Research Presentation Session: Interventional Radiology

RPS 1209 - New insights in musculoskeletal interventional radiology

March 1, 08:00 - 09:00 CET

7 min
Usefulness of augmented reality with computed tomography fusion in chronic total occlusion percutaneous femoral interventions
Irene Nieri, Paris / France
Author Block: I. Nieri, J. M. Pernes, K. Najeh, S. Kalinger, C. Del Giudice; Paris/FR
Purpose: Femoral interventions could be challenging, particularly in the presence of CTO. The aim of the study was to evaluate the use of augmented reality superpositioning of a CT fusion to treat femoral lesions in patients with claudication and critical limb ischaemia in a retrospective registry
Methods or Background: From November 2022 to August 2023, a total of 47 patients (study group mean age 81 years old, 41 male), 32 of whom were suffering with claudication and 15 with critical limb ischaemia, with femoral CTO lesion were treated by endovascular recanalisation supported by augmented reality (Vessel Assist, GE Healthcare) to guide the procedure. A preprocedural CT scan was performed on all patients, that was used to fuse the 3D volume rendering with the fluoroscopy during the procedure in an augmented reality pattern. These patients were compared to a historical cohort of 120 matched patients (control group).
The primary outcome of the study dose area product (DAP) and total cumulated air kerma (CAK) were evaluated. Technical success, fluoroscopy time and amount of used contrast agent were also evaluated.
Results or Findings: Technical success was obtained in all procedures. No difference in terms of risk factor and lesion length was observed between the study group and control group. DAP and CAK were significantly lower in the study group compared to the control group (3611.5 versus 15408.0 mGy*cm², p<0.001 – CAK 19.8 versus 68.5 mGy, p<0.001). Fluoroscopy time was significantly inferior compared to the study group (528 versus 1108s, p<0.001). Moreover, in the study group a significant inferior amount of contrast agent was used (67.9 versus 156.0 ml, p<0.001).
Conclusion: The use of augmented reality CT fusion during femoral recanalisation may reduce x-ray exposure and fluoroscopy time without any difference in technical success. A reduced amount of contrast media was used in the study group.
Limitations: The bias of a matched control study was an identified limitation.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information: Ethics committee approval was not required for this retrospective study.
7 min
Study protocol: percutaneous treatment in patients with lumbar spinal stenosis. Rationale and design of a phase III, multicentre, randomised, controlled trial
Alessandro Napoli, Rome / Italy
Author Block: A. Napoli, G. Alfieri, M. Mattone, S. Perotti, C. Catalano; Rome/IT
Purpose: The study aimed to compare the efficacy and safety of percutaneous therapy and surgical treatment for the management of lumbar spinal stenosis.
Methods or Background: This represents the protocol for a multicentre, prospective, randomised, controlled, phase III trial comparing percutaneous therapy (PT) and surgical treatment (ST) for the management of lumbar spinal stenosis. Eligible patients are between 65 and 85 years with radiologically proven lumbar spinal stenosis causing neurogenic claudication. Patients will be randomly assigned to one of the two groups, PT and ST. Patients in the PT group will undergo treatment under local anaesthesia and mild sedation in prone position using a minimally invasive percutaneous approach under fluoroscopic guidance. Primary endpoints will be overall pain as measured by a numerical rating scale (range 0-10), functional disability as measured by the Zurich Claudication Questionnaire and adverse events. Outcomes will be assessed at 3-, 6- and 12-months following treatment. Statistical analysis will be performed on an intention-to-treat basis.
Results or Findings: We determined that a minimum sample size equal to 216 patients is needed to detect between-group differences of at least 2 NRS points at 3-month follow-up, allowing for a standard deviation of 2.5. Assumptions for the study design considered a two-tailed significance with alpha 5% and 90% statistical power.
Conclusion: A phase III trial will provide evidence on the actual efficacy of percutaneous treatment of patients with lumbar spinal stenosis. The intended size of the study population is sufficiently large to detect differences between the two groups.
Limitations: Unedified limitations were (1) that this was an open-label trial and (2) the absence of a sham or placebo group.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information: No information provided by the submitter.
7 min
Percutaneous computer tomography (CT): guided treatment of lumbar joint synovial cysts
Sonia Triggiani, Milan / Italy
Author Block: S. Triggiani, G. Pellegrino, M. T. Contaldo, A. M. Ierardi, S. A. Angileri, P. Biondetti, P. Torcia, G. Carrafiello; Milan/IT
Purpose: The aim of the study was to describe our experience of percutaneous treatment of eight patients with lumbar facet synovial cysts (LFCS).
Methods or Background: Eight patients referred to our centre for neurological symptoms such as low back pain and radiculopathy, refracting to the oral unpainful therapy. At MRI scan all of them were diagnosed for LFCS: five patients on the right side, three on the left side. All but two cysts (L5-S1) were at L4-L5 level.
The patients underwent CT-guided treatment in an aseptic environment. All of them were positioned prone and local anaesthesia was administered. Under CT- guidance, a 21-gauge needle was inserted into the facet joint with a posteroanterior approach homolateral to the cyst and 1-2 mL of non-ionic contrast agent was locally injected to localise the cyst. The rupture was performed through the injection of dilute contrast in the cyst with a high-pressure syringe. The treatment was considered successfully completed when an extravasation of contrast was observed outside the cyst’s wall and into the epidural space.
VAS-score was used to evaluate pain before and after the treatment.
Results or Findings: Before the treatment all patients referred a VAS-score of more than six, up to ten. 100% of procedures achieved the successful rate, radiologically intended as contrast extravasation in the site of the cyst.
On telephone follow-up at six to ten months after the treatment, all patients referred a VAS-score lower than four. No complications occurred.
Conclusion: The benefits of CT-guided cyst rupture technique can justify the future prevalence of surgical choice, as all patients achieved an immediate improvement in pain and no complications were reported during the procedure and on telephone follow-up.
Limitations: Identified limitations were (1) that a small series was used and (2) that this was a single centre retrospective study.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information: Not applicable as the study was retrospective.
7 min
Genicular artery embolisation for the treatment of symptomatic knee osteoarthritis
Florian Nima Nima Fleckenstein, Berlin / Germany
Author Block: F. N. N. Fleckenstein, B. Gebauer, B. Hamm, F. Collettini; Berlin/DE
Purpose: Genicular artery embolisation (GAE) is an innovative minimally-invasive therapy for patients with symptomatic knee osteoarthritis (OA) refractory to conservative treatments, aiming to reduce synovial arterial hypervascularity. This study aimed to evaluate the safety and efficacy of GAE for the treatment of symptomatic knee OA.
Methods or Background: A retrospective, single-centre study was conducted at our institution. Patients enrolled in the study were aged 40 to 90 years, had moderate to severe knee OA (Kellgren-Lawrence grade 2 to 4), and had previously experienced failure of conservative therapy. Baseline pain (assessed using the visual analog scale [VAS]) and symptom scores (Knee Injury and Osteoarthritis Outcome Score [KOOS]) were evaluated. After achieving femoral arterial access via a 4 Fr sheath, embolisation was performed using Imipenem/Cilastatin. Target vessels were determined using digital subtraction angiography in correlation with the patients' pain points. Adverse events and symptom scores were assessed at six weeks, three months, and six months after GAE.
Results or Findings: A total of 46 patients were enrolled, with a median age of 69 years (IQR, 61, 74). Knee OA severity was grade 2 in 12% of patients, grade 3 in 41%, and grade 4 in 47%. Technical success was achieved in 100% of procedures. Transient skin discoloration and transient mild knee pain after the procedure were noted in 18% of all cases, as expected. No complications were reported. The KOOS daily activity index and VAS improved by 87% and 71%, respectively, at six months from a median baseline of 57 (of 100) and 7 (of 10), respectively.
Conclusion: This retrospective study demonstrates that GAE is an effective and safe treatment for reducing OA-associated symptoms that are refractory to conservative therapy.
Limitations: This was a retrospective single-centre study, without a placebo or control arm.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: No information provided by the submitter.
7 min
Patellar tendinopathy: a promising treatment approach with stromal vascular fraction (SVF)
Nicolas Papalexis, Bologna / Italy
Author Block: G. Martinese, N. Papalexis, G. Facchini, M. Di Carlo, M. Casavola, G. Vara, G. Filardo, S. Zaffagnini, M. Miceli; Bologna/IT
Purpose: Patellar tendinopathy is a common overload-related pathology in both athletes and the general population, which can hinder sports activities and limit daily life functions. The use of stromal vascular fraction (SVF) is an innovative approach in the treatment of cases resistant to conservative therapy. The aim of this study is to assess the effectiveness and safety of the experimental SVF treatment at 12 months post-infiltrative procedure, along with clinical and radiological correlations. A secondary objective is to evaluate interoperator agreement on certain radiological parameters to establish reproducibility.
Methods or Background: Thirteen patients (11 males and 2 females) were included, treated with ultrasound-guided SVF infiltration obtained from subcutaneous abdominal adipose tissue. Each patient was clinically assessed at the baseline and 12-month follow-up using the following questionnaires: VISA-P, VAS scale, EQ-5D, EQ-VAS, and Tegner score. Simultaneously, B-mode ultrasound evaluation, colour and power Doppler, microvascular imaging (MVI), and compressive elastography were performed by two operators with varying levels of experience.
Results or Findings: No adverse events were reported following the infiltrative procedure. A significant clinical improvement was observed in all questionnaires (increase in VISA-P from 57.36±17.67 to 80.2±19.80; p=0.001), with a significant correlation with reduced vascular signal (VAS-colour Doppler C.I.=-0.747; p=0.024), thickness reduction (EQ-VAS-thickness C.I.=0.68; p=0.04), and increased elastographic modulus (Tegner score-E1 C.I.=0.65; p=0.04). Interoperator agreement proved to be excellent for various ultrasound parameters (colour Doppler ICI=0.91; 95% CI=0.08-0.94).
Conclusion: Ultrasound-guided SVF infiltration is a safe and promising procedure for treating patellar tendinopathy, with significant clinical and radiological improvements at a 1-year follow-up.
Limitations: Identified limitations were (1) that this was a non randomised study and (2) that there was a lack of control group.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: This study was approved by the Institutional Review Board and by the Ethics Committee.
7 min
The performance of non-contrast magnetic resonance angiography using cardiac-gated 3D fast spin-echo for 3D fusion guidance in transarterial embolisation for refractory shoulder pain
Yi-Chih Hsu, Taipei / Taiwan, Chinese Taipei
Author Block: Y-C. Hsu, Y-C. Chen, C. Tung, L-H. Chiang; Taipei/TW
Purpose: Transarterial embolisation (TAE) is a widely used the treatment for aggravating musculoskeletal pain in the extremities, that is refractory to conservative treatment. Three dimensional (3D) fusion guidance for fluoroscopic navigation has been used to overcome difficulties in identifying overlapping vessels during TAE. As a pre-fusion imaging for fluoroscopic navigation, the main advantage of using magnetic resonance angiography (MRA) is that it can be performed without the use of contrast media. However, a feasible sequence for non-contrast MRA (NC-MRA) suitable for the upper extremity has not yet been established. The aim of this study was to evaluate the performance of NC-MRA using cardiac-gated 3D fast spin-echo (FSE) in the detail of arterial morphology of the shoulder.
Methods or Background: Seven consecutive patients who had refractory shoulder pain underwent NC-MRA and TAE. Two reviewers assessed image quality for visualisation of shoulder arteries by using a qualitative 4-point scale (1=not assessable to 4=excellent). The number and morphology of arterial branches of subclavian and axillary arteries that were adequate for TAE treatment of refractory shoulder pain were also evaluated. The results were compared with those from digital subtraction angiography during TAE. Interobserver agreement was evaluated with the κ statistic.
Results or Findings: NC-MRA using cardiac-gated 3D FSE is technically successful for arterial depiction of the shoulder. Image quality was considered excellent (median=4) and the κ coefficient was 0.85. Additionally, NC-MRA correctly represented arterial branches of subclavian and axillary arteries that were adequate for TAE treatment of refractory shoulder pain in all patients.
Conclusion: NC-MRA using cardiac-gated 3D FSE is technically and clinically feasible and represents a promising technique for 3D fusion guidance in TAE for refractory shoulder pain.
Limitations: The small number of patients was an identified limitation.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: This study was approved by the research institution of Tri-Service General Hospital.
7 min
Intra-articular hyaluronic acid and platelet-rich plasma as monotherapy or combination therapy, what is the evidence?
Sheng-Fei Oon, Melbourne / Australia
Author Block: S-F. Oon, C. Nguyen; Melbourne/AU
Purpose: This study aimed to use a validated evidence-based practice tool to identify best current evidence for combined intra-articular hyaluronic acid (HA) and platelet-rich plasma (PRP) versus monotherapy in treating knee osteoarthritis.
Methods or Background: Knee osteoarthritis is a degenerative joint disease characterised by progressive loss of articular cartilage from wear and tear. Combined HA and PRP intra-articular injections gained recent interest and may relieve pain and reduce progression of osteoarthritis through synergistic mechanisms. Current literature causes confusion due to mixed conclusions, even among meta-analyses. We used the McMaster University and National Health Service five-step systematic approach to conduct a bottom-up search through the primary and secondary literature. We limited our search to review and meta-analysis articles in the English language only, within the last three years.
Results or Findings: A total of 69 articles were retrieved and evaluated for validity and strength. Five final articles were selected for individual review and the results tabulated. For combined HA+PRP versus HA alone, HA+PRP demonstrated significant improvement in stiffness and physical function symptoms at 3, 6 and 12 months (p <0.001). There was no statistically significant difference between PRP+HA and HA alone in pain control (p=0.195). For HA+PRP versus PRP alone, pain reduction was seen at one month with PRP only. After this time, no statistically significant difference was found between the two groups with regards pain, stiffness or physical function.
Conclusion: Combination PRP with HA demonstrates superior symptom control when compared to HA monotherapy, but combination PRP and HA does not provide further long term statistically significant symptom control over PRP monotherapy.
Limitations: The limitation of articles to the English language and within the last 3 years could have reduced the robustness of search. Meta-analyses were of low quality due to extensive heterogeneity of the included studies.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information: Ethical approval waived by Peter MacCallum Cancer Centre Ethics and Governance Committee: "Literature reviews of publically available information do not require ethics committee review."

This session will not be streamed, nor will it be available on-demand!