Prostatic Artery Embolization (PAE)

1. Introduction

• Informed written consent was obtained.

2. Set Up

• The patient was brought to the procedure suite, and placed in the supine position.
• A timeout was performed.
• Both groins were sterilely prepped and draped.

3. Access

• Local Anesthetic was given.
• The right common femoral artery was punctured with a 21-gauge needle.
• A 0.018-inch wire was advanced through the needle into the right common iliac artery and aorta under fluoroscopic guidance.
• The needle was exchanged over the wire for a 5 French coaxial transitional dilator, which was exchanged over a 0.035-inch Bentson wire for a 6 French sheath, which was connected to a pressurized dilute heparinized saline infusion.

4. Mapping (Angiography)

• Contrast was injected through the side-arm of the sheath with imaging over the right common femoral artery.
• This demonstrated a normal-appearing right common femoral artery with proper positioning of the femoral artery access for use of a vascular closure device.
• A 5 French CONTRA2 catheter was advanced through the sheath and formed in the intra-abdominal aorta.
• The Bentson wire was then advanced and both the wire and catheter were advanced into the left iliac artery and subsequently the internal iliac artery.
• The wire was removed, and a digital angiogram was performed.

5. Vessel Selection

• Angiogram from the left internal iliac artery demonstrated a large artery supplying the region of the prostate extending from the anterior division of the internal iliac artery.
• A Fathom® Steerable Guidewire and Sniper® Balloon Occlusion Microcatheter were advanced into the anterior division.
• A repeat angiogram was performed.
• The origin of the prostate artery was identified as coming from the internal pudendal artery.

6. Embolization

• The microwire and microcatheter system were advanced into the internal pudendal artery and into the prostate artery.
• Contrast injection confirmed positioning.
• A cone beam CT was performed, which confirmed the absence of nontarget embolization vessels.
• 200 μg of nitroglycerin were injected through the associated catheter. An embolization solution using one vial of 100-300 μm Embosphere® Microspheres and approximately 11 mL of contrast totaling 20 mL was mixed. The balloon was inflated, the vessel was embolized to stasis. The balloon was deflated, and further embolization was performed. A total of a fifth of a vial of Embosphere® Microspheres was administered from this location.
• The microcatheter and microwire were removed.

7. Repeat for Contralateral Blood Supply

• The CONTRA2 catheter was retracted and advanced into the infrarenal abdominal aorta, and then, along with the Bentson wire, the internal iliac artery was selected.
• It was then confirmed with contrast injection and a digital angiogram.
• Digital angiogram from the right internal iliac artery demonstrated the likely prostatic supply to extend from the anterior division of the internal iliac artery, likely from branches of the obturator artery.
• Through the CONTRA2 catheter, a SwiftNINJA® Steerable Microcatheter and Fathom® Steerable Guidewire were used to select the anterior division of the internal iliac artery.
• An angiogram demonstrated the prostate being supplied from branches of the proximal and distal obturator artery.
• The catheter was advanced into the distal obturator artery.
• An angiogram demonstrated some supply to the prostate, but a sufficiently selective position could not be reached.
• The catheter was withdrawn and used to select a more proximal branch of the obturator artery.
• Angiogram and cone beam CT confirmed supply to much of the prostate.
• 200 μg of nitroglycerin were administered. Under fluoroscopic guidance, 10.5 mL of the 100-300 μm Embosphere® Microspheres were administered until collateral vessels opacified.
• Having achieved stasis, the procedure was terminated.
• The microcatheter was then removed.

8. Closure

• A Bentson wire was advanced through the CONTRA2 catheter.
• The catheter was removed.
• The sheath was then removed over a wire.
• Immediate hemostasis was achieved at the right groin with a 6 French Angio-Seal™ Vascular Closure Device and 2 minutes of manual compression.
• A sterile dressing was applied.
• The patient appeared to tolerate the procedure well.