Geniculate Artery Endovascular Embolization Post-Total Knee Arthroplasty for Hemarthrosis Treatment: A Systematic Review of the Literature

Abstract

Purpose:

To provide an updated systematic review on the use of geniculate artery embolization (GAE) in the management of recurrent hemarthrosis post-total knee arthroplasty (TKA).

Materials and Methods:

A systematic literature review was conducted, and all clinical reports in the English language from inception to July 2022 were identified. References were manually reviewed to identify additional studies. Demographics, procedural techniques, post-procedural complications, and follow-up data were extracted and analyzed using STATA 14.1.

Results:

A total of 20 studies (9 case reports, 11 case series; n= 214) were included for review. In all cases, patients underwent coil embolization of one or more geniculate arteries. Procedure success was reported in 94.8% (n=203/214) of cases without perioperative adverse events. Improvement of symptoms was seen in 72.6% (n=119/164) of cases, with 30.7% (n=58/189) of cases requiring repeat embolization. Recurrent hemarthrosis occurred in 22.2% (n=22/99) of cases over a mean follow-up of 48 months.

Conclusion:

GAE appears to be a safe and effective treatment for recurrent hemarthrosis following TKA. Future studies in the form of randomized controlled trials should be conducted to further evaluate such embolization techniques and compare outcomes between GAE and standard techniques.

Clinical Impact

Conservative management of post total knee arthroplasty (TKA) hemarthrosis is successful in only one third of cases. Geniculate artery embolization (GAE) has recently gained attention due to its minimally invasive nature compared to open or arthroscopic synovectomy promising faster rehabilitation, decreased infection rates and less additional surgeries. The purpose of this article was to summarize current literature, provide an updated review on the use of GAE in the management of recurrent hemarthrosis post-TKA and describe immediate and long-term outcomes in an effort to help optimize current treatment algorithms.

Keywords

geniculate embolization endovascular coil percutaneous recurrent hemarthrosis total knee arthroplasty

Introduction

Recurrent hemarthrosis of the knee is an uncommon but potentially debilitating complication of total knee arthroplasty (TKA) that occurs with a frequency of 0.3% to 1.6% annually.^1,2 Although the etiology is often unclear, hemarthrosis may occur as a result of direct trauma to arterial blood supply surrounding the knee (ie, popliteal or geniculate artery injury),³ inherited or acquired bleeding disorders,^4,5 arteriovenous fistula,⁶ pseudoaneurysm,⁷ or most commonly, hypertrophic synovitis secondary to repetitive trauma or impingement of the synovium between the prosthesis components.^2,8,9 Clinical manifestations typically include painful effusions and joint stiffness, with onset varying from 2 months to 18 years (2 years on average)⁹; delayed presentations confer a diagnostic challenge and are more likely to result in less favorable outcomes.^3,10

Initial management of hemarthrosis post-TKA is aimed at providing symptomatic relief via rest, ice, cooling, and joint aspiration(s)^10,11; however, conservative management is successful in only one third of cases.¹² In patients who fail conservative measures, open or arthroscopic synovectomy have been the mainstay therapies.^12,13 While effective, open synovectomy is invasive and associated with increased rates of infection, and delayed rehabilitation is less invasive arthroscopic synovectomy is associated with rebleeding.^8,13 Geniculate artery embolization (GAE) has recently gained attention due to its minimally invasive technique that has not demonstrated a need for additional surgeries.^11,13 Sundaram et al¹⁴ conducted a systematic review and meta-analysis from studies published between 1998 and 2018 and report GAE as a potentially safe and effective treatment for recurrent hemarthroses after TKA. The purpose of this article was to summarize current literature and provide an updated review on the use of GAE in the management of recurrent hemarthrosis post-TKA.

Methods

Systematic Review

This systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines (Figure 1).¹⁵ Systematic searches were conducted in PubMed and Cochrane Central. Main keywords used in the search algorithm included: “geniculate,” “embolization,” “endovascular,” “coil,” “percutaneous,” and “hemarthrosis.” The search was conducted by two independent investigators and any disagreements were resolved by consensus. In order to identify further eligible articles, the references of the included articles were also manually reviewed. Inclusion criteria included: all available studies or case reports of adult patients (ie, >18 years old) with hemarthrosis post-TKA treated with coil embolization and published up to July 2022. If an article did not report on outcomes of interest it was excluded from review. Further exclusion criteria included studies of patients less than 18-years old, orthopedic surgeries other than TKA, treatment of recurrent hemarthrosis without embolization of the geniculate artery. The primary endpoints were procedural success (ie, persistent geniculate artery embolization) and recurrence (ie, recurrent hemarthrosis over time). Secondary outcomes include (1) improvement of symptoms and (2) need for any re-interventions during follow-up. Descriptive statistics were used to describe the cumulative incidence of primary and secondary endpoints. STATA 14.1 (StataCorp, College Station, Texas) was used as statistical software.

Results

Systematic Review

The initial literature search yielded 80 potentially relevant records and 20 articles satisfied the predetermined search and inclusion criteria after full text evaluation and were included in this systematic review. The PRISMA flow diagram is shown in Figure 1.

Characteristics of the Studies and Patients

All included studies were case reports (n=9), case series (n=6), or retrospective review studies (n=5). Overall, 212 patients underwent geniculate artery embolization after knee arthroplasty surgery for hemarthrosis. Most of the patients were male (65.7%; N=140/212) and the median age was estimated to be 67 of age (range: 35–93 years of age). Among studies with available data most of the patients (n=63; 10 studies) presented with joint pain associated with swelling with/without serosanguineous output from a previously placed drain, remotely from index procedure (ie, >6 months). Important study and patient characteristics are summarized in Table 1. In almost all cases the target artery was accessed with anterograde approach and micro-coils were used in the majority of the cases. Procedural characteristics are shown in Supplementary Table 1.

Table 1.

Important Study and Patient Characteristics.

Study	Country	Design	Total patients	Age, yrs	Female	Orthopedic procedure	Time for intervention	Main symptoms at presentation	Comorbidities	AC/Anti-PLT
Puijk et al⁷	Netherlands	Case report	1	67	No	TKA	Mean 24 days	Painful, effused knee, max flexion 80 degrees	Osteoarthritis of the knee, recurrent TIAs	x1 Dabigatran bridged to LMWH
Pow et al¹	Australia	Case series	25	67	20F	23 (92%) TKA	Mean 17 months (range 2-54 months)			x6 ASA, x2 warfarin, x1 rivaroxaban
Luyckx et al⁸	Belgium	Case series	31 (39 embolizations)	67 (48-90)	14F	29 TKA, 2 UKA	Mean 17 months
Agarwala et al³	India	Case report	1	65	Yes	TKA	1 day	Drain with bloody output
Purudappa et al⁹	USA	Case report	1	66	No	TKA	3 months	Pain, swelling
van Baardewijk et al²	Netherlands	Case series	14 (24 total embolizations)	66.7	8F	TKA	Mean 6.9 months	Pain, swelling		x1 warfarin, x1 apixaban
Ogilvie et al¹³	USA	Case series	5	72.4 (57-81)	1F	TKA	31 months (range 14-44)	Pain, swelling, loss of mobility		x1 aspirin, x1 aspirin & clopidogrel, x1 aspirin, clopidogrel & warfarin
Guevara et al¹²	USA	Case series	10 (14 embolizations)	57.4	7F	TKA				x1 warfarin
Weidner et al¹¹	USA	Case series	13	67 (55-84)	5F	TKA	Mean 47 months (range 2-103)	Painful effusion
Azubuike et al¹⁶	USA	Case report	1	93	Yes	TKA	2yrs	Knee hemarthrosis s/p mechanical fall	longstanding thrombocytosis & TIA (on clopidogrel 75mg daily)	x1 clopidogrel
Bagla et al¹⁷	USA	Case series	5	57-77	2F	TKA	Range 8–18 years
Park et al⁴	USA	Case report	1	35	Yes	TKA	9 days	Swelling	Hemophilia C
Rukavina et al¹⁰	Switzerland	Case report	1	72	Yes	TKA	1 month	Swelling
Given et al¹⁸	Australia	Case series	1	55	No	TKA	1 yrs	Painful hemarthrosis
			1	61	No	TKA			MRSA post-op
			1	77	No	TKA	6 months
Kalsi et al⁶	UK	Case report	1	79	Yes	TKA	8 yrs
Kickuth et al⁵	Switzerland	Case report	1	40	No	TKA	6 days	Pain, stiffness, inability to walk	Severe hemophilia A
Cornman-Homonoff et al¹⁹	USA	Retrospective study	81 (82 embolizations)	65.3 (41–86)	35	TKA	Mean 9.2 (0.7–66.4) months		1x vonWillebrant, 1x SLE
Yoo et al²⁰	Korea	Case series	3	66	2	TKA				x1 fondaparinuxx1 ASA
Barrientos et al²¹	Chile	Case report	1	63	No	TKA	7 months	Pain
Power et al²²	Canada	Retrospective study	13 (14 embolizations)	Median 70	8	TKA	Mean 21 months	Pain, swelling		x4 warfarin

Abbreviations: AC, anti-coagulation; anti-PLT, anti-platelet; F, females; LMWH, low molecular weight heparin; TKA, total knee arthroplasty; yrs, years; UKA, Unicompartmental knee arthroplasty; ASA, aspirin; SLE, systemic lupus erythematosus; MRSA, Methicillin-resistant Staphylococcus aureus; TIA, transient ischemic attack.

Immediate and Long-Term Clinical Outcomes

Procedure was successful in 94.8% of cases with available (n=203/214), with 3 access site complications reported, including two cases of groin hematomas and one access site pseudoaneurysm, while one study reported one case of distal superficial femoral/popliteal artery dissection that was treated endovascularly. Improvement of symptoms were reported in 72.6% (N=119/164) of the cases after first treatment session. Among the studies with available data, about 30.7% (N=58/189) of the cases required a type of re-intervention during follow-up including repeated embolization sessions, arthroscopic debridement (one case) or surgical exploration (two cases), with 22.2% (N=22/99) of the cases experiencing recurrent hemarthrosis up to 48 months from index procedure. Immediate and long-term outcomes are summarized in Table 2.

Table 2.

Short- and Long-Term Outcomes.

Study	Procedural success	Access site complications	Follow-up period	Imaging used during follow-up	Improvement of symptoms after first session	Recurrent hemarthrosis	Need for re-intervention
Puijk et al⁷	Yes		5 yrs	Ultrasound	Yes	No	Arthroscopic debridement
Pow et al¹	27/29 (93%)	1 SFA/popliteal artery dissection, 2 groin hematomas, 1 vasospasm			27/29 (93%)	6/25 (25%)	4/25 (16%)
Luyckx et al⁸	26/31 (84%)		82 months (range 3–121)			7/31 (23%)	7/31 (23%)
Agarwala et al³	Yes
Purudappa et al⁹	Yes		1 yrs	CT angiography	Yes	No	No
van Baardewijk et al²	12/14 (86%)		Mean 26.8 months		12/14 (86%)		x4 repeated interventions, x3 third procedure
Ogilvie et al¹³	4/5 (80%)	No			4/5 (80%)	1/5 (20%)	4/5 (80%)
Guevara et al¹²	10/10 (100%)		Mean 18.2 months (range 1.6–55.2), 1 patent lost to follow-up			4/10 (40%)	x4 (3 of which had serious comorbidities at baseline)
Weidner et al¹¹	12/13 (92.3%)	No	24 months	Angiography	12/13 (92.3%)	1/13 (7.7%)
Azubuike et al¹⁶	Yes		1 month
Bagla et al¹⁷	5/5 (100%)		Mean 25.4 months (range 16–24)			No
Park et al⁴	Yes	No	1 yrs	Angiography	Yes	No	No
Rukavina et al¹⁰	Yes		2 yrs
Given et al¹⁸	Yes			Angiography	After 2nd intervention	Yes	Yes
Given et al¹⁸	Yes			Angiography	yes	No	No
Given et al¹⁸	Yes			Angiography	Yes	No	No
Kalsi et al⁶	Yes
Kickuth et al⁵	Yes	No	3 months	CT angiography	Yes	No	No
Joshua Cornman-Homonoff et al¹⁹	81/81 (100%)	1 access site pseudoaneurysm	Median of 21.5 months		Clinical success/resolution of hemarthroses, was achieved in 56%, 79%, and 85% of patients following the first, second, and third treatment, respectively		29 repeated embolizations (65.9%, 25.6%, and 8.5% underwent 1, 2, and 3 treatments)
Yoo et al²⁰	Yes					2/3 (67%)	x2 exploration, x1 re-embolization
Barrientos et al²¹	Yes		2 yrs		Yes
Power et al²²	13/13 (100%)				12/14 (86%)		1 repeated embolization

Abbreviations: CT, computed tomography; yrs, years; SFA, superficial femoral artery.

Discussion

Recurrent hemarthrosis after TKA, while infrequent, may significantly impair postoperative outcomes, making rapid diagnosis and adequate treatment crucial to avoid permanent disability.^9,10 While conservative measures may be used to manage first time bleeding, recurrent hemarthrosis often requires more aggressive therapy. Synovectomy, either open or arthroscopic, has shown success in most cases; however, it is associated with an increased morbidity due to the need for repeat surgery.^8,11 More recently, femoral arteriography to localize the bleeding source in combination with selective embolization has offered a minimally invasive treatment option with favorable outcomes.^10,12 In patients with an unidentified source of bleeding or hypervascularity on angiogram, geniculate artery embolization (GAE) has demonstrated efficacy in resolving current hemarthrosis and preventing future occurances.^1,2,14,16

In a systematic review and meta-analysis performed by Sundaram et al¹⁴ in 2018, selective geniculate artery embolization was found to provide symptomatic relief in 86% of patients after an average of 1.3 embolization procedures. This review included 8 papers published between 1998 and 2018, for a total of 59 patients. While the findings from this previous review are encouraging, our review provides an updated summary of the literature including 20 studies published up until July 2022 for a total of 212 patients who underwent GAE. Our analysis demonstrates procedure success in 95.2% of cases with 72.6% patients reporting symptomatic relief after one embolization session, while in cases of persistent symptoms further sessions of endovascular therapy may be required. Re-intervention rates were found to be about 30.7% with 22.2% of patients experiencing recurrent hemarthrosis up to 48 months post-procedure.

While our findings demonstrate that GAE may be a safe and effective modality for managing recurrent hemarthrosis post-TKA some important technical points need to be kept in mind to avoid complications. First, it is imperative to choose the appropriate particle size. The risk of ischemic complications is higher when small particles are used for embolization as they may easily travel to small (cutaneous) branches. Therefore, we recommend avoiding the use of particles smaller than 100 μm. The same applies for particles larger than 500 μm due to an increased risk of recurrent hemarthrosis because of proximal vessel occlusion. Over the years, we developed a preference for spherical particles with a size of 250 μm. Second, subtotal instead of total devascularization should be aimed for in order to avoid ischemic complications, including skin necrosis. In order to prevent nontarget embolization, wedge embolization should be avoided when possible as well as forceful injection, certainly after embolization, to minimize reflux into the popliteal or anterior tibial artery. Embolization should be performed under constant fluoroscopic guidance. Finally, it is mandatory to use a microcatheter to access the geniculate arteries. If one or more geniculate branches are not accessible, embolization through collaterals should be performed to achieve sufficient devascularization.⁸

Limitations

The results of the present study should be interpreted in the context of several limitations. First, all the included studies are case series and case reports including only small number of patients and having variable follow-up duration. The non-randomized observational nature of these studies limits the generalizability of our results as it is possible that only cases with favorable outcomes were reported (ie, publication bias).

Conclusion

Selective GAE offers a potentially safe and effective treatment option for recurrent hemarthrosis following TKA with acceptable outcomes when conservative measures fail to control symptoms.

Supplemental Material

sj-docx-1-jet-10.1177_15266028231157642 – Supplemental material for Geniculate Artery Endovascular Embolization Post-Total Knee Arthroplasty for Hemarthrosis Treatment: A Systematic Review of the Literature

Supplemental material, sj-docx-1-jet-10.1177_15266028231157642 for Geniculate Artery Endovascular Embolization Post-Total Knee Arthroplasty for Hemarthrosis Treatment: A Systematic Review of the Literature by Christina M. Melian, Stefanos Giannopoulos, Ioannis Tsouknidas, Panagiotis Volteas, Dimitrios Virvilis and George J. Koullias in Journal of Endovascular Therapy

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Stefanos Giannopoulos

Ioannis Tsouknidas

Dimitrios Virvilis

Supplemental Material

Supplemental material for this article is available online.

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