Prostate Artery Embolization Technique: Advantages of Radial vs Femoral

[Dr. Christopher Beck]:
Okay. All right. Let's get into the meaning of today's topic where we're going to talk a little bit about access, site selection. For some of the younger audience or for some of the trainees, will you discuss just in broad strokes, femoral versus radial, and specifically when it comes to this procedure?

[Dr. Blake Parsons]:
Exactly. There was a hard stop on how tall someone was. Especially for men, it became very difficult. And then Boston came out with TruSelect recently, which goes out to a hundred and seventy five centimeters, so that definitely helped. For us here and how I choose back and forth a little bit, I honestly probably look at it more on a weight base, being in Oklahoma to some degree. And then still heights plays a part of it. Now, the other issue we'll get into just in the product I use while I'm doing it, and from a radial approach is, there is some limitation just because of wire options from a radial standpoint because of the length of the microcatheter. But I will tell you, I do way more femoral than I do radial.

[Dr. Christopher Beck]:
All right. So before we get too much into a radial versus femoral, can you talk a little bit more about your radial technique? We can start out just talking about who is a suitable candidate for radial artery access.

[Dr. Blake Parsons]:
Yeah. Obviously, I do a Barbeau on everybody that I'm going to do a radial stick on. From an ultrasound standpoint, I pretty much go from the standard. It needs to probably be at least two millimeters. I'm going to use a four or five slender sheath is what I use for access, everything, obviously ultrasound-guided. So four or five French standard cocktail heparin, nitro, verapamil. So 3000 of heparin, 2.5 of verapamil and then 200 to 300 of nitro just depending on their pressures. And then I typically use a glide wire or even use a Baby-J glide to make your way down. I typically use a glide cat, just a standard 45 angle to be able to get down into the pelvis. But that's my typical initial setup to get there.

[Dr. Christopher Beck]:
Blake, let me ask you this, whenever you're doing a radial access, how's the patient positioned? Do you have them arm out or down by the side?

[Dr. Blake Parsons]:
I do them the exact same way I do my fibroids. I do their arms straight out to the side. How we set up our room is then I put the monitors right behind their arms, so the monitors are just to the left of the patient's head. So I'm actually looking across their arm, looking parallel to them, but I'm to their side. I'm not actually looking towards the patient. I'm just looking across the arm. And then I put my... We have a large room, so this is why I can do this. And then I have a long table that I put out to the end of their arm. And so I can run all my wires and everything down this long table.
[Dr. Christopher Beck]:
Yeah. I think some people like that. I'm with you in terms of radial access. I like the arm, I guess it's abducted with the arms out and I stand in between that corner where their armpit is basically. And then I can't actually get my big monitors in front of me, but we have a set of slave monitors and that works out pretty well. So height-wise, TruSelect decide, which does have the new longer length microcatheter. Do you have a rough cutoff to when if a patient's above a certain height, you're just like, "Oh, I'm not going to mess with the radial access"?

[Dr. Blake Parsons]:
Fibroids have a standard length of say 5’10” for the new TruSelect 61 probably because... I mean, the problem you're going to run into still is... And that gets into the patient's age. Obviously, you start getting into the 80s, these patient's arteries get extremely torturous. You're going to not only lose pushability and things like that, but you're going to eat up a lot of catheter link and then try to get down. And then a lot of times, if you have to go and get a few pudendal branch, you still could come up short. And so that's always the risk of going radial on someone that's a little taller.

[Dr. Christopher Beck]:
Okay. Fair. And what is your 5F catheter that you're getting down with?

[Dr. Blake Parsons]:
The glide. I use the long glide cath. So, a hundred and fifty.

[Dr. Christopher Beck]:
And how long is the microcatheter?

[Dr. Blake Parsons]:
So from the wrist, I'll use the TrueSelect 175.

[Dr. Christopher Beck]:
Okay. Gotcha. And is that the same with your fibroids?

[Dr. Blake Parsons]:
Yeah. Actually, I'll use a shorter. I'll do a 120 and then use the 150 microcatheter, because most of the women, I'm doing on a 5’10”.

[Dr. Christopher Beck]:
Sure, sure. Gotcha. Whenever you're hooking up, do you hook up two-way bores to the back of your 5F catheter?

[Dr. Blake Parsons]:
I do, except for prostates, I won't just in case I need that extra couple of centimeters.

[Dr. Christopher Beck]:
All right. That was my question. Actually, I understand that we did a podcast with Aaron Fischman and it was actually a shorter adapter that you can use. I think the two-way bores, it's around six or seven centimeters that you lose through a microcatheter. And there's another shorter adapter that's closer to like two CMs. I never got the name from... We'll have to grab that.

[Dr. Blake Parsons]:
Yeah. He's the radial master so he'll know.

[Dr. Christopher Beck]:
Sure, sure. All right. So prostate artery embolization, radial versus femoral. If you have your druthers, if you have the perfect patient who shows up. He's 55, no atherosclerotic disease. He's five, six. So height's not going to be an issue. What's your preferred access? Is it a radial or a femoral?

[Dr. Blake Parsons]:
At this juncture, it's femoral. I'm faster to do it femoral than I am to do it radial. And the likelihood you're going to be able to seal that patient on your way out. And so, from a bleeding risk standpoint, there's not much difference. We're pretty aggressive at our place. So if we do say an angioseal, we start setting them up within 30 minutes, which is not crazy, but we get them up pretty quick. I mean, they're out the door within two hours usually.

[Dr. Christopher Beck]:
All right. This is one of the things that I think is very intimidating for interventional radiologists, who are trying to get into prostate artery embolization is you see a lot written about non-targeted embolization and things you have to worry about with shunts, with non-targeted embolization to either a rectal or a penile branch. Can you talk a little bit about that, but in the context of what size do you too use? Because you mentioned it earlier that there's sometimes a size particle that you can use that can make you feel uncomfortable, that maybe if you're not exclusively within the perfect prostate artery, that you don't have to worry about end-organ damage if you're having some non-targeted embolization.

[Dr. Blake Parsons]:
I primarily use 300 to 500. After the paper came out showing there's no real difference, then I was like, "Yay, let's stay with the three to five." So I feel so much safer now. And that being said, if I get into a prostate artery and it's a hundred percent prosthetic blush, I can't see anything. Then I will go down a little bit in size and do an initial embolization to get a little distal and then back pack that, so to speak with three to fives. Now, those guys on the post-operative standpoint, they're definitely going to have more post-op ischemic discomfort/prostatitis the smaller the bead you use. But I haven't seen really a major difference in outcomes other than patients being uncomfortable post-op for three to four days of using smaller versus larger beads. So pretty much, just with the data that's out there, I haven't noticed a big difference in patient satisfaction, IPSS, score improvement, all that with just strictly using three to fives versus using smaller.

[Dr. Christopher Beck]:
How about the technique where you do a more proximal embolization with the larger beads. And then you advance the microcatheters as distal as possible and then do another embolization?

[Dr. Blake Parsons]:
Yeah. I tried to do that at the very beginning. And then now, I basically just select as distal as possible, run out the gate. And then, I do give nitro. You typically give about a hundred of nitro to try to pump them up some... And then the shunts are always changing, so I typically give a little bit of embolic and then I'll take another run just to make sure, because you can have inflow from the pudendal artery. And then all of a sudden, you start embolizing things and now it's dumping into the pudendal instead of coming from the pudendal. I do an initial little short embolization and then do a contrast run just to make sure everything still looks good. And then I finish off. And as long as I'm starting to see pretty good pruning and everything, say I use small beads at first, then I'll make sure I get some good pruning. And then I'll use a three to fives to really pack it in.

[Dr. Christopher Beck]:
What's your end point in terms of stasis?

[Dr. Blake Parsons]:
Yeah, three to five. I will say in older guys, I know this has been a relatively newer topic that's been taboo, but of coiling the artery on the way out. I've actually watched a video conference about this specifically and more and more guys are starting to do it, especially older guys. If I have a guy in his 80s that had hard arteries to get into in the first place, A, the likelihood is if they have early recurrence, it's not from their prosthetic artery. It's probably from some collateral branch and I don't want to have to go back in there. That's the view amongst everyone else that does it too, so I'll just go ahead and... I'd use micro coils, like a three by two micro nest or whatever, and I'll pack them in at the end, pretty distal.

I don't do that for everyone. For younger guys, I find that I don't just in case they may get five years and they start to have recurrence of symptoms and they want to do the same procedure again. Okay, well then, we'll go back and do it. But for the older population, I have found myself starting to do more and that's been really in the last couple of months that I've started doing that. Now, it's interesting too because their ischemic pain is greater. And those guys, I've noticed that you ended up going ahead and coiling as well.