SIR 2019: Transcatheter arterial embolization: A nonsurgical treatment for tennis elbow

Transcatheter arterial embolization (TAE) is an effective nonsurgical treatment for lateral epicondylitis, or “tennis elbow,” a specialist told attendees of the Society of Interventional Radiology (SIR) annual meeting held in Austin, TX, in March. Yuji Okuno, MD, PhD, director of the Okuno Clinic in Tokyo, presented findings of a prospective study of 52 patients that demonstrated TAE improved tendinosis and tear scores in the majority of them.

Lateral epicondylitis is a painful chronic condition caused by overuse and repetitive stress to the tendons and muscles around the elbow. Chronic tennis elbow can cause loss of grip and arm strength, limited use of the arm, and burning sensations on the outer portion of the arm. Treatments include nonsteroidal anti-inflammatory drugs, corticosteroid injections, extracorporeal shockwave therapy, sclerotherapy, growth factor treatment, stem cell treatment, and surgery.

TAE is an image-guided, non-surgical treatment that decreases abnormal blood flow to the injured area to reduce inflammation and pain. Dr. Okuno explained that the treatment requires only a needle hole to access the radial artery in the wrist. A catheter is moved through the wrist to the elbow where the inflamed blood vessels are embolized, preventing excess blood flow to the affected part of the elbow. Treatments takes approximately one hour at his outpatient clinic, and were performed under local anesthesia. He used imipenem/cilastatin sodium as an embolic material.

Dr. Okuno and his colleagues invented the treatment, previously reporting their early experience in 2013 and 2017.^1,2 The prospective study cohort included 52 patients with lateral epicondylitis causing moderate to chronic pain for at least six months, and which was resistant to conservative treatment for at least 90 days. The patients received TAE between March 2013 and October 2017. None of the patients experienced major adverse events. Forty-eight patients were followed for up to four years.

Dr. Okuno said that the Quick Disability of the Arm, Shoulder and Hand scores significantly decreased from baseline at one, three, six, and 24 months’ post treatment. The median score at one month was 52.1, at six months 5.6, and at 24 months 3.7. Visual analog scale pain rating scores, pain-free grip strength, and patient-rated Tennis Elbow Evaluation scores also showed statistically significant reductions.

Magnetic resonance imaging (MRI) performed on 32 patients two years following treatment showed an improvement in tendinosis and tear scores compared to baseline. No patients showed bone marrow necrosis, obvious cartilage loss, or muscle atrophy.

A study conducted in the Republic of Korea in the same time frame of 13 patients to assess the effectiveness and safety of TAE to relieve pain associated with 15 cases of shoulder and tendinopathies had similar results.³ Jin Ho Hwang, MD, of the Department of Radiology of Konkuk University School of Medicine in Seoul, and colleagues reported that they achieved 100% technical success and 73% clinical success rates.

These patients underwent TAE between November 2015 and December 2016 to alleviate persistent pain that did not respond to conservative treatment, including non-steroidal anti-inflammatory drugs, corticosteroid injection and extracorporeal shockwave therapy. Seven of these patients had lateral epicondylitis.

The researchers assessed the 13 patients using a 10-point visual analog scale (VAS) at baseline, and one day, one week, one month, and four months afterTAE. They defined clinical success as a decrease in the VAS of more than 50% of the baseline score, achieved in 11 of 15 cases. Seven of the patients achieved pain relief within one week and an additional two patients within one month. None of the patients experienced any major adverse events.

Writing in the April 2018 issue of the Journal of Vascular and Interventional Radiology, the researchers suggest that TAE works because any increase of inflammatory cells and proinflammatory cytokines would decrease by occlusion of abnormal vessels, resulting in reduction of the inflammatory process. Additionally, they wrote that “stimulation of new unmyelineted sensory nerve growth near abnormal blood vessels affected by angiogenesis could be reduced after embolization.”

“Considering that the failure rates associated with surgical treatment for tendinopathy are inconsistent, transcatheter arterial embolization might be a helpful option for patients with chronic shoulder or elbow pain related to tendinopathy before considering surgery if they do not benefit from conservative treatment,” the authors wrote.

REFERENCE

1. Okuno Y, Matsumura N, Oguro S. Transcatheter arterial embolization using imipenem/cilastatin soddium for tendinopathy and enthesopathy refractory to non-surgical management. J Vasc Interv Radiol. 2013;24(6):787-792.
2. Iwamoto W, Okuno Y, Matsumura N, et al. Transcatheter arterial embolization of abnormal vessels as a treatment for lateral epicondylitis refractory to conservative treatment: a pilot study with a 2-year follow-up. J Shoulder Elbow Surg. 2017;26(8):1335-1341.
3. Hwang JH, Park SW, Kim KH, et al. Early results of transcatheter arterial embolization for relief of chronic shoulder or elbow pain associated with tendinopathy refractory to conservative treatment. J Vasc Interv Radiol. 2018;29(4):510-517.