In prostate artery embolization (PAE), do we embolize both prostate arteries or a single artery?

Bilateral Embolization is Required for Prostate Artery Embolization

In prostate artery embolization (PAE), both prostatic arteries should be embolized to achieve optimal clinical outcomes and reduce the risk of treatment failure. 1

Rationale for Bilateral Embolization

Bilateral embolization is the standard approach in PAE for several important reasons:

• Anatomical considerations: The prostate receives blood supply from both sides, with extensive collateral circulation and anastomoses between vessels 2
• Hemodynamic factors: Unilateral embolization may lead to increased compensatory flow through the non-embolized side
• Clinical effectiveness: Bilateral embolization provides more complete devascularization of the prostate gland, leading to better symptom improvement

Technical Aspects of PAE Procedure

Pre-procedure Planning

• Detailed imaging (CT angiography or MRI) to evaluate prostatic arterial anatomy
• Assessment of arterial access options (common femoral arteries are preferred) 1
• Evaluation for anatomical variants which are common in prostatic arterial supply 3

Procedural Steps

1. Arterial access via common femoral arteries (unilateral or bilateral approach)
2. Initial aortography to identify pelvic arterial anatomy
3. Selective catheterization of internal iliac arteries
4. Super-selective catheterization of prostatic arteries using microcatheters (4F or smaller)
5. Embolization of both prostatic arteries sequentially 4

Embolization Technique

• Use of calibrated microspheres or other embolic agents
• Complete stasis in the target vessels should be achieved
• Verification of adequate embolization before concluding the procedure

Special Considerations

Anatomical Variations

• Prostatic arterial supply is highly variable with multiple possible origins 2, 3
• Common variations include:
  • Origin from internal pudendal artery
  • Origin from obturator artery
  • Accessory prostatic arteries
  • Anastomoses with vesical and rectal arteries

Technical Challenges

• Atherosclerosis and vessel tortuosity in elderly patients
• Small caliber of prostatic arteries (0.5-2mm)
• Risk of non-target embolization to adjacent structures 5

Management of Unilateral Embolization Scenarios

If one prostatic artery cannot be catheterized due to technical difficulties:

• Make multiple attempts with different catheter shapes and approaches
• Consider alternative access (e.g., radial approach)
• Document the reason for inability to embolize both sides
• Inform the patient about potential reduced efficacy

Expected Outcomes

Bilateral PAE is associated with:

• Better symptom improvement
• Greater reduction in prostate volume
• Lower risk of treatment failure or recurrence
• Improved quality of life outcomes

Conclusion

Bilateral embolization is the standard of care in PAE procedures. While unilateral embolization may be performed when technical limitations prevent bilateral treatment, it should be considered suboptimal and may result in inferior clinical outcomes. The complex and variable nature of prostatic arterial anatomy necessitates a thorough understanding of vascular variants and technical expertise to successfully perform bilateral embolization.