Shivank Bhatia

Prostate Artery Embolization (PAE) in the Management of Refractory Hematuria of Prostatic Origin Secondary to Iatrogenic Urological Trauma: A Safe and Effective Technique

INTRODUCTION Incidence of refractory hematuria of prostatic origin (RHPO) is extremely rare, with an iatrogenic etiology even rarer. When conservative methods fail to control bleeding, more invasive surgical methods are needed. In this article we describe our experience with prostatic artery embolization (PAE) as a minimally invasive alternative treatment option in patients with RHPO secondary to iatrogenic urologic trauma. TECHNICAL CONSIDERATIONS Three patients presented with RHPO. The etiologies were transurethral resection of prostate surgery, Foley catheter removal with a supratherapeutic international normalized ratio and self-traumatic Foley catheter removal respectively. Stepwise management with conservative and medical methods failed to control bleeding. Under local anesthesia and moderate sedation, bilateral PAE was performed via a right common femoral artery access and using cone beam computed tomography. An embolic mixture containing 300-500 um Embosphere® Microspheres (Biosphere Medical, Rockland, MA) was injected under fluoroscopic guidance until stasis was achieved. PAE using the described technique was a technical and clinical success in all three patients. Hematuria resolved within a period of 24 hours. There were no intra- or periprocedural complications. CONCLUSION PAE offers a reasonable option in treatment of RHPO, regardless of the cause and may be attempted prior to surgical techniques or sometimes in conjunction. Being minimally invasive and performed under local anesthesia, PAE is especially useful when excessive bleeding prevents adequate visualization of a bleeding source during cystoscopy and in the elderly age group with several comorbidities. An added advantage is the prostatic parenchymal ischemia leading to significant prostate volume reduction and alleviation of the obstructive symptoms.

Role of prostate artery embolization in the management of refractory haematuria of prostatic origin

Prostatic haematuria is among the most common genitourinary complaints of emergency room visits, distressing and troublesome to men and a challenging clinical problem to the treating physician. The most common aetiologies of prostatic haematuria include benign prostatic hyperplasia and prostate cancer. Prostatic haematuria usually resolves with conservative and medical methods; failure of these interventions results in refractory haematuria of prostatic origin (RHPO), a potentially life‐threatening scenario. Several different treatments have been described, with varying degrees of success. Patients with RHPO are often elderly and unfit for radical surgery. Prostate artery embolization (PAE) has evolved as a safe and effective technique in the management of RHPO. Use of a superselective approach optimizes clinical success while minimizing complications. This minimally invasive approach improves patients with haemodynamic instability, serves as a bridge to elective surgery, and is a highly effective treatment for RHPO. It may obviate the need for more invasive and morbid surgical therapies. The aim of the present review was to describe the current management of RHPO and the technique of PAE and to review its efficacy and associated morbidity.

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.

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.

Radiofrequency ablation in primary non-small cell lung cancer: What a radiologist needs to know.

Lung cancer continues to be one of the leading causes of death worldwide. In advanced cases of lung cancer, a multimodality approach is often applied, however with poor local control rates. In early non-small cell lung cancer (NSCLC), surgery is the standard of care. Only 15-30% of patients are eligible for surgical resection. Improvements in imaging and treatment delivery systems have provided new tools to better target these tumors. Stereotactic body radiation therapy (SBRT) has evolved as the next best option. The role of radiofrequency ablation (RFA) is also growing. Currently, it is a third-line option in stage 1 NSCLC, when SBRT cannot be performed. More recent studies have demonstrated usefulness in recurrent tumors and some authors have also suggested combination of RFA with other modalities in larger tumors. Following the National Lung Screening Trial (NLST), screening by low-dose computed tomography (CT) has demonstrated high rates of early-stage lung cancer detection in high-risk populations. Hence, even considering the current role of RFA as a third-line option, in view of increasing numbers of occurrences detected, the number of potential RFA candidates may see a steep uptrend. In view of all this, it is imperative that interventional radiologists be familiar with the techniques of lung ablation. The aim of this article is to discuss the procedural technique of RFA in the lung and review the current evidence regarding RFA for NSCLC.

Treatments for Benign Conditions of the Prostate Gland

Histologically, the prostate is comprised of a network of branched tubuloalveolar glands that are surrounded by a richly innervated, well-vascularized fibromuscular stroma. Benign prostatic hyperplasia (BPH) is often referred to as the most common benign neoplasm in the aging male. It is a distinct histopathologic entity that is characterized by cellular proliferation of both components of the prostate: the glandular and stromal elements. From a clinical standpoint, this may be associated with age-dependent, bothersome, and progressive voiding symptoms.

Successful management of a case of refractory prostatic hematuria by prostate artery embolization via a brachial artery access

Therapy for prostatic hematuria includes functional, biochemical approaches and transurethral resection of the prostate (TURP). If these fail, a life-threatening situation called refractory prostatic hematuria (RPH) can result. Hemostatic packing of the prostatic bed and salvage cystectomy under general anesthesia maybe the only options left; however, most of these patients are not surgical candidates (1). Prostate artery embolization (PAE) is a novel, minimally invasive option for treating prostatic hematuria (2). We present an emergent case of RPH where femoral access for PAE was not available, therefore brachial access was performed. An 86-year-old male with prostate cancer presented with gross hematuria. In spite of blood transfusion, continuous bladder irrigation, and a channel TURP, he continued to bleed. Hemoglobin (Hb) was 6.9 mg/dL in spite of blood transfusions. An emergent arteriography was planned. The patient had a recent six-week history of bilateral femoral cut-down access for placement of an aortic endograft (Fig. 1). Hence, we used a brachial artery access using ultrasound guidance. Selective right and left PAE were performed via right common femoral artery access using Embosphere® Microspheres (Biosphere Medical, Rockland, MA, USA (Fig. 2). Procedure time was 120 minutes, fluoroscopy time was 68 minutes and total radiation dose 94649 μGyM2. Post-procedure ultrasound of the brachial artery demonstrated a small brachial hematoma that was treated conservatively using a compression dressing with no further complications. By the ninth post-procedure day, hematuria resolved, Hb stabilized at 7.2 without blood transfusions. The femoral artery has been the route of choice for endovascular interventions. However, in conditions such as severe infra-renal aortic disease and recent intervention, other vessels have to be used. There is a general reluctance to puncture the brachial artery due to the risk of spasm, brachial neuropathy, distal embolization, the need for long instruments and potential risk of stroke (3). In spite of this, brachial punctures are frequently described in coronary artery literature, with a technical success of 99.6%. Ultrasound may useful to visualize surrounding critical structures, as well as arterial anatomic variations (4). Brachial artery access for PAE has not been described. The technique of PAE has often been compared to uterine artery embolization (UAE) due to similar vascular anatomy and vascular approach. In a recent report, UAE performed via a brachial approach was shown to be safe and technically valid, with ease of selective catheterization and without the need of catheter exchanges. This also may be better accepted by patients due to early ambulation, avoidance of bladder catheterization, and also a lower radiation dose (5). Fig. 1 Coronal CT scan reveals the aortic endograft (red arrows).