Angiography Institute

Benign Prostatic Hyperplasia (BPH), also known as enlarged prostate, is the non-cancerous enlargement of the prostate gland, located next to the urethra. It affects around 50% of men in their 50s and about 90% of men in their 70s and 80s. In this condition, the total number of cells within the prostate gland increases. As the prostate gland enlarges, it can slow down or block the flow of urine from the bladder, a condition known as urinary obstruction or obstruction of the urinary flow. BPH can also cause chronic blood in the urine. The diagnosis of BPH includes a detailed examination to rule out other possible causes of Lower Urinary Tract Symptoms (LUTS).

Symptoms:

- Enlarged prostate
- Difficulty in urination
- Weak urine flow
- Nocturia (frequent urination during the night)
- Waking up at night to urinate
- Inability to empty the bladder completely
- Straining to empty the bladder
- Increased frequency of urination
- Blood in the urine
- Blood in semen

Treatment:

Prostatic Artery Embolization (PAE)
PAE is a novel approach to treating Lower Urinary Tract Symptoms (LUTS). Through image guidance, an interventional radiologist makes a small incision either in the wrist or the groin to insert a catheter into the artery and guide it to the blood vessels of the prostate gland. Once the catheter is in place, tiny particles are injected through the catheter to block the blood flow to specific areas of the prostate. This prevents oxygen from reaching the prostate tissue, leading to shrinkage of the prostate gland. Patients who undergo PAE reported high satisfaction, with no urinary incontinence or sexual side effects. The only visible sign of the treatment is a small puncture mark on the wrist or groin. Minimal side effects may include increased frequency and/or urgency of urination, pelvic pain, blood in the urine, blood in stool, and diarrhea. Most of these side effects resolve on their own within a short period.

SIR Statement on PAE
The Society of Interventional Radiology (SIR) statement on PAE for BPH states that PAE is a promising, innovative, safe, and effective treatment, based on short-term follow-up. Patient satisfaction is high, and the procedure is cost-effective. PAE is a technically challenging procedure, with the potential for complications if not performed with precision. Interventional radiologists, with their knowledge of arterial anatomy, experience with micro-catheter techniques, and expertise in other embolization procedures, are the most qualified specialists to perform PAE.

Background Information:
While there are many other treatments for symptomatic BPH, interventional radiologists offer a novel treatment called Prostatic Artery Embolization (PAE), a minimally invasive procedure with less risk, less pain, and faster recovery compared to traditional surgery, and not associated with the risk of sexual side effects commonly associated with surgical procedures.

Internal hemorrhoids are a highly prevalent problem in the population. They cause symptoms such as bleeding during bowel movements, protrusion of the hemorrhoids outside the anus, and itching. Typically, the first line of treatment for symptomatic hemorrhoids includes good hydration, stool softeners, and local creams. However, many patients do not find sufficient relief with conservative treatment and proceed to interventional therapies. There is a range of "endoscopic" treatments available, such as rubber band ligation of the hemorrhoids. These treatments are quick and can be performed in proctology clinics. However, the persistence of symptoms after endoscopic treatment is high. The next stage in treatment involves surgical options, with hemorrhoidectomy being the most common procedure. Hemorrhoidectomy is considered very effective but comes with risks (bleeding, abscess, fistula, infection) and long and sometimes challenging recovery. There are other less invasive surgeries than hemorrhoidectomy, but they are considered less effective.

Symptoms:

- Blood on toilet paper
- Blood in the stool
- Prolapsed hemorrhoids
- External hemorrhoids
- Hemorrhoid bleeding
- Hemorrhoids protruding from the anus

Is Embolization Suitable for You?

Embolization is considered an alternative to surgery for those whose main issue is bleeding and is also suitable (although less beneficial) for those with significant prolapse of the hemorrhoids. Embolization is a good option for patients who are on blood thinners (for heart stents, massaging procedures, coagulation issues, etc.), those with inflammatory bowel disease (such as Crohn's or colitis), or those who are not interested in surgery or procedures through the rectum.

Treatment: Hemorrhoid Embolization

Hemorrhoids are an anatomical structure in the lower rectum that consists of soft tissue and blood vessels. The main physiological function is to enable control over bowel movements. Today, we understand that the primary issue causing internal hemorrhoids is increased arterial blood flow, leading to secondary engorgement of veins within the hemorrhoids. This understanding has led to research (led by Prof. Vincent Vidall, France) on the option of identifying and closing all the arteries supplying the hemorrhoids through a minimally invasive procedure called embolization.

The Procedure: Hemorrhoid Embolization

Using only local anesthesia, a catheter (a very thin tube with a diameter of millimeters) is inserted through an artery in the leg or the root of the hand and navigated to the arteries supplying the hemorrhoids. Once the catheter is in the supplying arteries of the hemorrhoids, these arteries are closed (embolization) with tiny coils made of metal. The patient remains under observation for a few hours and can return home on the same day, most of the time without the need for painkillers. Relief of symptoms can occur immediately but may take up to three months. Patients can resume full activity within 1-2 days after the procedure.

Varicose veins in the legs are a very common condition, especially among women who have had multiple pregnancies. It is essential to emphasize that varicose veins are a genuine medical disorder and not just a cosmetic concern. Nowadays, there is a well-established and minimally invasive procedure with a high success rate (>90%), so there is no need to suffer from varicose veins. The incorrect blood flow direction ("reflux") is a very common cause of chronic pain and swelling, and even leg ulcers. It is also the most common cause of varicose veins, which can be associated with pain, heaviness in the legs, leg fatigue, swelling, itching, inflammation, and deep vein thrombosis.

Symptoms:

- Swollen legs
- Leg pain
- Heaviness in the legs
- Bulging veins in the legs
- Leg fatigue
- Varicose veins
- Edematous legs
- Leg pain

Treatment:

Elastic stockings assist patients with sensations of pain and heaviness in the legs. However, they do not address the underlying problem, which is venous insufficiency (reflux) in the varicose veins. Additionally, many patients find elastic stockings uncomfortable. Traditionally, venous insufficiency was treated with open surgery to remove the main varicose vein causing insufficiency. The traditional surgery is an effective treatment; however, it requires anesthesia, leaves patients with scars, and is associated with several weeks of recovery time. There is plenty of evidence that "endovenous ablation," a non-surgical treatment based on catheterization, is as effective as surgery but with significantly fewer complications, local anesthesia only, less pain, and much shorter recovery time.

At the Shaare Zedek Medical Center, we offer endovenous ablation with a special catheter called "Venis" or with a different type of catheter called "radiofrequency ablation" (similar to 'laser'). Patients undergo an initial evaluation at the angiography clinic, where blood tests and a physical examination are performed. Duplex ultrasound is also conducted to determine the anatomy of the patient's varicose veins and, most importantly, to ascertain if the patient has venous insufficiency ("reflux") in the saphenous vein, which is the main cause. The official duplex ultrasound can be performed through the local health fund, although it is necessary to exclude deep vein thrombosis. If the patient is a suitable candidate for endovenous ablation, they will be scheduled for the procedure. The procedure takes about 1 hour and is done with local anesthesia only. Patients typically experience minimal discomfort (if any) during or after the procedure. They can return home on the same day as the procedure and can resume regular activities immediately. Afterward, they will come for follow-up at the angiography clinic two weeks after the procedure, and further follow-up is not usually necessary.

Uterine fibroids are benign growths in the uterus and are highly prevalent among women of childbearing age, with around 40% of women affected by them. In most cases, fibroids are asymptomatic, but in a minority of cases, significant symptoms may be present, including increased and prolonged bleeding during menstruation, pelvic pain, discomfort in the bladder or rectum area, pain during sexual intercourse, and fertility disturbances. There are various treatments available for fibroid symptoms, including contraceptive pills for preventing pregnancy or surgical solutions. The surgical procedures are tailored based on the symptoms, fibroid size, and its location in the uterus, and they can include partial or total removal of the fibroid or even the whole uterus.

Uterine fibroid embolization is a minimally invasive alternative to surgery. The procedure involves the insertion of a tiny catheter into an artery in the upper leg. The catheter is guided to the uterine arteries, where microscopic particles are injected to block the blood supply to the fibroid. After the procedure, the patient can usually be discharged on the same day or the next morning and can return to full activity within a few days.

Symptoms:
- Pelvic pain
- Abdominal pain
- Excessive bleeding during menstruation
- Intermenstrual bleeding
- Heaviness in the pelvic area
- Pelvic fullness
- Uterine fibroids
- Uterine cramps

Pain management:
Mild pain or discomfort may occur for a few days after the procedure. Most women who undergo the procedure experience pain during and in the days after the procedure. This can be managed with pain relief medications given through an intravenous line and then orally for several days to a week.

Embolization vs. Surgery:
The benefits of embolization over surgery include shorter hospital stay, faster recovery time, quicker return to daily activities, and avoidance of complications associated with major surgery (infection at the surgical site, bleeding, scarring, etc.). Numerous clinical studies have demonstrated that embolization is as effective as, and sometimes even superior to, surgery in alleviating symptoms and providing patient satisfaction. However, a potential drawback of embolization is the need for additional procedures or repeat embolization in about 1 in every 5 women. Additionally, there is a concern about its impact on fertility, and surgical intervention might be preferred in some cases. Though there are reports of pregnancies after embolization, women considering this procedure will need to undergo an MRI examination before the treatment to assess the anatomy and blood supply to the uterine fibroids.

Vascular malformations encompass a wide range of conditions, including hemangiomas, vascular malformations, and venous malformations. These abnormalities can lead to symptoms like swelling and pain. While some cases can resolve on their own, others may require non-surgical or minimally invasive interventions. Our medical center takes pride in offering advanced, comprehensive, and patient-centered treatments for these conditions. We collaborate with various specialists to provide the most effective care possible, aiming to improve the quality of life for our patients.

Various types of vascular malformations include venous, arteriovenous, lymphatic, capillary, and hemangiomas. Venous malformations are low-flow and may cause skin, muscle, and organ issues. Arteriovenous malformations are high-flow and more complex to treat. Lymphatic malformations are soft masses that may bleed and are treated with sclerotherapy. Capillary malformations are birthmarks and can be lightened with laser treatment. Klippel-Trenaunay Syndrome involves multiple malformations and limb overgrowth. Hemangiomas are benign neoplasms and infantile hemangiomas often disappear on their own but may require beta-blocker treatment if problematic.