Chris Dobzyniak, MD, gives updates in the management and treatment of osteoporotic vertebral compression fractures and Adam Lustig, MD, discusses prostate artery embolization.
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Return to Main Symposium Page Hello and welcome. Today we're going to discuss updates in the management and treatment of osteoporotic vertebral compression fractures. My name's Chris Tabs ENIAC. I'm the chief of interventional radiology at Medical Center. Radiologists in the medical director for the Department of Interventional Radiology, its internal for General Hospital. Also an assistant professor of radiology for Eastern Virginia Medical School. I have no relevant disclosures to make today some goals of our talk. Today, we're going to understand the epidemiology of osteoporotic compression fractures were going to describe how to identify, evaluate and treat vertebral compression fractures. We're going to try to understand the pros and cons of nonsurgical management versus vertebra augmentation for vertebral compression fractures. And we're gonna try to develop an understanding for the mentality, risk following a vertebral compression fracture and understand ways to minimize these risk for our patients. A little background. Little epidemiology on the U. S. There's greater than 750,000 vertebral compression fractures that occur each year. It is the most common fracture, and individual individuals with osteoporosis and a number is greater than the number of hip and wrist fractures combines a very common. It's estimated that approximately 25%. Postmenopausal women will experience a vertebral compression fracture. This results in approximately 150,000 hospitalizations for year for management of pain. And, he asked, average hospital stay is approximately eight days following admission for a vertebral compression fracture as of 2000 and five. So about 15 years ago, now the the costs related to these fractures these hospitalizations was about 17 a billion dollars. Um, when we think about fractures, there's really three types of fractures. Three shapes, really the most common eyes. The wedge fracture where the nice, rectangular cheaper body takes on more of a triangular wedge shaped appearance. Obviously, the second most common is a bike on cave, where the fracture begins to take on sort of a bow tie appearance and then the least common. It's just sort of a crush where the entire vertebral body eyes shortened and stature ast faras location of fractures. They can certainly occur anywhere along the spine. However, there are areas where they tend to be a little bit more common. On this is the mid Jurassic region, and at the historical lumbar junction on this is simply correspond to the most mechanically compromised regions of the spine, So risk factors for developing overachiever compression fracture. Not surprisingly, severe osteoporosis. Andan These situations Fractures can really result from very minimal trauma. The patient may sneeze or cough. Lift a small object like a gallon of milk or, you know, a pitcher of water, um, taking a bad step when coming out coming down their porch or even just sitting back into into a couch or chair too quickly. So very minimal trauma on. Oftentimes, though, they're really a similar story. Um, if the osteoporosis is done severe, so mild osteoporosis or osteopenia thes air, I really see going to require a bit more force. These are patients that may describe, you know, falling in the shower from slipping on ice or trying to lift a heavy object. Often, you know these air elderly people. They may have been trying to pull a loved one or reposition a loved one in bed, and they may have this acute onset of pain. Um, common stories, you know, lifting a suitcase. Individuals with normal mineralization. This is going to require, you know, really significance of your trauma. So we're talking about, you know, high impact car accidents. You know, significant sports related trauma and maybe not surprisingly, having a vertebral fracture, um, increases your risk for future fracture. And what we've seen is after in a patient, has one vertebral compression fracture. Their chances of getting another one increased fivefold. For patients who have two or more concurrent vertebral compression fractures, that chance of another fracture increases 12 fold and patients with three or more vertebral compression fractures, uh, that have occurred there. Incidents of another fracture increases actually 75 fold. So s so the presence of a fracture really increases the risk for having another one. And this is really not surprisingly, if you sort of think about the mechanics of the of the spine and way the forces along the spine maybe directed. So if you look at this 1st 1st column, we see it, you know, relatively normal looking spine and the vector of force or any force is that air distributed along the spine are really evenly distributed across the entire vertebral body, uh, in the inter vertebral disc and really oriented along the long axis of the bone as we have a fracture and we begin to lose some height the typical fracture is that wedge fracture. Remember, we begin to lose some height along the anterior aspect of their cheaper body. Now, the vector of that force that had traditionally been along the long access to the spine starts to be directed a little bit more interior Lee. And that's exaggerated Mawr with more fractures. That vector becomes Maura Maura Interior Lee directed along the length of the spine. And as you see by the time we get to the third panel now, rather than that force being kind of uniformly distributed it throughout the entire region, nobody is sort of eyes focused on the anterior aspect of the vertebral body, and it tends to sort of pinch Thea anterior aspect and the forces of directed along that anterior aspect. And that's where the fractures tend to occur. So it's putting an abnormal force on a smaller and smaller portion of the vertebral body, and it's just much more prone to fracture. What are the consequences when a patient does have over cheaper compression fracture? Well, there's a lot. Um, there's the direct health consequences. So we see kind of in this this spiral. Here we see the patient has a virtual compression fracture. They have back pain that may result in the spinal deformity that can decrease their lung capacity. They develop that ketosis at home hunched over appearance, and it's sort of a restrictive lung disease that the lungs can't inflate as they would. Um, this further impairs the function of the individual. They may have loss of appetites, sleeping problems because it's it's hard for them to lay flat. It's uncomfortable. If they have COPD, it may be it may be exacerbated. Um, this all leads sort of decreased activity, more bone loss, more muscle loss, and that's going to get really lead to increased fracture fracture risk in those increased lung problems. This ultimately results in an increased mortality, and there are some quality of life consequences as well. These can't get around as well. They have to use a walker. A cane. Um, you know, they may be hunched over. They're gonna lose him. Self esteem. Because their appearance, they may not be able to engage in activities that they have in the past, you know, leading to social isolation and really depression is potential consequence. When this happened. So we talked about the immortality. And what does that mortality look like? So, uh, mortality, finding the diagnosis of vertebra of a vertebral compression fracture and a Medicare population. So in elderly population and it's sort of all over the map five years, four years, 10 years is what that mortality rate looks like after a fracture. So anywhere from 39% all they have to 85% a 10 years. So there does appear to be an increase in mortality associated with these fractures. Now, the question obviously becomes, you know, are these just unhealthy people, um, that, you know, would have would have high mortality in five years or four years or 10 years, as the case may be, anyways, or is it truly the fracture? So Elizabeth Kato sort of investigated that she looked at the study of about 10,000 women, almost 10,000 women greater than 65 years old on she compared those with and without of retrieval, compression fracture. And what she showed was that there was about a 23% higher age adjusted mortality rate for women following a vertebral compression fracture. Onda Her findings suggested that those women who did have mortality were 2 to 3 times more likely to die of pulmonary related causes. So pneumonia, COPD, etcetera. And this is all sort of important because I think we've sort of demonstrated that there is a There is a risk after these fractures. There isn't there's a potential for increased mortality, and there's certainly some debilitating factors and morbidity that goes along with this. So they're sort of they're sort of became this confusion about what to do with these people. What to do with these patients? After two articles were published in 2000 and nine in the New England Journal of Medicine, it's sort of questioned the usefulness of vertebra plastic. So at this point, people really didn't know what to do. We fell back to doing more and more nonsurgical management. Andi, as we saw in the previous couple slides. Um, if we don't treat these patients right, uh, they have significant morbidity mortality. So from 2000 and nine, when these articles were published, we're doing about it. Keifer blasting about 24% of patients who presented with a vertebral compression fracture by 2014 that had dropped to 14%. So there was a there was a There was a large shift over about a four or five year period because people just didn't know what to do anymore or the evidence was suggesting. There we go in a different direction than we traditionally have. So it's important to recognize patients with with a fracture because we need to know when to treat and how to treat eso. There's gonna be some sort of key signs and symptoms that are going to suggest whether the patient has a vertebral compression fracture and allow us to sort of grade, you know, is a low probability, intermediate or high probability that they have the same type of fracture. So this is a nice little list in each. One of these little bullet points basically gives the patient a new additional point of scoring, and we sort of add them up at the end, and they're going to give us the scores can allow us to determine the probability of a fracture. So as we just sort of run through these, is there a new severe limitation and mobility or activities of daily living secondary to the this nuance of pain? Does the pain diminish or resolve with rest. So commonly these patients will tell you. Yeah, I'm up if I'm sitting straight up or if I'm trying to stand the pain is excruciating. But if I lay back in my recliner, I lay down flat and bad. The pain gets better. Um, is there a recent history of minimal low velocity trauma or injury? Now, these are the things we talked about earlier in the presentation. It could be very minimal, right? I sneeze. And then I had pain. I took a bad step, and then I had pain. I tried to pick up a suitcase and then I had pain. So is there some suggestion of an injury that may have resulted in something new that's going on with the patients back? It is the pain related activity movement. They may tell you that, you know, when I when I ride in the car, every bump is excruciating. When I tried to get up from bed to a seated or standing position, the pain is excruciating. On day, we're gonna be looking for other clues, and we're going to score these as well. Is there a past medical history that's gonna put these patients at risk. Is there osteoporosis or osteopenia? Is there a previous vertebral compression fractures we saw that increases our risk of another fracture? And then is there a chronic use of corticosteroid? And then we're gonna move on to our physical exam. We're gonna look is their tendons to pal patient of percussion over this finest process. So I like to start a T two because it's easy to help it. It just sort of start counting. My way down the spine is processes. As you get to the one that's fractured. The patient will typically tell you Yep, that's the one, or they'll let you know in other ways that that's the spot that hurts obviously, could be a little bit difficult to count to the exact spot. Um, in obese patients or larger patients, Usually you get a pretty good sense of sort of the level, and you can get a pretty good sense of when I push on the midline of the back in this spot. It hurts, even if you can identify the exact level and then you again. You're looking for pain. That's exacerbated by the change in position or patient that's reluctant to move you ask him to go from from the chair upon to the exam table, and they're really hesitant to do it. And is the is the is the back pain midline, right? Is it off to the side? Um, you know, which may suggest more of a muscular thing. So we're going to score all of these and they're going to give us a score of 123 being low probability 4 to 16, intermediate probability and greater than seven being high probability for vertebra, acute vertebral compression fracture. And this is really going to sort of tell us what to do next. So that's going to tell us whether patient needs to undergo further evaluation or assessment for fracture. So those who we feel are low probability for fracture. Maybe they just got some muscular back pain or some strange um, we're probably not going to do anything right away. Maybe we're just going to watch. We're going to do some symptomatic treatment. But those that are sort of intermediate probability or high probability for pretty poor compression fracture, we have to assess a little bit further. Um, and traditionally we've gone to the lateral spine X ray right you can see it's it's cheap. It's easy to get quickly. It's quick to get, um, and it's okay. Sometimes it's helpful. Um, it could be used to screen, but honestly, they're notoriously insensitive, and it's very difficult to distinguish between acute and chronic fractures. Um, unless you have a recent to compare to you, you may not be able to tell whether something's new or old. Really. The gold standard for assessment when you have, um, intermediate or high probability for fracture is to go to a memory that the kind of sequence we care most about eyes the stir sequence to kind of the fluid, sensitive sequence. It's really going to tell us whether there's there's, there's a demon in the bone on. This is really where you want to go in. In situations where there is a new intermediate or high probability for material compression fracture. Maybe that's fine. Radiograph is maybe is where you start with somebody who has a little probability for fracture. Um, obviously, there's patients that cannot undergo Emery for whatever reasons they have. Ah, pacemaker. They have some other implantable device. They have claustrophobia. Whatever the case may be, Um, and those patients. Kind of The second go to is to do a C t of the spine that the area of interest, um, combined with a bone scan, C t will really allow us to determine the anatomy. But again, much like the lateral spine X ray, even in acute fracture, if we don't have something to compare it to, it could be really difficult to determine the age of the fracture. The bone scan will really allow us to say, Yep, this is new, and the C T will allow us to say this is what the fracture looks like. So radiologic assessment. So here's that. Here's kind of a couple lateral spine X rays. And then that Marie, as we sort of look at the first panel. So first week, post fracture we see kind of in the middle of the screen. Probably about t 10 there, unfortunately, toned it down a little too much, but we see a very subtle deformity along the superior and play of this vertebral body, compared if we compared to the ones adjacent to it. This is easily something that could be sort of blown by or missed. Um, if you don't have the you know, the appropriate I or history to know what you're looking for When we look about eight weeks later, however, we start to see that they were taking on that that wedging appearance. And now that deformity is much less subtle. This rich everybody's sort of undergoing the slow progressive collapse. Obviously, this patient was still having pain post eight weeks after their fracture. Eso they got another radiograph. At this point, it was suggested that this fracture was acute or sub acute patient went on to Marie. So this is eight weeks after the injury, and we still see on this memory image. Um, this, uh, this, uh, bony a demon is basically it's a white is the adjacent cerebral spinal fluid. So even eight weeks after this patient hasn't really undergone any significant healing. Actually, the fracture has gotten worse on, but there's still there's still I mean pain after this conservative management. Um, now, again, this is sort of another example of the same thing, and this sort of reinforces that idea that these fractures could be acute and the deformity can be acute or that they can progress over time. So first panel at the top shows a patient with new onset back pain. Um, in early December of this year, um, at the l one vertebra body level, we see some subtle deformity along the superior end plate, and we see a little fracture fragments, sort of extending from the anterior aspect ever to everybody. But overall, the vertebral body height is pretty well preserved, just a minimal loss. This was actually missed on the read. The patient came back about 10 days later with continued pain not getting any better on did. They obtained a lateral spine radiograph, and we see that there's been additional loss of height endeavor to everybody. That little fracture fragment interior early almost appears like it's being displaced in the vertebral bodies. Getting lower. Lower patient was considered for nonsurgical management, which we'll talk a little bit more about shortly. Andi sent home about a week later, patient reports pain still excruciating, heads back to the emergency department and gets another C T. The amount of height loss looks about similar to the radiograph on December 23rd, but now we're seeing some retro portion of the fracture fragments along the post. You aspect of the vertebral body. We get a better look at that little expelled fragment interior. Early on, we could really get a sense when we compared to the adjacent vertebral bodies. They have lost about 50% of the height, and we can see the beginning of an exaggerated typhus. Iss um, nonsurgical management was continued patient presented on January 8, again with excruciating pain. Finally, an m r. I was gotten on. We see that bony oedema. So this patient's gone about a month now on distill in excruciating pain. She's had a lot of problems just getting around and doing their activities of daily living. Annmarie shows us why the lower panel here shows this kind of that progressive fracture over time. So these air older images so they're they're not quite as pretty, but January 2003 we see we see a This is not that stir sequence. So we see the the fractured bone, which is which is circled here as looking dark, traditionally like to look for the stir sequences where it looks bright, but we see we have a little bit of height loss. About a month later, we see that now there's about 60% height loss that that for Cuba body. These air bulls still treatable lesions. However, by May of 2000 and three, uh, this vertebral bodies basically completely collapsed. So we have seen some retro portion of Thea fracture fragments. We see compression and distortion of the spinal cord. We see an exaggerated ketosis. Um, there's really nothing you can do for this patient at this point in this patients who have chronic problems. Um, and it may require surgical decompression. All right, so now we've figured out how to evaluate these patients. We figured out how to assess them with memory or C T and bone scan. Um, we have to look at what kind of the goals of treatment are Number one. We want to stabilize the fracture. We want to prevent any further height, loss or deformity. We want to improve the patient's pain and get them back on their feet. We want to decrease or minimize the utilization. Any narcotic medications. We want to improve the patient's function so they can go about their lives. We want to prevent any hospitalizations or visits to the ER on. We want to make sure that we're considering how to best decrease that patients long term morbidity and mortality. All right, so management so really breaks down into sort of two pathways. Nowadays, there's nonsurgical management aimed at reducing pain during the healing process. So we prescribe the patients, typically narcotic or non narcotic pain management. Uh, and we try to get the patient to wear one of these clamshell braces, thes plastic clamshell braces to stabilize the fracture and sort of take the pressure off. There's some potential negatives to this, however. The patient's hate wearing these braces older patients with a little bit of arthritis in their hands, these air really hard to get on without help. Eso the compliance which is wearing the brace is not is not particularly high, um, in narcotic dependence. Obviously, this has become a bigger and bigger issue. As time has gone by on, do you know 89 10 weeks of of of repeated narcotic prescriptions. I don't think we should discount and then obviously worsening to for me. So, you know, even in the setting of, you know, compliant patient wearing the brace on not getting narcotic dependent. Um, there's nothing really been done that's gonna that that guarantees there won't be a worsening to form. Um, the other treatment algorithm or other pathway is what we call vertebral augmentation. And this is Kifle plasticky and vertebra Plastic. Sort of two similar treatment treatment modalities. Um, and these were aimed at pain relief. So trying to trying to relieve the pain as quickly as we can, uh, and fracture stabilization. Now the potential negative to this are as it requires, an invasive procedure requires a patient undergo some some sort of anesthesia or sedation and requires disruption to the skin barrier. So how do we decide whether patients best served with nonsurgical management so bracing and pain management versus vertebral augmentation? Kaifu Classy and vertebra plastic? Well, fortunately, this past year, three guys out of U. C. L. A. Put together what they feel. It's the clinical care pathways for patients who are assessed for having for people compression fractures. And that panel consists of what they felt were the experts so neurosurgeons, interventional radiologists and interventional neuro radiologist, pain management specialist and orthopedic surgeons. They then went on to review what they felt were the best. 83 are the best. The best studies. Randomized control studies, systematic reviews and observational studies, which totaled 83 number on DSO sort of is there cut off for any of these to be included, they had to include at least 200 patients in their assessment. And this panel got together. And they tried to make recommendations on how to assess patients, how to further assess patients, how to treat them, how to do manage them and follow up. So they looked at the sort of 10 signs and symptoms that we talked about earlier to determine whether patients low, intermediate or high probability for fracture. They made recommendations on the relevance of the three diagnostic procedures. So that's X ray UH, M R. I and Bone scan with C. T Onda. Then they looked at 576 2 discrete clinical scenarios and made a recommendation on whether those patients and that specific clinical scenario were better served with vertebra plast e I'm sorry. Vertebral augmentation vertebra, plastic type of plastic versus nonsurgical management bracing and pain control on. Then they looked at, looked at and made recommendations about appropriate follow up care. Any clinical recommendations that they made had to require greater than 75% agreement amongst all the panel members. This is sort of the flow short they came up with. So if we start over on the left at the top corner here, patient presents with back pain, right? So we're going to assess them and we're gonna We're they sort of throughout certain patients. So high velocity traumas, eso patients younger than 18 and patients with malignant fractures. They really sort of folks focusing on these osteo product or osteo Penick fractures. They looked at those key signs and symptoms, So that has a Has the patient been on steroids? Have they had a previous fracture? Do they have a point? Tenderness over there, spineless process. So they haven't carried activities have been living All those things we talked about earlier on that's gonna allow us to predict the probability that they have a vertebral compression fracture, low intermediate or high low probability frack patients with low probability for fracture going to going to serve a watchful waiting conservative treatment. So we're going to manage the pain, but we're not necessarily going to get any imaging, but we're going to reassess them. We're going to see them back. We're going to reassess them because over time their symptoms may change. On day may move from a low probability to an intermediate or high probability. So it's important to see patients even if this sort of enters into the back, your head is a possibility, but you think it's low to eventually see them back or check in with them just to make sure that their pain is improving and not getting worse on. But they don't begin to check off a few more boxes on those key signs and symptoms. So those patients with intermediate or high probability for fracture we talked about They go on to Marie. They can't get a memory C, T and bone scan. So is there a vertebral compression fracture is they're not. Obviously, if there's no, they go back into, you know, sort of assessment for another cause on DWI. Move on in the algorithm. Those patients who do show a fracture on their memory or C t. We're going to then assessed to determine whether their best served with nonsurgical management or whether their best served with vertebral augmentation. And we're gonna make a recommendation, you know? Are they are they appropriate candidate for nonsurgical management. Are they somewhere in between, or is it a strong recommendation that they undergo overachiever augmentation? So whatever the treatment is, we're then going to we're going to complete on. We're gonna follow them up, and we're going to see about 2 to 4 weeks later. Is your pain better? Is your pain worse? Andi, is there something now we need to do and we can reassess them and go right back to the beginning of this cycle if needs be. All right. So what are those seven key findings used to prescribe management. These are these are the things that we're going to use to determine whether we're going to go down the nonsurgical management pathway or whether we're going to go down the vertebra, augmentation, pathway. And again, we're just going to sort of give each of these we're going to check The boxes were gonna sort of give a score to each of these. So what's the duration of the pain? Is it less than a day's? A couple days is it is. It is a multiple weeks. What is the imaging finding show? Is there a fracture? Is there not a fracture on doesn't match up with where the patient has pain. Um, what is the degree of the vertebral body? Height reduction. Is it a mild fracture? I less than 25%. Or is a severe fracture greater than 40% of height loss already? Is there any deformities or chaotic deformity? Have we seen an alteration in the patients? Uh, posture. Um, what's the progression of the vertebral height laws? Is it getting worse than the previous example? We showed a couple X rays where it was very mild. By the time we got to the later imaging, it was, you know, a more moderate or severe type of fracture. Do we have evidence that that's changing over time, that will get to score, and then and then what's going on with symptoms? Have these symptoms improved? Are the symptoms stable? But they're on medication or the symptoms worsening despite the fact that they're on optimal, uh, medication. And then what is the impact of the vertebral compression factor and daily functioning? Right. Um, is it a little bit inconvenient, but they're able to do everything. Do they have some limitations, or are they basically not able to do anything? And these were all gonna help us determine whether we should go with them or invasive for Tebow augmentation or whether they're better served with nonsurgical management. So it's important that we choose the right one again. We saw the New England Journal of Medicine articles back in 2000 and nine. That sort of suggested, um, that Richard augmentation wasn't useful. Um, but I think we have some good evidence that shows that maybe that's not the case. Eso How do we How do we sort of choose the correct pathway? Um and I think we have to put these side by side. So when we get to the point where we've said we have a fracture and the flow chart suggests that we do one thing, what's the importance of doing that? So patients who are clearly fall into the nonsurgical management clearly fall into the nonsurgical management, Um, pathway right there definitely served correctly with nonsurgical management. Those who clearly fall into the vertebral augmentation pathway are best served by vertebral augmentation. But what happens when we decide what happens when we see a patient is best served by vertebral augmentation? Hiphop? Last year vertebra plast e and we put them in the nonsurgical management pathway, right? And that's really what we see here. And I'm going to sort of skip past this slide because we'll see it a little bit more detail in the next slide. So these air studies that sort of compared those two things, um, and sort of looked at what happens when you have a patient that's best served by vertebral augmentation, and you put them into the nonsurgical management pathway. So on looked at over two million patients. He had 1.7 million with nonsurgical management. Andi. He had about 380,000 that got vertebra augmentation. And what we see is non surgical patients who we felt would have benefited from vertebra augmentation and got nonsurgical management. There was a 55% in 24% higher mortality for those patients who underwent nonsurgical management at the one year and 10 years mark versus Balloon Kifle plastic. He should similar findings with vertebra plastic, 30% in 8% higher mortality for patients at one in 10 years. Um, when they didn't, when they didn't undergo the appropriate treatment and we see these really throughout a bunch of articles, and we have a fairly large numbers, 32% higher risk for nonsurgical management, 40% 40 40% here, 43% here, 55% here. The McCulloch's study showed that there basically wasn't a difference. But when we look at sort of the numbers in total, I think we begin to see a pattern that shows that when we think somebody's appropriate can offer vertebra augmentation and they get that they do better. They have a little immortality. Mhm, mhm. So a little bit more on choosing the right pathway. So what's the effectiveness of vertebra? Augmentation versus nonsurgical management? So a few other things to keep in mind. So again, these are patients who we've determined through that rand UCLA pathway that are appropriate candidate for two vertebral augmentation. So there's a three times greater pain reduction at one week versus nonsurgical management. There's a four times greater improvement in quality of life at one month for these patients. When they get kinfolk last year over two augmentation versus nonsurgical management, they should improve mobility. There's five fewer days of restricted activity at one month, and there's less use of narcotics, so 70% of patients treated with balloon Kifle plasticky. We're no longer taking pain medication at six months versus about 57% for nonsurgical management. So the probability that you get them off narcotics is much higher. Um, this again shows that sort of pain relief. So here we are in the first. The first half in both of these charts is before treatment. So patient presents of the fracture, we assess their pain. And this is how they score both of activity and at rest. And what we see when we follow these patients at two hours, one week, one month, six months, one year, two years is that that improvement in pain after treatment is consistent, Uh, up to at least two years in these two articles Ah, little bit more about in choosing the the importance of choosing the correct pathway when we look at patients. And again, these are patients who we feel would best benefit from vertebra augmentation. And we sort of look at them. Um, those who get treated with type of blast e Azzan patients are all patients are much more likely to end up at home versus in, um, a nursing facility or rehab facility. So discharged a home. Nonsurgical management, 21% balloon Kaifu Plastic. 38% in this study discharged home 23% with nonsurgical management, 60% with balloon Kaifu plastic 33% with nonsurgical management. In this study, 57% are going home after balloon Kifle plastic If we look at the readmission rates So this is patients who ended up in the hospital? Uh, you know, nonsurgical management felt were able it was felt that they were able to go home or at least be discharged. What's the probability that they end up back? So nonsurgical management Readmission rates 61.9% blanket capacity, 35% for tuber plastic, sort of in the middle of 52% on this study. So vertebral augmentation. Let's talk a little bit about the procedure itself. For two augmentation really falls into two categories. Balloon Kaifu. Classy invertebrate, Classy. They're very similar. I'm gonna talk a little bit more about balloon angioplasty because it has a little bit of it. Has one extra step that allows us to talk about, but they're very similar. A minimally invasive procedure. It could be done with a unilateral bilateral approach. So one needle or two needles V about a 3 to 4 millimeter incision on either side of the vertebral body typically takes about 30 minutes to treat one level, um, to treat one fracture. Typically, we do these with moderate sedation, sometimes general anesthesia, but that's usually dictated by any underlying commodities that the patient may have. We watch these patients about 2 to 3 hours after the procedure and then typically will send them home. We see them back in the office about 2 to 4 weeks later. We give the phone call the next day to see how they're doing and then see them back to make sure that they're really doing well. What about the 2 to 4 week mark? So this is sort of a little schematic is to what? What a balloon. Kaifu Plast e looks like in the first panel. We see the fracture has has occurred in the second panel. We see our little needle, our little cannula coming down. The balloon has been inflated. Attempting to reduce that fracture and create a cavity. We then fill that cavity with cement on. Let it interdigital within the within the rest of the rest of the fracture and the bone. Ah, the little side of the bottom here shows really what the patients left with too little pinpricks on either side of the bone. They go home with a couple of band aids a couple hours later. Yeah, so this is the This is more what it looks like in reality. So in the first slide, we have a fracture at l one. We've placed our to Kanye La's in the second side. The lateral view we see. We've withdrawn those keano's slightly and placed the deflated balloons into the anterior aspect of the vertebral body. The third image shows those balloons inflated. So we're creating that cavity and trying to reduce whatever level of fracture we can on then the bottom to him. Just so that feeling of cement. So we want to see you want to see cement Phil from the left to right lateral margins. We want to see cement filled from the top to the bottom margin, but nothing go anywhere else. This patient did have a little bit of cement travel along one of the needle tracks. This is the patient from earlier with that big fracture fragment, retro pulse materially and that big fracture fragment. And surely eso the cement is feeling right along all of that fracture line. But really nothing going out into the soft tissues. Nothing going into the adjacent disc spaces. So when we are thinking about thes, we obviously have to think about contraindications and really the big ones or any sort of active infection in the body we don't want. We don't wanna put cement. We don't wanna put the cement in when the patient may have bacteria circling around. That's sort of the big contraindications. Most other things we can sort of we could sort of work around. So technical complication rates and these were really related to cement going in the wrong places. So this was looked at back in 2000 and seven, Onda. At that time, the cement was really much thinner. It was harder to control the X ray equipment. One wasn't quite as good. It was harder to see, So these things have all sort of dropped over this time. But this gives you a fairly good idea. Eso the cement contract place you don't want to go, could be picked up by veins. It can actually. You know, the old cement was very thin. It could be actually travel up to the heart onto the lungs. Every now and again, we'll see an old X ray that shows a little bit of cement out in the lungs. Um, it could go to an epidural vein, Not a big deal. Just sort of sits there. Um, it could go into the disc space. That could be problematic, because it can result in some pain and it increases the probability of a fracture later on. But again, we put this under under under X ray guidance. So if we see it going there, we can stop. So in reality, we've gotten much better Sort of controlling these things on. Then we talked a little bit about follow up already. So whether they fall into the vertebral augmentation or the nonsurgical management algorithm, we're gonna want to get back with them about 2 to 4 weeks after whatever that was after instituting nonsurgical management or after the vertebral augmentation procedure, we're gonna want to check in, see how they're doing. We want to go through all those questions we're gonna wanna push on their back and do that same physical exam we did before and get a sense of what's going on, you know? Are there symptoms resolved? Great. Now we're moving on to treatment and education of their osteoporosis and trying to minimize the risk of these, whether that's fall prevention or medical osteoporosis management, exercise regimes or physical therapy, let's say the symptoms aren't resolved well, were they in the nonsurgical management pathway, they're still having symptoms. Maybe it's time we reassess them. And maybe they move somewhere along that algorithm to surgical management of virtual augmentation. Um, or not unusual, they'll come back with another fracture. Some of these patients are very high risk. They've had their one faction. They have their increased risk for another fracture. Retreat one. They come back with another one. So sometimes if they're still having ongoing pain, that's the reason why. All right, so in conclusion, vertebral compression factors are common fractures, clear risk factors and detectable symptoms. When fractures are suspected, patients should be assessed by both physical exam and advanced imaging. An algorithmic verge can be taken to appropriate manage for cheaper compression fractures be either nonsurgical management or vertebra augmentation for Cuba Augmentation is available Option associate with a low complication rate for patients suffering from for typical people. Compression fractures can provide fracture stabilization in correction of spinal deformity. Patients will experience significant reduction in pain and improvement of mobility. This will improve their overall quality of life. For general augmentation can result in both decrease morbidity and mortality when utilized in the appropriate the appropriate patient population. So Richard Burr augmentation procedure is designed to reduce back pain, correct and prevent angular deformity, restore vertebral body height and stabilized compression fractures. It does show good short term and long term results with respects to reduction, improvement in pain, improvement in quality and sustained quality of life, improvement of mobility. And it has a low complication rate. Thank you for your time. I appreciate everybody listening. Um, this is my office phone number. If anybody has any questions they would like to ask, Feel free to call our vertebra. Fractured coordinator's office is given as well here. 3883401 We can be reached that way as well. Um, feel free to reach out. Thank you for listening and have a good day. Hi. My name is Adam Lustig. I'm a physician. Welcome to my talk on prostate artery embolization. I'm an interventional radiologist, and let's just get right into it. So the goals for this presentation is to show that P A or prostate artery embolization is a safe and effective alternative treatment toe BPH, which is benign prostatic hyperplasia. We're going to explain that A is another tool in the toolbox for BPH treatment and understand that a collaborative approach is best. So, um, the outline for the presentation today is a little bit of background on what BPH is. Then what is a p A. How's it done? We'll go over some of the literature. We'll talk about safety of P A and specific clinical scenarios and then discuss who is a good candidate for this procedure, and then we'll review a case of mine that I did within the last year. So be pH is a proliferation of glandular tissue and stromal tissue in the peripheral zone. It causes outlet obstruction and lower urinary tract symptoms, which are common commonly referred to as Lutz um deeper. Each is the prevalence of it increases with age often talks about 50% of men 50 years old will have it. 70% of men at 70 years old will have it. So it's an increasingly common, uh, disease process as men age one way, One of the best ways to track how many symptoms men are having is to use a survey or a score. And it's the I. P. S s score, which is called the International Prostate Symptoms Scale, or the EU A, which this was developed by the American Urologic Association. So it's often, ah, term the score. It's a validated survey, 35 different points. Um, and a man will just take the survey, and you can sort of evaluate how they're doing, how how bad their blower urinary tract symptoms are, and a male can notice a three point changes. It's noticeable if there symptoms improve or get worse by three points and after ah, treatment of BPH, a 30% reduction is considered clinically successful and effective. The survey also has a quality of life score as well at the very end. So here's an example of the survey. It's seven different questions and, um, it ranges from incomplete emptying frequency, intermittent see urgency, we extreme straining or not Curia. So there's the seven lower urinary tract symptoms, and it asks in the last month. How often have you experienced these symptoms? And you circle zero for not at all or five for almost always. You add those up and you have, ah, score of either 1 to 7, which is mild. 8 to 19, which is moderate, or a 20 to 35 which is severe. Um, and at the very end, there's a quality of life. Score. If you were toe live this way the rest of your life with your in your condition as it is right now. How would you feel about that? So that ranges from zero being delighted or six being terrible. Most men who are good candidates for PPA or some sort of ah, procedural or surgical treatment for their BPH are sort of in the mid twenties and are usually around 4 to 5 just to give you a sort of a frame of reference. Uh, more on the background of the pH treatments or first line therapies include medical medication treatment, Alfa one blockers or five Alfa reductase inhibitors. Um a, uh, this this type of procedure medication is good for very mild BPH symptoms somewhere in the, uh, lower end of that survey scale that we just looked at and this will give men a good 3 to 7 point improvement. Um, the unfortunate part is these have a lot of side effects. Um, raining from retrograde ejaculation, Ortho static hypertension, decreased libido and erectile dysfunction. A lot of side effects that men don't really want to have. Eso there are lots of other treatment options that have been developed p achieving one of them. The gold standard for a long time has been a terp or trans urethral resection of the prostate. Usually is the next thing that, um, then go to if their medical therapy feels it can treat up to an 80 or 100 grand prostate, which is pretty large. Um, this results in a typical reduction of the I. P. S s or a you a score around 15 to 16 points s. So this is kind of what we're looking at to get in improvement of also, the urinary flow rates are improved. The downside is the morbidity is not insignificant. Around 10% morbidity, ranging from common potential complications of ejaculate, Torrey dysfunction, Erectile dysfunction, Urethral stricture, urinary retention. U t I need for possible transfusion and incontinence. The next type of treatment, uh, that someone might have is an open prostatectomy. Um, these are the gold standard for prostates larger than 100 g. Um, significant reduction I pss for reduction of around 13 to 18 points. Um, however, these require longer recovery. And there's a cut off on a surgical perspective when the prostate gets too big that this is no longer an option. Um, as you would expect, a more invasive surgical approach has even more morbidity of around 17%. Um, including major bleeding, sepsis, urinary retention, incontinence or your referral structure. Because of those, um, those two modalities of treatment have are are more invasive. These other minimally invasive surgical therapies have been developed. These include trains, your re throw microwave or your wreath roll lift is another one. Another one is water vapor. Thermal therapy for laser therapy. These air typically done by urologists. Um, the way these occur and entreat the obstruction is they cause destruction or displacement of the obstructing your prostatic tissue thes air less morbid than terp or open prostatectomy they do have, ah slightly less improvement in the sport. Around 10 to 12, there are higher rates of re treatment. Um, these may or may not be in office based procedure as opposed to a surgical of our procedure, and they may or may not require anesthesia or a Foley catheter insertion again. One downside, um, in particular is that these air not typically recommended for very large prostates or for a prominent median lobe? Mm hmm. So that brings us to prostate artery embolization. So what is P A E? It's not a new procedure, but it is a new indication. Um, the procedure of embolization has been performed for years. In particular in the prostate. Has been the first time it was reported was in the 19 seventies for massive prostate bleeding. Uh, mobilization of the prostate arteries is performed to induce shrinkage of the prostate due to lack of blood flow. Um, this, uh, also can cause a reduction in the Alfa One receptors, which can contribute to smooth muscle relaxation. Not only are you making the prostate smaller and shrinking the amount of obstruction of the urine, but you also are helping reduce and caused the smooth muscle fibers inside the prostate to relax. S a little bit of a history about embolization for prostate bleeding. Just kind of lead us to where we are now in the modern era of using this from BPH Treatment 1976 it was initially used to control massive prostate leading in 1977. Another intra arterial embolization was used to perform bleeding from cancer of the prostate. Um 1981. There was therapeutic conclusion of the hype of gastric arteries with glue, patient with vesicles and prostate cancer. Internal iliac artery embolization was used to control severe bladder and prostate bleeding in 1988. Again another internal a lack already immunizations, control of severe bladder and prostate hemorrhage. In 1990 um, in 2000, DeMerit had a patient in the post. A case report back at a patient who had DPH was otherwise an overall good health but had very severe BPH symptoms had difficulty avoiding Andi. Zehr attributed Thio his B p h. He had a severe all right classifications on the I P SS scale and what he did was, ah, go in and M belies his prostate arteries because he also showed up with severe bleeding. And, um, he noticed after several months that his lawyer urinary tract symptoms improved quite a bit. This is kind of an ah ha moment. And from then, the ball has just been carried by other interventional radiologist to do this procedure, and we're actually finding out that is a very good treatment option for BPH. So how is it actually done? Um, Well, first you need a medical evaluation. Um, it's best to have a urologist. I see you first kind of go over your urinary history and make sure that the lower Neri symptoms that patient is experiencing is actually from a prostate origin. Not all lower your new track symptoms is due to our due to a large prostate can be due to bladder dysfunction, among other things. So you definitely need to have a full urinary evaluation and determined that the lower urinary check symptoms are from a prostate origin. Once that's established, the procedure is done as an outpatient basis. You come into the higher lab the morning of give you some pre medication with ibuprofen and an antibiotic. We either use the left radial artery or the femoral artery to go into the arterial system. We select the prostate arteries on either side, and M belies with tiny particles. Um, after a few hours of recovery, the patient will go home on a series of medication to help reduce inflammation of the prostate from the endless embolization. Procedure itself, Of course, of antibiotics to help reduce infection. Ah, steroid pack for one week to help again reduce inflammation and a few pain pills in case there's any pain, and it's usually very minimal. Here is a graphic that shows bladder appear enlarged prostate with loves pushing up into the base of the bladder. The catheter here on the right is selecting into the prostate. Artery particles are being injected into the arteries, and that is repeated on the other side. Here's an angiogram of the internal iliac artery. On the left, you can see all the branches of internal iliac artery, and what we're trying to find is that prostate artery, which is usually tortuous, little dilated and is sort of distinct from all the other ones in that it crosses over the operator artery typically and is heading towards midline when you have a 45 degree It's lateral view of the pelvis and internal alien artery eso in this case, the prostate arteries. Right here. It would be a manner of pushing the Katherine down further using ah, micro Catherine selecting this artery. So switching gears, um, a little bit to a literature review. Um, there is, ah, paper published a consensus paper by the J. P. I. R s I. R. Just the Society of Interventional radiology, where they did a literature review and repugnant search for the terms prostate or prostatic and embolization. They found 280 articles of the last ah, 8 to 10 years and the sort of pare that down to 67 after they excluded a bunch of duplicates and other case reports and technical papers. A total of 2200 patients had were included in these studies. In the longest duration, follow up was up to 6.5 years. Three of those 67 were randomized controlled clinical trials, comparing PHP versus a terp, which is the gold standard. Three of them were non randomized controlled comparative trials to or ph versus turf and one of the versus open prostatectomy. 17 were unique cohort studies. 11 different countries were included in a six of them were meta analysis and there were 19 review articles. So I'm just going to go over the three randomized controlled clinical trials and briefly touch on the rest. So the first sort of landmark one was in 2013 by gal and they compared Ph versus Turpin. A head to head had 114 patients in two year follow up. And here are the two groups you can see. They're pretty similar with age group being around 67 66 years old of note the prostate bombs around 64 63 g. In each group, the I P SS scores were again around 23 in each group, and the quality of life scores were around 4.84 point six in each group. Eso here the results thistles. The I. P. S s core reduction on the left and the mean quality of life. Score reduction on the right. The P A E group is in blue and the Turk group is in red. So what you want is a drop in the I. P. S s score and a drop in the quality of life score. Ah, the X axis is time in months. So one thing we can see right off the bat here is that the Turk group quickly drops their I P. S s score in quality of life Score at the one month follow up. Mark, um, to be expected when you physically remove obstruction from the surgical approach Uh, the P a group, it takes him a little bit longer to get there. However, once you reach six months for both the i p SS and the quality of life Now you notice that these two guys are, um statistically, uh, the same. There's no difference from a statistical standpoint that both groups reached the same I pss and quality of life score in that again also makes sense because it takes time for the prostate to strength and sort of resolve the obstruction. When you cut off the blood flow as opposed to a surgical approach, physically removing the obstruction, um, in their turf groups, they found they're more likely to require require a fully catheter insertion and inpatient hospitalization, a longer hospital stay in general and mawr major complications. The second randomized controlled trial was done in 2016 by current Valley. He had 30 patients that he randomized P a year or Turk, and both groups had quite a significant improvement in their high pss score of 21 approximately interment. 21 m p. A. Ah, there's no difference between these two groups. There are no major complications in the p A, and overall complications were not compared between the groups. The last randomized controlled clinical trial was in 2018 by 18 by angler. He had 48 patients for P eight and 51. For a term. He follows patients out to 12 weeks. Um, and there's no significant difference in the I P SS improvement in both both groups. So, um, at three months out and from his paper, the two groups were statistically the same. The improvement was around 9.2 for P. A and 10.8 for Turkey. I would expect both of those to get even a little bit better over time. Hey did find that the Turk group had three times as many adverse events in the PD group on does range from blood loss, duration of hospitalization and capitalization also being higher in the Turk group. Um, the prospective trial next I wanna talk about is done in 2015 by Rousseau. They did a 1 to 1 match peer analysis had 160 total patients. Um, again, a very similar graph that we're seeing here with an improvement in i. P s s score in both groups, with the open prostatectomy group having a better improvement initially, the band, the EPA group, and both of them being sustained out to the 12 month mark. As you would expect their arm or complications in, uh, big surgeries compared Thio minimally invasive procedures. Um, which is? What he found is well, that the open prostatectomy group had seven day longer hospital stay and a large, bigger overall complication rate 31% and open prostatectomy and 8.8 in the P A group with major complications being around 3.8% in the open prostatectomy group in zero in Apia. Eager, um, interestingly, erectile dysfunction slightly was improved in the P A group and worsened in the open prostatectomy group. This was not statistically significant, but it was a trend using the I I F survey. Another perspective trial is was done. 2018 um 3. 305 patients from 17 different centers were performed in the U. K. I had 216 ph patients. 89 Turk patients. Um, at one year the results from the I. P. S s scores were improvement in 15 15.2 in the Turk group and 10.9 in the pH group. The P A group had lower complication rates and quicker return to normal activities. As you would expect, um, of the cohort studies, 12 of them were prospective and five them. Retrospective. In the last five years, Largest was by Portuguese group Pisco. He has done 630 patients total. His technical success rate is a bilateral PIA is 92%. If you include a unilateral P a, then that goes up to 98% which many doing Ah, consider a unilateral PIA technical success because of the cross collateral communication of arteries in the pelvis. Oftentimes, if you can get one side, the patient will improve their symptoms. He defined clinical success as an I P SS improvement of at least 25% from baseline and getting toe less than 15. Uh, similarly quality of life improvement from a clinical perspective was considered getting it below or equal to three and a decrease of at least one from baseline. Um, his clinical success rates at between the one and three year mark for 82% in at the 3 to 6.5 over 76%. Andi, he saw he measured a lot of different clinical parameters, including not just the i ps escort, but, uh, in the quality of life. But the prostate volume P floor it post word residual and the erectile dysfunctions. For one thing that came from his papers, that these results that he found work durable. Up to this point, we really only had 1 to 2 year data. Don't have the 6.5 to data that this paper show, Um so granted, the long term follow up numbers are are pretty low. Of only 36 patients out of his 650 um, it did show that these results actually not only are durable, but they actually continue to improve over time. As you can see, the PSS score drops. Um, the further out you go. Similarly, with quality of life score, the patients remain satisfied up to the 6.5 year timeframe time frame. Other cohort studies with more than 25 patients and greater than a year follow up showed a range of improvement of I P. S s scores from 11 to 18. A range of improvement of quality of life scores from about 2 to 4.7. Technical success rates for bilateral P A range from 86 to 97%. Peak flow rates increased by 3 to 10 mL per second. What's raid? Residual decreases by 30 to 75%. Prostate going decreased by 20 to 45% in erectile function remains stable or even slightly improved trends. S O. I think all that data shows pretty clearly that p A is, uh is effective. So what about the safety of P A. Well, uh, as with any embolization procedure, you can experience something called post embolization syndrome. That's a constellation of sort of low grade symptoms, including pain, frequency, nausea, low grade fever and particularly in the p e situation mild. This area can last upto one week. It's anticipated or expected following a PhD. And that's why we send patients home on those lists of medications. Help reduce these kind of symptoms. Um, it's really symptomatic management. Only you don't need patients don't need to come back to the clinic or back to the ER to get treated. Um, a low percentage rate of acute urinary attention when the prostate sort of swells up from being angry from being able ized that the patient is very close to being an acute urinary retention. In this procedure is performed, they could go into a cute your urinary retention. So, um, ground 2 to 4.5%. And a urinary tract infection could also be a potential, uh, complication of around 2.5 to 7% again, which is why we send patients home on one week course of antibiotics. Major complications of this procedure are rare. Of the 2000 patients in, uh, this literature review that was performed, only six had major complications. Um, so the worst word to that required surgery for bladder wall ischemia due to non target embolization. And that's when the particles go down different artery that you don't want them to, such as the vestibule vestibule artery going to the bladder. No vascular access. Complications were reported. Onda Failure of technical or clinical success as a complication is, um, sort of a point for discussion. Um, some papers that are published include a failure as of either technical or clinical success as a complication, um, in the p E groups, but they don't include it in the surgical groups, which does skew the numbers a little bit. So when you're reviewing these papers, just sort of keep that in mind. Eso no study has actually shown a decrease in the erectile dysfunction score. Post p A. However, some have shown a few slight improvements and trends. Um, other types of potential complications from other treatments or BPH are like retrograde ejaculation or decreased ejaculation. Um, for P A e uh, the best study, uh, that was performed with a prospective trial, and it used the validated scoring tool. Um, it showed no change in ejaculate torrey function at when your post p a and uh, in general. Most of that analysis estimated the risk to be around 0 to 2.3%. So essentially non existent. Andi Uh, not something that we typically worry about, or even council need to counsel patients about eso. One main difference is that this procedure uses radiation. Um, in contrast, eso when you talk about the safety of prostate already embolization and we have to talk about radiation risks. So this procedure is similar to other ire procedures already being performed in terms of dose to the patient. Um, these patients that need this type of procedure are typically older, so we're not talking about doing a long procedure on ah young young people who are going to be living for a long time to potentially develop cancer from radiation. So it's something we always kind of keep in the background mind. These patients are an older population, so the risk of causing a cancer from radiation by itself is very, very low. There has been one report of radiation dermatitis. Um, in general there had been one prospective study of radiation parameters used in P. A. This is by a single operator, and his his mean flora time was around 30 minutes. The mean skin doses around 2.5 gray on that spread across the whole body as the procedures being performed with not in one spot. Uh, the other thing is the detector and the radiation source, or moved throughout the procedure as different public witty's and different views of the arteries and the prostate, or need to be viewed. So it's not about that skin doses not being directed at one spot in the body the entire time. Um, and over all these parameters, these members are similar to other types of procedures that we already are performing, like radio mobilization for liver cancer or job leads, uh, embolization type cases for me. Personally, I've done 35 of these by now, in my parameters are very similar. Around 2.2 gray average does 37 minutes of floral time. Um, my average sedation time, which is analogous to my procedure. Time is around 2.5 hours, and my average contrast uses 145 mL again. Those air pretty on par with other big higher type procedures, embolization procedures that were already performing. So what are some specific clinical scenarios? Well, one part of the most common is when the prostate not only is enlarged, but it is very large. Um, we're talking over 100 grand, prostate or larger. I've treated one gentleman who had a prostate over 500 g in with a pH before. And those types of Christians actually tend to do better because the price it is larger, the arteries air larger. It's actually easier for me to get into. And, um, overall, they have a sort of better result because the prospect has more room to shrink. Eso One study showed that patients with prostate larger than 100 g actually had improvement from 15 to 18. And there, I guess escort as opposed to 14, um, and patients who have an indwelling Foley because of acute or chronic urinary retention. Because the process is so large, these patients studies have shown that you can get around that 90% of the time. Patients can have Catherine Independence by three months. Another study showed that that they found around 60%. So if there's a patient is an in dwelling fully from in the march prostate and they can't really, they're not a good candidate for any other type of procedure toe. Help reduce that, um p A. You might be, um, a good treatment option for them other clinical scenarios he material so bleeding that can not be controlled by other methods typically used by urologists. Um, uh, P A is a good alternative treatment because the the whole goal is to stop the blood flow to the prostate. So if they're bleeding is from a prostate origin, then this could be a good potential treatment option for them. Um one. There's one paper study that showed the technical and clinical success rate is around 7200%. The later re bleeding rate eyes around 12 to 25% which is much less than other types of treatments for, um, bph origin, causing the materia Um, The next thing we'll talk about is where the cost analysis of this procedure versus a Terp paper study by Sonny Bagila showed that overall, the overall cost of EPA is around 15 or $1600 has pushed three Turk, which is around $5000 broken that down the different, um, individual cost. You see that the major source of the cost is from the O. R. Time in the anesthesia time, and the patient meeting ended overnight admission and that's that's not something that we need to do for PES. We do. RPS with modern sedation has now patient type procedures, so patients come in, get their procedure, hang out for a couple hours and then go home. We don't need anesthesia we don't need or because we have our own higher our labs and the patient does not need to be admitted. So that's a good benefit not only to the patient, um, comfort level, but also for cost savings for the hospital. This is an FDA approved procedure using the MBA sphere devices, which are the actual particles that are used. So this isn't an off label type of procedure. This is been approved for the treatment of B. P H, and not just a Hugh mature er bleeding organ. So the FDA has looked into this and has approved it, and that was in 2017. So since then, this was procedure has sort of been ramping up in popularity, so bottom line A is a safe and effective treatment for BPH, and he materia in the carefully selected patient has a very low risk of major complications. It's not as effective as a prostatectomy, but it has similar effectiveness to a terp at six months, with that result being durable upto at least 6.5 years for our data that we have so far, it has lower complications than the other treatment options out there. And it is an FDA approved procedure for BPH treatment. So who is a good candidate? Well, really, Anyone who has lower urinary tract symptoms from BPH origin and, uh, if they do not want surgery or they have too many side effects from medication, So really, that, you know, that is a lot of people out there. Um, So one of the reasons why I wanted to do this presentation is to sort of let let the community know that this procedure is an option. Um, again, it's it's important to be evaluated by Urologist Thio, sort of getting your ordinary urinary tract symptoms completely worked up and make sure it's not a bladder dysfunction. Um, in that, either luminary urinary tract symptoms are actually from a BPH origin. I don't want to do this procedure on someone who has these symptoms, and it's not going to improve it all from the procedure. Um so other other specific scenarios that who would be a good candidate would be some with a very large prostate, and we're talking at least 80 g or over usually, um, very large prostates are around 200 or even greater than that. Those types of patients aren't really good candidates for other types of procedures, and in fact, it actually makes my my procedure. This this prostate marginalization easier because the arteries air bigger. Other types of patients who are on the blood thinners or have an underlying Koegel apathy or who have persistent you maturity that cannot be fixed otherwise are also excellent candidates for this procedure. I just want to go over this one case that I did last year. This is an 83 year old male with PhDs. Prostate 120 g was causing him a jury A and lower urinary tract symptoms he presented to the ER with gross human. Suria, his a aware MPs s score was 26 quality of life was five. As you would imagine, with these types of symptoms, he had a history of atrial fibrillation and was on anti coagulation. Um and he urology did continues bladder irrigation. He had multiple full operations in the bladder um, in the prostate, and he's just did not stop his bleeding. They counseled on IR for prostate artery embolization during his admission. So here you see a catheter. This is an oblique view of the left internal iliac order. You see Catholic coming here off screen, which is in the right groin up and over the air or sheath, which ends right there. And a catheter that ends right here. You can see the internal iliac artery with the prostate artery again crossing the operator and heading towards the midline. This is the prostate artery. So now it's a matter of getting catheter into here. Uh, one nice technology that we have at Norfolk General, which is fairly unique in our community, is cone BMC T with an MBA guide package software package on the machine. And what this allows us to do is inject, contrast and do a CT scan of the patient from that artery while they're on the table during the procedure. From then, we can take that CT image and cut out all the bones and all the other stuff that I don't really care about and sort of have the computer determined where the prostate is and how Thio, how to get to the prostate from the artery that the catheters in So you can see the Catholic. The computer is showing the prostate and blue, which I manually selected. And then I told the computer where my current catheter is, and it figured out how I need to get there by going through this artery. Um, and this is a good confirmation of what I see. And geographically, sometimes it picks up other arteries that are really tiny and difficult to see eso. Then I use that as a road map, and I just follow that line. I get my little tiny micro catheter into that prostate artery, and it allows for the procedure to be quicker and allows me to be more confident with, uh, which artery I'm in. So here you can see an injection of the left prostate. You see the left prostate artery here, and then this is a left Hemi prostate is a good injection of, um, all the little tiny arteries that air filling in the left prostate. You can see most of it is being enhanced here. Eso after embolization with these little tiny particles, which are 100 to 300 microns in size. Um, the injection now no longer shows that prostate feeling. So compare that picture. That picture, the prostate filling from the arterial perspective is is more or less gone. The prostate artery itself, the main sort of trunk and origin of it is still there. But all the little capital areas and little art is going to the prostate or done similarly on the right. This is the origin of the right prostate artery. Give your frame of reference. This is the bladder. And this is the right your order coming down here. This is a unique situation where this patient had, um, prostate feeling on the right, but also had a collateral that was going a little bit higher than I would expect. Typically, um, on a prostate artery. This right here did not really seem to be going to the prostate itself. So I did an oblique view, or more or less, the lateral view. And this artery is actually going to the dome of the bladder, not something I want to m belies. So what I did is I put a little tiny medic oil in there to catch all of the particles and continued to m belies the right prostate artery. And this is my final shot where the prostate is no longer enhancing. And there's an interesting view. You see a lot of contrast in the bladder with two filling defects which the right and left globes are pushing up into the base of the bladder. Eso this patient didn't really well, he was discharged on post on day two with no further bleeding. Um, I saw him several times up to 1.5 years later. And his I guess s score had dropped to 12. And his quality of life is now too. And that was quite a bit good improvement from his initial ah scores. Since then, he has had no he materia and he is still in anti coagulation. A very good result for this patient. Eso that's about it. Thanks for watching and listening to me. Talk about prostate are demobilization. If you have a patient or want any more information, you can always reach me. Um, that number for the i r clinic at Norfolk General is the best way to reach me. And, uh, thanks for watching