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Review
. 2023 Apr;24(4):313-323.
doi: 10.3348/kjr.2022.0814. Epub 2023 Jan 19.

Prostatic Artery Embolization: An Update

Tiago Bilhim  1   2
Affiliations
Review

Prostatic Artery Embolization: An Update

Tiago Bilhim. Korean J Radiol. 2023 Apr.
No abstract available

Keywords: Benign prostatic hyperplasia; Internal iliac artery; Lower urinary tract symptoms; Prostatic artery; Prostatic artery embolization.

PubMed Disclaimer

Conflict of interest statement

Tiago Bilhim is a paid consultant for Merit Medical and has received speaker fees for Philips Medical, Cook Medical, Terumo and is a stock holder for EmbolX.

Figures

Fig. 1
Fig. 1. Angiographic anatomy of the four major internal iliac artery branches. A. A roadmap image of the left internal iliac artery with a type A bifurcation (left anterior oblique projection of 35° with the caudal-cranial projection of -10°), with the posterior division giving rise to the SG and the anterior division having a short common gluteal-pudendal trunk that bifurcates into the IG and IP (arrow: superior vesical artery, dotted arrow: prostatic artery). B. Digital subtraction angiography of the left internal iliac artery with a type B bifurcation (left anterior oblique projection of 35° with the caudal-cranial projection of -10°) with the posterior division giving rise to the SG and IG and the anterior division giving rise to the IP and OBT. C. Digital subtraction angiography of the right internal iliac artery with a type C bifurcation (right anterior oblique projection of 35° with the caudal-cranial projection -10°) with the internal iliac artery trifurcating into the SG, IG, and IP. Of note is the proximity between the IG and IP during their initial course, with the IG continuing towards the gluteal region as opposed to the IP that re-enters the pelvis around the sciatic notch with a typical “L” appearance. The OBT is also absent in the pelvic sides of (A) and (C), indicating that it originates from the inferior epigastric artery, a side branch of the external iliac artery (accessory OBT). The SG is the branch that exclusively arises from the posterior division of the internal iliac artery with a superiorly concave trajectory. The OBT is the only branch that has a straight downward trajectory into the obturator foramen with a typical “mermaid tail” termination with two muscular branches (curved arrows in B). Arrows: the first branch of the anterior division of the internal iliac artery is always the superior vesical artery, providing the major vascularization to the bladder. Dotted arrow: the prostatic artery arising proximally from the common gluteal-pudendal trunk with a “typical” parallel trajectory to the IP and a similar “L” appearance. IG = inferior gluteal artery, IP = internal pudendal artery, OBT = obturator artery, SG = superior gluteal artery
Fig. 2
Fig. 2. Angiographic anatomy of the four most frequent prostatic artery origin patterns during microcatheter selective catheterization under roadmap guidance. A. Right PA from the SVA in a right anterior oblique projection of 35° with a caudal-cranial projection of -10° (Supplementary Video 1). B. Left PA from the IP in a left anterior oblique projection of 35° with a caudal-cranial projection of -10° (Supplementary Video 2). C. Right PA from the common gluteal-pudendal trunk in a right anterior oblique projection of 35° with a caudal-cranial projection of -10° (Supplementary Video 3). D. The PA from the OBT in an anterior-posterior projection: in this type of anatomy, steep oblique projections may be discarded to reduce radiation exposure after selective OBT catheterization with a 5F catheter (Supplementary Video 4). IG = inferior gluteal artery, IP = internal pudendal artery, OBT = obturator artery, PA = prostatic artery, SG = superior gluteal artery, SVA = superior vesical artery
Fig. 3
Fig. 3. Angiographic anatomy of rare or variant PA origin patterns seen during repeat PA embolization or in patients with atherosclerosis. A. Left PA arising from the penile artery (arrow), one of the two terminal branches of the IP. Dashed arrow: the other IP terminal branch, the perineal-scrotal artery. Roadmap in a left anterior oblique projection of 35° with a caudal-cranial projection of -10° (Supplementary Video 5). B, C. Revascularization of the right PA during repeat PAE from a distal collateral of the OBT before (B: digital subtraction angiography in a right anterior oblique projection of 35° with a caudal-cranial projection of -10°) and after (C: digital subtraction angiography in anterior-posterior projection) selective catheterization of the PA. Note that the whole prostate is vascularized by this single-sided PA, which is frequently seen in repeat PAE. D, E. Left PA arising from the external iliac artery outside of the internal iliac artery territory (from an Acc OBT). Selective digital subtraction angiography of the inferior epigastric artery in a right anterior oblique projection of 25° (D). CBCT 3D reformat (E). F-H. Right PA arising from a distal collateral branch of the SVA during a repeat PAE. Angiography in a right anterior oblique projection of 35° with a caudalcranial projection of -10° (F). CBCT 3D reformat after selective catheterization of the common arterial trunk vascularizing the bladder (SVA) and prostate (PA) (G). Digital subtraction angiography in an anterior-posterior projection confirming the selective catheterization of the PA with anastomoses to bilateral penile arteries (arrows) (H). I-L. Left PA from the SG via the posterior division of the internal iliac artery. 3D volume rendering CT angiography reformat (I). Digital subtraction angiography (J). Selective catheterization of the PA under roadmap guidance (K). Selective PA angiography (L). M-P. Right PA from the IG. 3D volume rendering CT angiography reformat (M). Digital subtraction angiography of the IG (N). Selective PA angiography (O, P). Acc = accessory, CBCT = cone-beam computed tomography, IG = inferior gluteal artery, IP = internal pudendal artery, OBT = obturator artery, PA = prostatic artery, SG = superior gluteal artery, SVA = superior vesical artery
Fig. 4
Fig. 4. Central-gland (arrows) and peripheral gland (dashed arrows) PAs. A. Selective catheterization of the left central-gland PA under roadmap guidance with a left anterior oblique projection of 35° and a caudalcranial projection of -10° (Supplementary Videos 6, 7). B. CBCT 3D reformat confirming super-selective catheterization of the central gland PA without any vascularization to the bladder. C, D. Digital subtraction angiography in an anterior-posterior projection (C) and CBCT 3D reformat (D) after selective catheterization of the right central-gland PA during a repeat PA embolization (the whole – bilateral – central gland is vascularized through this single artery, with no vascularization to the bladder). E, F. Selective left peripheral-gland PA angiography with a left anterior oblique projection of 35° and a caudal-cranial projection of -10° (E) and CBCT 3D reformat of the same artery demonstrating vascularization to the peripheral gland of the prostate as well as the rectum (F). G, H. Selective left peripheral-gland PA angiography with an anterior-posterior projection (G) and CBCT 3D reformat of the same artery demonstrating vascularization to the peripheral gland but no rectal vascularization (H). Even though the angiographic patterns of the central-gland and peripheral-gland PAs are different, they can sometimes be similar; thus, CBCT confirmation is needed to certify correct central-gland targeting before embolization. Additionally, note the close proximity of the central-gland PAs to the bladder arteries and the peripheral-gland PAs to the rectal arteries, with the potential for non-target embolization. The arrow points to central-gland PA that is not seen in (E-H); the dashed arrow points to peripheral-gland PA that is not seen in (B-D). CBCT = cone-beam computed tomography, PA = prostatic artery
Fig. 5
Fig. 5. Imaging protocol approach during PAE. A-H. Pre-procedural MR in (A-E) and PAE in (F-H) from the same patient. (A) Sagittal and (B) axial T2-weighted imaging of the prostate show an enlarged transitional zone with predominance from the left side (arrows) and protrusion into the bladder base, compatible with benign prostatic hyperplasia. (C) As a mapping tool, a 3D-MIP MR angiography reformat of the left internal iliac artery branches was used. (D) Subtracted and (E) non-subtracted axial MIP MR angiography reformats show a predominance of the vascularization of the left side of the prostate. (F) Roadmap imaging of the left internal iliac artery in a left anterior oblique projection of 35° with a caudal-cranial projection of-10° was used for catheterization of the PA. (G) Selective angiography of the left PA; and (H) Cone-beam computed tomography after selective catheterization of the central-gland branches of the left PA. IG = inferior gluteal artery, IP = internal pudendal artery, MIP = maximum intensity projection, OBT = obturator artery, PA = prostatic artery, PAE = prostatic artery embolization, SG = superior gluteal artery
Fig. 6
Fig. 6. Examples of challenging selective catheterizations of the PAs arising from the SVA under roadmap guidance with a right anterior oblique projection of 35° and a caudal-cranial projection of -10°. Note that the SVA courses inward and forward as opposed to the PA, which courses downward to reach the bladder base and then turns inward into the prostate. A. Using an 0.014’’ guidewire (Supplementary Video 8). B. Using an 0.016’’ guidewire (Supplementary Video 9). C. Using an 0.014’’ guidewire (Supplementary Video 10). D. Using a steerable microcatheter and an 0.016’’ guidewire (arrow: tight stenosis at SVA origin) (Supplementary Video 11). IG = inferior gluteal artery, IP = internal pudendal artery, OBT = obturator artery, PA = prostatic artery, SG = superior gluteal artery, SVA = superior vesical artery
Fig. 7
Fig. 7. Variant PA anatomy. A-L. Single versus dual blood supply to the prostate in the same patient (A-D), rectal anastomoses (E-H), PA from the penile artery (I, J), penile anastomoses (K, L). Axial (A) and coronal (B) CBCT reformats after bilateral selective catheterization of the PA with fused imaging. Note the duplicated blood supply on the right as opposed to the single blood supply on the left. (C) Sagittal CBCT after selective catheterization of the right central gland PA (arrows, A-D), depicting retrograde opacification of the peripheral gland PA (dashed arrows in A, C) through intraprostatic anastomoses (D). The coronal CBCT reformats after selective catheterization of the left PA. Digital subtraction angiography with anterior-posterior (E) and (F) right anterior oblique projections of 35° with a caudal-cranial projection of -10°; axial (G) and sagittal (H) CBCT reformats of a peripheral gland PA (dashed arrows in E-H) with prominent rectal anastomoses leading to retrograde filling of the inferior mesenteric artery (curved arrows in E, G, H). Right PA arising from a penile artery (curved arrows in I, J) after selective angiography (I) and with a (H) sagittal CBCT reformat. Selective left PA angiography with (K) and without (L) digital subtraction denoting distal anastomoses to the penile artery (curved arrows in K, L). In these situations, coil embolization of the anastomoses is impossible, and embolization may be performed with careful monitoring of particle distribution. CBCT = cone-beam computed tomography, PA = prostatic artery
Fig. 8
Fig. 8. Accessory pudendal arteries provide collateral blood supply to the penis (curved arrows) and may also give rise to the PA. This is a very challenging variant anatomy, as non-target embolization may lead to severe penile ischemia. A-C. Coil embolization of the penile branch distally to the PA (dashed arrow in C) was performed before particle embolization of the whole artery. Digital angiography with (A) and without (B) bone subtraction in a right anterior oblique projection of 35° with a caudal-cranial projection of -10°. Note that the PA is always behind the pubic bone, whereas the penile branch courses vertically behind and then underneath the pubic symphysis. D. Another option is selective catheterization of the PA under roadmap guidance and proceeding with selective embolization of the PA, sparing the penile branch (Supplementary Video 12). PA = prostatic artery
Fig. 9
Fig. 9. Protective coil placement to avoid non-target embolization during PAE. A-L. Coil embolization of the bladder branches (A-D), coil embolization of an Acc OBT (E-H), coil embolization of the penile anastomoses (I-L). Anterior-posterior projection selective left PA digital subtraction angiography (A) and axial CBCT reformat (B) depict a bladder branch (arrows) that was selectively embolized with coils (Supplementary Video 13). Anterior-posterior projection selective left PA digital subtraction angiography (C) and sagittal CBCT reformat (D) after coil embolization of the bladder branch (arrows) depict preserved PA opacification with the exclusion of bladder perfusion, allowing a safe PAE. Anterior-posterior digital angiography without (E) and with (H) bone subtraction showing a PA arising from an Acc OBT. Selective catheterization of the left PA was not feasible; therefore, coil embolization of the Acc OBT was performed distally to the PA (arrows in G, H), enabling particle distribution into the PA and avoiding non-target embolization. (I) A roadmap image in a right anterior oblique projection of 35° with a caudal-cranial projection of -10° after selective catheterization of the right PA depict a large penile anastomosis (arrow). (J) Sagittal CBCT reformats of the right PA after coil embolization of the penile anastomosis (arrow) distally to the PA origin, depicting preserved PA opacification with complete blockage of penile opacification, enabling a safe PAE. (K) Digital subtraction angiography in a right anterior oblique projection of 35° with a caudal-cranial projection of -10° after selective catheterization of the right PA, showing a large penile anastomosis (arrow) that was selectively coil-embolized (arrow in L), enabling a safe PAE. Acc = accessory, CBCT = cone-beam computed tomography, OBT = obturator artery, PA = prostatic artery, PAE = prostatic artery embolization
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References

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