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BackTable / VI / Podcast / Transcript #148
Podcast Transcript: Radial vs. Femoral for Prostate Artery Embolization
with Dr. Blake Parsons
We talk with Dr. Blake Parsons about his approach to Radial vs. Femoral access for Prostate Artery Embolization for BPH, including patient selection, device considerations, and practice pearls. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Developing a Prostate Artery Embolization Practice
(2) PAE Access Site Selection: Femoral vs. Radial
(3) Radial Access for Tortuous Iliac Arteries
(4) Developing Muscle Memory for Prostate Artery Embolization
(5) Identifying the Prostate Artery
(6) Technique to Avoid Non-Targeted Embolization
(7) Techniques to Localize the Prostate Artery
(8) Closure for Radial vs Femoral PAE
(9) PAE Pre- & Post-Procedure Management
(10) Helpful Resources for PAE
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[Dr. Christopher Beck]:
Ladies and gentlemen, welcome to BackTable Podcast, your source for all things endovascular and minimally invasive. If you are a new listener, welcome. For all of our regular listeners, welcome back and thank you for listening. You can find all previous episodes of the podcast on iTunes, Spotify, or our website, which is https://www.backtable.com , very easy to remember. Subscribe to the podcast, leave us a review or reach out to us on social media. Let us know how we can make this podcast a better resource for our endovascular community, and we'll do our best to make that happen.
So today we're going to discuss some details around access site selection for specifically prostate artery embolization, and we'll get into some of the details of that procedure. To help us with the discussion, we're going to have Dr. Blake Parsons. Blake is an interventional radiology physician based out of Oklahoma. He's been on the show a few times before. You can find him on old episodes. First one he did was episode 69, where we talk about retrograde pedal access and episode 129, where we go into some of the business tips and tricks for the OBL and ASCs for the entrepreneurial-minded interventional radiologists and vascular surgeons out there. Blake, welcome back to the show, man.
[Dr. Blake Parsons]:
Hey, appreciate it as always.
[Dr. Christopher Beck]:
All right. So for those who have not caught you on some of our earlier episodes, will you just tell people a little bit about your background and what kind of practice you have?
[Dr. Blake Parsons]:
Yeah. I'm as you said a vascular and interventional radiologist. I'm based here in Oklahoma City. We have a hybrid outpatient, so OBL/ASC practice called Cardiovascular Health Clinic that was formed about five years ago. We do the mass majority of our procedures out of this facility. Just from a training standpoint, I did my fellowship at Medical College of Wisconsin and I graduated from there and started my practice here in 2017. So been up a little over four years now.
[Dr. Christopher Beck]:
Okay. Nice. And as far as your current practice, what does it look like in terms of what kind of procedures are you guys doing and specifically how much of that is prostate artery embolization?
[Dr. Blake Parsons]:
I would say the vast majority of my outpatient practice is going to be a lot of peripheral vascular work. So I do a lot of peripheral arterial disease. In this part of the country, like others, we see a ton of diabetic foot wounds. I also do all the venous work for our group, so a lot of acute and chronic DVTs as well as superficial. And then embolization wise, uterine fibroid embolizations, prostate embolizations. And then we actually do quite a bit of pelvic congestion as well here, just because we're in a unique practice.
If you've listened to any of our previous podcasts they've had, we used to be one vascular surgeon, now we've hired another one. So we have two and we have another one on the way. So there'll be three total vascular surgeons with me. And then we currently have four interventional cardiologists. Several of our interventional cardiologists see a lot of women with POTS and a lot of them subsequently also have a pelvic congestion syndrome. And we have several gynecologists in town that refer for pelvic congestion syndrome. So those are the main makeups of our outpatient procedures here at our OBO.
[Dr. Christopher Beck]:
As far as prostate artery embolization, when did you get started with it? How many are you doing, maybe in a given month, age and... Yeah, go ahead.
[Dr. Blake Parsons]:
Yeah, exactly. I started right out the gate. Well, I guess I had to wait a little bit. It was FDA-approved in January of 2018, so I did training. I actually went out and hung out with Ari Isaacson as well as Bagla, prior. And then we just hit the ground running in January of 2018. I've probably done around, I think the last numbers are somewhere around 350 to four. So we do almost three to four week typically, so quite a few. I'd say the mass majority of ours is from self-referral. We do have quite a few primary care physicians as well, that believe in it and have seen the outcomes and send us quite a few patients.
And then I know we do... I have a group of urologists that we work with that we send patients back and forth. So if someone, I don't think is a candidate, then I'll send them to them for further evaluation and other treatment options. And then vice versa. If they have someone with a monster prostate or something they don't feel comfortable with or they're on anticoagulation, recent coronary stenting, that type of stuff. Or a poor anesthesia candidate, then they will refer to me as well.
[Dr. Christopher Beck]:
I don't know about the audience, but I was really shocked by that number. I didn't think you were to come in near as high as like three 50 or 400. That's an incredible number. That's like a great referral system.
(1) Developing a Prostate Artery Embolization Practice
[Dr. Christopher Beck]:
So take me a little bit about how the prostate artery embolization practice developed. It seems like you guys have a steady referral now, but how was it in the beginning?
[Dr. Blake Parsons]:
It still runs the same way as it has from day one. A lot of it is outreach marketing, and I will tell you that your audience is older men. And they're about the only ones that still read the paper. So we do a lot of advertisements in the paper. That honestly just exploded the business because you got a lot of guys out there that have been suffering for years and they know the surgical options and they would just rather suffer with getting up four times a night than they would undergoing some type of transurethral procedure.
It hits home and these guys, they're still reading the paper every day and they see us in. A lot of our self-referrals come from that. And then the others just geting out and hitting the streets and talking to your primary care. We have a good relationship already with a lot of primary care doctors just because of my group and my partner's and all the cardiovascular stuff that we already did for them. So this was... They trusted us and then this has just been an ad on.
(2) PAE Access Site Selection: Femoral vs. Radial
[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]:
Okay. Nice.
[Dr. Blake Parsons]:
Instead of having to have their arms at the side, run it down.
[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]:
Oh, so it's a hundred and fifty?
[Dr. Blake Parsons]:
Yeah.
[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.
(3) Radial Access for Tortuous Iliac Arteries
[Dr. Christopher Beck]:
All right. So when is radial a better fit for you? Are there circumstances where you start out femoral and then you have to, I wouldn't say bail, but then turn to radial?
[Dr. Blake Parsons]:
Yeah. I think for me personally, radial has a great utilization in guys with tortuous iliac arteries, because trying to get up and over and have support from a femoral access is tough. You're going to end up having to use a 25 centimeter sheath and go up and over because what's going to happen is you're going to get right into the beginning of the prostate artery and you have no pushability. And next thing you know, everything's fallen out and falls back up into the aorta and then you're angry.
To save you the trouble of getting up and over, changing out your sheaths and everything, coming from above is much easier. Now the caveat to that, you got to think of as higher up. So as these patients are getting older and they're 80, not only are their iliac arteries getting torturous, but their thoracic aorta is as well. And their takeoff to that left subclavian artery can be pretty sharp. And so then your issue is, are you losing length because of their tortuosity? And are you losing pushability due to that steep turn, trying to get back down the thoracic aorta? That's just something you got to keep in mind as well.
[Dr. Christopher Beck]:
How about using cone-beam CT with... Well, I'll just back up and ask you, do you use a cone-beam CT for your prostate artery embolization?
[Dr. Blake Parsons]:
No, and I never have, but I'm in an OBL so we don't have any... That's too fancy for us. We actually have a fixed unit that we use. We just don't have cone-beam CT on it. But in my training, obviously, I know Ari loves it. And I'll use the term, has shown the obvious benefits of it. And then I'm probably more on the bad will side where I do it all without. I've always done it without so yeah, I feel confident when I'm embolizing and when branches are going after... It takes you about 50 that you're not sweating to death in there, but once you finally get a pretty decent hang of the anatomy, then it's not too bad.
(4) Developing Muscle Memory for Prostate Artery Embolization
[Dr. Christopher Beck]:
I was going to ask you, when did you hit that threshold where after you had about 50 cases under your belt, then all of a sudden, things start to click and you started having... It's like pattern recognition, then all of a sudden, the prostate artery just jumps out at you rather than you having to go through and identify vessels?
[Dr. Blake Parsons]:
Exactly. I tell people, "You're going to start off. Your first couple are going to take two and a half, three hours. And you're going to be like, 'This is not worth it.'" In the OBL space, you're like, "Oh my gosh, I could do something else for the payment and the amount of time you're utilizing. This is crazy." But what you'll see exactly is the more you get on your belt... I always tell people when they come talk or come visit or watch us do cases... I tell them 50. That's my number just because it felt like I did 50 before I started feeling confident right off the bat. The biggest thing of cutting down your time as you do that first iliac angiogram, and boom, you already know exactly where it's coming off of. You're not searching. And then now you're selecting random arteries that look like they could be prosthetic arteries. That's what chews up all of your time.
And then the other thing that prolongs your case and that you have to get confident with is bead size and collaterals. So feeling comfortable about what you can embolize, knowing it's probably going somewhere else and is it going to cause a problem or the bead's big enough that they're going to likely get stuck in these little small collaterals and you don't really have to worry about them. Or are you going to get some schema out of the rectum? Are you going to get basically to the penile artery? These are all the things you're worrying about on your first 50 of them. And I think that's the biggest thing where you become, I wouldn't say ‘lax, but you get more confident about the size of the arteries you're looking at, where they're going. Their inflows, outflows. Do you need to coil off all these branches... Those type of things, because those are what add time to your case.
(5) Identifying the Prostate Artery
[Dr. Christopher Beck]:
Sure. One thing that I wanted to touch on, in terms of helping identify the prostate artery, do you have a go-to obliquity or positioning the eye to where it... I understand that maybe each patient is different, but your standard obliquity and maybe cranial or caudal tilt to give you a best shot at seeing the takeoff of the prostate artery?
[Dr. Blake Parsons]:
I do it for some reason every time. No cranial or caudal that's even, but I do 48 degrees. I don't know how it came up with 48 degrees. I think it just did it. At the beginning I was like, "It feels lucky, so I'm sticking with it." But pretty steep, I think Bag will tell you he just goes as steep as his C-arm will let him go. And that works for the mass majority of the time, but there'll be definitely times because all these guy's anatomy is different so that you actually need to go contralateral or straight AP to be able to see the takeoff of it. And that does happen not infrequently, but I always start off with ipsilateral 45 to 48 degrees.
[Dr. Christopher Beck]:
All right. That's what I wanted to just clarify for the audience. So if you're selecting the left prostatic artery, you go LAO 48 degrees, no cranial or caudal tilt, right?
[Dr. Blake Parsons]:
Correct.
(6) Technique to Avoid Non-Targeted Embolization
[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.
[Dr. Christopher Beck]:
Interesting. You said that was described in a paper, what the... I'll think of the name of that paper so we can-
[Dr. Blake Parsons]:
And then Fischman, I think he has started... Don't quote me, but I'm pretty sure I've got something from him not too long ago where he has started coiling more as well. But I can tell you I know that's been like taboo forever. Don't shoot me, but that's kind of what the big no, no in embolization world, but to jail yourself out from getting distal again. But yeah, like I said, for that specific population that's what I started doing.
[Dr. Christopher Beck]:
That's right. That's the outlook for the appropriate patient works. Okay. So going back a little bit to radial and femoral. One of the big advantages, and we mentioned it for radial access is the fact that you have good pushability. But also selection of your internal iliacs is a little bit more straightforward in terms of, there's not an up and over process. And then one of the things that gets discussed a little bit is, if you're accessing your right groin and you are femoral, what does it look like as far as for you to access the ipsilateral? So right coming from iliac access, accessing the right internal iliac artery. How do you hook in and then you go micro?
[Dr. Blake Parsons]:
So what I do, and what I started doing probably two years ago is I always... So obviously right iliac access, I go up and over, I do the left side first. So I get a SOS from a femoral approach. I do a glide cobra cath. I go with a glide wire, go up and over and select the left internal, do my shots, treat that side. With the wire over, I take the glide cath out and then I put a 5 French SOS in. And I put that over, format over the aortic bifurcation. And then I actually then select the ipsilateral side and come down, puff my way down. And I use that SOS catheter to select the ipsilateral internal iliac artery. And then I do my shot through that SOS catheter. So then I do my right obliquity at 45 to 48 degrees ipsilateral with that SOS catheter. And then once I've done that, then I go in with my micro.
[Dr. Christopher Beck]:
Okay. And so that that might be where I see one of the disadvantages to femoral is that, I guess, when you're hooked in with the SOS, essentially when you decide to go micro, you're really just a couple of centimeters beyond the takeoff of the right internal iliac. Does that ever... How big of a hurdle is that to overcome in terms of then going from internal iliac to anterior division to prostate artery?
[Dr. Blake Parsons]:
To be honest, most people's internal iliac arteries are not that long. And what's weird, and I'm sure there's some papers out there, someone smarter than me has figured out. But I have found that for some reason the right side... And it probably is from an anatomical perspective. But the right internal iliac artery is typically shorter than the left. And from an anatomic standpoint in length of the common trunk. So usually when I get a micro in there I'm only a centimeter, two away from the bifurcation. And so I haven't had any issues with trying to do that. Because trying to get like, say, do a Waltman's loop and come up and down, or use a specialty catheter. You can definitely do that, but then you've got even more risk of when you start to push, you could knock that Waltman's loop could start to knuckle up into the aorta.
[Dr. Christopher Beck]:
I will say just from my own personal experience I've done the Waltman loop a couple of times for prostate artery embolization, it's never ended well. Like I'm able to get pretty close to the ostium of the prostate artery. But the downside of the Waltman loop is just as soon as you're right where you want to be, you go to advance your micro catheter, just a hair more. And then all of a sudden you start unforming your loop and you can see your 5 French catheter starting to back out. So, from my experience I've given up on that technique, which I used to use when I was doing fibroids. I would sometimes do a Waltman but, I think, I'm actually in your camp now. It's just easy to hook in with a SOS and then just go micro from right there.
[Dr. Blake Parsons]:
I agree. Yeah. The SOS is very hard to knuckle out of that internal…
[Dr. Christopher Beck]:
Yep-
[Dr. Blake Parsons]:
You're going to knuckle a micro-catheter way before you ever flopped that SOS catheter out.
(7) Techniques to Localize the Prostate Artery
[Dr. Christopher Beck]:
Yeah, totally agree. So talking about some ways to identify the prostatic arteries, maybe looming early ons, so you feel like maybe a little bit like you want to try this procedure. Did you use a Foley catheter? So I've seen some things described as far as, like some crutches that can help you. Some people will place a Foley and you can use that Foley balloon to use as a local landmark, is where your prostate blush should be. I've seen some people put BB markers on the base of the penis for them to help maybe identify a penile branch a little bit better. Do you have anything like that that was helpful for you early on?
[Dr. Blake Parsons]:
No. So I never used a Foley, just because I figured that's part of the reason these patients don't want to have trans urethral. So I never used a Foley. What I will say is a prostate primarily... Let's say a 60 gram prostate, 30 is normal, so enlarged but not crazy, 60 to 80, something like that. It's always going to typically be, if you're straight, no caudal, no cephalad tilt. It's going to be right in the pubic synthesis, on the cephalad margin of it. That's where you're focused. And so when you're doing your run, let's just say, we're doing the left side, we've got to lift oblique 48 degrees whatever. We're taking a look. I kind of go by the rule. I know there's all these papers defining how often the prostate artery comes off of it. I can't remember any of the naming systems.
So I just go in rules of like 25. So, 25% of the time it's going to be off the vesicular trunk, 25% of the time obturator, 25% of the time it's essentially pudendal. And then the other 25% of the time you don't know where the hell it is, then you just got to find it. But you're going to mainly, a lot of times, if the standard it's straightforward anatomy, it's going to be curly, pigtail looking and it typically crosses your obturator artery. When you see that, and then you select it, then I will go back AP and take a dedicated shot into that prostatic artery.
And then you should see primarily horizontal arteries. You shouldn't see arteries running north to south. North to south, this is going to be rectum. And if you push enough in there through your run, you're going to see a blush in the rectum anyway, or blush at the base of the penis. And you know that you've got stuff going the wrong direction. It should be pretty much well-defined. And when you push enough contrast in there, you can actually see the whole left hemisphere of the prostate light up for you, and you know it's the prostate artery.
[Dr. Christopher Beck]:
Yeah, I think that helps certainly on when, one, taking a look at a couple other, like what prostatic blush looks like, but if you've ever read any cross sectional. To me when I did my first case and I saw... Actually, when I did my first case solo, and then I was so worried about seeing the prostatic artery. It did jump out at me in a way. I'll also want to highlight something for the audience. And you mentioned it that the prostate artery many times, like when you're at that steep of an obliquity, will cross the obturator. Can you talk about how you identify the obturator and that kind of crossing anatomy.
[Dr. Blake Parsons]:
Exactly. So your obturator is typically going to run pretty straight north-south, and then it's going to have basically an upside down Y on the bottom of it. So it's going to fork. And it's going to be there now. Typically, it comes off the anterior division, but they can come off your superior gluteal and other kind of funky locations. But typically it's going to be off the interior division.
And then you're going to see your pudendal obviously make almost like a boomerang type of anatomy where it goes down towards the hip. And then it's going to come back down towards the base of the penis. And that prostatic artery typically comes off in between those two arteries. And then you're going to see these pigtail curly cues. And that's going to come back across towards the midline across that obturator artery.
[Dr. Christopher Beck]:
So this first came on my radar, there was a lecture at SIR, I think it was 2018 for those people who have the digital video library. And there was a guy, I think he was out of Yale, but he basically did a show intel where he talked about identifying the obturator, identifying the pudendal. And then he's like, "Really, you only have a handful of arteries left." And talked about how the prostatic artery in 98% of patients would cross the obturator artery. It was a great lecture. And he did a ton of pattern recognition. It really helped me out early on. And it's exactly what you're describing right now.
[Dr. Blake Parsons]:
Definitely. I mean, when you first start off, that's it, that's the hardest part of in cutting down your time and feeling confident in this pattern recognition. It takes seeing lots of different anatomy, lots of runs to be able to just know. It starts to jump out at you when you do the iliac shot, and when you're first starting off, there are tons of papers out there. There's numerous anatomy papers with great pictures and just go through those, and let that ingrain in your mind. So when you start to see shots that you're taking, you're like, "Oh yeah, I've seen this or something similar to this in a picture."" So you feel a little bit more confident.
[Dr. Christopher Beck]:
Sure. Can you talk a little bit about your time with Dr. Bagla and Dr. Isaacson in terms of either shadowing them? How long did you go out and check out their shops?
[Dr. Blake Parsons]:
So for both, I just did a course. I think maybe for Ari, I went out with Terumo, and did a Terumo course. I think we did two or three cases that day. And then the other one, I think I went out with probably Boston or somebody. I mean, I don't even know how many he's done at this point, a ton. And we sat down and watched do three, four of them as well. And I had already started doing some of them. So I had a little bit of an idea and I did Bagla’s after I did Ari’s had, and I went to Stream somewhere in between, around that as well. I think it was the first one they had.
So I had a good idea, which was great. Because by the time that I went to Bagla's, I knew what I was looking at and what I was looking for. And then I could really just dig into him about some of these minor details about things that he's looking for, how he embolizes, how much... Is he trying to get in? What's mixtures all these types of things, so. Okay. But I didn't do any kind of prolong, like, oh, I spent a week with one of them.
[Dr. Christopher Beck]:
Got you. I think there's a lot of value in having done a couple of cases on your own, then to go out and spend time with... Yeah. I think there's a lot of value in that. That was pretty a smart move on your part.
(8) Closure for Radial vs Femoral PAE
[Dr. Christopher Beck]:
So let's talk a little bit about, so you're done with the case, talk about closure for radial and closure for femoral and for just the trainees out there and talk about how that's different and advantages and cons of both.
[Dr. Blake Parsons]:
Yes. From a radial standpoint, we just TR band, everyone and we have our TR band protocol. So, obviously the bonus is that patient gets to sit up right away, and when you go to the bathroom, we can let them go to the bathroom. Or femoral, like I said, we're still pretty aggressive, but I do try to... angioseal my typical closure device. So I usually use a six French shealth to angioseal on everyone. To verify for the young folks that are listening or med students thinking about going in. We're obviously getting ultrasound guided access into the femoral artery.
So I evaluate the whole artery for calcium plaque, anything that could possibly cause me an issue when deploying the system. And then obviously I do a groin run before sealing to make sure that it is okay, adequate size, no large plaque in there that could peel off and cause me an issue. And then do the sealant. Like I said, we start setting them up though, pretty quick, so 30 minutes, and then we get them out pretty quick as well. Usually about two hours they're out the door.
[Dr. Christopher Beck]:
That's pretty good. As far as your post-op recovery period for radial versus femoral, are the radial patients still sticking around about two hours or-
[Dr. Blake Parsons]:
Yes.
[Dr. Christopher Beck]:
Okay.
[Dr. Blake Parsons]:
Yeah. Essentially for us, that's why... Since we don't have a six hour protocol that they have to hang around in, there's not a whole lot of difference from the patient's standpoint. Even satisfaction for most of the guys... Most of them had heart casts just because of their age and underlying things. They're just happy that they can get in without having to lay flat for six hours. So yeah, those that have been through femoral access are happy to get out in a shorter amount of time, for sure.
[Dr. Christopher Beck]:
I think that, just to highlight another point, is that the foundation... A lot of times we talk a lot about closure, what can go right, what can go wrong. But really like closure really starts with your access and good access, picking not just the common femoral artery, but the right spot on the common femoral can sometimes save you so much headache on the back end. I think that's under-appreciated or sometimes it doesn't get talked about enough.
[Dr. Blake Parsons]:
Well, and that's what IR-101 and people that had an MCW trained me. And they harped on it for an entire year. Every time you got in, as minute as you thought it may be. But knowing senior needle tip, knowing exactly where you're entering the artery, because say there's a plaque that's on the distal aspect of the common femoral will access above it. So that way that you can have potentially a good spot to be able to do a seal. You didn't just jail yourself from being able to seal the patient and for other reasons, obviously too. But that's definitely 101.
[Dr. Christopher Beck]:
I also feel like if you're in the limb salvage business, probably getting very, very meticulous about your vascular access site becomes increasingly important. I would imagine in patients who you're working on for peripheral arterial disease.
[Dr. Blake Parsons]:
Oh definitely. The majority of people, I guess listening to this podcast are IR guys. So that's what we pride ourselves on, is our ultrasound guided skills. So those are things that you got to have them.
(9) PAE Pre- & Post-Procedure Management
[Dr. Christopher Beck]:
So one of the other routes I wanted to go down was, so your patients are out the door, it's a two hour recovery. Before they leave, is there any kind of pain or... I was thinking either pain regimen, antiinflammatories, maybe steroids. Is there anything you do either for pre or post-op that helps with getting that transition, getting these guys out the door?
[Dr. Blake Parsons]:
They all get IV antibiotics, but other than that preoperatively nothing. As long as they don't have diabetes... So I don't give them anything in my facility post-op. So the three scripts I give everybody, I write them a Medrol Dosepak, and I write them antibiotic, and I write them pyridium just in case they get some dysuria. So I'll write them... You can buy pretty over the counter, but I can prescribe it 200 milligrams TID so it's stronger. But I give them those three things. I would say, it's not really that maybe 15 to 20% of guys have significant post-op pain. I'd still say the mass majority of the guys I do, don't even know I did anything other than they have a band-aid wherever I stuck them.
But the guys that are going to have more issues are typically in my practice. I've seen the guys with bigger glands. Like the other day I did one of who was 250 of gram gland to look like a cantaloupe. He definitely had a lot of post-op discomfort. I've only had to write axial pain medicine, like Norco, Percocet, whatever, twice. But otherwise, no, I typically don't. If they're having some issues with discomfort too, ibuprofen, just taking ibuprofen schedule. But for the most part, no issues that by the time that Medrol Dosepak starts to kick in, it really cools down and the inflammation prostatitis. And then the dysphoria and the peridium really does help. They'll call you because they think they're dying. Because it turns their urine an orangey red color.
[Dr. Christopher Beck]:
That's right.
[Dr. Blake Parsons]:
So I always get called about that. They're a peeing blood, but now it's just they're pretty...
[Dr. Christopher Beck]:
Sure. As far as expectation management with your patients, when do you paint a picture? Or what is the picture that you paint as far as recovery in terms of when you start to see relief, how much relief do you get? Is it graded? Is it instantaneous?
[Dr. Blake Parsons]:
I will tell you that I've seen results all over the board. So when I do my clinic evaluation student consultation, I assume for the first time. I tell it's pretty much two weeks to two to three months, everyone's different. I've got guys that come in at two weeks that swear they pee like they're 40 again. And I've got guys that take two to three months before they really start seeing an improvement. So everyone's different. Some of it I think is based on gland size, but I can't really put my finger exactly on why it is. I've got guys that swear they pee better the next day.
Obviously I'm sure there's some type of a placebo effect to it as well, but that's why we did the sham study to prove that that's not all true. But yeah, now it's on the map. So I'd tell them, "Look, you're going to see me at two weeks. If you're not seeing improvement, you're going to be upset. I'm not going to be upset. I'm only seeing you at two weeks because I just want to make sure where access is okay. You don't have any postoperative complications, that type of thing."
[Dr. Christopher Beck]:
Yeah. So that gets to my other question about postoperative care is you mentioned that you see him two weeks after the procedure and then do you see him again at a certain time point?
[Dr. Blake Parsons]:
Yeah. So I see him at two weeks, and then I see him at two months. And every single time I see them, they fill out their IPSS score. And I tell them... There are also guys, like guys in general, "We don't want to go to the doctor." And then you add a couple of years to the hospital if they don't want to go to the doctor. So filling out more paperwork just irritates them. But I make them fill out that paperwork. And I tell them the reason why is because I want to track. You started getting three, six months out a year. You forget how bad things were at the beginning. So this is a great way to also be able to show your patients say, "Hey, when you came in, you had an IPSS like this the 29 and now you're down to a 12, or an 8 or whatever. Then they're like, "Oh yeah, great. I knew I was doing what I was doing well, but this is awesome."
[Dr. Christopher Beck]:
Something about metrics that can tap into the psyche, which helps people feel better. And there's something about the same nisha effect where you get to be a year out. Then you start feeling better and it's hard to remember how it felt when you were miserable.
[Dr. Blake Parsons]:
Oh, exactly.
(10) Helpful Resources for PAE
[Dr. Christopher Beck]:
Rounding out this show. Were there any articles or advice for people interested in prostate artery embolization that you found particularly helpful when you were starting out? It doesn't have to be articles. It could have been like you mentioned the Stream course, it could be anything that you found that really helped jumpstart this procedure for you and was a big unlock.
[Dr. Blake Parsons]:
Yeah. Anything and everything. Everyone's different but I think the more exposure you can have the better. Because it's pelvic anatomies. It's crazy. And so everyone's different. So starting out, all the lectures anybody had at SIR meetings. I'd watch everyone, and I'm still watching. In the Stream meetings. There's tons of meetings out there now. There's tons of information. There's tons of papers, immersing yourself in as much of it as you can because everyone, a lot of people are going to say the same stuff, but in every one of them you can catch something different that's like, "Oh, yeah, I hadn't thought of it that way." Or, "Oh, I like this from this guy." You can tailor it to some degree what you like. What you think works for you, how does it make you deal with progress? Your progression through the case is easier. Those to anything to make you comfortable and confident to some degree of getting through the case and having a good outcome for the patient.
[Dr. Christopher Beck]:
And one more thing I wanted to ask about is as far as those interested in learning more about radial access, one of the things I wanted to know is do you consider radial access like for prostate artery embolization, is that a must have a skillset if you're looking to get into this procedures or if you're locked into femoral, can you basically get this procedure done with femoral?
[Dr. Blake Parsons]:
100%... By no means do you have to have a radial access in your pocket. You can do this from the femoral all day, every day. Now, we talked about earlier the more torturous they are the... I'd start off with some probably younger age, if you can. Patients just because like I said, 75 to 80 is kind of the magic number when all of a sudden things start getting a lot more torturous. Their arteries are more calcified. It just becomes much more of a challenge to get up and over and to have the stone. But, no, you definitely don't have to have radial artery access or that skill set to be able to do prostate artery embolization.
[Dr. Christopher Beck]:
I don't know if you would agree with this statement I've always found that like if you're just getting into prostate artery embolization, it's probably not the first case you want to do if you're still new is... If your comfort level is with femoral, then for your first prostate artery embolization go femoral. But for radial cases good ones to start out on like good chip shots at least what I consider good practice cases for radial access are UFEs. The anatomy is a little bit more straightforward, patients tend to be shorter and your target vessel is typically pretty easy to access.
[Dr. Blake Parsons]:
Definitely. And just the getting... So this is even taken even a step further back if you're really don't have much radial experience and if you do any diagnostic like arterial work even doing it from the radial. Just working under set up your access, sheets, cocktails which you like, you're wiring catheters to be able to select the descending thoracic aorta and get down into it, all that can benefit you as well.
[Dr. Christopher Beck]:
Yeah. For sure. All right. Blake any closing thoughts on prostate artery embolization?
[Dr. Blake Parsons]:
This field is continuing to grow and I think once we have a little more help from our urology colleagues in which is always it's been a tasking, there's been a lot of guys out there that are really trying to help push this forward, and make it even more mainstream for a population because the population wants it. I can't tell you how many times you do a procedure on a guy who's either had a previous transurethral procedure and it didn't turn out how I wanted it. And now he's having great results and they're upset, this was never even given as an option to him. And the same thing is fibroid embolization. We just need to do a much better job with prostate embolization and we did or are doing with fibroid embolization in patient awareness and letting people know that this is now there... And in educating your urology colleagues as well because they're a big factor in this. And just for overall, for our patients making sure that they're getting the appropriate procedure as well.
[Dr. Christopher Beck]:
That's right. You don't just got to commend you having 350 and 400 under your belt, congratulations to you in your practice. You're championing this procedure and bring it to the forefront, so. And I really appreciate you coming on the podcast [crosstalk 00:47:14] just to talk today.
[Dr. Blake Parsons]:
No, thanks as always. We always love being on and anytime we we're happy.
[Dr. Christopher Beck]:
All right. Nice. So to our audience, thank you guys for listening. If you enjoyed the podcast but want more, please check out the show notes to this episode, those are usually about a week delayed following the podcast when we put this out. But those are going to be able to be found at https://www.backtable.com. If you enjoyed the podcast and want to support the show here are two easy ways, first take one second hit the subscribe button on whatever platform you're listening on, this helps platforms like iTunes or Spotify know that you or audience value what we're doing and your interest in giving our latest content as we're producing it. Second, if you're really getting a lot of value from these podcasts please go to iTunes and leave us a short written review this helps us in so many different ways. We read every one of them, we love the feedback. That about wraps things up, we'll see you next time on the BackTable podcast.
Podcast Contributors
Dr. Blake Parsons
Dr. Blake Parsons is a practicing Interventional Radiologist in Oklahoma City.
Dr. Christopher Beck
Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.
Cite This Podcast
BackTable, LLC (Producer). (2021, August 16). Ep. 148 – Radial vs. Femoral for Prostate Artery Embolization [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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