This video of a live transradial prostate artery embolization demonstrates how this minimally invasive procedure treats the urinary symptoms associated with BPH. With a small pinhole in the skin, the IR team was able to block the prostatic artery with micro beads to alleviate the urinary symptoms without side effects like erectile dysfunction.
um So I'm gonna turn the the slides over to dr shalini is going to present the case for you guys. Alright so we're gonna present a case of prostatic artery embolization as you know. So it's chief complaint here of lots of lower urinary tract symptoms secondary to Bph 74 year old 20 year history of Bph. Which which has been managed well with finasteride until the past year when he started seeing a new urologist that recommended he stopped finasteride due to increased cancer risk. He then switched to docks. Is chosen by a new urologist. He also has a history of erectile dysfunction which he takes $2 fill without any improvement. His let's include incomplete emptying increased urinary frequency in bacteria about 2-4 times a night and weak stream. He's seeking a minimally invasive approach to his Bph symptoms. His past medical history, history and surgical history of veronese disease and abdominal hernia. Or free times three. Next slide P. S. A. Was 10.2 says post negative biopsy in 2019 In office. The euro flow measured urinary stream at 3.6 ml a second with severe hesitancy and intermittent see his I. P. S. S. Score of 16 Q. L. Five II PP. Grade three which is greater than 10 millimeters into the bladder. So the treatment options for him include medical management. PhD of course transmitted from microwave thermo therapy. My favorite trans regional needle ablation or tuna and homey um laser in the creation of the prostate and of course prostatectomy. So we have our cd recon done by our astute P. Dy three Ir resident over here. Mr Carlin. Doctor Darlin. So he did a nice recon here. You can see how large the prostate here in blue. It almost looks like the bladder in this picture but it measures 248 CCs. And on the right as well. Next slide here we have another return done by dr Carlin. Ah This is the origin of the right side of the hip audacity and the prostatic artery which it looks like the type to in this case. Alright so uh we've got access with a 545 slender sheath. Uh And then we came down. You guys can see the floral feed. We came down the arch with a Uh aqua vert for French vert which is 125 cm and a Benson wire. Um You guys can see the anatomy here and this is actually a pretty tricky iliac anatomy. It took us a few minutes to actually get into that internal iliac on the right side. But we're able to do that uh with a glide wire. And this was our first NGO. And you guys can match that up with what we saw in the pre C. T. A. So I do a C. T. A. And pretty much every case for several reasons. I think we talked. I know someone was talking in the previous case about planning and I think this is a key part of planning for our, for our prostate civilizations to find out exactly what we're gonna be dealing with. So this is a two point oh two room oh pro great micro catheter with an 016 fathom wire. Okay. Um, we are going to sort of just, it looks like we're pretty deep into the vessel already. So we're going to sort of stop here. We're gonna take our wire out. We're gonna do a quick little angio. Thanks. Let's go a little harder. They're pretty big. Yeah, it's very tortuous and we're basically hugged. I I'm using, I'm using 200 hydro pro rule. Okay, These are 200 hydro pearls. These are the Toronto hydro pearls, 200 microns. Aaron, do you use cone beam ct and elbow guide routine? I am not using Ember guide or cone beam ct in cases like this. I'm going to echo what you said rahul. We use cone beam cT in problem solving cases. We don't necessarily use it in every single case. Um, that's just been my philosophy recently. But I think um, BMC T is a very, very useful tool um, as the panel is as accurately described, but I think in a case like this, it's probably not necessary. I typically will give nitro before we analyze. We sometimes will even give verapamil. Uh, there are some cases where I think we can use verapamil to get the vessels the collateral vessels to change, but we didn't really see any here. Um I'm sorry. We didn't get a chance to discuss the the images. But this is a big prostatic artery as you guys can see. So we're just symbolizing and then we're almost done with a complete vial of particles on this one side, wow, impressive. Hey rahul, I have a question. Can you hear me? I can hear you. Um I don't do PhD but I'm curious is there any literature or any experience in inter arterial lidocaine injection to reduce pain afterwards? Because we do that routinely for you fee. And it's very helpful do any of the panelists do that? No. Um There we don't see a lot of post post procedural pain. We see a lot of the this area and burning um hesitancy. We're starting to actually see a collateral here. You guys can see that very um very subtly on the monitor here. So we're gonna take a one X. As we inject sometimes. That helps sort of get a sense of what we're dealing with. But this is actually that's probably not not actually. Maybe it is a collateral. What I will tell you is that we're going to probably put a coil in this artery at the end of the procedure. And I know that we we've talked about this in the past but this is just something that we've been doing and we've been studying this for for a little while now. We've had really good results. Um in terms of repeat procedures or not having a repeat procedure and um uh potentially decreasing the recurrence rate. Yeah. Alright that was a two millimeter C. X. Coil for laid down pretty nicely. And you know as an electrolytic detachment there we call it the pickle. That's good. Sorry four millimeters rule four millimeters four millimeters four millimeters. You guys can zoom in on the on the detach er for us. You guys can see that. Mm Well we're actually almost done but let me let me just go back and we'll show you what we're dealing with. I sort of want to get everybody's thoughts. So we did call that artery on the other side. We'll talk about that in a second. You guys can see that's hub, that's the 125 vert. And so we're just into the origin and and and this patient's not super tall. So this is one of the limitations obviously but we have longer catheters. Now if we really wanted to uh to go and use like a 1 30 potentially even a 1 50 now that we have the true select, we can use a 1 75 micro catheter. So we have a few more options in terms of length so that we we think this is a type four origin. We were sort of unsure on the on the C. T. So this is this just sort of confirmed it for us and you guys can see it on the screen there. Um And then basically we took the pro grade two oh the alpha as rahul was talking about. And we just probed around that origin. We we got down into that trunk there And we saw it and so we went into it. Uh it took a few minutes to get in. We used the just a regular fathom wire fathom 16 it's sort of a smaller vessel than the other side. The other side was like a eufy right? It was a hose. Um and we used almost a full vial. Maybe 3/4 of a vial on the right. This was interesting. So we gave a little bit of nitro here um as as Francisco was talking about. And then we did a we did a very slow injection. Try to figure out exactly what those branches are. I think some of those initial branches, we're probably going posted early to the rectum. I think everybody on the panel can weigh in and tell me if they agree. And so we pushed the microcap they're a little bit further in to about here and we did two views. I know Francisco loves to views right? We did a bleak and we did a cranial caudal ap and we see a lot of prostate blush on that image. And so that's where we're emphasizing from. So I usually use about the same size particle but I I do like the concept of upsizing these this is my favorite size right now. But I go back and forth about what I like to use. I think this size the 200 micron hydro pearl sort of fits into all the categories that I want to achieve with these embolization. I wanted I want a little bit more distal penetration, But I don't really like the 100 size anymore. I think that you get a little bit too much uh post operative side effect for the first few days. And so I I sort of Like these but I could up size them potentially to 400. And I know you know there's really no no data supporting that. Smallment sizes are better, at least between the 12 threes and the 3-5. Um And you know that very well Francisco but I think uh I think in this case it's relatively straightforward. I'm gonna go ahead and finish this vessel and then maybe we'll do a repeat angie on this side uh to see if there's another branch feeding it like the post, your lateral needs more imbo I look for 3 to 5 beats stasis. But remember if you you may get reflux before you get stasis and you may actually get collaterals uh potential collateral that are forming or not not forming, but that are that are pacifying before you get to that end point. So I think the endpoint is really one of those things whether you see too much reflux or you see um collaterals or you have stasis. So one of those three. And that that's that's generally how you know I'm very vigilant about watching. I think some people when they do these embryos not necessarily prostate but maybe you fi intermittently floral. But I do I floral constantly and I sort of save all my floral time for this part. I try to minimize my floral time before. But um are our floral times have been very good as of late with these with these new uh dose minimization platforms that we have. And so we're really not having any issue with dose. I know that's a big criticism for some of these uh these embryos were starting to get a little reflux. So to answer your question we're probably close to being to being done with this spot and then we're going to do a little perfected. Here we go, a little more distal. Um We're gonna go real slow here when we do the D. S. A. Alright let's go real slow about as slow as we can go. Really slow with the three. This is a three CC syringe. Okay I like the way that looks but I still think we can go more distal. You can see that branch going down at the bottom. That could probably let me see that wire. Let's see if we can get a little further in. So we have a little bit of you know our our catheter is getting close to the end here. Yeah but they're starting to work on your wife. No I have pretty good torque. It's just I think that it's gonna be hard for me to actually find that origin. Unless I do a different oblique. And you can see the real benefit of perfected here because we're actually getting a lot more distal penetration to that bottom branch. And I'm gonna take a one X. Here just so you guys can see. But you can see that the the lower part of the gland, maybe not so much the median lobe um is feeling pretty dramatically here. 100% agree. I think um you can look at it both ways because if you take out that branch completely then it won't be a source of recurrence potentially at least through the main artery. You will you will see it through the collaterals. Um And so that may be the poster or lateral branch or maybe the Pew dental branch. It could be the superior particular branch. Any of those three are probably the most common in my experience. But our recurrence rates have dropped a little bit since we started doing this. And so I I'm hopeful that the data that we present this year at S. I. R. Hopefully will. Uh well we'll show that that's okay. I mean we're just symbolizing we're getting a great embolization on this side. And we talked about endpoints were basically at that endpoint now um we're pretty distal. We could probably go a little bit more distal but I think we're filling up that bottom uh segment of this artery very well uh with not very much reflux and as Catherine performing really well. This is our, you know, second side with the calf. There are no issues, no kinks, nothing. Um So I'm pretty happy. I'm just gonna show you guys a quick one X. Of the stain sometimes. What I'll do at the end is I'll do a cone beam ct of the entire gland. But what you typically see is only the lateral side that you just m belies unless you're using a radio opaque bead. Um and which we're not, we're using the 200 hydro poles as I mentioned. So um we're gonna drop a coil here actually. Um you can go ahead to go to room two, we're just gonna finish this and then we're basically done. We're gonna put the tr band on and we're gonna get out of here. Alright. Sounds good