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Prostate Artery Embolization

Prostate Artery Embolization Procedure Prep

Learn more on the BackTable VI Podcast

BackTable is a knowledge resource for physicians by physicians. Get practical advice on Prostate Artery Embolization and how to build your practice by listening to the BackTable VI Podcast, reading exclusing BackTable Articles, and following the work of our Contributors.

Ep 427 TREAT Symposium: Advancing Clinical Education with Live Cases with Dr. Aaron Fischman
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Pre-Procedure Prep

Indications

• Benign prostatic hypertrophy (BPH) with lower urinary tract symptoms (LUTS)
• Intractable hematuria

Patient Population

Treat patients with moderate to severe LUTS
Patients who have failed or cannot tolerate conservative medical management
• Hypotension
• Retrograde ejaculation
• Decreased sexual drive
Surgery
• Patients often concerned about potential morbidity or complications
• Contraindication to surgery related to patient comorbidities
Prostate size > 40

Workup

IPSS
• Many agree with an International Prostate Symptom Score (IPSS) < 8, PAE not indicated
• Quality of Life (QoL)
• IPSS a a good survey for assessing LUTS

Urodynamics:
• Specialized test to assess detruser strength
• Can discern between neurogenic bladder and bladder outlet obstruction
• Neurogenic bladder can be seen in spinal cord injury, MS, diabetics.

Uroflowmetry
• Qmax: > 10 mL/s unlikely to benefit from PAE
• If Qmax > 10 mL/s, consider other causes of LUTS

Labs: PSA, BMP and urinalysis
Imaging
• Ultrasound: can evaluate prostate size and evaluate bladder for post void residual (PVR) volume.
• CTA or MRA: can estimate prostate size and potentially evaluate prostate arteries
• MR: can evaluate prostate size and underlying neoplasm. Can compare pre MRI with post MRI to assess change in volume and enhancement

In summary:
• Recommend consistent preprocedural workup for patients
• Use IPSS
• Need basic understanding of uroflowmetry and post void residual volume
• Need algorithm for prostate cancer evaluation
• Preprocedural imaging can range from basic to complex
• LUTS are not always secondary to BPH

Prostate Artery Embolization Podcasts

Listen to leading physicians discuss prostate artery embolization on the BackTable VI Podcast. Get tips, tricks, and expert guidance from your peers and level up your practice.

Episode #447

VI

In this episode, Dr. Mark Little shares his insights about genicular artery embolization (GAE), implications for patients with knee osteoarthritis, possible applications in other MSK interventions, and the importance of research for advancing the field. Dr. Little is a consultant diagnostic and interventional radiologist at Berkshire Imaging and Visiting Professor at the University of Reading in England.

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Episode #427

VI

In this episode of BackTable Podcast, host Dr. Sabeen Dhand interviews guest Dr. Aaron Fischman about the TREAT Symposium and its evolution into TREAT Live, a platform for broadcasting live endovascular cases. Dr. Fischman is a vascular and interventional radiologist at Mount Sinai in New York.

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Episode #416

VI

In this episode of the BackTable Podcast, host Dr. Michael Barraza interviews guest Dr. Charles Nutting about prostatic artery embolization (PAE) in the outpatient-based lab (OBL) setting. Dr. Nutting is an interventional radiologist at Endovascular Consultants in Lone Tree, Colorado. The doctors discuss procedure techniques, patient selection, follow-up care, and benefits of the OBL environment over the hospital.

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Episode #397

VI

En este episodio del podcast, el Dr. Iñigo Insausti Gorbea y la Dra. Sara Lojo Lendoiro, se centraron en la técnica de embolización prostática como alternativa mínimamente invasiva para el tratamiento de la hiperplasia benigna de próstata.

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Episode #387

VI

In this episode of BackTable, host Dr. Michael Barraza is joined by Dr. Nainesh Parikh from Moffitt Cancer Center. Dr. Parikh has worked extensively on prostate artery embolizations (PAE), having performed around 250 PAEs since joining Moffitt in 2017. The conversation delves into the multifaceted applications of PAE, with a specific focus on its role in prostate cancer.

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Episode #367

VI

In this episode, host Dr. Aaron Fritts interviews Dr. Aaron Kovaleski on good old-fashioned TV and radio marketing. Aaron is an interventional radiologist and founder of Endovascular Consultants of Colorado, who has found success in using tried and true methods of advertising to grow his practice.

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Episode #323

VI

En los confines de la medicina, a veces es necesario un espíritu intrépido para desafiar las prácticas establecidas y abrir nuevos horizontes. El reconocido doctor Francisco Carnevale, una figura emblemática en el campo de la radiologia intervencionista, personifica a la perfección esta audacia. Su historia es la epopeya de un hombre que tuvo la inquietud de explorar la embolización de la próstata, un enfoque innovador en el tratamiento de la hiperplasia prostática.

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Episode #280

VI

In this episode, host Dr. Michael Barraza interviews interventional radiologist Dr. Samdeep Mouli about controversies in prostate artery embolization, including technique, durability, and how we can leverage the data to unite IRs and establish PAE as standard of care.

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Episode #220

VI

STREAM Meeting Founders Ari Isaacson and Sandeep Bagla tell us about what to expect at the next meeting in September, including PAE and GAE practice building tips, as well learn about new embolization procedures such as adhesive capsulitis and thyroid arterial embolization.

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Episode #164

VI

Urologist Dr. Claus Roehrborn and Interventional Radiologist Dr. Sandeep Bagla discuss the pros and cons of Prostate Artery Embolization (PAE) compared to other Minimally Invasive Surgical Treatments (MISTS) for Benign Prostate Hyperplasia (BPH). They also discuss the importance of a collaborative, multidisciplinary approach when offering these treatment options, including agreeing on the best treatment for the patient.

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Episode #148

VI

We talk with Dr. Blake Parsons about his approach to Radial vs. Femoral access for Prostate Artery Embolization for BPH, including patient selection, device considerations, and practice pearls.

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Episode #145

VI

We talk with STREAM meeting founders Dr. Ari Isaacson and Dr. Sandeep Bagla about its origin story, as well as what they have planned at STREAM 2021 for docs who want to learn Prostate Artery Embolization, Musculoskeletal Embolizations, and new techniques for Pain Therapy.

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Episode #96

VI

Interventional Radiologist Ari Isaacson and Urologist Matt Raynor at UNC Health tell the story of how they successfully built a collaborative PAE program for the treatment of benign prostatic hyperplasia (BPH), including the challenges they faced along the way, and tips for success in working together.

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Episode #17

VI

Special guests Dr. Ari Isaacson and Dr. Sandeep Bagla sharing their experiences with prostate artery embolization, including a candid discussion on practice building, equipment, and a brief intro on what to expect at the upcoming STREAM PAE course Jan 13 in Washington DC.

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Procedure Steps

Antibiotic

• 400 mg Ciprofloxacin IV preprocedure
• Continue 500 mg Ciprofloxacin PO BID x 5-7 days following procedure

Outpatient Procedure

Sedation: ranges from local to MAC
Foley helpful especially when starting out, but try to avoid as comfort level and experience increase
BB marker on base of penis also helpful when starting out

Procedure in Summary

• Access: radial vs femoral
• Catheterize left internal iliac artery (IIA)
• DSA: 45° ipsilateral oblique
• 2.1 or 2.4-Fr microcatheter for prostate artery
• Confirm placement with DSA
• Confirm placement and potential non-target embolization with cone-beam
• 100 mcg nitroglycerine into prostate artery before embolization
• Many choices for embolics. Sizes range from 100-500 μm
• Endpoint: stasis or near stasis
• Repeat for contralateral prostate artery

Radial

• Good vector to catheterize the internal iliac arteries
• May have challenges for cone-beam CT
Femoral - sometimes bilateral access needed

Catheterize IIA

• Depends on tortuosity
• Can start with basic C2 catheter if using femoral approach
For femoral access and ipsilateral IIA
• Can pull reverse curve catheter like Sos into the IIA
• Waltman loop or RUC helpful to access anterior division of IIA

Identify Prostate Artery

Consider cone beam CT at beginning of procedure with flush catheter in aorta
• Gives nice overview of anatomy
• Can observe anatomic variants
• Can be helpful when choosing an obliquity for IIA DSA to identify origin of prostate artery
• Potential cone beam protocol: 6 mL/s for 42 mL (allows for 2 seconds to fill artery and a 5 second spin)
• Dilute contrast: 1:1 ratio of contrast to saline
DSA in IIA
• Helpful to access anterior division of IIA
• 45° ipsilateral oblique
• Prostate artery crosses main trunk of obturator artery (if present) > 95% of time
• Obturator easy to identify with distal fork
• Recommend looking at lots of angiograms prior to first case
• Understanding branches of IIA will help identify prostate artery

Catheterize Prostate Artery

• Many different techniques and tools
• Average diameter 1.6 mm
• Artery prone to spasm
• Recommend starting with 2.1-Fr microcatheter
• Preshaped microcatheters can be helpful
• Shapeable microwire usually fine
• 0.016" double angle Glidewire GT (Terumo) helpful
Confirm placement and evaluate for non-target embolization with cone-beam CT
• Many protocols
• Consider 0.5 mL/sec for 8 mL with 8 second delay (will obtain arterial information and parenchymal filling)

Potential Non-Target Embolization

• Often easiest maneuver is to advance microcatheter distal to potential non-target branch
• Embolize with non-target vessel with Gelfoam or coils
• Larger particles (300-500 μm) may reduce chance of end tissue necrosis

Prostate Artery Embolization Articles

Read our exclusive BackTable VI Articles for quick insights on prostate artery embolization, provided by physicians for physicians.

Prostatic Artery Embolization: Standardization of Advanced Techniques

Variety in prostatic artery embolization (PAE) procedure techniques, such as catheter choice, endpoints, particle sizes, and use of coils or liquids can lead to inconsistent procedure outcomes. Interventional radiologist Dr. Sam Mouli explains his techniques and recommendations to better standardize prostatic artery embolization in practice.

PAE Procedure Workup: The Role of Uroflow and Pre-Procedural Imaging

The rapid evolution of the PAE procedure has led to the utilization of various pre-procedural practices. Questionnaires, Uroflow, CT, MRI, and cone beam CT have been used, among other tools, to work up patients with benign prostatic hyperplasia (BPH) and plan treatment. Learn more about PAE procedure workup.

PAE Prostate Procedure: The Case for Early Intervention

Interventional radiologist Dr. Sam Mouli shares his view on the role of the PAE prostate procedure in the treatment of BPH, and explains when the PAE prostate procedure may be appropriate as a first-line therapy.

Prostate artery embolization technique

Prostate artery embolization technique may vary depending on which arterial access site is chosen (radial vs femoral). Different PAE techniques may also be utilized to minimize off-target embolization.

Prostate artery anatomy

Understanding the variations in prostate artery embolization anatomy is crucial for improving technical success, reducing the chance of re-vascularization and minimizing non-target embolization. The variations in origin of the prostate artery can be sorted in a classification system.

Prostate anatomy imaging for prostate artery embolization

Prostatic artery embolization (PAE) experts Dr. Ari Isaacson and Dr. Sandeep Bagla debate their preferred imaging modalities, and discuss what imaging techniques helped them get started with PAE.

Image of nontarget embolization in prostate artery embolization

The consequences of nontarget embolization can deter interventional radiologists and patients from following through with a prostatic artery embolization (PAE) procedure. PAE experts Dr. Sandeep Bagla and Dr. Ari Isaacson discuss their PAE technique, why it's effective, and how it helps them minimize nontarget embolization.

Benign prosttic hyperplasia 3D drawing

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.

Prostate artery embolization side effects

Prostate artery embolization side effects are uncommon and generally mild. PAE expert Dr. Ari Isaacson discusses his experiences with acute urinary retention, post-PAE syndrome, and what side effects interventional radiologists should expect.

Physician shaking hands to build prostate artery embolization practice

Prostatic artery embolization (PAE) experts Dr. Ari Isaacson and Dr. Sandeep Bagla share how they built up benign prostate hyperplasia (BPH) referral from urologists and primary care physicians.

Image of prostatic artery embolization

Prostatic artery embolization (PAE) microcatheter and guidewire selection is covered by experts Dr. Ari Isaacson and Dr. Sandeep Bagla for different PAE cases. They cover the Terumo Progreat microcatheter, Direxion microcatheter, Merit Maestro microcatheter, & more.

Post-Procedure

Complications

Non-target embolization: rectum, bladder and penis
Urinary retention
• Up to 8%
• More likely with larger volume prostates
• Treated with 1-2 weeks of indwelling Foley catheter
• Some operators will tell patients with > 150 g prostates to expect to go home with Foley
Minor complications
• Hematuria
• Hematospermia
• Pain

Post-Procedural Care

• Can be discharged day of procedure
• 1-3 hour recovery time
• Discharge pain regimen to include anti-inflammatory, opioids for break through pain, antiemetics

Follow-Up

• 1, 3, 6 and 12 month visits
• IPSS at each visit
• Similar to UFE, maximal benefit between 3-6 months
• Post procedure imaging and urodynamics usually reserved for troubleshooting

Outcomes at 12 Months

• IPSS improved by 20 points
• QoL improved by 2.5 points
• PVR decreased by 86 mL
After 2 years, IPSS, Qol and urinary flow similar. TURP better at reducing prostate size

Prostate Artery Embolization Tools

Check out prostate artery embolization apps, calculators, and decision aids to assist you in your day to day practice.

Prostate Volume Calculator

BackTable's prostate volume calculator is an essential tool for doctors and patients alike. Accurate, fast, and easy-to-use. Try it today!

Ellipsoid Volume Calculator

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References

[1] Moradzadeh N, Ranade A, McWilliams J. Angiographic features to aid identification of the prostatic artery during prostatic arterial embolization [abstract]. In J Vasc Interv Radiol. 2019;30(3):Supplement, Page S59. Abstract No.126.
[2] Bagla S, Isaacson AJ. Tips and Tricks for Difficult Prostatic Artery Embolization. Semin Intervent Radiol. 2016;33(3):236‐239. doi:10.1055/s-0036-1586145
[3] Carnevale FC, Iscaife A, Yoshinaga EM, Moreira AM, Antunes AA, Srougi M. Transurethral Resection of the Prostate (TURP) Versus Original and PErFecTED Prostate Artery Embolization (PAE) Due to Benign Prostatic Hyperplasia (BPH): Preliminary Results of a Single Center, Prospective, Urodynamic-Controlled Analysis. Cardiovasc Intervent Radiol. 2016;39(1):44‐52. doi:10.1007/s00270-015-1202-4
[4] Uflacker A, Haskal ZJ, Bilhim T, Patrie J, Huber T, Pisco JM. Meta-Analysis of Prostatic Artery Embolization for Benign Prostatic Hyperplasia. J Vasc Interv Radiol. 2016;27(11):1686‐1697.e8. doi:10.1016/j.jvir.2016.08.004
[5] Gao YA, Huang Y, Zhang R, et al. Benign prostatic hyperplasia: prostatic arterial embolization versus transurethral resection of the prostate--a prospective, randomized, and controlled clinical trial. Radiology. 2014;270(3):920‐928. doi:10.1148/radiol.13122803
[6] Martins Pisco J, Pereira J, Rio Tinto H, Fernandes L, Bilhim T. How to perform prostatic arterial embolization. Tech Vasc Interv Radiol. 2012;15(4):286‐289. doi:10.1053/j.tvir.2012.09.002
[7] BackTable, LLC (Producer). (2017, November 27). Ep 17 – Prostate Artery Embolizations [Audio podcast]. Retrieved from https://www.backtable.com/shows/vi

Disclaimer: The Materials available on https://www.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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Podcasts

Exploring GAE: Clinical Insights & Outcomes with Dr. Mark Little on the BackTable VI Podcast)
TREAT Symposium: Advancing Clinical Education with Live Cases with Dr. Aaron Fischman on the BackTable VI Podcast)
PAE in the OBL with Dr. Charles Nutting on the BackTable VI Podcast)
Embolización Prostática: ¿Merecemos Estar en las Guías Clínicas? con Dr. Iñigo Insausti Gorbea on the BackTable VI Podcast)
Beyond BPH: PAE in Prostate Cancer with Dr. Nainesh Parikh on the BackTable VI Podcast)
Iliofemoral Stenting: Decision-Making & Best Practices Explored with Dr. Kush Desai and Dr. Steven Abramowitz on the BackTable VI Podcast)

Articles

Prostatic Artery Embolization: Standardization of Advanced Techniques

Prostatic Artery Embolization: Standardization of Advanced Techniques

PAE Procedure Workup: The Role of Uroflow and Pre-Procedural Imaging

PAE Procedure Workup: The Role of Uroflow and Pre-Procedural Imaging

PAE Prostate Procedure: The Case for Early Intervention

PAE Prostate Procedure: The Case for Early Intervention

Contributors

Dr. Francisco Carnevale on the BackTable VI Podcast

Dr. Francisco Carnevale

Dr. Iñigo Insausti Gorbea on the BackTable VI Podcast

Dr. Iñigo Insausti Gorbea

Dr. Ari Isaacson on the BackTable VI Podcast

Dr. Ari Isaacson

Dr. Aaron Kovaleski on the BackTable VI Podcast

Dr. Aaron Kovaleski

Dr. Blake Parsons on the BackTable VI Podcast

Dr. Blake Parsons

Dr. Matt Raynor on the BackTable VI Podcast

Dr. Matt Raynor

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