Prostate artery embolization

Three things you will learn at my lecture

1. The three key parameters for the success of a prostate artery intervention (PAE) are: the volume of the gland, the architecture of the prostate, and the vascular anatomy.

2. The armamentarium for PAE (particles & liquids) has developed so rapidly that it is possible to offer each patient an individualized treatment.

3. There are no shortcuts in PAE! My tip: understand the architecture of the gland in the context of the symptoms before relying on the vessels.

Prof. Dr. Attila Kovács
Speaker bio

Add this session to your calendar!

Anatomy & procedural planning

Prostate volume (PV), intravesical prostate protrusion (IPP), prostatic urethral angle (PUA) and tissue dominance – collectively referred to as prostate architecture – are important predictors of whether a patient is suitable for PAE and what success can be expected after PAE.¹ The prostate architecture is best assessed by MRI. The vascular anatomy, on the other hand, by CT-angiography. Prostate artery embolization (PAE) is a technically demanding procedure due to the highly variable origin, the small caliber and the winding course of the prostatic arteries.^1,2,3 Success depends on identifying the correct origin and avoiding “non-target” embolization to adjacent organs.

Liquids & particles

The choice of embolic agent – spherical particles or liquid “glue” – is a decision based on procedural goals, patient anatomy, and the radiologist’s experience. Both are used to decrease the blood flow in the prostate, though they offer different technical and clinical advantages. While microspheres (100 – 500 µm) are the established choice (PV-reduction of roughly 30 – 50%), recent studies show that glue is a safe, effective, and fast alternative with comparable symptom relief.^4,5 One advantage of glue is better visibility: the spread of glue can be observed in real-time, reducing the risk of accidentally non-target embolization. The disadvantage is, glue requires high expertise to avoid “gluing” the catheter in place.^6,7

Figure 1. Typical course of prostate artery embolization (PAE). A. The pre-interventional planning MRI (coronal T2w) shows right-dominant and adenoma-dominant hyperplasia of the prostate. B. Typical contrast enhancement of the right prostate lobe in angiography. C. Complete devascularisation of both prostate lobes just two days after PAE (coronal T1-weighted MRI). D. Measurable shrinkage of the prostate after just two months; the coronal cranio-caudal diameter of the prostate is reduced from 5.7 cm before therapy to 4.3 cm. The reduced perfusion of the prostate persists.

Tips & tricks

Standardized pre-intervention imaging is essential for planning PAE and makes the actual intervention significantly easier. MRI is used to measure prostate volume and to assess the prostate architecture. A CT-Angiogram of the pelvis is essential as a “roadmap” to identify the PA’s origin, diameter, and any atherosclerotic barriers. Ipsilateral oblique angiographic views (30° – 50°) are recommended to better visualize the branching of the internal iliac artery. Cone-Beam CT (CBCT) is critical for confirming that the microcatheter is in a safe position before releasing particles or glue. The ‘PErFecTED technique’ (proximal embolization first, then embolize distal) achieves better results than flow-controlled PAE. Be aware of the current evidence on when PAE can be used – namely, much earlier than is commonly communicated in interdisciplinary settings.

Attila Kovács

Clinic for Diagnostic and Interventional Radiology and Neuroradiology, Bonn/DE

Professor Kovács’ medical training includes cardiac surgery, radiology, and neuroradiology. Since 2012, he has been chief physician at a specialised clinic for diagnostic and interventional radiology and neuroradiology, with its own outpatient ambulance and inpatient ward, in Bonn, Germany (formerly Robert Janker Klinik, now WEGE Klinik). Professor Kovács is an experienced interventionalist in all areas of image-guided, minimally invasive procedures. He offers a wide range of interventional procedures at his clinic, including almost the entire spectrum of interventional oncology, as well as PAE, GAE, etc. In addition, he regularly offers workshops and master classes. He is a member of national and international professional societies (DeGIR, CIRSE), is an ESIR lecturer, a CIRSE academy author, and reviewer for CVIR and several highly respected journals. He is the PI of the CIRSE-sponsored registry RESPECT. Prof. Kovács is married and has two children.

References

¹ Kovács A, Bücker A, Grimm MO, Habermann CR, Katoh M, Massmann A, Mahnken AH, Meyer BC, Moche M, Reimer P, Teichgräber U, Wacker FK; Position Paper of the German Society for Interventional Radiology (DeGIR) on Prostatic Artery Embolization. Rofo. 2020 Sep;192(9):835-846.

² Oerther B, Sigle A, Franiel T, Teichgräber U, Bamberg F, Gratzke C, Benndorf M. More Than Detection of Adenocarcinoma – Indications and Findings in Prostate MRI in Benign Prostatic Disorders. Rofo. 2022 May;194(5):481-490

³ Helrich S, Pate W, Garg N, Barbosa P, Wason S. Comparison of magnetic resonance imaging to ultrasound for prostate sizing. Can J Urology. 2021;28(6):10889–10899

⁴ Cornelis FH, Bilhim T, Hacking N, Sapoval M, Tapping CR, Carnevale FC. CIRSE Standards of Practice on Prostatic Artery Embolisation. Cardiovasc Intervent Radiol. 2020 Feb;43(2):176-185

⁵ Rostambeigi N, Sapoval M, Bilhim T, McClure T, McWilliams JP, Carnevale FC, Kovács A, Little MW, Bhatia S, Parikh NS, Young SJ, Ayyagari R, Mouli SK, Golzarian J. Standardized Technique for Prostatic Artery Embolization: A Delphi Consensus Study on Optimized Methods and Emerging Concepts. J Vasc Interv Radiol. 2026 Feb;37(2):107902

⁶ Loffroy R, Quirantes A, Guillen K, Mazit A, Comby PO, Aho-Glélé LS, Chevallier O. Prostate artery embolization using n-butyl cyanoacrylate glue for symptomatic benign prostatic hyperplasia: A six-month outcome analysis in 103 patients. Diagn Interv Imaging. 2024 Apr;105(4):129-136

⁷ Mohamed, N.S.A., El Khatib, E., Justaniah, A.I. et al. N-butyl cyanoacrylate glue application in prostate artery embolization for benign prostatic hyperplasia: a systematic review of safety and efficacy. CVIR Endovasc 2025; 8, 98

⁸ Carnevale FC, Moreira AM, Antunes AA. The “PErFecTED technique”: proximal embolization first, then embolize distal for benign prostatic hyperplasia. Cardiovasc Intervent Radiol. 2014 Dec;37(6):1602-5

⁹Sapoval M, Thiounn N, Descazeaud A, Déan C, Ruffion A, Pagnoux G, Duarte RC, Robert G, Petitpierre F, Karsenty G, Vidal V, Murez T, Vernhet-Kovacsik H, de la Taille A, Kobeiter H, Mathieu R, Heautot JF, Droupy S, Frandon J, Barry Delongchamps N, Korb-Savoldelli V, Durand-Zaleski I, Pereira H, Chatellier G; PARTEM study group. Prostatic artery embolisation versus medical treatment in patients with benign prostatic hyperplasia (PARTEM): a randomised, multicentre, open-label, phase 3, superiority trial. Lancet Reg Health Eur. 2023 Jun 26;31