Introduction Cerebrovascular intervention in children is often challenging due to the small size of the parent vessels. However, complex interventional cases still often require guiding catheters with a sizeable lumen and reasonable support. We review our experience with pediatric neurointervention over the last 1.5 years at Vanderbilt Children’s Hospital to identify pediatric-specific access systems that provide optimal lumen diameter and support.
Materials and methods We performed 82 pediatric cerebrovascular interventional procedures in children ages 8 days to 17 years since July 2013. These procedures included diagnostic cerebral angiography (48), Wada testing (4), tumor embolization (2), AVM embolization (10) aneurysm embolization and flow diversion (5), intra-arterial chemotherapy (12), and arterial sacrifice (1). These cases were reviewed to identify pediatric-specific access platforms for intracranial intervention.
Results For diagnostic angiography, a 4 French Terumo Glide catheter was used for all patients ages 7 and younger. A 4 French or 5 French Glide catheter was used in patients older than 7. For therapeutic intervention in children less than 5 years old, a 4 French transfemoral access system was always used. In infants, a 4 French micropuncture system was often used as the sheath, with subsequent direct navigation with the microcatheter. In toddlers, a 4.3 French DAC is used with a 4 French groin sheath. The DAC is steam-shaped to obtain a hockey stick configuration, allowing selection of the great vessels. In children ages 6 and older, a 5 or 6 French access system may be used. Five French guiding catheters used were the Cordis Envoy or the Concentric DAC (again steam-shaped). Six French systems included the Cordis Envoy, Penumbra Neuron, and Cook Shuttle Sheath. On one occasion a 4 French Terumo Glide catheter was used for internal carotid artery access in an infant, which was complicated by vasospasm. This was treated with nitroglycerin and resolved. No other complications related to the guide system were encountered.
Conclusion Guide catheter access systems are key to successful procedures. Using systems with adequate support and lumen diameter is important, particularly in procedures using parallel catheters such as balloon-assisted technique, or with flow diversion deployment. In our experience at the Vanderbilt Children’s Hospital Cerebrovascular Program, we have found that children over age 5 can usually tolerate 5 or even 6 French guide systems when needed. We report separately that the size of the cervical vessels grows rapidly until approximately age 5, at which point they are near-adult size (Ladner et al ., submitted). In younger patients, we often utilize a 4.3 French Concentric DAC with a steam shape, which can be used with a 4 French groin sheath. We find that the 4.3 French DAC provides welcome support, particularly in small children, without causing much vasospasm or arterial deformation, and thus we now often use this rather than primary aortic navigation with the microcatheter.
Disclosures M. Froehler: None.
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