Genicular artery embolization for persistent knee pain
A woman in her sixties had chronic knee pain persisting despite intra-articular injections, with targetable inflammatory blushing areas on DSA. Five genicular artery branches were assessed superselectively; at one month, the VAS pain score had decreased from 7/10 to 0–1/10. This result represents the short-term response of a single patient.
Knee pain persisting despite intra-articular injections
A woman in her sixties presented with chronic knee pain in which signs of inflammation were prominent. The initial pain level was assessed as 7/10 using the visual analogue scale (VAS).
Different intra-articular injection treatments had previously been administered, but the patient had experienced only limited and temporary benefit. As her symptoms persisted, she was assessed for genicular artery embolization.
Blushing areas consistent with inflammation on DSA
Selective DSA series showed prominent pathological staining, that is, “blushing” areas, in some genicular artery branches around the knee, consistent with an inflammatory process.
The pre- and post-procedure images of the superior lateral, superior medial and middle genicular artery regions showed how this abnormal vascular staining changed with targeted embolization.
A minimally invasive option after limited response to conservative treatments
Genicular artery embolization is not a first-line treatment for knee pain. In this case, the persistence of pain despite previous intra-articular treatments, the prominent signs of inflammation and the presence of targetable pathological vascular areas on DSA were considered together before the decision to proceed.
The aim was to selectively reduce the abnormal vascular network accompanying the inflammatory tissue while preserving the knee’s normal circulation.
Superselective treatment of five genicular arteries through 4F femoral access
The procedure was started by placing a 4F sheath in the femoral artery. Five genicular artery branches around the knee were catheterised superselectively with a microcatheter, and control DSA series were obtained in each vessel to assess pathological vascular staining.
Target areas in which blushing, an indicator of inflammation, was detected were embolized with imipenem/cilastatin. A control image was obtained after embolization at each target, the disappearance of blushing was confirmed, and the procedure was completed.
The before-and-after embolization sequence in three regions on DSA
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What you see Prominent pathological staining accompanying inflammation is seen in the tissue around the knee supplied by the vessel.
Why it matters The blushing area indicated the abnormal vascular region to be targeted for embolization.
During the procedure Inflammatory blushing is seen on DSA of the superior lateral genicular artery. Initial DSA series obtained after superselective catheterization of the superior lateral genicular artery. -
What you see The pathological vascular staining seen initially is no longer observed.
Why it matters The disappearance of blushing showed that the planned embolization endpoint had been reached in this target area.
After the procedure The blushing in the superior lateral genicular artery region disappears after embolization. Control DSA series obtained from the same region after imipenem/cilastatin embolization. -
What you see Prominent pathological vascular staining consistent with inflammation is seen in the superior medial region.
Why it matters This angiographic finding identified the second target embolization area.
During the procedure Inflammatory blushing is seen on DSA of the superior medial genicular artery. Initial superselective DSA series of the superior medial genicular artery. -
What you see The initial blushing appears to have disappeared in the target region.
Why it matters The control DSA confirmed that the abnormal vascular staining had been reduced to the intended level.
After the procedure Blushing disappears after embolization in the superior medial genicular artery region. Control series obtained from the superior medial genicular artery after imipenem/cilastatin embolization. -
What you see Pathological staining accompanying inflammation is seen in the middle genicular artery region.
Why it matters The blushing area indicated the third representative target region.
During the procedure Inflammatory blushing is seen on DSA of the middle genicular artery. Initial superselective DSA series of the middle genicular artery. -
What you see The initial pathological staining is no longer seen after the procedure.
Why it matters The final control confirmed that the planned angiographic endpoint had also been reached at this target.
After the procedure The blushing in the middle genicular artery region disappears after embolization. Control DSA series obtained from the middle genicular artery after imipenem/cilastatin embolization.
Same-day discharge and marked reduction in pain at one month
The patient was kept under observation for four to five hours after the procedure and discharged on the same day.
At the one-month follow-up, the VAS pain score, initially 7/10, was seen to have decreased to 0–1/10. This result represents the short-term clinical response of this patient; the degree and duration of response may vary between patients.
What this case teaches
In knee pain that persists despite intra-articular treatments, not only structural changes but also the clinical and angiographic indicators of inflammation are important. In appropriately selected patients, pathological blushing areas on DSA may provide targets for genicular artery embolization.
In this case, marked pain reduction was observed at one-month follow-up after superselective assessment of five genicular artery branches and embolization of only the target blushing areas.
What this means for the patient
Genicular artery embolization is a minimally invasive option that may be considered in some patients who do not respond adequately to conservative treatments and who have appropriate clinical and imaging findings.
This treatment is not suitable for every case of knee pain. Patient selection should be based on a combined assessment of the cause of the pain, joint structure, signs of inflammation, previous treatments and individual expectations.
Risks and alternatives
Possible risks
Bruising, bleeding, altered skin sensation or unintended blockage of a normal vessel can occur. Long-term safety and benefit remain uncertain.
Other options
Tailored exercise, weight management when relevant, pain medicines or injections where suitable, and joint replacement assessment for severe disease.
NICE considers the evidence on benefit and long-term safety insufficient and recommends this procedure only in a research setting in the UK. Any proposal here needs an individual discussion of this uncertainty.
Clinical source: NICE
This is one patient. Imaging is anonymised and published with that patient’s written consent. Individual results vary, and nothing here is a prediction of your own outcome or a substitute for a consultation.