E2582. Role of Cone-Beam Computed Tomography in Prostatic Artery Embolization
  1. Kenneth Huynh; University of California, Irvine
  2. Rebecca Bennett; University of California, Irvine
  3. Joseph Carbone; University of California, Irvine
  4. Louis Fanucci; Oregon Health and Science University
  5. Nadine Abi-Jaoudeh; University of California, Irvine
  6. James Katrivesis; University of California, Irvine
Prostatic artery embolization (PAE) is an increasingly utilized and effective alternative to surgery in the treatment of lower urinary tract symptoms due to benign prostatic hyperplasia. However, given the complex pelvic vasculature and aberrant arterial variation, PAE remains technically challenging with high risk of non-target embolization. Cone-beam computed tomography (CBCT) has evolved the practice of PAE by allowing distinct discrimination of overlapping pelvic arteries, their origins, and the angulation necessary for prostate artery selection. CBCT in conjunction with digital subtraction angiography (DSA) provides essential information that can change treatment planning and augment procedural safety and success.

Educational Goals / Teaching Points
Review the typical and variant pelvic arterial anatomy relevant to selective prostate artery embolization (PAE), illustrate, through case-based review, the utility of automatic feeder detection software with intraoperative cone-beam computed tomography (CBCT) in PAE, and discuss the advantages and potential pitfalls of CBCT relative to digital subtraction angiography.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Origins of the prostate artery are highly variable and classified into 5 subtypes: Type I (common trunk of the superior and inferior vesical arteries), Type II (anterior division of the internal iliac artery), Type III (upper or middle third of the obturator artery), Type IV (upper or middle third of the internal pudendal artery), and rarely, Type V (accessory or aberrant origins). CBCT with automated feeder detection can help detect prostate feeding arteries in cases where the origin is obscured by multiple overlapping pelvic arteries on DSA. CBCT can also be used to evaluate for collateral vesical, rectal, and penile arteries to avoid non-target embolization. Potential pitfalls of CBCT include pseudo-rectal enhancement due to beam hardening artifact, retrograde opacification, and venous contamination.

Given the variability and tortuosity of pelvic arterial anatomy, incorporating intraoperative CBCT can facilitate catheterization of the prostate artery and mitigate potential non-target embolization. This educational exhibit will highlight the role of CBCT in discriminating pelvic arterial anatomy from corresponding DSA images, and discuss the pitfalls of CBCT and methods to avoid misinterpretation.