4. Lu-Yao GL, Albertsen PC, Moore DF, et al. Fifteen-year survival outcomesfollowing primary androgen deprivation therapy for localized prostate can-cer. JAMA Intern Med 2014; 174:1460–1467.

Carbon Dioxide Angiography forProstatic Artery Embolization in aPatient with MassiveProstatomegaly and ChronicKidney Disease

From: Mathew Quirk, MDRavi N. Srinivasa, MD, FSIRJustin P. McWilliamsAdam N. Plotnik, MDDepartment of Interventional Radiology, David Geffen Schoolof Medicine at UCLA757 Westwood Plaza, Suite #2125, Los Angeles, CA 90095

Editor:Chronic kidney disease (CKD) secondary to obstructiveuropathy is a known complication of advanced benignprostatic hyperplasia (BPH) (1). Prostatic artery

embolization (PAE) effectively treats lower urinary tractsymptoms related to BPH and relieves urinary obstructionbut requires angiography, typically with iodinated contrastmaterial, which is relatively contraindicated in CKD. Thiscase of obstructive uropathy was treated with PAE per-formed with predominantly carbon dioxide (CO2) contrastmaterial.

Institutional review board approval was not requiredfor this report. A 70-year-old man with massive prosta-tomegaly had a 20-year history of lower urinary tractsymptoms and secondary bladder dysfunction, managedwith clean intermittent catheterization. He presented withsevere hematuria requiring 7 units of packed red bloodcells, bladder outlet obstruction requiring Foley catheterplacement, and continuous bladder irrigation with resul-tant acute-on-chronic kidney injury and a creatinineconcentration peaking at 4.3 mg/dL. The patient wasknown to have stage IV CKD with baseline creatinine inthe range of 2.3–2.6 mg/dL, secondary to obstructive

Figure 2. Carbon dioxide angiography in 45! oblique orienta-tion demonstrating the left prostatic artery (white arrows) arisingfrom the gluteal-pudendal trunk (dashed white arrow). LT ¼ leftside.

Figure 1. Sagittal T2-weighted magnetic resonance imagedemonstrating a markedly enlarged prostate gland (white ar-row). Volume was 772 cc.

None of the authors have identified a conflict of interest.

A.N.P.’s Twitter handle: @AdamPlotnik

https://doi.org/10.1016/j.jvir.2018.12.028

Volume 30 ▪ Number 10 ▪ October ▪ 2019 1637

uropathy. He was not undergoing dialysis. Magneticresonance imaging performed six months prior revealed a772-cc prostate gland (Fig 1). Because the patient was nota good candidate for endoscopic or surgical treatment dueto the large gland size and unlikelihood of volitionalvoiding after simple prostatectomy, he was offered PAE.Given his CKD, the plan was to minimize iodinatedcontrast by using predominantly CO2.

Right common femoral artery access was obtained, andCO2 aortography was performed using the CO2mmanderELITE System (AngioAdvancements, Fort Myers, Florida).The left internal iliac artery was selected, and 45! ipsilateraloblique CO2 angiography using 15 mL of hand-injectedCO2, filmed at 6 frames per second, demonstrated theorigin of the left prostatic artery from the gluteal-pudendaltrunk (Fig 2). The superior pedicle of the prostatic arterywas catheterized using a Progreat Alpha 2.0 microcatheter(Terumo Medical Corporation, Somerset, New Jersey).Small-volume iodinated contrast digital subtraction angi-ography (Fig 3) and cone-beam computed tomography (CT)(XperCT, Philips, Hanover, Maryland) (Fig 4) wereperformed, confirming prostatic blush and absence ofnontarget supply to other pelvic organs. Embolization wasperformed using 1 vial of 300–500 μm Embospheres(Merit, South Jordan, Utah), followed by 10 mL ofGelfoam slurry (Pfizer, New York City, New York. A totalof 45 cc of iodinated contrast was used. The procedurewas terminated after unilateral embolization in order todistribute the total iodinated contrast dose over separatesessions. Gross hematuria ceased after unilateralembolization, and the patient was discharged from thehospital.

To decrease the risk for recurrent hematuria, the patientreturned 3 weeks later for a contralateral embolizationprocedure. The right prostatic artery was catheterized afteridentifying its origin from the gluteal-pudendal trunk, usingCO2 (Fig 5). Digital subtraction angiography and cone-beam CT confirmed prostatic supply and absence ofnontarget supply to other pelvic organs. Embolization wasperformed, again using 1 vial of 300–500 μm Embospheres,

Figure 3. Contrast-enhanced digital subtraction angiographyusing a small volume of contrast demonstrating arterialenhancement of the left prostate without nontargetenhancement.

Figure 4. Cone-beam CT with microcatheter injection of the leftprostatic artery demonstrating enhancement of the left hemi-prostate. CT ¼ computed tomography.

Figure 5. Carbon dioxide angiography demonstrating the rightprostatic artery (white arrow) arising from the gluteal-pudendaltrunk (dashed white arrow).

1638 ▪ Letters Section Quirk et al ▪ JVIR

followed by 10 mL of Gelfoam slurry. A total of 25 cc ofiodinated contrast was used. The patient tolerated bothprocedures well without untoward side effects. He wasasymptomatic with no recurrent hematuria at 4-monthfollow-up. His renal function remained stable throughout,with serum creatinine concentrations of 2.3 mg/dL at 1 weekafter the first procedure and 2.1 mg/dL at 3 weeks after thesecond procedure

Surgical treatments for BPH should be considered inpatients with obstructive uropathy in order to moreimmediately and completely relieve the obstruction.However, in the present patient, who was not a surgicalcandidate or in those who refuse surgery, PAE may beperformed. CO2 is a well-described alternative contrastmedium which does not carry a risk of contrast-inducednephropathy (2). This property makes CO2 angiographypotentially well suited to PAE in patients with obstruc-tive uropathy, provided the prostatic arteries can bedepicted with sufficient contrast and spatial resolution.In this case, given the enlargement of the prostatic ar-teries, CO2 angiography allowed clear visualization.Smaller prostatic arteries may be more challenging tovisualize. A prior series of 19 patients described CO2pelvic angiography prior to PAE and reported that theorigin of the prostatic artery was depicted in 21 of 28hemipelvises (75%) (3). In this series (3), PAE was thenperformed using conventional iodinated contrast. Thecurrent case used predominantly CO2 contrast toperform the procedure itself; however, small volumes ofiodinated contrast should be used to exclude nontargetsupply to other pelvic organs, as small arterial anasto-moses may not be well depicted with CO2. A recentseries of 8 patients described intravenous and intra-arterial contrast-enhanced ultrasound in PAE used toconfirm correct catheter position, absence of nontargetsupply, and nonenhancement of the prostate gland afterembolization (4). This technique may allow furtherreduction in the requirement of iodinated contrast inPAE.

The present case demonstrates that prostatic arteryembolization may be safely and effectively performedwith predominant use of CO2 angiography, likelydecreasing the risk of contrast-induced nephropathy andexpanding the pool of patients who may benefit from thisprocedure.

REFERENCES1. Homma Y, Gotoh M, Kawauchi A, et al. Clinical guidelines for male lower

urinary tract symptoms and benign prostatic hyperplasia. Int J Urol 2017;24(10):716–729.

2. Hawkins IF, Cho K, Caridi J. Carbon dioxide in angiography to reduce therisk of contrast-induced nephropathy. Radiol Clin North Am 2009; 47(5):813–825.

3. Kably I, Narayanan S, Shah K, Narayanan G, Narayanan S. Is CO2 a suit-able contrast agent for identification of the origin of the prostate arteryduring prostate artery embolization? J Vasc Interv Radiol 2017; 28(2):S149–S150.

4. Nzekwu E, Mirakhur A, Lee A, Bakshi D. Intra-arterial and intravenouscontrast-enhanced ultrasonography in prostate artery embolization: a case-series. J Vasc Interv Radiol 2018; 29(10):1399–1402.

Pregnancy after SuperselectiveEmbolization of the CervicovaginalArteries for a Bleeding CervicalFibroid

From: John S. DeMeritt, MDEthan Wajswol, BSAnoop Wattamwar, MDDepartment of Radiology (J.S.D., A.W), Hackensack UniversityMedical Center30 Prospect Avenue, Hackensack, NJ 07601; andRutgers New Jersey Medical School (E.W.)Newark, New Jersey

Editor:Despite the success of uterine artery embolization (UAE) fortreatment of fibroids, the failure rate has been reported to behigh in patients with cervical fibroids (1). The purpose of thecurrent report is to describe a case of successful cervicalfibroid treatment using superselective cervicovaginal arteryembolization along with cone beam CT to confirm non-target tissue exclusion.

This case report was granted exemption from full review asper the policies set forth by the authors’ institutional review

Figure 1. Sagittal T2 MRI of patient prior to embolizationdemonstrating cervical fibroid (marked by white arrows).

Figures E1–E6 can be found by accessing the online version of this article onwww.jvir.org and clicking on the Supplemental Material tab. to the footnotessection at the beginning of the manuscript.

None of the authors have identified of conflict of interest.

From the SIR 2018 Annual Meeting.

https://doi.org/10.1016/j.jvir.2018.09.036

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