A Multivessel Transcatheter Arterial Embolization to Treat Hip Osteoarthritis

Chronic hip pain due to osteoarthritis (OA) is a prevalent source of disability in older adults. While total hip arthroplasty (THA) remains the standard treatment for end-stage disease, many patients are not surgical candidates due to comorbidities or personal preferences. Transcatheter Arterial Embolization (TAE) of the hip has emerged as a minimally invasive treatment for OA-related pain, but further evidence is warranted to establish its role in treatment pathways. This prospective, single-center pilot case series was conducted under IRB approval and reviewed the feasibility of multivessel hip TAE for pain treatment. Four patients with OA-related chronic hip pain underwent hip TAE which targeted the medial and lateral circumflex arteries, and obturator arteries. Technical success was reached in all cases, defined as a resolution in synovial blush on post-embolization angiography. Pain outcomes were measured at baseline, 1, 3, and 6 months post-procedure using the Visual Analog Scale (VAS). All four patients achieved ≥50% reduction in VAS from baseline (average 9.75 baseline --> 1.75 at the end of the study period). No ischemic complications were observed. Study results demonstrate multivessel hip TAE may be viable as an effective minimally invasive treatment for patients with OA-related hip pain, with meaningful and sustained pain reduction and no adverse complications occurring. Larger and sham-controlled studies are necessary to further generalize these findings and establish hip TAE. ---------------------------------------------------------------------- Introduction Chronic hip pain from osteoarthritis (OA) is a prevalent source of disability and joint pain, particularly among older adults (1 - 3 ). The lifetime risk of symptomatic hip OA in individuals living to the age of 85 is estimated to be over 25% (2). OA is a complex and multifactorial disease, characterized by pathological changes in cartilage, bone, and surrounding structures of the joint. Recent literature suggests that OA may be influenced by increased vascularity of the synovium (3 - 5). This results in joint pain, mobility impairment, and reduced quality of life (1, 4, 6). Conservative treatments are typically used to alleviate pain and improve function. Many patients experience temporary benefit from measures such as oral analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy, and/or intraarticular steroid injections (7, 8). For end-stage OA, total hip arthroplasty (THA) remains the definitive option. However, arthroplasty is not always feasible for patients due to advanced age, comorbidities, or personal preference (8, 9). As a result, there is a need for adjunctive, minimally invasive alternatives that can reduce pain and maintain mobility (10 - 12). Transcatheter arterial embolization (TAE) has shown promise in managing OA-related pain in the knee and shoulder (8, 10, 11, 13). The procedure involves selective cannulation and embolization of abnormal synovial hypervascularity to reduce inflammation (8, 10). By targeting synovial neoangiogenesis, hip TAE disrupts the inflammatory cascade and provides pain relief and functional improvement (13, 14). Although TAE has shown efficacy in various joints, there is limited research on application of this technique within the hip (14). Early studies have evaluated short-term outcomes of hip TAE among patients with moderate to severe OA of the hip, but long-term evaluation is necessary (12, 15). Given this relatively unexplored avenue, this pilot case series assesses the feasibility of multivessel TAE for OA-related hip pain. We present four patients with advanced hip OA and multiple comorbidities who underwent the procedure for pain relief. Methods This single-center prospective case series was conducted under full IRB approval. All four patients had chronic and persistent hip pain secondary to osteoarthritis, which was refractory to conservative treatments. Following clinical and imaging evaluation, the procedures were performed by an experienced interventional cardiologist with certification from the American Board of Endovascular Medicine. The procedure was performed using a multivessel approach, defined as the embolization of two or more arterial contributors to the hip joint (notably the medial and lateral circumflex femoral and obturator arteries). These vessels were selectively cannulated and embolized using Primaxin, a suspension of imipenem-cilastatin, and 50 - 100 µm or 100 - 300 µm Embospheres, to achieve complete cessation of pathological blush. Technical success was defined as the resolution of abnormal synovial hypervascularity or blush displayed in the post-embolization angiography. Pain outcomes were assessed using the Visual Analog Scale (VAS), a validated 0–10 measure of pain intensity, where 0 indicates no pain and 10 represents the worst pain imaginable (17). The objective was to evaluate the clinical success of hip TAE for OA-related pain. Clinical success was defined as a ≥50% reduction in VAS score from baseline, measured during follow-up evaluations at 1, 3, and 6 months. Case 1 A 79-year-old female with frailty, type II diabetes mellitus, OA, and chronic venous insufficiency presented with progressive bilateral hip osteoarthritis-related pain, worse on the left. Her symptoms were associated with severe limitations in activities of daily living (ADLs), with pain reaching a 10/10 VAS score. The patient had previously tried multiple conservative therapies, including oral analgesics, physical therapy, and intraarticular steroid injections, all of which failed to provide lasting relief. Due to her comorbidities and frailty, she was not a candidate for total hip arthroplasty and elected to undergo TAE for her left hip pain. Ultrasound-guided retrograde access of the right (contralateral) common femoral artery was obtained. A 5F Prelude sheath (Merit Medical) was placed and exchanged for a 5F 45 cm Roadster sheath, which was advanced into the left (ipsilateral) common femoral artery through an up-and-over approach. An abdominal aortogram was performed using a 4F 65 cm Berenstein catheter (Merit Medical) to delineate pelvic inflow prior to selective catheterization of the left-sided hip-supplying vessels. Using a Fielder XT-R wire and 1.4F 135 cm Caravel microcatheter (Asahi Intecc Medical), target arteries were selectively cannulated and injected with 50 mcg nitroglycerin, saline flush, and contrast dye to demonstrate angiographic blush. After confirming angiographic blush visualized in Figure 1, embolization of the left medial circumflex femoral artery was performed with 0.5 mL of Primaxin, the left lateral circumflex femoral artery with 0.2 mL of 100–300 µm Embospheres, and the left obturator artery with 0.2 mL of Primaxin. Post-embolization angiography confirmed a reduction of abnormal blush with preserved femoropopliteal flow. Hemostasis was achieved using a 5F Celt closure device (Vasorum) at the access site. At 1-month post-embolization, the patient reported marked improvement, with her VAS pain score decreasing from 10/10 to 1/10. By this time, she was able to resume routine activities such as standing, cooking, and shopping with minimal limitations. At 3 months, she reported complete resolution of left hip and compensatory back pain (VAS 0/10), an effect that sustained at her 6-month follow-up. In this case, hip TAE provided effective pain relief with meaningful improvement in daily function. Case 2 An 85-year-old female with hypertension, atrial fibrillation, and OA presented with progressive osteoarthritis-related left hip pain. Her discomfort limited ADLs, and she rated her pain 10/10 VAS score. Multiple intraarticular steroid injections to the left hip and knee provided only temporary relief. Given the persistence of pain, functional decline, and lack of further surgical options, she elected to undergo left-hip transcatheter arterial embolization (TAE) as a minimally invasive treatment. Ultrasound-guided retrograde access of the right (contralateral) common femoral artery was obtained, and a 5F Prelude sheath (Merit Medical) was placed. Following placement, the 5F Prelude sheath (Merit Medical) was exchanged for a 5F 45 cm Roadster sheath, which was advanced into the left (ipsilateral) common femoral artery through an up-and-over approach. An abdominal aortogram was performed using a 4F 65 cm Berenstein catheter, which delineated pelvic inflow before selective catheterization of the left-sided hip vessels. Using a Fielder XT-R wire and 1.4F 135 cm Caravel microcatheter (Asahi Intecc Medical), the left lateral circumflex femoral artery was selectively cannulated. Intraarterial nitroglycerin (50 mcg) was given before angiography to minimize vasospasm. Embolization was performed with 1.0 mL of Primaxin, resulting in reduction of angiographic blush while preserving femoro-popliteal flow, visualized in Figure 2. The medial circumflex femoral artery was not able to be cannulated due to diffuse calcific disease and thus not treated, and the obturator artery showed no significant blush. Hemostasis was achieved using a 5F Celt closure device (Vasorum). At baseline, the patient reported severe left hip pain rated 10/10 on the VAS, which significantly limited her activities of daily living. At 1 month, her pain improved to VAS 2/10, with increased mobility and reduced discomfort. At 3 months, she continued to note improvement (VAS 5/10) but described ongoing bilateral lower-extremity tenderness and swelling, consistent with previously documented chronic venous insufficiency. At 6 months, her hip pain remained improved relative to baseline (VAS 5/10) and she reported a sense of tightness, particularly when sitting. No ischemic or procedural complications were observed. Overall, hip TAE resulted in meaningful pain reduction and functional improvement over the 6-month follow-up period in a patient with multiple comorbidities. Case 3 An 83-year