Recanalization of portal vein thrombosis after pediatric liver transplantation: Efficacy and safety of the transsplenic access.

BACKGROUND: Endovascular management of portal vein thrombosis (PVT) is challenging. Transsplenic access (TSA) is growing as an access option to the portal system but with higher rates of bleeding complications. The aim of this article is to evaluate the efficacy and safety of transsplenic portal vein recanalization (PVR) using a metallic stent after pediatric liver transplantation. MATERIALS AND METHODS: This is a retrospective review of 15 patients with chronic PVT who underwent PVR via TSA between February 2016 and December 2020. Two children who had undergone catheterization of a mesenteric vein tributary by minilaparotomy were excluded from the patency analysis but included in the splenic access analysis. The technical and clinical success of PVR and complications related to the procedure via TSA were evaluated. RESULTS: Thirteen children with PVT were treated primarily using the TSA. The mean age was 4.1 years (range, 1.5-13.7 years), and the most common clinical presentation was hypersplenism (60%). Technically successful PVR was performed in 11/13 (84.6%) children, and clinical success was achieved in 9/11 (81.8%) children. No major complications were observed, and one child presented moderate pain in the TSA (from a total of 17 TSA). The median follow-up was 48.2 months. The median primary patency was 9.9 months. Primary patency in the first 4 years was 75%, and primary assisted patency was 100% in the follow-up period. CONCLUSIONS: Transsplenic PVR is a safe and effective method for the treatment of PVT after pediatric liver transplantation.

Prostatic Artery Embolization Using Polyethylene Glycol Microspheres: A 1-Year Follow-up Prospective Study Including 30 Patients.

PURPOSE: To evaluate safety and effectiveness of prostatic artery embolization (PAE) using polyethylene glycol (PEG) microspheres in patients with moderate-to-severe benign prostatic hyperplasia (BPH). MATERIALS AND METHODS: A single-center, prospective study of 30 patients who underwent PAE from August 2020 to December 2021 using PEG 400-µm microspheres was conducted. Patient evaluation data using International Prostate Symptom Score (IPSS), quality of life (QoL) score, prostate-specific antigen (PSA), peak urinary flow rate (Qmax), postvoid residual volume (PVR), and prostate volume (PV) at baseline and 3 and 12 months after PAE were obtained. RESULTS: Bilateral PAE was performed in all patients. One patient had early clinical failure (3.3%) and another presented with lower urinary tract symptoms (LUTSs) recurrence (3.3%) at the 12-month follow-up. Twenty-eight patients (93.3%) experienced significant and durable LUTS improvement. Mean absolute (and relative) improvement at 3 and 12 months were: IPSS, 14.6 points (-69%) for both; QoL, 3.3 points (-70%) and 3.5 points (-74%); Qmax, 6.3 mL/s (+78%) and 8.6 mL/s (+100%); PSA reduction, 1.2 ng/mL (-22%) and 1.0 ng/mL (-15%); PVR reduction, 48 mL (-56%) and 58.2 mL (-49%); PV reduction, 23.4 cm3 (-29%) and 19.6cm3 (-25%); (P < .05 for all). No major adverse events were observed. Minor adverse events included urinary tract infection (4/30, 13.3%), prostatic tissue elimination (3/30, 10%), penile punctiform ulcer (1/30, 3.3%), and urinary retention (1/30, 3.3%). CONCLUSIONS: PAE using PEG microspheres was observed to be effective with sustained LUTS improvement at the 12-month follow-up. The incidence of urinary infection and prostatic tissue elimination was higher than previously reported for other embolics.

Intestinal complications are common in patients with acquired diaphragmatic hernia after pediatric living donor liver transplantation.

BACKGROUND: Acquired diaphragmatic hernia (DH) following liver transplantation (LT) is usually considered a surgical emergency. Interplay of contributing elements determines its occurrence but, in children, LT with partial liver grafts seems to be the most important causative factor. METHODS: This retrospective study describes the clinical scenario and outcomes of 11 patients with acquired DH following LDLT. RESULTS: During the study period, 1109 primary pediatric LDLT were performed (0.8% DH). The median age and BW of the recipients with DH at transplantation were 17 months and 11.1 kg, respectively; 63.7% of the cases had a weight/age Z-score of less than -2 at transplantation. The median interval between transplantation and diagnosis of DH was 114 days (32-538 days). A total of 6 (54.5%) of the patients had bowel obstruction due to bowel migration into the hemithorax. Ten defects were right-sided. Three patients required enterectomy and enterorrhaphy. Two patients required a new bilioenteric anastomosis, and one of them had complete necrosis of the Roux-in-Y limb. The patient with left-side DH presented gastroesophageal perforation. CONCLUSION: Most defects necessitate primary closure as the first treatment, and recurrence is rare. The associated problems encountered, especially related to intestinal complications, can determine increased morbidity following DH repair. Early diagnosis and intervention are required for achieving better outcomes.

Role of Ultrasound Elastography in Patient Selection for Prostatic Artery Embolization.

PURPOSE: To determine the effects of prostatic artery embolization (PAE) on prostate elasticity as assessed using ultrasound elastography (US-E) and to describe baseline US-E's potential role in patient selection. MATERIALS AND METHODS: This was a prospective investigation that included 20 patients undergoing PAE to treat lower urinary tract symptoms attributed to benign prostatic hyperplasia (BPH). US-E with measurement of the prostatic elastic modulus (EM) and shear wave velocity (SWV) was performed before PAE and at 1-month follow-up. Baseline, 3-month, and 1-year follow-up evaluations included prostate-specific antigen, uroflowmetry, pelvic magnetic resonance imaging, and clinical assessment using the International Prostate Symptom Score (IPSS) and quality of life (QoL) metrics. RESULTS: Seventeen patients entered statistical analysis. US-E showed a significant reduction in mean prostatic EM (34.4 kPa vs 46.3 kPa, -24.7%, P < .0001) and SWV (3.55 m/s vs 4.46 m/s, -20.0%, P < .0001) after PAE. There were moderate positive correlations between baseline EM and 1-year IPSS (R = 0.62, P = .007) and between baseline SWV and 1-year IPSS (R = 0.68, P = .002). Baseline SWV ≥ 5.59 m/s and baseline EM ≥ 50.14 kPa were associated with suboptimal IPSS and QoL outcomes after PAE with high degrees of sensitivity (100%) and specificity (69-100%). CONCLUSIONS: PAE led to a positive effect on the BPH dynamic component related to prostatic elasticity. There was a moderate positive correlation between baseline prostatic elastographic parameters and 12-month IPSS. Measurement of baseline elastographic characteristics may become useful for the evaluation and selection of patients for PAE.

Prostatic Artery Embolization: Indications, Preparation, Techniques, Imaging Evaluation, Reporting, and Complications.

Benign prostatic hyperplasia (BPH) is a noncancerous growth of the transitional zone of the prostate, which surrounds the prostatic urethra. Consequently, it can cause lower urinary tract symptoms (LUTS) and bladder outlet obstruction symptoms that may substantially reduce a patient's quality of life. Several treatments are available for BPH, including medications such as α-blockers and 5α-reductase inhibitors and surgical options including transurethral resection of the prostate and prostatectomy. Recently, prostatic artery embolization (PAE) has emerged as a minimally invasive treatment option for selected men with BPH and moderate to severe LUTS. Adequate pre- and postprocedural evaluations with clinical examinations and questionnaires, laboratory tests, and urodynamic and imaging examinations (particularly US, MRI, and CT) are of key importance to achieve successful treatment. Considering that the use of PAE has been increasing in tertiary hospital facilities, radiologists and interventional radiologists should be aware of the main technical concepts of PAE and the key features to address in imaging reports in pre- and postprocedural settings. An invited commentary by Lopera is available online. Online supplemental material is available for this article. ©RSNA, 2021.

Prostatic Artery Embolization for the Treatment of Lower Urinary Tract Symptoms Due to Benign Prostatic Hyperplasia: 10 Years' Experience.

Background Long-term experience with prostatic artery embolization (PAE) for benign prostatic hyperplasia remains limited. Purpose To evaluate the efficacy, safety, and long-term results of PAE for benign prostatic hyperplasia. Materials and Methods This retrospective single-center study was conducted from June 2008 to June 2018 in patients with moderate to severe benign prostatic hyperplasia-related symptoms. International Prostate Symptom Score (IPSS), quality-of-life score, maximum urinary flow rate, postvoid residual volume, prostate-specific antigen (PSA), and prostate volume were assessed. PAE was performed with 100-500-µm embolic microspheres. Mixed-model analysis of variance and Kaplan-Meyer method was accessed, as appropriate. Results A total of 317 consecutive men (mean age ± standard deviation, 65 years ± 8) were treated. Follow-up ranged from 3 months to 96 months (mean, 27 months). Bilateral and unilateral PAE was performed in 298 (94%) and 19 (6%) men, respectively. Early clinical failure occurred in six (1.9%) and symptom recurrence in 72 (23%) men at a median follow-up of 72 months. Mean maximum improvement was as follows: IPSS, 16 points ± 7; quality-of-life score, 4 points ± 1; prostatic volume reduction, 39 cm3 ± 39 (39% ± 29); maximum urinary flow rate, 6 mL/sec ± 10 (155% ± 293); and postvoid residual volume, 70 mL ± 121 (48% ± 81) (P < .05 for all). Unilateral PAE was associated with higher recurrence (42% vs 21%; P = .04). Baseline PSA was inversely related with recurrence (hazard ratio, 0.9 per nanograms per milliliter of PSA; 95% confidence interval [CI], 0.8, 0.9; P < .001). Embolization with combined particle sizes (100-500 µm) did not relate to symptom recurrence (hazard ratio, 0.4; 95% CI: 0.2, 1.1 for 100-500-µm group vs 300-500-µm group and hazard ratio, 0.4; 95% CI: 0.1, 1.5 for 100-500-µm group vs 100-300-µm group; P = .19).None of the patients presented with urinary incontinence or erectile dysfunction. Conclusion Prostatic artery embolization was a safe and effective procedure for benign prostatic hyperplasia with good long-term results for lower urinary tract symptoms. © RSNA, 2020 Online supplemental material is available for this article.

Angiographic Findings during Repeat Prostatic Artery Embolization.

PURPOSE: To describe mechanisms of prostate revascularization based on imaging findings during repeat prostatic artery embolization (PAE; rPAE). MATERIALS AND METHODS: This is a retrospective analysis of 10 rPAEs performed between October 2012 and September 2018 in patients with recurrent lower urinary tract symptoms (LUTS) after PAE (mean age, 68.2 y ± 4.5). Two interventional radiologists reviewed PAE and rPAE images and defined 6 patterns of revascularization. Correlation between embolization of the posterolateral (PL) prostatic branch during previous PAE and prostate revascularization on rPAE was assessed by Fisher exact test. One hemiprostate was excluded because no detectable revascularization was observed. RESULTS: All patients showed LUTS improvement after previous PAEs (P < .01 for 5 outcome measures) and had recurrence during follow-up. rPAEs were performed a mean of 40.9 months after previous PAEs (18-96 mo). Of 19 hemiprostates analyzed, 11 presented revascularization by 2 or more branches (57.9%). The PL branch (29.0%) and the recanalized main prostatic artery (25.8%) were the most frequent revascularizing branches observed, followed by distal branches of obturator (12.9%), internal pudendal (12.9%), superior vesical (12.9%), and contralateral arteries (6.5%). Embolization of the PL branch during previous PAE significantly reduced the incidence of revascularization by this branch (P = .002). CONCLUSIONS: Mechanisms of revascularization in rPAE are diverse and complex. Revascularization by the PL branch and recanalization of the previously embolized prostatic artery were the most frequent patterns observed. Embolization of the PL branch may reduce the incidence of prostate revascularization and LUTS recurrence after PAE.

Prostatic artery embolization for treatment of benign prostatic hyperplasia in patients with prostates > 90 g: a prospective single-center study.

PURPOSE: To describe the safety and efficacy of prostatic artery embolization (PAE) with spherical microparticles to treat lower urinary tract symptoms associated with benign prostatic hyperplasia in patients with prostate volume > 90 g. MATERIALS AND METHODS: This prospective, single-center, single-arm study was conducted in 35 patients with prostate volumes ranging from 90-252 g. Mean patient age was 64.8 years (range, 53-77 y). Magnetic resonance imaging, uroflowmetry, and the International Prostate Symptom Score (IPSS) were used to assess clinical and functional outcomes. RESULTS: Mean prostate size decreased significantly from 135.1 g before PAE to 91.9 g at 3 months of follow-up (P < .0001). Mean IPSS and quality-of-life index improved from 18.3 to 2.7 and 4.8 to 0.9 (P < .0001 for both), respectively. A significant negative correlation was observed between prostate-specific antigen at 24 hours after PAE and IPSS 3 months after PAE (P = .0057). CONCLUSIONS: PAE is a safe and effective treatment for lower urinary tract symptoms secondary to benign prostatic hyperplasia in patients with prostate volume > 90 g. Excessively elevated prostate-specific antigen within 24 hours of PAE is associated with lower symptom burden in short-term follow-up.

Prostatic artery embolization using reflux-control microcatheter: prospective experience addressing feasibility.

PURPOSE: To evaluate the efficacy and safety of Prostatic Artery Embolization (PAE) using a reflux control microcatheter. MATERIALS AND METHODS: This is a prospective, single-center investigation that included 10 patients undergoing PAE for treatment of lower urinary tract symptoms (LUTS) attributed to benign prostate hyperplasia (BPH). Baseline, 3-month, and 12-month efficacy endpoints were obtained for all patients and included prostate-specific antigen (PSA), uroflowmetry, pelvic magnetic resonance imaging (MRI), and clinical assessment using the International Prostate Symptom Score (IPSS) questionnaire and the IPSS-Quality of life (QoL) item. Complications were assessed using the Cirse classification system. RESULTS: Ten patients entered statistical analysis and presented with significant LUTS improvement 12 months after PAE, as follows: mean IPSS reduction of 86.6% (2.8 vs. 20.7, - 17.9, P < 0.001), mean QoL reduction of 79.4% (1.1 vs. 5.4, - 4.3, P < 0.001), mean prostatic volume reduction of 38.4% (69.3 cm3 vs. 112.5 cm3, - 43.2 cm3, P < 0.001), mean peak urinary flow (Qmax) increase of 199.4% (19.9 mL/s vs. 6.6 mL/s, + 13.3 mL/s, P = 0.006) and mean PSA reduction of 50.1% (3.0 ng/mL vs. 6.1 ng/mL, - 3.0 ng/mL, P < 0.001). One patient (10%) needed transurethral resection of the prostate (TURP) after PAE due to a ball-valve effect. One microcatheter (10%) needed to be replaced during PAE due to occlusion. Non-target embolization was not observed in the cohort. CONCLUSION: This initial experience suggests that PAE using a reflux control microcatheter is effective and safe for the treatment of LUTS attributed to BPH.

Protection of nontarget structures in prostatic artery embolization.

OBJECTIVE: To describe the efficacy and safety of protective embolization during prostatic artery embolization, as well as to discuss its clinical relevance. MATERIALS AND METHODS: This was a retrospective, observational, single-center study including 39 patients who underwent prostatic artery embolization to treat lower urinary tract symptoms related to benign prostatic hyperplasia between June 2008 and March 2018. Follow-up evaluations, performed at 3 and 12 months after the procedure, included determination of the International Prostate Symptom Score, a quality of life score, and prostate-specific antigen levels, as well as ultrasound, magnetic resonance imaging, and uroflowmetry. RESULTS: Protective embolization was performed in 45 arteries: in the middle rectal artery in 19 (42.2%); in the accessory internal pudendal artery in 11 (24.4%); in an internal pudendal artery anastomosis in 10 (22.2%); in the superior vesical artery in four (8.9%); and in the obturator artery in one (2.2%). There was one case of nontarget embolization leading to a penile ulcer, which was attributed to reflux of microspheres to an unprotected artery. There were no complications related to the protected branches. All of the patients showed significant improvement in all of the outcomes studied (p < 0.05), and none reported worsening of sexual function during follow-up. CONCLUSION: Protective embolization can reduce nontarget embolization during prostatic artery embolization without affecting the results of the procedure. In addition, no adverse events other than those expected or previously reported were observed. Therefore, protective embolization of pudendal region is safe.

OBJETIVO: Descrever a eficácia e a segurança da embolização de proteção na embolização de artérias prostáticas e discutir sua relevância clínica. MATERIAIS E MÉTODOS: Estudo retrospectivo, observacional, de um único centro, que inclui 39 pacientes submetidos a embolização de artérias prostáticas para tratamento de sintomas do trato urinário inferior relacionados a hiperplasia benigna da próstata, de junho de 2008 a março de 2018. O acompanhamento foi realizado em 3 meses e 12 meses, incluindo International Prostate Symptom Score, escore de qualidade de vida, antígeno prostático específico, ultrassom, ressonância magnética e urofluxometria. RESULTADOS: Embolização de proteção foi realizada em 45 artérias: artérias retais médias em 19 (42,2%); artérias pudendas internas acessórias em 11 (24,4%); anastomoses com ramos da artéria pudenda interna em 10 (22,2%); artérias vesicais superiores em quatro (8,9%); e artéria obturatória em uma (2,2%). Houve um caso de embolização não alvo que provocou uma úlcera peniana, atribuída a refluxo de partículas para uma artéria não protegida. Não houve complicações relacionadas com os ramos protegidos. Os pacientes apresentaram melhora significativa em todos os resultados estudados (p < 0,05) e não relataram piora da função sexual durante o acompanhamento. CONCLUSÃO: Embolização de proteção pode ser realizada para diminuir embolização não alvo sem interferir nos resultados da embolização de artérias prostáticas. Além disso, não foi observado nenhum evento adverso diferente dos já esperados ou previamente publicados. A embolização de proteção na região pudenda é segura.

Management and treatment of decompensated hepatic fibrosis and severe refractory Schistosoma mansoni ascites with transjugular intrahepatic portosystemic shunt.

This study aimed to report the first case of a patient with hepatosplenic schistosomiasis mansoni, refractory ascites and portal vein thrombosis treated with a transjugular intrahepatic portosystemic shunt (TIPS), at the Instituto de Radiologia, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Brazil. After the procedure, the patient recovered favorably and progressed with portal pressure reduction and no deterioration of the liver function. Endovascular shunt modification is a conservative medical approach that often helps in reducing symptoms significantly, making it a less invasive and a safer alternative to liver transplantation for the treatment of schistosomiasis with portal hypertension.

Prostatic artery embolization for giant prostatic hyperplasia: a single-center experience.

OBJECTIVE: To describe the safety and efficacy of prostatic artery embolization (PAE) in patients with a markedly enlarged prostate. MATERIALS AND METHODS: This was a retrospective study including 18 consecutive patients (mean age, 74 years) with benign prostatic hyperplasia, all with a prostate volume ≥ 200 cm3, who were enrolled to receive PAE for the treatment of moderate-to-severe lower urinary tract symptoms. RESULTS: The PAE procedure was technically successful in 17 patients (94.4%). During follow-up, clinical failure (defined as an International Prostate Symptom Score [IPSS] ≥ 8) was observed in two (11.1%) of those 18 patients. At 3 months of follow-up, there was significant improvement over baseline in all relevant outcome measures: total IPSS (from 15.7 to 2.9); IPSS quality of life score (from 5.2 to 1.0); prostate specific antigen (from 11.4 to 1.82 ng/mL); peak urinary flow rate (from 7.45 to 18.6 mL/s); prostate volume (from 252.4 to 151.6 cm3); and post-void residual volume (from 143.7 to 28.3 mL)-p < 0.05 for all. Of the 18 patients, one (5.6%) presented detachment of prostate tissue and self-limited hematuria, which did not require specific treatment. CONCLUSION: In patients with a markedly enlarged prostate, PAE proved to be safe and effective, resulting in significant improvements in clinical, imaging, and urodynamic parameters.

OBJETIVO: Descrever a segurança e eficácia da embolização das artérias prostáticas (EAP) em pacientes com próstatas muito aumentadas (≥ 200 cm3). MATERIAIS E MÉTODOS: Este estudo retrospectivo incluiu 18 pacientes consecutivos com hiperplasia prostática benigna portadores de próstatas ≥ 200 cm3 (idade média de 74 anos), que foram submetidos a EAP para tratar sintomas de trato urinário inferior moderados a graves. RESULTADOS: A EAP foi tecnicamente bem-sucedida em 17 pacientes (94,4%). Falha clínica (IPSS ≥ 8) foi detectada em dois pacientes durante o seguimento (11,1%). Observamos melhora significativa em todos os parâmetros relevantes aos três meses de acompanhamento: IPSS: 15,7 vs. 2,9; qualidade de vida: 5,2 vs. 1,0); PSA: 11,4 vs. 1,82 ng/mL; pico de fluxo urinário: 7,45 vs. 18,6 mL/s); volume prostático: 252,4 vs. 151,6 cm3; e volume urinário residual: 143,7 vs. 28,3 mL - p < 0,05 para todos). Um paciente (5,6%) apresentou eliminação de tecido prostático e hematúria autolimitada durante o seguimento, que não necessitou de tratamento específico. CONCLUSÃO: A EAP em pacientes com próstata muito aumentada foi segura e eficaz, com significativas melhoras clínica, urodinâmica e imaginológica.

Virtual reality in interventional radiology education: a systematic review.

The aim of this study was to compare virtual reality simulation with other methods of teaching interventional radiology. We searched multiple databases-Cochrane Library; Medline (PubMed); Embase; Trip Medical; Education Resources Information Center; Cumulative Index to Nursing and Allied Health Literature; Scientific Electronic Library Online; and Latin-American and Caribbean Health Sciences Literature-for studies comparing virtual reality simulation and other methods of teaching interventional radiology. This systematic review was performed in accordance with the criteria established by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and the Best Evidence Medical Education (BEME) Collaboration. Eligible studies were evaluated by using the quality indicators provided in the BEME Guide No. 11 and the Kirkpatrick model of training evaluation. After the eligibility and quality criteria had been applied, five randomized clinical trials were included in the review. The Kirkpatrick level of impact varied among the studies evaluated, three studies being classified as level 2B and two being classified as level 4B. Among the studies evaluated, there was a consensus that virtual reality aggregates concepts and is beneficial for the teaching of interventional radiology. Although the use of virtual reality has been shown to be effective for skill acquisition and learning in interventional radiology, there is still a lack of studies evaluating and standardizing the employment of this technology in relation to the numerous procedures that exist within the field of expertise.

O objetivo deste estudo foi comparar a simulação de realidade virtual com outros métodos de aprendizagem na radiologia intervencionista. Foram realizadas buscas nas bases de dados eletrônicas Cochrane Library, Medline (PubMed), Embase, Trip Medical, Education Resources Information Center, Cumulative Index to Nursing and Allied Health Literature, Scientific Electronic Library Online, e Latin-American and Caribbean Health Sciences Literature para estudos comparando a realidade virtual com outros métodos de aprendizagem na radiologia intervencionista. Esta revisão sistemática foi realizada de acordo com o Preferred Reporting Items for Systematic Reviews and Meta-Analyses e a Best Evidence Medical Education (BEME) Collaboration. Os estudos elegíveis foram avaliados usando o questionário de Buckley no BEME Guide nº 11 e o modelo de Kirkpatrick. Cinco ensaios clínicos randomizados foram incluídos nesta revisão, após a aplicação de todos os critérios de elegibilidade e qualidade. O nível de evidência educacional encontrado entre os artigos variou, sendo três estudos nível 2B e os demais nível 4B de acordo com o modelo de Kirkpatrick. Não houve divergência entre os estudos de que a realidade virtual agrega conceitos e é benéfica para o ensino da radiologia intervencionista. O uso da realidade virtual para aquisição de conhecimento e aprendizagem em radiologia intervencionista tem se mostrado eficaz, mas ainda faltam estudos que avaliem e estruturem a utilização dessa tecnologia em relação aos inúmeros procedimentos existentes no campo de atuação.

Advanced image guidance for prostatic artery embolization - a multicenter technical note.

BACKGROUND: Prostatic artery embolization (PAE) is associated with patients' quality of life improvements and limited side effects compared to surgery. However, this procedure remains technically challenging due to complex vasculature, anatomical variations and small arteries, inducing long procedure times and high radiation exposure levels both to patients and medical staff. Moreover, the risk of non-target embolization can lead to relevant complications. In this context, advanced imaging can constitute a solid ally to address these challenges and deliver good clinical outcomes at acceptable radiation levels. MAIN TEXT: This technical note aims to share the consolidated experience of four institutions detailing their optimized workflow using advanced image guidance, discussing variants, and sharing their best practices to reach a consensus standardized imaging workflow for PAE procedure, as well as pre and post-operative imaging. CONCLUSIONS: This technical note puts forth a consensus optimized imaging workflow and best practices, with the hope of helping drive adoption of the procedure, deliver good clinical outcomes, and minimize radiation dose levels and contrast media injections while making PAE procedures shorter and safer.

Prostatic Artery Embolization: Equipment, Procedure Steps, and Overcoming Technical Challenges.

In the last decade, prostatic artery embolization (PAE) established itself as a safe and effective treatment option for lower urinary tract symptoms (LUTS) attributed to benign prostate hyperplasia (BPH), with reproducible results across multiple centers and endorsement by important international societies. However, PAE is also known to be a technically demanding procedure. Accompanying the prevalence of benign prostate hyperplasia, the procedure is usually performed in older patients, in whom atherosclerosis and comorbidities are common features. Also, prostatic vascular anatomy is described to be complex and variable, and pelvic structures are deeply interconnected by anastomosis. Thus, PAE demands a deep familiarization with materials and devices, intraprocedure imaging techniques, microcatetherization skills and with the pelvic vascular anatomy. Especially in the beginning of the learning curve, the procedure can be time-consuming and related to high radiation exposure for both medical team and the patient. In this article, the main points of technical concern during PAE are described and discussed, such as the equipment needed, the effect of different embolic materials, patient's preparation for the procedure, arterial access sites, identifying and catheterizing the prostatic arteries, the embolization techniques, among others. Finally, the most frequent technical challenges are presented, and the possible strategies to overcome them are exemplified and discussed.

Improvements in Irritative Versus Obstructive Symptoms of the International Prostate Symptom Score After Prostatic Artery Embolization in 174 Patients, in a Single Center.

AIM: The aim of this study is to compare the improvements in irritative versus obstructive symptoms of the International Prostate Symptom Score (IPSS) after prostatic artery embolization (PAE) in patients with benign prostatic hyperplasia (BPH). MATERIALS AND METHODS: Between 2010 and 2018, 186 patients underwent PAE in a single center and 174 patients were retrospectively selected. The inclusion criteria were symptoms due to BPH, refractory to pharmacological treatment and IPSS ≥ 8. The mean age of the patients was 63.7 ± 7.2 years, the mean prostate volume 89.5 ± 42.5 cm3, and the mean IPSS 19.0 ± 6.2 points. Patient data were reviewed at baseline, 3, 12 and 24 months and compared using the ANOVA mixed models and the Tukey's multiple comparison test. RESULTS: Obstructive subscores dropped more significantly than irritative subscores (p < 0.0001). The mean decrease in each IPSS item was frequency 2.4 (83%); urgency 0.8 (87%); nocturia 1.3 (49%); incomplete emptying 2.6 (83%); intermittency 2.3 (91%); weak stream 2.9 (82%); straining 1.6 (91%). The area under the curve for baseline obstructive scores was 0.7 (p = 0.006) and 0.59 (p = 0.182) for irritative scores. The most common BPH clinical manifestations include irritative and/or obstructive symptoms, the latter usually more prevalent. The IPSS drop observed after PAE suggests that it acts predominantly over obstructive symptoms (p < 0.0001). CONCLUSION: Although a predominant improvement in obstructive symptoms may be observed after PAE, nocturia complaints may require special attention. The severity of baseline obstructive symptoms may significantly predict clinical outcomes.

Effects of Prostatic Artery Embolization on the Dynamic Component of Benign Prostate Hyperplasia as Assessed by Ultrasound Elastography: A Pilot Series.

PURPOSE: To determine the effects of prostatic artery embolization (PAE) on prostatic elasticity as assessed by Ultrasound Elastography (US-E), as well as to describe the feasibility and role of US-E as a novel tool in both pre- and post-PAE evaluation. MATERIALS AND METHODS: This is a prospective, single-center investigation that included eight patients undergoing PAE for treatment of lower urinary tract symptoms (LUTS) attributed to benign prostate hyperplasia (BPH). Baseline and 3-month follow-up evaluations were performed and included prostate-specific antigen (PSA), uroflowmetry, pelvic magnetic resonance imaging and clinical assessment using the International Prostate Symptom Score (IPSS) questionnaire and the IPSS-Quality of life (QoL) item. US-E with measurement of the prostatic Elastic Modulus (EM) was performed before PAE and at 1-month follow-up. RESULTS: After PAE, US-E showed a significant reduction of prostatic EM as assessed in kPa (33.14 vs. 47.24, - 29.8%, p = 0.002) and in m/s (3.75 vs. 4.63, - 19.0%, p < 0.001). Also, the transitional/peripheral zone ratio was significantly reduced by 45.36% (0.53 vs. 0.97, p < 0.05). All eight patients presented with significant LUTS improvement after PAE (p < 0.05 for IPSS, QoL, prostate volume, peak urinary flow rate and PSA). CONCLUSIONS: Findings described in this study suggest that PAE significantly reduces prostatic EM, leading to a positive effect on BPH dynamic component related to prostatic elasticity. Also, it features US-E as an additional tool for pre- and post-PAE evaluation, describing a novel indication for this technology.

RECOMMENDATIONS FOR INVASIVE PROCEDURES IN PATIENTS WITH DISEASES OF THE LIVER AND BILIARY TRACT: REPORT OF A JOINT MEETING OF THE BRAZILIAN SOCIETY OF HEPATOLOGY (SBH), BRAZILIAN SOCIETY OF DIGESTIVE ENDOSCOPY (SOBED) AND BRAZILIAN SOCIETY OF INTERVENTIONAL RADIOLOGY AND ENDOVASCULAR SURGERY (SOBRICE).

Liver and biliary tract diseases are common causes of morbidity and mortality worldwide. Invasive procedures are usually performed in those patients with hepatobiliary diseases for both diagnostic and therapeutic purposes. Defining proper indications and restraints of commonly used techniques is crucial for proper patient selection, maximizing positive results and limiting complications. In 2018, the Brazilian Society of Hepato-logy (SBH) in cooperation with the Brazilian Society of Interventional Radiology and Endovascular surgery (SOBRICE) and the Brazilian Society of Digestive Endoscopy (SOBED) sponsored a joint single-topic meeting on invasive procedures in patients with hepatobiliary diseases. This paper summarizes the proceedings of the aforementioned meeting. It is intended to guide clinicians, gastroenterologists, hepatologists, radiologists, and endoscopists for the proper use of invasive procedures for management of patients with hepatobiliary diseases.

A Review of Adverse Events Related to Prostatic Artery Embolization for Treatment of Bladder Outlet Obstruction Due to BPH.

INTRODUCTION: Minimally invasive procedures have gained great importance among the treatments for benign prostate hyperplasia (BPH) due to their low morbidity. Prostate artery embolization has emerged as a safe and effective alternative for patients with large volume BPH, not suited for surgery. MATERIALS AND METHODS: Low adverse events rates have been reported following prostate artery embolization and may include dysuria, urinary infection, hematuria, hematospermia, acute urinary retention and rectal bleeding. Although most complaints are reported as side effects, complications can also be superimposed. RESULTS: The prostate gland is the most common source of complaints following PAE, where the inflammatory process can create a large variety of localized symptoms. Periprostatic organs and structures such as bladder, rectum, penis, seminal vesicle, pelvis, bones and skin may be damaged by nontarget embolization, especially due to the misidentification of the normal vascular anatomy and variants or due to inadvertent embolic reflux. Radiodermatitis may also happen in case of small vessel size, atherosclerosis, the learning curve and long procedure or fluoroscopy times. DISCUSSION: Regarding safety, it is pivotal to understand the pathophysiology of adverse events following PAE and their standardized reporting. The aim of this article is to discuss adverse events, their management and to review the current literature.

Protection of nontarget structures in prostatic artery embolization / Proteção de estruturas não alvo na embolização de artérias prostáticas

Abstract Objective: To describe the efficacy and safety of protective embolization during prostatic artery embolization, as well as to discuss its clinical relevance. Materials and Methods: This was a retrospective, observational, single-center study including 39 patients who underwent prostatic artery embolization to treat lower urinary tract symptoms related to benign prostatic hyperplasia between June 2008 and March 2018. Follow-up evaluations, performed at 3 and 12 months after the procedure, included determination of the International Prostate Symptom Score, a quality of life score, and prostate-specific antigen levels, as well as ultrasound, magnetic resonance imaging, and uroflowmetry. Results: Protective embolization was performed in 45 arteries: in the middle rectal artery in 19 (42.2%); in the accessory internal pudendal artery in 11 (24.4%); in an internal pudendal artery anastomosis in 10 (22.2%); in the superior vesical artery in four (8.9%); and in the obturator artery in one (2.2%). There was one case of nontarget embolization leading to a penile ulcer, which was attributed to reflux of microspheres to an unprotected artery. There were no complications related to the protected branches. All of the patients showed significant improvement in all of the outcomes studied (p < 0.05), and none reported worsening of sexual function during follow-up. Conclusion: Protective embolization can reduce nontarget embolization during prostatic artery embolization without affecting the results of the procedure. In addition, no adverse events other than those expected or previously reported were observed. Therefore, protective embolization of pudendal region is safe.

RESUMO Objetivo: Descrever a eficácia e a segurança da embolização de proteção na embolização de artérias prostáticas e discutir sua relevância clínica. Materiais e Métodos: Estudo retrospectivo, observacional, de um único centro, que inclui 39 pacientes submetidos a embolização de artérias prostáticas para tratamento de sintomas do trato urinário inferior relacionados a hiperplasia benigna da próstata, de junho de 2008 a março de 2018. O acompanhamento foi realizado em 3 meses e 12 meses, incluindo International Prostate Symptom Score, escore de qualidade de vida, antígeno prostático específico, ultrassom, ressonância magnética e urofluxometria. Resultados: Embolização de proteção foi realizada em 45 artérias: artérias retais médias em 19 (42,2%); artérias pudendas internas acessórias em 11 (24,4%); anastomoses com ramos da artéria pudenda interna em 10 (22,2%); artérias vesicais superiores em quatro (8,9%); e artéria obturatória em uma (2,2%). Houve um caso de embolização não alvo que provocou uma úlcera peniana, atribuída a refluxo de partículas para uma artéria não protegida. Não houve complicações relacionadas com os ramos protegidos. Os pacientes apresentaram melhora significativa em todos os resultados estudados (p < 0,05) e não relataram piora da função sexual durante o acompanhamento. Conclusão: Embolização de proteção pode ser realizada para diminuir embolização não alvo sem interferir nos resultados da embolização de artérias prostáticas. Além disso, não foi observado nenhum evento adverso diferente dos já esperados ou previamente publicados. A embolização de proteção na região pudenda é segura.