Prostatic Artery Embolization (PAE)

CHAPTER 1

Hi, I'm Dr. Raj Ayyagari. I'm an interventional radiologist here at Yale School of Medicine working in Yale-New Haven Hospital, and we're about to watch a prostatic artery embolization procedure. It's an angiographic, minimally-invasive procedure to treat benign prostatic hyperplasia, benign enlargement of the prostate gland. Typically patients can go for surgical treatment options including a TURP, a transurethral resection of the prostate, where they undergo anesthesia and a rigid metal scope is placed up the penis, and the gland is kind of shaved out. They can also have similar, maybe less invasive - slightly less invasive transurethral surgeries, like a green light laser treatment. This, however, is an angiographic procedure, which is even less invasive and carries far fewer risks and has a much shorter recovery time. Basically the way it works is, it's an outpatient procedure, the patient doesn't need any anesthesia at all, just a little bit of IV sedation medication. And sometimes it's not - actually it's also done for bleeding as well. The patient we have today, he has an enlarged prostate which has been causing him great difficulty urinating for several years but over the past 3 years he also had significant bleeding from his prostate, what's called hematuria, to the point where every time he strained to urinate, lots of blood would come out as well. Sometimes patients can even be in the hospital, in the ICU with life-threatening bleeding that's so severe that they need IV support for their blood pressure and things like that. Anyway, the way it works usually is, patients come in as outpatients for the procedure. We bring them into our angiography suite here, which is right behind me. Just a little bit of IV sedation and then the first step is to get access into the artery. So we can either go through the left radial artery or one of the femoral arteries. We just give them a little bit of local lidocaine anesthesia and then we put in a small 6 French or 5 French tube, which is just a couple millimeters in diameter, so no big incisions, no big cuts, no scars, no stitches. And once we put that little tube in, they feel a little pressure for about a minute or two, but once we are inside the second step is to kind of map out the arteries, and because patients don't - you don't have nerves in your blood vessels, really, you don't really sense that we're in there, so the entire rest of the procedure is pretty much painless. But we get inside and so the second step is we inject some dye and we map out all the arteries in the pelvis, and once we figure out where the arteries are that feed the prostate, kind of the third step is to kind of get selective with our little tiny microcatheter into the arteries feeding the prostate. Now, the second step, mapping everything out, is very important and kind of takes a lot of the time for the procedure because there are lots of arteries in the pelvis, they feed the rectum, the bladder, the penis, the prostate, among other things, and they can all be interconnected, and if we end up injecting our agent that we're going to cut off blood flow to the prostate with - if we end up injecting that into the wrong artery, you can imagine the results could be disastrous. So one has to be very careful, very skilled, and have a great knowledge of the arterial anatomy in the pelvis to make sure you are treating the correct arteries and not causing problems by treating the incorrect ones. So, we pick a side, usually, where we can access both the left and the right sides through the single access point, be it the wrist or the groin, and once we're in there, we - say we start out on the left side, for example, we steer our little catheter into the vessels, and then like I said, the third step is getting selective. We then map everything out again in that one vessel to make sure we are in - again, to confirm we're in the right spot, and once we're in the right spot the fourth step is just to inject the embolic agent. So for this procedure we use tiny little microscopic beads, they're typically 100 to 300 or 300 to 500 µm in diameter. We inject these beads, they're about the size of a grain of sand, and we just inject probably thousands of them into the vessel, and it's basically just like packing marbles into a drain, you just plug up the vessel and within minutes the vessel is shut down. We then slide our catheter out and then kind of repeat the process on the right side where we, again, get selective, and then once we map everything out we, again, inject the beads and kind of close up the other side of the prostate gland - the blood flow to the prostate. Sometimes the mapping just consists of an angiogram, like the images behind me here, where we just kind of inject dye and get a picture. Sometimes, to be more precise, we'll do what's called a cone beam CT, where the image actually - the camera rotates around the patient and we get a CAT scan right there on the table which really maps things out nicely and gives us a good 3-dimensional picture of the vessels and actually would allow us to kind of, with some pretty neat technologies, actually steer a catheter into the vessel using this 3D mapping technology. Anyway, once we're done, we take everything out. We take our little vascular access out and we close the little hole with, usually a little - almost like an absorbable little plug, which closes the hole right away. The procedure usually lasts around 2 hours, sometimes it's more like an hour if things are going very easily, very quickly. Sometimes, however, the vessels are very difficult to navigate and very small, and sometimes the procedure can take 3 hours or more, but on average about 2 hours. Once we're done, the patient goes up to the recovery area and just kind of is on bed rest for 2 hours. If we do it in the morning, we'll give them lunch, and then after about 2 hours we get them up and make sure they're okay on their feet, and then they go home. Usually, the day of the procedure, there's very little, if any, pain. Afterwards, once you cut off blood flow to the prostate, it will get inflamed, and in the first week after the procedure, they'll have usually a few days of inflammation which will then kind of get better over the week. Sometimes they'll get bladder spasms, sometimes they'll get a little rectal pain, sometimes a little penile pain, because all the nerves that supply the prostate are also very closely associated with these other organs, so any inflammation can kind of cause the whole area to get a little irritated. But it's usually pretty well managed with over-the-counter medications, ibuprofen and then a stool softener. We give a patient an antibiotic for a week, typically. Usually the second week, the inflammation is done, and they're kind of back to normal - the way they were before, I should say. And then the third week, the prostate really starts to shrink, and it's like going from a grape to a raisin, it kind of opens up and the urine can flow much more easily. If they've had bleeding issues, usually the bleeding stops right away. By the end of the fourth week, the prostate's really nice and open for most patients, probably about 8 out of 9 patients, and their urine flow is drastically improved and they really notice a significant difference. Usually, somewhere - the gland will continue shrinking over 3 or 4 months and usually somewhere in that period, if patients are on prostate medications, we'll stop the medications and get them off their medications. The medications can be quite, um, unpleasant to take, they can cause lots of side effects - decreasing sexual function, causing bad dizziness, so getting patients off the medications is always a great thing. And then sometimes we have patients who come in, they're so blocked up that they can't urinate a drop and they have these indwelling catheters, Foley catheters, and they're dependent on having that catheter their whole lives and that can be a terrible kind of impact on their quality of life, and also lots of risk for infection that can be very uncomfortable. So we do this procedure for those patients as well, who have these catheters in and can't get them out. And usually, again, about 7 out of 8 or 8 out of 9 patients can get their catheters out for good. But usually about one month after the procedure. Lots of patients who would normally come in for the typical gold standard, so to speak, of BPH treatments, the TURP that urologists do, there's another procedure on the market these days called the UroLift, which is quite popular. These procedures are really only for glands of a certain size. A normal size is maybe 30 to 50 ml in volume or smaller. Once glands get to the 50 or 80 ml size, that's, you know, enlarged prostates. 80 to 120 ml is a pretty big prostate. Those are usually the patients who are getting the surgical procedures, the TURP, the green light, the UroLift, perhaps. Once the glands go beyond 120 ml in volume most urologists won't feel comfortable doing these surgical procedures because they can be very long, they can be unsafe, the gland can just be too big to really work with and to take out enough tissue when they do the resection, so once patients get glands bigger than 120 ml, they really had very few procedural options before the advent of this procedure. Their typical options would be either having a catheter in place if they needed it, or getting a very invasive surgical prostatectomy, where they actually open the patient up and physically remove the entire prostate, which is a, you know, very invasive surgery. So, since this procedure's been developed, it's - we've been doing it for about 6 years now in common practice. It's a great therapeutic option for patients. And in our hands, at least so far, we've found basically equivalent results to the surgical procedures, the TURP, the green light, with far fewer side effects, a far lower level of invasiveness, and a much shorter recovery time, so it's a great procedure. But, that's prostate artery embolization.

CHAPTER 2

Alright, so this is our typical angiograph table. You want to say hi, Alyssa? Hello. Hi. This is our flush kit, saline and contrast, these are our syringes, this is kind of a normal, kind of standard angiographic table setup. And I'll take the Contra catheter, please. This is a 5 French angiographic catheter, which we will probably use to do most of our work. This is the table. These are the controls, these are the screens. This is just a protective shield. This is the angiographic machine and this is the ultrasound machine.

CHAPTER 3

And we start out first by getting femoral arterial access. We can do radial access, we can do femoral access, I typically do femoral access, but radial's a great option. And first we're going to mark our entry site with fluoroscopy looking at the, the bones. We like to enter more or less the inferior medial aspect of the femoral head. So we mark the skin based on the fluoroscopic landmarks, and now we'll use ultrasound to gain access into the artery. So we start with a very small 21-gauge needle. And - it's kind of the Seldinger technique where you start with a small needle and get access with a very small wire. This is 21 gauge. Little pinch and burn, sir. Get a little lidocaine in the skin. Needle goes in. Little pinch. Pop it in. We get a little blood dripping back. Store an image. That's it for the ultrasound, typically. Now we'll start with a very thin wire, 0.018-inch diameter. And we watch as it goes in to the femoral artery, and that's going smoothly. Could you slide the monitors a little bit more towards the head? A little bit more numbing medication here. And then so we use the Seldinger technique, it's a successive exchange overwire, through catheters, through needles, from a smaller system to a larger, fuller system that will allow us to actually do what we want to do today. So now once we have good, secure access, we then upsize things to a larger size that will be useful to work with. We'll use this transitional dilator, which will allow us to switch from the 0.018-inch wire - little pressure here - to the, uh - a 0.035-inch guidewire. And after... Okay. And I'll take the sheath. So now we're going to swap out over this wire for a 6 French sidearm access sheath, which Dr. Stevens is putting on. Just goes into the artery very easily. And, typically, that's it in terms of any discomfort the patient might feel. You can see it's just - once we kind of clean off things, it's just a nice small access. And this gives us all the access we need, typically, to do the procedure, and usually just - patients feel a little bit of pressure, a little bit of burning for a few seconds with the lidocaine. And then that's pretty much it. This procedure, a prostate artery embolization, is pretty painless during the procedure. So this - we're injecting a little bit of dye into the vessels to make sure we've accessed the artery in a good spot, which we have.

CHAPTER 4

So here's - now we're putting in this 5 French catheter. And we're going to try and select his other side. So we have all these different catheters that are all different shapes and sizes and lengths and, and they allow us to kind of steer through the body wherever we want to go, typically. So now this wire will go down his left common iliac artery if we're lucky. That's that. Pretty high bifurcation here, but hopefully we can deal with that. Okay, wire out. So we can steer this imaging equipment any way we want to get different angles. So now we're going to attempt to find his left internal iliac artery. I'm just puffing a little contrast in - and there it is. Can you cone in top to bottom? Open up, show me a little higher. Yeah. Good, thanks. Can we have an angle, glide, and a torque device, please? So now I'm going to do what's called a little road map. I step on fluoro. I inject some contrast. And then, I get a nice little road map of where I need to go. So this is a different kind of wire, it's a glide wire, which is very slippery and also has a tip on it, which is shaped so we can steer it around, help drive us into a certain spot. So I have the live image on the right and the road map image on the left of the screen. And I use that wire to steer myself into the vessel of choice, like that. And then the catheter, sometimes, like if you're lucky, like this, it just pops right in. Sometimes it's an hour long struggle to get this far. Take the wire out. And then we puff a little contrast to make sure we're in the right spot, which we are. Can we hook up, please? Now we're hooking up to this power injector here. Can you go forward on the injector, please? Okay, you can go back. So there's just certain obliquities we like, which will really open up the anatomy and show us what we need to see. So this is what's called an LAO, left anterior oblique, 30 degrees, and that's going to open up the branches of his left internal iliac artery. Let's do 3 for 12, 300 PSI, 0 rise. So we're going to do an injection here, which will map out everything for us. And we step out so we can look at the images on our monitors. So we have the patient do some breath-holding so he's nice and still during those few seconds that we acquire the images so they don't get blurry or misregistered. Okay, off. Could you freeze it for us? Thank you. So this - uh, go forward a few frames... Keep going. Okay, that's good, uh, go back to - One more? Go forward one. Thanks. So this is a view of his left internal iliac artery. And we like to map out everything and it can be very complicated, but this is basically the superior gluteal artery off the posterior division. Then you have his anterior division. This is his inferior gluteal artery. This is his pudendal - internal pudendal artery. This is his obturator artery, which has a characteristic Y, like a pitchfork appearance. And then you have to - once you've figured out all the major vessels, you then have to pick out the small ones and figure out which one is feeding the prostate. This is his - there's an umbilical artery, superior vesicular artery trunk right there, and then this, hopefully pretty large, and - now that I've said it, I'm going to jinx it - easy to get into, very large inferior vesicular artery, which will feed some of the bladder base, but usually at this point it's pretty much almost entirely feeding the prostate. His prostate's going to be right here. And so this vessel is feeding his prostate.

CHAPTER 5

Let's see, um... Can you give us a Sniper, please? And a Fathom wire? So now, to get more selective, we'll go from - so we have a 5 French catheter in, which is roughly about 2 mm in diameter, to a microcatheter, which is about - it's a 2.2 French, so it's basically about a millimeter in diameter. And this particular catheter has a balloon tip on the end, and - Can we have a Y adapter, as well? Has a balloon tip on the end so you can inflate the tip and then potentially kind of pack more beads in while not having beads reflux out. So the idea is here we're going to inject permanent beads, they're trisacryl gelatin, they're called Embospheres, is the brand. They go in, it's basically like packing marbles into a drain, once the beads go in, they stay in forever. They're like diamonds, they're forever. They plug up the vessel, shut down the flow, and then over time, over a few weeks to a few months, the prostate is starved of its supply, and it shrivels up like going from a grape to a raisin, which then opens things up, and then the patient's able to urinate a lot better. In some cases, lots of times, the patient also has severe bleeding from the prostate. An enlarged prostate can be quite vascular, and so in this patient's case he's had a lot of bleeding for - I think about 3.5 years, if I recall - if I recall what he told us in clinic, the bleeding would come on maybe every month or two. It would last for a week and a half, it'd be pretty severe. Uh, did you flush? Uh, 50... 50, 50. So we're priming the little balloon of this catheter. And I'll try to remember to demonstrate what it looks like afterwards, but we don't like to, um, unnecessarily inflate it before the procedure, before we put it in the patient, because if, if it gets a little big, then it can be a challenge to track it down all the tiny vessels, so... Alright, so, first... Load that in. So this little Y adapter allows us to hook this smaller microcatheter. And the balloon will be right here, but like I said before, we won't inflate it just yet. This will go coaxially through the outer 5 French catheter, which is in turn going coaxially through a 6 French vascular sheath. So this allows us to get progressively more and more selective into tiny vessels, and again this wire, just like before, is angled in such a way that we can steer it and direct ourselves into the, the vessel of choice. Alright, so bookmark that.

Alright so now I'm going to do another roadmap like we did before, just to help guide us in. Take a breath in. Blow it out, please. And stop breathing, don't breathe or move, keep holding, don't breathe or move... Okay, you can breathe normally. So that's our roadmap. So we're connecting, now, this little microcatheter through this little Y adapter to the 5 French catheter. Thanks. And now, we are going to, with our road map, drive our little microcatheter hopefully to our destination. And so, there's our microcatheter and little wire. So I think we need to put a, uh, bigger curve on the wire. So, this little wire that we have in here is a shapeable wire. So, in this particular case I need to put a sharper angle on the curve to find the vessel we wish to select. So I use this little thing called a shaper, which is just a needle, basically. And I take this, and I can make a bigger curve, like that. And so like I was saying before, typically once we get the access, the - this prostatic artery embolization procedure is pretty painless during the actual procedure itself. Patients will have inflammatory pain afterwards, but during the procedure, they - we just give them a little bit of sedation so they are typically awake and, uh, some people really are fascinated by it, and they'll actually want to watch the whole thing, which we do. So here I just selected the vessel of choice with the new shape of the wire - well, at least the vessel that I think we want. We'll see in a minute. But patients are usually just lightly sedated, they don't need general anesthesia. Like I said, there's very little pain with this, so, they're usually pretty comfortable. Sometimes, especially with this procedure, older patients have bad backs and just laying on the procedure table for - go ahead, wire out - for 2 hours can be a little painful, but, that's about it. So now we'll do a hand run. There it is. So... There it is, right there, nice, nice and big. So, we lucked out today. Alright, so, yeah. Another breath in. Blow it out. Please stop breathing, don't breathe or move, keep holding. Okay, you can breathe normally. Alright, so let's get the wire back in again. So now we have successfully found the inferior vesicular artery, which in his case happens to be quite large, which is probably why - or, a result of his large prostate that's been bleeding. It takes a lot of blood flow, and so the vessel that feeds it, over time, hypertrophies and becomes quite large. If we were doing this procedure in a young, like 30-year-old male with no enlarged prostate, we may never even see the vessel, but in this case it is very large, which makes our job lot easier today. I just have to find - there it is. Alright, so now, I'm going to slide our catheter over the wire into his inferior vesicular artery vessel. And get it around. Like that. Okay. So this drip out. Okay, wire out. We'll do a straight AP here for this run. And I'm going to inject a little more of the contrast here. And you'll see a picture of his left prostate. Take a small breath in. Blow it out. Stop, breathe - oh. Breathe normally. Okay, take another breath in. Blow it out, please. And stop breathing, don't breathe or move, keep holding. Keep holding. Okay, you can breathe normally. So that's his prostate, right there. The left prostate. There may be a few vessels feeding his bladder as well so we'll steer past them, but we'll get to that in a minute. So next is a cone beam CT, where we're going to basically do an on-the-table CT angiogram of his prostatic flow to make sure we are in the right spot and everything is mapped out, so we know the beads are just going where we want them to go and nowhere where they are not. Because like I said, these beads are permanent, and you want to cut off blood flow to the prostate but to nothing else. Can we go forward on the injector? If the beads were - okay, don't go back - if the beads were to go to another - an artery feeding another organ, like the rectum or the bladder or the penis, that could obviously be a bad thing, so we endeavor to avoid that, and the cone beam CT is designed to eliminate that risk. This procedure, the - it's otherwise pretty straightforward, but all the complexity and the risk is usually in either selecting the vessel, or - and/or making sure that we are not embolizing areas we don't want to embolize, so... Alright. We're all set up here.

CHAPTER 6

So now we're setting up a separate embolization table here. We make a little color-coded system, like a traffic light. Green is saline, yellow is contrast, red is embolization. So saline is green, you can just inject it without any worry, you can go, go, go. Yellow is contrast, not really going to cause any problems but you don't want to in put too much into a patient, so we just have to pause and yield to make sure we're doing the right thing. And then red is the embolization, so those are the beads. So you don't want to inject those unless you really are sure, so you stop, and just pause and make sure you're in the right spot before you inject them. And we keep this embolization table separate from the main table so that there's no accidental contamination, getting the beads on any of the other stuff because we don't want the beads to go down into his leg, into his other arteries. You know, we're working in his pelvis and his left or both legs. And so... So the patient just puts his arms up over his chest because we need a narrower kind of target to - when the camera spins around, when the imaging machine spins around. So it's going to spin around like that. It's a 200-degree acquisition. So they're centering him so that we get an optimized image. And we've injected nitroglycerin into his prostatic artery on the left side to help dilate it to prevent spasm or dissection when we're kind of putting our catheter through it, but also to open it up so that we can, kind of, hopefully pack more beads in and get a better effect. Okay. Breathe. So here is the coronal image. The patient's facing us, so this is his left, this is his right. And, uh, just move this out of the way. So this is his prostate. You can - and the white - all the blood vessels are filled with the dye so they're white so you can see all the blood flow to his prostate. And this big thing there, it's like a - a volca - So this is his bladder filled with urine that's filled - you know, that has dye in it, so it's more dense, so it's whiter. This is like a big volcano, this is called a median lobe, it's sticking up in his bladder. People without a large prostate won't have this, normally the bladder's a nice round thing, but this is this huge prostate. It's like a volcano, sticking up like an iceberg, and this is the part that bleeds, so you can see it gets a lot of blood flow to it. And this is what causes all of his bleeding and problems, and then this will also obstruct his urinary outflow. So, anyway, the point of this image is to make sure we're not putting beads into the rectum. So this is his rectum, and you can see there's a little bit of blood flow there, near the rectum, and - which is common, because a lot of these vessels are interconnected. And, uh - there may be some blood flow to his bladder as well. Let's look on... So these are ax - oops. This is an axial image. This is what most radiologists are accustomed to looking at. So, he's like a loaf of bread and each image is a slice. So this is towards his feet, that's the penis, the - pubic rami, or the - yeah, the pubic rami, and then here - so this is his prostate, we're going up towards his head. This is all the blood flow to the prostate, but there is some blood flow to his rectum, so we'll have to avoid that. And this is his prostate, so... And then I also look at the sagittal views to help me figure out where different blood vessels are. So, right now we're not very deep into this artery, we can kind of get deeper into it, more selective and bypass the vessels that feed the - anything that might feed the rectum or the bladder that we wish to avoid embolizing, and so, once we have this image, we can - This is called a MIP. A maximum intensity projection. And then you can rotate it around and get a good 3-dimensional view of things. But for my feeble mind, this usually tends to confuse me rather than help me, so, I just stick to the standard coronal and axial images, so... So this just gives the same information in a different format. This is the live images that were acquired that were used to construct those 3-dimensional multiplanar images. So this just shows us kind of the vessels in live action here. And so, this is posterior, and all these vessels, these little branches, are probably going to the rectum. His prostate's more anterior, so if we can just get our catheter all the way through here, we'll bypass all this stuff, which is feeding rectum and bladder. And actually you can see there, see, that's a little branch going up to his IMA there. So he's got what's called a rectoprostatic trunk, meaning one vessel feeds both his, uh... Let's see there. His middle rectal artery on the left, which then connects to the anastomoses to the, uh, inferior mesenteric artery, which is a separate vessel feeding his bowel. Um, so we will just have to get past that. So this gives me a good - allows me to select an angle.

So now - we just gave our patient some Toradol, which is an IV anti-inflammatory, because once we actually inject the beads, over the next few days, to sometimes as long as 2 weeks, as the prostate infarcts and shuts down it will get inflamed, and so we, uh, start with the anti-inflammatory right away. So now we're going to use the wire to gently get ourselves a little bit deeper into the vessel, right up to the prostate. And here you've got to be careful, because vessels are small and the slightest bit of trauma can cause dissections and spasm, which we learned yesterday on a case that we did at the VA. It was quite a challenging case. Okay, wire out. I think we're in a little too far into something - oh, no, that's great. Okay, so... Now, standard microcatheters will just be a tube, and um, you just have to get the tip as far as you can in where you want to go, and then when you inject, you just have to make sure the beads don't wash backward to the non-target areas. But this catheter, the Sniper microcatheter, has a little balloon on the tip, which I'm going to inflate now. And once you inflate the balloon it occludes the lumen of the artery, so that hopefully - if things go okay, the beads won't - it'll prevent the beads from backwashing. So let's see now. So now, we're just isolating the prostate, although there is a tiny little collateral there, that's going to go up to feed some bladder branches, but that will be very difficult to steer past and probably of no real consequence, so... Now I'm going to do a straight AP. Okay. Another breath in. Blow it out, please. Stop breathing, please, don't breathe or move, keep holding, keep holding. Okay, you can breathe. So that's a really nice view of his prostate. And like I said there's a tiny little branch going up to his bladder. I wonder if we want to get a little more selective. This is this tiny little branch that feeds - connects to a bladder branch. Not sure we're going to be able to get past it, though. Another breath in. Blow it out, please. Stop. Breathe normally. Okay, another breath in. Blow it out. And stop breathing, don't breathe or move, keep holding.. Okay, you can breathe normally. So I think it's right there, and it might be beyond or just at the bifurcation of these 2 main vessels, so I'd rather not take the chance yet. I'd rather put in beads now and kind of fill out as much as we can. And the flow is going to go this way and not - I mean a little bit might go that way but that's fine. And then once we get - kind of - we prune this a lot, then we can kind of get more selective. But I don't want to like, risk knocking that vessel out without having put beads in. Alright, so, the beads - let me just show for the viewing audience. These are the beads, you can't even really see them, they're so small. They're 100 to 300 μm. Some people will use - they come in different sizes and there's different brands. Some people will use 300 to 500 μm, I typically use 1 to 3s. There are even smaller ones, but lots of people think, and I believe correctly, that the smaller the bead, the easier it will pass through normal vessels into tiny little vessels and then even get through to other parts of the body, so you can get non-target embolization that way, but I believe that, at least, we've done about 125, 130 of these, and uh, almost all of them using the 100 to 300 beads, and have, knock on wood, to this point not had any real complication from non-target embolization, so, so I think - and we've had really good results, so I think the 1 to 3s, in our case, work pretty well, so - Alright. So now we're going to - so now, this is the setup here, we've got the red is the embolization bead syringes, the yellow are contrast, and we've got green saline syringes here. And we keep everything on a towel so that if there are any beads that leak out, we can kind of keep them contained on this one little area and then - so we don't contaminate the main working space. So, we like to mix thoroughly. And then we'll open to the patient, and then - we will start injecting the beads. And, actually, I'm going to go to... Eh, I'll just get rid of the road map. Alright, so, in go the beads. There's a little bit of contrast in the catheter that we're going to wash out, but... So now we are injecting. That's contrast. Now here come the beads. So we just try and do a nice gentle, controlled injection, so they don't go flying all over the place. Luckily - hopefully, we've - gotten selective to a point where that flying all over the place risk really isn't there anymore if we're good at what we're doing. Alright, so Dr. Stevens is slowly injecting the beads now into the left prostate. And I periodically change the obliquity to make sure everything is looking good in multiple angles. Step off fluoro for a second. That's a great picture, can you store that image, please? So this is his left prostate filled with the contrast and the beads, that's the urine-filled bladder, this is the median lobe, it's like an earth rise, like the astronaut pictures from the moon of the Earth. Yeah, I think so, yeah. Fluoro? Or it could be a seminal vesicle, even. Okay, go ahead, inject. Alright. So how much is that so far? Is that just the... Okay. Keep going. So we just periodically reload. You don't want to use too big of a syringe, because then it's really hard to keep the beads mixed and suspended well. If they're not mixed and suspended well, they can clump, and then you'll get - they'll clump too far upstream and they won't penetrate the capillaries very well, and then you'll get a less optimal penetration of the gland with the beads. And then presumably a less optimal infarct of the gland and less optimal effect, so... So this is the little inflated balloon of the catheter and it's nicely keeping the flow forward, away from those rectal arteries. So after you finish that syringe, why don't you clear. then we'll do a little hand run and see where we stand. Looks like it's slowing down a good amount. That's the problem, like, you can't, um - it's a different kind of endpoints with the Sniper, since you don't have the constant inflow, but I think that may be headed up to that bladder branch, so... Hmm, you can finish that off, little bit's okay. Just go slower. Smaller aliquots. Doing okay? You've given 102 so far? Okay. Alright, so now Dr. Stevens is going to, um, slowly, carefully clear the beads from the catheter, and we just do periodic interval checks to make sure everything's looking good and also to, uh, kind of figure out when we're getting to our end point. So that's bladder flow there, so slow down. Just give it a minute to sit. So we do embolization procedures like this all over the body. We do a very, very similar procedure for uterine fibroids in women. It's actually a very similar situation. It's hormone-induced overgrowth of benign reproductive system tissue. Women can go and have hysterectomies, surgical removal of the fi - of the uterus. They can have myomectomies, where they just remove the fibroids. Patients can also select to have uterine fibroid embolization, where we do essentially the exact same procedure except the arteries are feeding the uterus and the fibroids rather the prostate, but it's very similar anatomy, very similar technique. We just inject the beads, and then over a few months, the fibroids shrivel up and shrink down. And the patient will have cessation of their bleeding and then lots of improvement in their symptoms, the bulk symptoms, the fibroids pushing on the bladder, the rectum, just causing all sorts of problems. We also embolize tumors, malignant tumors, hepatocellular carcinoma in the liver. We do lots of embolization for emergencies, GI bleeders, pelvic trauma, splenic liver trauma - Yeah, let's do a run. So... That's okay, just shoot it. Gentle, because you have the balloon. Uh... okay, off. Inject more, like, I want to see - I want to see what this is. Because there's something pumping in. I don't want you to... Push it, really fill it. Okay, off. I don't know what that is yet. Do that again in straight AP. Just tap fluoro first to see where we are. Just use the 3. So now we have basically just pure, almost pure flow, just bladder, this is all bladder flow there. Coming across here, this is probably the base of the bladder. And then there's even crossover to his right side. This is a branch that runs along the pubic symphysis, and as you can see, branches out there, sometimes that'll even go to arteries feeding the penis. So there's all sorts of collateralization throughout the prostate and the pelvis. So now, it looks satisfactory, but, there is a man by the name of Francisco Carnivale in Brazil who's kind of the pioneer, the founding father of this technique - so take this back over - he has shown that, um, you can get a very good proximal embolization, but, if you actually then sink your catheter deeper and deeper in the prostate, there'll be actually lots of areas that still remain not maximally embolized, you can pack in more beads. So what we're going to try and do now is, uh, steer our way deeper into the prostate and see if we can pack in more. Let's see how things look without the balloon inflated. So you can see, comparing this to that, all this prostatic flow seems to be gone. But now we'll see how much more we can actually get in there. I think we can still pack in, even at this point, a significant amount more. Alright, so that's going easily. So now we're going to track our catheter in deeper into the prostate, if we're lucky. Take the wire out. So that's prostatic there. It's the periphery of it, so I don't know how much that's really going to help, but we might as well - we're here, so we'll pack some more in. So I'm reinflating the balloon gently. And now, Dr. Stevens brings over the little towel with all the embolization stuff on it. So we're going to reload. Alright, so we're just going to gently pack in a little bit more here. See if it'll go. So now I'm going to go straight AP because I want to watch what crosses over to the right side. And then also what may go down to the pubic symphysis and below. So I don't want anything to go past that point. Just give that a minute. Because a gland that big and vascular, I would expect it to take a little bit more than we put in. So that's ureter. Those are ureters. So that's the J-hooking of the ureter. And I'm pretty sure that's venous, but it could be seminal vesicle too. Never really sure how to interpret that. I feel like a couple - Actually, well, we can see on the cone beam for the right side... If - what those are. So, deflate the balloon. And we'll do a follow-up injection here to see how things look. Alright. So that looks pretty good, just a little bit of flow along this little vessel, it crosses over to the right, which is at the base of the bladder. I don't think that's prostate at all. So then, pull the catheter back. Maybe to here. Do another run. And so we've got... Preserved flow to all the things that we wished to avoid. And... No flow to anything that we wanted to embolize, so that looks pretty good. Okay, so that - so then, in the end, I wasted, over there, 3.5, right? Is that what we said? So, on the left, we injected 6 - I'm sorry, 4 cc. Okay, so now we have treated his left side, now we'll move over to the right and do basically the same thing.

CHAPTER 7

So we're in the LAO projection, which is what helped us select the, uh- to open up the vessels of the internal iliac artery. That's called an ipsilateral oblique, when you're obliqued toward the side that you're working on. This is contralateral to the right side. You like a contralateral obliquity to open up the internal and external artery iliac arteries, which is now what we're going to do on the right. So we're already positioned to start working on the right side.

So I pull the catheter back, so it's up into the aorta right now. Then I'm going to... Push it up a little, then twist it around. So it goes down his right side. And now, I puff a little contrast, looking for his internal, which is way down there. It's right there. We just slide into it. And then, now that we're in the internal iliac, we shift to the ipsilateral oblique on the right side, so this is RAO, right anterior oblique, 30 degrees. And I puff a little, make sure we're in, which we are. Can we hook up, please?

We'll have to see, but... So this is superior glute, inferior glute's coming off the superior glute, which is a common normal variant. So that's the posterior division, and then you got iliolumbar and lateral sacral vessels. The anterior division is from here onward, which is comprised of his internal pudendal, which is this, I think? Yeah. Which goes down and supplies a lot of the penis. The perineum, the rectum - sorry, the anus. This is the obturator, again the characteristic kind of pitchfork Y appearance, which opens out over the obturator foramen. And then... This, I believe, is a - looks like kind of a common vesicular trunk, his inferior vesicular... Okay, so, it's a little jumbled here. See, there's this thing. This is superior vesicular umbilical, that little aneurysmal thing, there's like a very narrow neck, and then - Then there's this thing, which I think is a double density in 2 vessels, and this is his rectal, middle rectal. And I believe this is - his inferior vesicular comes around. But if you notice, it doesn't really... This is prostate there. Right? But it doesn't really fill out all that well, which makes me wonder where the flow is here. And then you look on the obturator, and there's this branch, which then seems to really fill something here, right? And that's going to be the lower part of the prostate. So we may have 2 feeders. I think the, uh, obturator one is going to be the easiest to check first, and it may end up - sometimes you just get intraglandular, kind of cross flow, so you can get into one and fill the other. So, let's get into this one first and see what it gets us. And it may be this is not prostatic and it's just kind of pelvic sidewall, but, we'll just have to explore.

So there's commonly a little side branch off of the obturator that feeds the pelvic sidewall, the medial pelvic sidewall, right along the prostate, which will look like it's feeding the prostate, but not really. But then, there's 4 kind of classic, or typical, origins for the prostatic artery, and the obturator is one of them, so... Sometimes it looks like it, sometimes it is.

So there's a lot of, uh, art to this, trying to select the right wire, the right catheter, the right stiffness, the right length, the right diameter, the right shape. And, um, so let's reshape this wire. Thanks. So this - yes, this doesn't even have a good curve on it anymore, so we'll change that. Yeah. So this wire is shapeable and reshapeable, so you can kind of find the, uh, the angle that you like, and if you can't, then you can kind of modify it. And sometimes after lots of use in the patient's body, it'll lose its shape. So sometimes you just have to refresh it a bit. Do not go back.

So - we're going to do a little problem solving here, there's a vessel - the left side - the right side of his prostatic supply looks a little more complex, or compound, at least, multiple vessels. And so we're going to do a cone beam CT here to kind of see where we are and make sure... I think this vessel's feeding his upper right prostate. So lots of bladder flow, you can see his bladder filled with the contrast, and then all the vessels scooping around it. I'm just hoping we can find - and see the little - There's some branch - going right to that median lobe right there. Must be really high-yield. Alright, so we're going to open up the images for the right-side injection. And one, now, we will see some staining from the - the dye and the beads that we injected into the left gland, which is all this stuff. And here, now we'll see flow also to his right gland, so that's the flow to the median lobe we discussed, and... Hmm. There's actually flow throughout the gland here. Hmm. So it's actually supplying more to the gland than I perceived. We need to get - really far in. We have to get... So here we're just kind of mapping out the 3-dimensional shape of everything. This is getting a little more complex here, so... I'm going to move over here. So Dave, I think what we are in is the superior vesicular, which is - see this flash there? That's the inferior vesicular. And then... It's - well, it's like, it flashes - it connects to here and then it flashes up. So I don't know where the origin is. So this - these are the same angle - projections here. See - so we're in - this one. We're filling - in addition to the branches, we're filling this. See that? Yeah. So I think, actually, we wish to be - we're - in this guy, which would be a lot easier to get into. I would assume. But now that we're here, I'm wondering if we can just get what we need from here. So one, there's no rectal flow here. And if we can just get past - I've just got to do a hand run, I think. Sometimes you can just get from superior into, like, branches into the inferior and just do what you need to do. Sometimes there's just too much bladder flow that you can't get around. And sometimes, uh, you just have to pull out. And then you have to pull out and get into the other one. How much bladder do you think this is? It's - that's not a lot, but then - I mean that's not bladder, but then when you look, I mean, all this, it is eventually getting to bladder, so I don't mi - what you're pointing to is this stuff, which is kind of like - I don't think it's really - we don't have to worry about that. But something, and it's a little hard to tell, but something is connecting in, and I can't really tell on these static images, so…

So there's usually an umbilical - three things that typically supply the bladder. There's the umbilical, the superior vesicular, the inferior vesicular, and they can either have a common trunk, or the inferior vesicular maybe have a separate origin someplace else. And classically, the inferior vesicular supplies a little bit of the bladder, the base of the bladder, and then most of the prostate, if not all the prostate, on a given side. In him, I think he's got a little branch off of the superior vesicular feeding like that iceberg, median lobe, tip of the prostate, and then probably the inferior vesicular's supplying kind of the upper half, and then I think maybe there's this little kind of aberrant branch off of his obturator artery, which is supplying the inferior part of the gland.

Uh, yeah. Or at least, the tiny one that's feeding that median lobe, I can't - I don't think I can target it because it's - to get there, I'd have to go through all these bladder branches, and I don't think it's worth the time and risk to do that. Okay. Um... So I kind of - I looked at that one and I - although I felt like it was - would be nice to get, I kind of gave up on that, like just chose not to go after that. Now I'm checking which, classically, would be the the flow to the prostate, the inferior vesicular on his right. And we had tried previously to get into the obturator branch, thinking that was going to be the easy one, but, it wasn't, so we just kind of temporarily gave up on that one, with a plan to go back. But sometimes, you try one and it's really hard, and then you get into another and it turns out the other one feeds the whole prostate anyway and they both interconnect, so you can get at it - kind of get both regions from one vessel. So that's why I chose to give up on the more difficult one and go after an easier one and see. He's got confusing anatomy on the right side. And so if we're doing this in the liver, there's not a whole lot of - areas that you can embolize and cause problems, you can just kind of be a little bit more liberal. But in this area, obviously we don't want to infarct his bladder or his penis or his rectum, so we have to be very careful. Alright so there's prostate flow there. Unfortunately not up to his median lobe, but, maybe near it, and - so there's all this stuff in there, which, as long as it's not feeding the rectum, or the bladder, I'm not too worried about it, because it's usually just kind of like seminal vesicle flow, or just, I don't know what to call it flow, like just - just pelvic, whatever, fat, soft tissue, that... Um, but if you notice, there's something connecting to his pudendal, but that may just be overflow - backflow is what I think that is, because we injected over - kind of overinjected here on purpose to really fill things out. So I think we can get a little more selective here and then embolize. And so, see this thing? There's something running along the back of the prostate there. That can hit - that can be - there'll oftentimes be little branches going to the rectum, which you have to be careful of.

So while Dr. Stevens is injecting the beads on the right side, I'll tell you afterwards, when we're done, whenever that is, with the procedure, we'll do a little vascular closure on the 6 French femoral arteriotomy. We'll just use a device called Angio-Seal, which just puts a little dissolvable kind of collagen plug to plug the hole up, which will degrade and kind of go away after a few months. And then, if that seals correctly, which it almost always does, he'll just be on bed rest for 2 hours up in the recovery area, during which time he just kind of relaxes and hangs out, eats lunch. And then after 2 hours of precautionary bed rest, just so he doesn't get bleeding at the access site, he'll, uh - get close to the patient - we'll get him up, make sure he's okay on his feet, make sure he's able to urinate as well as he was before we did the procedure, which for a lot of people is very poorly, but, just to make sure he's not any worse than he was, which sometimes they can be, just from acute inflammation and swelling of the prostate. But as long as he's able to urinate as well as he could and no other issues, which is almost always the case, we send the patient home. And then they usually just go home on a week to two of antibiotics, just as a precautionary measure. The main pain control for this will be just over-the-counter ibuprofen, so Advil or Motrin. And then we put them on an over-the-counter uh, kind of a urinary antiseptic or kind of anti-inflammatory called Pyridium. And we give him an over-the-counter stool softener to make sure he doesn't get constipated and then we just tell him to stay really well hydrated. Some patients will get some bladder spasm afterwards, so we'll give them an anticholinergic - two medications, one's VESIcare, another is oxybutynin. And um, that helps with bladder spasm. On average, they'll have pretty significant inflammatory pain, like a prostatitis, like a urinary infection kind of pain - why don't you stop there for a minute. For 2 to 3 days. Some people really notice very little, some people it's pretty significant. On average it's 2 to 3 days. Some people will have it for a week, some people will have none at all. But again, usually pretty well treated with over-the-counter medications. And we tell people, usually the first week they'll be worse than they were, the inflammation - they'll get lots of urinary urgency and frequency from the inflammation. The bladder spasms, like I said. And then also, they might get a little swelling of the prostate, which may make their urinary flow a little bit worse than it was, temporarily. The - week 2, they're usually back to kind of the way they were, and then week 3, most patients start noticing a significant improvement in the urinary outflow as the gland starts shrinking. And by the end of week 4, almost everyone is feeling a lot better.

So on this side, we - on the left side we used the Sniper microcatheter, which had the balloon tip on the end so it could really help us avoid reflux, and thus - the beads going elsewhere apart from where we want them to go. On this side, we used this SwiftNINJA microcatheter, the benefit of which, it allowed us to kind of really steer into vessels much more easily, but we gave up the advantage of the, uh - we traded the advantage of the balloon tip for the steerability, so because we don't have the balloon tip now, we have to be more careful about reflux and - so we have to be much more vigilant about that.

CHAPTER 8

Alright, so we are done, we have, I think definitively embolized both the left and the right prostate glands. So now we're going to give him a little bit more repeat lidocaine at the skin access site area, and then we're going to close that with that Angio-Seal device, which I told you about, which - here it is. Basically, this is a little introducer sheath that goes in. We take the access sheath out over wire and put this into the body over the wire, into the vessel. And then, it'll have a little squirt of blood out of the back hole up here. And that will confirm that we're in the right spot, and then once we are, this device - this part of the device gets inserted and there's a little - the collagen plug is right in here, but, like most things in interventional radiology, you can't see it till you put it into the patient so, unfortunately it's kind of sheathed here and not very obvious. So you're going to straighten out the Contra under fluoro. And then send your wire up. Pull it, pull it. Okay. Oh? That's funny. There you go. Okay. So do you mind if I put this in, just for the sake of the camera? Hopefully the GoPro can catch this, so... Here's our access sheath over the wire. This is what we've been using the whole time, we're going to - little pressure here - we're going to pull that out over the wire and hold pressure, and then... Just a little pressure for another minute or so, and then we'll be done, okay? All went very well. So this gets inserted - over the wire into the body, and once we are in, you'll see the little jet of blood there, pull back and that's just out of the vessel, then we put it in just another millimeter or two, just so we're right in. We take out the wire, put the little plug into the device. Once it's in place, we click it back - sorry, a little pressure here. Slide everything back. Push it down inside. Give me a gauze, please? And that taps down everything. Kind of, it's a little sandwich, basically, that - a little plug inside the vessel, and then a little plug outside, and kind of closes the hole nicely so we have hemostasis. Little uncomfortable for him. So we're going to cut a little string here, and then that's it. So then we should have nice hemostasis. Looks good. Okay.

CHAPTER 9

So this is the injection - the balloon port, this is the main port, the injection port. I hook up the syringe to the balloon. Can you see? Inflate the balloon. Like a little jelly bean. And then when I take the syringe off, this little valve keeps the balloon inflated. And then... Then we hook up a syringe to the main lumen to inject our beads or dye or whatever we want to... And then when we are done, it just takes a little while to deflate, it takes several seconds, but, it deflates. Slowly but completely. I probably overinflated it, here. So it's taking a little longer to deflate. Now it's deflated. So now if I want to... I can overinflate it and burst it, just for fun, now that we don't need it anymore. So if you overinflate it... Well, I guess this one's pretty strong. But that's - Wow, that's big. Alright. Well, it doesn't want to rupture, so I'm not going to make a big mess. But that's the full extent of the balloon. How much do you usually inflate it? Like, uh, point - there we go. Like 0.3, 0.2 - eh, 0.2 cc, maybe? Maybe, yeah.

The other microcatheter that we use, this is the - again, the SwiftNINJA. Some creative names. And this catheter, rather than having the balloon tip, the - its advantage is its steerability. So you can, within a patient, you can kind of direct it to go where you want to go. So that's also - so, the balloon was really helpful on the left, and this steerability was very helpful on the right, so, without these little devices, the procedure would be much more difficult and probably, a lot more of a challenge to make it - to keep it safe. So there it is bending back and forth. And that's by - I'm just twisting this little wheel. And then once we're in, we can lock it into place. Say, for example, there, and then we can kind of steer it around like that to kind of - like, by spinning it. So... Alright! And, this is all that's left on the patient when we're done. Just a small bandage, with maybe a little 0.25 inch little skin nick. And so now we'll get him upstairs to the recovery area for a couple hours.

CHAPTER 10

So we just finished a prostatic artery embolization procedure. This was a 63-year-old male who had a very large prostate. It was so big that it was actually - I don't know if you can tell from the pictures, extending into his bladder, almost like a volcano or an iceberg. He also had severe bleeding from it. So we embolized it. On the left side, the procedure was very, very straightforward, very easy, we got right into the artery. We used a microcatheter, this device, which has a balloon tip on the end, which allows us to kind of prevent any kind of backward reflux of the beads to the organs that we don't wish to treat. We used that device, it's called a Sniper microcatheter, and we injected the beads very quickly, safely, very easily, it was very straightforward. We like all cases to be like that, but they're not always, and on - when we went over to the patient's right side, it was actually a very complex, difficult situation. He had 2 or maybe 3 vessels feeding the prostate on the right side, and all of them were small and kind of difficult angles to get into. So we used another device called the SwiftNINJA - it's a nice name - microcatheter, which has a steerable tip, so that we could kind of get into an area, and once we've mapped things out we could actually turn the tip, it, it rotates like 180 degrees, and we're able to steer into these different vessels and then inject the dye and map things out. And actually 2 of the 3 vessels did supply the prostate a significant amount, and without the help of that catheter, it would have been a very difficult - even more difficult procedure. But we were able to kind of get in to these 2 vessels that fed the prostate, in the end, and embolize it successfully, without any, uh, evidence of any complication or problem whatsoever. Even with all that difficulty, the case just went a little bit over maybe about 2.5 hours, 2 hours and 45 minutes. Usually they're on average 2 hours. And it looked like we had a great technical result in the end. The patient did very well, without any pain or any symptoms. And we just finished, and now he's up in the recovery room, and we'll discharge him later today in about 2 hours.