Pediatric interventional radiology offers many of the same benefits we’ve come to understand in adult IR. One of the initial differences you’ll see is that the adult IR world is more specialty specific (e.g., interventional neurosurgery or breast imaging procedures). In pediatric interventional, it’s more of a whole-child approach — we do everything from routine diagnostic procedures to innovative therapeutic treatments in almost every part of the body and brain.
Pediatric IR is a niche practice where there’s very little competition but a lot of patient focus. We spend a lot of time being with patients and families, performing procedures in the operative setting, using multiple technologies and imaging modalities, etc. And when it comes to pediatrics, there’s always extended family involvement and decision-making as well.
Since there are only 11 pediatric interventional training programs in the country right now, ours is a unique teaching path and opportunity for Central Florida. Pediatric interventional radiology procedures at Nemours Children’s Hospital (NCH) are currently performed by my team, and I’ve been identified as the only dual-trained pediatric diagnostic and pediatric interventional radiologist in the state. Local demand has been such that we’re adding a second pediatric IR practitioner this summer.
Although most of my referrals still find me based on word-of-mouth, a surprising number come through social media platforms where families have organized disease-specific blogs. I don’t even have a personal Facebook or Twitter; they find me by interacting with each other. And while there’s still an opportunity to educate doctors and patients about what we offer at NCH — even my colleagues are continually learning what we can do with pediatric IR — awareness in our community continues to rise.
Minimally Invasive: A Major Change in Health Care
When I present lectures to colleagues, I usually explain my vascular anomaly title as “tip of the iceberg,” and it’s because I often get calls to consult on patients who present with a small purple pimple or an unusual looking blackhead that turns out to be a venous or lymphatic malformation, respectively. What was initially thought to be “a nothing” can turn out to be something very significant, and it can go from bad to worse very quickly. With IR, I’m able to offer innovative but proven treatment — whereas we used to just have to wait and hope.
IR is a specialty that’s all about taking a minimally invasive approach when possible and appropriate. It offers so many advantages that appeal to families, especially given the types of diseases we deal with. An example is the balls of arteries and veins that you find in a child with vascular anomalies. Taking a scalpel to a problem like that can potentially lead to a lot of complications. So when you can devise other techniques for dealing with these disorders it really shines the light on what minimally invasive means for a patient. Oftentimes it offers solutions where one didn’t even exist before.
The best part of my specialty is the number of unnecessary surgeries, amputations and days in the hospital that can be avoided. Many of the children I see had multiple consults before they got here — as many as 10 different specialists. Suddenly, we’ve got a new solution that changes everything. They’ve seen the difference; lived the difference.
Upping the Risk
When I’m not treating vascular cases, I can frequently be found on the PICU floor. The ability to get stable central access on a very small baby is extremely difficult — a recent patient weighed in at just 900 grams — but through IR, I was able to insert a tunneled central line. It’s not a fancy procedure, but it was something that was potentially life-saving.
This is just one example of how IR can be applied across many specialties to reduce risk. If no one had been available to insert a central line using our techniques, invasiveness would have immediately gone up. The 900-gram baby, for example, would have been treated via incision and a dissection to try to find those tiny little vessels, or by moving to a riskier location. With our technology, no incision was required.
As medical technology gets smaller and less invasive, people are talking — and traveling. Orlando is a great medical tourism destination. Many of the disorders we treat with IR are potentially life threatening or life altering. But they don’t present as an emergency like appendicitis, so there’s time to plan ahead and travel for care. During my time in Boston, we were a busy international destination, with about 30 percent of pediatric IR patients coming from outside the Northeast and often outside the country, mostly Europe and the Middle East; sometimes Asia and Latin America. Clearly, the need is global.
When to Call for IR
Physicians should explore pediatric IR anytime they want to see if a less invasive approach exists. Treating vascular problems is a given, but IR can also help with many other procedures: biopsies, angioplasty catheters, abscess drainage, and tumor destruction via local chemotherapy, cryoablation or radiofrequency ablation. Truly, the opportunity for image-guided treatments is extensive.
Physicians should also reach out for help with procedures they don’t do often for the good of the patient; even “simple” things like a line placement or a biopsy (especially biopsies). We have the pediatric anesthesiologists and pediatric support staff for all of the expected and unexpected outcomes. Our clinic caters to the care of children; everything from our environment to pediatric interventional equipment that’s custom-made by companies to fit helps us help them. So whenever there’s danger of a complication or discrepancy in outcome, it’s better to make a phone call to find out if IR can help.
We’re also involved in a lot of research and teaching. I find that making the time to advance the science encourages more general and subspecialty physicians to refer their patients when appropriate. Whatever our practice looks like, the thing we all have in common is our desire to do what’s best for children.
By Craig Johnson, DO
Craig Johnson, DO, Director of Pediatric Interventional Radiology, joined Nemours from the Children’s Hospital of Wisconsin where he served as the Director of Interventional Radiology and built the fifth largest volume practice in the United States in a short period of time. Dr. Johnson ran a large service for children with vascular malformations. He is the first physician fellowship trained in both pediatric and pediatric interventional radiology in the State of Florida. In 2012, he received an award from the American Society of Neuroradiology for his expertise in vascular malformations. He is fluent in English and Spanish.