Imaging for Prostatic Artery Embolization (PAE): CTA, Cone Beam CTA, or DSA?

[Michael Barraza]
For preprocedure CTA, which kind of patients are you still doing these for?

[Ari Isaacson]
Let me give you a little history on this, and I'll tell you where I'm at with it.

Initially, I got CT in everybody. That's just cause when you're starting out with PAE, one of the biggest challenges is the anatomy, and determining where the origin of the prostatic artery is. I'm not the smartest guy, I'll just put it that way. So, I wanted to give myself the best opportunity to figure out what was going on. That meant having images the night before, looking at them, studying them, figuring out what approaches I was going to use. I was pretty meticulous in doing that, in that I would create 3D rendered images, and I would figure out what angle with the eye I wanted to see the origin of the prostatic artery the best. I'd create kind of a map for myself.

[Sandeep Bagla]
It's funny. In listening, back to Ari's conversation. Evolution, from going from the preoperative CT, to CTA, he told that story really well. I still to this day, find myself identifying certain shunts, depending on how hard I even inject the prostatic artery, with the microcatheter, and the syringe.

I find that there's so much variability in day to day PAE practice, that it's very hard scientifically to prove what we will see better with certain techniques, versus others. As you probably know, and I mentioned to Aaron not too long ago, just the other day, actually, was that I don't firmly believe Cone Beam is a significant value.

It takes a lot to say that, I'll be honest, because over the years, having sat on panels, where my colleagues have said, "You know, you should just tell everybody that it's great to use in the beginning. You have to use it." I'm a pretty traditional diagnostic angiography type of person, and maybe that's just being simple minded, of looking at, there are six, seven, eight arteries you need to be able to identify. When I feel really comfortable with a good digital subtraction angiography, I can not only identify the prostate, but also identify much of the flow dynamics and collaterals that I don't feel like I will get during a static image, per se, like a Cone Beam CTA or Cone Beam CT.

We published, a number of years ago, the Cobalt Cone Beam CT does improve your confidence level in identifying other collateral vessels. It also does lead to a significant number of false positives, so I think, taking in mind the good and bad with Cone Beam CT, overall, if I had to start over ... we did do this in the very beginning. We just did the procedure with good DSA, and we used the Cone Beam to confirm. But really, relied mostly on the subtraction and angiography.

[Michael Barraza]
Sonny, I'm interested to hear if you use Cone Beam in the same way as Ari. My vast experience of one day with Ari, what really blew me away, was how he was able to take the images obtained on Cone Beam CT, and create these immaculate rotating roadmaps, that allowed very easy identification, and the proper obliquity to catheterize the prostatic artery. That's where I wasted a lot of my time in the past. Are you doing the same thing?

[Sandeep Bagla]
No. For a number of reasons. One, is I think that while they do produce great images, I think that one of the things you get from a selective run, for example, the hypogastric artery, is that dynamic image. That dynamic image is very important for flow dynamics.

Oftentimes, I think if you get a roadmap, for example, which is not dynamic, and you try to go all the way from position A to position Z, sometimes the problem is you can overlook, or bypass, another vessel, which may have a different flow dynamic than the targeted vessel you've identified.

So, we don't do that. Although, I do appreciate the pretty images, and I do use many of Ari's images for my lectures, cause they're always good show stoppers. We don't tend to do that. We tend to just focus on subtraction.