Indications
Catheter arteriography in pediatric patients should be performed only when non-invasive imaging techniques are insufficient to answer the clinical question or as part of a planned endovascular intervention​.

Contraindication 
Absolute Contraindications
  • None established in current evidence
Major Relative Contraindications
  • Severe contrast allergy with history of anaphylaxis requiring extensive premedication protocols
  • Severe renal insufficiency (creatinine >3-4 mg/dL or >50% above baseline)
  • Significant volume restrictions precluding adequate contrast administration
  • Uncorrected severe coagulopathy with INR >2.0 or platelet count <50,000/mm³
  • Active sepsis with hemodynamic instability
  • Severe heart failure with inability to tolerate contrast load
Minor Relative Contraindications
  • Mild to moderate renal dysfunction requiring dose limitation and nephroprotective measures
  • Previous contrast reaction managed with premedication protocols
  • Mild coagulopathy correctable with blood products
  • Congestive heart failure requiring volume management

Pre-Procedure
Clinical Optimization 
  • Renal function optimization: Adequate hydration (1.5 mL/kg/hour normal saline 6-12 hours pre-procedure), discontinuation of nephrotoxic medications 48 hours prior
  • Coagulopathy correction: Target INR <1.5, platelet count >100,000/mm³, correction of known bleeding disorders
  • Allergy management: Premedication protocol for patients with contrast sensitivity (prednisolone 1 mg/kg 13, 7, and 1 hour pre-procedure; diphenhydramine 1 mg/kg 1 hour pre-procedure)
  • Cardiovascular optimization: Blood pressure control, treatment of active vasculitis, heart failure management
  • Comprehensive imaging review: Analysis of all available non-invasive studies to optimize procedural approach and minimize contrast usage

Labs
  • Complete blood count with platelet count and differential
  • Comprehensive metabolic panel including BUN, creatinine, electrolytes, glucose
  • Coagulation studies (PT, INR, aPTT) with specific attention to age-related normal values
  • Type and screen (crossmatch for 2 units if angioplasty or intervention planned)
  • Additional studies when indicated: thyroid function tests, hemoglobin A1c, inflammatory markers

Technique
Pre-Procedural Assessment and Planning
  • Mandatory ultrasound evaluation: Bilateral assessment of potential access sites with documentation of vessel patency, diameter, and depth
  • Contrast dose calculation: Maximum allowable dose 6 mL/kg using low-osmolar contrast agents (Optiray 300 or equivalent)
  • Radiation dose planning: Implementation of ALARA principles with dose reference levels appropriate for pediatric patients
  • Anesthesia planning: Risk stratification and appropriate sedation/anesthesia selection

Evidence-Based Vascular Access Protocol
  • Real-time ultrasound guidance: Required for all arterial access procedures to reduce complications and improve success rates
  • Probe selection: High-frequency linear array probe (7-15 MHz) with small footprint for pediatric anatomy
  • Primary access: Common femoral artery (most evidence-supported approach). Access above the femoral bifurcation. A shallower approach is required in children to avoid puncturing the posterior wall. 
  • Alternative access sites:
    • Axillary artery: For patients with femoral contraindications, using ultrasound guidance
    • Brachial artery: Limited to specific indications, higher complication rates
    • Radial artery: Emerging evidence in pediatric populations for specific procedures
  • Neonatal access: Umbilical artery permissible up to 5 days post-birth with specific catheter requirements

Technical Specifications Based on Current Standards
Micropuncture Access System
  • Initial access: 21-gauge echogenic needle (Echotip or equivalent) with 0.018-inch guidewire
  • Progressive dilation: 4 or 5 French micropuncture system convertible to 0.035-inch platform
  • Ensure sheath size is compatible with equipment needed for intervention. For angiography alone, a 4 French sheath will suffice.
  • Catheter sizing: 4 French systems accommodate most pediatric interventions (3 French available for smaller patients)
  • Radiation Safety Protocol (Enhanced ALARA Implementation)
  • Equipment optimization:
    • Use of pediatric-specific exposure protocols
    • Removal of anti-scatter grid for neonates and small infants
    • Progressive pulse fluoroscopy with last image hold
    • Appropriate filtration and collimation
  • Dose reduction techniques:
    • Minimize fluoroscopy time through experienced operators
    • Optimize patient positioning to reduce scatter
    • Use of appropriate gonadal and thyroid shielding
    • Digital magnification preferred over geometric magnification
  • Documentation requirements:
    • Total fluoroscopy time recording
    • Dose area product (DAP) or air kerma measurements when available
    • Radiation dose estimates in patient records

Advanced Angiographic Protocol

Catheter Selection and Positioning
  • Aortography: 4 French Omniflush or pigtail catheter via 0.035-inch glidewire
  • Selective catheterization: Steerable microcatheters for detailed vessel evaluation
  • Pressure monitoring: When clinically indicated for hemodynamic assessment

Contrast Administration Protocol
  • Injection parameters: Weight-based and anatomically-appropriate rates per established pediatric protocols. See Angiographic Rates.
  • Pump vs. hand injection: Mechanical injectors for aortic and large vessel studies, hand injection for selective studies
  • Concentration optimization:
    • Full-strength contrast for microcatheter injections
    • 50% concentration adequate for digital subtraction angiography through guide catheters
    • Biplane angiography utilization to minimize total contrast dose

Image Acquisition Standards
  • Acquisition rates:
    • Arterial phase: 3-4 frames per second
    • Venous phase: 1 frame per second for venous outflow assessment
    • Parenchymal phase: As clinically indicated
  • Image quality optimization:
    • Use of motion artifact reduction techniques
    • Optimal positioning and immobilization
    • Appropriate field of view selection

Pharmacological Interventions

Anticoagulation Protocol
  • Heparin administration: 75-100 IU/kg for patients <15 kg at time of sheath insertion
  • Monitoring: Activated clotting time (ACT) when prolonged procedures anticipated
  • Reversal: Protamine sulfate available for emergent reversal if needed
Adjunctive Medications
  • Vasodilators: Nitroglycerin 1-2 μg/kg for arterial spasm management
  • Antispasmodics: Glucagon 10 μg/kg to reduce bowel motion artifacts
  • Sedation: Age-appropriate protocols with continuous monitoring
Picture
Lower abdominal aortogram in patient with rectal bleeding.

Complications
Access-Site Complications (Evidence-Based Management)
  • Hematoma formation (5-15% incidence):
    • Immediate recognition and grading system implementation
    • Ultrasound assessment for size and expansion
    • Conservative management with compression and monitoring
    • Surgical consultation for expanding or compromising hematomas
  • Arterial occlusion (2-5% incidence, higher in smaller patients):
    • Immediate recognition through pulse examination and ultrasound
    • Catheter-directed thrombolysis consideration (alteplase 0.1 mg/kg)
    • Surgical thrombectomy for failed medical management
    • Long-term anticoagulation planning
  • Pseudoaneurysm formation (1-3% incidence):
    • Ultrasound diagnosis and size assessment
    • Compression repair for smaller lesions
    • Thrombin injection for large persistent lesions

Systemic Complications
Contrast-Induced Nephropathy (3-8% in pediatric populations)
  • Prevention strategies:
    • Adequate pre-procedure hydration
    • Contrast dose limitation (≤6 mL/kg)
    • Nephrotoxic medication avoidance
    • N-acetylcysteine consideration in high-risk patients
  • Management protocol:
    • Serial creatinine monitoring at 24 and 48 hours
    • Nephrology consultation for significant elevation
    • Fluid management optimization
    • Dialysis consideration in severe cases
Hypoglycemia (Predominantly neonatal)
  • Recognition: More common in neonates due to limited glycogen stores
  • Monitoring: Serial glucose measurements during procedure
  • Management: IV glucose boluses (0.5-1 g/kg) as clinically indicated
​

Post-Procedure
Immediate Post-Procedural Monitoring (0-4 hours)
  • Hemostasis management:
    • Manual compression minimum 15 minutes for adequate hemostasis
    • Ultrasound verification of vessel patency and absence of active hemorrhage
    • Deployment of appropriate compression device (Safeguard: 40 mL for standard patients, 7 mL for infants)
  • Vascular assessment:
    • Peripheral pulse examination every 30 minutes in recovery
    • Ultrasound confirmation when pulses difficult to palpate
    • Continuous monitoring for signs of vascular compromise
  • Device management:
    • Compression device deflation at 2 hours
    • Re-inflation if evidence of recurrent bleeding
    • Serial assessment until hemostasis confirmed
Extended Monitoring (4-24 hours)
  • Inpatient protocols:
    • Clinical re-examination on post-procedural day one
    • Laboratory follow-up as clinically indicated
    • Activity progression per institutional protocols
  • Outpatient management:
    • Structured telephone follow-up within 24 hours
    • Clear discharge instructions with complication recognition
    • Emergency contact information provision

References
  1. Temple, M and Marshalleck, F.  (2014). Pediatric Interventional Radiology: Handbook of Vascular and Non-Vascular Interventions. Heidelberg, New York, Springer.
  2. Towbin, R and Baskin, K. (2015). Pediatric Interventional Radiology. Cambridge, United Kingdom, Cambridge University Press.
  3. Heran MK, Marshalleck F, Temple M, et al. Joint quality improvement guidelines for pediatric arterial access and arteriography: from the Societies of Interventional Radiology and Pediatric Radiology. Pediatr Radiol. 2010;40(2):237-250. doi:10.1007/s00247-009-1499-8
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