ARTERIAL EMBOLIZATION

PROSTATIC ARTERY EMBOLIZATION

Introduction

Last updated: apr 5, 2023

Lower urinary tract symptoms (LUTS) due to benign prostatic hypertrophy (BPH) is a common problem affecting more than 20% of men between the ages of 30 and 79. The prevalence increases with age; approximately 80% of men are affected by BPH symptoms by 70 years of age. Conservative therapies such as lifestyle modifications or medical management are generally first line therapies. In patients who do not respond sufficiently, or have any evidence of renal insufficiency, urinary retention, recurrent urinary tract infections or hematuria, other forms of treatment are considered. Numerous treatment options exist including transurethral resection of the prostate (TURP), transurethral vaporization of the prostate (TUVP), prostatic urethral lift (PUL), amongst others.

Recently, prostate artery embolization (PAE) has emerged as an alternative treatment option for LUTS, falling between medical management and surgical options in the spectrum of BPH therapy

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Anatomy

The article below describes the pelvic vascular anatomy relevant to PAE, including common variations, and discusses the technical details related to each

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Indications

  • IPSS > 18
  • Failed medical therapy
  • Poor surgical candidates
  • Urinary indwelling catheter
  • Hematuria
  • > 80g (no upper limit)

Re-treatment

  • 70% success rate after 4 years
  • 50-60% success on re-treatment for initial responders
  • Initial non-responders are not candidates for re-treatment

Oncologie

  • Therapy-Resistant Post-Radiation Prostatitis
  • Possibility of avoiding androgen-reducing therapy after embolization
  • Volume reduction as a pre-radiotherapy consideration
  • Radioembolization option

 

Contra indications

Absolute

  • Chronic renal failure
  • Bladder atonia, neurogenic bladder
  • Urinary obstruction due to other cause than BPH
  • Prostate cancer
  • Tortuousity or artherosclerosis of the vessels (< 5)
  • Non visualization of the prostatic arteries on CT

Relative

  • Active UTI or prostatitis

 

Workup

  • AUA symptom score / IPSS
  • Correlated diagnoses like erectile or ejaculatory dysfunction
  • Medication
  • Physical examination incl DRE
  • Diagnostic tests
    • Blood (Na/Creatinine/PSA)
    • Urine (stix/sediment)
  • KUB/Prostate ultrasound
  • Post void Residue
  • Urodynamic studies
  • Bladder diary in case of nocturia
  • CTA
  • MR


 

Pre procedural

2 days before incl the day of the procedure

  • Omeprazol 20mg daily
  • Naproxen 1g twice daily
  • Ciprofloxacin 750 mg twice daily, continue 12d

 

Materials

Essentials

  • TruSelect 175 cm 2.0F micro catheter for transradial PAE
  • Guiding Catheter 5F
  • Microcatheter: 2.7F to 2.0F Shaped guidewire 0.018’
  • Embolization Material: Embozene™ (250 or 400µm), oplossen in 20 ml 50 % contrast and 50 % normal saline
  • solution
  • Micro-coils to avoid non-prostatic embolization
  • 5–10 mg of isosorbide mononitrate

Non-Essentials

 

Positioning the patient

  • Supine

 

The procedure in steps

  • TOP
  • Clean with chlorhexidine and apply sterile drapes
  • Infiltrate with lidocaine and bupivacaine
  • Retrograde access via a 6F sheath, 45 cm length; administer 5000 IU heparin
  • “Up-and-over” approach using a RIM katheter
  • Position proximally in the anterior division of the AII (ipsilateral oblique projection)
  • Superselective catheterization of the prostatic artery (4th branch distally)
  • Inject 5–10 mg of isosorbide mononitrate
  • Embolize proximally with particles until “pruned tree” appearance
  • Reposition distally and inject another 5–10 mg of isosorbide mononitrate
  • Embolize distally
  • Monitor for collateral vessels and avoid non-target embolization
  • Bilateral closure device upon completion\
  • SOP

 

Tips and tricks

  • In case of anastomosis through capsular branches, upsize to 400µm EMBOZENE™ Microspheres
  • Always avoid the superior vesical artery embolization – may cause severe bladder ischemia
  • Always attempt bilateral embolization but don’t despair if only unilateral is achieved for you may attempt a second procedure and patient may still have significant clinical improvement.

 

Complications

  • Dysuria (2-3 days) 2-17%
  • Urgency or frequency (bladder spasm) 20-42%
  • Post-embolization syndrome (fever, fatigue) 10%
  • Retention 4-5%
  • UTI 2-5%
  • Hematuria/hematospermia/hematochezia ( non target embolization, self limiting) 5-15%
  • Ejaculatory disorders; reduced volume
  • Non-target embolization (rectal, bladderwall, penile) < 1%

 

Post-op

Pain Medication

  • Omeprazol 20mg daily
  • Naroxen 1g twice daily
  • Ciprofloxacin 750 mg twice daily
  • After: Paracetamol; Metamizol U
Urinary Catheter
  • Patients with very large prostates, especially with prominent medium lobes, who do not have urine in the bladder during Foley introduction have a greater chance of trauma to the median lobe and consequent hematuria. If this happens, the Foley catheter and antibiotics should be maintained for 1 week after PAE under the urologist’s supervision. After a standard successful procedure, the Foley catheter should be removed immediately after PAE to observe voiding, and the patient can be discharged home the same day
  • Do not take out right after procedure (inflammation)
  • Maintain approximately for two weeks (risk of urinary retention)
  • Control Urinary Tract Infection (UTI) and adapted antibiotics

 

Follow-up

  • The International Prostate Symptom Score (IPSS)
  • Quality of Life (QoL)
  • International Index Erectile Function (IIEF)
  • Uroflowmetry: Qmax - peak urinary flow
  • US or MR for PV (Prostatic Volume)

 

Report

Time out akkoord. Procedure onder epiduraal. Patient in rugligging. Wassen met chloorhexidine en steriel afdekken. Echografisch geen stenose in de AFCD. Retrograde toegang, met 25 cm lange 6F sheaths. 5000 IE Heparine.

Up-and-over selektieve katheterisatie van de beide arteria prostatae met behulp van een Progreat 0.018" katheter.

Vervolgens embolisatie met 500-700 micon partikels, tot een "pruned tree" beeld onstaat.

Angioseal beiderzijds.

 

Literature

File NameTypePermissionsChanged DateDateSize

  1. Martins Pisco, J., Pereira, J., Rio Tinto, H., Fernandes, L., & Bilhim, T. (2012). How to perform prostatic arterial embolization. Techniques in Vascular and Interventional Radiology, 15(4), 286–289. https://doi.org/10.1053/j.tvir.2012.09.002

  2. Baum ST. Arteriographic diagnosis and treatment of gastrointestinal bleeding. In Baum ST, Pentecost MJ, eds. Abrams' angiography interventional radiology. 2nd ed. Philadelphia, Pa:Lippincott, Williams & Wilkins, 2006:488.

  4. Poultsides GA, Kim CJ, Orlando R 3rd, et al. Angiographic embolization for gastroduodenal hemorrhage: safety, efficacy, and predictors of outcome. Arch Surg. 2008;143:457-461.

  5. Eriksson LG, Sundbom M, Gustavsson S, Nyman R. Endoscopic marking with a metallic clip facilitates transcatheter arterial embolization in upper peptic ulcer bleeding. J Vasc Interv Radiol. 2006;17:959-964.

  6. Dixon S, Chan V, Shrivastava V et al. Is there a role for empiric gastroduodenal artery embolization in the management of patients with active upper GI hemorrhage? Cardiovasc Intervent Radiol. 2013 Aug;36(4):970-7.

  7. Shin JH. Recent update of embolization of upper gastrointestinal tract bleeding. Korean J Radiol 2012;13 Suppl 1:S31-S39.

  9. van Leerdam ME. Epidemiology of acute upper gastrointestinal bleeding. Best Pract Res Clin Gastroenterol. 2008;22(2):209-24.

  10. Sildiroglu O, Muasher J, Arslan B, Sabri SS, Saad WE, Angle JF, Matsumoto AH, Turba UC. Outcomes of patients with acute upper gastrointestinal nonvariceal hemorrhage referred to interventional radiology for potential embolotherapy. J Clin Gastroenterol. 2014;48(8):687-92.

  11. Strate LL, Gralnek IM. ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding. Am J Gastroenterol. 2016 Apr;111(4):459-74.

  13. van Dam J, Brugge WR. Endoscopy of the upper gastrointestinal tract. N Engl J Med. 1999;341(23):1738-48.

  15. Lefkovitz Z, Cappell MS, Lookstein R, Mitty HA, Gerard PS. Radiologic diagnosis and treatment of gastrointestinal hemorrhage and ischemia. Med Clin North Am. 2002 Nov;86(6):1357-99.

  16. Lee EW, Laberge JM. Differential diagnosis of gastrointestinal bleeding. Tech Vasc Interv Radiol 2004; 7: 112-22

  18. Strate LL, Gralnek IM. ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding. Am J Gastroenterol. 2016 Apr;111(4):459-74.

  19. Chaudhry V, Hyser MJ, Gracias VH, Gau FC. Colonoscopy: the initial test for acute lower gastrointestinal bleeding. Am Surg. 1998 Aug;64(8):723-8.

  20. Cummings CL. Value of early capsular endoscopy for severe gastrointestinal bleeding. J Natl Med Assoc. 2004;96(12):1653-6.

  21. Appleyard M, Glukhovsky A, Swain P. Wireless-capsule diagnostic endoscopy for recurrent small-bowel bleeding. N Engl J Med. 2001;344(3):232-3.

  24. Lim JK, Ahmed A. Endoscopic approach to the treatment of gastrointestinal bleeding. Tech Vasc Interv Radiol. 2004 Sep;7(3):123-9.

  25. Nicholson AA, Ettles DF, Hartley JE, et al. Transcatheter coil embolotherapy: a safe and effective option for major colonic haemorrhage. Gut 1998; 43:79–84.

  26. Zuckier LS. Acute gastrointestinal bleeding. Semin Nucl Med. 2003 Oct;33(4):297-311.

  27. Imbembo AL, Diverticular disease of the colon. In: Sabiston D, Editor. Textbook of Surgery (14th edn). Philadelphia, PA:WB Saunders, 1992:910.

  29. Loffroy R, Rao P, Ota S, De Lin M, Kwak BK, Geschwind JF. Embolization of acute nonvariceal upper gastrointestinal hemorrhage resistant to endoscopic treatment: results and predictors of recurrent bleeding. Cardiovasc Intervent Radiol. 2010 Dec;33(6):1088-100. doi: 10.1007/s00270-010-9829-7. Epub 2010 Mar 16.

  31. Eriksson LG, Sundbom M, Gustavsson S, Nyman R. Endoscopic marking with a metallic clip facilitates transcatheter arterial embolization in upper peptic ulcer bleeding. J Vasc Interv Radiol. 2006 Jun;17(6):959-64.

  32. Anthony S, Milburn S, Uberoi R. Multi-detector CT: review of its use in acute GI haemorrhage. Clin Radiol. 2007 Oct;62(10):938-49.

  33. Ernst O, Bulois P, Saint-Drenant S, Leroy C, Paris JC, Sergent G. Helical CT in acute lower gastrointestinal bleeding. Eur Radiol. 2003;13(1):114-7

  34. Mirsadraee S, Tirukonda P, Nicholson A, Everett SM, McPherson SJ. Embolization for non-variceal upper gastrointestinal tract haemorrhage: a systematic review. Clin Radiol 2011;66:500-509.

  35. Loffroy R, Guiu B, D'Athis P, Mezzetta L, Gagnaire A, Jouve JL, Ortega-Deballon P, Cheynel N, Cercueil JP, Krausé D. Arterial embolotherapy for endoscopically unmanageable acute gastroduodenal hemorrhage: predictors of early rebleeding. Clin Gastroenterol Hepatol. 2009 May;7(5):515-23.

  36. Aina R, Oliva VL, Therasse E, et al. Arterial embolotherapy for upper gastrointestinal hemorrhage: outcome assessment. J Vasc Interv Radiol 2001;12:195-200.

  37. Mirsadraee S, Tirukonda P, Nicholson A, Everett SM, McPherson SJ. Embolization for non-variceal upper gastrointestinal tract haemorrhage: a systematic review. Clin Radiol 2011;66:500-509.

  38. Loffroy R, Guiu B, Cercueil JP, Lepage C, Latournerie M, Hillon P, Rat P, Ricolfi F, Krausé D. Refractory bleeding from gastroduodenal ulcers: arterial embolization in high-operative-risk patients. J Clin Gastroenterol. 2008 Apr;42(4):361-7.

  39. Loffroy R, Guiu B, D'Athis P, Mezzetta L, Gagnaire A, Jouve JL, Ortega-Deballon P, Cheynel N, Cercueil JP, Krausé D. Arterial embolotherapy for endoscopically unmanageable acute gastroduodenal hemorrhage: predictors of early rebleeding. Clin Gastroenterol Hepatol. 2009 May;7(5):515-23.

  40. Poultsides GA, Kim CJ, Orlando R 3rd, Peros G, Hallisey MJ, Vignati PV. Angiographic embolization for gastroduodenal hemorrhage: safety, efficacy, and predictors of outcome. Arch Surg 2008;143:457-461.

  42. Gordon RL, Ahl KL, Kerlan RK, Wilson MW, LaBerge JM, Sandhu JS, Ring EJ, Welton ML. Selective arterial embolization for the control of lower gastrointestinal bleeding. Am J Surg. 1997;174(1):24-8.

  43. Funaki B, Kostelic JK, Lorenz J, Ha TV, Yip DL, Rosenblum JD, et al. Superselective microcoil embolization of colonic hemorrhage. AJR Am J Roentgenol 2001;177:829-836 7.

  44. Bandi R, Shetty PC, Sharma RP, Burke TH, Burke MW, Kastan D. Superselective arterial embolization for the treatment of lower gastrointestinal hemorrhage. J Vasc Interv Radiol 2001;12:1399-1405.

  45. Maleux G, Roeflaer F, Heye S, Vandersmissen J, Vliegen AS, Demedts I, et al. Long-term outcome of transcatheter embolotherapy for acute lower gastrointestinal hemorrhage. Am J Gastroenterol 2009;104:2042-2046

  46. Leitman IM, Paull DE, Shires GT 3rd. Evaluation and management of massive lower gastrointestinal hemorrhage. Ann Surg 1989;209:175-180

  47. Rosenkrantz H, Bookstein JJ, Rosen RJ, Goff WB 2nd, Healy JF. Postembolic colonic infarction. Radiology 1982;142:47-51.

  48. Koh DC, Luchtefeld MA, Kim DG, Knox MF, Fedeson BC, Vanerp JS, et al. Efficacy of transarterial embolization as definitive treatment in lower gastrointestinal bleeding. Colorectal Dis 2009;11:53-59

  49. Lipof T, Sardella WV, Bartus CM, Johnson KH, Vignati PV, Cohen JL. The efficacy and durability of super-selective embolization in the treatment of lower gastrointestinal bleeding. Dis Colon Rectum 2008;51:301-305

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The information contained herein has been obtained from sources believed to be reliable. However, no warranty as to the accuracy, completeness or adequacy of such information is implied. No liability is accepted for errors, omissions or inadequacies in the information contained herein or for interpretations thereof. The reader assumes sole responsibility for the selection of these materials to achieve its intended results. The opinions expressed herein are subject to change without notice.

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