Early Results of Transcatheter Arterial Embolization for Relief of Chronic Shoulder or Elbow Pain Associated with Tendinopathy Refractory to Conservative Treatment

Transcatheter arterial tendinopathy embolization as a treatment for painful and refractory tendinopathy: a systematic review and meta-analysis

OBJECTIVE

Transcatheter arterial embolization (TAE) is a novel minimally invasive therapy for painful tendinopathy in patients with pain refractory to conservative management. The purpose of this study was to evaluate evidence on the efficacy of TAE for tendinopathy related pain.

MATERIALS AND METHODS

Using Embase, PubMed, and Web of Science, a systematic review and meta-analysis was performed to identify studies evaluating TAE for painful tendinopathy. The primary outcome measure was change in pain scale score at 6 months. A Ratio of Means (ROM) was used to compare the effect size post treatment as compared to baseline. The Visual Analog Scale (VAS) was used as the metric for comparison.

RESULTS

After screening titles, abstracts, and the full text, 5 studies met inclusion criteria. A total of 97 tendinopathy embolization procedures performed in 74 patients were included. Patients who underwent TAE demonstrated declines in VAS ROM at 1 day 0.53 [95% CI 0.31,0.88], 1 week (0.51 [95% CI 0.32,0.79]), 1 month (0.45 [95% CI 0.29, 0.71]), 3-4 months (0.33 [95% CI 0.22,0.48]), and 6 months following embolization (0.18[95% CI 0.13,0.26]), respectively.

DISCUSSION

TAE provides substantial short-term reductions in pain scores for patients suffering with refractory tendinopathy related pain of the rotator cuff, elbow extensor and flexor, Achilles, and patellar tendons.

Angioembolization in the management of joint pain: current concepts

Joint pain is a common complaint owing to its origin in inflammatory and degenerative joint diseases. Recent research has helped narrow down inadequate angiogenesis as one of the causes. Angioembolization has emerged as a treatment option for this condition when it is refractory to conservative treatment. This review describes angioembolization by elaborating on the mechanism, safety, efficacy, comparative analysis of treatment and the road ahead, in addition to summarizing the existing data on this treatment. The inferences from this review further consolidate transcatheter arterial embolization as one of the prime options for managing joint pain when it is refractory to conservative treatment and label it as one of the most exciting prospects. A limitation of this review is that most of the data were from open label case series or case reports.

Transarterial microembolization for the management of refractory chronic joint pain in osteoarthritis

Osteoarthritis (OA) is a chronic degenerative disease significantly impacting both patient quality of life and socioeconomics. Traditional treatment options, including pharmacological and surgical interventions, are often limited. Advancements in our understanding of the pathological mechanisms behind OA indicate the involvement of pathological angiogenesis. Transarterial microembolization (TAME), a minimally invasive radiological procedure, may present an innovative therapeutic approach. This review aims to consolidate current knowledge and experiences regarding TAME as a therapeutic modality for alleviating chronic joint pain associated with OA. It explores the role of TAME, focusing on its indications, patient selection, clinical outcomes, and future perspectives. Potential complications and associated risks are systematically addressed, alongside proposed strategies for risk mitigation and effective management.The presented patient cases originate from our institution, supplemented by a thorough review of relevant literature retrieved from PubMed.TAME represents a promising therapeutic approach, providing relief from the burden of joint diseases and substantially enhancing patient quality of life. Clinical outcomes emphasize the efficacy and safety of TAME in mitigating pain and improving functional capabilities in patients with chronic joint pain associated with OA. With mounting evidence of its therapeutic benefits and applicability to numerous joint-related pathologies, TAME offers a valuable addition to the arsenal of treatments for these conditions. · TAME is an innovative therapy for treating chronic joint pain related to OA.. · TAME is a technically challenging minimally invasive intervention requiring a high level of expertise.. · Understanding the challenges and complications of TAME can reduce risk and enhance procedural outcomes.. · Wilms LM, Jannusch K, Weiss D et al. Transarterial microembolization for the management of refractory chronic joint pain in osteoarthritis. Fortschr Röntgenstr 2024; DOI 10.1055/a-2288-5743.

Challenges and complications and their management of the transarterial microembolization for chronic musculoskeletal pain

Transarterial microembolization (TAME) is an increasingly well-known novel and minimally invasive treatment option for painful chronic musculoskeletal diseases that is gaining popularity. Although the safety and effectiveness of TAME have been established, limited knowledge of intraarticular and musculocutaneous arterial anatomy may lead to challenges and complications. This article aims to present cases illustrating these challenges and complications, based on multicenter experiences and a comprehensive literature review. Furthermore, the article also provides preventive tips, solutions, and follow-up strategies to reduce the learning curve for interventional radiologists and facilitate familiarity with post-TAME follow-up images for diagnostic radiologists. CLINICAL RELEVANCE STATEMENT: This article illustrates the intra- and post-interventional complications of transarterial microembolization (TAME) through detailed pictorial reviews, including how to distinguish them from normal angiographic findings. It provides strategies for their prevention, management, and follow-up, which can further improve clinical outcomes. KEY POINTS: • Transarterial microembolization for chronic musculoskeletal pain may result in intrainterventional challenges (IIC) and postinterventional complications (PIC), and their importance may be underestimated. • The intrainterventional challenges include microarterial perforation, arterial dissection, and catheter tip fracture, whereas postinterventional complications include tissue ischemia-related complications, puncture site hemorrhage, and arterial injury. • Being familiar with the intrainterventional challenges and postinterventional complications may help minimize the procedure risk and improve outcomes.

Transarterial Embolization for Adhesive Capsulitis of the Shoulder: Midterm Outcomes on Function and Pain Relief

PURPOSE

To determine the safety and potential effectiveness of transarterial embolization for adhesive capsulitis of the shoulder.

MATERIALS AND METHODS

This prospective study analyzed consecutive adult patients with adhesive capsulitis referred for embolization between January 2018 and May 2023 after a poor response to treatment (symptoms and limitation of motion in ≥2 axes; ≤120° flexion, ≤50° external rotation and/or internal rotation with the shoulder abducted 90°) persisting for >3 months after having completed ≥6 weeks of analgesics and physical therapy. Different types of pain and mobility were measured before embolization and 1, 3, and 6 months after embolization. Overall upper limb function (Quick Disabilities of Arm, Shoulder, and Hand) and patient satisfaction were measured before and 6 months after embolization. Long-term follow-up comprised telephone interviews and clinical history reviews.

RESULTS

A total of 20 patients (12 [60%] women; median age, 50.7; interquartile ranges [IQR], 45‒55 years) were included; 6 (30%) had diabetes and 15 (75%) were off work. Median duration of symptoms before embolization was 39.4 weeks (IQR, 28‒49 weeks), and median duration of rehabilitation therapy was 12.8 weeks (IQR, 8‒16 weeks). Six months after embolization, significant improvements were observed in nocturnal pain (P = .003), pain on moving (P = .001), external rotation (P < .001), internal rotation (P < .001), active flexion (P < .001), passive flexion (P = .03), active abduction (P < .001), passive abduction (P < .001), and overall function (P < .001). Despite objective improvements, patient satisfaction was nearly unchanged. Only 1 patient experienced a mild adverse event.

CONCLUSION

Transarterial embolization is safe and potentially effective in treating adhesive capsulitis of the shoulder refractory to conventional treatment. Clinical improvements were maintained in the mid to long term.

In vitro study of the embolic characteristics of imipenem/cilastatin particles

BACKGROUND

Imipenem/cilastatin (IPM/CS) has long been administered intravenously as a carbapenem antibiotic. However, since this agent is poorly soluble in liquid, occasional reports have described its use as a short-acting, temporary embolic agent. The purpose of this study was to elucidate the characteristics of IPM/CS particles, which are thought to have pain-relieving effects against osteoarthritis-related pain, as an embolic agent.

METHODS

Three aspects of IPM/CS as an embolic agent were evaluated in vitro: particle size; particle shape; and change in particle size over time. For particle size, the long diameter was measured.

RESULTS

Mean particle size (n=244) was 29.2±12.0 µm (range, 1-60 µm). Shape (n=109) was round in 18.35%, elliptical in 11.93%, and polygonal in 69.72%, showing that most particles were polygonal. In observations of changes in particle size over time (n=9), particles had decreased to 75% of their original size at 82±10.7 min, 50% at 89.3±9.14 min, 25% at 91.3±8.74 min, complete dissolved at 91.8±9.02 min. A rapid shrinkage in diameter was seen in the final period.

CONCLUSIONS

IPM/CS particles are ultrafine and the majority display a polygonal shape. This substance shows ultra-short embolic activity. This study revealed the characteristics of a substance that demonstrates an embolic effect not found in existing embolic materials.

Musculoskeletal Embolotherapy

Painful articular musculoskeletal (MSK) conditions are common, debilitating and sometimes difficult to treat. Transcatheter embolisation may offer an alternative way to manage the pain associated with these conditions, but the field is still in its infancy. To date, the most commonly studied indication is knee osteoarthritis, but the technique has been trailed in multiple other tissue beds, including for adhesive capsulitis and tendinopathies. Whilst early results appear promising, the existing studies are mostly open-labelled and non-randomised; there is a need for high-quality evidence to robustly assess the procedures efficacy. In this review, we set out to evaluate the current evidence underlying the pathophysiology and mechanism of action of embolisation; discuss the technical aspects of the procedure including embolic selection, and appraise the published clinical outcomes and adverse effects. Finally, we discuss the future directions and research priorities in this rapidly developing field.

Evaluating the Safety and Effectiveness of Quick-Soluble Gelatin Sponge Particles for Genicular Artery Embolization for Chronic Knee Pain Associated with Osteoarthritis

PURPOSE

To evaluate the effectiveness and safety of genicular artery embolization (GAE) using quick-soluble gelatin sponge particles (QS-GSPs) to alleviate chronic knee pain associated with osteoarthritis.

MATERIALS AND METHODS

This retrospective study included 71 patients (97 procedures, including 26 patients for both knees) who underwent GAE to treat osteoarthritic knee pain between August 2019 and January 2022. QS-GSPs were used for all the procedures. Technical success was defined as the embolization of at least 1 feeding artery. Clinical outcomes were evaluated using a 10-point visual analog scale (VAS). Clinical success was defined as a decrease in the VAS score of >50%.

RESULTS

The technical success rate was 100% (97 of 97). The mean VAS scores at baseline, immediately after TAE, and at 1 day, 1 week, 1 month, 3 months, and 6 months after TAE were 6.3, 4.3, 5.0, 3.0, 2.9, 2.9, and 2.8, respectively. The clinical success rate was 72% (70 of 97 patients) at 6 months. No major adverse events were reported, and temporary skin color change (50.5%, 49 of 97) and hematoma at the puncture site (10.3%, 10 of 97) were observed.

CONCLUSIONS

GAE using QS-GSPs had a high technical success rate and was considered safe. Clinical outcomes using QS-GSPs were comparable with those of existing materials.

Transcatheter arterial embolisation for the relief of shoulder and elbow chronic joint pain refractory to conventional treatment: Systematic review

Angiogenesis and accompanying nerve fibres might cause unsettling joint pain. Studies have suggested that transcatheter arterial embolisation (TAE) of these abnormal neovessels could relieve pain and symptoms in patients with upper limb joint pain refractory to conventional treatment. This study aims to investigate the efficacy and safety of TAE in treating chronic pain of shoulder and elbow joints that have been resistant to other treatments. Using six databases, a systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The primary outcome involved changes in the visual analogue scale (VAS) after TAE; while secondary outcomes involved comparing other parameters where relevant. Average VAS decreased from baseline, then at 1 day, 1 week, 1 month, 3 months, 4 months, 6 months, 1 year, 2 years and 44 months (7.5 at baseline vs. 4.7, 4.3, 3.4, 2.1, 2.5, 1.2, 0.7, 1.1 and 0.1, respectively). Average Quick-DASH scores decreased from baseline, then at 1, 3 and 6 months (61.3 at baseline vs. 30.6, 19.3 and 6.9, respectively). Minor adverse events were reported in 27/143 (18.9%) patients, where they resolved spontaneously or with oral analgesia. TAE is a possible treatment option for refractory shoulder and elbow joint pain; however, randomised controlled trials are still required.

Transcatheter embolisation in chronic musculoskeletal disorders

Chronic musculoskeletal conditions affect millions of patients worldwide resulting in disability, reduced quality of life, and have a profound economic impact on the individual and society. Current treatment strategies fail patients who have not responded to conservative management but are not surgical candidates. Over the last decade, transcatheter embolisation has emerged as a potential treatment for these difficult to treat patients. By exploiting pathological neovascularisation within conditions such as knee osteoarthritis, adhesive capsulitis, and tendinopathy, embolisation has been used to improve patients' pain and function. This review explores the rationale for musculoskeletal transcatheter embolisation, illustrating the technique, and latest evidence for the most common procedures.

Angiographic Analysis of Anatomical Variants in Adhesive Capsulitis Embolization

PURPOSE

To analyze the complex shoulder vasculature and identify potential challenges during adhesive capsulitis embolization (ACE).

MATERIALS AND METHODS

Two interventional radiologists evaluated angiographic findings from 21 ACE procedures. The suprascapular artery (SSA), thoracoacromial artery (TAA), coracoid branch (CB), circumflex scapular artery (CSA), and anterior/posterior circumflex humeral artery (ACHA/PCHA) were assessed for their presence, course, diameter within 1 cm of origin, angle to the proximal parent vessel, and distance from the clavicle.

RESULTS

83 arteries were embolized: CB (20.5%), TAA (19.3%), PCHA (19.3%), ACHA (16.9%), CSA (14.5%), and SSA (9.6%). The CSA had the largest diameter (4.3 mm), while CB had the smallest diameter (1.0 mm). An acute angle to the parent vessel was noted with the SSA, TAA, ACHA, and PCHA. A common origin for CSA and PCHA was noted in 2 patients. A common origin for TAA and SSA was also noted in one patient. The CB appears perpendicular to the axillary artery and courses vertically toward the coracoid process. The TAA branches off the axillary artery and courses along the medial border of the pectoralis minor. The PCHA and ACHA originate from the axillary artery. The CSA is located on the medial side of axillary artery. The SSA originates from the thyrocervical trunk and courses laterally toward the superior border of the scapula.

CONCLUSION

An anatomical-technical guide is provided to help interventional radiologists during ACE to treat adhesive capsulitis.

Embolic Decision Making in Musculoskeletal Embolization

In his pioneering work, Okuno and colleagues demonstrated the benefit of musculoskeletal (MSK) embolization, using imipenem as an embolic agent, in various diseases such as knee osteoarthritis (KOA), adhesive capsulitis (AC), tennis elbow and other sports injuries. As imipenem is a last-resort, broad spectrum antibiotic, its use is often not feasible depending on countries and their drug regulation. Since then, several other studies have used other material products such as microparticles or liquid embolics. In addition, several products in development or that are used in other indications may prove useful after full clinical evaluation of safety and efficacy. In this article we will develop our recommendations, through an analysis of recent publications on MSK embolization.

Clinical Outcomes of Transarterial Embolization for Chronic Achilles Tendinopathy Refractory to Conservative Treatment: A Pilot Study

PURPOSE

To evaluate the effectiveness and safety of transarterial embolization (TAE) for chronic Achilles tendinopathy (AT) refractory to conservative treatment.

MATERIALS AND METHODS

This retrospective study included 20 patients (12 men and 8 women; mean age, 30.3 years) who received TAE using imipenem/cilastatin sodium for refractory chronic AT from May 2019 to April 2021. Nine patients had bilateral involvement. A total of 29 procedures were performed (8 for nonathletes and 21 for athletes). If feasible, embolization was performed superselectively of the arterial branch demonstrating hypervascularity, early venous drainage, and/or supplying the pain site noted using a radiopaque marker. The visual analog scale (VAS, 0-10) score was used to assess pain symptoms at baseline and during the follow-up period (1 day; 1 week; 1, 3, and 6 months; and open period). Clinical success was defined as a decrease of >50% in the VAS score at 6 months when compared with baseline.

RESULTS

In 25 (86.2%) of 29 procedures, clinical success was achieved. Significant decreases in the VAS scores were noted at 1 day, 1 week, 1 month, 3 months, and 6 months (6.86 at the baseline vs 3.48, 3.41, 3.10, 2.55, and 1.62, respectively; all P < .01). For patients available for the 12- and 24-month follow-ups (n = 19 and 6, respectively), the mean VAS scores significantly decreased (6.84 vs 2.00 and 7.33 vs 1.17, respectively; all P < .01). No serious adverse events were observed during follow-up.

CONCLUSIONS

TAE may alleviate pain for patients with chronic AT refractory to the conservative treatment with a low risk of adverse events.

Transcatheter Arterial Embolization for Alleviating Chronic Musculoskeletal Pain and Improving Physical Function: A Narrative Review

Chronic musculoskeletal pain imposes immense suffering and diminishes the quality of life for millions of patients worldwide; the pain persists despite the use of standard conservative treatments. Increases in our understanding of the pathophysiological mechanisms underlying musculoskeletal disorders indicate the involvement of inappropriate angiogenesis. Accordingly, the resulting neovessels are the target of emerging treatments for chronic musculoskeletal pain, including transarterial embolization. The use of this noninvasive procedure to treat pain refractory to standard therapy in a variety of musculoskeletal conditions is the focus of numerous recent investigations. Here, we describe the pathophysiological indications for the use of transarterial embolization and summarize the findings of studies investigating its use in a variety of histopathological conditions and anatomical sites.

Transarterial Embolization of Neovascularity for Refractory Nighttime Shoulder Pain: A Multicenter, Open-Label, Feasibility Trial

PURPOSE

To assess the feasibility of transarterial embolization (TAE) for recalcitrant nighttime shoulder pain in a multicentric study.

MATERIALS AND METHODS

This prospective, open-label, feasibility trial included 100 patients treated at 5 institutions. TAE was performed in 76 patients with adhesive capsulitis (AC) and 24 patients with symptomatic rotator cuff tears (sRCTs). The ipsilateral radial artery was punctured, and imipenem/cilastatin sodium was infused as an embolic agent. Adverse events, 10 point pain numerical rating scale (NRS), range of motion (ROM) of the shoulder joint, and quality of life (via the EuroQol-5D [EQ-5D]) were evaluated.

RESULTS

All patients exhibited neovascularity on baseline angiography, and all TAE procedures were performed successfully. No patient experienced a major adverse event. The mean nighttime pain NRS scores at baseline and 1, 3, and 6 months after TAE were 6.4 ± 2.2, 3.4 ± 2.6, 2.3 ± 2.5, and 1.6 ± 2.2, respectively (for all, P < .001). The mean ROM of anterior elevation at baseline and 1, 3, and 6 months after TAE were 97° ± 29°, 119° ± 28°, 135° ± 27°, and 151° ± 17°, respectively (for all, P < .001). The mean EQ-5D scores at baseline and 1, 3, and 6 months after TAE were 0.63 ± 0.17, 0.73 ± 0.16, 0.80 ± 0.17, and 0.84 ± 0.17, respectively (for all, P < .001). There was no significant difference in the clinical success rate between the AC and sRCT groups.

CONCLUSIONS

TAE for nighttime shoulder pain caused by AC and sRCTs was feasible with sufficient safety and efficacy.

Alteration of chronic inflammatory status by transarterial embolization in frozen shoulder evaluated by 18-fluorine-fluoro-2-deoxyglucose positron-emission tomography/computed tomography

BACKGROUND

Frozen shoulder (FS) is speculated to have an inflammatory etiology. On angiography, abnormal angiogenesis is observed around the affected shoulder, suggesting a possible source of inflammation and pain. The effectiveness and safety of transarterial embolization (TAE) targeting abnormally proliferating blood vessels have been reported. This study investigated changes in chronic inflammatory and hypoxic status before and after TAE in FS by 19-fluorine-fluoro-2-deoxyglucose (FDG) positron-emission tomography/computed tomography as a possible mechanism of the therapeutic response to TAE.

METHODS

Fifteen patients with unilateral FS, persistent for more than 6 months, who were refractory to conservative treatments, underwent TAE using the temporary embolic agent imipenem/cilastatin. Patients underwent positron-emission tomography/computed tomography with FDG (as a biomarker of inflammation) before and 8 weeks after TAE. Regional uptake was evaluated by the maximum standardized uptake value. The lesion-side-to-(contralateral-) normal-side uptake ratio was also calculated. Pain and functional scales, range-of-motion, and laboratory tests, including white blood cell, C-reactive protein, interleukin 6, vascular endothelial growth factor, and tumor necrosis factor α were evaluated.

RESULTS

On FDG-PET, the average maximum standardized uptake value of the lesion-side was significantly greater than that of the normal-side (maximum standardized uptake value before TAE: 3.11 ± 1.25 vs 1.95 ± 1.15, P = .0001; 8-weeks post-TAE: 2.36 ± 0.74 vs 1.78 ± 0.69, P = .0002). The mean lesion-side-to-(contralateral-) normal-side uptake ratios before TAE (1.71 ± 0.60) decreased after TAE (1.37 ± 0.29, P = .011). The decrease of FDG uptake (-21.1 ± 12.2%) showed a significant correlation with the change in the pain scale score (r = -0.56, P = .039) and extension score (r = -0.59, P = .026).

CONCLUSION

Chronic inflammation in FS, as demonstrated by FDG uptake, was decreased after TAE. Thus, chronic inflammation is likely to be an underlying mechanism that should be targeted for symptomatic improvement of frozen shoulder.

Feasibility of Neovessel Embolization in a Large Animal Model of Tendinopathy: Safety and Efficacy of Various Embolization Agents

Targeting neovessels in chronic tendinopathies has emerged as a new therapeutic approach and several embolization agents have been reported. The aim of this study was to investigate the feasibility of embolization with different agents in a porcine model of patellar tendinopathy and evaluate their safety and efficacy. Eight 3-month-old male piglets underwent percutaneous injection of collagenase type I to induce patellar tendinopathies (n = 16 tendons). They were divided into four groups (2 piglets, 4 tendons/group): the control group, 50–100 µm microspheres group, 100–300 µm microspheres group, and the Imipenem/Cilastatin (IMP/CS) group. Angiography and embolization were performed for each patellar tendon on day 7 (D7). The neovessels were evaluated visually with an angiography on day 14. The pathological analysis assessed the efficacy (Bonar score, number of neovessels/mm²) and safety (off-target persistent cutaneous ischemic modifications and presence of off-target embolization agents). The technical success was 92%, with a failed embolization for one tendon due to an arterial dissection. Neoangiogenesis was significantly less important in the embolized groups compared to the control group angiographies (p = 0.04) but not with respect to histology (Bonar score p = 0.15, neovessels p = 0.07). Off-target cutaneous embolization was more frequently depicted in the histology of the 50–100 µm microspheres group (p = 0.02). Embolization of this animal model with induced patellar tendinopathy was technically feasible with different agents and allowed assessing the safety and efficacy of neovessel destruction. Particles smaller than 100 µm seemed to be associated with more complications.

Safety and Efficacy of Embolization with Microspheres in Chronic Refractory Inflammatory Shoulder Pain: A Pilot Monocentric Study on 15 Patients

Purpose: Musculoskeletal (MSK) embolization is emerging in tendinopathy treatment. The objective of this study was to assess the efficacy and safety of MSK embolization with microspheres in the treatment of chronic shoulder pain. Patients and methods: This retrospective monocentric study included patients with chronic shoulder pain resistant to 6 months or more of conventional therapies who were treated with MSK embolization between 2017 and 2021. Embolization was performed using calibrated 100–250 µm microspheres. Clinical success was defined as pain reduction, i.e., a decrease in the visual analogue scale (VAS) pain score of ≥50% at 3 months after MSK embolization as compared to baseline. Adverse events were collected. Results: Fifteen patients (11 women, 4 men) were included, with a median age of 50.3 years (IQR: 46.7–54.5). The median duration of symptoms was 26.6 months (20.6–39.8). The median VAS pain scores were 7.0 (7.0–8.0) at baseline, 6.0 (3.5–7.0) at 1 month, 5.0 (4.5–6.5) and 5.0 (3.0–7.4) at 3 months and 6 months (p = 0.002). Three patients (20%) reported clinical success at 3 months. Three patients experienced minor complications after embolization (paresthesia, n = 2; transient osteo-medullary edema, n = 1) and two patients had moderate complications (transient skin ischemia). Conclusion: MSK embolization with microspheres for treatment of refractory chronic shoulder pain showed moderate results in terms of clinical success and safety.

Transarterial Embolization for the Treatment of Chronic Musculoskeletal Pain: A Systematic Review of Indications, Safety, and Efficacy

OBJECTIVE

The study objective was to evaluate the safety and efficacy of transcatheter arterial "embolization" (TAE) in the treatment of chronic "musculoskeletal pain" refractory to standard therapy.

METHODS

PubMed, EMBASE, and Cochrane Central Register of Controlled Trials were searched for original research articles evaluating TAE in patients with musculoskeletal conditions from database inception to January 21, 2020. Search terms employed were as follows: "embolization", "pain", "knee osteoarthritis", joint replacement, epicondylitis, tenderness, inflammation, WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index), microspheres, Embozene, geniculate artery, neovascularity, transcatheter, embolic, imipenem/cilastatin sodium, angiogenesis, and "musculoskeletal". Studies involving particle "embolization" for painful musculoskeletal conditions were included. Studies of TAE for hemarthrosis or malignancy-related "musculoskeletal pain" were excluded.

RESULTS

The primary search yielded 1,099 sources; 7 articles and 4 abstracts were included for data extraction. All were cohorts or case series, with low risk of bias and moderate to poor level of evidence. Heterogeneity between studies was high, precluding meta-analysis. The reviewed studies reported the safety and efficacy of TAE for the treatment of "knee osteoarthritis"; adhesive capsulitis of the shoulder; tendinopathy/enthesopathy of the knee, shoulder, elbow, and ankle; and cervical myalgia. All TAEs were reported as technically successful without major complications or subsequent serious adverse events, including no reported osteonecrosis, cutaneous ulceration, limb ischemia, cartilage degeneration, or myotendinous injury. TAE significantly reduced pain and improved function for all of the treated conditions, with durable response up to 24 months post procedure.

CONCLUSION

TAE appears to be a safe and effective treatment for some types of chronic refractory "musculoskeletal pain". Randomized placebo-controlled studies are necessary to confirm these findings.

Transcatheter arterial embolization for benign chronic inflammatory joint pain: a systematic review and meta-analysis

PURPOSE

To evaluate the efficacy and safety of transcatheter arterial embolization for the treatment of chronic inflammatory joint pain via a systematic review and meta-analysis.

MATERIALS AND METHODS

The MEDLINE and EMBASE databases were searched for studies reporting outcomes in patients with chronic inflammatory joint pain treated with transcatheter arterial embolization. Meta-analyses of pain score changes, changes in proportions of patients on analgesic medications, range of motion changes, technical success rates, and adverse events rates were performed. Subgroup analyses were conducted with respect to pain site (knee vs. shoulder).

RESULTS

Fourteen observational studies, including 346 patients, were reviewed. The pooled technical success rate was 95.8%, and no major adverse events were observed. The pooled mean difference in pain score at 1 week; 1, 3, and 6 months; and 1 year were 3.1, 4.0, 4.2, 5.1, and 5.5, respectively. Subgroup analysis demonstrated that shoulder embolization was associated with greater reduction of pain than knee embolization at 3 and 6 months (p<0.001 and p=0.018, respectively), whereas there was no significant difference in this regard between the sites at 1 month (p=0.734). The pooled proportions of patients on analgesic medication at baseline, 1, 3, 6, and 12 months were 81.1%, 36.3%, 42.3%, 28.2%, and 22.4%, respectively. The pooled estimated increases in range of motion among patients who underwent shoulder embolization were 55.6° for anterior elevation and 64.7° for abduction.

CONCLUSION

Transcatheter arterial embolization is an effective and safe therapeutic option for patients with chronic inflammatory joint pain.

Cadaveric Classification of the Genicular Arteries with Implications for the Interventional Radiologist

PURPOSE

To document and assess the genicular arterial variation in a large multicenter cadaveric sample and generate an anatomical classification with implications for Genicular Artery Embolization (GAE).

MATERIALS AND METHODS

A sample of 212 donor body lower limbs were dissected from three medical school institutions. The descending genicular artery (DGA), superior lateral genicular artery, superior medial genicular artery, middle genicular artery, inferior lateral genicular artery, inferior medial genicular artery, and anterior tibial recurrent artery (ATRA) were identified for gross anatomical appearance, location of origin, diameter of vessels, and variation in branching patterns.

RESULTS

A total of 198 DGA, 204 popliteal origin genicular arteries and 183 ATRA were adequately preserved and reviewed. Three types (A:26%, B: 71%, C:5%) of DGA branching patterns were proposed along with six types (I: 28%; II: 22%; III 15%; IV: 15%: V 10%; VI: 6%) of popliteal origin genicular artery branching variants. Right vs left comparisons did not reveal clinically significant differences in vessel distance (p = 0.30 - 0.82).

CONCLUSION

Despite the large number of possible anatomical variations of the genicular arteries, six main patterns corresponded to over 96% of the cases. The description and classification of the genicular arterial anatomy may provide useful information to the interventional radiologist and add to the technical nuances of GAE.

A Review of Musculoskeletal Embolization to Treat Pain Outside of the Knee

Chronic inflammation leading to musculoskeletal pain has garnered interest in the past decade with the success of genicular artery embolization for knee pain secondary to osteoarthritis. Outside the knee joint, musculoskeletal embolization has been applied to other anatomical locations, mainly shoulder pain secondary to adhesive capsulitis and elbow pain secondary to lateral epicondylitis. The success of these early trials and other case reports highlights the efficacy of musculoskeletal embolization and its future potential.

Results from a US Investigational Device Study of Adhesive Capsulitis Embolization (ACE) in the treatment of Shoulder Pain: The ACE Study

PURPOSE

To evaluate the safety and efficacy of arterial embolization to relieve shoulder pain secondary to Adhesive Capsulitis (AC).

METHODS AND MATERIALS

20 patients (18F, 2M: Mean age 51y) with AC resistant to > 30 days of conservative treatment were enrolled in a multi-center prospective study. Adhesive Capsulitis Embolization (ACE) was performed with 75 or 200 um spherical particles. Subjects were assessed before and after the procedure with MRI, VAS (0-100 mm), Single Assessment Numeric Evaluation (SANE, 0-100), and American Shoulder and Elbow Surgeons (ASES, 0-100) scores. Adverse Events (AEs) were recorded at all follow-up time points.

RESULTS

Hypervascularity was identified and embolization was technically successful in all patients with 83 arteries embolized in 20 patients. Baseline VAS, SANE, and ASES scores before the procedure were 89.2 mm, 27.2, and 30.9 mm, respectively. 1 (n=19), 3 (n=18), and 6 (n=12) months follow-up demonstrated significant improvements: 1 mo VAS (Δ Mean = -31.8, p = 1.2E-11), SANE (Δ Mean = 22.1, p = 1.8E-8), and ASES (Δ Mean = 14.2, p = 4.3E-5): 6 mon VAS (Δ Mean = -62.1, p = 7.0E-11) SANE (Δ Mean = 55.4, p = 4.1E-10), and ASES (Δ Mean = 44.5, p = 1.8E-6). Due to the coronavirus pandemic, the study was ended early and six patients did not complete the 6-month follow-up. No major adverse events were noted.

CONCLUSION

Interim findings suggest that arterial embolization is safe and effective for patients with AC refractory to conservative treatment.

Transcatheter Arterial Embolization Using Imipenem/Cilastatin Sodium for Chronic Low Back Pain Resistant to Conservative Treatment: A Pilot Study with 2-Year Follow-Up

PURPOSE

To evaluate the safety and 2-year follow-up clinical outcomes of transcatheter arterial embolization (TAE) using imipenem/cilastatin sodium for chronic low back pain resistant to conservative treatment.

MATERIALS AND METHODS

A retrospective review identified 14 patients who underwent TAE for chronic low back pain between October 2017 and August 2018. Patients with low back pain related to the facet or sacroiliac joint, lasting ≥ 6 months, refractory to ≥ 3 months of conservative treatment were eligible for TAE. Each patient received embolization of feeding arteries of painful regions. The changes in brief pain inventory (BPI) scores, adverse events, and the Oswestry Disability Index (ODI) were evaluated at baseline and 1, 3, and 24 months after TAE. Clinical success was defined as BPI maximum pain intensity decrease of ≥ 2 and ODI decrease of ≥ 10 points from baseline.

RESULTS

Follow-up data were available in 13 and 11 patients, at 3 and 24 months after embolization, respectively. Intention-to-treat clinical success was obtained in 11/14 (79%) of patients at 3 months and 8/14 (57%) of patients at 24 months after TAE. Mean BPI maximum pain intensity and ODI scores decreased significantly from baseline to 1, 3, and 24 months after treatment (7.6 vs.. 4.3, 3.4, and 4.1; 40.8 vs 21.5, 20.0, and 23.8, respectively; all P < 0.01). No major adverse events were associated with the procedures.

CONCLUSION

TAE is one possible treatment option for patients with chronic low back pain refractory to conservative treatment.

Current Status of Trans-Arterial Embolization in Pain Management of Musculoskeletal Inflammatory Conditions - An Evidence-Based Review

OBJECTIVE

To summarize the literature on trans-arterial embolization in inflammatory musculoskeletal conditions, focusing on efficacy and safety.

MATERIALS AND METHODS

PRISMA guidelines were followed. A systematic literature search revealed 19 studies, with a total of 394 participants, eligible for inclusion.

RESULTS

The included studies consisted of case reports/series and non-randomized interventional studies, with knee osteoarthritis and adhesive capsulitis of the shoulder as the most frequent conditions. In all studies except one, pain was reduced up to four years after treatment. All adverse events were transient. Due to high heterogeneity, meta-analysis was not possible.

CONCLUSION

The included early studies showed encouraging results regarding efficacy and safety. However, randomized, placebo-controlled trials are warranted.

Intra-arterial Infusion of Temporary Embolic Material in a Patient with Plantar Fasciitis: A Case Report

This case report concerns a 51-year-old woman with a 6-month history of severe right heel pain diagnosed as plantar fasciitis (PF) treated with intra-arterial infusion of imipenem/cilastatin (IPM/CS) through a 24G indwelling needle directly inserted into the posterior tibial artery (PTA). Angiography of the indwelling needle immediately before the infusion of IPM/CS demonstrated an increased number of abnormal vessels at the calcaneal attachment of the plantar fascia. Two procedures were planned: The first procedure was performed, and the second was performed 1 month after the first. A week after the first treatment, her pain gradually decreased. Three months after the first treatment, she no longer had difficulties with activities of daily living. Intra-arterial infusion of IPM/CS directly through an indwelling needle into the PTA represents a minimally invasive embolic treatment option for PF.

Short-term Results of Transcatheter Arterial Embolization for Chronic Medial Epicondylitis Refractory to Conservative Treatment: A Single-Center Retrospective Cohort Study

PURPOSE

To evaluate the effectiveness and safety of transcatheter arterial embolization (TAE) for chronic medial epicondylitis (ME) refractory to conservative treatments.

MATERIALS AND METHODS

This retrospective study included ten patients (14 procedures) who underwent TAE between May of 2018 and April of 2020 to treat chronic ME refractory to conservative treatments for at least 3 months. Imipenem/cilastatin sodium was used in 12 procedures, and quick-soluble gelatin sponge particles were used in the ensuing two procedures as an embolic agent. The visual analogue scale (VAS, 0-10) score and Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH) scores were assessed at baseline and at different post-treatment times (1 day; 1 week; 1, 3, and 6 months; and an open period). The clinical success of the procedure was defined as a decrease of more than 70% in the Quick-DASH scores at 6 months compared to the baseline.

RESULTS

Clinical success was achieved in 12 of 14 procedures (85.7%). No major complications were observed during the follow-up periods. The mean VAS scores were significantly decreased at 1 day, 1 week, 1 month, 3 months and 6 months (7.6 at baseline vs. 3.6, 3.6, 3.6, 3, and 0.9 after treatment; all P < .01). The mean Quick-DASH scores at baseline decreased significantly at 1 day, 1 week, and at 1, 3, and 6 months after treatment (71.9 vs. 48.5, 44, 37.7, 30.2, and 8.4; all P < .01). These improvements endured in nine patients for up to 12 months after treatment.

CONCLUSION

TAE effectively and safely relieved pain and promoted functional recovery in chronic ME patients refractory to conservative treatments. TAE may be a feasible treatment option for patients with ME intractable to conservative treatments.

A Rat Model of Frozen Shoulder Demonstrating the Effect of Transcatheter Arterial Embolization on Angiography, Histopathology, and Physical Activity

PURPOSE

To assess the angiographic findings and the effects of transcatheter arterial embolization on physical activity and histopathology using a frozen shoulder rat model.

MATERIALS AND METHODS

First, the angiographic and histopathologic findings of rats in which the shoulder was immobilized with molding plaster for 6 weeks (n = 4) were compared to control rats with normal non-immobilized shoulders (n = 4). Next, a total of 16 frozen shoulder rats were divided into 2 groups. In the transcatheter arterial embolization group (n = 8), imipenem/cilastatin was injected into the left thoracoacromial artery. The changes of physical activity before and after procedures were evaluated and compared with a saline-injected control group (n = 8). Histopathologic findings were also compared between the 2 groups.

RESULTS

Angiography revealed abnormal shoulder staining in all of the rats with a frozen shoulder. On histopathology, the numbers of microvessels and mononuclear inflammatory cells in the synovial membrane of the joint capsule were significantly higher compared with the control rats (both P = .03). In the transcatheter arterial embolization group, the running distance and speed were improved (P = .03 and P = .01, respectively), whereas there were no significant differences in the control group. The number of microvessels and mononuclear inflammatory cells in the transcatheter arterial embolization group were significantly lower than the control group (P = .002 and P = .001, respectively).

CONCLUSIONS

The rat frozen shoulder model revealed the development of neovascularization. Transcatheter arterial embolization decreased the number of blood vessels and inflammatory changes in the frozen shoulder and increased the moving distance and speed of the rats.

Clinical Outcomes of Transcatheter Arterial Embolization for Secondary Stiff Shoulder

PURPOSE

To assess the clinical outcomes of transcatheter arterial embolization (TAE) for secondary stiff shoulder (SSS).

MATERIALS AND METHODS

This is a retrospective analysis of prospectively collected data performed between January 2017 and December 2019. This study comprised 25 patients (20 women and 5 men; median age, 49 years; range 27-59) with SSS resistant to conservative management during at least 3 months. The median time of stiffness was 12 months. The etiology of SSS was postoperative in 14 patients (56%) and posttraumatic in the remaining 11 patients (44%). Periods of immobilization in all patients were associated. TAE was performed, and technical aspects, adverse events, changes for pain, and physical examination before and 6 months after TAE were assessed.

RESULTS

Abnormal vessels were observed in 20 of 25 (80%) of the procedures. Transitory cutaneous erythema was noted in 4 patients treated after TAE. Significant differences were observed in the median pain visual analog scale reduction between before and 6 months after TAE (8 vs 2, P < .001). Shoulder mobility significantly improved in both flexion and abduction degrees between before and at 6 months after TAE in (70° vs 150°; P < .001). No symptoms of recurrence appeared.

CONCLUSIONS

TAE can result in pain reduction and mobility improvement in patients with SSS refractory to conservative therapy.

Genicular Artery Embolization to Improve Pain and Function in Early-Stage Knee Osteoarthritis-24-Month Pilot Study Results

Ten patients with painful early-stage knee osteoarthritis underwent transcatheter arterial embolization of neoangiogenic branches from genicular arteries. At 12 months, 6 patients had responded to treatment according to study criteria. Median pain, function, and quality-of-life scores had improved by 15.4%, 21.3%, and 100%, respectively, for the 10 patients. Median 30-second chair stand test and 6-minute walk test scores had improved by 43% and 26%, respectively. No major adverse events occurred. Improvements following transcatheter arterial embolization provide evidence that embolization might be an effective treatment technique for people with early-stage knee osteoarthritis, although more rigorous evaluation is required.

Mid-Term Results of Transcatheter Arterial Embolization for Adhesive Capsulitis Resistant to Conservative Treatment

PURPOSE

To evaluate the mid-term clinical outcomes of transcatheter arterial embolization (TAE) for adhesive capsulitis (AC) resistant to medical treatments.

MATERIALS AND METHODS

This is a prospective analysis performed between February 2016 and February 2020. Inclusion criteria for TAE were shoulder pain, restriction of movement and no response to conservative treatment for at least 3 months. Demographic variables, risk factors, technical aspects, adverse events, changes by visual analogue scale (VAS) for pain and physical examination before and after TAE were assessed.

RESULTS

This study included 40 patients with AC (35 women and 5 men; mean age 50 ± 9 years old). Abnormal vessels were observed in 31/40 (77.5%) procedures. As embolic agent, imipenem/cilastatin was used. The mean follow-up was 21.2 ± 10.5 months. Significant differences were obtained in terms of pain reduction before and 6 months after TAE with the median visual analogue scale (VAS) of 8 vs. 0.5, P = 0.0001. Substantial differences were found regarding mobility in flexion and abduction before and 6 months after embolization, respectively (79.5° ± 18.5° vs. 133° ± 24.5°, P = 0.0001; 72.4° ± 18.8° vs. 129.7° ± 27.9°, P = 0.0001). No complications occurred. Complete recovery was obtained in 37/40 (92.5%) patients and partial recovery in 2/40 (5%). No clinical recurrence appeared.

CONCLUSIONS

Clinical results of transcatheter arterial embolization with imipenem/cilastatin are effective and stable in the mid-term follow-up for patients presenting with AC resistant to conservative treatments.

Effects of Transcatheter Arterial Microembolization on Persistent Trapezius Myalgia Refractory to Conservative Treatment

PURPOSE

To evaluate the safety and efficacy of transcatheter arterial microembolization for patients with trapezius myalgia.

MATERIALS AND METHODS

We retrospectively evaluated the prospectively collected data of patients with trapezius myalgia for > 6 months who were refractory to conservative treatment and were treated by transcatheter arterial microembolization between October 2017 and January 2019. Transcatheter arterial microembolization was performed using imipenem/cilastatin on the vessels of the transverse cervical artery, suprascapular artery, and circumflex scapular artery according to the region of pain.

RESULTS

Forty-two patients were treated by transcatheter arterial microembolization and followed up for 6 months. No major adverse events occurred related to the procedures. The brief pain inventory worst pain scores significantly improved at 1, 2, 3, and 6 months after transcatheter arterial microembolization (8.6 ± 1.3 (before procedure) vs. 5.1 ± 2.9, 4.4 ± 2.9, 4.1 ± 2.8, and 3.9 ± 2.9, respectively, P < 0.001). The brief pain inventory pain interference scores, including general activity, mood, walking ability, normal work, relations with others, sleep, and enjoyment of life, also significantly decreased at 1, 2, 3, and 6 months after transcatheter arterial microembolization compared to those at baseline (all P < 0.01). The clinical success rate at 6 months after transcatheter arterial microembolization was 71.4% (95% confidence interval, 55.4-84.3%).

CONCLUSION

Transcatheter arterial microembolization is a safe and effective treatment for persistent trapezius myalgia. Further evaluation with a control group is needed to confirm the effects of transcatheter arterial microembolization.

LEVEL OF EVIDENCE

Level 4, Case Series.

[Transarterial Periarticular Embolization (TAPE): Indications and Initial Experience in Germany]

PURPOSE

 The purpose of this article is to demonstrate the potential indications, procedural technique and initial results of the transarterial periarticular embolization (TAPE).

MATERIAL AND METHODS

 TAPE was performed in three patients with chronic pain in different joints. In the first case the patient suffered from osteoarthritis of the shoulder, in the second case from epicondylitis humeri ulnaris ("golfer-elbow") and in the third case from patellar tendinitis ("jumpers-knee"). Clinical as well as pain assessment was performed pre and post-interventionally.

RESULTS

 TAPE was performed with technical success in all three patients. For vessel access, either a transradial or transfemoral access was chosen. The joint supplying vessels were catheterized superselectively with microcatheters and embolized with Imipenem/Cilastatin diluted in contrast medium. After embolization of the knee the patient demonstrated skin redness, which disappeared within one week. No further complications were noted. All patients reported significant pain relief within the first day after intervention.

CONCLUSION

 TAPE is a novel therapy for the treatment of persistent, chronic joint pain and tendinopathies, supported by publications from institutes outside of Europe. The initial experiences made in our institute are encouraging and suggest that TAPE may have the potential as an adjunct therapy option for patients with therapy-resistant chronic joint and tendinopathy-pain.

KEY POINTS

  · TAPE is a novel therapy for treatment of degenerative joint pain and tendinopathies. · TAPE is a technically challenging endovascular procedure and requires high interventional expertise. · TAPE may have the potential to develop to a minimally-invasive therapy option for patients with chronic joint pain.

CITATION FORMAT

· Katoh M, Schott P, Freyhardt P et al. Transarterial Periarticular Embolization (TAPE): Indications and Initial Experience in Germany. Fortschr Röntgenstr 2020; 192: 1046 - 1052.

Short-term follow-up of embolization of hip synovitis

Background

Osteoarthritis (OA) is the most frequent joint disease, affecting 10% of men and 18% of women older than 60 years worldwide. Traditionally, treatment is based in pain management with joint replacement of end-stage disease. In this setting, transcatheter embolization has emerged as an alternative in reduction of pain in patients with OA.

Case presentation

A 77 years-old female presenting with two previous deep vein thrombosis and 10 years of hip pain. Magnetic resonance demonstrated a focal area of enhanced pericapsular signal near the superolateral margin of the acetabulum. Embolization of branches of the ascending branch of the lateral femoral circumflex artery was performed, with decrease of the pain and improvement in the image and her walking ability in a four-month follow-up.

Conclusion

This case report have shown that embolization of hip synovitis is feasible with early clinical success, in tune with the findings of genicular and shoulder embolization. Studies with more patients and long-term results are necessary to corroborate this finding.

Level of evidence

4