Angioplasty for Arteriogenic Erectile Dysfunction

Context and indications

Arteriogenic erectile dysfunction results from insufficient blood supply to the penile corpora cavernosa. Atherosclerotic or post-radiation stenoses of the pelvic arteries (internal iliac, internal pudendal, cavernosal arteries) reduce the blood flow required to achieve and maintain a rigid erection.

Approximately 70% of men with vasculogenic erectile dysfunction have an identifiable pelvic arterial stenosis. Angioplasty is offered when phosphodiesterase type 5 inhibitors (sildenafil, tadalafil) are insufficient and a significant stenosis is documented on imaging.

Pre-procedural workup

Diagnosis is based on:

• Penile Doppler ultrasound with intracavernosal prostaglandin E1 injection, assessing arterial inflow.
• Abdominopelvic CT angiography to locate and quantify stenoses in the penile arterial supply.
• Standardized IIEF-6 and IIEF-15 questionnaires to objectively assess the degree of dysfunction.

Arteriogenic erectile dysfunction shares the same risk factors as coronary artery disease (smoking, diabetes, hypertension, hyperlipidemia). It can be a sentinel sign of systemic atherosclerosis, warranting a concurrent cardiac workup.

Procedure

The intervention is performed in an angiography suite under local anesthesia and takes approximately 1 to 1.5 hours:

• Access route: puncture of the radial artery at the wrist (discharge within 1 hour) or the femoral artery at the groin.
• Selective catheterization of the internal iliac and then internal pudendal arteries under fluoroscopic guidance.
• Balloon angioplasty: a balloon is inflated at the stenosis to restore normal arterial caliber.
• If needed, placement of a stent (metallic endoprosthesis, often drug-eluting) to keep the artery open and limit restenosis.
• Completion angiography confirming a satisfactory result.

The most commonly treated lesions are located in the internal pudendal artery (approximately 75% of cases), followed by the internal iliac arteries (15%) and the cavernosal arteries (10%).

Results

Published data show:

• Technical success: 100% in the ZEN study (Rogers et al., JACC 2012; 30 patients, 45 pudendal lesions treated with zotarolimus-eluting stents).
• Erectile function improvement: approximately 60 to 65% of patients at 6 months, up to 84% at 12 months in per-protocol analysis.
• Residual stenosis: reduction from 63% stenosis before treatment to 23% after angioplasty.
• No major adverse events at 30 days or during 12-month follow-up.

The main limitation remains the restenosis rate (approximately 30-35% at 6 months for stents), higher than in coronary arteries, driving ongoing research into drug-coated balloons (paclitaxel, sirolimus) and bioresorbable stents.

Risks

Complications are rare and generally minor: puncture site hematoma, intraprocedural arterial spasm. No lasting sequelae have been described in published series. The risk of late restenosis warrants follow-up imaging.

Recovery

Same-day discharge. Rest for 3 to 5 days before resuming sexual activity, 7 days for strenuous exercise. Improvement is progressive. Clinical follow-up is scheduled at 1-3 months with IIEF questionnaire assessment and follow-up Doppler ultrasound.

Practical information

Outpatient procedure under local anesthesia, no hospitalization required. A prior consultation with the interventional radiologist allows review of the vascular workup and definition of the treatment strategy.