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

Clinical question
Is genicular artery embolization safe and effective for treatment of refractory hemarthrosis following total knee arthroplasty?

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

Reference
Cornman-Homonoff, J., Kishore, S.A., Waddell, B.S., Kesler, J., Mandl, L.A., Westrich, G.H., Potter, H.G., Trost, D.W., 2021. Genicular Artery Embolization for Refractory Hemarthrosis following Total Knee Arthroplasty: Technique, Safety, Efficacy, and Patient-Reported Outcomes. Journal of Vascular and Interventional Radiology 32, 1128–1135.. doi:10.1016/j.jvir.2021.04.020

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Study design
Retrospective review of patients who underwent genicular artery embolization between 2010 – 2020 at a single institution. Inclusion of patients who had previous total knee arthroplasty and experienced recurrent refractory hemarthrosis diagnosed either by clinical exam or arthrocentesis.

Funding Source
No reported funding

Setting
Academic setting:
Department of Radiology, Division of Interventional Radiology, NewYork-Presbyterian/Weill Cornell Medical Center.
Department of Radiology, Division of Interventional Radiology Memorial Sloan Kettering Cancer Center.
Department of Orthopedic Surgery, Department of Medicine and Department of Radiology and Imaging Hospital for Special Surgery.
New York, New York

Figure

Summary

Recurrent and repetitive bleeding into the joint (hemarthrosis) can be a debilitating complication of total knee arthroplasty. Current literature estimates about 0.1 – 1.6% incidence following surgery. Short term sequelae of recurrent hemarthrosis include wound breakdown, poor healing, and joint sepsis. Long term sequelae include painful swelling, joint stiffness, and impaired function. Impingement secondary to hypertrophic synovium is the most common cause. Current regimens include initial conservative measures such as immobilization and arthrocentesis. A large subset of patients will however require intervention for refectory hemarthroses with current therapies including arthroscopic and open synovectomy. The purpose of this study was to examine the technical aspects, safety, and efficacy of genicular artery embolization for postoperative hemarthrosis after total knee arthroplasty.

Pertinent demographic data was collected on patients meeting the inclusion criteria for the retrospective review as described above. All patients were initially managed conservatively and had pre-procedure MR angiography demonstrating synovial hyperemia as the causative factor. Pertinent exclusion criteria included additional causes such as presence of pseudoaneurysm formation or AV malformation. 81 patients were included with 1 patient having bilateral knee treatment during the study time frame. Patients had a mean age of 65 years, body mass index of 28 kg/m^2 with 57% male. 2.6% of patients had bleeding diathesis, 23.1% of patients were on antiplatelet therapy only, 5.1% of patients were on anticoagulation only, and 6.4% were on both. Average time from surgery to symptom onset was 14.9 months, average time from symptom onset to first embolization was 9.2 months.

Technical success was defined as angiographic resolution of synovial blush following treatment and clinical success was defined as resolution of hemarthrosis on follow up. Clinical follow up was obtained 7-14 days following embolization with additional follow up obtained in 3-month intervals via telephone interviews. All patients achieved technical success. Clinical success was identified as 56.1%, 79.3% and 85.4% following 1st, 2nd and third treatments. Complications were classified using SIR adverse event criteria, with mild, moderate, and severe complications. 12.8% (17) of treatments resulted in complications with the majority (15) considered mild. 14 of these were episodes of periarticular skin mottling, appropriately treated and responsive to conservative measures. There was a single moderate complication, an access site pseudoaneurysm, treated percutaneously with thrombin injection. The single severe complication was septic arthritis requiring surgery and prosthesis removal.

Commentary

This study adds to the existing literature describing genicular artery embolization (GAE) for refractory hemarthrosis with a larger data set and patient cohort. The authors evaluated the efficacy of GAE with results comparable to the existing data, achieving clinical success of 85%, with reported rates of 80-92% in the existing series. An important aspect of the study was the focus on repeat embolization. Repeat intervention was pursued in 34% of patients with refractory hemarthrosis with increasing clinical success with each additional treatment. 7 knees in the study underwent 3 interventions. As the authors mentioned, this may lead some to believe that initial treatments may have been incomplete despite immediate technical success. However, the need for repeat embolization may also be attributed to collateralization of the hyperemic synovium with subsequent incomplete regression and continued synovial impingement causing refractory hemarthrosis. Future studies and efforts may be well suited to delineate the timing of repeat intervention in relation to initial and subsequent symptomatology.

As mentioned above, the complication rate for the series was quite low. The most common complication identified was periarticular skin mottling. All instances identified in this series were effectively managed with conservative measures alone. Additionally, the authors noted the skin mottling was less prevalent when using larger particles (greater than 300 micron). The most severe complication was septic arthritis following embolization which required prosthesis removal and replacement. Of note, the affected patient did receive arthrocentesis following embolization and prior to the joint infection, making the exact etiology unclear. Prior studies have also described singular instances of septic arthritis with all protocols requiring preprocedural antibiotics.

The limitations of this study remain its retrospective analysis and somewhat subjective quality. Throughout the 10-year course of the study, the authors acknowledge some fine tuning of the technical aspects of the procedure; including particle size selection which introduced some data heterogeneity. Additionally, most cases were performed by a single operator which may reduce its overall reproducibility and generalizability. Follow up was obtained via telephone interviews which may introduce bias from patient reviews. The patients were referred at the discretion of the treating orthopedic surgeon after variable conservative management and symptomatology. A standardized referral pattern and treatment would be beneficial for future studies.

Post Author
Ahmad Hashmi, MD
PGY-5 ESIR,
University Hospitals Cleveland Medical Center,
Case Western Reserve University
@afhashmi2

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Perioperative Blood Loss after Preoperative Prostatic Artery Embolization in Patients Undergoing Simple Prostatectomy: A Propensity Score‒Matched Study

Clinical question
Is preoperative prostatic artery embolization (PAE) safe and effective at reducing intraoperative blood loss?

Take-away point
Preoperative bilateral PAE safely and effectively reduces intraoperative bleeding and operative time.

Reference
Sare A, Kothari P, Cieslak JA, et al. Perioperative blood loss after preoperative prostatic artery embolization in patients undergoing simple prostatectomy: a propensity score‒matched study. Journal of Vascular and Interventional Radiology. 2021;32(8):1113-1118.

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Study design
Retrospective cohort study

Funding source
Self-funded or unfunded

Setting
Single institution, Rutgers – New Jersey Medical School, Newark, NJ

Figure




Figure. (a) Mean estimated blood loss (mL) with standard deviations during prostatectomy in the group with embolization before surgery versus control group. (b) Mean operative time (minutes) of prostatectomy in the group with embolization before surgery versus control group. PAE = prostate artery embolization.

Summary

Benign prostatic hyperplasia (BPH) is a common cause of lower urinary tract symptoms, affecting most men over the age of 60 years of age and >80% of men at or above the age of 70. First-line treatment has historically involved lifestyle modifications and pharmacotherapy with 5-a-reductase inhibitors, a-blockers, and phosphodiesterase inhibitors, with surgery being recommended if these measures fail to provide adequate relief. Surgical options include TURP and prostatectomy, with complication rates increasing with increased prostate size. The most common complication is bleeding requiring transfusion, which has been shown to occur in 11.9% of patients undergoing open prostate resection, which is generally performed for patients with larger prostates. Preoperative embolization has been shown to be a safe and effective method of reducing operative estimated blood loss (EBL), transfusions, and hospital length of stay (LOS) for resection of a variety of hypervascular tumors, but has not yet been evaluated in patients undergoing prostatectomy.

In this retrospective case series, 63 patients with prostatic hypertrophy with severe lower urinary tract symptoms (LUTS) were analyzed. All patients had prostates with mass > 80 grams and subsequently underwent prostatectomy. Patients either underwent bilateral PAE or no embolization prior to the procedure; patients undergoing unilateral PAE were excluded. Data collected included demographics, comorbidities, preoperative prostate volume (by transrectal ultrasound), method of prostatectomy, PAE technical details, pre- and post-operative hematologic labs, EBL, operative time, transfusion, and duration of post-operative continuous bladder irrigation (CBI). In patients who underwent embolization, bilateral PAE was performed using 250-μm hydrogel microspheres until cessation of anterograde flow, followed by gelfoam slurry injection. Patients then underwent either robotic prostatectomy or open suprapubic prostatectomy within 2 weeks of PAE.

60 patients were analyzed in this study, including 16 patients undergoing bilateral PAE and 44 patients in the non-embolization arm. 32 of the non-embolization patients were used from the 44 for 2:1 propensity score-matching. In the embolization group, 11 patients underwent robotic prostatectomy while 5 underwent open suprapubic prostatectomy compared to 10 and 22 patients respectively in the non-embolization group. Demographics and baseline characteristics between groups were not significantly different. Median time between PAE and prostatectomy was 6 days (4-18 days). Mean EBL was 303 ± 219.7 ml in the PAE arm compared to 545 ± 380 ml in the non-embolization arm (p < 0.01). Mean operative time was 140.5 ± 35.4 minutes in the PAE arm versus 180.5 ± 56.6 minutes in the non-embolization arm (p < 0.01). Change in hemoglobin during surgery was 2.16 g/dl in the PAE group and 3.50 g/dl in the non-embolization group (p = 0.020). 6% of patients in the PAE group underwent transfusion compared to 19% in the non-embolization group, but with a mean of 0.19 units per patient in the PAE group versus 0.44 in the non-embolization group, which was not significantly different (p = 0.334). LOS did not significantly differ between groups, and no major or minor complications occurred.

Commentary

The AUA recommends surgery as standard of care for BPH; however, large prostates can be challenging to treat and have higher rates of bleeding complications. Prostate artery embolization has been shown to be safe and effective for treating both prostate related hematuria and LUTS. This study demonstrated a decrease in operative blood loss and mean operative time in patients undergoing preoperative PAE before prostatectomy for prostates of large size (>80 g). It did not, however, demonstrate a statistically-significant reduction in LOS or transfusion. The lack of difference in transfusions may be due to low sample size in combination with variability in transfusion thresholds between Urologists. The only prior study similar to the one summarized here found decreased LOS and intraoperative blood loss, but only used change in hematologic lab studies and did not assess EBL. This does suggest that lack of significant difference in LOS in this study may be due to its small sample size. This is an acknowledged limitation of the study in addition to its retrospective nature. One challenge in standardization posited by the authors is the relatively large range of time between PAE and prostatectomy, which may have resulted in differences in the development of collateral circulation prior to surgery, resulting in clinically-significant differences in blood loss. Future investigations should focus on randomized trials involving multiple high-volume centers as well as research into the timeline of collateral generation in the prostatic vasculature. Finally, it would be interesting to evaluate the effectiveness of unilateral dominant PAE for the purpose of operative blood loss reduction.

Post Author
Jared Edwards, MD
General Medical Officer
Medical Readiness Division
Naval Surface Forces Pacific, San Diego, CA
@JaredRayEdwards

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