Angiographic Analysis of Anatomical Variants in Adhesive Capsulitis Embolization.

PURPOSE: To analyze the complex shoulder vasculature and identify potential challenges during adhesive capsulitis embolization (ACE). MATERIALS AND METHODS: Two interventional radiologists evaluated angiographic findings from 21 ACE procedures. The suprascapular artery (SSA), thoracoacromial artery (TAA), coracoid branch (CB), circumflex scapular artery (CSA), and anterior/posterior circumflex humeral artery (ACHA/PCHA) were assessed for their presence, course, diameter within 1 cm of origin, angle to the proximal parent vessel, and distance from the clavicle. RESULTS: 83 arteries were embolized: CB (20.5%), TAA (19.3%), PCHA (19.3%), ACHA (16.9%), CSA (14.5%), and SSA (9.6%). The CSA had the largest diameter (4.3 mm), while CB had the smallest diameter (1.0 mm). An acute angle to the parent vessel was noted with the SSA, TAA, ACHA, and PCHA. A common origin for CSA and PCHA was noted in 2 patients. A common origin for TAA and SSA was also noted in one patient. The CB appears perpendicular to the axillary artery and courses vertically toward the coracoid process. The TAA branches off the axillary artery and courses along the medial border of the pectoralis minor. The PCHA and ACHA originate from the axillary artery. The CSA is located on the medial side of axillary artery. The SSA originates from the thyrocervical trunk and courses laterally toward the superior border of the scapula. CONCLUSION: An anatomical-technical guide is provided to help interventional radiologists during ACE to treat adhesive capsulitis.

Outcomes of Hemorrhoidal Artery Embolization from a Multidisciplinary Outpatient Interventional Center.

PURPOSE: To evaluate the safety and efficacy of outpatient transarterial embolization for symptomatic refractory internal hemorrhoids. MATERIALS AND METHODS: Retrospective analysis of 134 patients who underwent hemorrhoidal artery embolization (HAE) for symptomatic internal hemorrhoids between August 2021 and June 2022 (76 men and 58 women) was performed. The mean age was 54.9 years, with a mean Goligher hemorrhoid grade (HG) of 2.1. Branches of the superior rectal artery (SRA) or middle rectal artery supplying the corpus cavernosum recti were embolized with both spherical particles and microcoils. Standard-of-care evaluations were performed at baseline and the 1 month follow-up, which included hemorrhoid-related pain (HRP) (0-10), hemorrhoid symptoms score (HSS) (5-20), quality of life (QoL) (0-4), French bleeding score (FBS) (0-9), and HG (0-4). Clinical success was defined as improvement of symptoms without additional treatment. RESULTS: Embolization of at least 1 hemorrhoidal artery was achieved in 133 (99%) of the 134 patients. The mean number of SRA branches embolized per patient was 2.9 ± 1.0. Clinical success was seen in 93% (124 of 134) of patients at the 1-month follow-up, with 10 patients requiring repeat embolization. There were significant improvements in all mean outcomes at 1 month: HSS (11-7.8; P < .01), HRP (4.1-1.3; P < .01), QoL (2.2-0.8; P < .01), FBS (4.4-2.2; P < .01), and HG (2.3-1.2; P < .05). There were no severe adverse events. CONCLUSIONS: HAE is a safe and effective outpatient treatment for refractory symptomatic internal hemorrhoids in the short term.

Multicenter Randomized Sham Controlled Study of Genicular Artery Embolization for Knee Pain Secondary to Osteoarthritis.

PURPOSE: To assess the safety and efficacy of genicular artery embolization (GAE) compared with a sham procedure in the treatment of knee pain secondary to mild to moderate osteoarthritis (OA). MATERIALS AND METHODS: A multicenter, single-blinded, randomized controlled trial was conducted to evaluate knee OA symptom reduction after GAE versus sham procedure. Subjects (n = 21) with mild to moderate OA and intractable knee pain were randomized 2:1 to either GAE or a sham procedure. Subjects who were randomized to the sham procedure and did not report clinical improvement in both the total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and visual analog scale (VAS) scores were unblinded and able to crossover to treatment at 1 month. Longitudinal data were collected for 12 months, and subjects were excluded if they required additional analgesics at follow-up. Reductions in the VAS and total WOMAC scores were compared using mixed-effects linear regression models. RESULTS: All subjects in the sham group failed to show significant improvements at 1 month and crossed over to the treatment arm. There was a statistically significantly greater pain reduction in the treatment group than in the sham group at 1 month (VAS, 50.1 mm; standard error [SE], 10.6; 95% confidence interval [CI], 29.0, 72.3; P<.01). Disability improvement was also significantly greater in the treatment group (WOMAC, 24.7 points; SE, 10.4; 95% CI, 3.5, 45.9; P=.02). Only minor adverse events were reported. Five subjects were excluded after increased analgesic use. Sensitivity analysis with all excluded patients confirmed significant improvements at 1 and 12 months. CONCLUSION: In patients with mild to moderate knee OA, GAE results in symptomatic improvement greater than the sham procedure with clinically significant reduction in pain and disability.

Results from a United States Investigational Device Study of Adhesive Capsulitis Embolization in the Treatment of Shoulder Pain: The Adhesive Capsulitis Embolization Study.

PURPOSE: To evaluate the safety and efficacy of arterial embolization to relieve shoulder pain secondary to adhesive capsulitis (AC). MATERIALS AND METHODS: In total, 20 patients (18 females, 2 males; mean age, 51 years) with AC resistant to >30 days of conservative treatment were enrolled in a multicenter prospective study. Adhesive capsulitis embolization was performed with 75-µm or 200-µm spherical particles. Subjects were assessed before and after the procedure with magnetic resonance imaging, visual analog scale (VAS; 0-100 mm) scores, Single Assessment Numeric Evaluation (SANE; 0-100) scores, and American Shoulder and Elbow Surgeons (ASES; 0-100) scores. Adverse events were recorded at all follow-up time points. RESULTS: Hypervascularity was identified and embolization was technically successful in all patients, with 83 arteries embolized in 20 patients. Baseline VAS, SANE, and ASES scores before the procedure were 89.2 mm, 27.2, and 30.9, respectively. The 1-month (n = 19), 3-month (n = 18), and 6-month (n = 12) follow-ups demonstrated significant improvements. At the 1-month follow-up, VAS score decreased by 31.8 (P = 1.2E-11), SANE score increased by 22.1 (P = 1.8E-8), and ASES score increased by 14.2 (P = 4.3E-5). At the 6-month follow-up, VAS score decreased by 62.1 (P = 7.0E-11), SANE score increased by 55.4 (P = 4.1E-10), and ASES score increased by 44.5 (P = 1.8E-6). Due to the coronavirus pandemic, the study ended early; 6 patients did not complete the 6-month follow-up. No major adverse events were noted. CONCLUSIONS: Interim findings suggest that arterial embolization is safe and effective for patients with AC refractory to conservative treatment.

Genicular Artery Embolization for the Treatment of Knee Pain Secondary to Osteoarthritis.

PURPOSE: To evaluate the efficacy and safety of embolization of hyperemic synovial tissue for the treatment of knee pain secondary to osteoarthritis (OA). MATERIALS AND METHODS: Twenty patients with radiographic knee OA and moderate-to-severe pain refractory to conservative therapy were enrolled in a prospective, 2-site pilot study. Genicular artery embolization (GAE) was performed with 75- or 100-µm spherical particles. Patients were assessed with magnetic resonance imaging at baseline and at 1 month and with the Visual Analogue Scale (VAS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at baseline and at 1, 3, and 6 months. Adverse events were recorded at all timepoints. RESULTS: Embolization of at least 1 genicular artery was achieved in 20/20 (100%) patients. Mean VAS improved from 76 mm ± 14 at baseline to 29 mm ± 27 at 6-month follow-up (P < .01). Mean WOMAC score improved from 61 ± 12 at baseline to 29 ± 27 at 6-month follow-up (P < .01). Self-limiting skin discoloration occurred in 13/20 (65%) patients. Two of 20 (10%) patients developed plantar sensory paresthesia that resolved within 14 days. CONCLUSIONS: GAE to treat knee pain secondary to OA can be performed safely and demonstrates potential efficacy. Further randomized comparative studies are needed to determine true treatment effect versus placebo effect.

How to "Get Out of Trouble" During Prostatic Artery Embolization.

Prostatic artery embolization can be an extremely challenging procedure often giving the operator the sense of "being in trouble." This feeling can occur during different stages of the procedure including initial identification of the prostatic artery, catheterization of the prostatic artery, and prevention of non-target ischemia via extra-prostatic anastomoses during embolization. This brief guide provides techniques developed from prior experience with these frustrating situations that could potentially help the prostatic artery embolization operator "get out of trouble."

Current Concepts and Future Directions of Minimally Invasive Treatment for Knee Pain.

PURPOSE OF REVIEW: The purpose of this paper is to review the percutaneous interventions available for the treatment of osteoarthrosis of the knee that address pain and prolong the time to arthroplasty. RECENT FINDINGS: Corticosteroid injection and viscosupplementation have been the most studied, but there is still no consensus about their value. Thermal nerve ablation, including both radiofrequency ablation and cryoneurolysis, is a promising new modality of therapy that may increase in clinical use given current data showing favorable outcomes. Of the future therapies that are currently under investigation, synovial embolization via the geniculate arteries represents an exciting new approach that may soon be available clinically. There are various percutaneous interventions available for the treatment of osteoarthrosis of the knee that address pain and prolong the time to arthroplasty.

Cost Analysis of Prostate Artery Embolization (PAE) and Transurethral Resection of the Prostate (TURP) in the Treatment of Benign Prostatic Hyperplasia.

PURPOSE: Prostatic arterial embolization (PAE) has emerged as a minimally invasive alternative to TURP; however, there are limited cost comparisons reported. The purpose of this study was to compare in-hospital direct costs of elective PAE and TURP in a hospital setting. MATERIALS AND METHODS: Institutional Review Board-approved retrospective review was performed on patients undergoing PAE and TURP from January to December 2014. Inclusion criteria included male patients greater than 40 years of age who presented for ambulatory TURP or PAE with no history of prior surgical intervention for BPH. Direct costs were categorized into the following categories: nursing and operating room or interventional room staffing, operating room or interventional supply costs, anesthesia supplies, anesthesia staffing, hospital room cost, radiology, and laboratory costs. Additionally, length of stay was evaluated for both groups. RESULTS: The mean patient age for the TURP (n = 86) and PAE (n = 70) cohorts was 71.3 and 64.4 years, respectively (p < 0.0001). Intra-procedural supplies for PAE were significantly more costly than TURP ($1472.77 vs $1080.84, p < 0.0001). When including anesthesia supplies and nursing/staffing, costs were significantly more expensive for TURP than PAE ($2153.64 vs $1667.10 p < 0.0001). The average length of stay for the TURP group was longer at 1.38 versus 0.125 days for the PAE group. Total in-hospital costs for the TURP group ($5338.31, SD $3521.17) were significantly higher than for PAE ($1678.14, SD $442.0, p < 0.0001). CONCLUSIONS: When compared to TURP, PAE was associated with significantly lower direct in-hospital costs and shorter hospital stay.

Robotic-Assisted Versus Manual Prostatic Arterial Embolization for Benign Prostatic Hyperplasia: A Comparative Analysis.

PURPOSE: Prostatic artery embolization (PAE) is a safe and efficacious procedure for benign prostatic hyperplasia (BPH), though is technically challenging. We present our experience of technical and clinical outcomes of robotic and manual PAE in patients with BPH. MATERIALS AND METHODS: IRB-approved retrospective study of 40 consecutive patients 49-81 years old with moderate or severe grade BPH from May 2014 to July 2015: 20 robotic-assisted PAE (group 1), 20 manual PAE (group 2). Robotic-assisted PAE was performed using the Magellan Robotic System. American Urological Association (AUA-SI) score, cost, technical and clinical success, radiation dose, fluoroscopy, and procedure time were reviewed. Statistical analysis was performed within and between each group using paired t test and one-way analysis of variance respectively, at 1 and 3 months. RESULTS: No significant baseline differences in age and AUA-SI between groups. Technical success was 100% (group 1) and 95% (group 2). One unsuccessful subject from group 2 returned for a successful embolization using robotic assistance. Fluoroscopy and procedural times were similar between groups, with a non-significant lower patient radiation dose in group 1 (30,632.8 mGy/cm2 vs 35,890.9, p = 0.269). Disposable cost was significantly different between groups with the robotic-assisted PAE incurring a higher cost (group 1 $4530.2; group 2 $1588.5, p < 0.0001). Clinical improvement was significant in both arms at 3 months: group 1 mean change in AUA-SI of 8.3 (p = 0.006), group 2: 9.6 (p < 0.0001). No minor or major complications occurred. CONCLUSIONS: Robotic-assisted PAE offers technical success comparable to manual PAE, with similar clinical improvement with an increased cost.

Revascularization for critical limb ischemia using the SpiderFX embolic protection device in the below-the-knee circulation: initial results.

PURPOSE: To examine the safety and efficacy of the SpiderFX embolic protection device (EPD) in the below-the-knee (BTK) circulation in patients with critical limb ischemia (CLI). MATERIALS AND METHODS: A single-center retrospective review was performed to identify patients with CLI and single-vessel runoff in whom the SpiderFX EPD was used in the BTK circulation. Technical success and device-related complications were the primary endpoints. Retrieval of macroscopic debris in the EPD, 1-year freedom from major adverse limb events (MALEs), and 30-day perioperative death were also evaluated. A major amputation, surgical bypass, endovascular thrombectomy, or endovascular thrombolysis was considered a MALE. Thirty-six patients (21 men; mean age, 75.8 y) treated between 2008 and 2013 had endovascular revascularization with use of the SpiderFX EPD in the BTK circulation. RESULTS: The SpiderFX EPD was successfully deployed in all cases; the technical success rate of revascularization was 100%. Two minor and zero major complications were observed related to the SpiderFX. Two MALEs, a major amputation and a subsequent surgical bypass, were observed in the cohort. All MALEs occurred within 1 year of treatment (1-y freedom from MALE rate, 90%). Debris was retrieved in the SpiderFX device in 47% of patients. CONCLUSIONS: The use of the SpiderFX EPD in the BTK circulation in patients with CLI is safe and frequently retrieves debris.

Recurrent cholecystitis and cholelithiasis in a gallbladder remnant 14 years after a converted cholecystectomy.

A 52-year-old man presented to the emergency department with a one-day history of epigastric pain. The patient reported a remote history of a "difficult" laparoscopic cholecystectomy that was converted to an open cholecystectomy in 1994. Further operative details were unavailable. Multiple radiologic studies were obtained, all demonstrating a saccular cystic structure in the gallbladder fossa containing calculi. A completion open cholecystectomy, or "recholecystectomy," revealed a remnant gallbladder with cholecystitis and cholelithiasis. Multimodality imaging findings are reviewed.