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Prostate Artery Embolization Technique: Advantages of Radial vs Femoral

Author Zuby Syed covers Prostate Artery Embolization Technique: Advantages of Radial vs Femoral on BackTable VI

Zuby Syed • Dec 3, 2021 • 137 hits

Arterial access for prostate artery embolization can be performed via a trans-radial or trans-femoral approach. Patient physical characteristics and microcatheter selection can dictate the technique performed. Additionally, different PAE techniques such as choice of embolizing agent and proximal vs distal site of embolization can minimize complications arising from embolization of non-targeted sites.

Dr. Blake Parsons discusses his approach to Radial vs. Femoral access and other techniques for prostate artery embolization 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

• Arterial access for prostate artery embolization can be performed through the radial or femoral artery.

• Based on the provider preference and available equipment, the patient’s height and length of microcatheter can preclude trans-radial access for prostate artery embolization.

• If iliac arteries appear tortuous on iliac angiogram, a radial approach may be better suited to minimize operating time and reduce disposal utilization.

• One technique to avoid non-targeted embolization involves carefully utilizing different sizes of embolizing beads at either proximal or distal sites of the artery while performing contrast runs throughout the procedure.

Prostate artery embolization technique

Image provided by Dr. Ari Isaacson.

Table of Contents

(1) Prostate Artery Embolization: Radial vs Femoral Access Site Selection

(2) Radial Access for Tortuous Arteries on Iliac Angiogram

(3) Prostate Artery Embolization Techniques to Avoid Non-Targeted Embolization

Prostate Artery Embolization: Radial vs Femoral Access Site Selection

Arterial access for prostate artery embolization can be performed through the radial or femoral artery. In some cases, patient height and product selection (i.e. length of microcatheter) may be a limitation to selection of trans-radial access. However, the industry is modifying microcatheters to meet larger length demands. For example, the TruSelect Microcatheter from Boston Scientific has a 175 cm length. This longer length matches demands of needing a tool with pushability to make it through tortuous arteries on the operator’s way to the pudendal artery.

[Dr. Christopher Beck]:
Okay. All right. Let's get into the meaning of today's topic where we're going to talk a little bit about access, site selection. For some of the younger audience or for some of the trainees, will you discuss just in broad strokes, femoral versus radial, and specifically when it comes to this procedure?

[Dr. Blake Parsons]:
Exactly. There was a hard stop on how tall someone was. Especially for men, it became very difficult. And then Boston came out with TruSelect recently, which goes out to a hundred and seventy five centimeters, so that definitely helped. For us here and how I choose back and forth a little bit, I honestly probably look at it more on a weight base, being in Oklahoma to some degree. And then still heights plays a part of it. Now, the other issue we'll get into just in the product I use while I'm doing it, and from a radial approach is, there is some limitation just because of wire options from a radial standpoint because of the length of the microcatheter. But I will tell you, I do way more femoral than I do radial.

[Dr. Christopher Beck]:
All right. So before we get too much into a radial versus femoral, can you talk a little bit more about your radial technique? We can start out just talking about who is a suitable candidate for radial artery access.

[Dr. Blake Parsons]:
Yeah. Obviously, I do a Barbeau on everybody that I'm going to do a radial stick on. From an ultrasound standpoint, I pretty much go from the standard. It needs to probably be at least two millimeters. I'm going to use a four or five slender sheath is what I use for access, everything, obviously ultrasound-guided. So four or five French standard cocktail heparin, nitro, verapamil. So 3000 of heparin, 2.5 of verapamil and then 200 to 300 of nitro just depending on their pressures. And then I typically use a glide wire or even use a Baby-J glide to make your way down. I typically use a glide cat, just a standard 45 angle to be able to get down into the pelvis. But that's my typical initial setup to get there.

[Dr. Christopher Beck]:
Blake, let me ask you this, whenever you're doing a radial access, how's the patient positioned? Do you have them arm out or down by the side?

[Dr. Blake Parsons]:
I do them the exact same way I do my fibroids. I do their arms straight out to the side. How we set up our room is then I put the monitors right behind their arms, so the monitors are just to the left of the patient's head. So I'm actually looking across their arm, looking parallel to them, but I'm to their side. I'm not actually looking towards the patient. I'm just looking across the arm. And then I put my... We have a large room, so this is why I can do this. And then I have a long table that I put out to the end of their arm. And so I can run all my wires and everything down this long table.
[Dr. Christopher Beck]:
Yeah. I think some people like that. I'm with you in terms of radial access. I like the arm, I guess it's abducted with the arms out and I stand in between that corner where their armpit is basically. And then I can't actually get my big monitors in front of me, but we have a set of slave monitors and that works out pretty well. So height-wise, TruSelect decide, which does have the new longer length microcatheter. Do you have a rough cutoff to when if a patient's above a certain height, you're just like, "Oh, I'm not going to mess with the radial access"?

[Dr. Blake Parsons]:
Fibroids have a standard length of say 5’10” for the new TruSelect 61 probably because... I mean, the problem you're going to run into still is... And that gets into the patient's age. Obviously, you start getting into the 80s, these patient's arteries get extremely torturous. You're going to not only lose pushability and things like that, but you're going to eat up a lot of catheter link and then try to get down. And then a lot of times, if you have to go and get a few pudendal branch, you still could come up short. And so that's always the risk of going radial on someone that's a little taller.

[Dr. Christopher Beck]:
Okay. Fair. And what is your 5F catheter that you're getting down with?

[Dr. Blake Parsons]:
The glide. I use the long glide cath. So, a hundred and fifty.

[Dr. Christopher Beck]:
And how long is the microcatheter?

[Dr. Blake Parsons]:
So from the wrist, I'll use the TrueSelect 175.

[Dr. Christopher Beck]:
Okay. Gotcha. And is that the same with your fibroids?

[Dr. Blake Parsons]:
Yeah. Actually, I'll use a shorter. I'll do a 120 and then use the 150 microcatheter, because most of the women, I'm doing on a 5’10”.

[Dr. Christopher Beck]:
Sure, sure. Gotcha. Whenever you're hooking up, do you hook up two-way bores to the back of your 5F catheter?

[Dr. Blake Parsons]:
I do, except for prostates, I won't just in case I need that extra couple of centimeters.

[Dr. Christopher Beck]:
All right. That was my question. Actually, I understand that we did a podcast with Aaron Fischman and it was actually a shorter adapter that you can use. I think the two-way bores, it's around six or seven centimeters that you lose through a microcatheter. And there's another shorter adapter that's closer to like two CMs. I never got the name from... We'll have to grab that.

[Dr. Blake Parsons]:
Yeah. He's the radial master so he'll know.

[Dr. Christopher Beck]:
Sure, sure. All right. So prostate artery embolization, radial versus femoral. If you have your druthers, if you have the perfect patient who shows up. He's 55, no atherosclerotic disease. He's five, six. So height's not going to be an issue. What's your preferred access? Is it a radial or a femoral?

[Dr. Blake Parsons]:
At this juncture, it's femoral. I'm faster to do it femoral than I am to do it radial. And the likelihood you're going to be able to seal that patient on your way out. And so, from a bleeding risk standpoint, there's not much difference. We're pretty aggressive at our place. So if we do say an angioseal, we start setting them up within 30 minutes, which is not crazy, but we get them up pretty quick. I mean, they're out the door within two hours usually.

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
00:00 / 01:04

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Radial Access for Tortuous Arteries on Iliac Angiogram

Radial arterial access for prostate artery embolization may be preferred for tortuous iliac arteries, which are more likely to be present in older patients (>80 years old). Radial access may allow the proceduralist to optimize time efficiency and device utilization, as sheaths do not have to be changed as often to improve pushability.

[Dr. Christopher Beck]:
All right. So when is radial a better fit for you? Are there circumstances where you start out femoral and then you have to, I wouldn't say bail, but then turn to radial?

[Dr. Blake Parsons]:
Yeah. I think for me personally, radial has a great utilization in guys with tortuous iliac arteries, because trying to get up and over and have support from a femoral access is tough. You're going to end up having to use a 25 centimeter sheath and go up and over because what's going to happen is you're going to get right into the beginning of the prostate artery and you have no pushability. And next thing you know, everything's fallen out and falls back up into the aorta and then you're angry.

To save you the trouble of getting up and over, changing out your sheaths and everything, coming from above is much easier. Now the caveat to that, you got to think of as higher up. So as these patients are getting older and they're 80, not only are their iliac arteries getting torturous, but their thoracic aorta is as well. And their takeoff to that left subclavian artery can be pretty sharp. And so then your issue is, are you losing length because of their tortuosity? And are you losing pushability due to that steep turn, trying to get back down the thoracic aorta? That's just something you got to keep in mind as well.

Prostate Artery Embolization Techniques to Avoid Non-Targeted Embolization

Using different size embolizing beads, targeting proximal vs distal parts of the artery, and performing contrast runs throughout the procedure are all techniques to ensure that the embolizing agent is reaching its target location while sparing non-targeted anatomy.

[Dr. Christopher Beck]:
All right. This is one of the things that I think is very intimidating for interventional radiologists, who are trying to get into prostate artery embolization is you see a lot written about non-targeted embolization and things you have to worry about with shunts, with non-targeted embolization to either a rectal or a penile branch. Can you talk a little bit about that, but in the context of what size do you too use? Because you mentioned it earlier that there's sometimes a size particle that you can use that can make you feel uncomfortable, that maybe if you're not exclusively within the perfect prostate artery, that you don't have to worry about end-organ damage if you're having some non-targeted embolization.

[Dr. Blake Parsons]:
I primarily use 300 to 500. After the paper came out showing there's no real difference, then I was like, "Yay, let's stay with the three to five." So I feel so much safer now. And that being said, if I get into a prostate artery and it's a hundred percent prosthetic blush, I can't see anything. Then I will go down a little bit in size and do an initial embolization to get a little distal and then back pack that, so to speak with three to fives. Now, those guys on the post-operative standpoint, they're definitely going to have more post-op ischemic discomfort/prostatitis the smaller the bead you use. But I haven't seen really a major difference in outcomes other than patients being uncomfortable post-op for three to four days of using smaller versus larger beads. So pretty much, just with the data that's out there, I haven't noticed a big difference in patient satisfaction, IPSS, score improvement, all that with just strictly using three to fives versus using smaller.

[Dr. Christopher Beck]:
How about the technique where you do a more proximal embolization with the larger beads. And then you advance the microcatheters as distal as possible and then do another embolization?

[Dr. Blake Parsons]:
Yeah. I tried to do that at the very beginning. And then now, I basically just select as distal as possible, run out the gate. And then, I do give nitro. You typically give about a hundred of nitro to try to pump them up some... And then the shunts are always changing, so I typically give a little bit of embolic and then I'll take another run just to make sure, because you can have inflow from the pudendal artery. And then all of a sudden, you start embolizing things and now it's dumping into the pudendal instead of coming from the pudendal. I do an initial little short embolization and then do a contrast run just to make sure everything still looks good. And then I finish off. And as long as I'm starting to see pretty good pruning and everything, say I use small beads at first, then I'll make sure I get some good pruning. And then I'll use a three to fives to really pack it in.

[Dr. Christopher Beck]:
What's your end point in terms of stasis?

[Dr. Blake Parsons]:
Yeah, three to five. I will say in older guys, I know this has been a relatively newer topic that's been taboo, but of coiling the artery on the way out. I've actually watched a video conference about this specifically and more and more guys are starting to do it, especially older guys. If I have a guy in his 80s that had hard arteries to get into in the first place, A, the likelihood is if they have early recurrence, it's not from their prosthetic artery. It's probably from some collateral branch and I don't want to have to go back in there. That's the view amongst everyone else that does it too, so I'll just go ahead and... I'd use micro coils, like a three by two micro nest or whatever, and I'll pack them in at the end, pretty distal.

I don't do that for everyone. For younger guys, I find that I don't just in case they may get five years and they start to have recurrence of symptoms and they want to do the same procedure again. Okay, well then, we'll go back and do it. But for the older population, I have found myself starting to do more and that's been really in the last couple of months that I've started doing that. Now, it's interesting too because their ischemic pain is greater. And those guys, I've noticed that you ended up going ahead and coiling as well.

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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