Elevating your practice with GAE and PAE: insights from leading experts

Episode Transcript

Recorded live from the Cook booth at SIR, and featuring leading experts in the field of interventional radiology, discussing a wide range of IR related topics, this is the Cook@ SIR Podcast Series.

Hello, everyone. Welcome to a special live episode from the Cook Medical booth at SIR 2025. I’m Dr. Keerthi Prasad, and today I’m joined by Dr. Zagum Bhatti to talk about two game-changing procedures, GAE and PAE. I’m sure everyone is hearing a lot about these, and there’s a lot of interest. These procedures are reshaping patient care in the office-based lab setting. Today, we’ll cover the referral process after a brief introduction of the procedure, some procedural details, and some of the technical pearls for mastering the technique behind these procedures. We’ll also kind of dive into how these procedures are driving better patient outcomes and why everyone should really be looking into adding these to their practice.

Zagum, let’s kick it off with PAE. What’s driving, growing interest in this procedure, and how do you see it fitting into IR in general?

I really think it’s the minimally invasive nature of the procedure that really is so attractive to men suffering from lower urinary tract symptoms. Historically, the only option—or one of the options men had was to undergo a transurethral procedure, which obviously is associated with recovery—sometimes a prolonged recovery, pain, bleeding, some not-so-insignificant side effects down the road. And so, I think as our data has grown behind PAE and this has become adopted, more and more interventionalists are now offering this procedure. I think men are finding out about it and they’re keen to explore this as an option for their BPH. What would you say is driving the growing interest behind GAE?

Sure. Yeah, that’s a great question. I think it’s a lot of the same things, right? This is minimally invasive. It’s out there. People are hearing about it. Patients are looking for these solutions, and a lot of IRs are providing the service now, so just increasing awareness, increasing availability, and there’s a huge unmet patient need. Yeah, and I guess along those lines, how are patients typically finding you?

Most men who see us in my practice are self-referred, so they’re suffering from LUTS. They may or may not have seen a urologist in the past. They may be taking medication to deal with these symptoms, and many of them have been offered TURP or some of the other urological procedures, and they don’t want a transurethral procedure. They’re afraid of it, and they’re looking for an alternative option, and so many of them find us through their own research or they see some of our digital marketing efforts. They learn more about PAA that way, and they reach out.

Sure. So—

How about with GAE?

Sorry. Are these patients pretty well educated on the procedure when they come to meet you?

Many of them are. Many of them are, yes. I would say most men who come in and see us, they’ve done extensive research and they’ve read quite a bit about it. They’ve talked to a lot of people about it, talked to the urologist or PCP about it, and so generally, they are, and they’re really looking to see if they’re a candidate for a procedure or not. Yeah.

Sure. And are you referring to urologists that they haven’t been worked up, or …?

I do refer to—so obviously, lower urinary tract symptoms, very common in older men. The most common cause for urinary tract symptoms is BPH, but of course, a whole host of other things can cause LUTS, and so, for men with—especially if they have hematuria that hasn’t been previously worked up, if they haven’t been screened for cancer, or if they have signs and symptoms that may point to another etiology, I will refer them to urology for additional workup. How about—talk to me about GAE. How are those patients finding you? Who’s referring those patients to you?

Sure. Yeah, that’s a great question. I think there are two kind of distinct pathways for patients to find us. The first is self-referral. So, we have direct-to-patient advertising, and a lot of those patients, in our experience, they’ve actually tried several medical procedures, usually over maybe the course of a decade. They’ve done PT, done NSAIDs for a long time on and off, sometimes injections, steroids, viscosupplementation, those are very popular. And the truth about a lot of knee pain is, it’s kind of waxing and waning, right? So, they’ve gotten those procedures, they’ve gotten better. A lot of times, they’ve tried those again; they’re not working. Now, they’re looking for a new solution. So, they’re finding us online, they’re hearing about the procedure. We have some people that are referred from friends. We’ve done GAE on them.

The other kind of pathway that we see often is patients who aren’t candidates for knee replacements, or maybe they’ve had a knee replacement, they have pain. So we get a lot of those from the pain management physicians. So, they’ve tried various ablations, various injections, and it’s no longer working. They’ve seen the patient a few times, and they’ll send them to us, GAE. In the osteoarthritis population, it works great, right? The data’s reproduced. We tell patients, “Hey, your pain’ll get cut in half.” If it works, right? So, 70% of people, it works. And in the pain management world, that’s incredible, right?

Absolutely.

The docs are thrilled, the patients are thrilled, and about 20% of patients have pain after total knees, so a lot of those actually end up in the pain management world too. The docs are seeing them. They don’t have a lot of solutions, so they send those over as well.

Sure. Sure. What about orthopedic surgery? Do you get any referrals from them?

Based on what I just told you, you’d think you would, but we actually don’t, and it’s interesting because the surgeons really don’t want to revise these patients, right? It’s a big operation. It typically doesn’t really work, right? The reasons for having pain after a total knee are, typically, synovitis or dysregulated pain, right? So people have been in chronic pain before surgery. They have just a much higher chance of having chronic pain. We’ve approached several orthopedic surgeons. I think they’re waiting for more literature in their realm, but I do think it’s probably locally dependent, right? You have those relationships, you can kind of build that.

Yeah, it makes sense.

How about with PAE? Are you seeing a lot of urologists refer? Any other specialists?

I don’t see a lot of referrals from urology. I think it’s good to be collaborative. As I mentioned, I do—we’ll send some patients to urology for additional workup, uroflowmetry, et cetera, but we don’t tend to see a lot from urologists. Again, a lot of our patients are self-referred, or—actually, I tend to see, I do have several PCPs who refer to me because they’re seeing these men, they’re managing their BPH and their medications. Many of these patients, they don’t want surgery, and so they’re sort of following up with their PCP, and many PCPs are eager to have another option to help deal with this problem.

Yeah, I think that’s a good point. A lot of BPH, it’s such a common problem, just like knee pain, right, it’s managed by PCPs.

Yeah, absolutely.

Or a lot of it is. So, maybe you can kind of describe the patient process, right? If you get a referral or patient self-referred to, what do you do with them next?

Yeah, so we start with a consultation in the office. We do a thorough history and physical. As I mentioned, many of these men have been worked up in the past, they’ve seen a urologist, so we review everything that’s been done up until that point. We review their medications, what’s worked, what hasn’t worked, have they been having side effects, and we’ll review any imaging that they’ve had done, as well. Many men have already had transrectal ultrasound performed, some MRI for cancer screening. Many have even had biopsies, and so we’ll review all of that.

For men who have not had any previous imaging, I will do transabdominal ultrasound in the office. I don’t do transrectal ultrasound currently, but I will do transabdominal ultrasound. I can give you a really pretty good look at the prostate. You can get a good look at the bladder as well. And obviously, we have them fill in an IPSS form. We want to determine if there are any other factors that are contributing to their symptoms, and if they’re a candidate for PAE, if they want to proceed, then these days, if they haven’t had a recent PSA, I’ll go ahead and order that. These days, I’m actually doing more and more imaging prior to the procedure. When I first started doing PAE back in 2018, I relied a lot on cone-beam CT. I started doing these in the hospital.

Sure.

Now I’m 100% outpatient based, so I don’t have that luxury. I gained enough experience with PAE to where I didn’t feel like I needed—certainly cone beam CT, but what I’ve realized over time is that some preplanning can be very helpful, and so in this population, we see—again, they tend to be older men. They can have tortuous iliac arteries, they can have atherosclerosis. It can be good to know that up front, prior to the procedure. I also feel that either CTA or MRA can be very helpful in identifying the prostatic artery origins, because that can tell us what projections we need to best identify those during the procedure that can help us limit our contrast usage, our radiation dose, and so, I’m doing that more and more.

Great.

MR, in particular, I think can be valuable, especially if I have someone who maybe has not seen urology, has not had up-to-date screening for cancer. I do think it can alert us to any potential suspicious nodules in the prostate as well.

Sure.

Sort of a one-stop shop. It gives us good information about gland morphology, presence of any suspicious nodules, and then helps us look at the vascular anatomy.

Sure. So you’ll kind of tack on the MRA with that?

I do. Yeah. So I get MRI prostate, with and without contrast, in addition to an MRA of the pelvis.

Awesome. That’s a great idea. Yeah. And for us in the OBL setting, sometimes it’s hard to get those images, so how do you go about that? Do you have relationships with certain centers, or—

Yeah, there are a couple of centers in town that I utilize. There’s one I started utilizing just within the last year. What I like about them is that they’re able to get my patients in quickly, and generally get all my patients scanned within a week. I have access to their imaging portal, so as soon as the scan has been done, I get an email alerting me that it’s been done, and I can then click on a link and view the images myself.

That’s awesome.

That’s what I’ve been doing.

Yeah. Yeah, that’s perfect.

How about for GAE? What type of workup are you doing? Are you getting imaging? Are you getting X-rays? Are you getting MRI?

Yeah. Yeah, that’s a great question. So, a typical GAE patient with us, if they’ve had an X-ray in the last year or so, that’s kind of what’s making the diagnosis, right? They know they have osteoarthritis. Somebody has told them that at some point. Invariably, at least half of them say it’s bone on bone, but it’s not, right?

Yeah. I’ve had that experience too.

People like telling people that. But for us, it’s important to have an X-ray in the last six months to a year. That’s kind of what I’m looking for. If anything’s changed drastically since then, obviously, I’m going to order a new one. Something we do in the office, it’s pretty easy, right? The question always is, Do you need an MRI? There’s some emerging data on MRI with GAE. It’s not something we employ today. I think it’s cost-prohibitive. And also, getting it approved is tough, so if you look at the guidelines for getting a total knee arthroplasty, MRI is not in there.

Right, right.

So, asking the payers to pay for an MRI before a GAE, it’s a tough battle sometimes.

Absolutely.

And what could you potentially gain from the MRI? I think if you see some synovitis, it probably increases your likelihood of success in that patient. I don’t think that it’s a necessity, though. I think you have enough to go off of based on physical exam and the X-ray. What are we looking for in physical exam? It’s really stability. You don’t want to see anything blatantly abnormal that’s suggesting there’s something else going on, because if there’s a severe ligament or meniscal injury, you’re not going to get the success you want with the GAE, right?

Right.

Because we’re really trying to treat osteoarthritis or post-total knee arthroplasty pain. For us, we’re not typically getting labs, unless we’re going femoral access, we’ll get some basic preprocedural labs, but pedal, we’re generally not. Patients on Coumadin, we’ll check an INR, that kind of stuff. Obviously, any renal issues, we’re going to make sure they can get contrast, that kind of thing. But the workup is pretty simple, so if they meet that criteria of having an X-ray, having the diagnosis, then we’re going to make sure they’ve had an injection. I like to try less-minimally invasive things, right? That’s what we’re selling. We should make sure the patients get the right procedures, so at least an injection or two in the past, if they’ve tried PT, even better, and then obviously NSAIDs, conservative things.

Yeah. Yeah. Makes sense. Okay. You mentioned femoral access. Do you typically— Maybe we can talk a bit about your technique for doing GAE. Do you typically get femoral access? Do you utilize any other—

Yeah. That’s a great question.

…access sites.

Sure, that’s a question we get a lot? So for us in the OBL, I think your two best options for GAE are antegrade or pedal. I think internationally, antegrade is much more common. I think in a lot of the countries, specifically in Asia, the body habitus they deal with is a little bit different than what we see. So for us, pedal is kind of key. It’s really enabled us, on a workflow standpoint, we’re able to move through more patients in a day. The rest time is lower. And also from a patient-risk standpoint, hematoma over the dorsalis pedis needs two fingers, right?

Sure.

At the groin, you might have a problem on your hands, especially in a small lab. The staff, you know, they may not be that comfortable in a situation where you have to deal with something like that, so you’ve got to keep all those things in mind. And then for us, also, from the patient standpoint, right? They’re used to getting knee injections, things like that. Here, we’re a little poke in the foot, right? No incisions, nothing like that.

Minimally invasive.

Exactly. The groin feels kind of invasive to a lot of people if they haven’t had a lot of medical procedures in the past, right?

Right, right.

Yeah.

Absolutely.

That’s kind of how we approach it. So it’s usually going to be pedal for me. We’re going to use a base catheter generally 4 French, do a nice angiogram at the adductor canal, and at the pop, repeat it. Identify the origins of the vessels. On our preprocedure exam, we’ve identified where the patient’s tender, and we’re going to target the treatment to that area, typically engage with the base catheter, follow it with the microcatheter. Usually, we’re using a 2.5 French Cantata.

Okay.

Yeah. In our patients, works great. I think if you have a smaller patient, sometimes you might need something smaller, right? But 95% of the time, the 2.5 French is great. It tracks really well. And importantly, with the embolic, it’s good. You’re not getting clumping or clogging.

Yeah. Yeah. What embolic are you using?

Generally, we’re using beads, usually 100 micron beads. Yeah. Very, very dilute. So, we usually dilute to about 20 mLs, injecting in 0.2 aliquots, maybe 0.2 to 0.4 per vessel. Try not to go over that. That’s when you really start getting some nontarget stuff to the skin. I think that’s all you really need. In most patients, I’d say we average about two to three vessels. I mean, you’ve done some GAE, does that sound about right to you?

That’s exactly right. Yeah. I do something very similar. I tend to go a bit more femoral.

Sure.

Something I wanted to ask you about, actually. There was a period of time where I went exclusively transpedal—

Okay.

… and it was always the inferior medial genicular artery that I had trouble with.

Sure. Yeah, yeah.

In terms of my base catheter, just finding a good base catheter to give me enough support to catheterize that particular vessel.

Yeah.

And so, I went back to transfemoral—antegrade transfemoral.

Yeah. Yeah, yeah. That’s understandable, I think. That’s a challenging one.

Yeah, yeah.

Yeah.

But I’ll use a—typically, transfemoral, I’ll use a 4 French base catheter, Bern shape. And then, I use the 2.5 French Cantata.

Great. Are you using a sheath, or are you going sheathless?

That’s something I’ve changed recently, and, again, in an effort to make this less invasive, I used to go—use a 5 French sheath and then actually use a closure device. Now, I’m just barebacking a 4 French Bern catheter, actually.

Great. Nice. Nice, nice. Yeah.

Our patients, typically, they don’t have atherosclerosis, right?

Yeah.

We don’t tend to see that very frequently. Relatively healthy vessels. I think you get enough vasospasm there to seal that little hole, so I do 10 minutes of pressure, having to lay flat for 30 minutes. I’ve never had an issue doing that.

Just 30 minutes?

Just 30 minutes. Yep. I have not— Yeah, and it’s the same recovery I did when I used the closure device, as well, actually.

Yeah, yeah.

So I like that. I’ve been doing that for the past several months. So, bareback a 4 French catheter, 2.5 French Cantata microcatheter. And the same way you do it, we’re treating to where the patients have pain, right?

Yeah. Yeah.

Most of our patients have medial compartment pain, and that’s generally two vessels.

Sure, yeah.

Yeah, typically either the descending genicular artery or the superior medial genicular artery, and then the inferior medial genicular artery.

Yeah. Yeah, with that inferior medial, that can be a challenge from pedal. We’ll do one or two things. I’ll be honest with you, a lot of times I can actually get a 4 French catheter to engage it, like just an angled one. You just have to get enough wire in there. You have a hydrophilic soft-tip catheter, it’s not an issue. The other approach is using a slightly bigger—you can use a 5 French tight curve, TC-BNK. It’s kind of like the tighter rim shape. I wouldn’t drag that around in the pop, but as long as you know where you want it to land, it’s perfect. It’ll engage right away. Give it a little puff, make sure, send your micro in. So, those are really easy ways to do it. If you’re having trouble engaging directly with a catheter, I actually tend to pull the base catheter back and I’ll just use an angle glide wire, and it’ll usually select it, get in pretty far, send in the base cath just to the osteum, right? Just engage it a little bit. Send in the micro. Yeah. Works really well.

That’s great. That’s great.

Yeah. Yeah. That 30 minutes, though, that’s pretty nice.

It’s worked very well.

Yeah, that’s great.

Thus far.

I mean, pedal, we’re doing the same thing, right? We keep them 30 minutes.

Yeah, essentially.

Yeah, that’s excellent. That’s something I need to look into. Thanks for sharing your GAE technique there. How about PAE? How are you approaching these? Radial? femoral?

I like the idea of radial.

Yeah. We all do.

Theoretically, it should get you easier access into the anterior division of the internal iliac artery.

Yeah.

But I think where we have some challenges, and the reason why I don’t do it, is because of the anatomic variability of the prostatic arteries, in addition to our patient population. Again, they many times have tortuous arteries. If they have tortuous iliac arteries, they may have a tortuous subclavian artery. The other thing I actually worry about is atherosclerotic disease in the aortic arch or the proximal subclavian artery—

Sure.

… so I want to avoid issues there.

Yep.

And so, I really go transfemoral exclusively.

Okay.

I also feel like I have a good amount of control as well.

Okay.

Occasionally, it can be challenging with tortuous anatomy, and so that’s where sometimes you’ll need to use a longer sheath. Sometimes to catheterize a contralateral prostatic artery or contralateral iliac artery, you’ll need to maybe use a buddy wire technique to stabilize your sheath in the common iliac artery or even advance that sheath into the internal iliac artery.

Yeah. What sheath are you using in those situations?

I’m typically using just a 6 French 45 cm sheath.

Got it.

Braided sheath.

Got it, got it. Okay. Going up to six.

6 French.

Yeah. Okay. So you can use that buddy wire.

Well, if I need to use the buddy wire, I’ll then use a 7 French.

Got it. Okay.

Yeah. And then I’ll just have an 018 wire as my buddy wire into the external iliac artery.

Yeah. Okay.

But typically, it’s just a short—I might start off with a long sheath if I’ve seen the preprocedure MRA and it looks like I’m going to have some difficulty, but typically, I’ll start off with a short 6 French sheath.

Okay.

Get up and over, typically just using either a Bern or a C2 to get into that contralateral internal iliac artery, do a good angiogram. So I think that’s really important is to do really good angiography.

What projections are you usually taking?

Yeah, so, it’s ipsilateral oblique.

Okay.

So about 30- to 40-degree ipsilateral oblique. And this is also where I think the preprocedure imaging can be very helpful, because it’s not always ipsilateral oblique. Sometimes you have to go contralateral, actually, oblique to get to really visualize the prostatic artery, but typically, it’s ipsilateral oblique with a little bit of cranial angulation, 5 to 10 degrees of cranial angulation. I think it’s really important to do a good power injection, actually.

So you’re using a power injector in the office?

I’m using a power injector.

Okay, great. What volume? What rate?

So generallym it’s like 5 for 10.

Five for 10?

Five for 10 gets me pretty good imaging.

Great. Okay.

I’ll first catheterize the internal iliac artery trunk and actually do a hand run first. And I want to see what that posterior division looks like. If I can advance my catheter beyond the bifurcation, I find that that gets me even better imaging.

Still using a power injector then?

Still using a power injector. Yeah.

Okay.

So I do that ,and then I’m using, typically, a 2.5 French Cantata catheter.

Okay. Yeah.

And so, that’s worked very well for me. What I like about that is that it’s 2.5 French, but it tracks almost like a 2.0 microcatheter.

Yeah, yeah, I know what you’re talking about. Yeah.

Since I started using that a couple of years ago, I have not—I actually don’t carry 2.0 microcatheters on my shelves anymore.

Okay, wow. Okay.

So it’s been that good for me. And you get better injection rates as well, right?

Yeah, of course—

So, I mean, you sacrifice your injection rates when you go to a 2.0 microcatheter, so that’s what I really like about this particular catheter. But catheterizing the prostatic artery and—

Are you shaping a wire?

I am shaping a wire.

Okay. What kind of shape are you doing, generally? Do you have a standard that you start with, or … ?

I’m trying to get a double curve.

Yeah.

Just a double curve.

Cool.

I actually do the same thing with my microcatheter. So, the Cantata is shapeable—

Yeah. Yeah.

And I actually get the same sort of double curve on my Cantata. I do that for GAE as well. Actually, for all the embos that I do.

Yeah. Okay.

It’s the same shape for my microcatheter and my microwire. That’s just worked really well for me.

Yeah. Cool.

And catheterizing prostatic artery, doing good angiography. We’re looking for shunts. We’re looking for anastomoses. That’s a key element, I think, to this procedure. There is—GAE has anastomoses as well, right? All of those jugular arteries anastomose with each other, and you have nontarget vascular territories you have to be mindful of. I think the potential for an adverse event with PAE is much higher, though.

Of course. Yeah.

Right, and we have to watch out for rectal arteries, vesicular arteries, the penile artery. Obviously, that’s one, that’s probably what I worry about the most.

Yep. Patients too.

Absolutely. Absolutely. Yes. So I think that’s important. And you mentioned—I do the same thing, by the way, in how you embolize, you know, do your GAE in terms of using 0.2 CC aliquots. I do the exact same thing with PAE. I use 0.2 CC aliquots because as you embolize, the flow dynamics will change and you can uncover a lot of these anastomoses that you didn’t realize were there. And so, I will inject 0.2 CCs, flush that out slowly, do a repeat angiogram, and see what I’m left with, and then continue embolizing.

Yeah. Same technique on the GAEs. The 0.2 aliquot, that’s kind of the dead space of the microcatheter, right, so it’s a pretty safe bet. Are you using any medications while emboing, before emboing?

Yes. I use very liberally nitroglycerin.

Okay.

So, I think that’s very important. That can—you know, again, there are a number of anastomoses here that we have to contend with, and you’ll see them most of the time, actually. And so, the nitroglycerin helps lower the vascular resistance within the prostatic artery bed, and it can get you reversal flow in those arteries that you don’t want to embolize.

Got it. Yeah.

And just allow for better uptake, I think. Unlike GAE, with PAE, we want to get good distal penetration of our involved material, and so, we’re trying to induce necrosis, right, and so for those two reasons, I use nitroglycerin.

Got it. Got it.

Do you do the same with GAE?

Never use any nitro in the geniculars. Kind of part of our pedal cocktail. Right?

Okay, yeah.

We’re kind of doing a standard radial pedal cocktail, some heparin, verapamil, nitro, but that’s just on access. I feel like you’re looking for problems that maybe you don’t otherwise have in the geniculars.

Sure. Sure.

I mean, I don’t fault anyone for doing it. I think it’s a good idea, but also, in the, interest of speed, it’s a quick embo, right, like—

It is.

… the GAE. Sometimes we don’t even use a wire. I’m sometimes shaping the Cantata, like you said.

Yes.

You don’t even need a microwire, right? It goes right in.

Exactly. Exactly.

And then, at that point, just want to get the patient out of there, right? You know, they’re laying down, they’re not super-comfortable all the time, either, you know? Same people have back pain, things like that.

Right, right. Yeah, makes sense. Makes sense.

What size embolic are you using? Are you coiling frequently? Tell me about that.

I’m not coiling very frequently. Again, if there’s a nontarget artery, there’s a middle rectal artery or something that I just cannot avoid, obviously, I will coil it. Sometimes in order to catheterize the prostatic artery or to get into the anteromedial branch, you may have to coil for your wire to deflect into that branch, so sometimes it can be quite tortuous down there.

That’s a smart technique. Yeah.

But I would estimate I’m probably only coiling about 10% of the time.

Got it.

In terms of the embolic agent I’m using, I use Embosphere 100 to 300.

Okay. Yeah.

Yeah.

What kind of total volumes are you typically seeing?

Total volume, it really depends on the size of the prostate.

Yeah.

Right? My average patient is probably 70 to 80 grams.

Sure.

Seventy, 80 gram prostate, and so, it’s about 0.8 to a CC per side, and I dilute it. You mentioned your dilution for GAE. I use the same dilution for both GAE and PAE, so—

Yeah. Great.

… so about a CC each side of that mixture.

Yeah. Yeah, great. And, actually, taking a step back, on the size of the gland, is there a size that’s too small, that you’ll say, “Hey, I probably don’t want to do a PAE on this person?” Have you run into it?

No, no, I don’t think there is—I think you do have to question whether or not that’s the etiology of their symptoms.

Okay. Sure.

If you have imaging showing that they only have a 25 CC gland, you have to question, Is that really the etiology of their symptoms? But to answer your question, if you determine their issues, BPH, and it is a little bit of a smaller gland, and so, I won’t infrequently see glands of 35 to 40 CCs. You can definitely treat those patients. I do think this is advice for people maybe just starting or getting into PAE. You probably want at least a hundred cases under your belt before you’re embolizing the 40 CC prostate.

For sure.

Because I think, again, the tough thing about this procedure is, the anatomy is very challenging, right? Prostatic artery can arise from one of several different locations. There’s a lot of variability in its appearance. You want to develop that pattern recognition, and so I think for those starting out, it’s probably best to stick to the larger glands.

Yeah.

Once you get more experience under your belt, then you can treat those smaller prostates.

Sure. I think that’s great advice. Yeah. I don’t do as many prostates as you do, but I’m always a little more comfortable when they’re the bigger ones.

Absolutely. Absolutely.

Yeah.

I still get nervous for smaller prostates. You want a nice juicy prostate.

Yeah. Any particular technique that you’re using? There’s a few different described techniques, right? Like perfected, these things. Any of them that you’ve seen that have been particularly helpful in any situations or across the board?

No. Apart from what I’ve described, I think the most important thing is to have mastery of the anatomy.

Yeah, 100%

That is so key with PAE. It’s a difficult procedure, very steep learning curve. That, honestly, is the most important thing, to know where these arteries typically arise from, to know some of the strange locations where they may arise? In terms of actual procedure, technique, during the procedure, once, as we’re embolizing the prostate, I don’t do the perfected technique. That’s something I tried doing early in my experience, and I found that I was seeing a lot of other shunts when I did that.

Yeah. Yeah.

I’ve had a lot of good success with just catheterizing the distal artery, but not going intra-prostatic, not going into the prostate.

Sure. Like a more standard embolization, flow directed. Right?

Flow-directed embolization. Exactly.

Yeah. That’s great. That makes a lot of sense.

I guess one other thing is just, to highlight again the importance of angiography, is doing frequent angiograms. I mentioned that I do power injection for my nonselective angiograms, but they’re all hand injections once I’m in the prostatic artery.

Yeah.

What’s nice about that is you can sort of change the pressure at which you’re injecting your contrast. And you can get a good idea as to the enhancement of the gland and also whether or not there are other shunts present, so I typically do a very slow injection, and then at the end of my run, I’ll actually increase the pressure, try to see what it looks like when I get reflux, what other anastomoses are present—

Yeah, I know exactly what we’re talking about. Yeah. I do the exact same thing, actually. You kind of light it up, light it up, and then push hard.

Exactly.

Yeah, it works great. Works great. I think that’s actually the simplest way to image in all these vascular beds. When we’re doing GAE, I’m typically not pressuring it as much, pressurizing as much. Maybe you’ve seen this before, but oftentimes on geniculars, when we select the arteries in the region of the patient’s pain, it actually recreates their pain.

Yes. Yes, I do see that very commonly—

Which, it’s great for us because we know we’re in the right spot, right, but trying to minimize how uncomfortable it is for the patient, so I’m a little careful on those. I’m trying to do it consistently, like pre- and post.

In terms of your injection rate?

Yeah, just like my hand injections, because I want to make sure that the blush is going away but it’s not because I’m going easy on the injection.

Exactly.

And sometimes after the patient’s said they’re in pain, you’re reluctant to do the same injection, right?

Right, right.

We typically use Omnipaque due to availability in our labs, but I have heard from people that use Visipaque it’s less painful on those injections, so that’s something people might want to consider.

Yeah.

Yeah. Not a ton of—

As you mentioned, there is some value, I think, in reproducing their pain.

Yeah, 100%. Yeah, I agree. And also, with chronic pain, people, they experience it in different ways. Sometimes it’s actually hard for them to describe, so a technical pearl there is, if you’ve recreated that, you can actually ask them like, “Hey, is that the pain that we’re talking about? And that’s what I want you to focus on, so when we follow up, tell me if you’re still having that pain.” A lot of pain patients, their pain is multifactorial.They have back problems, different things. I want to know if their knee is better. That’s really important, I think.

Right. That’s a good point.

Yeah. As far as some of the other GAE pearls we’ve kind of learned over the years, people often ask, How do you approach the total knees? Patient, there’s a bunch of metal in the way, you know, so a couple of things to keep in mind. As long as they haven’t been revised too many times, at least half of the normal arteries are still going to be present. And in our experience, it’s oftentimes the superolateral that’s the culprit there, and I think it’s due to changes in the knee tracking, and to catch that, people will try to do different laterals, things like that. I actually think the easiest thing to do is get a true AP and then just some CC angulation, like 30, 40 degrees, and you’ll actually come out kind of on top of the prosthesis and you’ll see the origin of the superolateral and oftentimes the superiomedial as well. We all know the descending genicular is like the easiest one to get, but I think those are pretty important on those post-total knees, something related to that tracking and the synovitis they have, but just another one I throw out there.

Do you find that you’re embolizing typically about two vessels for those patients as well, or … ?

Yeah. Yeah, typically two. If you have to get the inferiors, they’re a little tough on those. Those are going to just be hard to find. You’ll see the sides of them, but the origin, you’re trying to look in between the prosthesis—

Inferolateral especially, right?

Yeah. It’s really tough in those patients. Yeah, it’s usually about two there. I think in the osteoarthritis patients, we actually treat a little bit more, maybe just time and exposure, a lot of radiation. Maybe you’re reluctant to keep going sometimes in those total knees, right? The procedure just gets kind of long. But when we look at our data as a whole, we have great results on those post-total knees. And interestingly, the patients where we only treated one vessel, they all seem to do really well as well, so I’m not sure, but as long as you’re getting the hypertrophic vessels, treating that blush, I think you’re giving yourself the best shot.

I probably haven’t treated as many post-TKA patients as you have, but one thing I’ve noticed is that it seems that they require a little bit more embolization. Has that been your experience, where you need a little larger volume with embolic?

Yeah, 100%. Hundred percent. That’s a great point to bring up. We’re doing about a CC, maybe 1.2 CCs, in a larger vessel in those patients. You see that huge blush. It takes quite a bit. I know some people who will chase it with some larger beads as well. I think that’s probably a good idea if that’s what you’re seeing. I haven’t had to do that too often.

So you’re sticking to the 100 micrometer articles for those?

Yeah, typically using the hundreds. I’m just a little bit more comfortable with that. I think if you’re using a lot of Imipenem for your embolizations, which is very common—I think we see less of it in the US, but—you probably are going to need some beads in those patients, because that’s not going to be able to really treat all of that. Yeah. Yeah. So as far as outcomes, we all kind of know the data behind these procedures. What do you tell patients to expect in the days after a PAE?

Yeah, so I tell my patients that they’re going to experience some side effects for a few days. Typically, it’s about 48 hours for most men after a PAE, although my experience for men with prostates larger than 100 grams, it can be three or four days of side effects. And these men are typically experiencing some dysuria, some sort of cramping, kind of pelvic pain. Bladder spasms are very common. They’ll have some hematuria as well. That typically, for I would say 90% of patients, resolves by about 48 hours after the procedure.

Okay. Are you prescribing anything?

Yeah. I prescribe a few things. I give every patient Pyridium as needed. I think that works pretty well. Most men will feel—

For the burning? Yeah.

Yeah. They’ll have bladder spasms, and they’ll have this urge to—their urgency will actually get a lot worse, and so that’s where the Pyridium can be very helpful.

Oh, interesting.

Most men that first night, especially, have a lot of trouble getting to sleep.

Yep.

And so, I’ll actually prescribe Valium as well just to help them, those first couple of nights, to get some rest.

Yeah, yeah, yeah. That’s important.

I put everyone on a Medrol Dosepak as well. I think that can help decrease some of the inflammation that we create when we do this embolization.

Got it, yeah. Any antibiotics?

Yeah, I do prescribe antibiotics as well. Yeah, five-day course of, typically, Cipro.

Cool. Got it. Got it. Yeah.

What about post-GAE? Are you prescribing anything for your patients?

No, generally not prescribing anything. We give patients some access precautions, depending on what we did, but generally, I say, “Hey, take it easy. You had a procedure. It may not feel like you did because you don’t see any incisions or anything, but take it easy, go back to normal, usually the next day.” There’s not a whole lot there, but I do tell them, within the first two weeks, the knee can flare up, because we are inducing some ischemia. Some inflammation is going to follow. I’ll say, “Hey, it’s going to feel like you overdid it, so NSAIDs if you can take them; Tylenol, that helps too, kind of alternate them; heating pack or ice pack.

I’ll usually tell them to use the heating pack and ice pack the first day as well. And I say, “Hey, use whichever one feels better.” I used to always say that the ice pack, but no one uses it. Then I found out that my patients use heating packs, always say they feel better.

I’ve had that same experience.

Really? Yeah.

You think that the ice pack maybe would be more helpful, but most patients, absolutely, they say it’s heat actually feels better.

Yeah. Yeah, so I encourage them to use that a lot. And some patients call, but just kind of talk them through that day or two. Usually, it only lasts a day or two when it’s flared up, and I tell them, “Start expecting the results to start showing up within the first two weeks,” during that time. I think two weeks is a reasonable amount of time. Is that kind of what you see?

That’s exactly what I tell patients as well.

Yeah.

“Hopefully, you may feel a whole lot better by the next day, but it can take upwards of two weeks for you to sort of have maximal benefit.”

Yeah.

I wanted to ask you about this as well: We just talked about postprocedure pain, exacerbating their pain transiently. Which patients do you tend to see that in? Do you see that in your Kellgren and Lawrence grades 3 and 4 patients? Does it not correlate with severity of osteoarthritis?

Yeah, that’s a good question. I think that the threes, for sure ,are the ones who seem to experience that more. The fours, it depends how bad of a four. Sometimes—and maybe you’ve seen this as well—some of those fours, there’s less to embolize, actually, than what you’d expect, and I think it’s kind of burned out. Those patients, I feel like they don’t—those are the ones who tend to respond worse, and they don’t tend to have a lot of pain either, though, but probably because we’re just using smaller volume embolic, right? But yeah, the more advanced patients, I think they’re the ones that tend to have more of these flare-ups. Is that what you see, or do you see something different or … ?

I think I see exactly the same thing. I have seen some grade 4s have pain, and so, I will tell my grades 3 and 4 patients, “Hey, don’t expect this, but you may see some increase in your pain for a few days.”

Yeah. Yeah.

“Experience any pain, you know, we’ll help you get through it”.

Yeah.

Yes, fortunately, rarely, I see it in my grade 2 patients.

Great. Yeah. Yeah, that’s really helpful. Thanks. I think just knowing what to tell patients is sometimes the hard part when you’re getting started, right? You’re like, “What do I say?” Right?

Absolutely. Absolutely.

“How do I talk them through this?” As we wrap up, Dr. Bhatti, what best practices do you think, in PAE, others should adopt? If you had to pick one or two things, what best practices do you think are key?

That’s a good question. I think my best advice to IRs looking to introduce this to their practice, introduce PAE to their practice or grow their PAE service lines, is to really take ownership of the disease process. Really become an expert on prostate health and take ownership of the disease process. That’s really my best advice. We’ve talked about several technical aspects of the procedures and how we can help to ensure success and minimize complications, but I think that’s my best advice.

That’s great advice. Can’t argue with that.

How about for GAE?

Yeah, for GAE, it’s interesting. I think from a technical standpoint, the bar is lower than PAE. You’d agree, right? It is probably an easier procedure, right?

Yes.

I think as GAE evolves, the questions we need to answer to the patients and our referring physicians are more around the patient-selection aspect, right? How do we—right now, we can get good results, but how do we really hone in on the people who are going to do the best? I think those are questions that are still being answered. When you talk to the pain docs, though, they have the same problem with all of their procedures, so you hope it’s going to get better, but maybe this is the field that we play in, right?

That’s right. That’s right.

And then I think as IRs pick up this procedure, it’s going to be important that we just get out there, talk to the referring docs, explain this to them. It’s a novel use of embolization, right? But I think MSK embolization is really going to play a big part of IR’s future. And when you talk to the referring physicians, these concepts of hypervascularity and inflammation, it actually makes sense with them. It really resonates with what they see and their experience over the years.

Yeah, I agree with that.

Yeah. Any resources you think people should check out, for GAE or PAE?

I think that there are a number of—for both procedures, I think there are a number of great papers out there. Again, I want to emphasize with PAE, it’s really all about the anatomy. Anatomy is very important to GAE as well, obviously. And for those starting out, I remember when I started doing both procedures, that was the tough thing, was just figuring out the anatomy.

For sure.

And so there are a number of good papers out there, talking about not only anatomy, but patient selection and best practices.

Sure.

And then follow up and continue management of these patients.

Yeah, very important. Very important. Thanks. Thanks for sharing that. Well, any final thoughts before we wrap up? I think we’ve covered a lot here, right?

Yeah, no, I think these are both very exciting procedures, and I think with both—I’m excited to see how we can continue to improve upon these procedures and help more patients.

Agreed. Well said. Well, thank you, everyone, for your time, and hope you enjoyed this discussion. If you need more resources, Cook, SIR, these are the places to look.

That’s right.

Yeah. Cool. Thanks a lot, Zagum.

All right. Thank you.