Adam Lustig, M.D., Interventional Radiologist at Medical Center Radiologists, discusses a case presentation of a prostate artery embolization on a 61 year old male who had an enlarged prostate and wanted a minimally invasive option.
Hi, I'm Dr Adam Lustig. I'm an interventional radiologist. I worked for a medical center, radiologist or M C. R, and primarily work at Sentara Norfolk General and Sentara Leigh perform a variety of minimally invasive procedures on a variety of diseases. So I want to talk to you today about case presentation of a prostate artery embolization. I did a few months ago. There's a 61 year old gentleman who has an enlarged prostate and lower urinary tract symptoms from his enlarged prostate. He wanted a nonsurgical option, a minimally invasive option that didn't have quite the level of potential complications that could come with surgery. So he came to me. He saw me in clinic in our Norfolk general office, and we talked to him about the potential options in the procedure. And he had an I. P. S s score, which is an international prostate symptoms scale or the way score. In the twenties, his was 24 which is pretty standard. The max is 35. He had pretty severe BPH and lawyer and track symptoms. So I discussed with him the procedure and I'd like to go over with you today. So here this the beginning of the procedure, getting access into the arterial system through the radial artery ultrasound guidance. And once we get flash, we advance the wire through the needle and get access into the radio artery over the wire. We will place a sheath, which is coming in right here, and it's got a side port where we can get continuous sailing being flushed through the she so it doesn't form a clot at the tip of the sheath. And now we have a way to advance in exchange capitals and wires safely into the arterial system. Eso through the radio artery, advancing a flush catheter so we can take a good flush picture of the pelvic arteries in the aorta and advancing this using X ray guidance in real time to see the Catholic going down the aorta into the pelvis. And now we're doing a cone beam C T, which is a in contrast injection through the catheter in the pelvic Iroda while doing a CT scan on the table. This is a fairly new machine that we have in Norfolk General, and this is the result. We get a sita of the pelvis. You could see the arteries have contrast in it, and I'm drawing a sort of border around the prostate, which will help the computer determine which arteries air going and supplying the prostate. You can see me pointing to the left prostate artery there, and once we once we have a nice picture, I can cut out all the extraneous anatomy that I don't need, like the pelvic bones and some other arteries and vessels that just aren't important for this case. After I cut that out, we get a nice vessel map and you can see in the red and yellow lines or what the computer thinks are the prostate arteries. And I agree with the computer in this case. So using this in real time, we can overlay that on the real time Fluoroscope E, which can help guide the catheters and wires during the procedure. And what that does is reduce radiation, reduces contrast usage and reduces the amount of times I need to do a wire or catheter exchange to inject contrast, and this will rotate in real time. If I move the gantry left or right around the patient, that three D map will actually shift in real time there you can see on the screen it's over, laid on the right side in sort of an oblique projection. So once we get to the prostate artery, we inject these particles that are 300 to 500 microns in size and hear him in the left prostate artery and injecting little particles that they're going to actually m belies the prostate artery. And that's that's the actual crux of the procedures. Injecting those tiny particles into the prostate artery to M belies the prostate tissue and ultimately shrink the prostate to relieve the patient's lower urinary tract symptoms. And so here it's, ah, manifold of the big syringe on top in blue, and we load the smaller syringe in red with more particles and that will be injected into the artery once we are done with one side to go to the other side and repeat the same process. Um, those particles will travel pretty distantly and which is what we want. We also want to include the main trunk of the prostate artery so that we can reduce recapitalization of the artery in the future, and what I like to do is inject a little bit of gel foam, which is what is being mixed here. And the jail phone just has larger particles. And there's a higher volume that you can inject into the main trunk of the prostate artery, and so that will m belies completely both prostate arteries and decreased significantly the blood flow to the prostate gland itself, which will, over time, allow the prostate to shrink compared to other procedures like terp or prostatectomy. This will take several months for the prostate to shrink, and the patient may not and will not actually get immediate relief of their lower urinary tract symptoms because it will just take a few few months for the prostate to shrink. But at the six month time point, we have data that shows there is no statistical difference between the amount of improvement in lower urinary tract symptoms that a patient experiences between a terp and P a e, her prostate artery embolization. So it's really just that timeframe of waiting until the prostate shrinks and relieves that obstruction. So once we're done immobilizing both sides, we have to pull out the sheath from the radio artery and the way we close up the hole in the artery is by using a TR band, which is a wristband that has a little pocket of air that we can inflate using a syringe with various amounts of air. And we deflate that to the point where there's still flow in the artery. So you can kind of see the pocket of air beating as the pulses is going through the artery. But we don't want it to be fully inclusive. We obviously don't want it to be leaking s. This is a standardized way too close radio access, and that is the end of the procedure. So the patient will now stay for a few hours and go home the same day, and we'll see him back in clinic in a month. So this patient went home the same day as they typically dio, and he followed up in my clinic in a month and then three months later, and his i. P. S s score has dropped both times, which is pretty typical. What we expect. He started out at a 24 and now he's around 10. And that's a pretty significant reduction. Pretty, uh, typical for you. Expect for prostate artery embolization. His quality of life is much improved and he's very happy. He had no complications and this is sort of a pretty typical experience for, uh, patient going through this procedure.