Comparing prostatic artery embolization to surgical and minimally invasive procedures for the treatment of benign prostatic hyperplasia: a systematic review and meta-analysis.

BACKGROUND: To summarize current evidence to report a comparative systematic review and meta-analysis of prostatic artery embolization (PAE) with transurethral resection of the prostate (TURP) and open simple prostatectomy (OSP) for the treatment of benign prostatic hyperplasia (BPH). METHODS: A systematic literature search was performed to identify studies published from inception until August 2021. The search terms used were (prostate embolization OR prostatic embolization) AND (prostatic hyperplasia OR prostatic obstruction) as well as the abbreviations of PAE and BPH. Risk of bias was assessed using the Cochrane Risk of Bias tool for randomized controlled trials (RCTs) and the Risk of Bias in Non-randomized Studies-of Interventions (ROBINS-I) tool for observational studies. Random-effects meta-analysis was performed using Revman 5.4. RESULTS: Seven studies were included with 810 patients: five RCTs and one observational study compared PAE with TURP, and one observational study compared PAE with OSP. The included studies had considerable risk of bias concerns. TURP and OSP were associated with more statistically significant improvements in urodynamic measures and BPH symptoms compared to PAE. However, PAE seems to significantly improve erectile dysfunction compared to OSP and improve other outcome measures compared to TURP, although not significantly. PAE appeared to reduce adverse events and report more minor complications compared with TURP and OSP, but it is unclear whether PAE is more effective in the long-term. CONCLUSION: PAE is an emerging treatment option for patients with symptomatic BPH who cannot undergo surgery or have undergone failed medical therapy. Overall, PAE groups reported fewer adverse events. Future ongoing and longer-term studies are needed to provide better insight into the benefit of PAE compared to other treatment options.

Initial Canadian Experience of Prostate Artery Embolization for Symptomatic Benign Prostatic Hyperplasia: Midterm Outcomes.

INTRODUCTION: This study aimed to assess the midterm outcomes and safety of prostate artery embolization (PAE) for the treatment of benign prostatic hyperplasia (BPH). METHODS: A single-center, retrospective review of PAE performed for BPH was performed. Validated International Prostate Symptom Score (IPSS), quality of life (QoL) index, and International Index for Erectile Function (IIEF-5) questionnaires were completed at baseline and at least 12 months post-procedure. Prostate imaging was performed preprocedure as well as 3 months and 12 months post-procedure to assess prostate volume (PV). Uroflowmetry was also performed at baseline and 12 months post-procedure to assess urine flow rate (Qmax) and post-void residual (PVR) volume. Adverse events were graded according to Society of Interventional Radiology (SIR) guidelines. RESULTS: Eighty male patients underwent the PAE procedure (mean age 69 years). Prostate volume decreased significantly from a mean volume 156 to 107 mL after 12 months post-procedure, commensurate with a mean reduction of 27.5% (P < .05). Significant improvements were seen in IPSS (21.8 vs 10.5) and QoL (4.5 vs 2.0) from baseline to 12 months post-procedure (P < .05). There was no significant change in IIEF-5 score. There was a significant reduction in PVR (202 vs 105 mL) and improvement in Qmax (5.9 vs 10.0 mL/s) between baseline and 12 months post-procedure (P < .05). No major complications occurred; 4 minor complications occurred (SIR grade A or B). CONCLUSION: Prostate artery embolization achieved a clinically and statistically significant prostate volume reduction, symptom and QoL improvement, and enhanced uroflowmetry parameters in patients with BPH.

Portal Vein Embolization: Correlation of Future Liver Remnant Hypertrophy to Type of Embolic Agent Used.

PURPOSE: The purpose of this study was to compare the effectiveness of portal vein embolization (PVE) with different embolic agents used at our centre. Specifically, the effectiveness of N-butyl cyanoacrylate (NBCA) glue is compared with that of polyvinyl alcohol (PVA) particles. METHODS: We performed a retrospective chart review of all patients (N = 77) who underwent PVE at our institution over a 5-year period. Pre- and postprocedural computed tomography or magnetic resonance imaging, when available, were used to measure the volume of total liver volume and future liver remnant (FLR). The absolute values obtained were used to calculate percentage of FLR. The growth in FLR was determined 4-6 weeks after PVE. Technical details of the procedure including the type and amount of embolic agent used were obtained from the chart reviews, electronic patient records, and radiology reports. Statistical analysis was performed using Kruskal-Wallis test, Wilcoxon rank sum test, and the Spearman correlation coefficient with post hoc analysis. Results are expressed as mean ± SD (P < .05 considered statistically significant). RESULTS: NBCA (n = 29) produced a mean change in FLR of 14.8% compared with 9.3% for PVA particles (n = 24; P = .007). Mean change in FLR was 10.1% in the group where a combination of NBCA and PVA particles was used (n = 24). The effect of glue volume and glue-to-lipiodol ratio on the outcome was not found to be statistically significant (P = .5 and .7, respectively). CONCLUSIONS: We conclude that NBCA glue is a better embolic agent than PVA particles in inducing liver hypertrophy.

Percutaneous Recanalization of Iliac Artery Occlusions by Radiofrequency Perforation: Initial Experience.

The success rate of endovascular therapy for iliac occlusions is often limited by failure to traverse the lesion. A single institution's experience with the use of radiofrequency-assisted recanalization of occlusions in 10 iliac arteries is described. The median length of occlusion was 43 mm (range, 14-64 mm; mean, 42 mm). Revascularization was achieved in all cases. One case was complicated by vessel perforation with no adverse sequelae after stent insertion. All patients reported symptom resolution, and no target lesion reintervention or surgery was required. The median follow-up was 42 months (range, 11-63 mo; mean, 35 mo).

AMPLATZER Vascular Plug 4 for proximal splenic artery embolization in blunt trauma.

A consecutive case series was conducted evaluating proximal splenic artery embolization (SAE) with the AMPLATZER Vascular Plug 4 (AVP4) (St. Jude Medical, Inc, St. Paul, Minnesota) in eight patients with high-grade splenic trauma. Three proximal and five combined proximal and distal subselective coiling procedures were successfully performed. Mean time from device deployment to splenic artery occlusion was 4.5 minutes (range, 2.1-10.0 min; standard deviation, 2.8 min). There were no immediate complications. One patient developed a perisplenic abscess requiring percutaneous drainage and antibiotics. Results of this initial study show the suitability of the AVP4, with its ease of deployment without a guiding sheath and accurate placement, as a viable adjunct to nonoperative management of blunt splenic injury.

Randomized Controlled Trial of Percutaneous Radiologic Gastrostomy Performed With and Without Gastropexy: Technical Success, Patient-Reported Outcomes and Safety.

PURPOSE: The aim of this study is to compare balloon-retention percutaneous radiologic gastrostomy (PRG) tube insertion performed with and without gastropexy, primarily focusing on pain and patient-reported outcomes. MATERIALS AND METHODS: Research ethics board approved a dual-arm, single-centre, randomized trial of 60 patients undergoing primary 14-French PRG tube insertion (NCT04107974). Patients were randomized to receive either PRG with gastropexy or without gastropexy. Data were collected for technical outcomes, patient-reported outcomes pre-procedure, post-procedure and at 1-month, as well as quality of life parameters at 1-month post-procedure (EQ5D-5L, Visual Analogue Scale and Functional Assessment of Cancer Therapy-Enteral Feeding questionnaires). Complications occurring up to 6-months post-procedure were recorded. RESULTS: Sixty patients were randomized to the gastropexy group (n = 30) or non-gastropexy (n = 30) group. One non-gastropexy patient was withdrawn from the study due to failed insertion. PRG procedural time was significantly longer when using gastropexy (mean 11.4 ± 7.19 min) compared with non-gastropexy (mean 6.79 ± 4.63 min; p < 0.05). Pain scores did not differ between the two groups pre-procedure, post-procedure and at 1-month follow-up, nor did 1-month quality of life parameters. Six (20%) minor complications occurred in the gastropexy group and nine (31%) minor complications in the non-gastropexy group (p = 0.330). Two (6.9%) major complications occurred in the non-gastropexy group (p = 0.458). CONCLUSION: There is comparable patient tolerability when balloon-retention PRG insertion is performed with or without gastropexy sutures. This study also demonstrated a trend towards fewer complications when gastropexy is utilized. However, further larger trials are required to compare complications of the two approaches for PRG insertion. LEVEL OF EVIDENCE: Level 2, randomized trial.

Peripherally Inserted Central Catheters (PICCs) at the Bedside by X-ray Technologists: A Review of Our Experience.

INTRODUCTION: Peripherally inserted central catheters, also known as PICC lines, are very common procedures for patients in the hospital who need to have long-term intravenous access, for various reasons such as antibiotics or total parenteral nutrition. At our institution, there is currently only one interventional radiology (IR) suite in our department to accommodate all IR procedures. Therefore, the bedside PICC program was introduced to help alleviate the workload in the IR suite and to improve overall patient care. Under the supervision of the hospital's interventional radiologists, trained x-ray technologists (medical radiation technologists [MRTs]) are inserting PICCs at the bedside. The purpose of this article is to describe the creation of a bedside PICC program by x-ray technologists in a hospital setting and to analyze the PICC insertions performed by MRTs over a six-year period. METHODS: In 2012, a bedside PICC insertion program was developed at our hospital, whereby two technologists would perform the procedure, using the Site-Rite® 8 Ultrasound System alongside the integrated Sherlock 3CG™ Diamond Tip Confirmation System. Training on these systems and procedural techniques, including venipuncture, sterile technique, and equipment knowledge and troubleshooting was provided for technologists. The point-of-care program was revamped in 2017 in that only one technologist would go to the bedside alone for PICC insertions. All data for the analyses were obtained from the Radiology Information System program used by our medical imaging department, called Coral RIS/PACS. RESULTS: Owing to staffing issues and inconsistent scheduling, an overview of yearly volumes of bedside PICCs performed increased from 45 in 2012 to 486 in 2018. After program changes made in 2017, these changes yielded a total volume of 382 of bedside PICCs performed, and an even more remarkable amount of 486 in 2018. For these two latter years, an evaluation of the program was carried out by analyzing how many bedside PICCs were performed successfully by the solo technologist. Overall success was achieved for both years: in 2017, 82% of the cases were performed by the technologist alone without any assistance, and likewise 89% in 2018. CONCLUSION: Since the onset of this process improvement initiative, the bedside PICC program by MRTs under the supervision of the interventional radiologists at our institution has benefited many patients and the hospital as a whole. It was apparent during the development of the program that consistent scheduling of trained and dedicated MRTs to do these bedside procedures on a regular basis improved the efficiency of the program.

Critical lower-limb ischemia: the diagnostic performance of dual-phase injection MR angiography (including high-resolution distal imaging) compared with digital subtraction angiography.

PURPOSE: To prospectively compare contrast-enhanced (CE) magnetic resonance (MR) angiography against digital subtraction angiography (DSA) in patients with critical lower-limb ischemia. MATERIALS AND METHODS: Thirty patients with critical lower limb ischemia underwent both CE MR angiography and DSA. CE MR angiography commenced with a dedicated high-resolution study of the below-knee arteries followed by a three-station bolus-chase examination. Two blinded observers recorded the severity of the most significant stenosis within each arterial segment. Interobserver agreement was calculated and, with DSA as the reference standard, the sensitivity and specificity of CE MR angiography for the detection of significant stenosis (>or=50% luminal narrowing) or occlusion was calculated. RESULTS: All 390 arterial segments were scored by both observers. Sensitivity was higher in the distal segments (92%-96%) compared with the proximal segments (69%-79%). Specificity was similar in distal (90%-91%) and more proximal segments (86%-96%). Overall, interobserver agreement was excellent (kappa = 0.95 for CE MR angiography and DSA) and was superior within the distal segments. Twenty-eight segments that were considered occluded on DSA were shown to be patent on CE MR angiography and 16 segments that were considered occluded on CE MR angiography were shown to be patent on DSA. CONCLUSIONS: In patients with critical lower-limb ischemia, CE MR angiography with high-resolution distal imaging is highly accurate for assessment of the below-knee arteries. Both DSA and CE MR angiography may identify patent vessels that are considered occluded based on the other modality.

Initial Experience With Viabahn VBX as the Bridging Stent Graft for Branched and Fenestrated Endovascular Aneurysm Repair.

PURPOSE: To evaluate the feasibility and safety of a novel balloon-expandable, heparin-bonded endoprosthesis (Viabahn VBX, W. L. Gore and Associates) when used as a bridging stent graft (BSG) with fenestrated and branched endovascular aneurysm repair (FB-EVAR). FB-EVAR and BSGs increase repair complexity with the potential for endoleak formation, stenosis, thrombosis, and graft migration. The mechanical construction of the Viabahn VBX and its antithrombogenic properties may provide an advantage for FB-EVAR over existing BSGs. The efficacy, safety, and clinical outcomes were assessed. MATERIALS AND METHODS: Research ethics board approved, prospective, single arm cohort, pilot study of patients undergoing FB-EVAR between February 2017 and January 2018. Fenestrated and branched endovascular aneurysm repair was performed per the standard institutional protocol by a team composed of vascular surgeons and interventional radiologists. Viabahn VBX endografts were used for all intended visceral branches as long as appropriately sized devices were available (Under Investigational Testing Authorization from Health Canada). Patient characteristics, procedural details, and technical and clinical outcomes were reviewed and summarized. RESULTS: FB-EVAR was performed in 13 patients (9 male and 4 female) mean age of 74 (range: 61-83) with a total of 41 Viabahn VBXs stents implanted. Mean maximum aneurysm size was 6.7 cm (range: 5.5-9.0 cm) and included 5 juxtarenal abdominal aortic aneurysms and 8 thoracoabdominal; 3 type V, 3 type IV, and 2 type III (Crawford Classification). The Viabahn VBX was successfully deployed in 40 (98%) of 41 of cases. At median follow-up of 223 days (range: 2-462), there was a (40/40) 100% Viabahn VBX patency rate. Seven endoleaks were identified intra- or post procedurally in 6 (46%) of 13 cases, including 1 type IB, 3 type II, 2 type III, and 1 unclassified. Nine complications occurred in 6 patients. CONCLUSION: The Viabahn VBX stent is a safe and effective BSG for FB-EVAR with no early stent thrombosis. Further evaluation is required to determine longer term stent efficacy.

Radiofrequency guide wire recanalization of venous occlusions in patients with malignant superior vena cava syndrome.

Fibrotic central venous occlusions in patients with thoracic malignancy and prior radiotherapy can be impassable with standard catheters and wires, including the trailing or stiff end of a hydrophilic wire. We report two patients with superior vena cava syndrome in whom we successfully utilized a radiofrequency guide wire (PowerWire, Baylis Medical, Montreal, Quebec, Canada) to perforate through the occlusion and recanalize the occluded segment to alleviate symptoms.

Endograft collapse following endovascular repair of traumatic aortic injury.

The advent of endovascular treatment of traumatic thoracic aortic injuries offers a valuable, minimally invasive alternative to open surgical repair. However, there are limitations of the current endovascular stent graft technology for this group of patients. After endovascular repair meticulous follow-up is required with a high index of suspicion for potential complications including the lethal complication of endograft collapse.