January 8, 2026 • 37 mins
Chronic knee pain affects millions of Americans, especially as we age, and osteoarthritis is often the cause. In this episode, host Debra Schindler talks with Dr. Moutasem Aljundi, vascular and interventional radiologist at MedStar Health, to explore an emerging, minimally invasive treatment option you may not have heard of: genicular artery embolization (GAE).
Dr. Aljundi explains how GAE works by reducing abnormal blood flow that fuels inflammation inside the knee joint, helping relieve pain and stiffness caused by osteoarthritis. The conversation covers who may be a good candidate, how the outpatient procedure is performed, recovery time, success rates, and how GAE compares to other treatments like steroid injections, nerve ablation, and knee replacement surgery.
If you’re living with chronic knee pain and looking for alternatives, or ways to delay knee replacement, this episode offers valuable insight into a promising option that’s changing how knee osteoarthritis is treated.
For more information about genicular artery embolization for knee pain, go to medstarhealth.org and search interventional radiology or for an appointment, call 240-434-7024. If you would like to comment on this podcast or recommend a topic for another episode of DocTalk, send an email to doctalk@medstar.net.
For more episodes of MedStar Health DocTalk, go to medstarhealth.org/doctalk.
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(00:02):
Comprehensive, relevant,and insightful conversations about health
and medicine happen here on MedStarHealth Doc Talk.
These are real conversations withphysician experts from around the largest
healthcare system inthe Maryland, DC region.
There are a lot of reasons whyapproximately 25% of adult Americans have
(00:23):
chronic knee pain. Those joints bear alot of weight and are prone to injury.
Then there's osteoarthritis,arguably the most common joint disease
in the world. And what is that? Well,it happens when the protective cartilage
at the end of the bones gradually wearsaway and oh, the pain when the
buffer between them is gone.
(00:43):
Bone on bone pain can lead to a longlist of treatment options. Today,
we're going to talk about onethat you may not have heard of,
genicular artery embolization or GAE.
It's new to me and I can't wait tohear more about it from today's guest.
Welcome vascular and interventionalradiologist, Dr. Moutasem Aljundi,
board certified in interventionalradiology and diagnostic
(01:06):
Health. I'm your host, Debra Schindler.
Thanks for being with me today,Dr. Aljundi.
Thank you, Deborah, andthanks for hosting me.
From the research I did, genicularartery embolization is still fairly new,
and there isn't a lot of solid datayet about how many GAE procedures are
performed in the US. Is it fair to saythat GAE is still an emerging treatment?
(01:28):
It is emerging. However,it's been established and became
increasingly popular in the UnitedStates over, I would say,
the past five to six years.
It's been done outside the UnitedStates for longer than that.
It's a procedure that becameincreasingly popular around 2016, 2017,
and in the United States, I'dsay after 2020, 21. As you said,
(01:52):
chronic knee pain. The leading causefor that is knee osteoarthritis,
which is a disease that has highprevalence in the US and in the world.
And there is a lot of research thatis happening all over the world on new
procedures and interventions,as well as surgeries to help
patients with knee pain.
(02:12):
This is probably one of the newestinterventions that we've had,
and there is still more to know about it.
There is still moreresearch that is being done,
particularly to look at the long-termefficacy as well as the safety of the
procedure. We have very good data onthe short-term and intermediate-term
results,and this data shows very promising
results in helping patients withchronic knee osteoarthritis.
(02:37):
Well, it seems from my research anyway,that genicular artery embolization
is usually only available at academicmedical centers or large
interventional radiology programs,such as MedStar Washington
Hospital Center,which is one of our
sister hospitals in DC.
What drew your interest in it to bringit here to MedStar St. Mary's Hospital?
(02:58):
Well, when I joined MedStarHealth back in 2021, first,
I work here in St. Mary's Hospital,but I also do procedures at
MedStar Washington Hospital Center,as well as MedStar Southern
Maryland Hospital. The goal was to,when I joined MedStar Health,
is to build a comprehensiveIR service here at MedStar St.
(03:20):
Mary's Hospital to be able to providethe services that we provide in DC and
our larger centers for our localcommunity here at St. Mary's Hospital.
Nice.
And many of those procedureswere not performed here before,
but slowly we were ableto build, I would say,
a comprehensive clinical IR practice here.
(03:40):
We started by establishing aninterventional radiology clinic where we
evaluate patients pre-procedurally,then we perform the procedure here
and we do our own follow-ups here.
And I think that has helped a lot ofpatients because previously patients would
have to travel to get a lot of theseprocedures in one of our tertiary
(04:01):
hospitals.
Well, listen, I can tell you, Ijust got back from a trip to Greece,
and most of the peoplein my tour were over 50,
and at least half of ushad our knees wrapped up,
including myself and myhusband for different issues.
So knee pain is so commononce you hit the age of 50,
it just seems like everybodyhas a story to tell.
(04:23):
Let's go through some of the standardtreatment options for knee pain.
The prevalence of knee pain is very high.
It mostly happens in peopleabove the age of 50 to 60.
You see it equally in men and womenwith a slightly more seen in females.
The leading cause of chronicknee pain is knee osteoarthritis.
(04:43):
And knee osteoarthritis can bedivided into primary osteoarthritis,
which is mainly causedby wear and tear factors.
And then secondary osteoarthritis thatcan be caused by secondary reasons such
as injuries, trauma, kneeinfections, and other reasons.
And there are other sources of arthritisor other arthritis that happen in the
knee that are inflammatory in nature.
Those include oriatic arthritis,rheumatoid arthritis, and
(05:08):
other ratiologies. But by far,the most common cause
of chronic knee pain,particularly in patients above
the age of 50 to 60 is primaryknee osteoarthritis.
The wear and tear of the old knee.
Yes.
Where does this genicular artery ablationcome into play? What does that mean,
(05:28):
genicular?
Genicular means knee.
An array is the arris of the knee andembolization is the medical word for
stopping or decreasing the bloodsupply to an organ. In simple words,
it means that we are decreasingthe blood flow to the knee.
And we're getting into a littlebit more into the details.
Why do we need to do that?
(05:48):
And how does it help patients withknee pain from osteoarthritis?
But let's go back and talk a littlebit more about the etiology of the
osteoarthritis. For a long time,we used to think it's
just simple wear and tear.
The knee joint is a joint that connectsthe femur bone in the thigh and
the tibia in the leg. Andin between those two bones,
(06:09):
there is cartilages and menisci,which act as buffers to prevent friction
between the bones when you move yourknee. With wear and tear,
what ends up happening is thosecartilages get damaged and the bones get
closer to each other and they starttouching each other when you're moving,
and that leads to inflammation.
And with time,that inflammation keeps getting
(06:30):
worse and it leads to knee pain.
What we've also discoveredthat the pathophysiology
includes also a repetitive injury,and that happens because when
the cartilages get damaged,they release chemicals
into the joint space.
Those include stuff likecytokines, interleukins,
(06:51):
and other enzymes.
Those enzymes end up causing more damageto the cartilage because they cause
more degradation in the cartilageand they lead to more inflammation.
And most patients end up getting intothis vicious cycle where wear and tear
causes damage to the cartilage,more chemicals are being
released into the joint and moredamage is happening.
(07:14):
So the idea of genicularembolization came from the fact that
this process is a chronic processwhere there is a vicious cycle of
damage and inflammatoryprocess that is happening,
and that inflammatoryprocess causes more damage.
And that's what happens in the knee joint.
In chronic inflammation,for the inflammation
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to continue happening,the body initiates an immune response.
And part of that immune response isincreasing the blood supply to the area to
maintain that inflammatory process.
The inflammation happens because the bodyis trying to react to that injury that
is happening, thatdamage that is happening.
So inflammation is anincrease of blood flow?
(07:57):
Part of the inflammatory process is,yes, increase of blood flow to the knee.
And the inflammation iswhat causes the pain?
Part of the pain, yes,is caused by the chronic inflammation
that is happening in what we call thecynovium,
which is the outer lining of the kneejoint. There's other things that are
happening, which isformation of osteophytes,
which is excessive bony spares that happenin the knee joint, buildup of fluid,
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which we call joint effusion. Also,these things contribute to
the stiffness, the pain,and all the other symptoms that patients
with knee osteoarthritis experience.
So when you think aboutinflammation, to simplify it,
any inflammatory process involvesan increase of blood supply.
So when you get stuck by a mosquito,that area gets red and swollen because
there is a localized inflammation thathappens there.
(08:44):
And it gets read because the bodythrough that inflammatory process is
increasing the blood flow to that area.
Same phenomena is happening in the knee.
So the idea was that we need to stopthat inflammation or minimize that
inflammation.
And one of the ways to stopthat inflammation is by
blood supply to the knee whilemaintaining the major blood supply to the
(09:07):
tendons and other parts of the knee.
That's why Dr. Akuna in Japanstarted his research on Jenica R.
Embolization. I think he started in 2012.
And the first study that waspublished on a large scale of
patients on gene care artery embolizationwas published by Dr. Akuno and his
partners in 2017. Thatstudy involved, I think,
(09:30):
75 patients and 92knees that were treated,
and it showed promisingresults in improving pain,
stiffness,and other symptoms of chronic
osteoarthritis in patientsup after the procedure for three years.
So interestingly,this doctor in Japan was not an
orthopedist or sports medicine doctor.
(09:52):
He was an interventional radiologist.
Most of us go for kneepain to an orthopedist or a
but they need to see an interventionalradiologist. Explain why.
Because the treatment for kneeoso arthritis, as you said,
it starts with minimal interventionssuch as lifestyle modification
that includes weight loss, cold packs,sometimes elevation of the
(10:15):
lower extremities help with it.
But when the osteoarthritisbecomes moderate or severe,
those interventions are notenough to help with the pain.
And most patients start with medicaltreatment that includes non-steroidal
and anti-inflammatorymedications such as ibuprofen,
as well as joint injections. Those includesteroid injections, gel injections,
(10:37):
some that are more other novelinjections include plasma injections
and stem cells that have been studied.
And then in cases with moderateto severe osteoarthritis,
also patients go to see an orthopedicsurgeon to be evaluated for a knee,
total knee arthroplasty or peoplecall knee replacement surgery.
(10:59):
The golden standard for the treatmentof severe ostoarthritis is still knee
replacement surgery. However,there is a lot of patients out there
who cannot have knee replacement surgeryfor medical reasons or would like to
hold off on knee replacement surgery forone reason or another. And that's
where genicular embolization comes in.
(11:21):
So it is an intervention that isappropriate for patients who have failed
conservative measures-.
Continue to have pain. ... and.
Continue to have pain despite conservativetreatment and are either not good
candidates for knee replacement surgeryor would like to hold off on knee
replacement surgery.
That's where it falls into the spectrumof treatment of knee osteoarthritis.
(11:44):
I also read that somepatients who opt for this GAE
have had a knee replacement,but still have residual pain,
and it seems to help with that.
Yes.
So about 15 to 20% of patientswho have knee replacement surgery,
they still complain about knee pain.
And this is one of the interventionsthat is available for them to
(12:08):
consider if they continue to havesymptoms of knee pain after knee
replacement surgery.
I would say the patient population thatwould be good candidates for this are
patients who have mild to moderateosteoarthritis. Those are being evaluated,
of course, by their orthopedic surgeon,but they can also be evaluated
by an interventional radiologist.
(12:28):
There is a both subjective andobjective evaluation that can be done.
And based on that evaluation,we can determine their
candidacy for the treatment.
The most common surveys that weuse to evaluate the severity of the
symptoms of osteoarthritis aresomething called WOMAC score.
(12:48):
There's also a COS score, a VAS score.
Those are scores that are basicallybuilt on a survey that the patient fills
that include pretty much all thesymptoms of osteoarthritis. And this
enables us to get an objective idea onhow severe the osteoarthritis in the
patient's symptoms,and also helps us evaluate the response
to the treatment after we do theintervention. The WOMAC
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score, for example,is a survey that includes 96
questions that the patient answersbefore the procedure
when they are being evaluated for theprocedure and we have them fill it in
their follow-up visit after theprocedure to evaluate the response for
treatment. For us, aftergenicular embolization,
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the threshold for success is 50%improvement in their WOMAC score
or their pain level. A lot ofpatients have much more improvement,
but the threshold for success,it's 50% or more improvement in EP.
So how long have you beendoing the procedure here?
St. Mary's about a year now, andwe've been doing it in the system for,
(13:55):
I think, two years.
Is it too soon to askyour rate of successes?
I would say ...
Let me answer this question by sayingthat the experience in the United States
has been so far,and my experience has been similar
to other physicians' experiences.
About 70% successful.
70% Of patients are veryhappy with the result?
(14:16):
Yes. And we're still tryingto figure out those patients,
though 30% of patients whodid not have improvement,
what are the reasons for that?
Because a lot of patients that we evaluatefor the procedure and they seem like
good candidates for the procedure and wethink that they would have improvement
among those 30% end upnot having improvement,
(14:37):
but that does not correlate withthe severity of symptoms or the
findings on their imaging.
A lot of times we obtain an MRI ofthe knee to evaluate for sinovirus,
which is the inflammation ofthe outlining of the knee joint.
And we do think that theareas of inflammation should
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pain for the patients and wouldcorrelate to what we call angiogenesis,
which is the increase of bloodflow to the outlining of the knee.
But there is still more to be studiedon the procedure to evaluate, of course,
the long-term results of it.
Well, the first studyjust came out in 2017,
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so I think it's fair to say thatwe are still early in evaluating or
looking at the success of.
Genicular. After that study, therehave been many studies that came out,
many in the United States that came out.
And most of the studies that were donehave shown that the procedure has good
efficacy, at least on theshort and intermediate term.
(15:39):
I would say most of the studies havefollowed up patients now up into a year,
and some studies have followed up patientsto two years with very good success
rates.
The 2017 study have shown90% improvement and the WOMAC
scores at one year, and those patientswere followed up for three years,
and about 80% have had nointervention at three years,
(16:01):
no additional interventionsneeded three years. Of course,
some of the patients were not followedup for three years for one reason or
another. Some of the studies thatwere done in the United States,
now they're trying to keep followingup patients to try to identify the
long-term efficacy as well as thesafety profile of the procedure.
So the 70% that you mentioned beforewho had a successful procedure
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or came away feeling that they haveshown improvement, who are they?
What qualifies them as an ideal candidate?
What do you think led to their success?
So for us,a good candidate for a gene care
embolization procedure is a patientwho has been diagnosed with chronic
knee osteoarthritis that has failedconservative measures and is either
(16:44):
not a candidate for total kneearthroplasty or would like to hold
off or total knee arthroplasty for onereason or another.
Most patients with mild to moderateosteoarthritis would be great candidates.
But 30% of them aren't having thegreat improvement that 70% are having.
(17:05):
What do you think thedistinguishing factor is?
That could be related toother reasons of knee pain.
So chronic inflammation is oneof the etiologies of knee pain in
osteoarthritis, but as I said,there are other changes that happen in
the knee with chronic osteoarthritis,and that could be contributing to it.
Well, walk me through the procedure.
I'm a patient, I'm coming in,I'm having this done today.
(17:28):
What is going to happen?
So interventional radiology is a specialtywhere we perform minimally invasive
procedures that are image guided.
So pretty much all of our proceduresinvolve small incisions that are a
size of pinhole. In generic embolization,the patient comes into an interventional
radiologist suite. In most cases,the genetic embolization is an outpatient
(17:50):
procedure that is being done undermoderate sedations. Some
people call it twilight.
So after the patient is being evaluatedin clinic, they come as an outpatient,
they get an IV,and they come into an interventional
radiologist suite where they receiveIV sedation.
They're laying flat on their back?
They're laying flat on their back onthe interventional radiology suite
(18:14):
table where there is an x-ray machinethat is going to be moving around them
that would help us visualizethe RAs that we want to treat.
We create a pin size holein the groin of the patient,
and then we insert a hollow tube that isthe size of a spaghetti noodle into the
RA that goes down the thigh into the knee.
After that,we use contrast dye to evaluate
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the RAs around the knee.
And what we're trying to findhere is which REs are supplying
the areas of pain. Inpre-procedural evaluation,
we place imaging markers that can beseen on x-ray that would show us the
areas of maximum pain that patientshave. Once we've identified those arrays,
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there are six or seven RAs thatmost of the time we interrogate.
We use a smaller catheter tonavigate into those smaller arrays.
And after that,we inject small particles that would
go into the distal capillaries,the very tiny REs that
are feeding the cynovium.
And the goal is to minimizethe blood flow in that area
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without stopping theblood flow to the knee.
So we want to take that excessive bloodflow that is keeping the inflammatory
process happening whilemaintaining the blood flow into the
main artery that is feeding the areaof the knee so that patients don't get
complications.
After we're done with that,sometimes we do a CT scan while the
patient is on the table to identifythe arterial blood supply to the cynovium,
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as well as to otherstructures around the knee,
and make sure that we are not sendingthose particles to any other structures
that we do not want tostop blood blood flow to.
What's particularly important here is theblood flow to the skin around the knee
because we want to minimize any ofthose particles go into the skin that
would cause-.
Because I understand that reducing theblood flow to the inflamed tissues helps
(20:13):
decrease inflammation and pain,but it seems risky to interfere with the
blood flow to the knee, like you said,to the skin or to other parts of
the knee that need that blood flow.
So how do you make surethat you're not embolizing?
And we didn't talk about what'shappening with the embolization.
How does that happen? How are youembolizing those little arteries,
(20:36):
those tiny little-.
The idea of stopping blood flowto organs is actually not new.
There are other well-establishedprocedures that we've
period of time where we go and stopblood flow either completely or partially
to certain organs to help witha certain medical problem.
Such as what?
Examples for that is prostateartery embolization, for example.
(20:58):
It's a well-established procedure thatwe perform to stop the blood flow to
the prostate in patients who have benignenlargement of the prostate or what is
called benign prosthetichyperplasia. And by doing that,
we help the prostate shrink andthat would alleviate the symptoms of
prostate enlargement, suchas urinary obstruction,
(21:22):
urinary infections, and othersymptoms or prostate enlargement.
And you're watching it withthe contrast and the imaging.
You're able to see that.
On a screen. When you're doing anembolization, you are doing it live.
So you are watching yourcontrast going into the knee.
And one of the things that we have tomention here is that we're talking about
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small arteries and the embolicparticles that we're using,
we're talking about very small amounts.
The total amount of embolic that isbeing used in a typical genicular
embolization case, notmore than two to three ccs.
Tell me how the embolization happens.
So once you have inserted what we calla microcatheter or a small catheter into
the genicular RA, you dowhat we call an angiogram,
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which is an x-ray image withcontrast being given to evaluate the
blood supply to the cynovium,as well as if that RA has any additional
blood supply to any other organs.
We try to go as selective as possible.
If there is other branchesthat are going to the knee,
we try to other structures such asthe skin, we bypass those branches.
(22:29):
We go deeper in the RA until we get intoa location where it is safe to deliver
the embolic material, the embolic bartles.
Then we inject those embolicbarticles in the artery.
The average amount that I would use in asingle genicular artery is about 0.3 to
0.5 ccs of embolic. After that,we recheck the RA to make sure
that we have decreased that extrablush, extra blood flow to the knee while
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we're maintaining normal blood flow.
Today. And how does that appear to youwhen you know that it's been successful?
Are you just not seeing the vein againshow up on this image because it's.
Gone? You see blood flow into themajor artery that is going to the knee,
but you don't see itexcessively filling ...
(23:17):
We call it blush,and it's very difficult to explain
without actually looking at images.
I see.
If I had images, I would've shown youthe before and after embolization,
but you see kind of a stainingof contrast and blood on the
cynovium before,and that staining goes away
after the embolization.
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That tells us that we minimize,we block those small capillaries and
the distal part of the artery that we'recontributing to the inflammation.
So you know right away that youhave just neutralized these arteries
that are going to feed to thepain or this inflammation?
Yes. The small-.
You can tell that right away.
Yes. The small capillaries. Soafter injecting the embolic,
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you normally do a follow-up angiogramto evaluate the completion of treatment.
And if you see that you have decreasedthat blood flow to that part of the knee,
then you know that yourtreatment has completed. Yes.
What kind of kneeconditions would benefit ...
We talked about osteoarthritis andwhat about a meniscus tear like I have,
(24:21):
like I'm suffering with right now.
So if the meniscus tearhas led to osteoarthritis
and chronic inflammation in theknee, that might be an option.
Patients who have knee injuries,we have to always keep in mind that
there are surgical procedures that can bedone that treat the actual
pathology in the knee. For example,in menuscar tears, there is surgeries
(24:44):
that can be done by orthopedic surgeons.
We can fix that meniscal tear and itmight be a better option for patients.
In general, I think genetic embolization,most of the data that we have now
are for patients who have primaryosteoarthritis,
meaning that patients have just wearand tear that led to thinning of the
(25:04):
cartilage and chronicinflammation in the knee.
Would GAE be an alternativeto a knee replacement?
Alternative, no. I think itwould be a junk treatment.
It would add to the spectrum ofresiments that are available.
Maybe you can postpone aknee replacement having.
That- That would be one of the reasonsyou use genical RA embolization.
(25:26):
It would be used for patients whocannot get knee replacement surgery or
patients who've had knee replacementsurgery and they still have symptoms of
knee pain after knee replacement surgery.
Knee replacement surgery been aroundfor a long time and it's a very,
very successful procedure and it has avery good safety profile and it's been
studied.
Tried and true.
And it's been studied a lot.
We have to understand that theprevalence of the disease is very high.
(25:48):
And a lot of patients, theycannot, for one reason or another,
cannot undergo knee replacement surgeryor they would like to postpone the
procedure.
So genetic art embolization comesinto along that spectrum to help those
patients.
How is it different from nerve ablation?
And in generic nerve ablation,what we do is we don't
treat the etiology of theosteoarthritis. We try to
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treat the symptoms of it.
So there are around four nervesthat it sensation from the knee,
and those nerves are the sensory nervesthat make you feel the pain from what is
happening in the knee. So what wedo is it's a two-step procedure.
So the first step is a test where weinsert needles into the locations of those
four nerves, again in anIR suite under imaging.
(26:34):
The patient is in a twilight.
Patient again is twilight. It's verysimilar. It's an outpatient procedure.
Patient comes in, they get anIV, they get twilight medication,
and then they are flat on theinterventional radiology table.
We use x-ray to identifythe anatomy of the knee,
and then we insert small needlesinto the location of those nerves.
Then we inject pubificate,which is a local anasteric that
(26:54):
blocks the function of those nerves.
This is the test part of treatment.
That helps us identify who are thepatients that are candidates for genical
nerve ablation and who are not.
We normally follow up with patientsin a few days after the test block.
This is called geneker nerve block.
We follow up with patientsa few days after that.
And if the patients report 50% ormore improvement of pain, again,
(27:18):
the threshold for us hereis 50% improvement in their
They would be candidate for genic nerveablation. In geneic nerve ablation,
we use cooled radiofrequencytechnology in which we insert
four needles into the locations ofthose four nerves around the knee under
twilight sedation, and weburn those nerves there.
(27:39):
The test is a temporary andit helps us identify the-.
And you want to see if it's going to work.
Exactly. Patients who wouldbe a candidate for ablation.
The test normally is done onceat the initial intervention,
and if the patients are goingto have repetitive ablations,
they don't have to get testedevery time. They get an ablation.
The problem with a lot ofthe interventions that were
(28:00):
embolization for knee pain,lifestyle modification and
medications, oral medications,and before total knee replacements,
they're temporary. So most of them,they give you relief from knee pain for
about three to six months when they'resuccessful. And that includes
steroid injections, nerve ablation,and all the others. So one of
the things that I tell patients,if you're a candidate for
(28:24):
drinking nerve ablation,expect that this would give you
relief if the procedure is successful,to give you relief for about
six months, if it is successful.
And most patients would require twoablations a year. Some patients,
the effect of it is a little bitlonger, can go up to nine months.
And I've had patients for a year,but I would say for most patients,
effect of it is betweenthree to six months,
(28:46):
and they have to have repetitiveablations. Genegra embolization,
on the other hand,at least what the data has shown
us that when it is successful,patients have relief for one year
and it could be longer than that.
So sometimes patients choose to go forgeneric embolization just for the sole
reason that I want to have one procedurethat gives me as long as possible of a
(29:08):
relief as compared to a procedure whereI have to come back in three to six
months to have another procedure.
Is the relief after theprocedure immediate?
Most of the patients would experiencerelief within the first few weeks after
the procedure.
It's kind of a progressive reliefbecause it would take time for the
inflammation to decrease.
Most of the studies that have been donehave looked at patients at one month,
(29:31):
three or four months after the treatment,six months, 12 months, and 24 months.
When it works,most patients have reported relief or
improvement in their knee pain at onemonth after the procedure. Patients at
one to three months after the treatment.
And for patients who reportimprovement in their symptoms,
most of them,they report for significant improvement
(29:51):
at one month after the procedure.
Do they ever get a second procedurethat ultimately produces an even greater
result? Of.
For generic embolization,we're still trying to figure out
the long-term efficacy of it.
For genicular nerve ablationis a different story. Yes.
They will most likely at sixmonths- They can get multiple.
They will get another procedure.
(30:13):
And I think one of the advantages ofnerve ablation and R embolization is that
you're not using steroids. The problemwith steroids is steroids are great.
It's a great intervention to start with.
The problem with them is that yourbody develops tolerance to the
steroid with multiple injections. Andmost patients come to you and say, "Okay,
well, I had a steroidinjection that worked first,
(30:35):
but then after the secondor third injection,
it's not giving me the same resultsor it works for much shorter period of
time.".
A patient comes to you with knee pain.
How do you decide betweengenetic artery embolization or
genecular nerve ablation? How doyou decide which procedure to do?
Many patients are actuallycandidates for both procedures.
(30:55):
We try to select patientsbased on their symptoms,
how severe is their osteoarthritis is,and if they've had interventions before.
Some patients, genetic arteryembolization is contraindicated to.
If you have peripheralartery disease, for example,
where you have calcium in the REsthat are feeding the leg down,
those are not good candidatesfor generic embolization.
(31:16):
If you have a localized infection ora recent infection around the knee,
you don't want to perform ageneic artery embolization.
Patients with renal impairment, forexample, because we're using contrast dye,
although it's a very smallamount of contrast dye,
but if you have another alternative whereyou don't have to use a contrast dye,
those patients, I offer them geneticnerve ablation first. For me,
those procedures are interchangeable.
(31:38):
I offer both procedures to thepatients and a lot of times,
and patients sometimes choose one overthe other. And I tell them that if it
doesn't work,we can always cross to the other procedure
and do the other procedure becausethose are targeting different parts of
the knee or they're treating the kneepain in two different ways.
Now,since you're going in through the femoral
artery for this catheter procedure,essentially,
(31:59):
does the patient have to lay still forsix hours or whatever after the procedure
to make sure that there's no bleeding?
The incision that we make and the holein the artery that we make is very small
hole that most patients are withintwo hours after the procedure.
They can get up and move around. Wehold pressure after the catheter is out.
And most patients,they can get up out of bed and move
(32:19):
around after two to three hours after theprocedure and they can
go home on the same day.
The most important thing that also makesa big difference in patient's quality
of life is that they are able to returnto their daily activities the day after
the procedure. So that's alsoimportant to a lot of patients.
Some patients would like to postponeknee replacement because they don't have
(32:42):
the time for recoveryfor knee replacement.
They're taking a trip or their daughter'sgetting married and they want to dance
at the wedding.
Believe it or not,most of my patients come in with certain
timelines that they want their kneepain. They need their pain better.
They need their pain betterbefore they need that.
Timeline. I needed it formy trip to Greece for sure.
(33:04):
What should patients ask their doctorsif they would like to entertain this
procedure for knee pain?
I think patients with knee pain shouldbe educated about the options that they
have.
What I'm trying to do here and what wetry to do in other venues is we try to
educate not only patients,but also physicians or practitioners
in the community about all theseoptions because they
(33:24):
might not know about them.
Do orthopedists send you patients?
Yes.
Most of my patients actually come fromour partners in orthopedic surgery.
We have a very good and strong workingrelationship with orthopedic surgeons
here in St. Mary's Hospital.
Through that relationshipwith interventional surgery,
you can create a treatmentplan for patients. For example,
(33:47):
sometimes orthopedic surgery sendsme patients who need pain relief
until they get their knee replacementsurgery in six months or nine months.
And they have an occasion or a tripthat they have to go to in those nine
months. They would like to havethat pain relief during that period.
So a lot of times I perform a kneeablation to give them that relief
(34:08):
and bridge them to get theirknee replacement surgery.
I guess it's like anyone going in fora cortisone shot or their gel shots.
It's a temporary relief, but effective.
It is,but it's not the temporary relief that
you get from the steroid injection or thenerve ablation.
What we've seen that it gives youmuch longer relief as compared to
(34:30):
some of the other interventions that we.
Have. Can artery embolization beused on other types of joint pain,
maybe hip pain, for example?
There are early studies out there thatare been evaluating the effectiveness of
similar procedures on different jointpains. Nothing has been established yet,
but the thought is that if thisworks very well for the knee,
why not use it for other joints? Sure.
(34:51):
I know there is a lot of studies that areout there that are looking at shoulder
pain or shoulder osteoarthritis,elbow osteoarthritis,
and plantar fasciitis is actuallyone of the most studied areas
for embolization. Again, a lot ofthese diseases are very common,
but have a high prevalencein the community.
(35:11):
And if disease like plantar fasciitis,sometimes the interventions that are
available are not very helpful with.
So it would be great to have.
An additional- Or they're very painful.
Yeah, they're very painful.
And it would be great to have anotherintervention that could help those
patients.
Is there anything that patients can doto improve either before or after the
procedure to improve the outcome of it?
(35:34):
I always say that any intervention thatwe do for back pain, for knee pain,
for hip pain, physical therapyis always very helpful.
And I pretty much refer all mypatients to physical therapy
after I do the intervention because itwill help patients in restoring the range
of motion around that jointand restoring muscle strength.
(35:54):
Sometimes when you are in pain,you're not using the joint as much because
of pain and you end up losing musclemass around that joint. Well.
This is all very new andexciting, Dr. Aljundi.
What is it that you think patients needto take away from this podcast about
genecular artery embolization?
I think the message is there isa promising intervention that is
(36:17):
available for patients with kneeosteoarthritis that has shown good
results, good safety profile,that might be an option for them.
Not everybody is a goodcandidate for the procedure,
but specifically for those patientswho are not candidates for total knee
arthroplasty and they are dealing withosteoarthritis pain on daily basis
(36:37):
and the steroid injectionsdon't work for them,
they basically run out ofoptions for neosteoarthritis.
That's an option for them.
And I think that is where thisprocedure becomes life changing for some
patients.
There's so much work that you guys doin interventional radiology that I am
learning about. Every time I do a podcast,it's something new and exciting
in that specialty. Do you love it?
(37:01):
That's where I actually went.
One of the main reasons I wentinto interventional radiology,
it's a medical specialty where youperform cutting edge procedures
with advanced imaging.
There is always innovation.
There are always newprocedures that come out.
And the fact that we treat medicalconditions pretty much all over the body.
So we treat liver cancers, kidneycancers, back pain, knee pain,
(37:25):
fibroids, prostates.
My day could include patientswho have prostate problems,
then Uterine problems,then back pain problems,
then cancer treatments. Soit always keeps me excited.
It always keeps me motivatedto come to work and try to help
patients. I think many of the proceduresthat we do have great results in
(37:50):
changing the quality oflife for our patients.
Well, I love your passion and yourenergy. Thank you, Dr. Aljundi.
My pleasure.
Thank you for sharing your expertisewith us here on MedStar Health Doc Talk.
For more information about genicularartery embolization for knee pain,
go to medstarhealth.org andsearch interventional radiology
or for an appointment, call240-434-7237.
(38:17):
If you would like to comment on thispodcast or recommend a topic for another
episode of DocTalk, send an email todoctalk@medstar.net.
Comprehensive, relevant,and insightful conversations about health
and medicine happen here on MedStarHealth Doc Talk.
These are real conversations withphysician experts from around the largest
healthcare system inthe Maryland, DC region.
There are a lot of reasons whyapproximately 25% of adult Americans have
(00:23):
chronic knee pain. Those joints bear alot of weight and are prone to injury.
Then there's osteoarthritis,arguably the most common joint disease
in the world. And what is that? Well,it happens when the protective cartilage
at the end of the bones gradually wearsaway and oh, the pain when the
buffer between them is gone.
(00:43):
Bone on bone pain can lead to a longlist of treatment options. Today,
we're going to talk about onethat you may not have heard of,
genicular artery embolization or GAE.
It's new to me and I can't wait tohear more about it from today's guest.
Welcome vascular and interventionalradiologist, Dr. Moutasem Aljundi,
board certified in interventionalradiology and diagnostic
(01:06):
Health. I'm your host, Debra Schindler.
Thanks for being with me today,Dr. Aljundi.
Thank you, Deborah, andthanks for hosting me.
From the research I did, genicularartery embolization is still fairly new,
and there isn't a lot of solid datayet about how many GAE procedures are
performed in the US. Is it fair to saythat GAE is still an emerging treatment?
(01:28):
It is emerging. However,it's been established and became
increasingly popular in the UnitedStates over, I would say,
the past five to six years.
It's been done outside the UnitedStates for longer than that.
It's a procedure that becameincreasingly popular around 2016, 2017,
and in the United States, I'dsay after 2020, 21. As you said,
(01:52):
chronic knee pain. The leading causefor that is knee osteoarthritis,
which is a disease that has highprevalence in the US and in the world.
And there is a lot of research thatis happening all over the world on new
procedures and interventions,as well as surgeries to help
patients with knee pain.
(02:12):
This is probably one of the newestinterventions that we've had,
and there is still more to know about it.
There is still moreresearch that is being done,
particularly to look at the long-termefficacy as well as the safety of the
procedure. We have very good data onthe short-term and intermediate-term
results,and this data shows very promising
results in helping patients withchronic knee osteoarthritis.
(02:37):
Well, it seems from my research anyway,that genicular artery embolization
is usually only available at academicmedical centers or large
interventional radiology programs,such as MedStar Washington
Hospital Center,which is one of our
sister hospitals in DC.
What drew your interest in it to bringit here to MedStar St. Mary's Hospital?
(02:58):
Well, when I joined MedStarHealth back in 2021, first,
I work here in St. Mary's Hospital,but I also do procedures at
MedStar Washington Hospital Center,as well as MedStar Southern
Maryland Hospital. The goal was to,when I joined MedStar Health,
is to build a comprehensiveIR service here at MedStar St.
(03:20):
Mary's Hospital to be able to providethe services that we provide in DC and
our larger centers for our localcommunity here at St. Mary's Hospital.
Nice.
And many of those procedureswere not performed here before,
but slowly we were ableto build, I would say,
a comprehensive clinical IR practice here.
(03:40):
We started by establishing aninterventional radiology clinic where we
evaluate patients pre-procedurally,then we perform the procedure here
and we do our own follow-ups here.
And I think that has helped a lot ofpatients because previously patients would
have to travel to get a lot of theseprocedures in one of our tertiary
(04:01):
hospitals.
Well, listen, I can tell you, Ijust got back from a trip to Greece,
and most of the peoplein my tour were over 50,
and at least half of ushad our knees wrapped up,
including myself and myhusband for different issues.
So knee pain is so commononce you hit the age of 50,
it just seems like everybodyhas a story to tell.
(04:23):
Let's go through some of the standardtreatment options for knee pain.
The prevalence of knee pain is very high.
It mostly happens in peopleabove the age of 50 to 60.
You see it equally in men and womenwith a slightly more seen in females.
The leading cause of chronicknee pain is knee osteoarthritis.
(04:43):
And knee osteoarthritis can bedivided into primary osteoarthritis,
which is mainly causedby wear and tear factors.
And then secondary osteoarthritis thatcan be caused by secondary reasons such
as injuries, trauma, kneeinfections, and other reasons.
And there are other sources of arthritisor other arthritis that happen in the
knee that are inflammatory in nature.
Those include oriatic arthritis,rheumatoid arthritis, and
(05:08):
other ratiologies. But by far,the most common cause
of chronic knee pain,particularly in patients above
the age of 50 to 60 is primaryknee osteoarthritis.
The wear and tear of the old knee.
Yes.
Where does this genicular artery ablationcome into play? What does that mean,
(05:28):
genicular?
Genicular means knee.
An array is the arris of the knee andembolization is the medical word for
stopping or decreasing the bloodsupply to an organ. In simple words,
it means that we are decreasingthe blood flow to the knee.
And we're getting into a littlebit more into the details.
Why do we need to do that?
(05:48):
And how does it help patients withknee pain from osteoarthritis?
But let's go back and talk a littlebit more about the etiology of the
osteoarthritis. For a long time,we used to think it's
just simple wear and tear.
The knee joint is a joint that connectsthe femur bone in the thigh and
the tibia in the leg. Andin between those two bones,
(06:09):
there is cartilages and menisci,which act as buffers to prevent friction
between the bones when you move yourknee. With wear and tear,
what ends up happening is thosecartilages get damaged and the bones get
closer to each other and they starttouching each other when you're moving,
and that leads to inflammation.
And with time,that inflammation keeps getting
(06:30):
worse and it leads to knee pain.
What we've also discoveredthat the pathophysiology
includes also a repetitive injury,and that happens because when
the cartilages get damaged,they release chemicals
into the joint space.
Those include stuff likecytokines, interleukins,
(06:51):
and other enzymes.
Those enzymes end up causing more damageto the cartilage because they cause
more degradation in the cartilageand they lead to more inflammation.
And most patients end up getting intothis vicious cycle where wear and tear
causes damage to the cartilage,more chemicals are being
released into the joint and moredamage is happening.
(07:14):
So the idea of genicularembolization came from the fact that
this process is a chronic processwhere there is a vicious cycle of
damage and inflammatoryprocess that is happening,
and that inflammatoryprocess causes more damage.
And that's what happens in the knee joint.
In chronic inflammation,for the inflammation
(07:34):
to continue happening,the body initiates an immune response.
And part of that immune response isincreasing the blood supply to the area to
maintain that inflammatory process.
The inflammation happens because the bodyis trying to react to that injury that
is happening, thatdamage that is happening.
So inflammation is anincrease of blood flow?
(07:57):
Part of the inflammatory process is,yes, increase of blood flow to the knee.
And the inflammation iswhat causes the pain?
Part of the pain, yes,is caused by the chronic inflammation
that is happening in what we call thecynovium,
which is the outer lining of the kneejoint. There's other things that are
happening, which isformation of osteophytes,
which is excessive bony spares that happenin the knee joint, buildup of fluid,
(08:21):
which we call joint effusion. Also,these things contribute to
the stiffness, the pain,and all the other symptoms that patients
with knee osteoarthritis experience.
So when you think aboutinflammation, to simplify it,
any inflammatory process involvesan increase of blood supply.
So when you get stuck by a mosquito,that area gets red and swollen because
there is a localized inflammation thathappens there.
(08:44):
And it gets read because the bodythrough that inflammatory process is
increasing the blood flow to that area.
Same phenomena is happening in the knee.
So the idea was that we need to stopthat inflammation or minimize that
inflammation.
And one of the ways to stopthat inflammation is by
blood supply to the knee whilemaintaining the major blood supply to the
(09:07):
tendons and other parts of the knee.
That's why Dr. Akuna in Japanstarted his research on Jenica R.
Embolization. I think he started in 2012.
And the first study that waspublished on a large scale of
patients on gene care artery embolizationwas published by Dr. Akuno and his
partners in 2017. Thatstudy involved, I think,
(09:30):
75 patients and 92knees that were treated,
and it showed promisingresults in improving pain,
stiffness,and other symptoms of chronic
osteoarthritis in patientsup after the procedure for three years.
So interestingly,this doctor in Japan was not an
orthopedist or sports medicine doctor.
(09:52):
He was an interventional radiologist.
Most of us go for kneepain to an orthopedist or a
but they need to see an interventionalradiologist. Explain why.
Because the treatment for kneeoso arthritis, as you said,
it starts with minimal interventionssuch as lifestyle modification
that includes weight loss, cold packs,sometimes elevation of the
(10:15):
lower extremities help with it.
But when the osteoarthritisbecomes moderate or severe,
those interventions are notenough to help with the pain.
And most patients start with medicaltreatment that includes non-steroidal
and anti-inflammatorymedications such as ibuprofen,
as well as joint injections. Those includesteroid injections, gel injections,
(10:37):
some that are more other novelinjections include plasma injections
and stem cells that have been studied.
And then in cases with moderateto severe osteoarthritis,
also patients go to see an orthopedicsurgeon to be evaluated for a knee,
total knee arthroplasty or peoplecall knee replacement surgery.
(10:59):
The golden standard for the treatmentof severe ostoarthritis is still knee
replacement surgery. However,there is a lot of patients out there
who cannot have knee replacement surgeryfor medical reasons or would like to
hold off on knee replacement surgery forone reason or another. And that's
where genicular embolization comes in.
(11:21):
So it is an intervention that isappropriate for patients who have failed
conservative measures-.
Continue to have pain. ... and.
Continue to have pain despite conservativetreatment and are either not good
candidates for knee replacement surgeryor would like to hold off on knee
replacement surgery.
That's where it falls into the spectrumof treatment of knee osteoarthritis.
(11:44):
I also read that somepatients who opt for this GAE
have had a knee replacement,but still have residual pain,
and it seems to help with that.
Yes.
So about 15 to 20% of patientswho have knee replacement surgery,
they still complain about knee pain.
And this is one of the interventionsthat is available for them to
(12:08):
consider if they continue to havesymptoms of knee pain after knee
replacement surgery.
I would say the patient population thatwould be good candidates for this are
patients who have mild to moderateosteoarthritis. Those are being evaluated,
of course, by their orthopedic surgeon,but they can also be evaluated
by an interventional radiologist.
(12:28):
There is a both subjective andobjective evaluation that can be done.
And based on that evaluation,we can determine their
candidacy for the treatment.
The most common surveys that weuse to evaluate the severity of the
symptoms of osteoarthritis aresomething called WOMAC score.
(12:48):
There's also a COS score, a VAS score.
Those are scores that are basicallybuilt on a survey that the patient fills
that include pretty much all thesymptoms of osteoarthritis. And this
enables us to get an objective idea onhow severe the osteoarthritis in the
patient's symptoms,and also helps us evaluate the response
to the treatment after we do theintervention. The WOMAC
(13:11):
score, for example,is a survey that includes 96
questions that the patient answersbefore the procedure
when they are being evaluated for theprocedure and we have them fill it in
their follow-up visit after theprocedure to evaluate the response for
treatment. For us, aftergenicular embolization,
(13:34):
the threshold for success is 50%improvement in their WOMAC score
or their pain level. A lot ofpatients have much more improvement,
but the threshold for success,it's 50% or more improvement in EP.
So how long have you beendoing the procedure here?
St. Mary's about a year now, andwe've been doing it in the system for,
(13:55):
I think, two years.
Is it too soon to askyour rate of successes?
I would say ...
Let me answer this question by sayingthat the experience in the United States
has been so far,and my experience has been similar
to other physicians' experiences.
About 70% successful.
70% Of patients are veryhappy with the result?
(14:16):
Yes. And we're still tryingto figure out those patients,
though 30% of patients whodid not have improvement,
what are the reasons for that?
Because a lot of patients that we evaluatefor the procedure and they seem like
good candidates for the procedure and wethink that they would have improvement
among those 30% end upnot having improvement,
(14:37):
but that does not correlate withthe severity of symptoms or the
findings on their imaging.
A lot of times we obtain an MRI ofthe knee to evaluate for sinovirus,
which is the inflammation ofthe outlining of the knee joint.
And we do think that theareas of inflammation should
(14:58):
pain for the patients and wouldcorrelate to what we call angiogenesis,
which is the increase of bloodflow to the outlining of the knee.
But there is still more to be studiedon the procedure to evaluate, of course,
the long-term results of it.
Well, the first studyjust came out in 2017,
(15:18):
so I think it's fair to say thatwe are still early in evaluating or
looking at the success of.
Genicular. After that study, therehave been many studies that came out,
many in the United States that came out.
And most of the studies that were donehave shown that the procedure has good
efficacy, at least on theshort and intermediate term.
(15:39):
I would say most of the studies havefollowed up patients now up into a year,
and some studies have followed up patientsto two years with very good success
rates.
The 2017 study have shown90% improvement and the WOMAC
scores at one year, and those patientswere followed up for three years,
and about 80% have had nointervention at three years,
(16:01):
no additional interventionsneeded three years. Of course,
some of the patients were not followedup for three years for one reason or
another. Some of the studies thatwere done in the United States,
now they're trying to keep followingup patients to try to identify the
long-term efficacy as well as thesafety profile of the procedure.
So the 70% that you mentioned beforewho had a successful procedure
(16:24):
or came away feeling that they haveshown improvement, who are they?
What qualifies them as an ideal candidate?
What do you think led to their success?
So for us,a good candidate for a gene care
embolization procedure is a patientwho has been diagnosed with chronic
knee osteoarthritis that has failedconservative measures and is either
(16:44):
not a candidate for total kneearthroplasty or would like to hold
off or total knee arthroplasty for onereason or another.
Most patients with mild to moderateosteoarthritis would be great candidates.
But 30% of them aren't having thegreat improvement that 70% are having.
(17:05):
What do you think thedistinguishing factor is?
That could be related toother reasons of knee pain.
So chronic inflammation is oneof the etiologies of knee pain in
osteoarthritis, but as I said,there are other changes that happen in
the knee with chronic osteoarthritis,and that could be contributing to it.
Well, walk me through the procedure.
I'm a patient, I'm coming in,I'm having this done today.
(17:28):
What is going to happen?
So interventional radiology is a specialtywhere we perform minimally invasive
procedures that are image guided.
So pretty much all of our proceduresinvolve small incisions that are a
size of pinhole. In generic embolization,the patient comes into an interventional
radiologist suite. In most cases,the genetic embolization is an outpatient
(17:50):
procedure that is being done undermoderate sedations. Some
people call it twilight.
So after the patient is being evaluatedin clinic, they come as an outpatient,
they get an IV,and they come into an interventional
radiologist suite where they receiveIV sedation.
They're laying flat on their back?
They're laying flat on their back onthe interventional radiology suite
(18:14):
table where there is an x-ray machinethat is going to be moving around them
that would help us visualizethe RAs that we want to treat.
We create a pin size holein the groin of the patient,
and then we insert a hollow tube that isthe size of a spaghetti noodle into the
RA that goes down the thigh into the knee.
After that,we use contrast dye to evaluate
(18:37):
the RAs around the knee.
And what we're trying to findhere is which REs are supplying
the areas of pain. Inpre-procedural evaluation,
we place imaging markers that can beseen on x-ray that would show us the
areas of maximum pain that patientshave. Once we've identified those arrays,
(18:59):
there are six or seven RAs thatmost of the time we interrogate.
We use a smaller catheter tonavigate into those smaller arrays.
And after that,we inject small particles that would
go into the distal capillaries,the very tiny REs that
are feeding the cynovium.
And the goal is to minimizethe blood flow in that area
(19:24):
without stopping theblood flow to the knee.
So we want to take that excessive bloodflow that is keeping the inflammatory
process happening whilemaintaining the blood flow into the
main artery that is feeding the areaof the knee so that patients don't get
complications.
After we're done with that,sometimes we do a CT scan while the
patient is on the table to identifythe arterial blood supply to the cynovium,
(19:50):
as well as to otherstructures around the knee,
and make sure that we are not sendingthose particles to any other structures
that we do not want tostop blood blood flow to.
What's particularly important here is theblood flow to the skin around the knee
because we want to minimize any ofthose particles go into the skin that
would cause-.
Because I understand that reducing theblood flow to the inflamed tissues helps
(20:13):
decrease inflammation and pain,but it seems risky to interfere with the
blood flow to the knee, like you said,to the skin or to other parts of
the knee that need that blood flow.
So how do you make surethat you're not embolizing?
And we didn't talk about what'shappening with the embolization.
How does that happen? How are youembolizing those little arteries,
(20:36):
those tiny little-.
The idea of stopping blood flowto organs is actually not new.
There are other well-establishedprocedures that we've
period of time where we go and stopblood flow either completely or partially
to certain organs to help witha certain medical problem.
Such as what?
Examples for that is prostateartery embolization, for example.
(20:58):
It's a well-established procedure thatwe perform to stop the blood flow to
the prostate in patients who have benignenlargement of the prostate or what is
called benign prosthetichyperplasia. And by doing that,
we help the prostate shrink andthat would alleviate the symptoms of
prostate enlargement, suchas urinary obstruction,
(21:22):
urinary infections, and othersymptoms or prostate enlargement.
And you're watching it withthe contrast and the imaging.
You're able to see that.
On a screen. When you're doing anembolization, you are doing it live.
So you are watching yourcontrast going into the knee.
And one of the things that we have tomention here is that we're talking about
(21:43):
small arteries and the embolicparticles that we're using,
we're talking about very small amounts.
The total amount of embolic that isbeing used in a typical genicular
embolization case, notmore than two to three ccs.
Tell me how the embolization happens.
So once you have inserted what we calla microcatheter or a small catheter into
the genicular RA, you dowhat we call an angiogram,
(22:08):
which is an x-ray image withcontrast being given to evaluate the
blood supply to the cynovium,as well as if that RA has any additional
blood supply to any other organs.
We try to go as selective as possible.
If there is other branchesthat are going to the knee,
we try to other structures such asthe skin, we bypass those branches.
(22:29):
We go deeper in the RA until we get intoa location where it is safe to deliver
the embolic material, the embolic bartles.
Then we inject those embolicbarticles in the artery.
The average amount that I would use in asingle genicular artery is about 0.3 to
0.5 ccs of embolic. After that,we recheck the RA to make sure
that we have decreased that extrablush, extra blood flow to the knee while
(22:54):
we're maintaining normal blood flow.
Today. And how does that appear to youwhen you know that it's been successful?
Are you just not seeing the vein againshow up on this image because it's.
Gone? You see blood flow into themajor artery that is going to the knee,
but you don't see itexcessively filling ...
(23:17):
We call it blush,and it's very difficult to explain
without actually looking at images.
I see.
If I had images, I would've shown youthe before and after embolization,
but you see kind of a stainingof contrast and blood on the
cynovium before,and that staining goes away
after the embolization.
(23:37):
That tells us that we minimize,we block those small capillaries and
the distal part of the artery that we'recontributing to the inflammation.
So you know right away that youhave just neutralized these arteries
that are going to feed to thepain or this inflammation?
Yes. The small-.
You can tell that right away.
Yes. The small capillaries. Soafter injecting the embolic,
(23:59):
you normally do a follow-up angiogramto evaluate the completion of treatment.
And if you see that you have decreasedthat blood flow to that part of the knee,
then you know that yourtreatment has completed. Yes.
What kind of kneeconditions would benefit ...
We talked about osteoarthritis andwhat about a meniscus tear like I have,
(24:21):
like I'm suffering with right now.
So if the meniscus tearhas led to osteoarthritis
and chronic inflammation in theknee, that might be an option.
Patients who have knee injuries,we have to always keep in mind that
there are surgical procedures that can bedone that treat the actual
pathology in the knee. For example,in menuscar tears, there is surgeries
(24:44):
that can be done by orthopedic surgeons.
We can fix that meniscal tear and itmight be a better option for patients.
In general, I think genetic embolization,most of the data that we have now
are for patients who have primaryosteoarthritis,
meaning that patients have just wearand tear that led to thinning of the
(25:04):
cartilage and chronicinflammation in the knee.
Would GAE be an alternativeto a knee replacement?
Alternative, no. I think itwould be a junk treatment.
It would add to the spectrum ofresiments that are available.
Maybe you can postpone aknee replacement having.
That- That would be one of the reasonsyou use genical RA embolization.
(25:26):
It would be used for patients whocannot get knee replacement surgery or
patients who've had knee replacementsurgery and they still have symptoms of
knee pain after knee replacement surgery.
Knee replacement surgery been aroundfor a long time and it's a very,
very successful procedure and it has avery good safety profile and it's been
studied.
Tried and true.
And it's been studied a lot.
We have to understand that theprevalence of the disease is very high.
(25:48):
And a lot of patients, theycannot, for one reason or another,
cannot undergo knee replacement surgeryor they would like to postpone the
procedure.
So genetic art embolization comesinto along that spectrum to help those
patients.
How is it different from nerve ablation?
And in generic nerve ablation,what we do is we don't
treat the etiology of theosteoarthritis. We try to
(26:11):
treat the symptoms of it.
So there are around four nervesthat it sensation from the knee,
and those nerves are the sensory nervesthat make you feel the pain from what is
happening in the knee. So what wedo is it's a two-step procedure.
So the first step is a test where weinsert needles into the locations of those
four nerves, again in anIR suite under imaging.
(26:34):
The patient is in a twilight.
Patient again is twilight. It's verysimilar. It's an outpatient procedure.
Patient comes in, they get anIV, they get twilight medication,
and then they are flat on theinterventional radiology table.
We use x-ray to identifythe anatomy of the knee,
and then we insert small needlesinto the location of those nerves.
Then we inject pubificate,which is a local anasteric that
(26:54):
blocks the function of those nerves.
This is the test part of treatment.
That helps us identify who are thepatients that are candidates for genical
nerve ablation and who are not.
We normally follow up with patientsin a few days after the test block.
This is called geneker nerve block.
We follow up with patientsa few days after that.
And if the patients report 50% ormore improvement of pain, again,
(27:18):
the threshold for us hereis 50% improvement in their
They would be candidate for genic nerveablation. In geneic nerve ablation,
we use cooled radiofrequencytechnology in which we insert
four needles into the locations ofthose four nerves around the knee under
twilight sedation, and weburn those nerves there.
(27:39):
The test is a temporary andit helps us identify the-.
And you want to see if it's going to work.
Exactly. Patients who wouldbe a candidate for ablation.
The test normally is done onceat the initial intervention,
and if the patients are goingto have repetitive ablations,
they don't have to get testedevery time. They get an ablation.
The problem with a lot ofthe interventions that were
(28:00):
embolization for knee pain,lifestyle modification and
medications, oral medications,and before total knee replacements,
they're temporary. So most of them,they give you relief from knee pain for
about three to six months when they'resuccessful. And that includes
steroid injections, nerve ablation,and all the others. So one of
the things that I tell patients,if you're a candidate for
(28:24):
drinking nerve ablation,expect that this would give you
relief if the procedure is successful,to give you relief for about
six months, if it is successful.
And most patients would require twoablations a year. Some patients,
the effect of it is a little bitlonger, can go up to nine months.
And I've had patients for a year,but I would say for most patients,
effect of it is betweenthree to six months,
(28:46):
and they have to have repetitiveablations. Genegra embolization,
on the other hand,at least what the data has shown
us that when it is successful,patients have relief for one year
and it could be longer than that.
So sometimes patients choose to go forgeneric embolization just for the sole
reason that I want to have one procedurethat gives me as long as possible of a
(29:08):
relief as compared to a procedure whereI have to come back in three to six
months to have another procedure.
Is the relief after theprocedure immediate?
Most of the patients would experiencerelief within the first few weeks after
the procedure.
It's kind of a progressive reliefbecause it would take time for the
inflammation to decrease.
Most of the studies that have been donehave looked at patients at one month,
(29:31):
three or four months after the treatment,six months, 12 months, and 24 months.
When it works,most patients have reported relief or
improvement in their knee pain at onemonth after the procedure. Patients at
one to three months after the treatment.
And for patients who reportimprovement in their symptoms,
most of them,they report for significant improvement
(29:51):
at one month after the procedure.
Do they ever get a second procedurethat ultimately produces an even greater
result? Of.
For generic embolization,we're still trying to figure out
the long-term efficacy of it.
For genicular nerve ablationis a different story. Yes.
They will most likely at sixmonths- They can get multiple.
They will get another procedure.
(30:13):
And I think one of the advantages ofnerve ablation and R embolization is that
you're not using steroids. The problemwith steroids is steroids are great.
It's a great intervention to start with.
The problem with them is that yourbody develops tolerance to the
steroid with multiple injections. Andmost patients come to you and say, "Okay,
well, I had a steroidinjection that worked first,
(30:35):
but then after the secondor third injection,
it's not giving me the same resultsor it works for much shorter period of
time.".
A patient comes to you with knee pain.
How do you decide betweengenetic artery embolization or
genecular nerve ablation? How doyou decide which procedure to do?
Many patients are actuallycandidates for both procedures.
(30:55):
We try to select patientsbased on their symptoms,
how severe is their osteoarthritis is,and if they've had interventions before.
Some patients, genetic arteryembolization is contraindicated to.
If you have peripheralartery disease, for example,
where you have calcium in the REsthat are feeding the leg down,
those are not good candidatesfor generic embolization.
(31:16):
If you have a localized infection ora recent infection around the knee,
you don't want to perform ageneic artery embolization.
Patients with renal impairment, forexample, because we're using contrast dye,
although it's a very smallamount of contrast dye,
but if you have another alternative whereyou don't have to use a contrast dye,
those patients, I offer them geneticnerve ablation first. For me,
those procedures are interchangeable.
(31:38):
I offer both procedures to thepatients and a lot of times,
and patients sometimes choose one overthe other. And I tell them that if it
doesn't work,we can always cross to the other procedure
and do the other procedure becausethose are targeting different parts of
the knee or they're treating the kneepain in two different ways.
Now,since you're going in through the femoral
artery for this catheter procedure,essentially,
(31:59):
does the patient have to lay still forsix hours or whatever after the procedure
to make sure that there's no bleeding?
The incision that we make and the holein the artery that we make is very small
hole that most patients are withintwo hours after the procedure.
They can get up and move around. Wehold pressure after the catheter is out.
And most patients,they can get up out of bed and move
(32:19):
around after two to three hours after theprocedure and they can
go home on the same day.
The most important thing that also makesa big difference in patient's quality
of life is that they are able to returnto their daily activities the day after
the procedure. So that's alsoimportant to a lot of patients.
Some patients would like to postponeknee replacement because they don't have
(32:42):
the time for recoveryfor knee replacement.
They're taking a trip or their daughter'sgetting married and they want to dance
at the wedding.
Believe it or not,most of my patients come in with certain
timelines that they want their kneepain. They need their pain better.
They need their pain betterbefore they need that.
Timeline. I needed it formy trip to Greece for sure.
(33:04):
What should patients ask their doctorsif they would like to entertain this
procedure for knee pain?
I think patients with knee pain shouldbe educated about the options that they
have.
What I'm trying to do here and what wetry to do in other venues is we try to
educate not only patients,but also physicians or practitioners
in the community about all theseoptions because they
(33:24):
might not know about them.
Do orthopedists send you patients?
Yes.
Most of my patients actually come fromour partners in orthopedic surgery.
We have a very good and strong workingrelationship with orthopedic surgeons
here in St. Mary's Hospital.
Through that relationshipwith interventional surgery,
you can create a treatmentplan for patients. For example,
(33:47):
sometimes orthopedic surgery sendsme patients who need pain relief
until they get their knee replacementsurgery in six months or nine months.
And they have an occasion or a tripthat they have to go to in those nine
months. They would like to havethat pain relief during that period.
So a lot of times I perform a kneeablation to give them that relief
(34:08):
and bridge them to get theirknee replacement surgery.
I guess it's like anyone going in fora cortisone shot or their gel shots.
It's a temporary relief, but effective.
It is,but it's not the temporary relief that
you get from the steroid injection or thenerve ablation.
What we've seen that it gives youmuch longer relief as compared to
(34:30):
some of the other interventions that we.
Have. Can artery embolization beused on other types of joint pain,
maybe hip pain, for example?
There are early studies out there thatare been evaluating the effectiveness of
similar procedures on different jointpains. Nothing has been established yet,
but the thought is that if thisworks very well for the knee,
why not use it for other joints? Sure.
(34:51):
I know there is a lot of studies that areout there that are looking at shoulder
pain or shoulder osteoarthritis,elbow osteoarthritis,
and plantar fasciitis is actuallyone of the most studied areas
for embolization. Again, a lot ofthese diseases are very common,
but have a high prevalencein the community.
(35:11):
And if disease like plantar fasciitis,sometimes the interventions that are
available are not very helpful with.
So it would be great to have.
An additional- Or they're very painful.
Yeah, they're very painful.
And it would be great to have anotherintervention that could help those
patients.
Is there anything that patients can doto improve either before or after the
procedure to improve the outcome of it?
(35:34):
I always say that any intervention thatwe do for back pain, for knee pain,
for hip pain, physical therapyis always very helpful.
And I pretty much refer all mypatients to physical therapy
after I do the intervention because itwill help patients in restoring the range
of motion around that jointand restoring muscle strength.
(35:54):
Sometimes when you are in pain,you're not using the joint as much because
of pain and you end up losing musclemass around that joint. Well.
This is all very new andexciting, Dr. Aljundi.
What is it that you think patients needto take away from this podcast about
genecular artery embolization?
I think the message is there isa promising intervention that is
(36:17):
available for patients with kneeosteoarthritis that has shown good
results, good safety profile,that might be an option for them.
Not everybody is a goodcandidate for the procedure,
but specifically for those patientswho are not candidates for total knee
arthroplasty and they are dealing withosteoarthritis pain on daily basis
(36:37):
and the steroid injectionsdon't work for them,
they basically run out ofoptions for neosteoarthritis.
That's an option for them.
And I think that is where thisprocedure becomes life changing for some
patients.
There's so much work that you guys doin interventional radiology that I am
learning about. Every time I do a podcast,it's something new and exciting
in that specialty. Do you love it?
(37:01):
That's where I actually went.
One of the main reasons I wentinto interventional radiology,
it's a medical specialty where youperform cutting edge procedures
with advanced imaging.
There is always innovation.
There are always newprocedures that come out.
And the fact that we treat medicalconditions pretty much all over the body.
So we treat liver cancers, kidneycancers, back pain, knee pain,
(37:25):
fibroids, prostates.
My day could include patientswho have prostate problems,
then Uterine problems,then back pain problems,
then cancer treatments. Soit always keeps me excited.
It always keeps me motivatedto come to work and try to help
patients. I think many of the proceduresthat we do have great results in
(37:50):
changing the quality oflife for our patients.
Well, I love your passion and yourenergy. Thank you, Dr. Aljundi.
My pleasure.
Thank you for sharing your expertisewith us here on MedStar Health Doc Talk.
For more information about genicularartery embolization for knee pain,
go to medstarhealth.org andsearch interventional radiology
or for an appointment, call240-434-7237.
(38:17):
If you would like to comment on thispodcast or recommend a topic for another
episode of DocTalk, send an email todoctalk@medstar.net.
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