Sandeep Bagla

Early Results from a United States Trial of Prostatic Artery Embolization in the Treatment of Benign Prostatic Hyperplasia

PURPOSE To report early findings from a prospective United States clinical trial to evaluate the efficacy and safety of prostatic artery embolization (PAE) for benign prostatic hyperplasia (BPH). MATERIALS AND METHODS From January 2012 to March 2013, 72 patients were screened and 20 patients underwent treatment. Patients were evaluated at baseline and selected intervals (1, 3, and 6 mo) for the following efficacy variables: American Urological Association (AUA) symptom score, quality of life (QOL)-related symptoms, International Index of Erectile Function score, peak urine flow rate, and prostate volume (on magnetic resonance imaging at 6 mo). Complications were monitored and reported per Society of Interventional Radiology guidelines. RESULTS Embolization was technically successful in 18 of 20 patients (90%); bilateral PAE was successful in 18 of 19 (95%). Unsuccessful embolizations were secondary to atherosclerotic occlusion of prostatic arteries. Clinical success was seen in 95% of patients (19 of 20) at 1 month, with average AUA symptom score improvements of 10.8 points at 1 month (P < .0001), 12.1 points at 3 months (P = .0003), and 9.8 points at 6 months (P = .06). QOL improved at 1 month (1.9 points; P = .0002), 3 months (1.9 points; P = .003), and 6 months (2.6 points; P = .007). Sexual function improved by 34% at 1 month (P = .11), 5% at 3 months (P = .72), and 16% at 6 months (P = .19). Prostate volume at 6 months had decreased 18% (n = 5; P = .05). No minor or major complications were reported. CONCLUSIONS Early results from this clinical trial indicate that PAE offers a safe and efficacious treatment option for men with BPH.

Percutaneous Irreversible Electroporation of Surgically Unresectable Pancreatic Cancer: A Case Report

The present report describes a case of percutaneous irreversible electroporation (IRE) in a 78-year-old man with surgically unresectable stage III (tumor/node/metastasis stages, T4N0M0) pancreatic adenocarcinoma. Two ablations were performed for a 4.1-cm mass encasing the celiac and superior mesenteric artery. At 3 months, a solitary liver metastasis developed, which was treated with radiofrequency ablation followed by gemcitabine chemotherapy. At 6-month follow-up, magnetic resonance imaging demonstrated no residual disease and a decreasing cancer antigen 19-9 level. Percutaneous IRE shows promise as a feasible and potentially safe method for local tumor control in patients with surgically unresectable disease.

Society of Interventional Radiology position statement: prostate artery embolization for treatment of benign disease of the prostate.

Prostatic artery embolization (PAE) is a promising new treatment for lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). It has therefore garnered much interest in the interventional community. This article will review the scientific background for this therapy, describe the current devices available for treatment, and state the position of the Society of Interventional Radiology (SIR) with regard to the study and potential adoption of this therapy.

Utility of cone-beam CT imaging in prostatic artery embolization.

PURPOSE To evaluate the utility of cone-beam computed tomography (CT) in patients undergoing prostatic artery (PA) embolization (PAE) for benign prostatic hyperplasia. MATERIALS AND METHODS From January 2012 to January 2013, 15 patients (age range, 59-81 y; mean, 68 y) with moderate- or severe-grade lower urinary tract symptoms, in whom medical management had failed were enrolled in a prospective United States trial to evaluate PAE. During pelvic angiography, 15 cone-beam CT acquisitions were performed in 11 patients, and digital subtraction angiography was performed in all patients. Cone-beam CT images were reviewed to assess for sites of potential nontarget embolization that impacted therapy, a pattern of enhancement on cone-beam CT suggesting additional PAs, confirmation of prostatic parenchymal perfusion before embolization, and contralateral prostatic parenchymal enhancement. RESULTS Cone-beam CT was successful in 14 of 15 acquisitions, and PAE was successful in 14 of 15 patients (92%). Cone-beam CT provided information that impacted treatment in five of 11 patients (46%) by allowing for identification of sites of potential nontarget embolization. Duplicated prostatic arterial supply and contralateral perfusion were each identified in 21% of patients (three of 11). Prostatic perfusion was confirmed before embolization in 50% of acquisitions (seven of 14). CONCLUSIONS Cone-beam CT is a useful technique that can potentially mitigate the risk of nontarget embolization. During treatment, it can allow for the interventionalist to identify duplicated prostatic arterial supply or contralateral perfusion, which may be useful when evaluating a treatment failure.

Comparative Analysis of Prostate Volume as a Predictor of Outcome in Prostate Artery Embolization

PURPOSE To determine the role of prostate volume as a predictor of outcome after prostatic artery embolization (PAE). MATERIALS AND METHODS From January 2012 to September 2014, 78 consecutive patients undergoing PAE were evaluated at baseline and 1, 3, and 6 months. Analysis was performed comparing prostate volume groups (group 1, < 50 cm3; group 2, 50-80 cm(3); group 3, > 80 cm3) at baseline and follow-up to assess for differences in outcomes of American Urological Association (AUA) symptom index, quality of life (QOL)-related symptoms, and International Index of Erectile Function (IIEF). RESULTS Mean baseline prostate volumes were 37.5 cm(3) in group 1 (n = 16), 65.7 cm3 in group 2 (n = 26), and 139.4 cm3 in group 3 (n = 36). There were no significant differences in baseline age, AUA symptom index, QOL, or IIEF between groups. Bilateral embolization was successful in 75 of 78 patients (96%). Two patients underwent unilateral embolization, and treatment failed in one patient as a result of bilateral atherosclerotic occlusion. A significant reduction in AUA symptom index was achieved within groups from baseline to 1, 3, and 6 months (n = 77): in group 1, from 27.2 to 14.0, 12.9, and 15.9, respectively (P = .002); in group 2, from 25.6 to 17.1, 16.3, and 13.5, respectively (P < .0001); and in group 3, from 26.5 to 15.2, 12.5, and 13.6, respectively (P < .0001). There was also a significant improvement in QOL. Comparative analysis demonstrated no statistically significant differences in AUA symptom index, QOL, or IIEF between groups. Two minor complications occurred: groin hematoma and a urinary tract infection. CONCLUSIONS PAE offers similar clinical benefits to patients with differing gland sizes and may offer a reasonable alternative for poor candidates for urologic surgery.

The Interventional Radiology Clinic: Key Ingredients for Success

During the past two decades, the practice of interventional radiology has evolved into one that mandates longitudinal patient care taking place before, during, and after interventional procedures. This requires the establishment of relationships between physicians and patients that often must be fostered in an outpatient clinic setting. Recognition of this practice shift was formally made by the American College of Radiology with the publication of a document concerning the importance of clinical patient management within the practice of interventional radiology. This article will review the clinical patient management as it relates to the practice of interventional radiology, with a focus on the physician-patient relationship and the components of a successful outpatient clinic.

Nontuberculous mycobacterial lymphadenitis of the head and neck: radiologic observations and clinical context

ObjectiveTo summarize the radiologic findings in our series of immunocompetent children with NTMA and to review the clinical and laboratory findings, as well as the treatment and clinical courses, in these patients.Materials and methodsWe reviewed the computed tomographic (CT) studies, as well as the clinical courses of eleven patients with laboratory-confirmed diagnosis of NTMA, and recorded the anatomic locations of the affected lymph nodes.ResultsIn 10 of 11 patients, there were peripherally enhancing, centrally cystic nodes. In 7 of the patients, there was (usually mild) inflammation of the regional fat and overlying skin thickening. Adenopathy in the parotid and submandibular regions was most common. In 4 of the patients, there was more than one nodal group involved.ConclusionIn a child who presents with enlarging neck masses and with radiologically demonstrated centrally cystic nodal masses exhibiting relatively little mass effect or inflammatory change in the surrounding fat, the diagnosis of NTMA should be entertained.

Recurrent Hemarthrosis Following Knee Arthroplasty Treated with Arterial Embolization.

Recurrent hemarthrosis is an uncommon but troublesome complication following knee arthroplasty. This study reports the results for 13 patients with spontaneous recurrent hemarthrosis after knee arthroplasty treated with arterial embolization. The average interval between arthroplasty and embolization was 47 months (range, 2-103 months), and the average time from onset of hemarthrosis to embolization was 4.1 months (range, 1-11 months). Geniculate arterial embolization lead to resolution of hemarthrosis in 12 of 13 patients (92.3%). The one clinical failure likely represented a case of misdiagnosed periprosthetic joint infection. Two patients experienced transient cutaneous ischemia related to distal particulate embolization that resolved spontaneously. Selective geniculate arterial embolization is an effective and safe treatment modality for recurrent hemarthrosis after knee arthroplasty.

Pitfalls of cone beam computed tomography in prostate artery embolization.

Prostatic artery embolization (PAE) is becoming increasingly well recognized as an option to treat men with lower urinary tract symptoms from benign prostatic hyperplasia (BPH) [1–9]. Advantages of PAE over existing transurethral techniques (microwave, laser, resection) include the lack of the following complications, which range from 5 to 15 %: urethral trauma or retrograde ejaculation, sphincter injury, nerve damage limiting sexual function, and risk of urological bleeding. This has significant clinical impact with many men avoiding surgical treatment for BPH secondary to fear of complications from existing therapies. PAE also may have a financial impact with the procedure performed on an outpatient basis, whereas the ‘‘gold standard’’ TURP procedure typically requires hospital admission. The procedure however is limited by its inherent technical challenges. Vascular anatomy supplying the prostate is varied [10] with technically challenging size and tortuosity of the target vessels. The use of smaller microcatheters (2.4-French or smaller) and those with preshaped tips are critical to overcome challenging anatomy and ensure adequate antegrade flow during embolization. Rare complications of nontarget embolization [3, 11] have been described, which is related to misrecognition of the target vessel, reflux or collateral flow to nontarget sites. Cone beam computed tomography (CBCT) in the setting of PAE has demonstrated the ability to detect potential sites of nontarget embolization prior to embolization and variant anatomy, which may allow for improved safety during embolization [12]. CBCT is considered critical during PAE, both to decrease risk, and increase operator confidence before embolization [13]. CBCT has demonstrated similar benefits with hepatic embolization [14–18], including the added benefit of predicting outcomes after embolization. Despite the increased safety in performing PAE with CBCT, there are certain pitfalls and artifacts that interventional radiologists should be aware of. In this pictorial essay, the authors set forth to illustrate the following: pseudo-rectal enhancement, retrograde opacification, penile enhancement, metallic artifacts, and venous contamination.

The interventional radiology clinic: what you need to know.

It is increasingly recognized that clinical management in interventional radiology is necessary. To effectively participate in such management requires patient management infrastructure. The cornerstone of this effort is the clinical office.