This 65-year-old patient with urinary symptoms associated with BPH and reported low quality of life had a successful PAE to relieve symptoms with no sexual side effects. Dr. Fischman walks through the procedure step by step, from insertion of the catheter to use of specialized catheters and wires to reach the prostatic artery, review of the anatomy, and insertion of beads to block the flow of blood to the artery.
Alright so we have a 65 year old male with BPH symptoms include weak stream bacteria. Getting up 5 to 6 times a night frequency and urgency as I PSs is 14 was moderate and SQL is five. Next slide He has a PSR of 6.5. His trans rectal ultrasound also shows BPH aerodynamics show avoided volume of 94 Ml PVR 62 Ml. Q. Max of six Ml per second and an elevated cadet uh M. R. I. Prostate volumes 84 mL. And there's no focal, suspicious lesion to suggest prostate cancer. Next slide. So symptomatic Bph treatment options include prostatectomy, terp trans urethral a blade of techniques trans urethral implants on prostate artery ablation and prostate artery embolization. Um Next slide considerations in this case for going from a trans radial approach include patient height, whether we have equipment long enough to reach prostate artery, whether we're gonna use balloon occlusion techniques. Um The most patient positioning and the room set up for cone beam ct great. I actually marked the style oid process with a line here. Just so you can see the difference the distance between where we're gonna access which is about an inch above the style oid in this case and you can see how big that artery is. So this should not be an issue. I already gave a little lidocaine. Um And so we're gonna just center that and we're going to try to access it right above. Ah That dot that I made. This is a needle from the kit. Let's see if I can still do this. You see the needle going into the, into the vessel right there and if you look at the needle, it's actually dripping arterial blood which is perfect and you can let go of it in that situation. This is the wire from the kit. It should go without any resistance. If you feel resistance you should stop and floral. But I typically don't floor. Oh this is the new uh ideal sheath from Merit. This is 45. It's very similar to the 45 Slender. It's basically the exact same concept that you can put a five French catheter In a four French sheath. And I always have my finger over the puncture site when we do this just because I want to make sure that even a little blood that sort of collects under the skin doesn't create a bruise as we were talking about before. And I usually just take a little gauze and advance the sheath with the, with the gauze. It should go without any problem without a nick. Okay, so nice and smooth. I don't know if you guys can see that right in and then that comes out and now we're gonna put in our cocktail. So I mentioned before that our cocktail, there's a mixture of heparin, nitroglycerin and verapamil. You always want to put a little blood in the syringe, you can see that here, it's gonna burn a little bit, okay, the rap milburn's a little bit um some people using that card up in. But we typically use rap mill. We haven't had an issue with it. And now I'm gonna hook this up to a saline flush bag. And the reason we do that is because if we're doing an exchange of a catheter and clearly in this type of case you might have to do that. Um it's nice to have a flush running. So when you do the exchange, you don't build up clot. Uh we are in a oblique projection. We've already done a cone beam ct and we set up in propeller. So this allows us in a, you know, not super tall patient to put the head very close to the II so we can spin and still see the pelvis and then we can leave the left arm down. And that's what proprietary from phillips that allows us to do that. Um So let me show the floral feed. We were having some issues getting down with this. Benson wire. You guys can see we were sort of messing around here. We were worried that he had some sort of subclavian stenosis and he may actually have a subclavian stenosis. We were sort of seeing the I am a there and we saw the vert a little bit. So we were starting to think maybe we have to do groin. So we ended up getting down Marcin very successfully puffed himself into the internal iliac artery here with the use of a glide wire. We just popped in. Let me see here we go and that worked really well. We did a. D. S. A. And the anatomy is beautiful. Uh we we have a little reflux. This is a five for 25 injection. We have a little bit of reflux into the external but we were able to see very clearly the prostatic artery on this image. See the potential very nicely inferior gluteal. The vesicular looks like it comes off of where our catheters oriented directly into it. And you can see the vesicular branches sort of going north and then below the bladder. We see the prostatic arteries and we actually see the medium low very nicely here. So then what we did was put up a cone beam ct we actually started in this position here and we did a spin The next step. If you focus on the wrist we have a lot of catheter sticking out here. This is nice. This is the 1:30. Probably don't need a 1 30 in this case. But it's nice because this is oh four oh and it's going to allow us to put in whatever catheter we want. Um I have a 20 pro grade on the table. This is this is actually a A 2.1 French sector c micro catheter. Um I like to use the balloon catheters for prostate for a lot of reasons and we can talk, we're gonna talk about that as well. But if you see this, this catheter, there's a couple of markers here. And this balloon actually allows us to inflate in the proximal segment so we can get a little bit more distal perfusion in the prostate and prevent reflux and also reverse collaterals when we see them, if we see them in the parental branches. So this cone beam cT was was done at three for 30 with an eight second delay. And I'm going to scroll through the axle right here so you guys can see what we did. We see very nicely. Both the normal gland and the median lobe right here. Okay, so I highlighted both of those the same way you would highlight a tumor if you were doing vessel guidance. And this allowed me to pick those as my target. And then you attach a dot where you think your uh proximal vessel is. And then this allows you to find the vessels that are feeding off of the internal iliac into that prostatic branch. And so I usually rotate this into the projection that we are interested in which in this case was About 25°. It was this way. And it shows me not only that I'm covering the gland here, but I'm also covering the median lobe on the on the left side, which is exactly what we want in a lot of these patients. If we take a look at the floral feed, they very easily can related the branch here. So marston I think is going to do it might pull back a little bit and do a run So you really can't get more perfect than that. I guess the question is um what are we gonna do about that branch at the most inferior branch now? Art do you think that's going to the prostate or? No I think that's the lower branch. Maybe going to the prostate but there's a little bit of some perforation laterally. We could maybe do a flow redirect there. I think this is a capsule er branch coming down the lateral aspect. But I usually typically use cone beam ct as a safety check if I'm not sure. But it's a beautiful median lobe perfusion. I think a great idea here is to inflate the balloon. So we're gonna do that. Now. Marks is going to inflate the balloon. Uh and then we're gonna see if we can change the flow dynamics in that branch a little bit. Maybe we'll get more profusion. Maybe we'll get less. It's hard to predict the balloon sort of goes from those proximal two dots on this calf there. The sniper behaves a little bit differently. But now what we're gonna do is we're gonna do a gentle de esa to see if that changes the flow any nitro. We could use some nitro checked a little bit harder. Let's get some nitro mary lou. So it probably worked against us in this this situation. What do you guys think it kind of depends on how hard you're injecting because you don't know if it's the same injection both times. But it does look like you have that spasm, that segment of spasm uh in in the proximal prostatic artery. The other option is to re inflate the balloon and see if we can redirect the flow a little bit more. But it looked like when we before we gave the nitro most of the flow was actually it was redirecting the flow into the rectal branch and not the prostatic branch. So probably what I would have favored doing now is to repeat the NGO. And then maybe we'll calculate selectively the top branch. So we have a fathom 14 with the scepter. The tuo program which will probably use on the other side. Just because I think sometimes with these at least with the scepter it's hard to reuse it on both sides. Although sometimes you can. So that's what we're gonna do now. Um the anabolic agent that we're gonna use. And this is a I don't know there's some questions about anabolic agents for prostate and what the right sizes. The data. One of the initial papers by carnevale supports using the larger size. Uh and it being equivalent to the to the smaller size meaning 3 to 5 verses 1 to 3 if you're using the smaller size. It compresses a bit. And that sometimes can be a little challenging with potential collateral. So what we're gonna try to use today is the M. one Lumi B. This is without drug loading. Obviously this is very off label just so everybody knows this is not approved for this procedure. This comes prepackaged. And so I usually load this with a denser contrast material because the beads are very heavy. I used ice of you 3 70 in this case, which is appropriate. And that's in the I. F. You. But this will allow us to see where the beads go and they'll stay there and that's nice the size and I know Ari and I have talked about this quite a bit. The 75-1 50 size may be the perfect size for this for this procedure, mainly because these beads don't compress. So if you're using 100 to 300 MBS fear or 100 magazine, which are both approved for prostate embolization. The compression is a little bit more slow. Slow, slow. It's gorgeous. I think what what we might do is start with the balloon down. So why don't you do an angio with both? And we'll see the difference. Yeah, that's what we're going to show. Right slow. We're gonna try to do the same speed. I mean you can use the power injector but I don't like that here. You should you should angio like, you know, inject like you're going to symbolize very slowly. I think I usually do very slow and then I speed up at the end. That's what carnival taught us when we were down in brazil. That's, that's great. Um, you're seeing, I think you're seeing a little venus drainage at the end downward, which is, so let's do balloon up and see if it changes very gentle with this balloon. That's probably, that's it. That's all we need. Right, what do you think? That's nice. Beautiful. So I think we're good to go. I'm gonna do one CC at a time. So this is one CC of Lumi M one. Here we go. Wait, hold on. We could give a little nitro. So these are, these start to settle a little bit differently. I mean they are heavy, they're heavier beats. Um, you've got to really keep them mixed. See they're settling already. The carnival technique and this is the, this is how I learned how to do it is one ccm bolic, one CC flush, three CC flush repeat. Um, and that allows you to get more distribution. Again, that was without a balloon catheter. So that, that concept may or may not be necessary with a balloon. I'm not sure. I don't think anybody knows. So, you know, luckily, this was not hard to get into, but it looks like we clogged the catheter. So one of the limitations of this Catherine. This is why I don't love using it. Is that I think, I think this particular version of it. This balloon catheter is very finicky. So we're gonna switch to the to a pro grade which is my favorite cather to use for this. But I wanted I wanted to have the balloon as an option. Um It didn't help that much in this case so I'm okay with it. So what we'll do now and I think maybe we'll use a two week here. I don't know if you guys can see this exactly. This is the flow 40 device. Um It's a it's a very short TUI there's a shorter one but that doesn't have the sidearm. This one has the sidearm and this will allow us to get some catheter stability. Which is why I like it. Alright, we're gonna stop right here. We're gonna do a little run and then we're gonna start again interesting. Right? The flow changed quite a bit. I'm thinking maybe we should coil this. Um Can you get the wire all the way down into that uh into the eye pianissimo. Yeah that's what we're gonna do. Like R. E. Was saying very slow in the beginning this is the speed that you're going to inject the prosthetic artery. So I think it's safe to symbolize here because we're not injecting very fast. So I think we're gonna go a little more particles and see what happens here. Let's not clog the catheter, it's time. The nice thing about these particles. And this is good and bad. We could do a non contrast coming at the end of the procedure. And we're still going to see they will be careful. We're still going to see the the anabolic agent which is nice but it looks to me like we're getting it into the gland and possibly also the median lobe. We're just trying to be real gentle here. We're getting perfect. So what you what you're doing now, you can see the U. I. Call this the yo yo technique. Yeah. And so what you're you're seeing that anastomosis as you inject and the point is to not inject hard enough that it goes all the way down and your endpoint is going to be when you know you have a kind of pressure equalization right there. If you don't know you can point it you don't have a pointer but you can kind of see that anastomosis as it goes down as you inject and then it comes back up when you're not injecting. Um I know art spends a lot of time seeing uh seeing bph patients in his office and I'm hoping he'll for one minute just tell us how he's what he does to evaluate patients. Um This patient um had an M. R. I. We don't always do M. R. I. But I know everybody has different opinions about this. We always do some sort of cross sectional imaging whether it's C. T. A. R. M. R. I. But I think are probably has a very good and unique protocol that he might want to tell everybody about. Thanks Aaron. Uh I think the basic first step that starts with the questionnaire is everyone gets an I. P. S. S. Score when they come in and we track their progress once their I. P. S. S. Score becomes above eight 10 and we try medications and we offer them and if you know that about 20% of patients to 40% will fail medication just so they don't like the side effects. That really is a lot of opportunity. Especially when 85% of men Over the age of 45 have some signs of our of bph or lower urinary tract symptoms once they do and once they failed medication I think I do a standard work up which is a flow and a post void residual. I want to see how fast it's going and what's left in the bladder. I think those are two important things given the early adoption of PE and trying to be as diligent as possible to determine who's going to benefit, who won't. I do do your own dynamics. Um patients to assess their bladder bowel obstructions. I do not do assist though because I'm not going trans urethral for treatment of the procedure but they will get euro dynamics and a key thing if you look at the indication sheets for all the particles for PE they say no prostate cancer. I mean it's important to check patients for an elevated P. S. A. And if the PSC is elevated. I obtained an M. R. I. Of the prostate and make sure there's no suspicious lesions. And I have a discussion with the patient regarding prostate cancer screening. And it's a shared decision should they have a biopsy or not depending on what their PSA is. And that's a significantly long talk. But it's always important to get through that and at least have that address prior to treating patients and that you rule them out for having prostate prostate cancer. Once that's complete, I offer the patient the options I know P. A fits in a unique space because it's anyone with a prostate larger than 40 g and there's no upper limit ari what's the largest? You've done 607 50. You guys went uh he no he didn't. But it was it was more for it was more for bleeding at the time. It's great pictures though he materials a great presenting thing. The most common cause of grocery material being infection. The second would be grocery material secondary to BPH. I think people's practices as they change and they start addressing these patients. So there's a lot of opportunity to find patients for this procedure. You guys this has been a great discussion but I do think we are ready to go live in room one So we're going to switch over. I was just a space filler. Thanks Nora. Well, we can come back later. If we have anything interesting. We may do a cone beam ct. Thanks everybody.
