Effect of Prostate Artery Embolization on Erectile Function - A Single Center Experience of 167 Patients.

BACKGROUND: Prostate artery embolization (PAE) is an emerging therapy for lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH). AIM: This retrospective study was conducted to assess the effect of prostate artery embolization (PAE) on erectile function in a cohort of patients with LUTS attributable to BPH at 3-months after the procedure. METHODS: A retrospective review was performed on 167 patients who underwent PAE. Data collected included Sexual Health Inventory in Men (SHIM) scores at 3, 6, and 12 months post-PAE, in conjunction with the International Prostate Symptom Scores (IPSS), Quality of Life (QoL) scores, and prostate volumes. Primary outcome was erectile function as assessed by SHIM scores at 3 months after PAE. An analysis was performed to identify patients with a ±5-point SHIM change to group them according to this minimum clinically significant difference in erectile function. Adverse events were recorded using the Clavien-Dindo (CD) classification. OUTCOMES: At 3 months following PAE, median IPSS decreased by 16.0 [IQR, 9.0-22.0] points, median QOL decreased by 4.0 [IQR, 2.0-5.0] points, and median prostate volume decreased by 33 g [IQR, 14-55]. RESULTS: Median SHIM score was 17.0 [IQR, 12.0-22.0] at baseline, 18.0 [IQR, 14.0-23.0] at 3 months [P = .031], 19.0 [IQR, 14.5-21.5] at 6 months [P = .106] and 20 [IQR, 16.0-24.0] at 12 months [P = .010] following PAE. In patients with no erectile dysfunction (ED) at baseline, 21% (n = 9) reported some degree of decline in erectile function post-PAE. However, 38% (n = 40) of patients who presented with mild-to-moderate ED reported improvement in their erectile function 3 months following PAE. Overall, the changes in baseline SHIM score were relatively small; 82% (n = 137) of patients did not have more than 5 points of change in their SHIM scores at 3 months following PAE. CLINICAL IMPLICATIONS: Our findings suggest PAE has no adverse impact on erectile function for most patients. STRENGTHS & LIMITATIONS: The study was performed at a single center with 1 operator's experience, and is retrospective with no control group. CONCLUSION: Findings suggest that prostate artery embolization has no adverse effect on erectile function in the majority of patients with LUTS attributable to BPH at 3 months after the procedure. Bhatia S, Acharya V, Jalaeian H, et al., Effect of Prostate Artery Embolization on Erectile Function - A Single Center Experience of 167 Patients. J Sex Med 2022;19:594-602.

Efficacy of Prostatic Artery Embolization for Catheter-Dependent Patients with Large Prostate Sizes and High Comorbidity Scores.

PURPOSE: To evaluate efficacy and safety of prostate artery embolization (PAE) in urinary catheter-dependent patients with large prostate volumes and high comorbidity scores. MATERIALS AND METHODS: A retrospective single-center review was conducted of 30 patients with urinary retention at time of PAE from November 2014 through February 2017. Mean (range) age was 73.1 years (48-94 y), age-adjusted Charlson comorbidity index was 4.5 (0-10), duration of urinary retention was 63.4 days (2-224 d), International Prostate Symptom Score quality-of-life (IPSS-QOL) was 5.3 (3-6), and prostate volume was 167.3 cm3 (55-557 cm3). These parameters were collected at 3, 6, and 12 months after PAE. Trials of voiding were performed approximately 2 weeks after PAE and, if failed, every 2 weeks thereafter. Adverse events were graded using the Clavien-Dindo classification. RESULTS: At a mean (range) of 18.2 days (1-72 d), 26 (86.7%) patients were no longer reliant on catheters. Follow-up was obtained in all patients eligible at 3 and 6 months and 17 of 20 (85.0%) patients eligible at 1 year. Mean (range) IPSS-QOL improved significantly to 1.2 (0-5), 0.7 (0-4), and 0.6 (0-4) at 3, 6, and 12 months (all P < .001). Mean (range) prostate volume decreased significantly to 115.9 cm3 (27-248 cm3) at 3 months (P < .001). Two patients experienced grade II urosepsis complications, which were successfully treated with intravenous antibiotics. All other complications were self-limited grade I complications. CONCLUSIONS: PAE represents a safe and effective option for management of patients with urinary retention, especially patients with large prostates who are not ideal surgical candidates.

Role of Coil Embolization during Prostatic Artery Embolization: Incidence, Indications, and Safety Profile☆.

PURPOSE: To determine if coil embolization is a safe adjunctive measure to prevent nontarget embolization during prostatic artery embolization (PAE). MATERIALS AND METHODS: A retrospective analysis of patients who underwent PAE with coil embolization (cPAE) or without coil embolization (nPAE) between January 2014 and June 2016 was conducted. Adverse events, identified in accordance with SIR guidelines, and procedural variables were compared between the 2 cohorts. RESULTS: Of 122 patients, 32 (26.2%) underwent coil embolization in 39 arteries, with coils placed to prevent nontarget embolization (n = 36), treat prostatic artery extravasation (n = 2), and occlude an intraprostatic arteriovenous fistula (n = 1). Compared with nPAE, cPAE had a nonsignificant increase in dose area product (64,516 µGy·m2 vs 52,100 µGy·m2, P = .053) but significantly longer procedure (160.1 min vs 137.1 min, P = .022) and fluoroscopy (62.9 min vs 46.1 min, P = .023) times. One major complication (urosepsis) occurred in each group (cPAE, 1/32 [3.1%]; nPAE, 1/80 [1.3%]). Both cases resolved after 2 weeks of intravenous antibiotics. A minor ischemic complication (1/32 [3.1%]) occurred in a patient with coil embolization, which manifested as white discoloration of the glans penis and resolved with topical therapy. There were no statistically significant differences in major and minor complications between cohorts at 1-month and 3-month follow-up visits. CONCLUSIONS: Although coil embolization leads to increases in procedure and fluoroscopy times, it is a safe adjunctive technique to occlude communications between the prostatic artery and pelvic vasculature to potentially prevent nontarget embolization.

Intra-Arterial Platelet Infusion for Intractable Hemorrhage and Refractory Thrombocytopenia in Children With Gastrointestinal Graft-Versus-Host Disease.

Acute gastrointestinal graft-versus-host disease (GVHD) refractory to first-line treatment with systemic corticosteroids results in increased morbidity and potential mortality. We retrospectively assessed the feasibility and efficacy of catheter-directed intra-arterial platelet infusion (IAPI) in two pediatric patients with steroid and transfusion refractory gastrointestinal GVHD causing intractable lower gastrointestinal hemorrhage and refractory thrombocytopenia, that were referred for salvage therapy. Immediate angiographic response was noted with a resolution of hemorrhage and decreased blood requirements. We reviewed the literature regarding this treatment modality and compared it to the available minimally invasive transcatheter techniques to control gastrointestinal hemorrhage.

Single-center experience in prostate fiducial marker placement: technique and midterm follow-up.

PURPOSE: To describe the technique, technical success, and complications of prostate fiducial marker implantation using transrectal ultrasound (US) guidance in patients undergoing image-guided radiation therapy. MATERIALS AND METHODS: A retrospective review was performed of patients who underwent fiducial marker placement from January 2010-April 2013. In each case, gold markers were placed in the prostate using transrectal US guidance. Computed tomography (CT) was performed after the procedure and evaluated to confirm correct placement. Technical success, complications, and development of symptoms during radiotherapy were reviewed. RESULTS: Transrectal US-guided fiducial marker placement was performed on 75 patients (mean age, 62 y; range, 48-79 y) with a mean Gleason score of 7.25 (range, 6-10). Fiducial marker placement was confirmed in the intended location of the prostate or prostate bed for 297 of 300 markers (99%) on follow-up CT imaging. Two markers were placed just outside the prostate capsule, and one marker was lost. Complications included sepsis (n = 1; 1.3%), self-limiting perirectal or intraprostatic hemorrhage (n = 3; 4%), nausea (n = 1; 1.3%), transient hypotension (n = 1; 1.3%), epididymitis (n = 1; 1.3%), and urinary tract infection (n = 1; 1.3%). Complications were seen more frequently in patients with high tumor grade (P = .001) and in patients who developed metastatic disease (P = .01). CONCLUSIONS: Transrectal US-guided implantation of fiducial markers is technically feasible, is well tolerated, and has a good safety profile.

Pulmonary embolism versus pulmonary vasculitis in Hughes-Stovin syndrome: Characteristic computed tomography pulmonary angiographic findings and diagnostic and therapeutic implications. HSS International Study Group.

BACKGROUND AND AIM: Hughes-Stovin syndrome (HSS) is a rare systemic vasculitis with widespread venous/arterial thrombosis and pulmonary vasculitis. Distinguishing between pulmonary embolism (PE) and in-situ thrombosis in the early stages of HSS is challenging. The aim of the study is to compare clinical, laboratory, and computed tomography pulmonary angiography (CTPA) characteristics in patients diagnosed with PE versus those with HSS. METHODS: This retrospective study included 40 HSS patients with complete CTPA studies available, previously published by the HSS study group, and 50 patients diagnosed with PE from a single center. Demographics, clinical and laboratory findings, vascular thrombotic events, were compared between both groups. The CTPA findings were reviewed, with emphasis on the distribution, adherence to the mural wall, pulmonary infarction, ground glass opacification, and intra-alveolar hemorrhage. Pulmonary artery aneurysms (PAAs) in HSS were assessed and classified. RESULTS: The mean age of HSS patients was 35 ± 12.3 years, in PE 58.4 ± 17 (p < 0.0001). Among PE 39(78 %) had co-morbidities, among HSS none. In contrast to PE, in HSS both major venous and arterial thrombotic events are seen.. Various patterns of PAAs were observed in the HSS group, which were entirely absent in PE. Parenchymal hemorrhage was also more frequent in HSS compared to PE (P < 0.001). CONCLUSION: Major vascular thrombosis with arterial aneurysms formation are characteristic of HSS. PE typically appear loosely-adherent and mobile whereas "in-situ thrombosis" seen in HSS is tightly-adherent to the mural wall. Mural wall enhancement and PAAs are distinctive pulmonary findings in HSS. The latter findings have significant therapeutic ramifications.

Prostate artery embolization in a patient with left ventricular assist device.

Increased number of left ventricular assist device placement in patients with end stage heart failure as well as years of survival increases the likelihood of need for non-cardiac procedures. Prostate artery embolization is a safe, minimally invasive procedure performed in the setting of lower urinary tract symptoms or refractory gross hematuria of prostatic origin. These patients require a multidisciplinary approach to weigh the benefits and risks of the procedure and provide optimal periprocedural care. We report a case of technically successful prostate artery embolization performed in a patient with HeartWare HVAD presenting with refractory hematuria of prostatic origin (RHPO).

Pulmonary vasculitis in Hughes-Stovin syndrome (HSS): a reference atlas and computed tomography pulmonary angiography guide-a report by the HSS International Study Group.

INTRODUCTION: Hughes-Stovin syndrome (HSS) is a systemic vasculitis characterized by widespread venous/arterial thrombosis and pulmonary artery aneurysms (PAAs), which is associated with serious morbidity and mortality. All fatalities reported in HSS resulted from unpredictable fatal suffocating hemoptysis. Therefore, it is necessary to recognize pulmonary complications at an early stage of the disease. OBJECTIVES: The aims of this study are to develop a reference atlas of images depicting the characteristic features of HSS by computed tomography pulmonary angiography (CTPA). To make a guide for physicians by developing a classification of PAAs according to the severity and risk of complications associated with each distinct lesion type. METHODS: The Members of the HSS International Study Group (HSSISG) collected 42 cases, with high-quality CTPA images in one radiology station and made reconstructions from the source images. These detailed CTPA studies were reviewed for final image selection and approved by HSSISG board members. We classified these findings according to the clinical course of the patients. RESULTS: This atlas describes the CTPA images that best define the wide spectrum of pulmonary vasculitis observed in HSS. Pulmonary aneurysms were classified into six radiographic patterns: from true stable PAA with adherent in-situ thrombosis to unstable leaking PAA, BAA and/or PAP with loss of aneurysmal wall definition (most prone to rupture), also CTPA images demonstrating right ventricular strain and intracardiac thrombosis. CONCLUSION: The HSSISG reference atlas is a guide for physicians regarding the CTPA radiological findings, essential for early diagnosis and management of HSS-related pulmonary vasculitis. Key Points • The Hughes-Stovin syndrome (HSS) is a systemic vasculitis characterized by extensive vascular thrombosis and pulmonary artery aneurysms (PAAs) that can lead to significant morbidity and mortality. • All fatalities reported in HSS were related to unpredictable massive hemoptysis; therefore, it is critical to recognize pulmonary complications at an early stage of the disease. • The HSS International Study Group reference atlas  classifies pulmonary vasculitis in HSS at 6 different stages of the disease process and defines the different radiological patterns of pulmonary vasculitis notably pulmonary artery aneurysms, as detected by computed tomography pulmonary angiography (CTPA). • The main aim of the classification is to make a guide for physicians about this rare syndrome. Such a scheme has never been reached before since the first description of the syndrome by Hughes and Stovin since 1959. This classification will form the basis for future recommendations regarding diagnosis and treatment of this syndrome.

A critical analysis of 57 cases of Hughes-Stovin syndrome (HSS). A report by the HSS International Study Group (HSSISG).

BACKGROUND: Hughes-Stovin syndrome (HSS) is a systemic disease characterized by widespread vascular thrombosis and pulmonary vasculitis with serious morbidity and mortality. The HSS International Study Group is a multidisciplinary taskforce aiming to study HSS, in order to generate consensus recommendations regarding diagnosis and treatment. METHODS: We included 57 published cases of HSS (43 males) and collected data regarding: clinical presentation, associated complications, hemoptysis severity, laboratory and computed tomography pulmonary angiography (CTPA) findings, treatment modalities and cause of death. RESULTS: At initial presentation, DVT was observed in 29(33.3 %), thrombophlebitis in 3(5.3%), hemoptysis in 24(42.1%), and diplopia and seizures in 1 patient each. During the course of disease, DVT occurred in 48(84.2%) patients, and superficial thrombophlebitis was observed in 29(50.9%). Hemoptysis occurred in 53(93.0%) patients and was fatal in 12(21.1%). Pulmonary artery (PA) aneurysms (PAAs) were bilateral in 53(93%) patients. PAA were located within the main PA in 11(19.3%), lobar in 50(87.7%), interlobar in 13(22.8%) and segmental in 42(73.7%). Fatal outcomes were more common in patients with inferior vena cava thrombosis (p = 0.039) and ruptured PAAs (p < 0.001). Death was less common in patients treated with corticosteroids (p < 0.001), cyclophosphamide (p < 0.008), azathioprine (p < 0.008), combined immune modulators (p < 0.001). No patients had uveitis; 6(10.5%) had genital ulcers and 11(19.3%) had oral ulcers. CONCLUSIONS: HSS may lead to serious morbidity and mortality if left untreated. PAAs, adherent in-situ thrombosis and aneurysmal wall enhancement are characteristic CTPA signs of HSS pulmonary vasculitis. Combined immune modulators contribute to favorable outcomes.

Intractable hematuria due to giant prostatic hyperplasia effectively treated with prostatic artery embolization.

Giant prostatic hyperplasia (GPH) is a rare pathology traditionally treated with an open suprapubic prostatectomy. This procedure is risky, and fatal hemorrhagic complications can occur. Often, patients with GPH present with diminished renal function due to obstructive nephropathy, making them unfit for less invasive endovascular therapies using traditional contrast agents. Here we present a case of a patient with intractable hematuria due to GPH, as well as diminished renal function, who was successfully treated using prostatic artery embolization with CO2 digital subtraction arteriography as a contrast agent.

Prostatic Artery Embolization in Refractory Hematuria of Prostatic Origin.

Hematuria of prostatic origin has multiple etiologies including benign prostatic hyperplasia (BPH), iatrogenic urological trauma, prostate cancer, and radiation therapy. Hematuria secondary to benign prostatic hyperplasia can occur because of the increased vascularity of the primary gland, itself, or because of the vascular re-growth following a transurethral resection of the prostate. Prostatic hematuria usually resolves with conservative measures; however, refractory hematuria of prostatic origin may require hospitalization with treatment with blood transfusions, repeated indwelling urinary catheterization, and continuous bladder irrigation. Prostate artery embolization is an emerging minimally invasive procedural therapy for men with BPH that was originally utilized for the treatment of refractory hematuria of prostatic origin . This article aims to summarize the currently available evidence around prostate artery embolization for the treatment of refractory hematuria of prostatic origin.

Prostatic Artery Embolization: Variant Origins and Collaterals.

Prostate artery embolization (PAE) is a minimally invasive treatment for benign prostatic hyperplasia associated lower urinary tract symptoms. The prostatic arterial anatomy, origins and collaterals, are highly variable and can lead to technical pitfalls and suboptimal results during PAE. In this paper we aim to discuss the variant prostate artery origins and collateral circulation to provide a primer on relevant anatomy for interventional radiologists performing PAE.

Endoscopic Ultrasound-assisted Diagnosis of Obscure Gastrointestinal Bleeding.

Hemosuccus pancreaticus (HP) describes hemorrhage originating from the pancreatic duct. HP is an extremely uncommon source of upper gastrointestinal bleeding and is often misdiagnosed in most community hospitals. HP is believed to be associated with arterial aneurysm, pancreatitis (acute or chronic), local inflammation, pseudocyst, and tumor or cystic neoplasms. We report a case of a 62-year-old man with multiple cysts in the pancreas on CT scan who presented with an obscure upper GI bleed in which we performed step-wise investigations that led us to the diagnosis of hemosuccus pancreaticus, which was made through endoscopic ultrasound. After diagnosis, the patient was treated successfully by interventional radiology.

An Approach to Endovascular and Percutaneous Management of Transjugular Intrahepatic Portosystemic Shunt (TIPS) Dysfunction: A Pictorial Essay and Clinical Practice Algorithm.

Transjugular intrahepatic portosystemic shunts (TIPS) have evolved as an effective and durable nonsurgical option in the treatment of portal hypertension (PH). It has been shown to improve survival in decompensated cirrhosis and may also serve as a bridge to liver transplantation. In spite of the technical improvements in the procedure, problems occur with the shunt which jeopardizes effective treatment of the PH. Appropriate management is vital to ensure the longevity of the conduit. Shunt revision techniques include endovascular revision techniques and new shunt creation or, in the appropriate patients, alternative/rescue therapies. The ability of interventional radiologists to restore adequate TIPS function has enormous implications for quality of life with palliation, morbidity/mortality related to variceal bleeding and survival if transplant candidates can live long enough to receive a new liver. As such, it is imperative that these treatment strategies are understood and employed when these patients are encountered. In this review, the restoration of appropriate shunt function using various techniques will be discussed as they apply to a variety of clinical scenarios, based on literature. In addition, illustrative case examples highlighting our experience at an academic tertiary medical center will be included. It is the intent to have this document serve as a concise and informative reference to be used by those who may encounter patients with suboptimal functioning TIPS.

Amplatzer vascular plug as an embolic agent in different vascular pathologies: A pictorial essay.

The Amplatzer Vascular Plug (AVP) is a cylindrical plug made of self-expanding nitinol wire mesh with precise delivery control, which can be used for a variety of vascular pathologies. An AVP is an ideal vascular occlusion device particularly in high-flow vessels, where there is high risk of migration and systemic embolization with traditional occlusion devices. We performed 28 embolizations using the AVP from 2009 to 2014 and achieved complete occlusion without complications.

Endovascular Management of Refractory Hepatic Encephalopathy Complication of Transjugular Intrahepatic Portosystemic Shunt (TIPS): Comprehensive Review and Clinical Practice Algorithm.

Transjugular intrahepatic portosystemic shunt (TIPS) has evolved as an effective intervention for treatment of complications of portal hypertension. The use of polytetrafluoroethylene-covered stents have improved the patency of the shunts and diminished the incidence of TIPS dysfunction. However, TIPS-related refractory hepatic encephalopathy (rHE) poses a significant challenge. Approximately 3-7 % of patients with TIPS develop rHE. Refractory hepatic encephalopathy is defined as a recurrent or persistent encephalopathy despite appropriate medical treatment. Hepatic encephalopathy can be an extremely debilitating complication that profoundly affects quality of life. The approach to management of patients with rHE is complex and typically requires collaboration between different specialties. Liver transplantation is the ultimate treatment for rHE; however, the ongoing shortage of organ donation markedly limits this treatment option. Alternative therapies such as shunt occlusion or reduction can control symptoms and serve as a 'bridge' therapy to liver transplantation. Therefore, interventional radiologists play a key role in the management of these patients by offering a variety of endovascular techniques. The purpose of this review is to highlight some of these endovascular techniques and to develop a therapeutic algorithm that can be applied in clinical practice for the management of rHE.

Multimodal endovascular management of a Jehovah's Witness patient with Hugues-Stovin syndrome presenting with ruptured pulmonary artery aneurysm and cardiopulmonary thromboembolism.

Hughes-Stovin syndrome is a very rare disease with fewer than 40 cases reported in the literature. The disease is thought to be a variant of Behçet's disease that can manifest with massive haemoptysis due to ruptured pulmonary arterial aneurysms in the setting of deep venous thrombosis. This association might impose a therapeutic dilemma when anticoagulation has to be balanced with the excessive risk of bleeding, especially if the patient refuses any blood replacement, and is not a surgical candidate. We present a case of a 41-year-old Jehovah's Witness patient with Hughes-Stovin syndrome that presented to the emergency room with haemoptysis due to multiple ruptured pulmonary artery aneurysms. Her work-up showed concomitant cardio-venous thromboembolism and pulmonary infarction. She was successfully managed via a bloodless single-wall venous puncture, allowing endovascular treatment of bilateral pulmonary aneurysms with subsequent caval filtration. The course was uneventful, and the patient was discharged under immunosuppressant.