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.

Glenohumeral Artery Embolization: the next frontier of MSK embolization?

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

Clinical question

Is transarterial embolization for adhesive capsulitis of the shoulder safe and effective?

Take away point

Transarterial embolization for adhesive capsulitis of the shoulder is safe, effective, and with long-lasting clinical improvements.

Reference

Lanciego, C., Puentes-Gutierrez, A., Sánchez-Casado, M., Cifuentes-Garcia, I., Fernández-Tamayo, A., Dominguez-Paillacho, D., Ciampi-Dopazo, J.J. and Marquina-Valero, M.A., 2024. Transarterial Embolization for Adhesive Capsulitis of the Shoulder: Midterm Outcomes on Function and Pain Relief. Journal of Vascular and Interventional Radiology, 35(4), pp.550-557.
Click here for abstract

Study design

Prospective, observational, descriptive study

Funding Source

None

Setting

Academic

Figure

Figure 4(a) Pre-embolic angiogram in the late arterial phase showed areas of hyperemia in territories dependent on the thoracoacromial and anterior humeral circumflex arteries (white arrowheads). (b) Postembolic angiogram showed resolution of the hyperemia after embolization with imipenem/cilastatin sodium (black arrowheads).

Summary

Adhesive capsulitis, commonly known as frozen shoulder, is a condition characterized by pain and progressive loss of both active and passive shoulder mobility, leading to functional disability. While most cases respond to conventional treatments such as physical therapy and medication, about 30% of cases remain refractory to these interventions, resulting in chronic symptoms. Recent studies have explored the role of increased vascularization in adhesive capsulitis and have evaluated the effectiveness of transarterial embolization (TAE) in treating refractory cases by occluding arterioles to reduce inflammation and pain.

This prospective study, conducted from January 2018 to May 2023, involved embolizing arterioles in patients with MRI-compatible adhesive capsulitis and persistence of symptoms for more than 3 months who had not responded to standard treatment. Participants were selected based on clinical and magnetic resonance imaging criteria. Exclusion criteria included patients under 18, those with systemic diseases, shoulder fractures, or a history of shoulder surgery. The embolization procedures were carried out by experienced interventional radiologists and involved arteriography to identify the hypervascular arterial supply to the shoulder capsule (early vascular filling, hyperemia, anomalous vessels, or early venous return,), followed by selective catheterization and embolization using small amounts (0.2–0.4 mL) of suspended microparticles (10–70 μm) formed by diluting a mixture of 500-mg imipenem (IMP) and 500-mg cilastatin sodium (CS) (Aurovitas, Teramo, Italy) in 5–10 mL of iodinated contrast. Embolization endpoint was complete or nearly complete stasis. Safety was assessed by recording adverse events, and effectiveness was measured by improvements in pain and range of motion over a 6-month period post-procedure followed by monthly interview by rehabilitation physicians.

The study included 20 patients, with 60% being women, 95% right-handed, and 30% having diabetes. Significant improvements were noted in shoulder mobility and function, as well as reductions in various types of pain, especially nocturnal pain. No significant adverse events were reported, and most patients experienced sustained benefits, with 70% reporting cessation of analgesic use during long-term follow-up. However, diabetic patients had a less favorable long-term response as they continue to require analgesics.

Musculoskeletal embolization, aiming to break the circle of hypervascularization, pain, and inflammation, is emerging as a potential treatment for inflammatory musculoskeletal conditions refractory to conventional therapy. This study's findings support the safety and effectiveness of TAE, with significant improvements in pain and shoulder mobility observed early on and maintained over time. The use of IMP/CS as an embolic agent appears to be safe, with a low rate of adverse events. While the study adds valuable information to the field, limitations such as a small sample size and lack of a control group suggest a need for larger, multicenter studies with longer follow-up periods to further validate the long-term effectiveness and establish TAE as a standard treatment option for adhesive capsulitis.

Commentary

This article presents a study investigating the use of transarterial embolization as a treatment for adhesive capsulitis (frozen shoulder), which is a condition causing pain and restricted movement in the shoulder. The results suggest that embolization is a safe procedure that can offer significant relief from pain and functional disability in patients with adhesive capsulitis. Clinicians and healthcare professionals could benefit from understanding the potential of transarterial embolization as an alternative treatment for adhesive capsulitis, particularly in cases where standard therapies are ineffective. However, to integrate this knowledge into clinical practice, additional information such as standardized protocols, long-term outcomes validation, comparison with other treatments, and specific considerations for patient selection (e.g., the impact of diabetes on treatment efficacy) would be valuable. Trans-arterial embolization may be considered in the management pathway of shoulder adhesive capsulitis.

Combating Steal: Percutaneous Interventions for Dialysis Access Steal Syndrome

Percutaneous Management of Dialysis Access Steal Syndrome: Interventions and Outcomes from a Single Institution’s 20-Year Experience

Clinical question

To evaluate the outcomes of percutaneous interventions in Dialysis Access Steal Syndrome and assess their safety and effectiveness .

Take away point

Percutaneous interventions in patients with Dialysis Access Steal Syndrome was demonstrated to provide symptomatic improvement, and decrease the need for follow up surgical intervention.

Reference

Rigsby DC, Clark TWI, Vance AZ, Chittams J, Cohen R, Mantell MP, Kobrin S, Trerotola SO. Percutaneous Management of Dialysis Access Steal Syndrome: Interventions and Outcomes from a Single Institution's 20-Year Experience. J Vasc Interv Radiol. 2024 Apr;35(4):601-610. doi: 10.1016/j.jvir.2023.12.566. Epub 2024 Jan 1. PMID: 38171415.

Click here for abstract

Study design

Retrospective single institutional study

Funding Source

None reported

Setting

Academic: Perelman School of Medicine, University of Pennsylvania

Figure

Figure 1. Flow diagram describing patient progression from initial dialysis access steal syndrome (DASS) evaluation by a referring surgeon to interventional radiology (IR) percutaneous study with or without intervention to follow-up. DRAE = distal radial artery embolization.

Summary

 
Dialysis access steal syndrome (DASS) occurs when blood flows preferentially through the dialysis access circuit, depriving downstream tissues of oxygen-rich blood. This can lead to pain, ulcers, and tissue loss in the ipsilateral limb in up to 10% of dialysis patients. Known risk factors for DASS include older age, female sex, diabetes mellitus, coronary artery disease and peripheral arterial disease. Fistulography is recommended for initial diagnostic workup of DASS and can define the vascular anatomy and assess the degree of intervention required. Percutaneous interventions like distal radial artery embolization and minimally invasive ligation endoluminal-assisted revision percutaneous banding procedure can be performed and are described as the percutaneous equivalents to open surgeries, which include surgical access banding, distal revascularization with interval ligation, and distal radial artery ligation. Access ligation, which is the definitive treatment, is used sparingly due to the importance of maintaining hemodialysis access. Data on the clinical performance of percutaneous interventions is limited.

This study used data from a single institution over a period of 20 years. A retrospective chart review was performed for the 212 patients with 286 fistulograms meeting the inclusion criteria. Patient symptoms were recorded, flow through the access was quantified using a flow measurement (ReoCath, Transonic) catheter and categorized via the 2019 Kidney Disease Outcomes Quality Initiative. Each case fell into one of two categories: diagnostic fistulogram alone or undergoing fistulogram plus intervention. Technical success of the procedure was measured by reporting standards published by the Society of Interventional Radiology and clinical success by any reported improvement in DASS symptoms at the next follow up visit. Patients with severe ischemic tissue loss who received prompt surgical intervention were excluded.

The authors used a multiple logistic regression model to analyze the data, investigating the associations between DASS intervention and major adverse events, access preservation, and follow up surgery. Access was considered not preserved if follow up visit notes contained any indication of access abandonment or takedown. Covariates that were used in the regression model were female sex, upper arm access location, graft access type, diabetes mellitus, coronary artery disease and peripheral arterial disease. Odds ratios were also adjusted for correlation among multiple within-patient events using the robust Huber-White procedure.

Fistulograms revealed that 45% of patients had percutaneously treatable causes of DASS. Previous studies have reported anywhere from 20%-83% of patients having treatable causes of steal, but only about 33% of those patients underwent fistulograms before surgery. Two patients experienced adverse events that included a left common femoral artery hematoma and chest pain that required a 2-day hospital admission. The DASS interventions in this study demonstrated high rates of technical (94.0%) and clinical (54.2%) success that were consistent with similar modalities performed by vascular surgery. Analysis identified that the intervention group had 60% lower odds of follow up surgery and 70% lower odds of undergoing access revision surgery. Hemodialysis access preservation rate did not differ between the intervention and nonintervention groups, at an encouraging 88.0%.

There are limitations to this study that are due to its design, as a retrospective review it is unable to determine causality. The restriction to a single center also decreases the generalizability of the results to a broader population. There was a lack of complete follow up data due to an absence of standardized follow up intervals. This was mentioned by the authors that the true clinical success rate could be anywhere from 44% to 54% if all patients that were lost to follow up were accounted for.

Commentary

With an increasing prevalence of people receiving hemodialysis access, this study adds a large patient cohort to the Interventional Radiology literature on percutaneous management of DASS. Their analysis, which revealed that percutaneous interventions provided comparable outcomes to surgical interventions while maintaining a minimal side effect profile, was well designed and appropriately accounted for possible confounding variables. The implication was that Interventional Radiology can play a bigger role in the management algorithm of DASS and percutaneous interventions should be considered the first-line treatment for DASS. As the authors correctly noted, further research focusing on establishing causality through randomized control trials and investigating possible unintended consequences of percutaneous venous outflow optimization will elucidate the roles of percutaneous DASS interventions better.

Post Author

Anthony M. Camargo, BA
MD candidate, Class of 2025
University of Massachusetts Chan Medical School
@anthonymcamargo

Infrapopliteal Calcium Score for PAD

Clinical Utility of Infrapopliteal Calcium Score for the Evaluation of Severity of Peripheral Artery Disease

Clinical question

To identify associations between computed tomography (CT)–based lower-extremity calcium score (LECS) across different anatomic segments and the presence, severity, and clinical outcomes of peripheral artery disease (PAD).

Take away point

An infrapopliteal calcium score of >188 Agatston units was associated with increased odds of having CLTI and was a potent predictor of CLTI and all-cause mortality among claudicants who were prospectively followed.

Reference

Lee, Sujin, Mari Tanaka, Shiv Patel, Nikolaos Zacharias, Sandeep Hedgire, Rajeev Malhotra, and Anahita Dua. "Clinical Utility of Infrapopliteal Calcium Score for the Evaluation of Severity of Peripheral Artery Disease." Journal of Vascular and Interventional Radiology 35, no. 3 (2024): 370-376.

Click here for abstract

Study design

Retrospective multi-institutional database with a prospective component for model validation

Funding Source

None reported

Setting

Academic

Figure

Kaplan–Meier and Cox proportional hazards analysis of chronic limb-threatening ischemia (CLTI) and death among claudicants. Patients with an infrapopliteal calcium score of ≥188 had a significantly higher risk of progressing to CLTI or death compared with those with a calcium score of <188 (log-rank P = .0036). On the univariate Cox proportional hazards model, an infrapopliteal calcium score of ≥188 was associated with a hazard ratio of 5.58 for CLTI or death (P = .0095). LECS = lower-extremity calcium score.

Summary

Vascular calcification is a key feature of atherosclerotic cardiovascular disease, the leading global cause of morbidity and mortality. In peripheral artery disease (PAD), calcification in the lower extremities correlates with increased severity of ischemia and heightened risk of amputation. Despite evidence linking calcification in specific segments to adverse outcomes, the relationship between calcification at different anatomical sites and peripheral artery disease symptom severity remains unclear. This knowledge gap is particularly relevant as current guidelines recommend intervention only at advanced stages of peripheral artery disease symptoms. There is a need for quantitative markers. This study aims to establish associations between computed tomography-based lower-extremity calcium scores and peripheral artery disease symptom presence and severity, to enhance risk assessment and facilitate timely intervention.

This study utilized a multi-institutional database to evaluate patients who underwent CT angiography of the aorta and bilateral lower-extremity runoff between January 2016 and January 2020. Patients were categorized based on documented symptoms, including claudication, ischemic rest pain, and ulcers. A total of 139 patients met inclusion criteria. Lower-extremity calcium scores (LECSs) were quantified using the Agatston method on CT angiography images. Additionally, ankle-brachial index (ABI) and toe-brachial index (TBI) values obtained within 6 months of the CT scan were included. The optimal cutoff point for infrapopliteal calcium score in identifying patients with chronic limb-threatening ischemia (CLTI) was determined using the Youden J statistic and validated using bootstrapping technique. A prospective cohort of claudicants was followed until October 2022 for CLTI and all-cause mortality.

Multivariable analysis identified only hemodialysis and lower ankle-brachial index (ABI) as independent factors associated with increased odds of claudication. Lower-extremity calcium score in any of the anatomic segments was not independently associated with having claudication. On the other hand, multivariable analysis confirmed the independent association of high infrapopliteal calcium scores with CLTI, along with inability to perform daily activities and absence of hemodialysis dependence. Receiver operating characteristic analysis demonstrated improved predictive accuracy for CLTI when including infrapopliteal calcium scores in the model. Prospective follow-up of claudicants revealed that those with infrapopliteal calcium scores ≥188 Agatston units had a significantly higher risk of progressing to CLTI or death compared to those with lower scores. Cox proportional hazards analysis confirmed infrapopliteal calcium score as a robust predictor of CLTI-free survival, even after adjusting for potential confounders.

Arterial calcification is an independent risk factor for cardiovascular morbidity and mortality, but its impact on lower-extremity vasculature remains less understood. CT-based quantification of lower-extremity arterial calcification provides valuable information for risk stratification in PAD patients. Higher infrapopliteal calcium scores may identify patients at earlier stages of disease progression, enabling timely interventions to prevent CLTI and associated adverse outcomes.

Limitations of the study include its small sample size and retrospective design. Additionally, certain factors such as hemodialysis and surgical bypass procedures may confound the associations observed. Further prospective studies with larger cohorts are needed to validate the utility of infrapopliteal calcium score in evaluating peripheral arterial disease progression and guiding clinical management.

Commentary

This is a well done and well written study on the clinical utility of CT lower extremity calcium score for the evaluation of peripheral arterial disease. The methods and statistical analyses were appropriate and the prospective validation was appreciated. The findings have several implications for the management of peripheral arterial disease. First, infrapopliteal calcium score can serve as a prognostic indicator, enabling clinicians to identify claudicants who are at highest risk of disease progression. Second, infrapopliteal calcium scores can inform clinical decision-making regarding the timing and type of interventions. Overall, this study underscores the potential of CT-based lower-extremity arterial calcium score as a valuable tool in the evaluation and management of peripheral arterial disease. Further research and validation studies are warranted to confirm these findings and integrate infrapopliteal calcium scoring into clinical practice effectively.

Percutaneous Lumbar Discectomy (PLD)

Patient-Reported Outcomes and Return to Work after CT-Guided Percutaneous Lumbar Discectomy: A Prospective Study

Clinical question

What capabilities does percutaneous lumbar discectomy have in reducing pain and increasing functional capacities for patients with symptomatic lumbar disc herniation?

Take away point

87% of employed patients were able to return to work during the follow-up, with a median time of 8 days post procedure.

Reference

Ranc, P.-A., Rudel, A., Bentellis, I., Prestat, A., Elbaze, S., Sala, V., Torre, F., Pavan, L.-J., Uri, I. F., & Amoretti, N. (2024). Patient-reported outcomes and return to work after CT-guided percutaneous lumbar discectomy: A prospective study. Journal of Vascular and Interventional Radiology, 35(3), 390–397. https://doi.org/10.1016/j.jvir.2023.12.007

https://www.jvir.org/article/S1051-0443(23)00896-5/fulltext

Study design

Prospective, observational, descriptive

Funding Source

None

Setting

Academic single center, Pasteur 2 Hospital University Medical Center (Nice, France)

Figure

Evolution of the Oswestry disability index (ODI) during the first 6 months

Summary

The purpose of this study was to understand the effectiveness of percutaneous lumbar discectomy under combined CT and fluoroscopic guidance, specifically its effects on pain relief, the length of recovery through hospital stays and/or time taken to return to work. Evaluation of patient-reported outcomes based on validated functional disability indices was also performed.

This study had 87 patients, 57 of which were employed with a median age of 56. The criteria were lumbar radicular pain visualized on magnetic resonance, failure of conservative treatment, and failure or recurrence after a peri-radicular nerve block. Patients were excluded if they had lumbar stenosis, neurologic deficits, or history of previous surgical discectomy at site of pain.

An initial planning CT was obtained to determine the access and approach for the procedure. Transdural or juxtadural access were preferred for central canal zone or subarticular zone hernias, and posterolateral or lateral approaches for herniation of foraminal and extraforaminal topography. 20-gauge guide needle was introduced to the herniated disc with contrast confirmation of its position. The Herniatome decompression probe was utilized for fragmentation and aspiration. Technical success was defined by correct targeting and tactile feedback.

The data gathered included pain measurements with visual analog scale, duration of the symptoms up to 1 year before treatment, the treated lumbar level, and topography of the herniated disc. The Oswestry disability index was obtained by questionnaire to evaluate the degree of functional disability. The participants were followed-up at 1-month interval with a lumbar MRI to evaluate any complications, then at 3 and 6 months through a blinded observer call.

The median Oswestry disability index decreased from 44 to 20 in 1 month, to 12 within 3 months, and to 7 at 6 months showing a significant increase in functionality (P < .001). At the end of follow-up, for 85% of the patients a decrease in visual analog scale score of >50% was found. With regard to the length of hospital stay, 96.5% were discharged on the same day of procedure, with the remaining patients being discharged the next day. Of the 57 actively working patients, 50 (88%) returned to work after a median time of 8 days. There were no major adverse events.

These results were consistent with those of the study by Liu et al, which evaluated the evolution of Oswestry disability index as well as differences in patients treated with endoscopic discectomy vs. percutaneous discectomy. McCormick et al also showed a 30% decrease in Oswestry indices with a different decompression probe. Ultimately, this study showed a significant decrease in the Oswestry disability index and an improvement in functional capacities after CT-guided percutaneous lumbar discectomy, leading to a faster return to work time which translates to higher patient satisfaction and decreased socioeconomic burden.

Commentary

In light of the increased incidence of younger adults developing disc herniation, this study highlights the medical and economic benefits of minimally invasive techniques in patients with refractory herniated disc syndromes. The effectiveness profile of percutaneous lumbar discectomy was comparable to previously published retrospective studies. But the current prospective study enabled evaluation of the socioeconomic impact. The methods of study were adequate in providing both qualitative and quantitative analyses. Nonetheless, as the authors rightly noted, a control group to analyze the differences compared to surgical or conservative methods would provide more real-world implications. It is clear from the data though that percutaneous lumbar discectomy has clinical and economic significance as illustrated by the median visual analog score decrease of 6 and median return-to-work time of 8 days. Minimally invasive percutaneous approaches are powerful and cost-effective additions to the refractory herniated disc management toolkit.

Post Author

Christopher Loiselle, MS, OMSIV
Lincoln Memorial University-DeBusk College of Osteopathic Medicine
@Caloiselle

Magnetic Anastomosis for Ureteral Obstruction

Magnetic Compression Anastomosis of Benign Short-Segment Ureteral Obstruction

Clinical Question

Is magnetic compression anastomosis safe, effective and feasible in benign short-segment ureteral obstruction.

Take Away Point

Magnetic compression anastomosis is safe and effective technique in combating the short benign ureteral obstruction demonstrating over 90% successful technical rate and no adverse events.

Reference

Ünal E, Çiftçi TT, Akinci D. Magnetic compression anastomosis of benign short-segment ureteral obstruction. Journal of Vascular and Interventional Radiology. 2024;35(3):398-403. doi:10.1016/j.jvir.2023.11.020

Click here for article

Study Design

Retrospective, observation, descriptive study

Funding Source

No reported funding

Setting

Academic, Hacettepe University School of Medicine, Ankara, Turkey

Figure

Figure 2. A 48-year-old woman with previous history of surgery and radiotherapy for cervical carcinoma developed right hydroureteronephrosis. Cystoscopy-guided ureteral double-J stent placement performed at an outside hospital resulted in misplacement of a double-J stent into the lumen of the inferior vena cava (Video 1, available online at www.jvir.org). Perforation and false passage through the retroperitoneal space resulted in a diffusely narrowed ureter. (a) First, retrograde ureteral access was gained (white arrowheads) with the support of a vascular sheath (black arrow) and angled 5-F catheter (white arrow). (b) Anterograde access was obtained through the indwelling nephrostomy (not shown), and both access routes were used to reach the stricture (arrowheads). The short ureteral obstruction could not be traversed from the anterograde or retrograde access. (c) Magnets were pushed over the stiff guide wires to the ureteral obstruction as far as possible (arrows). (d) When the magnets were close enough to each other, they coupled and exerted pressure on the intervening tissue. On the fourth day, apposition of the magnets was evident radiographically. After magnetic compression anastomosis, the ureteral obstruction could be traversed by a guide wire. (e) Biopsy forceps were advanced through the lumen of a long vascular sheath (arrow) to push or to grab the magnets. (f) The magnets were pushed through the bladder and out of the urethra via through-and-through access (arrow). (g) Magnets (arrowheads) adhered to the guide wire (Amplatz, arrow) because of the ferromagnetic composition of the core and windings of the guide wire. (h) Finally, a double-J stent was placed from below, and the percutaneous nephrostomy tube was removed.

Summary

Magnetic compression anastomosis is becoming more popular due to its effectiveness and ease in tackling certain pathologies such as biliary strictures. The authors of this paper decided to investigate the feasibility, effectiveness, and safety of this technique against benign short-segment ureteral strictures with failed antegrade and retrograde recanalization attempts for double-J stent placement. Favorable results would allow significant improvement in patient’s quality of life, especially among those whom surgery is contraindicated or would otherwise have to tolerate a permanent nephrostomy tube with interval exchanges.

The authors performed a retrospective observational study across the time span from March 2018 to June 2022. Inclusion criteria was the presence of benign ureteral stricture and for whom surgery was contraindicated. Exclusion criteria were as follows: less than 18 years of age, malignant ureteral obstruction, length of ureteral gap of stricture exceeding magnet’s attraction capacity, and urinary tract infection refractive to medical therapy. The study comprised of 11 patients (3 male and 8 female), all of whom had indwelling nephrostomy tubes and had prior difficulty with anterograde/retrograde ureter stent placement. 5 of these patients had ileal conduits.

Technical success rate was defined as successful adherence of the magnets and subsequent ureteral stent placement. Adverse events were classified according to Society of Interventional Radiology classification system. The following parameters were also recorded: length of time of magnetic adherence, single-rotation fluoroscopy times of first and second steps procedure.

The first and second steps of the procedure are summarized below.

First step:
Both retrograde and anterograde access were performed to place the magnets in their respective positions. A combination of hydrophilic wire, 9 French vascular sheath, and 5 French 45 degrees angled catheter was used to gain access into the ureters via retrograde approach with eventual exchange to a stiff guidewire to place the magnet in the caudal portion of the stricture. A combination of 5 French catheter and hydrophilic wire was used during anterograde approach to reach the cranial part of the stricture for placement of the second magnet via stiff guidewire. Magnets’ positions relative to each other were evaluated using serial abdominal plain films until adherence was achieved.

Second step:
Anterograde and retrograde accesses were achieved in the ureters in the same manner as from the first step. Hydrophilic wire was used to traversed the magnets, with contrast injection confirming successful traversal. Balloon catheters or forceps were then used to remove the magnets, either by push or pull maneuvers through the urethra using a through-and-through access stiff guidewire. Afterwards, balloon dilatation was performed at the magnetic compression site and either 8 French double J stent or 8-12 French biliary drainage catheter was placed. Nephrostomy catheters were removed, and no antibiotics were given prior to patient discharge.

Technical success was 91% with no adverse events. 73% of the patients developed microscopic hematuria after the procedure which resolved within 72 hours. The mean time for magnetic adherence was 5.7 days. The mean fluoroscopic time for the first step was 9.45 minutes and the mean time for the second step was 15.7 minutes.

The reason this procedure works is that the magnets cause ischemia of the intervening tissues. The remaining tissues eventually adhere to each other and recanalization is achieved without compromising the integrity of the ureter. This optimizes the chances of subsequent intraluminal guidewire traversal, unlike other procedures such as the rendezvous technique which risks extraluminal traversal.

The study referenced several limitations, namely the retrospective design and the small patient population with only preliminary results provided. The author also emphasized the importance of proper patient selection for this technique as it is potentially useful in only limited context, such as the length of the stricture being within the capacity of the magnets.

Commentary

Magnetic compression anastomosis is not only a cool concept, but is also elegant and efficient when tackling certain problems. As a resident, I lost count of the times I saw my attending frustratingly attempting to pass strictures. Now I wonder how many of those cases could have been ameliorated by this technique, how much shorter the procedural times would have been, and how much radiation we could have minimized.

One thing not to gloss over is the importance of follow-up. The potential long-term complications of intra-abdominal magnets can be dreadful. Other than the abovementioned exclusion criteria, patients who have trouble with medical management compliance may not be optimal candidates for this technique. In the article’s defense, the data presented thus far are preliminary data, inviting opportunities for further research and optimal patient selection can be investigated in future studies.

Post author

Naeem Patel, DO
Radiology Resident, PGY4
Department of Radiology, Interventional Radiology Division
Hartford Hospital, Hartford, CT
@Naeemp7Patel

Empiric vs. Targeted Embolization in Postpancreatectomy Hemorrhage

Transcatheter Arterial Embolization for Delayed Postpancreatectomy Hemorrhage: A Retrospective Study of 312 Patients

Clinical Question 

Is empiric embolization as effective and safe as targeted embolization for treating delayed postpancreatectomy hemorrhage?

Take Away Point 

Empiric embolization is safe and equally effective as targeted embolization in managing delayed postpancreatectomy hemorrhage, showing no significant difference in clinical success and 30-day mortality rates between the groups.

Reference 

Tan, Wenle, Yuan, Kai, Ji, Kan, Xiang, Tao, Xin, Hainan, Li, Xiaohui, Zhang, Wenhe, Song, Zhenfei, Wang, Maoqiang, & Duan, Feng. (2024). Transcatheter Arterial Embolization for Delayed Postpancreatectomy Hemorrhage: A Retrospective Study of 312 Patients. Journal of Vascular and Interventional Radiology, 35, 241–250. Click here for abstract

Study Design 

Retrospective observational cohort study

Funding Source 

Supported by the National Natural Science Foundation of China (No. 82172037)

Setting 

Single-center study at the Chinese PLA General Hospital, Beijing, People’s Republic of China.

Figure 

Figure 2A 66-year-old woman with adenocarcinoma of the duodenal papilla underwent pancreaticoduodenectomy. The patient developed severe abdominal bleeding 46 days after surgery with the hemoglobin concentration decreasing ≥3 g/dL. (a) Contrast-enhanced computed tomography showed a pseudoaneurysm of the hepatic artery. (b) Angiography showed a pseudoaneurysm of the hepatic artery. (c, d) The common hepatic artery was embolized with microcoils and gelatin sponge. Hemostasis was successful after targeted embolization.

Summary 

Conducted at the Chinese PLA General Hospital, this study retrospectively analyzed 312 patients with delayed postpancreatectomy hemorrhage treated from January 2012 to August 2022, comparing the outcomes of empiric embolization (EE) versus targeted embolization (TE).

Of the 312 patients, 185 patients were found to have positive digital subtraction angiography findings and 175 of them underwent targeted embolization based on the findings. Specifically, the common hepatic artery (30.3%), branches of the superior mesenteric artery (21.7%), splenic artery (20.0%) and left gastric artery (19.4%) were found to be the most frequently embolized arteries in the targeted embolization group.

No extravasation or any vascular abnormalities were detected in 137 (43.9%) patients by digital subtraction angiography. Of these patients, 68 patients were subjected to empiric embolization of the assumed ruptured arteries (EE group), and 69 patients received conservative treatment (NE group). In the cases with negative-result digital subtraction angiography, the principles for empirical embolization were as follows:

(a) computed tomography angiography before angiography highly suspected arterial bleeding;

(b) hemodynamic instability due to acute blood loss;

(c) patients with high suspicion of arterial bleeding according to the character and speed of bleeding;

(d) according to the intraoperative conditions of pancreatectomy, empirical embolization should be performed for bleeding arteries highly suspected by pancreatic surgeons without affecting the main functions of the organs.

In the empiric embolization group, the left gastric artery (42.6%), common hepatic artery (19.1%), splenic artery (14.7%), and stump of gastroduodenal artery (11.8%) were found to be the most frequently embolized arteries. In the absence of clear indications of hemorrhage, it was generally not recommended to perform empirical embolization on branches of the superior mesenteric artery for the purpose of preventing intestinal necrosis.

The clinical failure rates of targeted embolization, empiric embolization, and no embolization groups were 29.7%, 30.9%, and 49.3%, respectively. 243 cases in targeted embolization and empiric embolization groups were included in the follow-up prognostic analysis of this study. The 30-day mortality rates were 14.9% (26/ 175) and 10.3% (7/68) in the targeted embolization and empiric embolization groups, respectively. Embolization-related adverse events occurred in 19 patients. Six patients experienced liver abscesses (targeted embolization group, n = 5; empiric embolization group, n = 1), 1 of whom died of septic shock. Five patients in the targeted embolization group experienced splenic abscesses, and 1 patient in the empiric embolization group showed an abscess in the tail of the pancreas. A patient in the targeted embolization group who presented with ischemic necrosis of the bowel after embolization of the superior mesenteric artery branch underwent laparotomy.

The study found no significant differences in clinical success or 30-day mortality rates between empiric embolization and targeted embolization, demonstrating that empiric embolization can be a viable option in cases with angiographically negative findings. Factors such as malignant disease, Grade C pancreatic fistula, intra-abdominal infection, and concurrent extraluminal and intraluminal hemorrhage were identified as risk indicators for clinical failure. Advanced age and intra-abdominal infection were risk factors for 30-day mortality.

Commentary 

The findings underscore the viability of empiric embolization as an effective treatment strategy for delayed postpancreatectomy hemorrhage, particularly in challenging cases where targeted embolization is not feasible due to negative angiographic findings. This study contributes valuable insights into the management of a complex and high-risk patient population with low clinical success rate of 70% and mortality of 13.6%, suggesting that treatment approach can be tailored based on specific clinical scenarios without compromising patient outcomes. Future prospective studies could further validate these findings and refine treatment protocols

Y90 for lung cancer mets to liver?

Y90 Transarterial Radioembolization of Primary Lung Cancer Metastases to the Liver

Clinical question

Is Yttrium-90 transarterial radioembolization safe and effective in patients with primary lung cancer metastasized to the liver?

Take away point

This retrospective analysis of 57 patients with lung cancer metastatic to the liver demonstrated effectiveness on local control and progression free survival. Overall, the treatment suggested an acceptable safety profile, with 11 severe or life-threatening adverse events within 30 days.

Reference

Yttrium-90 Transarterial Radioembolization of Primary Lung Cancer Metastases to the Liver. Alexander, E M.D. et al Journal of Vascular and Interventional Radiology, Volume 35, Issue 2, 214-225.

Click here for abstract

Study design

The study was a retrospective, observational, descriptive, single center study.

Funding Source

NIH/NCI Cancer Center Support Grant P30

Setting

Memorial Sloan Kettering Cancer Center, New York

Figure

Figure 1. A 55-year-old woman with EGFR-mutant NSCLC with progressing liver metastases in the left hepatic lobe. (a) Axial portal venous-phase CT image demonstrated a lesion in segment IV (arrow), resulting in biliary dilatation. (b) Coronal portal venous-phase CT image demonstrated the lesion (arrow). (c) Angiography of the celiac axis demonstrated the left hepatic artery (arrow) and the middle hepatic artery (arrowhead), where resin microspheres were delivered in a split administration. (d) Axial portal venous-phase CT image obtained 6 months after yttrium-90 radioembolization showed atrophy of the treated left hepatic lobe with persistence of biliary dilatation (arrow). (e) Coronal portal venous-phase CT image demonstrated marked size reduction of the tumor (arrow). CT = computed tomography; EGFR = epidermal growth factor receptor; NSCLC = non–small cell lung cancer.



Figure 4. Overall survival in months was estimated using the Kaplan–Meier (KM) method. NSCLC = non–small cell lung cancer; SCLC = small cell lung cancer.

Summary

Lung cancer is the second most diagnosed cancer in the United States with approximately 40% of patients presenting at diagnosis with metastatic disease. Patients with metastatic disease to the liver indicates a worse prognosis compared to metastasis at other sites, with an overall survival of 3 months for patients with non-small cell lung cancer or small cell lung cancer. Treatment options are limited to systemic therapies such as chemotherapy, targeted therapy, and immunotherapy. Several small case series have demonstrated the use of radioembolization with an acceptable safety profile that prompted further investigation.

The authors of this paper assessed the safety and effectiveness of yttrium-90 transarterial radioembolization in patients with primary lung cancer metastasized to the liver. They performed a retrospective study of 57 patients who were treated between August 2010 and May 2021. Treatments were delivered with either glass or resin microspheres. Primary outcomes of this study were safety, local progression-free survival, and overall survival after yttrium-90 treatment. Clinical laboratory values, biochemical toxicities and radiographic response were monitored approximately 1 month after treatment and at 3-month intervals thereafter.

Of the 79 treatments reviewed, 40 (51%) were associated with side effects within 1 month of yttrium-90 treatment. 29 of those patients experienced mild-moderate adverse events, which included self-limited post-embolic syndrome with symptoms of fatigue, abdominal pain, nausea, and weakness. There were 9 serious adverse events that required prolonged hospitalization or unplanned escalation of care. There was 1 life threatening event marked by acute renal failure and 1 death of a patient from pneumonia. Of note, there were statistically significant increases in aspartame transaminase and alkaline phosphatase at 1 month post treatment. At 3 months, these levels remained high with the addition of increases in total bilirubin, and alanine transaminase. 17 of the patients developed ascites with a median occurrence 19.2 months after treatment.

RECIST 1.1 was used to evaluate treatment response within 6 months of radioembolization, with median local progression free survival of 7.6 months for non-small cell lung cancer, 3.6 months for small cell lung cancer, and 30.6 months for lung carcinoids. Median overall survival was 8.3 months for non-small cell lung cancer, 4.1 months for small cell lung cancer, and 43.5 months for lung carcinoids. For non-small cell lung cancer, presence of bilobar disease, more tumors, and lobar treatment were negative predictors of overall survival. For lung carcinoids, tumor involvement of >50% was a negative predictor of overall survival.

Limitations of this study include the retrospective study design from a single institution and the small patient cohort. The difference in prognoses between the primary lung cancers and the differences in microsphere, volume, and formulation of the therapeutic treatment presented additional limitations.

Commentary

This study demonstrated that yttrium-90 transarterial radioembolization can treat primary lung cancers metastasized to the liver with an acceptable safety profile. The greatest effectiveness of the treatment was observed with lung carcinoid tumors, which had significantly longer baseline local progression-free survival and overall survival when compared to small cell and non-small cell lung cancer.

Historically, transarterial radioembolization was often used after failure of multiple lines of therapy. Liver decompensation and ascites due to overall disease progression and hepatotoxic medications are difficult to distinguish from adverse effects attributable to the yttrium-90 treatment. Since treating refractory tumors with larger tumor burden have known increased risks of late occurring adverse events, studies like this are important to assess yttrium-90 transarterial radioembolization’s safety profile and delineate its role in the treatment algorithm of lung cancer liver metastases.

In this author’s opinion, the next steps for this promising treatment option in patients with lung cancer metastases to the liver involve prospective studies targeting a single type of lung cancer with a uniform therapeutic delivery method. Prognostication models for late occurring adverse events should be investigated to better triage patients for yttrium-90 transarterial radioembolization and allow close-interval follow-ups. Lastly, combination therapies of yttrium-90 transarterial radioembolization and systemic therapies demand further investigation.

Post Author

Anthony M. Camargo, BA
MD candidate, Class of 2025
University of Massachusetts Chan Medical School
@anthonymcamargo

Percutaneous deep venous arterialization in an OBL setting

Percutaneous Deep Venous Arterialization in Patients with No-Option Critical Limb Ischemia Performed in an Office-Based Laboratory Setting

Clinical Question

Is percutaneous deep venous arterialization with commercially available devices safe and feasible in an office-based laboratory among patients with critical limb ischemia and no-option distal arterial occlusive disease?

Take Away Point

Percutaneous deep venous arterialization using commercially available devices in an office-based setting, despite having high rates of occlusion and reintervention, showed favorable rate of overall survival and amputation-free survival along with improved wound healing.

Reference

Shanmugasundaram S, Herman K, Rundback JH. Percutaneous deep venous arterialization in patients with no-option critical limb ischemia performed in an office-based laboratory setting. Journal of Vascular and Interventional Radiology. Published online October 2023. doi:10.1016/j.jvir.2023.10.003

Study Design

Retrospective, observation study consisting of 22 patients

Funding Source

No reported funding

Setting

Private, NJ Endovascular and Amputation Prevention Center, West Orange, New Jersey

Figure

Summary

Endovascular reconstructions have been one of the mainstays in addressing peripheral vascular disease. However, subsets of patients have severe degree of disease such that traditional approaches are not feasible due to lack of distal targets to re-establish flow, with high risks of amputation and mortality. The emergence of deep venous arterialization attempts to mitigate this challenge, and has evolved from a purely surgical technique to a percutaneous, office-based, procedure.

The authors of this paper performed a retrospective observational study to assess the safety and feasibility of percutaneous deep venous arterialization in an office-based laboratory for patients with no-option critical limb ischemia. The study consisted of 22 patients (10 males and 12 females) who underwent the procedure from January 2018 and November 2021. All 22 patients were classified as having no-option disease characterized as chronic total occlusion, previous failed endovascular/open surgical approaches, or absence of reconstituted arteries for surgical bypass in the lower leg or foot. Primary outcome was amputation-free survival at 6 months. Secondary outcomes comprised of primary and secondary graft patency of arteriovenous conduit, limb salvage, wound healing, change in Rutherford classification, reintervention rate and overall survival, all of which were tabulated at 30 days, 6 months, and 12 months. Technical success was defined as antegrade blood flow through the venous circuit. The technique is summarized in Figure 1.

The results demonstrated 95.5% technical success rate. While the primary graft patency significantly decreased over time and the reintervention rate subsequently increased, the amputation-free survival and overall survival plateaued at 70.3% and 83.6% respectively within the follow-up period. Furthermore, more than 75% of the patients in each time interval experienced improved wound healing and more than 50% experienced improvement in the Rutherford classification system throughout the 12 months.

These results show that percutaneous deep venous arterialization using commercially available devices helps delay amputation, improves survival, and enables wound healing. Of note, there are other larger trials which explored similar questions, namely PROMISE I, PROMISE II, and ALPS trial via Limflow system, and showed comparable results.

The occlusion rate of the arteriovenous conduit in a short period of time is a concern in this article as well as the aforementioned larger trials. The authors believe that the predominant cause is the progression of venous stenosis distal to the stent graft in the pedal venous outflow. As a result, self-expanding stents were used increasingly during posterior tibial percutaneous deep venous arterialization. The use of valvulotome in the Limflow system may also help address this. The other possible explanation for the high occlusion rate is that it is a consequence of venous arterialization akin to a hemodialysis fistula.

Despite the high occlusion rate of the arteriovenous conduit, the rate of wound healing was favorable across the 12-month span. The authors initially attributed the wound healing to retrograde flow through the presumed nonobstructed venous circuit into the retrograde capillary bed. The current hypothesis is that by promoting blood flow into the distal capillary beds of the leg/foot via intervention, oxygenation is improved and flow to hibernating collaterals is increased, leading to cascades of physiological responses including angiogenesis which promote wound healing.

The dissociation between high occlusion rates of the arteriovenous conduit and improved wound healing served as an important limitation of the study. It is unclear if the wound healing was attributed to the procedure alone or the improved wound care patients received through multidisciplinary approach. Additional limitation of the study was the retrospective nature of the study and inability to compare outcomes with a control group or those who underwent surgical deep venous arterialization. Additionally, multiple patients lost to follow-up over 12-month period made it difficult to assess the long-term effects or the durability of the procedure.

Commentary

The study investigated the feasibility of percutaneous deep venous arterialization in patients with critical limb ischemia. Despite the limitations of the study, the results were overall favorable to confidently allow appropriately trained specialists to offer it as an option to otherwise no-option patients with critical limb ischemia. More studies, such as the actively undergoing PROMISE III trial, can further aid in understanding of the intervention. If the Limflow system were to be approved for use in the United States, the dedicated valvulotome in the device can help combat the distal venous stenosis likely contributing to the high occlusion rate of the conduit.

One interesting aspect mentioned in the article is that it is unclear if the improved rate of wound healing was attributed to the procedure alone or the multidisciplinary approach of postprocedural wound care. My opinion is that this uncertainty actually highlights the effectiveness multidisciplinary approach can bring to the table. It fosters a holistic approach to patient care, enabling us to make tailored and coordinated clinical decisions to patients. In the long run, this integrates interventional radiology as an integral member of the treatment team and the proceduralists’ clinical opinions into consideration outside of the procedural room.

Post author

Naeem Patel, DO
Radiology Resident, PGY4
Department of Radiology, Interventional Radiology Division
Hartford Hospital, Hartford, CT
@Naeemp7Patel

ESRD confers a 7-fold risk of major adverse limb events in patients undergoing percutaneous vascular interventions

Association between End-Stage Renal Disease and Major Adverse Limb Events after Peripheral Vascular Intervention

Clinical question

Does End-Stage Renal Disease predict major adverse limb events post-peripheral vascular intervention?

Take away point

End-stage renal disease gives patients a more than 7-fold risk of below-knee amputation after percutaneous vascular intervention compared to patients without End-stage renal disease.

Reference 

Association between End-Stage Renal Disease and Major Adverse Limb Events after Peripheral Vascular Intervention. Babore, Y et al. Journal of Vascular Interventional Radiology 2023 Sep 9:S1051-0443(23)00655-3. doi: 10.1016/j.jvir.2023.06.042.

https://www.jvir.org/article/S1051-0443(23)00655-3/fulltext

Study design

This was a retrospective, observational, propensity score matched cohort study

Funding Source

No funding listed

Setting

Academic, University of Pennsylvania

Figure

Kaplan-Meier curves comparing patients with and without end-stage renal disease (ESRD) with 95% CIs. (a) Major adverse limb event (MALE) (P = .0001, log-rank test); (b) major amputation (P < .0001, log-rank test); (c) above-knee amputation (AKA) (P = .02, log-rank test); (d) below- knee amputation (BKA) (P < .0002, log-rank test); (e) bypass reintervention (P = .75, log-rank test); (f) percutaneous vascular intervention (PVI) reintervention (P = .2, log-rank test).

Summary

Peripheral arterial disease affects over 200 million people worldwide. Patients with peripheral arterial disease who underwent amputation above the ankle have a one-year mortality of 50% and 3-year mortality of 70%. End-stage renal disease is a known risk factor for poorer outcomes of revascularization, with higher risks of major adverse limb events and major amputations. However, robust assessment of the effect of end-stage renal disease on major adverse limb events after percutaneous vascular interventions is lacking. The recent BEST-CLI trial comparing endovascular therapy and surgical bypass among patients with critical limb ischemia, could not assess the effects given that only 11% of the included patient population had end-stage renal disease.

This paper seeks to assess how end-stage renal disease affect percutaneous vascular interventions, leading to higher complications and major adverse limb events (defined as reintervention or major amputation). The researchers gathered information from one institution where they reviewed patient records, institutional and clinic data systems to find patients who underwent tibial percutaneous vascular intervention for critical limb ischemia (Rutherford Category 4-6). The patients with end-stage renal disease were defined as a glomerular filtration rate of <15 mL/min/1.73 m2 or need for long-term kidney replacement therapy to live. Ultimately, the study included 350 patients, 88 of whom had end-stage renal disease.

Propensity score matching was used to define a contemporaneous control population against the population of interest with end-stage renal disease. Kaplan-Meier modeling was performed for comparisons from the time of the percutaneous vascular intervention to the primary study endpoint of major adverse limb events. Cox proportional hazards models were also used to estimate hazard ratios and the significance of the effect for each variable of interest (medication therapy, comorbid factors such as HgbA1c, hypertension, interventions performed, and limb events).

Ultimately, Kaplan-Meier estimates revealed a significant difference in mean times to major adverse limb events (P = 0.0001), as well as estimated duration without major adverse limb events at 6, 12, and 24 months. There were also significant differences in mean times to major amputation (P < .0001), above knee amputation (P = .02), and below knee amputation (P = .0002) between the end-stage renal disease group and the control group. Most importantly, patients with end-stage renal disease were associated with a 7-fold increase in major amputations and the effect was primarily driven by below knee amputations since these patients tend to have more distal disease involvement.

Commentary

This study highlighted peripheral arterial disease, an important disease state that impacts a large patient population. Several modifiable and nonmodifiable risk factors associated with the disease were known. And risk stratification using these factors is crucial for individualized treatment planning and outcome prediction. It was clear by the analyses that end-stage renal disease severely impacts not just the initial pathogenesis of peripheral arterial disease, but the procedural outcomes and complications. Also interesting was the fact that the effects were mostly driven by below knee amputations, which tend to confer a better quality of life and lower mortality compared to above knee amputations.

To further expand on the clinical knowledge in the context of end-stage renal disease and percutaneous vascular interventions, a wider patient population and different treatment approaches would be beneficial. The authors had also found some potential inconsistencies with other major trials and medical foundations. One example was that “higher HbA1c level was the only independent predictor of above knee amputations and was found to confer lower risk.” “Cox proportional hazards analysis revealed a 2-fold increase in the risk of MALE in patients on anticoagulant therapy” was the second example. These seemingly counterintuitive findings may be due to the design of the current study and will require further investigation to clarify.

Ultimately, this paper provided critical clinical value in the evaluation of patients with end-stage renal disease and peripheral arterial disease. Closer follow-up is warranted in patients with end-stage renal disease who underwent percutaneous vascular interventions and new treatment strategies are necessary to decrease their risks of major adverse limb events.

Post Author

Christopher Loiselle, MS, OMSIV
Lincoln Memorial University-DeBusk College of Osteopathic Medicine
Twitter Handle: @Caloiselle