1. Elective procedures can be performed safely with a platelet count of >50,000 per µL, prothrombin time (PT) <18 seconds, partial thromboplastin time (PTT) <32 seconds, and international normalized ratio (INR) <1.2, with an INR <1.5 preferred for urgent cases.

2. Preprocedural antibiotic prophylaxis is rarely indicated (there may be exceptions, including children with cardiac shunts, those with suspected infection in whom foreign bodies such as embolization coils will be implanted, as well as end-organ embolization procedures with a potential for abscess formation).

3. Preprocedural assessment should include recording the child’s height and weight.

4. Very young patients, those undergoing lengthy diagnostic and interventional procedures, including those requiring intermittent breath holds, will likely require more aggressive sedation and possibly general anesthesia via laryngeal mask or endotracheal intubation.

5. Maintain appropriate homeostatic and monitoring environment during the arteriographic procedure. Young children, especially those under 2 years of age, are very susceptible to ambient temperature changes. Therefore, temperature monitoring is recommended.

Pediatric vessels are often superficial, especially in the neonate or young infant, with the arteries much straighter and having very little or no intrinsic vascular disease. Pediatric vessels tend to occlude more easily, primarily due to the larger catheter-to-vessel ratio, especially in children <15 kg, coupled with a greater occurrence of vasospasm and dissection. Lack of vessel tortuosity makes intraarterial navigation straightforward.

1. The standard arterial site is the common femoral artery. Uncommonly, other sites and approaches may be required, including axillary, brachial, and umbilical access.

2. Use of ultrasound guidance is strongly advocated for obtaining access.

3. Dermatotomy should be done carefully to avoid injury to the vasculature which may lie immediately beneath the skin.

4. Guidewire advancement should be effortless and is best monitored under fluoroscopy.

5. Micropuncture systems in both 4 Fr. and 5 Fr. are readily available and allow easy conversion of 0.018-in. access to 0.035-in. or 0.038-in. guidewire systems.

6. Expert opinion advocates routine use of vascular sheaths, especially if several catheter exchanges, multiple manipulations, or interventional procedures are expected.

7. The smallest catheter that can accomplish the objectives of the study should be used. In most diagnostic cases, 4 Fr. can be used for those >10 kg and 3 Fr. catheters are now increasingly available for those <10 kg.

8. Dedicated pediatric-length catheters are now available, as adult-type preshaped catheters may not have the appropriate configuration or curvature for pediatric arteriography.

9. Intraprocedural systemic heparinization can prevent vascular thrombosis, and its use is well accepted, especially in arteriography performed on infants <10 to 15 kg. This is typically administered as a 75 to 100 IU per kg intravenous (IV) bolus dose once vascular access is obtained.

10. As the younger child and infant are prone to volume overload and contrast nephrotoxicity, volume of injected contrast medium and flush must be carefully monitored.

11. Tailoring the size of the syringes used during the case to the size of the patient can aid in minimizing inadvertent phlebotomy or fluid overload.

12. Contrast dose should be limited to 4 to 5 mL per kg for neonatal arteriography, whereas 6 to 8 mL per kg should be regarded as the maximum volume for pediatric patients beyond this age.

1. Manual compression of arterial puncture site for 10 minutes which does not obliterate the pulse

2. All attempts at manual hemostasis should be done gently. Avoid prolonged occlusive pressure to ensure maintenance of perfusion to the distal extremity and to minimize the possibility of thrombosis of the access artery.

3. Generally speaking, use of closure devices is not recommended especially in infants and small children.