Prostatic artery embolization performed in anteroposterior projections versus steep oblique projections: single centre retrospective comparative analysis

Abstract

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.

Angiographic Imaging of Prostatic Artery Origin in a Greek Population and Correlation With Technical and Clinical Aspects of Prostatic Artery Embolization

“…Type III is considered probably the easiest type for PA catheterization because the obturator artery is almost always easy to catheterize and because of the favorable angle of PA origin from the obturator [ 2 , 8 ]. Moreover, types III and IV appear to be more suitable for the application of the ’’AP-PAE’’ approach, which is easier and associated with lower radiation exposure compared to standard PAE with oblique views [ 13 ].…”

A Retrospective, Single-Center Study of Technical-Procedural Factors Affecting Radiation Dose During Prostatic Artery Embolization

“…AP-PAE was another effective dose-limiting technique in both simple and multiple regression analyses. As emphasized in its original description [8], AP-PAE relies heavily on preprocedural CTA and is more likely to succeed in cases with larger PAs and with favorable anatomy. Compared to this first report, in the present series, AP-PAE could be successfully applied in significantly more patients (52.5% versus 26%), perhaps as a result of the newer equipment and of increased experience; AP-PAE failed in less than 10% of the patients in whom it was attempted (three patients, eventually excluded from the study), and even in these cases, the additional dose attributed to AP-PAE was negligible.…”

“…Although these projections are fundamental in the delineation of the prostatic artery (particularly its origin), they are also associated with significantly higher radiation doses than anteroposterior (AP) views. With a recently described approach [8], it is possible, in cases with larger prostatic arteries and with favorable anatomy, to perform PAE utilizing only anteroposterior fluoroscopy and/or DSA (AP-PAE). In the present study, AP-PAE was considered as having been successfully applied when embolization of the prostatic artery of at least one pelvic side had been accomplished with AP projections only.…”

“…However, the utilization of such a low- dose protocol has not been reported in large PAE studies. PAE with anteroposterior (AP) imaging only and intentionally unilateral PAE have also been proposed as options to limit radiation dose [8,9], but they have not been adequately validated yet. Further research is therefore required to extensively test existing and newer approaches for the reduction of radiation exposure during PAE and identify the most efficient and practical of these solutions, which could be incorporated into the standard PAE procedure.…”