Keywords
embolization - muscular - knee - TAME - genicular artery embolization - osteoarthritis
Introduction
Affecting over 100 million people worldwide, osteoarthritis (OA) is the most common
form of degenerative joint disease and the leading cause of chronic musculoskeletal
pain and functional limitations [1]. Chronic musculoskeletal pain often results in reduced daily activities and, consequently,
a diminished quality of life for affected patients [2].
Depending on the severity of the disease, therapeutic approaches for OA range from
pharmacological interventions, such as anti-inflammatory drugs and pain relievers,
to shock-wave therapy, intra-articular corticosteroid injections, and surgical joint
replacement [2]. However, alternative treatments like intra-articular glucocorticoid injections
could result in significant cartilage tissue loss with prolonged use, thus potentially
worsening OA [3]. Moreover, many patients in advanced stages of the disease no longer respond to
conservative forms of treatment or exhibit contraindications for long-term pain medication
[4]. As a result, patients who are too young for joint replacement or have a high perioperative
mortality due to their preexisting medical conditions still pose a challenge for medical
treatment today [5]
[6].
In response to these challenges, transarterial microembolization (TAME) has emerged
as an innovative treatment strategy for patients with chronic joint pain, particularly
those resistant to conservative treatments or experiencing persistent pain after surgery.
This review aims to highlight the potential applications of TAME in the treatment
of chronic refractory joint pain in OA. The pathophysiology, potential indications,
technical aspects, and adverse events are examined, with a specific focus on discussing
clinical applications in patients with OA.
Pathophysiological Mechanisms and Angiogenesis in Osteoarthritis
Pathophysiological Mechanisms and Angiogenesis in Osteoarthritis
Pathophysiologically, OA is characterized by irreversible damage to the articular
cartilage, remodeling of subchondral bone, formation of osteophytes, and thickening
of the joint capsule [7], which ultimately leads to irreversible joint damage [8]
[9]. The underlying pathomechanisms of these remodeling processes and the exact causes
of chronic joint pain, which is the leading clinical symptom of OA, are very complex
and not yet fully understood. Anecdotal evidence suggests that chronic bone and synovial
inflammation result in the stimulation of angiogenesis, synovial hyperplasia, and
recruitment of inflammatory cells [10]
[11]. A variety of factors including altered biomechanics and an increased release of
proinflammatory cytokines, chemokines, prostaglandins, matrix-reducing enzymes (e.g.,
matrix metalloproteases), sphingolipids, and vascular endothelial growth factor play
a crucial role in this process in arthritic joints [8]
[11]
[12]. The resulting imbalance of pro- and anti-angiogenic factors leads to increased
angiogenesis in the subintima of the synovial membrane [8], the menisci [7], the osteochondral junction [13], and the deep layers of the articular cartilage of the affected joint [14]. While healthy articular cartilage has a natural resistance to the formation of
blood vessels due to the specific structure of its proteoglycan matrix, the loss of
proteoglycans in arthritic articular cartilage leads to reduced resistance and thus
facilitates the formation of new vascular channels and consequently the penetration
of new blood vessels [11]
[15]
[16]. Via common regulatory signaling pathways, these blood vessels lead to growth stimulation
of sensory nerve fibers [9], which penetrate the synovium as well as non-calcified cartilage and osteophytes
at the osteochondral junction and are therefore postulated to be the cause of arthritic
joint pain [7]
[8]
[17]. In addition, angiogenesis is an essential stage of endochondral ossification, and
the sensory innervation of osteophytes may explain the association between radiographic
osteophyte formation and pain perception [7]
[8]. Thus, it is hypothesized that pathological angiogenesis contributes to the development
of structural damage and pain in osteoarthritic joints [4]
[18]
[19]
[20]
[21]
[22].
Patient Selection and Assessment
Patient Selection and Assessment
Patient selection and assessment are crucial steps in considering TAME as a viable
treatment option. Patients typically include individuals with chronic musculoskeletal
pain, particularly those diagnosed with OA, who experience persistent musculoskeletal
pain after unsuccessful conservative treatments or even after an endoprosthesis. A
further prerequisite is chronic knee pain despite adequate drug therapy (duration
of therapy > 6 months) or an intolerance or contraindication to non-steroidal anti-inflammatory
drugs and/or opioids. Furthermore, candidates for TAME include patients who are either
considered too young or too medically compromised for endoprosthetic joint replacement,
as well as those experiencing persistent pain after undergoing joint replacement surgery.
In cases involving a joint prosthesis, it is imperative to exclude other causes of
pain, such as periprosthetic infection, instability, arthrofibrosis, prosthesis loosening,
or implant malposition, before proceeding with TAME. Patients with multiple comorbidities
who are deemed unsuitable for joint replacement due to various reasons also qualify
for this treatment. Contraindications for TAME encompass acute joint infection (considered
an absolute contraindication) and relative contraindications such as renal insufficiency
and coagulation disorders, characterized by an INR greater than 1.5. As with any intervention,
conducting a comprehensive evaluation of the patient’s medical history, pain symptoms,
and radiological findings is essential to ensure the safety and efficacy of the procedure.
Pre-procedural imaging usually includes standard X-rays and ultrasound as part of
the clinical assessment. The use of MRI, while not universally required, is determined
based on the specific clinical scenario and the joint under consideration. MRI offers
detailed visualization of soft tissues, making it invaluable in cases where comprehensive
assessment of synovitis, cartilage integrity, and other soft tissue components is
necessary. Its application is particularly pertinent in complex joints or when initial
assessments with X-rays and ultrasound yield inconclusive results, and if the clinical
examination is ambiguous. Therefore, the decision to incorporate MRI into the diagnostic
process is guided by its potential to enhance understanding of the joint’s pathology,
rather than as a routine requirement for all cases. Examining MRI features before
genicular artery embolization (GAE) in knee OA, Choi et al. reported that bone marrow
lesions, meniscal injury, and a high Kellgren-Lawrence (KL) grade were associated
with poor outcomes [23]. To date, TAME is a promising option for those who are unresponsive to traditional
conservative therapies, and patient selection and assessment play a pivotal role in
tailoring the treatment to individual needs, thus maximizing the potential benefits
of this innovative approach while minimizing potential risks. Given that the indication
for treatment is complex and crucial to the success of the procedure, TAME should
be meticulously planned in close collaboration between radiologists and orthopedic
surgeons. This interdisciplinary approach ensures that patient selection is based
on a comprehensive assessment, leveraging the expertise of both specialties to optimize
treatment outcomes. However, as the initial studies mainly focused on the feasibility,
efficacy, and safety of TAME in various musculoskeletal conditions, there is currently
insufficient knowledge about which patients could really benefit most from TAME. Studies
including patients with milder symptoms are currently lacking. However, if TAME could
notably delay or even prevent joint replacement surgery, the potential economic impact
would be enormous. Future research should therefore aim to further identify specific
patient groups and diseases that would benefit most from TAME to facilitate future
patient selection.
Technical Aspects
Against the background of pathological angiogenesis in OA, TAME, which was initially
applied to address bleeding [24] or reduce the size of hypervascular tumors [25], has emerged as a versatile therapeutic approach for various musculoskeletal conditions.
By accurately identifying and subsequently embolizing these pathological blood vessels,
TAME interrupts and subsequently normalizes blood supply in the affected tissue area.
This reduces the influx of inflammatory mediators, interrupting the intricate interplay
between angiogenesis, chronic inflammation, and pain, thereby alleviating symptoms
and potentially delaying or even preventing further joint damage [10]
[11]. While clinical applications such as hemostasis and tumor reduction aim for the
complete embolization of the target tissue, in the musculoskeletal context, TAME specifically
targets pathological neovessels while simultaneously preserving the larger feeding
vessel. Therefore, the endpoint of embolization in TAME is pruning of the neovessels,
rather than a complete closure of the feeding vessel.
The technical aspects of the TAME procedure can vary greatly depending on the specific
anatomical site and the musculoskeletal condition being addressed, which would exceed
the scope of this review. However, core principles underlying TAME remain consistent
across different anatomical sites: Following local anesthesia with prilocaine (Xylonest
1%) under sterile conditions, femoral or radial arterial access is established using
a guiding catheter (i.e., 3–5F) which is then advanced towards the anatomical target
area. Recently, a transpedal arterial access for genicular artery embolization has
also been described [26], with limited patient numbers in order to promote this access as a standard, but
it might become useful in patients after failed femoral access [27]. Digital subtraction angiography is conducted by manually injecting contrast medium
to delineate the vascular anatomy and pathological hypervascularization. Using a 1.7-F
microcatheter, for example, smaller branches of the supplying joint vessels are then
accessed, evaluating each of those branches individually to identify potential hypervascularization
by blush-like contrast medium enhancement and triggering of pain. Once abnormal hypervascularization
has been identified and pain could be provoked, permanent or non-permanent embolic
agents, diluted with iodinated contrast medium, are slowly injected into the target
vessel until complete absence of the previously observed hypervascularization is established.
To reduce skin perfusion and thus minimize the risk of skin damage, it is recommended
to apply ice to the embolized joint [18]
[28]
[29]
[30]. Since various arterial anastomoses are often present, several branches of the larger
supporting vessel must be examined to ensure successful embolization. Once the procedure
is completed, the catheter is removed, and hemostasis is achieved by manual compression
or the use of a closure device. After a successful procedure, patients are observed
depending on the access site for two to six hours to monitor the puncture site, manage
pain sensations, and address any post-interventional complications. After this initial
observation, patients are discharged on the same day.
To date, a variety of permanent [18]
[31] and non-permanent [4]
[32] embolic agents have been used. However, the ideal embolic material for TAME in musculoskeletal
tissues has yet to be determined. To this end, a recent meta-analysis evaluated the
efficacy and safety of GAE using imipenem/cilastatin sodium solution (IPM/CS), microspheres,
resorbable microspheres, and polyvinyl alcohol [33]. GAE was effective in improving pain scores using the visual analog scale (VAS)
and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). No
significant difference was found between the different embolic agents in terms of
pain relief [33].
Complications and Adverse Events
While TAME offers effective relief from chronic musculoskeletal conditions, patients
may experience some mild, transient side effects. Notably, while post-interventional
complications have shown a wide range in incidence from 7.1% [19] to 80% [26], it’s crucial to highlight the absence of major complications that necessitate additional
vascular intervention or even surgery. Complication rates, however, appear to be influenced
by the size of the embolic particles used. Smaller particles (<100 µm) have been associated
with a higher rate of complications, as seen in both animal models [34] and human studies [26]: In a study in a large animal model, differences in complications were found depending
on the size of the embolic particles, with smaller particles (i.e., <100 µm) leading
to more complications [34]. This observation is supported by Bagla et al., who reported two cases of transient
plantar sensory paresthesia after GAE with 75 µm microspheres [26]. These events were attributed to non-target embolization, which likely compromised
the arterial supply to a branch of the tibial nerve [26]. Although both cases resolved without further intervention, the authors decided
to increase the particle size to 100 µm for subsequent cases and found that no further
adverse neural consequences occurred [26]. Beyond this, no other major complications were reported. Minor complications, such
as subcutaneous hemorrhage at the puncture site [18]
[26]
[28]
[29] or temporary cutaneous color changes in the treated area [4]
[19]
[20]
[21]
[26]
[30], artery vasospasm [21]
[22], and periprocedural pain [4]
[20]
[21], typically resolved spontaneously. The incidence of post-interventional complications
appears to correlate with the size of the embolizing agents used. Studies employing
larger particles, specifically 100–300 µm Embospheres, report fewer complications
[18], whereas higher complication rates are observed with smaller particles, such as
75 µm or 100 µm microspheres [26]. The increased risk associated with smaller particles is likely due to their propensity
to migrate and occlude distal and smaller vessels, leading to non-target embolization
and unintended ischemia. Conversely, larger particles are less likely to enter these
smaller channels, thus reducing the risk of adverse events. This emphasizes the critical
need to select an embolizing agent of appropriate size to ensure a balance between
the effectiveness of the embolization and patient safety.
Importantly, these issues resolved without the need for further extensive treatment,
emphasizing the overall safety and efficacy of TAME as a valuable therapeutic approach
for musculoskeletal diseases [4]
[19]
[20]
[21]
[26]
[30]
[33].
Clinical Application of Transarterial Microembolization in Osteoarthrosis
Clinical Application of Transarterial Microembolization in Osteoarthrosis
Pioneered by Okuno et al. in 2013, their successful treatment of tendinopathies and
enthesopathies marked the beginning of a series of studies highlighting the efficacy
of this technique in musculoskeletal conditions [4]. In addition to its role in hemarthrosis [35], TAME has been shown to offer pain relief in cases of musculoskeletal pain associated
with OA. In 2015, its use was extended to patients with musculoskeletal pain in the
knee associated with OA, demonstrating sustained pain relief for up to one year after
the procedure [19]. Moreover, the benefits of TAME for the shoulder and metacarpophalangeal joints
were investigated in further studies, thereby expanding the scope of its therapeutic
potential [20]
[21]
[22]
[36].
Osteoarthritis of the Knee Joint
The evidence that newly grown blood vessels and nerves could be potential sources
of pain in OA has spurred investigations into the use of TAME for embolization of
the genicular artery. While arthroplasty is inevitable in severe cases of knee joint
OA, GAE has proven successful in treating chronic knee joint pain that is refractory
to conservative treatments in patients with mild to moderate OA [18]
[19]
[20]. Anatomically, the geniculate arteries originate from the distal segment of the
superficial femoral artery, the popliteal artery and anterior tibial artery include
the descending genicular artery, the medial and lateral superior genicular artery,
the median genicular artery, the medial and lateral inferior genicular artery, and
the anterior tibia recurrent artery [20]
[37].
Several studies on the effectiveness of GAE for knee OA have consistently shown that
GAE is a safe and effective method for alleviating knee pain in patients with mild
to moderate knee OA who do not respond to conservative treatment [18]
[19]
[20]
[36]
[38]. [Table 1] summarizes the patient characteristics and clinical outcomes. In those studies,
the technical success rate was reported to range from 84% [18] to 100% [20]
[26]
[38]. GAE rapidly improved pain and physical functioning, as assessed using the VAS and
the WOMAC scores. A significant reduction in pain as well as an improvement in physical
function were observed at the 3-month [18], 6-month [26]
[38], and 1-year follow-up [20] in patients with mild to moderate knee OA. Moreover, a long-term study in 72 patients
with mild to moderate knee OA achieved a cumulative clinical success rate in 86.3%
after six months and 79.8% after three years [20], defined as improvement in pain symptoms six months after the first catheter arterial
embolization procedure [20]. Furthermore, MR imaging in 35 knee OA patients revealed a significant reduction
in the synovitis score between baseline and two years after the intervention, with
no reported osteonecrosis, cartilage loss, or tendinopathy [20]. In a recent multicenter, randomized, controlled trial, Bagla et al. demonstrated
that genicular artery embolization (GAE) resulted in significant pain relief and improved
functional outcomes in patients with mild to moderate osteoarthritis (OA), as compared
to those in the sham group. Functional improvement was quantitatively assessed using
the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score,
revealing a mean decrease of 24.7 points (Standard Error [SE] = 10.4), with a 95%
Confidence Interval (CI) of 3.5 to 45.9. This change was statistically significant,
with a p-value of 0.02, indicating a substantial improvement in patient functionality
post-treatment [39]. Minor complications such as a small groin hematoma [18] or transient skin color changes [20] were self-limiting. Importantly, no major complications were observed in these studies.
These findings underscore the efficacy of GAE as a treatment option for chronic knee
joint pain in mild to moderate knee OA. [Fig. 1] demonstrates representative images of genicular artery embolization in a 57-year-old
female patient with right-sided, medially dominant OA of the knee. The patient had
previously undergone multiple treatments, including hyaluronic acid injections and
cortisone, which only resulted in a short-term reduction in pain.
Table 1 Characteristics and clinical outcomes of included studies on genicular artery embolization.
|
Study Reference
|
Number of Patients
|
Duration of Follow-up (Months)
|
Score Results
|
Success Rate/Complications
|
|
Abbreviations: VAS – Visual Analog Scale; SD – standard deviation; CI – confidence
interval; KOOS – Knee Injury and Osteoarthritis Outcome Score; WOMAC: Western Ontario
and McMaster Universities Osteoarthritis Index; KL – Kellgren-Lawrence grading system;
GAE – genicular artery embolization
|
|
Little et al., 2021 [18]
|
38
|
12
|
Mean VAS improved from 60 (SD = 20.95% CI 53–66) at baseline to 36 (SD = 24.95% CI
28–44) at 3 months (p < 0.001) and 45 (SD = 30.95% CI 30–60) at 1 year (p < 0.05).
KOOS subscales significantly improved from baseline to 6 weeks (p < 0.001), 3 months
(p < 0.001), and 1 year (p < 0.05).
|
84% technical success (6 patients were not embolized); 0% major adverse events
4 patients with mild self-limiting skin discoloration;
1 patient with small self-limiting groin hematoma.
|
|
Okuno et al., 2015 [19]
|
14
|
12
|
Mean WOMAC total scores decreased from 47.3 ± 5.8 at baseline to 11.6 ± 5.4 at 1 month,
and to 6.3 ± 6.0 at 4 months.
|
100% technical success;
0% major adverse events
1 patient with self-resolving moderate subcutaneous hemorrhage.
|
|
Okuno et al., 2017 [20]
|
72 (95 joints)
|
24
|
Mean VAS score significantly decreased from 72 ± 16 at baseline to 38 ± 23, 29 ± 22,
19 ± 21, 13 ± 21, and 14 ± 17 at 1, 4, 6, 12, and 24 months, respectively (all p <
0.001).
The mean total WOMAC score significantly decreased from 43 ± 8.3 at baseline to 24
± 14, 14.8 ± 11, 11.2 ± 10, 8.2 ± 8.5, and 6.2 ± 6.4 at 1, 4, 6, 12, and 24 months,
respectively (all p < 0.001).
|
100% technical success;
86.3% clinical success rate at 6 months;
0% major adverse events
4 patients with transient cutaneous color change on the treated knee.
|
|
Lee et al., 2019 [38]
|
41 (71 joints)
|
12
|
KL 1–3: Mean VAS scores from baseline to 6 months post-GAE improved from 5.5 ± 2.2
to 1.9 ± 1.5 (all P = 0.00).
KL 4: Mean VAS scores from baseline to
6 months post- GAE changed from 6.3 ± 2.2 to 5.9 ± 2.0.
|
100% technical success;
0% major adverse events
5 patients with transient cutaneous color change on the treated knee.
|
|
Bagla et al., 2020 [26]
|
20
|
6
|
The mean VAS score improved from 76 mm ± 14 at baseline to 29 mm ± 27 at 6 months
(p < 0.01).
Mean WOMAC score improved from 61 ± 12 at baseline to 29 ± 27 at 6 months (p < 0.01).
|
100% technical success;
0% major adverse events
2 patients with self-resolving plantar sensory paresthesia.
|
Fig. 1 Right knee of a 57-year-old female patient with medially dominant OA of the knee before
(a, c) and after (b, d) transarterial microembolization. a Superselective digital subtraction angiography (DSA) from the medial superior genicular
artery before embolization indicates abnormal neovessels (arrow) adjacent to the medial
condyle (MC). b Post-embolization DSA of the medial superior genicular artery demonstrates elimination
of the pathological periarticular vascular network around the pain point at the medial
joint space (arrow). c Superselective DSA of the medial inferior genicular artery reveals hypervascularization
around the medial tibial plateau at the pain point (short arrow). d Post-embolization DSA of the medial inferior genicular artery with evidence of complete
embolization of the hypervascularity (short arrow). Abbreviations: LC – lateral condyle;
MC – medial condyle; DSA – digital subtraction angiography.
However, it is important to note that the severity of knee OA, as assessed using the
KL-scale, evidently affects GAE outcomes [38]. While a significant and long-lasting reduction in pain was observed in patients
with mild to moderate knee OA (KL grade 1–3) after GAE, patients with severe knee
OA (KL grade 4) only experienced a short-term reduction in pain intensity during the
first month after the intervention, followed by a gradual return to the original severity
level within 3 months after GAE [38]. This phenomenon might be attributed to the substantial loss of articular cartilage
in severe knee OA, resulting in direct bone-on-bone and causing significant pain [1]. Furthermore, it should be noted that while TAME has been shown to relieve pain
and, to some extent, may improve functional outcomes, it does not alleviate structural
limitations such as range of motion restrictions or joint contractures. This distinction
is important for physicians to understand the specific benefits of TAME and to set
appropriate expectations for patients regarding the procedure’s impact on joint mobility
and structural abnormalities.
While partial or complete arthroplasty as a last resort is a possible treatment option
in advanced stages of OA, postoperatively, 10% of patients still complain of persistent
joint pain [5]
[6]. For these patients, GAE is a potential treatment that may help to alleviate persistent
pain, potentially eliminating the need for further revision surgery. However, it is
important to clarify that persistent pain in patients with total knee arthroplasty
can have a variety of causes, including instability, wear, low-grade infections, and
periprosthetic fractures. These causes must be thoroughly investigated and definitively
ruled out before considering TAME as a treatment option. As TAME is absolutely contraindicated
in these cases, a consultation with an experienced orthopedic surgeon is essential
and should be considered mandatory to assess the suitability of TAME for patients
with painful total knee arthroplasty. This critical requirement for patient selection
protects against inappropriate use of TAME and ensures that treatment is tailored
to the underlying pathology. [Fig. 2] illustrates GAE in a 64-year-old female with persistent pain of the medial knee
joint following knee joint prosthesis.
Fig. 2 Digital subtraction angiography (DSA) of a 64-year-old female with left knee joint
prosthesis and persistent medial knee joint pain. In the overview angiography a hypervascularized areas are already visible in projection onto the medial joint space
(arrowhead). b The DSA after superselective probing of the descending genicular artery clearly demonstrates
hypervascularized areas projecting onto the medial joint space. c Following embolization with 100–300 µm Embosphere microspheres, the hypervascularized
areas are no longer visible.
Osteoarthritis of the Shoulder Joint
OA of the glenohumeral joint is estimated to affect over 30% of people over 60 years
of age in the USA [40]. While previous studies have successfully used TAME as a treatment approach for
patients with persistent symptoms of adhesive capsulitis [21]
[41]
[42], there is a lack of studies demonstrating the application of TAME for shoulder joint
OA. To date, there is only one report in the literature on the use of TAME for the
treatment of OA in the shoulder joint: in their case report Katoh et al. demonstrated
transarterial periarticular embolization in a patient with post-traumatic OA of the
shoulder [28]. However, although the patient reported significant pain relief as early as one
day postintervention, long-term follow-up data is missing [28].
[Fig. 3] shows representative images of TAME in a 51-year-old patient with OA-related pain
(KL grade 4) of his left shoulder. Both cortisone and multiple hyaluronic acid injections
had previously been unsuccessful and the patient did not want to undergo surgery due
to his young age and the fact that he was still mobile and active.
Fig. 3 Left shoulder of a 51-year-old patient with OA of the shoulder (Kellgren/Lawrence
grade IV) before (a, c) and after (b, d) transarterial microembolization. a Superselective digital subtraction angiography (DSA) of the ramus acromialis before
embolization indicates abnormal neovessels (arrow). b Post-embolization DSA demonstrates elimination of the hypervascularized areas, with
preservation of the carrier vessel. c Superselective probing of the anterior circumflex artery. DSA reveals a hypervascularized
area in projection onto the medial part of the humeral head (arrow). d Following embolization with 100–300 µm Embosphere microspheres, DSA demonstrates
complete elimination of the hypervascularized area.
Osteoarthritis of the Trapeziometacarpal Joint
Trapeziometacarpal (TM) OA, occurring at the base of the thumb, is a prevalent form
of OA that affects approximately 15% of adults over 30 years of age [43]. It significantly impairs thumb opposition, leading to considerable movement restrictions.
Treating these patients is often challenging due to their relative youth, high activity
levels, and demanding requirements for hand mobility [44]. Recently, TAME has been employed as a treatment approach for patients with persistent
symptoms of TM-OA. In a first feasibility study involving 31 patients, Inui et al.
evaluated intra-arterial IPM/CS infusion for the treatment of TM-OA refractory to
conservative treatments [32]. A technical success rate of 100% and no major adverse events were reported. Intra-arterial
infusion of IPM/CS significantly improved pain perception and functional capacity,
both short-term at 2 and 6 months and long-term at 24 months, as assessed using the
numerical rating scale and the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire.
Overall, the clinical success rate was 81% after 6 months and 74% after 24 months,
thus making intra-arterial IPM/CS infusion a suitable treatment option [32]. These rates were established based on patient-reported outcomes, specifically their
self-assessment on the Patient Global Impression of Change (PGIC). A patient’s condition
was deemed to have met the criteria for “clinical success” if they reported their
state as “much improved” or “very much improved” on the PGIC scale at 24 months post-treatment.
This high percentage of positive long-term outcomes highlights the potential of intra-arterial
IPM/CS infusion as a viable treatment option in this study [32].
In the example illustrated in [Fig. 4], we present a case of TAME treatment for TM-OA in a 67-year-old female patient.
Initially, the patient experienced significant pain, particularly during pressure
or forceful movements of the hands. As this case report is drawn from clinical observations
within our clinic and does not constitute a formal study, specific quantitative measures
such as hand force measurements and clinical scores were not collected. However, following
the application of TAME, the patient reported a notable improvement in both pain and
functional ability. These qualitative outcomes underscore the potential efficacy of
TAME in alleviating symptoms and enhancing hand function in patients with TM-OA, even
in the absence of quantifiable metrics typically associated with controlled studies.
Fig. 4 Right thumb of a 67-year-old female patient with trapeziometacarpal osteoarthrosis
(Eaton/Littler Stage III) before a and after b transarterial microembolization. a Digital subtraction angiography (DSA) with contrast injection from small vascular
branches from the princeps pollicis artery before embolization. Hypervascularization
with a “blush” around the trapeziometacarpal joint at the pain point (arrow). b Post-interventional DSA after embolization with 100–300 µm Embosphere microspheres,
with evidence of a reduced but still minimally demarcated hypervascularization (arrow
head). Due to their small size, those vessels could not be probed.
Osteoarthritis of the Interphalangeal Joints
OA of the finger most commonly occurs in the distal interphalangeal joint, predominantly
in women over 50 years of age [45]. Symptomatic OA of these joints leads to stiffness and compromised hand function,
thus impairing daily activities of affected patients. Due to its potential to limit
range-of-motion, arthrodesis is a last-resort treatment, typically reserved for those
patients suffering from severe pain and joint deformity [46]. While TAME has been explored as a possible intervention for interphalangeal joint
OA, the evidence supporting its use is limited and inconclusive. Initial attempts
to apply TAME in this context have been documented. However, the lack of comprehensive
follow-up data, as seen in studies with high attrition rates, limits the ability to
draw definitive conclusions regarding its safety and efficacy. Therefore, such treatments
should be considered exploratory, and recommendations for their use cannot be reliably
made based on the current literature. There is a clear need for further research,
including well-designed clinical trials with substantial follow-up, to fully evaluate
the potential of TAME for OA of the interphalangeal joints.
Osteoarthritis of the Hip Joint
With an estimated lifetime risk of symptomatic hip OA at 25%, it is a highly prevalent
form of OA [47]. In a preliminary study involving 13 patients, Correa et al. assessed the effectiveness
and safety of TAME of the lateral femoral circumflex artery [48]. The study demonstrated significant improvements in WOMAC and VAS scores over a
6-month follow-up period. However, the cohort was very mixed, with only 3 out of the
13 patients being treated for hip OA, while the other 10 patients suffered from greater
trochanteric pain syndrome [48]. Thus, further expanded randomized studies are needed to better evaluate the potential
role of TAME in hip OA.
[Fig. 5] demonstrates representative images of circumflex femoral artery embolization in
a 59-year-old male patient with symptomatic OA of the right hip (KL grade 2).
Fig. 5 Right hip of a 59-year-old male patient with hip OA (Kellgren/Lawrence grade II) before
a and after b transarterial microembolization. a Digital subtraction angiography (DSA) with contrast injection from the descending
branch of the lateral femoral circumflex artery before embolization. Hypervascularization
with a “blush” around the femoral neck. b Post-interventional DSA after embolization with 100–300 µm Embosphere microspheres,
with evidence of completely reduced hypervascularization.
Osteoarthritis of the Ankle Joint
While OA of the ankle joint is less common than knee or hip OA, the consequences for
the individual patient can be severe [49]. Therapy options are limited and range up to arthrodesis with long recovery times.
However, to the best of our knowledge, no report on TAME in OA of the ankle joint
has been previously published.
[Fig. 6] demonstrates a case involving the application of TAME for addressing lower ankle
joint OA in a 75-year-old male patient, who initially suffered extensive pain during
walking and rolling movements. This clinical case report does not include quantitative
metrics like ankle ROM, force measurements, function scores, or gait analysis. However,
post-TAME, the patient reported notable pain reduction and improved mobility, demonstrating
TAME’s potential to enhance quality of life for OA patients, even in the absence of
detailed quantitative data.
Fig. 6 Right foot of a 75-year-old male patient with OA of the lower ankle joint (Kellgren/Lawrence
grade IV) before a and after b transarterial microembolization. a Digital subtraction angiography (DSA) with contrast injection from the lateral tarsal
artery before embolization. Extensive hypervascularization with a “blush” around the
lower ankle joint at the pain point. b Post-interventional DSA after embolization with 100–300 µm Embosphere microspheres,
with evidence of reduced but still minimally demarcated hypervascularization (arrow
head) and patent main feeding arteries.
Conclusion
The presented studies and cases collectively highlight the therapeutic promise of
TAME in mitigating chronic musculoskeletal pain linked to OA and its diverse histopathological
conditions and anatomical sites. As such, TAME stands as a promising therapeutic approach,
providing patient relief from the burdens of joint diseases and significantly enhancing
their quality of life. With an expanding evidence base highlighting its therapeutic
advantages and the potential for application across a diverse spectrum of joint-related
pathologies, TAME is increasingly recognized as a significant enhancement to the treatment
options available for these conditions in selected cases. This recognition underscores
TAME’s role in offering a minimally invasive alternative that can provide relief and
improve the quality of life for patients who meet specific criteria for this treatment
approach.
While TAME is recognized as a safe and effective option for selected cases of chronic
musculoskeletal pain, it is imperative to acknowledge that its applicability and efficacy
are contingent upon the specific conditions of individual patients. This tailored
approach necessitates comprehensive understanding of potential challenges that may
arise during the intervention, as well as the importance of vigilant management of
post-treatment complications. The implementation of preventive measures, along with
early detection and adept management strategies by experienced interventional radiologists
are pivotal for optimizing patient outcomes and mitigating the likelihood of complications.
