Amazing Article in JVIR this month on IR MSK interventions that all future IRs should be aware of.
The authors used transcatheter embolization with a imipenem/cilastin compound to treat tendinopathies/Enthesopathy, treating everything from plantar fasciitis to Iliotibial band syndrome to Rotator cuff tendinopathy.
The technique was based off the hypothesis that normal human tendons have low vascularity and that in areas of pain, there is disorganized vascular ingrowth of neovessels. The IRs performing the study decided to use imepenem (a carbepenem antibiotic) and cilastin (a compound that inhibits the degradation of imepenem) for its safety profile: it has been used for embolization in animal models and was found to cause less necrosis.
The study was performed in 7 patients with tendinopathy/enthesopathy who had failed conservative treatment for 3 months and had moderate to severe pain on a visual analog scale (VAS) (patient breakdown: patellar tendinopathy, n=1; rotator cuff tendinopathy, n = 2; plantar fasciitis, n = 1; lateral epicondylitis, n= 1; iliotibial band syndrome, n = 1; and Achilles insertion tendinopathy, n = 1).
The authors used radial or femoral access to select distal arteries supplying the tendons (such as the acromial branch and thoracoacromial arteries supplying the rotatotor cuff) and interestingly in each case found abnormal small vessels at the sites of tendinopathy. There were no major adverse events after the procedures and all patients experienced a statistically significant decrease in mean visual analog scale pain scores!
This is amazing for several reasons. Number one, this opens a whole new arena for IRs in terms of providing minimally invasive therapies to treat extremely common problems. From the results of this small study, it seems patients with refractory pain may be able to avoid unnecessary surgery, and patients can avoid long-term use of medications with a great deal of adverse effects (NSAIDS, corticosteroids).
As many of you are aware, IRs have begun to open up clinics dedicated to treating patient symptoms (ie: Leg pain clinics where IRs diagnose, treat, and provide long-term management for anything that could cause leg pain from peripheral arterial disease to low back pathology). Tendon embolization would be an extremely useful therapy to add to ones practice. IRs would need to be adept in clinical diagnosis of musculoskeletal pathology, which again strengthens the argument for increased clinical training in IR residency. If not we would stand to lose this therapy to Ortho or potentially even PMNR practitioners. We need to own the disease to effectively provide the best care for our patients.
Number 2, it raises the question of pain treatment in general. The authors postulate that the results of the study indicate a close relationship between pain and blood flow, a relationship that is already well-established. Could targeted embolization be used to treat other areas of refractory pain, such as cancer pain?
Just wanted to make all future IRs aware of this study and wanted to hear your thoughts.
-B
The authors used transcatheter embolization with a imipenem/cilastin compound to treat tendinopathies/Enthesopathy, treating everything from plantar fasciitis to Iliotibial band syndrome to Rotator cuff tendinopathy.
The technique was based off the hypothesis that normal human tendons have low vascularity and that in areas of pain, there is disorganized vascular ingrowth of neovessels. The IRs performing the study decided to use imepenem (a carbepenem antibiotic) and cilastin (a compound that inhibits the degradation of imepenem) for its safety profile: it has been used for embolization in animal models and was found to cause less necrosis.
The study was performed in 7 patients with tendinopathy/enthesopathy who had failed conservative treatment for 3 months and had moderate to severe pain on a visual analog scale (VAS) (patient breakdown: patellar tendinopathy, n=1; rotator cuff tendinopathy, n = 2; plantar fasciitis, n = 1; lateral epicondylitis, n= 1; iliotibial band syndrome, n = 1; and Achilles insertion tendinopathy, n = 1).
The authors used radial or femoral access to select distal arteries supplying the tendons (such as the acromial branch and thoracoacromial arteries supplying the rotatotor cuff) and interestingly in each case found abnormal small vessels at the sites of tendinopathy. There were no major adverse events after the procedures and all patients experienced a statistically significant decrease in mean visual analog scale pain scores!
This is amazing for several reasons. Number one, this opens a whole new arena for IRs in terms of providing minimally invasive therapies to treat extremely common problems. From the results of this small study, it seems patients with refractory pain may be able to avoid unnecessary surgery, and patients can avoid long-term use of medications with a great deal of adverse effects (NSAIDS, corticosteroids).
As many of you are aware, IRs have begun to open up clinics dedicated to treating patient symptoms (ie: Leg pain clinics where IRs diagnose, treat, and provide long-term management for anything that could cause leg pain from peripheral arterial disease to low back pathology). Tendon embolization would be an extremely useful therapy to add to ones practice. IRs would need to be adept in clinical diagnosis of musculoskeletal pathology, which again strengthens the argument for increased clinical training in IR residency. If not we would stand to lose this therapy to Ortho or potentially even PMNR practitioners. We need to own the disease to effectively provide the best care for our patients.
Number 2, it raises the question of pain treatment in general. The authors postulate that the results of the study indicate a close relationship between pain and blood flow, a relationship that is already well-established. Could targeted embolization be used to treat other areas of refractory pain, such as cancer pain?
Just wanted to make all future IRs aware of this study and wanted to hear your thoughts.
-B
