Musculoskeletal Embolization Inflammatory and Degenerative Disease
Musculoskeletal embolization Inflammatory and degenerative Disease
Yuji Okuno Musculoskeletal Intervention Center Edogawa Hospital Conflict of interest: none Tokyo, JAPAN
J Vasc Interv Radiol 2013 June ; 24: 787-792 J Vasc Interv Radiol 2013 June ; 24: 787-792
• Tendinopathy and enthesopathy Lateral Epicondylitis (“Tennis Elbow”) Patellar Tendinopathy (“Jumpers’ Knee”) Achilles Tendinopathy etc
Case: Patellar tendinopathy
58y.o. male
High level long distance city runner 350km / month before disease onset
Due to his pain, he could not run for 10 months
Case: Patellar tendinopathy
Patellar tendon Patellar tendon
Affected side Unaffected side Selective angiography of lateral inferior genicular artery Before TAE
Patellar Normal appearance of lateral inferior genicular artery Normal Knee
patellar Selective angiography of lateral inferior genicular artery
Before Embolization
Patellar Selective angiography of lateral inferior genicular artery
After Embolization
Patellar Pain VAS (mm) 100
20 40 60 80 2 3 4 4 3 2 2012 0 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 11 12 10 9 8 7 6 5 4 3 2 1 11 12 10 9 8 7 6 5 Physical Physical Therapy Loxoprofen Change ofPainScore
2013 2014 2014 2013
180mg/day
Embolization （ month
）
1 1 2
2016
7
1year follow up of first 12 patients with tendinopathy and enthesopathy Our MSK Embolization from 2012 to 2016 June
• Tendinopathy and enthesopathy 98 cases • MSK shoulder pain (frozen shoulder etc) 128 cases • Knee osteoarthritis 95 cases • Sports injuries 44 cases • Persistent pain after joint replacement 32 cases
• Others (hip, ankle, wrist, elbow, etc) 152cases total n = 549 Today’s Contents
• Prevalence of abnormal vessels in MSK disorders • Embolic material • Short term effect • Safety • Long term result • Required knowledge to start MSK embolization
Today’s Contents
• Prevalence of abnormal vessels in MSK disorders • Embolic material • Short term effect • Safety • Long term result • Required knowledge to start MSK embolization
How often abnormal vessels are visible in angiography? Prevalence of abnormal vessels
Lateral epicondylitis (tennis elbow)
Most common cause of chronic elbow pain and disorders
10% of these patients develop chronic symptoms and eventually require surgical intervention Prevalence of abnormal vessels
48 elbow in 43 patients Diagnosis made with 1. Clinical history of pain at lateral elbow 2. Physical findings (by elbow surgeon)
Angiography & Embolization Normal appearance of elbow angiography Abnormal vessels in patients with tennis elbow Prevalence of abnormal vessels
Abnormal vessels were visible n =48 in 48/48 elbows invisible 0
visible 48 Frozen shoulder ( Adhesuve Capsulitis ) • Characterized by painful restriction of shoulder motion. • Many refractory cases (35% had residual pain at seven years [1])
Normal shoulder Normal and abnormal findings of selective angiography of thoracoacromial artery
Normal shoulder Frozen Shoulder
J Should Elbow Surg. 2014 C : Coracoid H : Humeral Head Intact Direct branch from Axillary artery C H C : Coracoid H : Humeral Head Intact Direct branch from Axillary artery C H C : Coracoid H : Humeral Head Intact Direct branch from Axillary artery C H C : Coracoid H : Humeral Head Intact Direct branch from Axillary artery C H 50y.o. male C : Coracoid H : Humeral Head Frozen Shoulder Direct branch from Axillary artery
C H 48y.o. female C : Coracoid H : Humeral Head Frozen Shoulder Direct branch from Axillary artery
C
H Prevalence of abnormal vessels
50 patients Diagnosis made with 1. Clinical history of pain at lateral elbow 2. Physical findings (by shoulder surgeon)
n =50 invisible Abnormal vessels were visible 0 in 50/50 shoulders visible 50 Scientific background of Frozen shoulder
• Hypervascularity in Frozen shoulder depicted by contrast enhanced MRI
Song et al. AJR 2011 • Gondim Teixeira et al. AJR 2012 • Ahn et al. Clin Imaging 2015
Scientific background of Frozen shoulder
• Increased neovessels in Frozen shoulder Observed during surgical procedure
• Bunker et al. J Bone Joint Surg Br 1995 • Wiley et al. Arthroscopy 1991. • Yamaguchi et al. Arthroscopy 2002
Normal shoulder Frozen shoulder Scientific background of Frozen shoulder
• Increased small vessels in Frozen shoulder Microscopic findings
Hagiwara et al. Osteoar Cartilage 2012 • Bunker et al. J Bone Joint Surg Br 1995 • Xu et al. J Shoulder Elbow Surg 2012 Normal and abnormal finding of descending genicular artery Normal knee Mild radiographic knee OA a b
Figure 1. Normal and abnormal vasculature of descending genicular artery MC, medial condyle; LC, lateral condyle. CVIR 2015 Prevalence of abnormal vessels
Knee Osteoarthritis 72/75 cases =96%
n =75 invisible 3
visible 72 Today’s Contents
• Prevalence of abnormal vessels in MSK disorders • Embolic material • Short term effect • Feasibility • Long term result • Required knowledge to start MSK embolization
What type of embolic material should we use? Embolic Material
Temporary Embolic particle • Imipenem/cilastatin sodium (IPM/CS) • Approved as an antibiotic • Compound slightly soluble to water • Forming small particle (diameter is 10-70 um) when we suspend with 5-10ml of contrast
• Already in use as an embolic agent in Japan from 1990 - to stop intestinal tumor bleeding (oozing) due to its safety profile Woodhams et al. Springerplus. 2013 Temporary Embolic particle
Aihara et al. Interv Radiol. 1999 Today’s Contents
• Prevalence of abnormal vessels in MSK disorders • Embolic material • Short term effect • Feasibility • Long term result • Required knowledge to start MSK embolization
Short-term effect of Embolization
• Frozen shoulder 48 cases
Nighttime pain relief* were observed in 67% within 1 week 84% within 1 month after embolization *nighttime pain decreased more than 50% of baseline
J Shoulder Elbow Surg 2014 JVIR under review Short-term effect of Embolization
• Mild to moderate Knee OA 75cases
Pain relief* were observed in 73% within 1 month 88% within 4 month after embolization *maximum pain decreased more than 50% of baseline
CVIR 2015 KSSTA under review Short-term effect of Embolization
• Tendinopathy and enthesopathy 98 cases Lateral Epicondylitis (“Tennis Elbow”) Patellar Tendinopathy (“Jumpers’ Knee”) Achilles Tendinopathy etc
Pain relief* were observed in 76% within 3 months 84% within 6 months after embolization *maximum pain decreased more than 50% of baseline Why embolization of abnormal vessels relieve pain?
• Improving inflammatory conditions (abnormal vessels maintain inflammation ) Mapp et al. Nat Rev Rheumatol. 2012
• Reducing stimulation from accompanying nerve fiber located close to small vessels (Nerve fiber grow around neovessels) Why embolization of abnormal vessels relieve pain? Control tissue Frozen shoulder
Figure1 Microscopic findings of shoulder capsule tissue from frozen shoulder (right) compared with control tissue (left). Nerve fibers were often located close to increased small vessels in frozen shoulder tissue. Xu et al. J Should Elbow Surg. 2012 PGP 9.5 Nerve Fiber Blood vessel Why embolization of abnormal vessels relieve pain?
Ljung et al 1999 J Orthop Res
in Tennis elbow tissue • Pain-related nerve fiver located at near increased small vessels Histological study detecting increased vessels and accompanying nerve fiver
• Tennis Elbow Sasaki et al. J Orthop Sci (2013) Ljung et al. Cells Tissue Organs (1999) Uchio et al. J Shoulder Elbow Surg (2002)
• Achilles tendinitis Alfredson et al. KSSTA (2003) • patellar tendinitis Danielson et al. KSSTA (2008) • Frozen shoulder Xu et al. J Shoulder Elbow Surg (2012) • Knee Osteoarthritis Walsh et al. Osteoarthritis and Cartilage(2007) • Shoulder Rotator cuff tear Gotoh et al. J Orthop Res (1998) • Chronic low back pain Gronblad et al. Spine (1991) • Anterior knee pain Bohnsack et al. Arch Orthop Traum Surg (2005) • Temporomandibular disorder Yoshida et al. J Oral Rehabil (1999)
Today’s Contents
• Prevalence of abnormal vessels in MSK disorders • Embolic material • Short term effect • Safety • Long term result • Required knowledge to start MSK embolization
Safety Profile
「Phase 1/2 trial of MSK embolization for consecutive 100 patients 」 UMIN 000014591
Complications CTCAE Grade Number Pain during procedure 1 12 Puncture site hematoma 1 7 Radial artery spasm 1 5 Post procedure pain 1-2 4 vomiting (CE side effect) 1 1 Fever ( >38) 2 1
Peripheral paresthesia none Muscle weakness none Dermal necrosis / color change none How about using Microsphere?
Small study using small sized (<100μm) microsphere for tendinopathy Change of pain score after embolization using small MS 7 days after Embolization using small-sized MS 7 days after Embolization 49 days afterEmbolization using small-sized MS using small-sized MS 7 days after Embolization 49 days after using small-sized MS Embolization using small- sized MS How about using Microsphere?
Although it does work, but there is a risk of making ischemic conditions Today’s Contents
• Prevalence of abnormal vessels in MSK disorders • Embolic material • Short term effect • Feasibility • Long term result • Required knowledge to start MSK embolization
Long-term result of Embolization for Frozen shoulder
JVIR under review Long-term result of Embolization for Knee Osteoarthritis
KSSTA under review Pain recurrence? Pain Recurrence? Follow up survey
Pain recurrence after your initial post embolization pain relief?
n = 52 n = 46 Before 6months [PERCENTAGAfter E] 6months No No [PERCENTAG Recurrence recurrence E] [PERCENTAG 100% E]
Frozen shoulder Tendinopathy and enthesopathy MRI Assessment at long-term follow-up MRI at 2 years after embolzation
Before Embolization 2 years after Embolization
KSSTA under review MRI at 2 years after embolzation
MRI T2 GRE Coronal
Before 2 years after Embolization Embolization
KSSTA under review MRI at 2 years after embolzation
Before Embolization 2 years after Embolization MRI at 2 years after embolzation
MRI findings at 2 years (n = 25) Findings 2 years after TAME
Bone marrow necrosis 0
Aggressive degenerative change 0
Obvious cartilage loss from baseline 0 Today’s Contents
• Prevalence of abnormal vessels in MSK disorders • Embolic material • Short term effect • Feasibility • Long term result • Required knowledge to start MSK embolization
Arterial anatomy of Shoulder joint
JVIR under review Distribution of abnormal vessels
JVIR under review Before embolization Before and After Embolization (Angiographic findings)
Before Emboli After Emboli A A C C H H Can temporary embolic material show prolonged effect? 2 months later Our embolization procedure Target: increased abnormal vessels (small diameter)
Treatment goal is not total vessels oclusion but decrease abnormal blood flow and remain physiological blood flow TAME (Transcatheter Arterial Micro/Musculoskeletal-Embolization) Thank you