CLINICAL STUDY Angiographic Findings during Repeat Prostatic Artery Embolization Andr  e Moreira de Assis, MD, Airton M. Moreira, MD, PhD, and Francisco C. Carnevale, MD, PhD ABSTRACT Purpose: To describe mechanisms of prostate revascularization based on imaging findings during repeat prostatic artery embolization (PAE; rPAE). Materials and Methods: This is a retrospective analysis of 10 rPAEs performed between October 2012 and September 2018 in patients with recurrent lower urinary tract symptoms (LUTS) after PAE (mean age, 68.2 y ± 4.5). Two interventional radiologists reviewed PAE and rPAE images and defined 6 patterns of revascularization. Correlation between embolization of the posterolateral (PL) prostatic branch during previous PAE and prostate revascularization on rPAE was assessed by Fisher exact test. One hemiprostate was excluded because no detectable revascularization was observed. Results: All patients showed LUTS improvement after previous PAEs (P < .01 for 5 outcome measures) and had recurrence during follow-up. rPAEs were performed a mean of 40.9 months after previous PAEs (18–96 mo). Of 19 hemiprostates analyzed, 11 presented revascularization by 2 or more branches (57.9%). The PL branch (29.0%) and the recanalized main prostatic artery (25.8%) were the most frequent revascularizing branches observed, followed by distal branches of obturator (12.9%), internal pudendal (12.9%), superior vesical (12.9%), and contralateral arteries (6.5%). Embolization of the PL branch during previous PAE significantly reduced the incidence of revascularization by this branch (P ¼ .002). Conclusions: Mechanisms of revascularization in rPAE are diverse and complex. Revascularization by the PL branch and recana- lization of the previously embolized prostatic artery were the most frequent patterns observed. Embolization of the PL branch may reduce the incidence of prostate revascularization and LUTS recurrence after PAE. ABBREVIATIONS DSA ¼ digital subtraction angiography, IPA ¼ internal pudendal artery, IPSS ¼ International Prostate Symptom Score, LUTS ¼ lower urinary tract symptoms, OA ¼ obturator artery, PAE ¼ prostatic artery embolization, PL ¼ posterolateral, Qmax ¼ peak urinary flow rate, QOL ¼ quality of life, rPAE ¼ repeat prostatic artery embolization, SVR ¼ superior vesical artery, TURP ¼ transurethral resection of the prostate In the past decade, prostatic artery embolization (PAE) has become an important minimally invasive alternative to surgical procedures for the treatment of lower urinary tract symptoms (LUTS) related to benign prostatic hyperplasia. Previous studies have established PAE as a safe and effective procedure associated with reduction in symptoms, improvement of functional and clinical outcomes, and decrease in prostate volume (1–10). However, recurrence of LUTS after PAE remains a concern. Although data regarding medium and long-term follow-up outcomes are scarce, it is suggested that as many as one fourth of patients who have undergone PAE will need repeat treatment at some point after the procedure. A single-center study (11) that included a large number of patients (N ¼ 630), which considered a moderate LUTS improvement after PAE as clinical success (International Prostate Symptom Score [IPSS]  15, quality of life [QOL] score  3 points, and no need for other treatments), demonstrated positive results in 85.1% of patients at short- term follow-up, 81.9% at medium-term follow-up, and 73.6% at long-term follow-up. Other groups described similar results based on different criteria for recurrence or clinical failure. Carnevale et al (12) compared outcomes of 2 From the Interventional Radiology Department, Radiology Institute, University of Sao Paulo Medical School, Dr. En eas de Carvalho Aguiar Ave., 255, Cerqueira C esar, 05403-000 S~ ao Paulo/SP, Brazil. Received November 8, 2018; final revision received December 27, 2018; accepted December 28, 2018. Address correspondence to A.M.d.A.; E-mail: andre.assis@criep.com.br; Twitter handle: @AndrAssis16 None of the authors have identified a conflict of interest. © SIR, 2019 J Vasc Interv Radiol 2019; ▪:1–7 https://doi.org/10.1016/j.jvir.2018.12.734