Genicular Artery Embolisation in Patients with Osteoarthritis of the Knee (GENESIS 2): Protocol for a Double-Blind Randomised Sham-Controlled Trial.

Knee osteoarthritis is a leading cause of chronic disability and economic burden. In many patients who are not surgical candidates, existing treatment options are insufficient. Clinical evidence for a new treatment approach, genicular artery embolisation (GAE), is currently limited to single arm cohort, or small population randomised studies. This trial will investigate the use of a permanent embolic agent for embolisation of abnormal genicular arterial vasculature to reduce pain in patients with mild to moderate knee osteoarthritis. Up to 110 participants, 45 years or older, with knee pain for ≥ 3 months resistant to conservative treatment will be randomised (1:1) to GAE or a sham procedure. The treatment group will receive embolisation using 100-micron Embozene™ microspheres (Varian, a Siemens Healthineers Company) (investigational use for this indication in the UK), and the sham group will receive 0.9% saline in an otherwise identical procedure. Patients will be followed for 24 months. At 6 months, sham participants will be offered crossover to GAE. The primary endpoint is change of 4 Knee Injury and OA Outcome Score subscales (KOOS4) at 6 months post-randomisation. The study will also evaluate quality of life, health economics, imaging findings, and psychosocial pain outcomes. The primary manuscript will be submitted for publication after all participants complete 6 months of follow-up. The trial is expected to run for 3.5 years. Trial Registration: ClinicalTrials.gov, Identifier: NCT05423587.

Cadaveric and Angiographic Anatomical Considerations in the Genicular Arterial System: Implications for Genicular Artery Embolisation in Patients with Knee Osteoarthritis.

PURPOSE: Genicular artery embolisation (GAE) is a novel treatment for patients with knee osteoarthritis (OA). Cadaveric dissection was undertaken to provide a complete description of the relevant arterial anatomy in order to perform safe and effective GAE. MATERIALS: Twenty human lower limb specimens were dissected. The morphology of the genicular arteries and presence of anastomotic connections was recorded and compared with angiographic images from patients having undergone GAE. Vessels were measured to investigate the risk of non-target embolisation (NTE), taking a diameter of 300 microns as the threshold for significance. RESULTS: The descending genicular artery (DGA) is the dominant vessel in medial OA, with 95% of cases revealing vessel division into muscular, saphenous and osteoarticular branches from a single pedicle. The superior medial genicular artery (SMGA) had a shared origin with the middle genicular artery (MGA) in 25% of cases. NTE to the MGA may damage the cruciate ligaments. In 85% of cases, there was an anastomosis between the DGA and SMGA, often encountered at angiography. The mean diameter of the anastomoses was 850 micron, presenting a risk for NTE. An anastomosis between the Inferior Medial Genicular Artery (IMGA) and medial sural artery was found in 5% of cases; the medial sural artery supplies blood to the tibial nerve and should be avoided. The IMGA and inferior lateral genicular artery provided supply to the patellofemoral joint in 69% and 88% of cases, respectively. CONCLUSION: An in-depth knowledge of genicular artery anatomy is required for interventional radiologists to perform safe and effective GAE in patients with knee osteoarthritis.

Novel Use of Hydrodissection for the Insertion of Suprapubic Catheter Under Ultrasound Guidance.

OBJECTIVE: To find a method of safely inserting a suprapubic catheter (SPC) under local anesthetic and under ultrasound guidance in patients who may not be fit for a general anesthetic but also are seen to have bowel overlying the anterior bladder wall which obscures a safe route to the bladder. MATERIALS AND METHODS: We used ultrasonography to visualize the bladder which was initially filled via the indwelling urethral catheter. A 22-gauge needle attached to a syringe filled with 30 mL of fluid (made up of 10 mL of 1% lidocaine plus 20 mL sterile water) was inserted transabdominally under ultrasound guidance into a space between the pubic symphysis and bowel. The fluid was then injected into the space to hydrodissect the bowel away from the bladder. Once the space had been created, an 18-guage needle was passed into the bladder and a SPC was inserted via the Seldinger technique. RESULTS: Successful SPC insertion was confirmed on ultrasound guidance with no associated bowel or other injury. Telephone follow-up with the patient 6 months later revealed that the patient had no complications and no infections. CONCLUSION: Hydrodissection can be considered when inserting SPC under local anesthetic under ultrasound guidance when there is bowel obscuring any safe route to the bladder. This may be particularly useful in patients who may not be fit for a general an aesthetic.

Barriers to a safety checklist and methods to improve usage of the WHO safety checklist in interventional radiology.

Our aims were to first assess uptake of the modified safety checklist (SC) for interventional radiology (IR), identify obstacles to using the SC, and then apply changes to local policy to reach maximum compliance. Retrospective data collection was performed of all patients who underwent an interventional procedure in the interventional suite at the Royal Berkshire Hospital in February, March and May 2014. Barriers to a SC: a lack of awareness about the SC; lack of training in how to complete the SC; lack of leadership-no team member had been given the role of promoting the SC and collecting and collating the SC; attitude of staff-some team members felt that the SCs were time consuming and further bureaucracy; out-of-hours procedures involved staff from outside departments who were not familiar with the SC; paper copies of the completed SCs were being misplaced. Results: February 2014 = 79%; staff education of the importance of the modified World Health Organization (WHO) checklist disseminated in the interventional suite and at clinical governance; each day a designated 'SC champion' in the interventional suite has the responsibility for overseeing the WHO checklist is completed for each patient; the use of a clipboard for storing checklists, amalgamated and scored at the end of each day. Any checklists not completed are highlighted and discussed with the consultant. March 2014 = 95%; junior nurse involvement in auditing to improve awareness and engagement; out-of-hours interventional radiologist ensuring that the checklist is completed for each patient. May 2014 = 100%.

Upper gastrointestinal bleeding: A rare complication of acute cholecystitis.

INTRODUCTION: Haemobilia is a rare complication of acute cholecystitis and may present as upper gastrointestinal bleeding. PRESENTATION OF CASE: We describe two patients with acute cholecystitis presenting with upper gastrointestinal bleeding due to haemobilia. Bleeding from the duodenal papilla was seen at endoscopy in one case but none in the other. CT demonstrated acute cholecystitis with a pseudoaneurysm of the cystic artery in both cases. Definitive control of intracholecystic bleeding was achieved in both cases by embolisation of the cystic artery. Both patients remain symptom free. One had subsequent laparoscopic cholecystostomy and the other no surgery. DISCUSSION: Pseudoaneurysms of the cystic artery are uncommon in the setting of acute cholecystitis. OGD and CT angiography play a key role in diagnosis. Transarterial embolisation (TAE) is effective in controlling bleeding. TAE followed by interval cholecystectomy remains the treatment of choice in surgically fit patients. CONCLUSION: We highlight an unusual cause of upper GI haemorrhage. Surgeons need to be aware of this rare complication of acute cholecystitis. Immediate non-surgical management in these cases proved to be safe and effective.

A review of vertebroplasty for osteoporotic and malignant vertebral compression fractures.

Vertebral compression fractures are a common clinical problem and the incidence of them will increase with the ageing population. Traditionally management has been conservative; however, there has been a growing trend towards vertebroplasty as an alternative therapy in patients with persisting severe pain. NICE produced guidance in 2003 recommending the procedure after 4 weeks of conservative management. Recent high-quality studies have been contradictory and there is currently a debate surrounding the role of the procedure with no agreement in the literature. We examine the evidence in both osteoporotic and malignant vertebral compression fractures; we also describe the benefits and side effects, alternative treatment options and the cost of the procedure. Finally, we recommend when vertebroplasty is most appropriately used based on the best available evidence.

Transabdominal ultrasound in the initial assessment of adult bowel diseases.

Transabdominal ultrasound is increasingly chosen as the initial imaging technique in the radiological work-up of bowel abnormalities in adults because ultrasound can provide substantial information about gastrointestinal disorders. In the presence of pathological changes in the intestine, sonographic findings, such as thickening of the bowel wall, changes in the perienteric fat and vascularity, have recognizable and reproducible appearances (Kuzmich et al, 2009). Although the diagnostic quality of ultrasound can be compromised by bowel gas and obesity, ultrasound has a number of strengths, including its ability to allow real-time correlation between the sonographic findings and the area of maximum tenderness combined with excellent spatial resolution, wide availability, lack of radiation and its non-invasive nature. This article illustrates the key sonographic features of commonly encountered bowel disorders in adults and highlights ultrasound techniques that may assist in diagnosis.

The thyroid incidentaloma--ignore or investigate?

OBJECTIVE: The purpose of this study was to evaluate the potential importance and need for further investigation of thyroid lesions detected during imaging investigations unrelated to the thyroid gland (thyroid incidentalomas). The management of these lesions is controversial because most malignancies detected will be papillary microcarcinomas, which will not manifest as overt disease. METHODS: A systematic literature search was performed, including the MEDLINE (1951 to date) and EMBASE (1974 to date) databases, using the Dialog DataStar and PubMed search engines and the Cochrane database. RESULTS: Relevant studies were reviewed, together with consensus documents, looking at the prevalence of thyroid incidentalomas and associated malignancy and the use of ultrasound and fine-needle aspiration cytologic examination in further investigation of incidentalomas. CONCLUSIONS: The management and importance of the thyroid incidentaloma remain controversial, although problems relating to these issues are likely to become increasingly common in radiologic practice. Once an incidentaloma has been observed, formal clinical and sonographic assessment should be considered, with fine-needle aspiration cytologic examination as appropriate, after an informed discussion with patient.