Contraindications to Prostatic Artery Embolization (PAE)
Updated: Mar 11, 2019
Patient selection is key to achieving good outcomes. Dr. Ari Isaacson describes his ideal prostatic artery embolization (PAE) patient, and discusses relative and absolute contraindications to PAE.
The BackTable Brief
Younger benign prostatic hyperplasia (BPH) patients with really large prostates (above 80 CCs) tend to be the least challenging to treat with prostatic artery embolization (PAE).
Older men tend to have more tortuous and/or atherosclerotic pelvic arteries, which can make a PAE procedure more difficult.
Dr. Isaacson strongly recommends against using PAE to treat vasculopaths - patients with a history of coagulation issues, lower extremity bypass grafts, stenting, etc.
When the prostate is small (less than 50 CCs) and has a prominent median lobe, embolization may not reduce the prostate enough to alleviate urinary symptoms.
Disclaimer: The opinions expressed by the participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
The Ideal PAE Patient
Okay. Let's take a step back, to where we've just selected the prostatic artery … Generally, what are you looking for to allow you to treat at this point, and what findings might lead you to change your plan?
The patients that I get excited about, I'll start with that, are patients with really large glands, so patients with 80 CCs and above. I consider those pretty large. I like younger men, who may not have as bad atherosclerotic disease, so that's helpful also.
Be Wary of Tortuous Pelvic Arteries
As men grow older, I think the arteries tend to become a little more tortuous, which can hurt you as well.
I think the number one thing that can make PAE really tough, is having very tortuous pelvic arteries, like the iliac artery, cause if you have to wind through some pelvic tortuosity, it takes away some of your control of your diagnostic catheter.
The patients that I would consider not doing, first of all, I would strongly, strongly warn people about attempting this on people who are known vasculopaths. You're setting yourself up for badness.
What in particular do you mean by vasculopath?
One screening question that I ask people, is, "Have you ever had any issues with coagulation? Have you ever had a bypass graft in your leg? Have you had any stenting in your legs?", things like that. If they say yes to any of those, I'll get some imaging first, but I'm leaning towards not doing a PAE on them.
A Small Prostate With a Prominent Median Lobe Can Preclude Efficacy
The other thing I would say, is if they have a small gland, and I say small, it's probably less than 50 CCs, so somewhere in the 30s or 40s, and a pretty prominent median lobe, that worries me, because I feel like we can't get enough action on the median lobe itself, to alleviate the urinary symptoms.
When the prostate is globally larger, you affect the lateral lobes a lot, as well as the median lobe, and I think you can get a better effect. But, when it's already a smaller prostate to begin with, I worry about those patients.
Dr. Sandeep Bagla is a practicing interventional radiologist with the Vascular Institute of Virginia.
Dr. Ari Isaacson is a practicing interventional radiologist with the UNC Department of Radiology in North Carolina.
Dr. Michael Barraza is a practicing interventional radiologist with Radiology Alliance in Nashville.
Cite this podcast:
BackTable, LLC (Producer). (2017, November 27). Ep 17 – Prostate Artery Embolizations [Audio podcast]. Retrieved from https://www.backtable.com/podcasts
The Materials available on the BackTable Blog are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients.