Impact of cone-beam CT and augmented planning on complete prostatic vascular anatomy identification for prostatic artery embolization

Purpose: Prostatic artery embolization (PAE) is an effective procedure to treat symptoms associated with benign prostatic hyperplasia. One important challenge is the correct identification of arteries feeding the prostate.
Digital Subtraction Angiography (DSA) is the state-of-the-art imaging technique for vessel visualization during PAE. However, cone-beam CT (CBCT) is being increasingly adopted to improve anatomical assessment.
A study based on DSA imaging only (de Assis et al, 2015) defined the standard pelvic vascular anatomy classification for PAE, categorizing prostatic arteries by their origin in five groups and reporting a prevalence of double vascularization in 8% of the 286 hemi-prostates analyzed. This study aims to update this prostatic vascular anatomy study based on the use of CBCT instead of DSA.

Materials and Methods: Three-dimensional angiographic findings during 186 PAE procedures using systematically CBCT and embolization planning software (Vessel/Embo ASSIST with Virtual Injection, GE Healthcare) were retrospectively collected. Findings included prostatic arteries classification and prevalence of multiple vascularization.

Results: From the total of 322 pelvic sides treated, 101 (31.4%) had at least one prostatic secondary branch, 6 (1.9%) had three independent prostatic arteries.
From all the 429 prostatic arteries found: Type I anatomy was identified in 33.3% (143/429), Type II in 13.5% (58/429), Type III in 12.1% (52/429), Type IV in 32.9% (141/429) and Type V in 8.2% (35/429).

Conclusion: Data suggests that up to 75% (8% against 31.4%) of secondary prostatic arteries can be missed when DSA is used alone. CBCT is recommended as the standard technique for vascular anatomical identification for PAE.