Utility of Cone-Beam CT Imaging in Prostatic Artery Embolization

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Bagla S et al. "Utility of Cone-Beam CT Imaging in Prostatic Artery Embolization". Journal of Vascular and Interventional Radiology. 2013. 24(11):1603-1607. https://www.jvir.org/article/S1051-0443(13)01182-2/fulltext

Clinical Question

To determine the utility and impact of intraoperative CBCT as compared to DSA alone during PAE for the treatment of symptomatic BPH.

Bottom Line

Intraoperative use of Cone-beam CT (CBCT) in prostatic artery embolization (PAE) decreases the risk of nontarget embolization and associated complications by providing superior identification of duplicated prostatic arterial supply and contralateral perfusion which may be difficult to visualize using digital subtraction angiography alone. [CBCT imaging directly impacted treatment in 5 of 11 PAE procedures (46%) in retrospective analysis of a prior prospective study].

Major Points

  • The use of intraoperative CBCT directly influenced PAE treatment by identifying nontarget embolization sites in 46% (5 of 11) of patients.
  • CBCT allowed for identification of duplicated prostatic arterial supply and contralateral perfusion in 21% (3 of 11) of patients.
  • Clinical success (AUA score improvement >3) was achieved in 93% (13 of 14) of patients.
  • No adverse events (per SIR AE classification system) occured during PAE utilizing intraoperative CBCT.

Design

  • Retrospective analysis of data collected from prior single center prospective cohort study investigating PAE for management of BPH in patients who have previously failed medical treatment.
  • N=15
  • Setting: Single Center in the United States
  • Enrollment: January 2012 to January 2015
  • Follow-up at 1-month
  • Primary outcome: Identification of potential sites of nontarget embolization via CBCT and DSA following selection of target artery utilizing standard technique. Clinical success measured by AUA score improvement >3 points.
    • Nontarget embolization sites were identified in 50% (7 of 14) of all acquisition events performed in 11 total patients undergoing additional CBCT/DSA imaging.
    • Nontarget embolization sites were identified in 46% (5 of 11) of patients undergoing additional CBCT/DSA imaging.
    • Identified sites of nontarget embolization were the rectum, bladder, penis, seminal vesicles, and pelvic/thigh musculature.
    • Clinical success at one month was achieved in 93% (13 of 14) of patients (P < .0001) with a mean improvement of 13.7 AUA points.

Population

Inclusion Criteria

  • Patients with Moderate- or severe-grade LUTS due to BPH who had failed medical management.
  • Patients had undergone clinical evaluation by an interventional radiologist and an urologist with preprocedural evaluation including American Urological Association (AUA) symptom score testing, CBC/CMP, PSA measurement, urodynamic testing, and prostate MRI.

Exclusion Criteria

  • Bladder carcinoma
  • Prostate Carcinoma
  • Renal insufficiency
  • Coagulopathy
  • Neurogenic Bladder

Baseline Characteristics

  • Mean age: 68 years
  • Mean AUA symptom score: 25
  • Mean prostatic volume: 64cm3
  • Mean International Index of Erectile Function score: 13
  • Mean peak urine flow: 9.1mL/s

Interventions

  • Eligible patients underwent PAE via single common femoral artery access. Selection of target artery occurred via selective bilateral hypogastric arterial catheterization with digital subtraction angiography (DSA).
    • Prior to embolization of selected target artery, additional DSA and CBCT was performed in 11 of 15 patients. Further selective catheterization was performed in individuals where CBCT imaging identified nontarget embolization.
    • All procedures were performed in a cone-beam CT-capable uniplanar flat-panel interventional suite by a board-certified interventional radiologist.

Outcomes

Primary Outcomes

  • Nontarget embolization sites were identified in 50% (7 of 14) of all acquisition events performed in 11 total patients undergoing additional CBCT/DSA imaging.
  • Nontarget embolization sites were identified in 46% (5 of 11) of patients undergoing additional CBCT/DSA imaging.
  • Identified sites of nontarget embolization were the rectum, bladder, penis, seminal vesicles, and pelvic/thigh musculature.
  • Clinical success at one month was achieved in 93% (13 of 14) of patients (P < .0001) with a mean improvement of 13.7 AUA points.

Adverse Events

Adverse event monitoring utilized existing SIR AE Classification scale (https://www.jvir.org/article/S1051-0443(17)30576-6/pdf) which categorizes major and minor complications including death, permanent adverse sequelae, prolonged hospitalization, unplanned increase in level of care, and other undesirable outcomes. See JVIR Standard of Practice for Adverse Event Classification for more details. Additional safety outcomes measured included specific urologic complications of impotence, incontinence, or prostatitis.

  • No major or minor complications as described in the SIR AE Classification system occurred.
  • No specific urologic complications were discovered at time of procedure or at 1-month follow-up.

Criticisms

  • Retrospective analysis of study originally designed for an alternative purpose limits complete interpretation of results as the decision to utilize intraoperative CBCT was based solely on interventionalists preference at time of procedure
  • Interventionists were not blinded to the results of CBCT imaging prior to indicating final target selection
  • Lack of randomization
  • Small sample size

Further Reading

Comparative Analysis of Cone-Beam CT Angiogram and Conventional CT Angiogram for Prostatic Artery Identification Prior to Embolization https://www.jvir.org/article/S1051-0443(17)30904-1/fulltext#sec2

Cone-beam CT during prostatic artery embolization: a necessary adjunct to DSA to prevent complication https://www.jvir.org/article/S1051-0443(14)01659-5/fulltext

Prostatic Arterial Supply: Anatomic and Imaging Findings Relevant for Selective Arterial Embolization https://www.jvir.org/article/S1051-0443(12)00790-7/abstract

Abbreviations

AUA (American Urological Association), BPH (benign prostatic hyperplasia), CBCT (cone-beam computed tomography), DSA (digital subtraction angiography), LUTS (lower urinary tract symptoms), PA (prostatic artery), PAE (prostatic artery embolization)

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