Prostatic artery embolization (PAE) angiography practice
AngioSim’s PAE module is a C-arm angle simulator for finding and opening the prostatic artery origin on selective internal iliac DSA. The vessel tree is hand-built. This page describes only the origins, views and pitfalls already stored in that module. Citations link to Sources.
AngioSim is an educational simulator, not a medical device. The arteries are a schematic model. It must not be used for diagnosis, planning or treatment. Read the disclaimer.
Prostatic artery origins in this model
The origin presets are de Assis types I–V, a double prostatic artery, and an accessory pudendal variant. Each can be shown on the right or the left. Frequencies below are the ones recorded for those presets.
Type I: common trunk with the superior vesical artery
The prostatic (inferior vesical) artery arises from the anterior division of the IIA in a common trunk with the superior vesical artery. Look for it just beyond the SVA take-off, coursing medially and caudally toward the prostate base.
28.7% of pelvic sides (82/286) [de Assis 2015]; reported series range 24.8–36.1% (pelvic-side or PA denominators differ).
Common trunk with the SVA: the SVA climbs cranially and anteriorly to the bladder dome, the PA runs caudally and medially to the prostate. Selecting the SVA instead of the PA is a classic pitfall (scenario pae-01).
Type II: anterior division, below the SVA
The prostatic artery arises independently from the anterior division of the IIA, inferior (distal) to the superior vesical artery origin.
14.7% of pelvic sides (42/286) [de Assis 2015].
An independent anterior-division origin below the SVA. In this model it opens best near AP or slightly contralateral — a reminder that the classic ipsilateral view is a starting point, not a rule.
Type III: from the obturator artery
The prostatic artery arises from the obturator artery, runs briefly alongside and posterior to it, then turns medially and anteriorly toward the prostate.
18.9% of pelvic sides (54/286) [de Assis 2015]; reported series range 12.7–21.2% (pelvic-side or PA denominators differ). Also cited: Bilhim 2023.
Obturator origin: the PA briefly follows behind the obturator before turning medially and anteriorly toward the prostate.
Type IV: from the internal pudendal artery
The prostatic artery arises from the proximal internal pudendal artery, before it leaves the pelvis. This was the most common pattern in de Assis 2015 and in Bilhim 2012 (34.1% of sides).
31.1% of pelvic sides (89/286) [de Assis 2015]; reported series range 23.5–34.5% (pelvic-side or PA denominators differ). Also cited: Bilhim 2012.
Internal pudendal origin, the commonest pattern. Beware a short trunk: reflux into the pudendal risks penile non-target embolization (scenario pae-05).
Type V: from the inferior gluteal artery (example of a less common origin)
Type V groups less common origins. Here the prostatic artery arises from the proximal inferior gluteal artery, which otherwise runs posteriorly out of the pelvis below piriformis.
5.6% of pelvic sides (16/286), all less-common origins combined [de Assis 2015]. The Sources registry states the same figure as all less-common origins combined, with the model example a PA from the IGA, not an IGA-specific prevalence. Also cited: Moschouris 2023.
Gluteal origin: the PA leaves the inferior gluteal artery, which heads posteriorly. Follow the IGA before calling a type II/IV origin.
Double prostatic arteries (type IV + type I)
Two independent prostatic arteries on one side: here a type IV artery from the internal pudendal supplies the peripheral gland (posterolateral branch) and a second artery from the SVA trunk supplies the central gland (anterolateral branch). Missing the second artery is a cause of incomplete PAE.
8.0% of pelvic sides (23/286) in de Assis 2015; 43% of sides in Bilhim 2012 (CTA + DSA) [de Assis 2015, Bilhim 2012]. The Sources registry also lists 28.6% in Rocha 2026 and notes that the definitions differ.
Two PAs on one side. If one hemigland stays unopacified after treating the first PA, look for a second (scenario pae-02).
Type IV with an accessory pudendal artery
A type IV prostatic artery plus an accessory pudendal artery from the obturator running along the anterolateral prostate to the penis. The accessory pudendal can mimic the prostatic artery; Bilhim 2012 found accessory pudendal arteries closely related to the PAs in 20% of pelvic sides.
Accessory pudendal in close relation to the PA: 20% of pelvic sides (30/150) [Bilhim 2012].
The accessory pudendal can mimic the PA. Confirm it is not the sole penile supply before any protective occlusion.
Working C-arm obliquities for the PA origin
Angle names in the module: LAO/RAO and cranial/caudal named by detector (image intensifier) position: cranial (+) = detector toward the head, beam travelling caudal→cranial; ipsilateral = RAO for right PA, LAO for left PA (Bilhim 2023). How to learn C-arm angles explains that convention.
Cited starting range, as stored for the module:
Cited practice spans 20–50° ipsilateral oblique with about 8–12° cranial tilt (standard 35–45° + ~10° cranial). Sources write the tilt as 'caudal-cranial' without a clear sign; AngioSim uses cranial (image intensifier toward the head) per Varun Danda's clinical review. Treat as a starting range, not a rule.
Sources for that range: Bilhim 2023, Moschouris 2021, Pilan 2022.
Saved views in the module:
- Classic: ipsilateral oblique 35° + cranial 10°. Standard: ipsilateral oblique 35–45° with ~10° cranial tilt (Bilhim 2023 writes this as a 'caudal-cranial' projection; interpreted as image intensifier toward the head — confirmed by Varun Danda). Reported practice ranges 20–50° with 8–12° tilt — use as a starting point and adjust. Bilhim 2023, Moschouris 2021, Pilan 2022.
- Ipsilateral oblique 45° + cranial 10°. Upper end of the classic 35–45° range, with ~10° cranial tilt. Bilhim 2023.
- Ipsilateral 25° + cranial 10°. Lower part of the 25–45° + 8–12° 'caudal-cranial' practice range (Moschouris 2021), often chosen from the planning CTA's best MIP angle. Moschouris 2021.
- AP. Straight AP. Internal iliac branches overlap heavily; used e.g. after selective obturator catheterization. Bilhim 2023.
- Steep ipsilateral 55°. Upper bound of the 25–55° ipsilateral range quoted as traditional guidance in the CBCT preprint. Fassia 2025.
- Contralateral oblique 15°. Preliminary: in a 21-patient CBCT preprint the model-optimal gantry angle was contralateral in 51% of cases (mean 3° contralateral). Not peer reviewed. Fassia 2025.
The Sources page also records the preprint result as contralateral in 51%; mean 3° contralateral; only ~16% within 25–55° ipsilateral; n=21. That preprint is not peer reviewed.
Pitfalls marked in the module
Preset teaching notes above are the origin pitfalls (selecting the superior vesical artery in type I, a short internal-pudendal trunk in type IV, calling a gluteal origin type II or IV, missing a second prostatic artery, and an accessory pudendal artery that can mimic the prostatic artery). The module also stores these non-target notes:
Penile branches and prostato-penile anastomoses
Apical prostatic branches can communicate with penile arteries, and the internal pudendal terminates as the penile artery. Particles reaching these vessels are non-target embolization of the penis. Protective coil placement before PAE is mainly used to exclude penile anastomoses. Anastomoses to adjacent arteries were documented in 57% of pelvic sides.
Rectal branches and prostato-rectal anastomoses
Peripheral-gland (posterolateral) branches can anastomose with middle and inferior rectal arteries, and the PA may share a trunk with rectal branches (8.4% of sides in Bilhim 2012). Rectal non-target embolization is a recognised risk; advance the microcatheter beyond rectal branches or protect them.
Vesical branches
Vesical branches to the bladder base can arise from the prostatic (inferior vesical) artery or its trunk; reflux into them risks bladder non-target embolization. Protective coiling can also be used for bladder anastomoses.
Accessory pudendal artery
An accessory pudendal artery runs along the anterolateral prostate to the penis and can mimic or give rise to the PA. It was closely related to the PAs in 20% of pelvic sides. Embolizing from the accessory pudendal trunk risks penile non-target embolization.
How to practice in AngioSim
- Open the simulator on the classic right-sided type IV view. The readout for that link is RAO 35° / CRAN 10°, which is ipsilateral oblique for a right prostatic artery.
- Compare straight AP, where the module says internal iliac branches overlap heavily.
- Open the matching left-sided view (LAO 35° / CRAN 10°). Ipsilateral oblique is LAO for a left prostatic artery.
- Step through the saved views listed above, then change the preset through types I–V, the double prostatic artery, and the accessory pudendal variant.
- For type II, use the preset teaching note: in this model it opens best near AP or slightly contralateral. The classic ipsilateral view is a starting point, not a rule.
An origin meter on the simulator marks whether a view leaves the prostatic origin unforeshortened and clear of overlap. Those thresholds are estimates on Sources.
Questions
Is this page for clinical use?
No. AngioSim is an educational simulator, not a medical device. The arteries are a schematic model. It must not be used for diagnosis, planning or treatment.
Which prostatic artery origins does the model include?
de Assis types I to V, a double prostatic artery, and an accessory pudendal variant. Type V is modeled as an inferior gluteal origin. The 5.6 percent figure is all less-common origins combined, not an inferior-gluteal prevalence.
What C-arm angle does the module use as a starting view?
Ipsilateral oblique 35 degrees with about 10 degrees cranial tilt, detector toward the head. Cited practice spans about 20 to 50 degrees ipsilateral and about 8 to 12 degrees cranial. Treat that as a starting range, not a rule.
How do I open the prostatic artery view in the simulator?
Choose Open the simulator. That link opens the classic right-sided type IV view: RAO 35 degrees and cranial 10 degrees. Change the preset and the side in the simulator.
Where do the numbers on this page come from?
They are the frequencies, view notes and citations stored in the PAE module and listed on the Sources page. Each source key links there.