Triple Agent Sedation: Midazolam, Fentanyl and Ket-amine for Pediatric Interventional Procedural Sedation.M.J. Temple, Hospital for Sick Children, Toronto, ON,Canada � D. Murray � S. Kemp

PURPOSE: The goal of this study is to assess the safety andefficacy of nurse administered, radiologist supervised seda-tion consisting of midazolam, fentanyl and ketamine bo-luses used to perform interventional procedures in children.

MATERIALS AND METHODS: All patients who underwentprocedures and received intravenous midazolam, fentanyland ketamine sedation are reviewed. Data were collectedfrom sedation records, quality assurance forms, patient chartand the ESH-IGT Database. Demographics, vitals, doses,adverse events, postprocedure patient follow-up and proce-dural performance data (fluoroscopy time, room time, abil-ity to perform procedure, procedural complications) wererecorded.

RESULTS: From May 2005 - September 2006, 316 patientsunderwent procedural sedation. 34 patients undergoing bi-opsy (n � 13), central venous access (7), abscess drainage(4), steroid injection (9) and cecostomy tube insertion (1)who received 3 sedation agents are included in the study.Age ranged from 14 m - 16 yrs (avg. 7.4 � 4.3 yrs) andweight from 11-90 kg (avg. 29.3 � 18.9 kg). Patients areASA 1 (n � 13); ASA 2 (15) and ASA 3 (6). Total drugdoses were midazolam 0.07 � 0.03 mg/kg, range 1- 3 doses;fentanyl 1.7 � 0.6 �g/kg, range 1- 5 doses and ketamine0.4 � 0.2 mg/kg, range 1-3 doses. Transient hypoxia treatedwith nasal O2 in 1 patient. Emergence reaction controlledwith midazolam in 2 patients. All procedures performedsuccessfully within 75 minutes (avg. 41 � 14 mins). Therewere no procedural complications. All sedations were suc-cessful. All patients that were questioned after recoverywere either happy with result or amnestic of event. 22/23patients questioned did not remember any pain or the pro-cedure itself. 1/23 patients remembered discomfort/pain butwould undergo sedation again.

CONCLUSION: All sedations were successful. There wereno significant adverse events. Synergistic effect of sedationagents allows potentially lower doses of ketamine with lowincidence of emergence reaction seen. Titration of 3 agentsallows: 1) individualized sedation optimization, 2) avoid-ance of general anesthesia in younger patients, and 3) widerrange of procedures to be performed under sedation.

Abstract No. 449 EE

Selective Unilateral Balloon Bronchial Occlusion in theManagement of Pulmonary Interstitial Emphysema.A. Robinson, BC Children’s Hospital, Vancouver, BC,Canada � M. Heran � G. Culham � A. Singh � D. Ori

PURPOSE: To demonstrate our experience with selectivemainstem bronchial balloon occlusion in the management ofsevere pulmonary interstitial emphysema in preterm neo-nates that have failed more conservative management.

MATERIALS AND METHODS: Retrospective selection ofcases was performed using our RIS-PACS system, identi-fying four cases in the last year. Selective bronchial accesswas achieved via the existing endotracheal tube using a

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floppy-tip wire and after ET tube replacement parallel to thewire, occlusion was performed with different balloons, in-cluding the non-compliant Maverick® Monorail cardiacangioplasty ballon and compliant Arrow diagnostic cardiacwedge balloon. Variations in technique occured between theprocedures, and as experience has grown, preferences forparticular techniques have developed. Post procedurallythere was no compromise in patient oxygenation or venti-lation.

TEACHING POINTS: Selective bronchial balloon occlusionis a safe and effective technique for the management ofpulmonary interstitial emphysema in preterm neonates. Ad-vantages of compliant balloons include not having to accu-rately measure the bronchial diameter, whereas disadvan-tages include their porous nature and difficulty inmaintaining inflation. Advantages of non-compliant bal-loons include ease of maintaining degree of inflation due toattachment of a pressure syringe device, whereas disadvan-tages include having to accurately measure the bronchialdiameter. Although a potential concern for both types ofballoon, no complication arose from balloon migration.Interestingly experience with both types of balloon hasdemonstrated that absolute occlusion is unnecessary as re-sistance to airflow around a partially inflated balloon issufficiently high to cause functional obstruction. Thus asmaller diameter balloon can be used, potentially avoidingpressure necrosis of the bronchial mucosa, or long-termdamage to the structural integrity of the bronchial wall.

Other: Practice Management

Abstract No. 450 EE

Percutaneous Cecostomy: Inpatient Management by In-terventional Radiology. A Nine-Year Experience.M.E. Atherton, University of Arkansas for Medical Sci-ences, Little Rock, AR, USA � C.A. James � S.T. Bhutta � M.B.Moore � P.B. Kuhn

PURPOSE: Evaluate inpatient management protocol by anInterventional Radiology (IR) team in patients undergoingpercutaneous cecostomy tube placement.

MATERIALS AND METHODS: An IR team admitted 71patients undergoing percutaneous cecostomy placement forfecal incontinence over a nine-year period. The cecostomytube placement procedure was successful in all but 2 cases(97.2%). At least 3 daily post-procedure rounds were heldby the IR team including procedure operator, IR coordinat-ing nurse, and IR procedure assistant. Review of a nine-yeardatabase regarding inpatient management of these patientsby the IR team was performed. Parameters prospectivelyentered into the database included length of hospital stay,intravenous (IV) fluid management, electrolyte disturbance,fever beyond 3 days post-procedure, complications requir-ing therapy and consultations of other services. In addition,alterations in the initial IR inpatient admission protocolwere identified.

TEACHING POINTS: Pre-procedure electrolyte abnormal-ities were identified on admission in 43 patients (60.6%).Twenty-four patients (33.8%) required post-procedure IVfluid bolus. Eleven patients (15.5%) developed post-proce-dure ileus requiring nasogastric suction. Eleven patients(15.5%) had fevers beyond 3 days requiring prolonged IVantibiotic therapy. One inpatient abscess cavity was de-tected and drained by IR. Consultation of other services wasrequired in 3 patients (4.2%), 1 for unrelated decubituswound healing and 2 for bowel leakage requiring surgical

treatment. Protocol changes early in the study period in-cluded increased pre-procedure IV fluid maintenance rateand increased presence of the IR coordinating nurse. Pro-tocol changes added beyond the study midpoint includedadding a contrast tube check 2 days post-procedure andconsidering a pre-admission contrast enema in the morecomplicated patients. An IR service can successfully man-age inpatients undergoing percutaneous cecostomy tubeplacement. A majority of post-procedure problems weremanaged successfully by the IR team. Consultation or trans-fer to other services was infrequent but critical in the pa-tients with bowel leakage.

Abstract No. 451

The Experience of Conducting Mortality and MorbidityReviews in a Pediatric Interventional Radiology Service.B. Tuong, Hospital for Sick Children, Toronto, ON, Can-ada � Z. Shnitzer � C. Pehora � P. Choi � M. Levine � B.Connolly, et al.

PURPOSE: To review the experience of conducting M&Msin a pediatric IR setting, the type/range of issues encoun-tered, lessons learned and the impact on patient care ofimplementing recommendations.

MATERIALS AND METHODS: Minutes of the interven-tional M&M Reviews (held monthly since 1997 and at-tended by all team members) were retrospectively enteredinto a dedicated IR database (Esh-IGT) to facilitate theiranalysis. Patient demographics, ASA level, sedation or GA,and procedure type were recorded. Each M&M issue wasassigned to one or more of ten categories (device, manage-ment, medication, patient, procedure, process or sedation/anesthesia-related, ethics, near-miss, other); each wasgraded as major or minor by SIR guidelines. Any recom-mendations made at the M&Ms were assigned to one of 5groups (technical, process, discussion, education, manufac-turer, other), and noted whether implemented or not (yes, noor partial).

RESULTS: 516 patients (294 male, 222 female) were dis-cussed at M&Ms from November 1996 to April 2006, out of31,716 patients seen during the same time period. 230(34%) were procedure-related, 134 (20%) patient-related,104 (15%) process-related, 65 (10%) device-related, 55(8%) management-related, 31 (5%) other, 27 (4%) sedation/anesthesia-related, 11 (2%) medication-related, 8 (1%) eth-ics-related and 9 (1%) were near-misses. There were 323(55%) minor complications (A�220, B�103) and 224(45%) major (C�50, D�178, E�8 and F�27). 27 (5%)deaths were reviewed. There were 350 recommendationsmade in all, 279 (80%) of which were implemented, 38(11%) partially and 33 (9%) were not. 175 (50%) wererelated to process changes, 73 (21%) technical, 50 (14%)discussion, 23 (7%) manufacturer, 28 (8%) education and 1(0.3%) other.

CONCLUSION: Approximately 1.6% of all cases were dis-cussed at M&Ms. A wide variety of issues were discussedthat ranged in severity, including death. The majority ofissues were minor, although a disproportionate number weremajor D (because of the need for GA in children). Manyrecommendations that ranged in scope were made and im-plemented, promoting change in practice. M&Ms provide auseful forum for changes in technique and process, encour-ages input from all team members and improves the deliv-ery of care in a pediatric IR service.

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