Geniculate Artery Embolization in Patients With Recurrent Hemarthrosis After Knee Arthroplasty: A Retrospective Study

Genicular Artery Embolization: A Review of Essential Anatomic Considerations

Genicular artery embolization is increasingly recognized as a safe and effective treatment option for symptomatic knee osteoarthritis and recurrent hemarthrosis after total knee arthroplasty. Genicular arteries are an essential contributor to vascular supply for the knee joint and demonstrate considerable variability. Familiarity with the anatomy and common variations is critical for preprocedural planning, accurate target selection, and minimizing adverse events in transarterial embolization procedures. This review aimed to provide a detailed discussion of the genicular artery anatomy that is relevant to interventional radiologists performing genicular artery embolization.

Geniculate Artery Endovascular Embolization Post-Total Knee Arthroplasty for Hemarthrosis Treatment: A Systematic Review of the Literature

PURPOSE

To provide an updated systematic review on the use of geniculate artery embolization (GAE) in the management of recurrent hemarthrosis post-total knee arthroplasty (TKA).

MATERIALS AND METHODS

A systematic literature review was conducted, and all clinical reports in the English language from inception to July 2022 were identified. References were manually reviewed to identify additional studies. Demographics, procedural techniques, post-procedural complications, and follow-up data were extracted and analyzed using STATA 14.1.

RESULTS

A total of 20 studies (9 case reports, 11 case series; n= 214) were included for review. In all cases, patients underwent coil embolization of one or more geniculate arteries. Procedure success was reported in 94.8% (n=203/214) of cases without perioperative adverse events. Improvement of symptoms was seen in 72.6% (n=119/164) of cases, with 30.7% (n=58/189) of cases requiring repeat embolization. Recurrent hemarthrosis occurred in 22.2% (n=22/99) of cases over a mean follow-up of 48 months.

CONCLUSION

GAE appears to be a safe and effective treatment for recurrent hemarthrosis following TKA. Future studies in the form of randomized controlled trials should be conducted to further evaluate such embolization techniques and compare outcomes between GAE and standard techniques.

CLINICAL IMPACT

Conservative management of post total knee arthroplasty (TKA) hemarthrosis is successful in only one third of cases. Geniculate artery embolization (GAE) has recently gained attention due to its minimally invasive nature compared to open or arthroscopic synovectomy promising faster rehabilitation, decreased infection rates and less additional surgeries. The purpose of this article was to summarize current literature, provide an updated review on the use of GAE in the management of recurrent hemarthrosis post-TKA and describe immediate and long-term outcomes in an effort to help optimize current treatment algorithms.

Genicular Artery Embolization for Primary Knee Osteoarthritis

Genicular artery embolization (GAE) is a novel treatment for knee osteoarthritis (OA) with increasing interest and utilization worldwide. The genicular arteries are selectively embolized using microspheres with subsequent cessation of abnormal synovial hyperemia, a process believed to arrest the inflammatory changes and pain associated with OA. Current data indicate that GAE offers sustained, 6-month improvement in Western Ontario and McMaster Universities Osteoarthritis index (WOMAC) and visual analog scale scores in 80 to 85% of patients with mild to moderate OA. As GAE gains traction, future studies are needed to establish its safety and efficacy relative to placebo and other standard-of-care therapies while also characterizing populations for which it is most effective.

Geniculate Artery Embolization: Role in Knee Hemarthrosis and Osteoarthritis

Roughly 37% of Americans 60 years of age and older experience chronic pain due to osteoarthritis (OA) of the knee. After conservative treatment (pharmacologic, physical therapy, and joint injections) fails, patients often require total knee arthroplasty to alleviate pain and regain knee function. Given the high economic burden of surgery paired with its invasive nature, many patients with this degenerative joint disease seek alternative treatment. Moreover, many patients with severe knee OA who also have comorbidities that preclude surgery-most often morbid obesity-are left without options. Geniculate artery embolization (GAE) is a minimally invasive intra-arterial intervention that was originally developed for the treatment of knee hemarthrosis that has recently been adapted for symptomatic knee OA. Through selective embolization of geniculate branches corresponding to the site of knee pain, GAE inhibits the neovascularity that contributes to the catabolic and inflammatory drive of OA. Preliminary trials over the past decade have demonstrated promising clinical results, including decreased pain and improved function and quality of life after treatment. Given such success, GAE provides another minimally invasive treatment option for knee OA to patients who feel reluctant to undergo or are ineligible for surgery. The authors review the radiographic manifestations and current standard of treatment of OA and hemarthrosis of the knee. Procedural technique, embolic selection, and clinical evidence for GAE in the treatment of OA and hemarthrosis of the knee are also explored. The online slide presentation from the RSNA Annual Meeting is available for this article. ^©RSNA, 2021.

Musculoskeletal Interventions: A Review on Genicular Artery Embolization

Symptomatic knee pain is one of the most common joint diseases that affects millions of people worldwide. The treatment for knee pain secondary to osteoarthritis (OA) begins with conservative therapy and progresses to surgical intervention when conservative therapy fails. Genicular artery embolization (GAE) offers an alternative option for patients who are poor surgical candidates. Multiple studies have been conducted worldwide demonstrating the safety and efficacy of GAE in patients with mild to moderate OA. The purpose of this article is to describe the current literature on GAE and highlight the latest findings from a randomized controlled trial comparing GAE versus sham embolization.

Recurrent Hemarthrosis After Total Knee Arthroplasty

Recurrent hemarthrosis is a rare complication after total knee arthroplasty (TKA). Its incidence is reported as less than 1%. Most patients present with acute knee pain and swelling in the absence of trauma, resulting in significant loss of function. The authors report a case of recurrent hemarthrosis in a 64-year-old female. She presented with repeated episodes of sudden-onset right knee pain, swelling, and bruising at 18 months after a right TKA. During revision knee surgery, the recurrent hemarthrosis was identified to have been caused by entrapment of hypertrophied knee synovium under the TKA tibial base plate. After excision of the synovial tissue and cementing of the tibial defect, the patient recovered well after surgery with no future recurrences of knee pain and swelling.

Genicular Artery Embolization for Refractory Hemarthrosis following Total Knee Arthroplasty: Technique, Safety, Efficacy, and Patient-Reported Outcomes

PURPOSE

To investigate the safety and efficacy of genicular artery embolization for treatment of refractory hemarthrosis following total knee arthroplasty.

MATERIAL AND METHODS

Patients who underwent genicular artery embolization with spherical embolics between January 2010 and March 2020 at a single institution were included if they had undergone total knee arthroplasty and subsequently experienced recurrent hemarthrosis. Technical success was defined as the significant reduction or elimination of the hyperemic blush. Clinical success was defined as the absence of clinical evidence of further hemarthrosis. Clinical follow-up was performed 7-14 days after the procedure and at 3-month intervals thereafter via a telephone interview. A total of 117 embolizations, comprising 82 initial, 28 first repeat, and 7 second repeat, were performed.

RESULTS

An average of 2.5 arteries was treated per procedure. The superior lateral genicular artery was the most frequently embolized. The most utilized embolic size was 100-300 μm. Follow-up was available for all patients, with a median duration of 21.5 months. 65.9%, 25.6%, and 8.5% of patients underwent 1, 2, and 3 treatments, respectively. Complications occurred following 12.8% of treatments, of which the most common was transient cutaneous ischemia. Technical success was achieved in all cases. Clinical success was achieved in 56%, 79%, and 85% of patients following the first, second, and third treatment, respectively. 83% of patients reported being either satisfied or very satisfied with the overall result.

CONCLUSIONS

Targeted genicular artery embolization with spherical embolics is an effective treatment for recurrent hemarthrosis with infrequent serious complications. Repeat embolization should be considered in cases of recurrence following initial therapy.