Interventions in the Chest in Children

Derek J. Roebuck, FRANZCR,* Mark J. Hogan, MD, Bairbre Connolly, MD, and Clare A. McLaren DCR(R)*
The scope for image-guided intervention in the chest is very wide and encompasses procedures in the heart, pulmonary and systemic vasculature, lungs and pleural cavities, airway, and esophagus. This review describes the most important procedures that are usually performed by radiologists. Percutaneous drainage is now the most common method of treating both empyemas and lung abscesses in children. Although most lung biopsies are carried out by other means, percutaneous biopsy and localization are important alternatives for the diagnosis of focal lung lesions. Esophageal strictures are common in children and are usually best treated by balloon dilatation. The use of retrievable or biodegradable stents has recently been introduced for refractory esophageal strictures. Similarly, balloon dilatation and stenting are now increasingly used in children with stenosis or extrinsic compression of the trachea or bronchi. Tech Vasc Interventional Rad 14:8-15 2011 Elsevier Inc. All rights reserved. KEYWORDS interventional radiology, empyema, lung biopsy, esophageal stricture, airway, dilatation and stenting

Empyema and Lung Abscess

Pneumonias in children can be complicated by pleural effusions, empyemas, and abscesses. Image-guided techniques are a valuable and nonoperative alternative with high success and low complication rates.1-4

Percutaneous drainage of abscesses is indicated when standard treatment fails, or preoperatively to reduce the risk of intraoperative spillage.

Procedural Steps
Appropriate sedation or general anesthesia (GA) is essential. For drainage of empyema, the patient is placed supine, with the affected side slightly elevated. In patients with lung abscess, there is a risk of spillage of pus into the unaffected lung, so tilting is not used. US determines the best site for access, and we use a 5- to 8-MHz curvilinear transducer with a small footprint. The midaxillary line allows for posterior tube placement without the patient having to lie on the tube. Focal collections may dictate the access site; however, with loculated pleural collections, a single access is usually sufcient when combined with brinolytics. Local anesthestic is used liberally up to 1 mL/kg of 1% lidocaine or 0.25% bupivacaine. The US probe is placed over the intercostal space, with the axis parallel to the ribs. A needle is advanced directly over the superior margin of the rib, to avoid the intercostal vessels which run under each rib, into the pleural space (Fig. 1). A wire is positioned posteriorly with uoroscopy, the tract dilated, and a pigtail catheter placed. Although 12-Fr catheters are most commonly used at our institution, smaller tubes may be used in infants. The patient is transferred back to the oor on water seal or with the drain closed, and attached to a

Clinical Symptoms and Indications

Chest radiographs can suggest an effusion. Ultrasound (US) can conrm the presence of uid and may identify underlying pulmonary abscesses.5 Although CT can identify uid, abscesses, and necrosis, it requires radiation, so use should be limited to only when absolutely needed.6 Drainage indications include signicant pleural uid (1 cm width), combined with an oxygen requirement, persistent fever, complex uid collection on US, or need for culture. Whereas serial pleurocentesis may be indicated in adults, children need sedation each time, and multiple procedures result in an unacceptable sedation risk. At our institution, unless the procedure is for diagnosis only, a tube is placed primarily.

*Department of Radiology, Great Ormond Street Hospital, London, UK. Section of Vascular and Interventional Radiology, Nationwide Childrens Hospital, The Ohio State University, Columbus, OH. University of Toronto, Hospital for Sick Children, Toronto, ON, Canada. Address reprint requests to Derek J. Roebuck, FRANZCR, Department of Radiology, Great Ormond Street Hospital, London WC1N 3JH, UK. E-mail: RoebuD@gosh.nhs.uk

1089-2516/11/$-see front matter 2011 Elsevier Inc. All rights reserved. doi:10.1053/j.tvir.2010.07.004

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9 gression of the necrotic pneumonia, and usually resolve with prolonged drainage at higher suction (up to 40 cm H2O).

Lung Biopsy
Lung biopsies in children are most commonly indicated for focal lesions, rather than diffuse parenchymal pathology. Diagnosis of benign lesions (eg, infection, inammation, granuloma) or malignant lesions (metastases, primary tumors) frequently require core tissue; occasionally ne needle aspiration sufces.7

Clinical Indications
Biopsy is only indicated if determining the nature of the lesion will change patient management and the benets outweigh the risks. Contraindications include uncorrectable coagulopathy, lack of safe trajectory, or prohibitively high comorbidities (eg, for safe anesthesia). Image-guided percutaneous biopsy is only one option. Alternatives include bronchoalveolar lavage, transbronchial biopsy, or surgical/thoracoscopic biopsy. The choice is determined by the need for complete excision rather than sampling, amount of tissue required, imaging appearances, and comorbidities, and is made on a case-by-case basis.7

Figure 1 A needle (large arrows) is inserted to drain empyema using US guidance. There are multiple loculations separated by brinous septa (small arrows).

standard chest drainage system at 20 cm H2O. A specimen is sent, but completely aspirating the space too rapidly at the time of drain placement may provoke uncontrollable coughing or reexpansion pulmonary edema and should be avoided. The technique for abscess drainage is similar to that for empyema; however, tube placement across normal lung or ssures is avoided. US guidance is used when possible; however, CT or uoroscopy may be needed. Unless the effusion is anechoic (rare), we start brinolytics. The dose of tissue plasminogen activator (tPA) is 2 mg in 20 mL of saline, but can be halved for children less than 10 kg.2,3 An alternative dose is 0.1 mg/kg (maximum of 3 mg).1 The tPA is injected into the tube, which is clamped for 1 hour, and then suction is resumed. This is repeated every 12 hours for a total of three doses.

Procedural Steps
GA is frequently required and must be planned with the anesthetists in advance. Previous imaging is examined to plan which lesion to target, the safest trajectory, the best imaging modality, and which needle to use.7 Supercial lesions abutting the pleura are amenable to real-time US-guided biopsy even if very small (eg, 2 mm).8 US performed by the interventionalist before the procedure will conrm visibility of the lesion. Except for large lesions, most US-guided biopsies are performed under GA with breath hold in the phase of respiration that permits the best lesion visibility (ideally end expiration, with or without positive end-expiratory pressure). Using a curved (eg, 8 MHz) or linear (eg, 12-15 MHz) probe, an automated needle is advanced to the pleural edge and red through the lesion (Fig. 2).8 Lesions with any overlying aerated lung will not be visible by US, but may be suitable for CT-guided biopsy or localization.9 The safest trajectory is chosen, avoiding major blood vessels and pleural interfaces. A coaxial technique may be used. Repeated thin axial images are obtained as the needle is advanced to the edge of the lesion and then red. Additional images are performed at the end of the procedure to assess for complications. Percutaneous localization (Fig. 3) is performed if the lesion will not be visible thoracoscopically, complete excision is required, or the potential diagnostic yield is considered too low by needle alone due to lesion size. The lesion is localized using US or CT. Using a 25-gauge needle and T-piece, approximately 0.5-1 mL of a mixture of the patients blood and methylthioninium chloride (methylene blue, 10:1 ratio) is injected at the supercial edge of the lesion to ensure thoracoscopic visibility. A localization needle may also be de-

Clinical Follow-Up
US is performed after brinolytics. If the uid has resolved, we follow tube output and chest radiographs daily, and remove the tube when output is 25 mL/d. Fibrinolytics continue if uid remains or recurs. At 72 hours, if the patient remains symptomatic, the patient is referred for CT to identify pulmonary abscesses.

Expected Outcomes
Success rates for empyema are 74%-99%, with a hospital stay of 6-20 days.1-3 Our success rate is now 94%, improved from 89% early in our experience, when failures were due to delayed or inadequate brinolytic treatment.2 For abscesses, the success rate is 71%-100%.3

Complications
Complications include bleeding, vascular injury, bronchopleural stula (BPF), anesthesia or sedation complications, and death. These are all rare, with one published report of a death from hemorrhage.6 BPFs are almost always due to pro-

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Figure 2 A 6-year-old patient with known rhabdomyosarcoma of middle ear. (A) Axial CT (2.5-mm slice) shows a small complex peripheral nodule posteriorly in the right lung, with overlying rib and scapula. Peripheral component adjacent to pleura measures 2 mm. (B) US image of area (8 MHz curvilinear probe) with arm rotated anteriorly demonstrates the supercial component of the lesion as a hypoechoic nodule interrupting the echogenic line of the pleura. (C) The lesion was then amenable to ultrasound guided percutaneous biopsy using an 18-gauge Biopty needle (Bard Peripheral Vascular, Tempe, AZ). Histology conrmed metastatic rhabdomyosarcoma.

ployed.10 The lesion is then resected by the surgeon under the same GA.10,11

Clinical Follow-Up and Outcome

An erect chest x-ray is performed about 1-2 hours after biopsy. A ward visit (inpatient) or follow-up phone call (outpatient) is indicated. A diagnostic biopsy is obtained in about 85% of procedures.7,8

Overcoming Technical Challenges

Development of a tiny pneumothorax during a US-guided biopsy, although not clinically signicant, may interfere with lesion visibility. Tilting the patient allows the free air to move out of the way, restores visibility, and permits completion of the procedure. Manipulation of the depth of respirations by the anesthetist can move a problematic lesion from behind a rib and make it accessible. Difcult lesions under the scapula may be accessed by repositioning the arm (Fig. 2). Lesions with a high chance of bleeding (eg, hypervascular, adjacent vessels) require preprocedure planning (eg, protection by contralateral single lung ventilation or placement of a bronchial blocker into the ipsilateral bronchus).

Complications
Pneumothorax is common (about 10%-15%) but usually requires no treatment.7,8 Air may enter the pleural space from the lung or from outside through the coaxial needle. Occasionally (2%), a chest tube is required.7 Small-volume hemoptysis is common,7,8,12 especially from central lesions or those adjacent to a bronchus. Life-threatening hemorrhage is rare, except in immunosuppressed children with fungal infection.12 Inadequate tissue sampling or difcult pathology may yield a nondiagnostic result.8,13

Figure 3 A 12-year-old patient with Ewing sarcoma of the femur. (A) Axial CT of the chest (2.5-mm slice) shows a 2.5-mm lesion posteriorly in the right lung. The lesion is not visible by US because of overlying aerated lung. (B) Methylthioninium chloride (methylene blue) mixed with autologous blood was used to tattoo the lesion. (C) The lesion was visible at thoracoscopy and was resected. Histology showed this to be a granuloma.

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Esophageal Intervention
Esophageal strictures are a common problem in childhood. They are almost exclusively benign; the most common causes worldwide are anastomotic narrowing (following surgery for esophageal atresia) and corrosive ingestion. They may be treated by balloon dilatation and/or stenting.

Clinical Symptoms and Indications

Dysphagia is not always due to a stricture, and a contrast study may be helpful before the rst dilatation. In children with known strictures, the need for dilatation is determined by the severity of the dysphagia.

Procedural Steps
Esophageal dilatation can be performed under sedation, but may lead to airway obstruction or a severe vagal response, and is easier with GA. The esophagus is accessed with a curved-tip catheter (5-Fr BMC; Cook Medical, Bloomington, IN), and dilute contrast injected (Fig. 4).14 Any guidewire can be used, but a oppy-tipped, 0.89-mm (0.035-inch), hydrophilic wire (Roadrunner; Cook Medical) is useful to cross difcult strictures (Fig. 4). The balloon size is based on the size of the patient and the cause and severity of the stricture.14 The target balloon diameter should be about the same as the diameter of the normal distended esophagus, or between 8 and 18 mm for most children. In some children (especially those with corrosive or reux strictures), it is best to dilate progressively at two or more separate procedures, and accept a less ambitious nal diameter. A much larger balloon (or two balloons side by side) will be required in achalasia.15

Figure 5 A 15-year-old male with autosomal recessive dystrophic epidermolysis bullosa (EB). Access to the esophagus from above was difcult due to restricted jaw movements. A 20-mm balloon catheter was inserted through his gastrostomy. Ination conrms the typical tight stricture, which is often seen in patients with EB at about the level of T4 (arrow).

Overcoming Technical Challenges

When it is not possible to cross an esophageal stricture from the mouth, a retrograde approach (via a gastrostomy) is almost always successful (Fig. 5). Complete occlusions can usually be crossed with a guidewire, but if necessary, sharp recanalization with a needle may be attempted.16 When the stricture can be crossed but the balloon cannot be fully inated, a cutting balloon may be used.17

Clinical Follow-Up and Procedural Outcomes

The success of dilatation is strongly dependent on the etiology of the stricture. A durable improvement in symptoms is usual in children with anastomotic strictures. Patients with dystrophic epidermolysis bullosa, by contrast, may require lifelong treatment. A program of repeated dilatations at progressively increasing intervals is often successful in children with corrosive strictures. There remain some patients, however, with refractory or recurrent strictures, in whom the search for alternatives to major surgery continues. One idea is to apply mitomycin to the stricture, either on a cotton pledget or by using a porous balloon. Another is to use retrievable or bioabsorbable stents.18-20
Figure 4 A 3.5-year-old male with corrected esophageal atresia and tracheoesophageal stula. (A) Contrast in the esophagus shows a tight anastomotic stricture (white arrow). The radio-opaque markers on the 14-mm balloon catheter (black arrows) conrm that it is centered on the stricture. (B) The balloon has been completely inated, dilating the stricture.

Complications
Intramural dissection of contrast is sometimes seen during balloon ination. This is asymptomatic and requires no treatment. Esophageal perforation by the guidewire alone can be treated by admission to hospital and observation. Rupture of the esophagus during balloon ination is a feared but rare

12 complication, occurring in 1% of procedures overall. It is usually treated conservatively,21 with close observation, antibiotics, intravenous uids, and often by passage of a nasojejunal tube over the guidewire to allow enteral feeding. Empyema or pneumothorax should be drained percutaneously. Surgical repair of the perforation is infrequently required.

D.J. Roebuck et al
the larynx, the entire trachea, and the major and segmental bronchi. Assessment of tracheobronchomalacia requires that the patient be breathing spontaneously. If these procedures are performed in a biplane angiography suite, it is possible to obtain high-resolution bronchography by injecting low-osmolality nonionic contrast, such as iohexol (Omnipaque 240; Nycomed, Nycoveien, Norway) through the working channel of the bronchoscope.22 Alternatively, if the child is intubated, a 5-Fr biliary manipulation (BMC; William Cook Europe, Bjaeverskov, Denmark) or similar catheter is used to introduce contrast into the airway. We use small aliquots (0.2-0.5 mL) and repeat as required. Assessment of tracheomalacia is facilitated by performing a dynamic study with a rapid frame rate and biplane acquisition.22 A manometer placed in the breathing circuit can accurately assess the airway opening pressure. A sample of airway secretions should be aspirated and sent to the laboratory for analysis. Although muscle relaxants are not essential for balloon dilatation and stent insertion, paralysis probably reduces the risk of pneumothorax (see below). Intravenous steroids (eg, dexamethasone 0.25 mg/kg) are often given empirically to try to reduce postoperative edema. Bronchography is particularly useful for obtaining measurements of the airway to select the size of balloons and stents and to aid their accurate placement. The technique of balloon dilatation is broadly similar to angioplasty. Once the area of stenosis has been delineated, a standard 0.035-inch guidewire is passed though a valved connector in the anesthetic circuit, and its tip is advanced to an appropriate bronchus using uoroscopic control. A standard angioplasty catheter is passed over the wire, and the balloon is rapidly inated by hand until the waist is abolished, then deated and removed.22 Some stenoses require the use of high-pressure balloons and an ination device. Cutting balloons have not been widely used in the airway because of concerns about bleeding. When a stenosis occurs at or very close to an airway bifurcation (eg, the carina), it is best to use a kissing balloon technique to minimize the risk of airway rupture (Fig. 6).22 Selection of stent type is complex and depends on the size and prognosis of the patient and the nature and location of the obstruction. Silicone stents (Dumon; Novatech, Aubagne, France) are unpopular in small children, mainly because they partially occlude the airway and sometimes migrate,23 but newer, thinwalled designs may reverse this trend. There is only limited experience with a plastic self-expanding stent (Polyex; Rsch, Kernen, Germany).24,26 Most centers now use metal stents. These fall into two broad categories. Balloon-expandable metal stents are rigid but have the advantage that they can be postdilated as the child grows. They are mostly used for recurrent tracheal or bronchial stenosis following surgery. Self-expanding metal stents are much more exible and therefore less likely to cause vascular erosion. They are suitable for relieving bronchial compression in selected patients. Self-expanding stents cannot be effectively postdilated and may, with growth of the patient, become limiting. They are very difcult to remove and are therefore most often used in children with a poor long-term prognosis.

Airway Intervention
Children with complex airway problems are best managed by a multidisciplinary team, including pulmonologists, surgeons (cardiothoracic and ENT), and intensivists.22 These patients can be particularly challenging, especially to radiologists unfamiliar with this eld. Certain simple tips may be helpful for the occasional practitioner (Table 1).

Clinical Symptoms and Indications

Children with airway obstruction present with symptoms ranging from stridor to dying spells, or may be ventilatordependent. In some cases, tracheal stenosis is noted at the time of attempted intubation for cardiac or other surgery. Airway obstruction may be due to stenosis, malacia (softening of the wall causing expiratory collapse), extrinsic compression, intraluminal lesions or material, or a combination of these. Careful assessment is required to evaluate each segment of the airway for the presence of these factors, and this often requires a combination of bronchoscopy, echocardiography, and cross-sectional imaging.22 Balloon dilatation and stenting are most applicable to the treatment of stenosis. Although balloon dilatation of congenital tracheal stenosis has been reported, the standard treatment is slide tracheoplasty. In acquired stenosis, surgery should only be contemplated when balloon dilatation has failed to achieve an adequate clinical response. Metal airway stents should be regarded as a last resort, to be used when surgery has failed or is impractical.22-25 Stenting also has a limited role in the treatment of malacia and extrinsic compression. The recent introduction of retrievable and biodegradable stents may broaden the indications in the future.

Procedural Steps
In general, exible bronchoscopy is best performed under GA via a laryngeal mask airway. This permits evaluation of
Table 1 Tips for Successful Pediatric Airway Intervention

Work as part of a multidisciplinary team A combination of bronchographic and bronchoscopic guidance works bestthe operator(s) should be skilled in both techniques Use kissing balloons for stenoses at airway bifurcations Permanent metal stents should only be used as a last resort Give careful thought to the best type of stent to use (balloon-expandable, self-expanding, retrievable, biodegradable) Premounted balloon-expandable stents may have a reduced capacity for postdilatation check this before inserting them

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Figure 6 A 14-month-old male with idiopathic carinal stenosis. (A) Bronchography shows involvement of the trachea (black arrow) and left (long white arrows) and right (short white arrow) main bronchi. (B) Kissing balloon dilatation was performed using 5-mm (right bronchus) and 4-mm (left bronchus) balloons. (C) The dilatation was repeated at the age of 23 months due to recurrent stenosis. He was asymptomatic at the age of 3.5 years; bronchography shows considerably improved appearances.

The technique of stent insertion is similar to balloon dilatation (Fig. 7). The stent size is chosen by taking measurements from the bronchogram or, more accurately, by test ination of an angioplasty balloon of the estimated size in the stenosis. Accurate deployment is critical, so these stents should not be placed without bronchographic guidance.22 Coverage of a bronchial orice by a bare stent is not contraindicated but is undesirable. When placing a stent in a main bronchus, it is often useful to leave a small length protruding into the trachea in case removal is required.

stenting, to evaluate for granulation tissue formation and other complications. Some children require infrequent follow-up, whereas others require a more aggressive approach.

Expected Outcomes
Outcomes of balloon dilatation depend on the nature of the stenosis. Anastomotic strictures (eg, following lung transplantation) do particularly well and almost never require stenting or surgical revision.28 Other strictures (eg, postintubation) often require more than one dilatation. Granulation tissue formation is common after insertion of balloon-expandable metal stents, especially in areas of previous surgery. This is most commonly of a cobblestone type, where tissue grows through the interstices of the stent. This is best treated with regular balloon dilatations at progressively increasing intervals.22 Polypoid granulations usually occur at the ends of the stent and may grow sufciently large to cause ball valve obstruction of the airway. They are usually best treated by removal or careful laser ablation at rigid bronchoscopy.22 The

Clinical Follow-Up
Immediate postoperative swelling may compromise the airway but usually resolves quickly, and we perform most airway dilatations as day-case procedures. Although quantitative assessment of response can be achieved with ow-volume loops,27 clinical assessment is more useful. Bronchography and exible bronchoscopy are used to evaluate recurrent symptoms following balloon dilatation. They are routinely used following

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Figure 7 A 7-month-old, ventilator-dependent female with exomphalos. (A) Flexible bronchoscopy shows slit-like extrinsic compression of the left main bronchus (LMB, arrows). (B) A 6-mm self-expanding nitinol stent (SMART Control; Cordis Europa, Roden, The Netherlands) has been deployed in the LMB, with immediate reexpansion of the left lung. Note that the proximal end has been intentionally left protruding into the trachea (arrow), to facilitate future removal. The stent is oversized compared with the bronchus to minimize long-term airway limitation. (C) Bronchoscopy conrms that the stent has reestablished patency of the LMB.

amount of granulation tissue varies from patient to patient and is less of an issue with self-expanding stents.

References
1. Feola GP, Shaw LC, Coburn L: Management of complicated parapneumonic effusions in children. Tech Vasc Interv Radiol 6:197-204, 2003 2. Gates RL, Hogan M, Weinstein S, et al: Drainage, brinolytics, or surgery: A comparison of treatment options in pediatric empyema. J Pediatr Surg 39:1638-1642, 2004 3. Hogan MJ, Coley BD: Interventional radiology treatment of empyema and lung abscesses. Paediatr Respir Rev 9:77-84, 2008 4. Khalil BA, Corbett PA, Jones MO, et al: Less is best? The impact of urokinase as the rst line management of empyema thoracis. Pediatr Surg Int 23:129-133, 2007 5. Kurian J, Levin TL, Han BK, et al: Comparison of ultrasound and CT in the evaluation of pneumonia complicated by parapneumonic effusion in children. AJR Am J Roentgenol 193:1648-1654, 2009 6. Jaffe A, Balfour-Lynn IM: Management of empyema in children. Pediatr Pulmonol 40:148-156, 2005 7. Cahill AM, Baskin KM, Kaye RD, et al: CT-guided percutaneous lung biopsy in children. J Vasc Interv Radiol 15:955-960, 2004 8. Fontalvo LF, Amaral JG, Temple M, et al: Percutaneous US-guided biopsies of peripheral pulmonary lesions in children. Pediatr Radiol 36:491-497, 2006

Complications
Airway rupture is extremely rare during balloon dilatation. Pneumothorax has occurred in 1% of our patients and is probably less likely in patients who are paralyzed during anesthesia. Stent complications include migration and erosion. Migration is extremely rare with properly deployed metal stents but occurs with Dumon stents. Vascular erosion is often fatal. It appears to be more common when the underlying airway wall is defective (eg, following pericardial patch tracheoplasty) and with balloon-expandable stents. Other problems include the difculty of removing embedded stents and potential long-term problems with stents that cannot be removed or postdilated.24

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9. McConnell P, Feola P, Meyers R: Methylene blue-stained autologous blood for needle localization and thoracoscopic resection of deep pulmonary nodules in children. J Pediatr Surg 37:1729-1731, 2002 10. Waldhausen JH, Shaw DW, Hall DG, et al: Needle localization for thoracoscopic resection of small pulmonary nodules in children. J Pediatr Surg 32:1624-1625, 1997 11. Partrick DA, Bensard DD, Teitelbaum DH, et al: Successful thoracoscopic lung biopsy in children utilizing preoperative CT-guided localization. J Pediatr Surg 37:970-973, 2002 12. Hoffer FA, Gow K, Flynn PM, et al: Accuracy of percutaneous lung biopsy for invasive pulmonary aspergillosis. Pediatr Radiol 31:144152, 2001 13. Hayes-Jordan A, Connolly B, Temple M, et al: Image-guided percutaneous approach is superior to the thoracoscopic approach in the diagnosis of pulmonary nodules in children. J Pediatr Surg 38:745-748, 2003 14. Ade-Ajayi N, Roebuck D, Spitz L: Esophageal dilatation, in Najmaldin A, et al (eds): Operative Endoscopy and Endoscopic Surgery in Infants and Children. London, Hodder Arnold, 2005, pp. 127-133 15. Khan AA, Shah SW, Alam A, et al: Efcacy of rigiex balloon dilatation in 12 children with achalasia: A 6-month prospective study showing weight gain and symptomatic improvement. Dis Esophagus 15:167170, 2002 16. Vo NJ, Racadio JM, Inge TH: Sharp recanalization of an esophageal occlusion after repair of esophageal atresia and tracheoesophageal stricture. J Vasc Interv Radiol 16:1401-1405, 2005 17. Wilkinson AG, MacKinlay GA: Use of a cutting balloon in the dilatation of caustic oesophageal stricture. Pediatr Radiol 34:414-416, 2004 18. Broto J, Asensio M, Vernet JM: Results of a new technique in the treat-

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ment of severe esophageal stenosis in children: Poliex stents. J Pediatr Gastroenterol Nutr 37:203-206, 2003 Vandenplas Y, Hauser B, Devreker T, et al: A degradable esophageal stent in the treatment of a corrosive esophageal stenosis in a child. Endoscopy 41:E73, 2009 (suppl 2) Zhang C, Yu JM, Fan GP, et al: The use of a retrievable self-expanding stent in treating childhood benign esophageal strictures. J Pediatr Surg 40:501-504, 2005 Martinez L, Rivas S, Hernandez F, et al: Aggressive conservative treatment of esophageal perforations in children. J Pediatr Surg 38:685-689, 2003 McLaren CA, Elliott MJ, Roebuck DJ: Tracheobronchial intervention in children. Eur J Radiol 53:22-34, 2005 Jacobs JP, Quintessenza JA, Botero LM, et al: The role of airway stents in the management of pediatric tracheal, carinal, and bronchial disease. Eur J Cardiothorac Surg 18:505-512, 2000 Anton-Pacheco JL, Cabezali D, Tejedor R, et al: The role of airway stenting in pediatric tracheobronchial obstruction. Eur J Cardiothorac Surg 33:1069-1075, 2008 Nicolai T: Airway stents in children. Pediatr Pulmonol 43:330-344, 2008 Tibballs J, Fasulakis S, Robertson CF, et al: Polyex stenting of tracheomalacia after surgery for congenital tracheal stenosis. Int J Pediatr Otorhinolaryngol 71:159-163, 2007 McLaren CA, Pigott N, Dunne C, et al: Assessment of the adequacy of bronchial stenting by ow-volume loops. Pediatr Radiol 36:860-862, 2006 Choong CK, Sweet SC, Zoole JB, et al: Bronchial airway anastomotic complications after pediatric lung transplantation: Incidence, cause, management, and outcome. J Thorac Cardiovasc Surg 131:198-203, 2006

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