geniculate artery embolization: how i do it?...technique • technically challenging – large...

Geniculate Artery Embolization: How I Do It?

Jafar Golzarian

Faculty Disclosures

Jafar Golzarian: Consultant – BSCI, Guerbet, Medtronic, Penumbra, QX Medical, Shape Memory, Sirtex

Dr. Jafar Golzarian has disclosed that the off-label use of particles will be discussed.

Brand names are included in this presentation for participant clarification purposes only. No product promotion should be inferred.

Access & Diagnosis

• Femoral approach, 5Fr short sheath most of the time• Up and Over• 5 Fr JB1

– AP view– Oblique/Lateral view

• Total Knee replacement

• Evaluate areas of hypervascularization with blush– OA vs Hemarthrosis

• Select the appropriate artery (ies) based on patient’s symptoms

Technique

• Technically challenging– Large conduits/small Genicular– Steep angles (>90 degree)– Rich collateral pathways

• Microcatheters:– 0.20/0.24”– Swan Neck shape ideal for superior and inferior

Genicular

• 65-year-old man referred for management of left knee

swelling and pain post partial knee replacement

• The patient had a surgery 15 years

• Swelling and inflammation started after when long walk

• He is using crutches to walk

• Had few drainage with some bloody fluid

Choice of Embolic• Agents that have been used

– Microspheres (100-300u vs 300-500 u)– Microcoils– Gelatin particles– PVA– Onyx– NBCA Glue

– For OA: Resorbable • Resorption time?

Temporary Embolic particle

Woodhams et al. Springerplus. 2013

• Imipenem/Cilastatin sodium (IPM/CS)

• Approved as an antibiotic

• Compound slightly soluble to water

• Forming small particle (diameter is 10-70 u) • when we suspend with 5-10ml of contrast

• Already in use as an embolic agent in Japan from 1990 to stop intestinal tumor bleeding (oozing) due to its safety profile

• Patient referred for recurrent symptomatic hemarthrosis following left total knee replacement 7 years ago

• Was doing well until 6 months ago, when she noticed sudden onset of painful swelling of left knee

• The pain (sharp) rated 10/10 subsided in 1 to 2 days. It changed to a radiating pain down the leg with slow resumption of normal activities

• These episodes were not related to any kind of activity. The patient has had 3 aspirations of 50-70 cc of bloody fluid

At the day of the procedure: she noticed Irregular patches (Blotches) at medial above kneePinkishLater these areas became tender to touch

Few days later: underlying lumps beneath these areas However the pain and tenderness has progressively gotten better

The skin over the lesions started to peel off around a week time

At three weeks, no more pain but redness and lump

At 3 month

Non-Target

• Studies show high rate of nontarget embolization• Use of good embolization technique is important• Recognize the collateral vessels• During embolization, the flow changes and more

normal vessels and collaterals may be visualized• Use of reflux reduction microcatheter may be helpful

• Patient with hemophilia

• Left TKA and tibial nail removal in 5/7/2019

• Pain, swelling and reduction of range of motion

• Needs to use crutches to walk

• Multiple aspirations of dark blood

• The knee examination shows swelling, and the

left knee feels much warmer than the right

Tips • Slow and steady injection of microspheres• The amount of particles needed for even the largest

Genicular arteries (Descending branches) are very low

• Goal is to reach reduction of blush as much as possible

• In case of important collateral pathways coil embolize– Or >300 Microns microspheres

• Early experience• GAE can be technically challenging

– Small collaterals and pathways– Steep angles

• Slow injection of the Microspheres is important• Small amount of particles are needed. • 300-500 Microns• Look for reflux• Use Reflux reduction catheters if possible

Conclusion