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Prostate Artery Embolization Anatomy

Author Zuby Syed covers Prostate Artery Embolization Anatomy on BackTable VI

Zuby Syed • Dec 3, 2021 • 175 hits

Identifying the origin of the prostate artery is an essential step during the prostate artery embolization procedure. The variations in prostate artery anatomy can be classified based on the system proposed by de Assis et al (2015). Accurate identification of the prostate artery is crucial for improving technical success, reducing the chance of re-vascularization, and minimizing non-target embolization.

Dr. Blake Parsons discusses his approach to identifying and targeting the prostate artery on the BackTable Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.

The BackTable Brief

• The prostate artery may have different sites of origin due to variations in human anatomy. The most common site of origin for the prostate artery is from the internal pudendal artery arising from the anterior division of the internal iliac artery.

• The variations in prostate artery origin can be sorted into a classification system proposed by de Assis et al (2015). There are 5 main patterns of anatomical variations of the prostate artery, 4 of which comprise roughly 95% of cases. Evaluation of this anatomy through a systematic approach and following a standard classification will allow for a faster, safer, and more effective procedure.

• Non-target embolization is often a consequence of misunderstanding the anatomy. Accurate identification of the prostate artery from its varying origin sites is crucial for improving technical success and preventing non-target embolization.

Prostate artery anatomy

Image provided by Dr. Ari Isaacson.

Table of Contents

(1) Identifying the Prostate Artery

(2) Techniques to Localize the Prostate Artery

Identifying the Prostate Artery

Due to variations of human anatomy, the prostate artery may have different sites of origin. The most common prostate artery origin is from the internal pudendal arteries arising from the anterior division of the internal iliac artery. If this anatomy is present, selection of the prostate artery may be performed at 45-48 degrees using the lateral anterior oblique view. However, if there is a variation to this anatomy, the trajectory may need to be adjusted either contralaterally or straight anterior to posterior.

[Dr. Christopher Beck]:
Sure. One thing that I wanted to touch on, in terms of helping identify the prostate artery, do you have a go-to obliquity or positioning the eye to where it... I understand that maybe each patient is different, but your standard obliquity and maybe cranial or caudal tilt to give you a best shot at seeing the takeoff of the prostate artery?

[Dr. Blake Parsons]:
I do it for some reason every time. No cranial or caudal that's even, but I do 48 degrees. I don't know how it came up with 48 degrees. I think it just did it. At the beginning I was like, "It feels lucky, so I'm sticking with it." But pretty steep, I think Bag will tell you he just goes as steep as his C-arm will let him go. And that works for the mass majority of the time, but there'll be definitely times because all these guy's anatomy is different so that you actually need to go contralateral or straight AP to be able to see the takeoff of it. And that does happen not infrequently, but I always start off with ipsilateral 45 to 48 degrees.

[Dr. Christopher Beck]:
All right. That's what I wanted to just clarify for the audience. So if you're selecting the left prostatic artery, you go LAO 48 degrees, no cranial or caudal tilt, right?

[Dr. Blake Parsons]:
Correct.

Listen to the Full Podcast

Radial vs. Femoral for Prostate Artery Embolization with Dr. Blake Parsons on the BackTable VI Podcast)
Ep 148 Radial vs. Femoral for Prostate Artery Embolization with Dr. Blake Parsons
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Techniques to Localize the Prostate Artery

Accurate identification of the prostate artery from its varying origin sites is crucial for improving technical success and preventing non-target embolization. The prostate artery can arise from different origins which have been sorted into a classification system proposed by de Assis et al (2015). This system provides a standardized framework for sorting the prostate artery origin into 5 types. Type I arises from the anterior division of IIA in a common trunk with the superior vesicular artery. Type II arises from the anterior division of IIA, inferior to the superior vesicular artery. Type III arises from the obturator artery. Type IV arises from the internal pudendal artery. Type V includes less common origins of the prostate artery. Evaluation this anatomy through a systematic approach following a standard classification, will allow for a faster, safer, and more effective procedure.

[Dr. Christopher Beck]:
Yeah, totally agree. So talking about some ways to identify the prostatic arteries, maybe looming early ons, so you feel like maybe a little bit like you want to try this procedure. Did you use a Foley catheter? So I've seen some things described as far as, like some crutches that can help you. Some people will place a Foley and you can use that Foley balloon to use as a local landmark, is where your prostate blush should be. I've seen some people put BB markers on the base of the penis for them to help maybe identify a penile branch a little bit better. Do you have anything like that that was helpful for you early on?

[Dr. Blake Parsons]:
No. So I never used a Foley, just because I figured that's part of the reason these patients don't want to have trans urethral. So I never used a Foley. What I will say is a prostate primarily... Let's say a 60 gram prostate, 30 is normal, so enlarged but not crazy, 60 to 80, something like that. It's always going to typically be, if you're straight, no caudal, no cephalad tilt. It's going to be right in the pubic synthesis, on the cephalad margin of it. That's where you're focused. And so when you're doing your run, let's just say, we're doing the left side, we've got to lift oblique 48 degrees whatever. We're taking a look. I kind of go by the rule. I know there's all these papers defining how often the prostate artery comes off of it. I can't remember any of the naming systems.

So I just go in rules of like 25. So, 25% of the time it's going to be off the vesicular trunk, 25% of the time obturator, 25% of the time it's essentially pudendal. And then the other 25% of the time you don't know where the hell it is, then you just got to find it. But you're going to mainly, a lot of times, if the standard it's straightforward anatomy, it's going to be curly, pigtail looking and it typically crosses your obturator artery. When you see that, and then you select it, then I will go back AP and take a dedicated shot into that prostatic artery.

And then you should see primarily horizontal arteries. You shouldn't see arteries running north to south. North to south, this is going to be rectum. And if you push enough in there through your run, you're going to see a blush in the rectum anyway, or blush at the base of the penis. And you know that you've got stuff going the wrong direction. It should be pretty much well-defined. And when you push enough contrast in there, you can actually see the whole left hemisphere of the prostate light up for you, and you know it's the prostate artery.

[Dr. Christopher Beck]:
Yeah, I think that helps certainly on when, one, taking a look at a couple other, like what prostatic blush looks like, but if you've ever read any cross sectional. To me when I did my first case and I saw... Actually, when I did my first case solo, and then I was so worried about seeing the prostatic artery. It did jump out at me in a way. I'll also want to highlight something for the audience. And you mentioned it that the prostate artery many times, like when you're at that steep of an obliquity, will cross the obturator. Can you talk about how you identify the obturator and that kind of crossing anatomy.

[Dr. Blake Parsons]:
Exactly. So your obturator is typically going to run pretty straight north-south, and then it's going to have basically an upside down Y on the bottom of it. So it's going to fork. And it's going to be there now. Typically, it comes off the anterior division, but they can come off your superior gluteal and other kind of funky locations. But typically it's going to be off the interior division.

And then you're going to see your pudendal obviously make almost like a boomerang type of anatomy where it goes down towards the hip. And then it's going to come back down towards the base of the penis. And that prostatic artery typically comes off in between those two arteries. And then you're going to see these pigtail curly cues. And that's going to come back across towards the midline across that obturator artery.

[Dr. Christopher Beck]:
So this first came on my radar, there was a lecture at SIR, I think it was 2018 for those people who have the digital video library. And there was a guy, I think he was out of Yale, but he basically did a show intel where he talked about identifying the obturator, identifying the pudendal. And then he's like, "Really, you only have a handful of arteries left." And talked about how the prostatic artery in 98% of patients would cross the obturator artery. It was a great lecture. And he did a ton of pattern recognition. It really helped me out early on. And it's exactly what you're describing right now.

[Dr. Blake Parsons]:
Definitely. I mean, when you first start off, that's it, that's the hardest part of in cutting down your time and feeling confident in this pattern recognition. It takes seeing lots of different anatomy, lots of runs to be able to just know. It starts to jump out at you when you do the iliac shot, and when you're first starting off, there are tons of papers out there. There's numerous anatomy papers with great pictures and just go through those, and let that ingrain in your mind. So when you start to see shots that you're taking, you're like, "Oh yeah, I've seen this or something similar to this in a picture."" So you feel a little bit more confident.

[Dr. Christopher Beck]:
Sure. Can you talk a little bit about your time with Dr. Bagla and Dr. Isaacson in terms of either shadowing them? How long did you go out and check out their shops?

[Dr. Blake Parsons]:
So for both, I just did a course. I think maybe for Ari, I went out with Terumo, and did a Terumo course. I think we did two or three cases that day. And then the other one, I think I went out with probably Boston or somebody. I mean, I don't even know how many he's done at this point, a ton. And we sat down and watched do three, four of them as well. And I had already started doing some of them. So I had a little bit of an idea and I did Bagla’s after I did Ari’s had, and I went to Stream somewhere in between, around that as well. I think it was the first one they had.

So I had a good idea, which was great. Because by the time that I went to Bagla's, I knew what I was looking at and what I was looking for. And then I could really just dig into him about some of these minor details about things that he's looking for, how he embolizes, how much... Is he trying to get in? What's mixtures all these types of things, so. Okay. But I didn't do any kind of prolong, like, oh, I spent a week with one of them.

[Dr. Christopher Beck]:
Got you. I think there's a lot of value in having done a couple of cases on your own, then to go out and spend time with... Yeah. I think there's a lot of value in that. That was pretty a smart move on your part.

Podcast Contributors

Dr. Blake Parsons discusses Radial vs. Femoral for Prostate Artery Embolization on the BackTable 148 Podcast

Dr. Blake Parsons

Dr. Blake Parsons is a practicing Interventional Radiologist in Oklahoma City.

Dr. Christopher Beck discusses Radial vs. Femoral for Prostate Artery Embolization on the BackTable 148 Podcast

Dr. Christopher Beck

Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.

Cite This Podcast

BackTable, LLC (Producer). (2021, August 16). Ep. 148 – Radial vs. Femoral for Prostate Artery Embolization [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com 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. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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