GAE Anatomy Considerations

Genicular Artery Embolization: A Review of Essential Anatomic Considerations

Given the nature of this featured article, a pictorial summary rather than a text summary is provided here.

Take away point

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.

Reference

Liu, S., Swilling, D., Morris, E.M., Macaulay, W., Golzarian, J., Hickey, R. and Taslakian, B., 2023. Genicular Artery Embolization: A Review of Essential Anatomic Considerations. Journal of Vascular and Interventional Radiology.

Click here for abstract

Study design

Review

Funding Source

None

Setting

Academic

Figure

Figure 1 A schematic diagram showed the descending genicular artery (1), saphenous branch (2), articular branch (3), superior lateral genicular artery (4), superior medial genicular artery (5), middle genicular artery (6), inferior lateral genicular artery (7), inferior medial genicular artery (8), and anterior tibial recurrent artery (9).



Figure 2 A 61-year-old person with osteoarthritis. Digital subtraction angiography (DSA) from the superficial femoral artery. Frontal view showed the descending genicular artery (1), saphenous branch (2), articular branch (3), superior lateral genicular artery (4), superior medial genicular artery (5), medial sural artery (S), inferior lateral genicular artery (7), and inferior medial genicular artery (8).



Figure 3 A 50-year-old person with osteoarthritis. Angiographic findings of the descending genicular artery. In the frontal view, the descending genicular artery arose medially from the superficial femoral artery and bifurcated into an articular branch (1) and common trunk of the muscular branch (2) and saphenous branch (3). The articular branch ramified into a subsegmental articular branch (4) supplying the patellofemoral space and a subsegmental articular branch (5) supplying the medial tibiofemoral joint space.



Figure 4 A 50-year-old person with osteoarthritis. Variant descending genicular artery branching pattern with angiography performed from the superficial femoral artery. The descending genicular artery bifurcated into a saphenous (1) and articular branch (2) with an inverted “Y” shape. The muscular branch (3) arose directly from the superficial femoral artery.



Figure 5 A 68-year-old person with osteoarthritis. Digital subtraction angiography (DSA) of the superior lateral genicular artery in the frontal projection showed a cutaneous branch (1), superficial patellar branch (2), deep branch (3), articular branch (4), middle genicular artery arising from a common trunk with the superior lateral genicular artery (5), and collateralization with the inferior lateral genicular artery (6).



Figure 6 A 61-year-old person with osteoarthritis. There was a common origin of the superior medial genicular artery (1) and middle genicular artery (2). The superior medial genicular artery ran along the medial femoral condyle toward the medial tibiofemoral joint.



Figure 7 A 68-year-old person with osteoarthritis. Angiography performed from the articular branch of the descending genicular artery when there was an absent or diminutive superior medial genicular artery demonstrated branches (white arrows) supplying territory usually perfused by the superior medial genicular artery and retrograde opacification of the superior lateral genicular artery branches (black arrows).



Figure 8 A 68-year-old person with osteoarthritis. Variant origin location of the inferior lateral genicular artery (ILGA). The inferior medial genicular artery (1) and ILGA (2) shared a common trunk off the popliteal artery near the joint line. The ILGA gave off a muscular (3) and fibular branch (4).



Figure 9 A 67-year-old person with osteoarthritis. Angiography of the inferior medial genicular artery (1) showed supply of the medial tibiofemoral joint with hypervascularity prior to embolization.



Figure 10 A 67-year-old person with osteoarthritis. Course of the middle genicular artery with a variant origin. The middle genicular artery (1) shared a common trunk with the superior lateral genicular artery (2) and coursed inferiorly.



Figure 11 A 68-year-old person with osteoarthritis. There was robust collateralization between the anterior tibial recurrent artery (1) and inferior lateral genicular artery (2).



Figure 12 A 75-year-old person with osteoarthritis. There was a common origin (1) of the sural artery (2) and inferior lateral genicular artery (3) arising off the posterior aspect of the popliteal artery. There was also a variant origin of the inferior medial genicular artery (4) arising from the tibioperoneal trunk.



Figure 13 A 61-year-old person with osteoarthritis. Robust collateralization of the genicular arteries. Injection from the inferior medial genicular artery (1) showed collateralization with the articular branch of the descending genicular artery (2).



Figure E1 A 68-year-old person with osteoarthritis. Digital subtraction angiography (DSA) from the superficial femoral artery. Lateral view showed the sural artery (1), superior lateral genicular artery (2), common trunk of the inferior medial genicular artery and inferior lateral genicular artery (3), inferior medial genicular artery (4), and inferior lateral genicular artery (5). A = anterior; P = posterior.



Figure E2 A 50-year-old person with osteoarthritis. Angiographic findings of the descending genicular artery. In the lateral view, the articular branch (1) coursed anteriorly. The saphenous branch (2) was, by comparison, more posterior and ran with the distribution of the saphenous nerve. The saphenous branch extended inferiorly with collateralization to the cutaneous branches of the inferior medial genicular artery (3). A = anterior; P = posterior.



Figure E3 A 50-year-old person with osteoarthritis. Descending genicular artery branching pattern with angiography performed from the descending genicular artery. The articular branch (1) was lateral to the saphenous branch (2). A diminutive muscular branch (3) supplying the vastus medialis arose from the proximal articular branch. Numerous cutaneous branches (open arrows) that extended to the skin originated from the saphenous branch.



Figure E4 A 67-year-old person with osteoarthritis. Digital subtraction angiography (DSA) of the superior lateral genicular artery in the lateral view showed the musculocutaneous branch (1), cutaneous branch (2), articular branch supplying the patellofemoral joint (3), and reflux into the sural (4) and popliteal (5) arteries. A = anterior; P = posterior.



Figure E5 A 67-year-old person with osteoarthritis with no identifiable superior medial genicular artery on angiography from the popliteal artery. Angiography from the superior lateral genicular artery demonstrated cross midline continuation of the superior lateral genicular artery to supply the superior medial genicular artery territory (circle). Additionally, there was retrograde opacification of the inferior lateral genicular artery (1).



Figure E6 A 68-year-old person with osteoarthritis. Variant origin location and angulation of the inferior lateral genicular artery. Low origin of the inferior lateral genicular artery (1) from the distal segment of the popliteal artery with collateral branches (2) to the superior lateral genicular artery (3).



Figure E7 A 50-year-old person with osteoarthritis. Angiographic findings of the inferior medial genicular artery. Injection of the inferior medial genicular artery (1) demonstrated retrograde opacification of the descending genicular artery’s articular (2) and saphenous (3) branches.



Figure E8 A 61-year-old person with osteoarthritis. Course of the middle genicular artery with a variant origin. The middle genicular artery (1) shared a common trunk with the superior medial genicular artery (2) and coursed inferiorly to enter the posterior aspect of the tibiofemoral joint. A = anterior; P = posterior.



Figure E9 Room setup with patient positioned on the fluoroscopy table with the target knee at the isocenter. The nontreatment knee was positioned as close to the edge of the table as the patient could tolerate comfortably to reduce overlap on various angulation and artifact during cone-beam computed tomography (CT). (a, b) The procedure table was set up perpendicular to the fluoroscopy table at the level of the groin access so that the used microcatheter and wire could be easily rested on the table. (c) The proceduralist stood on the cranial or caudal side of the table depending on the laterality of the target knee. A separate smaller embolization stable was set up to help avoid contamination of the equipment with embolic material (not shown).



Figure E10 A 75-year-old person with osteoarthritis. There was a common origin (1) of the sural artery (2) and inferior lateral genicular artery (3) arising off the posterior aspect of the popliteal artery. There was also a variant origin of the inferior medial genicular artery (4) arising from the tibioperoneal trunk. A = anterior, P = posterior.



Figure E11 A 61-year-old person with osteoarthritis. Robust collateralization of the genicular arteries. Injection from the inferior lateral genicular artery (1) showed collateralization with the articular branch of the descending genicular artery (2).

Commentary

This review discusses the genicular arteries and advises avoiding certain branches during genicular artery embolization (GAE) when possible. However, there are limitations to consider. While some outcomes of embolizing cutaneous branches are described, there's limited data on the clinical implications or chronic effects of nontarget embolization. Anatomic descriptions are based partly on cadaveric data, which may not fully represent GAE patients. The inflammatory state in GAE patients may lead to larger branch sizes and altered anatomy. Furthermore, genicular artery anatomy might change in patients who undergo GAE for hemarthrosis after total knee arthroplasty. Despite these limitations, understanding knee vascular supply is crucial for successful GAE and reducing nontarget embolization risk. Practicing good clinical technique by embolizing distal to tissue-supplying branches and assessing anastomoses presence may help minimize adverse events.