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Background To present and evaluate an approach for reduction of utilization of steep oblique angiographic projections during prostatic artery embolization (PAE). Methods Single-center, retrospective study of patients who underwent bilateral PAE (from October 2018 to November 2019) and in whom it was possible to embolize PA of at least one pelvic side utilizing anteroposterior projections only (AP-PAE group), with the following techniques: Identification of the origin of PA on anteroposterior angiographic views. Utilization of anatomic landmarks from the planning computed tomographic angiography. Distal advancement of the angiographic catheter or microcatheter in the anterior division of internal iliac artery. Gentle probing with microguidewire at the expected site of origin of the PA. The AP-PAE approach was initially applied to all PAE patients during the study period and when this approach failed, additional steep oblique projections were acquired; patients who underwent bilateral PAE, with both anteroposterior and oblique projections for both pelvic sides, formed the standard PAE (S-PAE) group. The AP-PAE group was compared with S-PAE group in terms of baseline clinical and anatomic features, technical/procedural aspects and outcomes. Results Forty-six patients (92 pelvic sides) were studied. AP-PAE was feasible in 12/46 patients (26.0%): unilateral AP-PAE in 9/46 patients (19.5%); bilateral AP-PAE in 3/46 patients (6.5%). AP-PAE group had larger prostates (p = 0.047) and larger PAs (p < 0.001). Body mass index (BMI) and other baseline features were comparable between the two groups (mean BMI, AP-PAE group: 27.9 ± 3.6, S-PAE group: 27.0 ± 3.5, p = 0.451). Mean fluoroscopy time and dose area product were lower in AP-PAE group (46.3 vs 57.9 min, p = 0.084 and 22,924.9 vs 35,800.4 μGy.m2, p = 0.018, respectively). Three months post PAE, comparable clinical success rates (11/12 vs 31/34, p = 0.959) and mean International Prostate Symptom Score reduction (60.2% vs 58.1%, p = 0.740) were observed for AP-PAE and for S-PAE group, respectively. No major complications were encountered. Conclusion AP-PAE is associated with significant reduction in radiation exposure and appears to be feasible, safe and effective, but it can be applied in a relatively small percentage of patients.

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Prostatic artery embolization (PAE) has gained acceptance as a minimally invasive, safe and effective treatment of symptomatic benign prostatic hyperplasia. Radiologic imaging is an indispensable part of post-interventional evaluation of PAE and serves both clinical and investigational purposes. In this context, ultrasonography (US) has a central and multifaceted role. Gray-scale US is routinely utilized for measurement of significant outcome parameters (prostatic volume, intra-vesical prostatic protrusion and post-void residual volume) before and after PAE. Improvement of these parameters may become more obvious one-month post-PAE, or later. Contrast-enhanced US (CEUS) with intravenous administration of a second-generation echo-enhancer can demonstrate prostatic infarcts (as enhancement defects) immediately post-PAE and monitor their resolution over time. The volume of prostatic infarcts can also be measured and compared to prostatic volume. Prostatic infarction is a definite sign of the local efficacy of PAE and a predictor of prostate shrinkage and (at least in some patients) of clinical success. CEUS can also be performed intraoperatively in the angio-suite, for on-site evaluation of the ischemic effect; a variation of this technique, with intraarterial (instead of intravenous) administration of diluted echo enhancer, can also be applied intraoperatively, to map the embolized territory and to prevent non-target embolization. Initial experience with US-elastographic techniques (shear-wave and strain elastography) has shown that they can detect and quantify the improvement of tissue elasticity post-PAE, thus providing new insights into the therapeutic mechanisms of this treatment. With utilization of high-end equipment, experience and standardized imaging protocols, US could be the primary modality for imaging evaluation of PAE.

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