Ep. 94 Genicular Artery Embolization in Post-TKA Pain Management with Dr. Rene Viso

Enjoy the podcast, but one more. Download our new BackTool app. You'll get early access to episodes, case discussions, and courses all in one place. Just search BackTool in the App Store or Google Play on your phone. This week on the BackTool podcast. The pre-match embolication was the nuclear medicine study with red blood studies, so we repeated after six months of the procedure. My anxiety told me that I should do three months, but the nuclear medicine, especially say, "It's not going to change in three months. You have to wait a leak six months." And you know, this day area, so we repeat the nuclear medicine for six months. That's native anti-K or just TK? That's TK native. We scheduled the same way. One month, three months, six months, 12 months. But with this, we're in the space in the semi-riarked three months and 12 months. Well, welcome everybody to BackTool on SK. I'm Kaivi Khrushasami. I'm an intervention radiologist at UAB, Alabama Birmingham. I have with me today a friend and colleague, Renee Viso, who is an intervention radiologist in South America in Argentina specifically. Renee, welcome. Thank you very much for being here. Tell us a little bit about yourself in your practice. Thank you, Kaivi. Thank you for bringing me here. So, I'm an intervention radiologist. I'm an originant from Venezuela. I moved on from Argentina like eight years ago and started to make practice initially in Buenos Aires. I moved up to the coast city four hours ahead from Buenos Aires called Mar de Plata. I worked in a private hospital and doing mostly narraterentional, but I was also very interested in doing MSK pathology, especially post TK pain in the knee. But I do most actually only in the knee also in the shoulder, especially all the post surgery patients is what I do most in my comfort. Fantastic. And I feel like you're being a little humble. I know you have a pretty large MSK practice. So that's our topic for today. We're going to talk about molecular artery embolization, specifically post surgery, post total neuropathy. We'll talk a little bit about pre-ampost as well. So tell us about the status of GAE in South America. How does it work? How does reimbursement work? Definitely in Argentina and anywhere else you can comment on. Yeah, in South America, there is an emerging technique right now because despite the almost a year that Okuna described the technique, we are still in a very few centers doing this in Argentina. And Argentina, I believe there is three or four centers currently doing this practice and Chile, for example, I'm aware of two centers in Colombia, also two centers, not sure about another countries. Of course, Brazil is completely apart because they have a lot of experience in MSK embolization, especially because they work of Dr. Joaquimola, Dr. Takimola, Dr. Correa, they will do a lot of intervention therapies in MSK. So I have something that we can get to inspiration for us, especially in Argentina. We have kind of issue here, for example, in Argentina, when you get retired, you're all in that 55, you get retired and the government gives you an insurance, a medical care that doesn't, it's not a progress acceptance, this practice. So it's kind of difficult right now to do these embolizations in the medical public system. And the private system, we are still able to do it, but that's the pain a lot of the private security that patients have. So we are working around now to give some educational and spreading the word about the embolization techniques in order to get more access to the social care and the medical care to approve this practice. I got it. Well, you know, a couple of things you said that were very interesting. One sounds like you have the ability to retire at 55. I hope that I'm able to do that at some 65. Okay, I'm a certain, but it's interesting how healthcare systems are different around the world right and different from, you know, what we deal with in the US. So let's dive into the meat of it a little bit. So when you talk about GE and you see patients in clinic for GE or potential genocular rehabilitation, how are you choosing this patients for native away patients and then for post TK patients. The native patients are those patients who don't want to get surgery or for because they don't want to do it. They have medical contractations to all a lot of cardiovascular risk. So those are the patients that they ought to send to us in my hospital in my practice. We have to like stairway that ends in the IR department because they initially pay the patients start with the ortho surgeon. If there is no surgical criteria, the patient don't want to get surgery is going to the pain medicine department in the pain medicine department. They adjust all the medications and start doing percutaneous therapy like general block, PRP, all that regenerative techniques and if the all fails and the answer is called directly to is go to the IR department. The main difference is the patients that already have surgery, the post TK patients because those patients like this ortho surgeon is nothing else to do with that. So they are sent directly to the medical department and after that they send it to me. And on those patients particularly we work together because we know this is a thing that works very good for us. So they like pain medicine department see a patient with a post TK thing is send it right now to the IR department. And then we do for no TK I mean native joints they usually go after the failure of two medical therapies for example the patient have to tool treatment for mycological treatments and fail for example. Can you grab a block those are the patient that sent to me got it well the post TK patients are important right I mean you know what is it 15 to 20% of TK patients have an unidentifiable cause of pain chronic pain right so it is a large percentage of patients around the world that still have pain post TK that potentially we can offer a solution for your group your team recently published on this will get to that in a minute but both populations are very important right so really wonderful work so okay. So let's say you see patient clinic what patients are you going to treat what kale scores are you looking for what imaging are you getting things like that for net joints for native joints and we'll do post TK as well yeah when we're still doing this we are very strategic about the kills score we don't treat patients with more than three. But we start to see there is a lot of people with new problem new pain the very disability poor quality life and we start to doing a high grade or process so it's like we also yeah call for we talk to the pension on this plane there is a chance that in maybe in six months the pains come back or maybe in in a week we don't know there is. Few evidence about what what happened with your pain but especially in KEL4 but the patients you know you have to take part of that you know you put in the shoes of that patient that is with pain the order sure says I can do a repeat replacement because you're to all or you are high risk of cardiovascular patients so the patients is the specific has nothing else to do is like it goes to the dead end so it's like. Let's try it say let's try it so primarily two and three go ahead I'm sorry yeah and we do MRI on those patients because we believe that the knee is not only bounce you know there is a lot of other structures there so for example many schools ligaments all that so we also do a non contrast MRI because insurance issues about the M in contrast in MRI so we do non contrast and try to see an instructor damage in the many school especially in the lateral one. There is a recently very interesting publication about with about MRI findings who predicts failure of the three minute three months was published by dr. Osmond and he found that more than three structural change damage in the knee is going to be very related to poor outcomes in the next three months so we try to do if there is cartilage damage if there is many stood damage and the rate of the one because sometimes the patient just has to be in the back of the patient. The intensive patient just have something that maybe is is cordable or treat only by surgeon and you just goes back to the orthosurgeon and treated so that's the pain. That's a great point I find in my practice I'm doing MRI with contrast although I will openly honestly say I don't know fully the value of adding contrast yet and you know the value of doing centivitis scoring and things like that right but to your point I think that's a great point. I think that's a great point. Do you conventional X-ray and to evaluate that the practices is not loosening? If there is no problem with that, the patients go to a nuclear medicine because MRI, there is a lot of artifact due to the practices and CT scans. So in my hospital they do red blood cells to evaluate the muscular pool of the knee and to these started infections, they do cyprophloxin, cyprophloxin, a nuclear medicine study that is, you know, the red cells are linked to the c-prophloxin and they injected and then some image 24 hours later after the injection and they see if there is any intake of the protestsis or the terapotasic tissue around the knee that's indicated or this high-level indication from protestsis infection. They also do CPR tests in the blood, so to see if there is any suspicious of infections, but that's basically our patients with treatment, all patients with TK pain, after TK, if there is no mechanical cause or other reason to explain the pain. Okay, I got you. It's an interesting algorithm and you know, I haven't really incorporated nuclear medicine studies into my algorithm. I have been getting MRIs post TK, we get our TK patient MRIs in a low-field scanner, so it's like a.55T and we've had some success there. The nuclear medicine scanning is super interesting, you know, from red blood cell scan, but then also from a technician, I think it's technician cyprophloxin, you said, right? I didn't even know that existed, so that's really interesting. I'm going to have to, you know, delve into that in my hospital. And then CRP, as you said, so you're checking CRP, if there's a super high CRP level, again, you're concerned about infection, you're working them up for infection, but are you checking CRP pre and post looking at correlation or anything like that? Pre-post embolization, I should say, I'm sorry. No, or we're currently not doing that, but we're asking an idea, we're talking more the orthosurgeons to check because it's not like a specific test or something, like that, or very complicated, it's just a sample test of blood, so we're going to give in. Okay, I got you. How about the physical exam? What scoring systems are you using? I assume you're using the same pre and post TKA? Are you doing any physical exam testing? Are you doing any functionality testing? Things like that. No, we are currently doing, you know, because the patient already have an evaluation in the pain medicine service. It's very easy for us because there's a doctor who is a specialist in pain, so it's like the patient is completely starting off that part, but we use the WAMAC score and the ABS score, both one, especially because they are really like the WAMAC score because, you know, the stop device in three, and especially we were able to see that when you use embolization in these types of patients, the stiffness part is not improving so very much, you know. I believe it's due to the fibroxybracic and other post-surgery control chains in the pre and pre and pre joint tissue. Okay. We really like those those scores. Okay, got it. So WAMAC total, WAMAC pain, VAS, anything else? No, those two. The twist of types of WAMACs, pain stiff and unfunctional it, and the BS score. The BS score. Okay, got it, but a little caution with the stiffness score, as you said. Okay, I think we probably do pretty similarly there. What about access sites? When you get into the procedure, what's your preferred access site, what are your devices, what are you doing? We always use an antiretrovremular approach. So it's what we almost in all patients have done. There's only one patient we do control lateral approach because we have to also do embolization for the hip. So we did both joints in the same position, but that's only one patient. The rest of the patient, the antiretrovremular, my main formation is never interventional. So I'm very comfortable with neurobascular device. So my base catheter is an internal amaryax catheter, 5-range. I really like those WAM because of the angle of the tip. It's very helpful to catheterization the nuclear arteries and my micro catheter of choice is the rubber, this 2.4-french micro catheter with a 0.0-inch micro wire, the legal. They come together as a package. So it's what I reduce. For my embodied engine, we always do temporally embolic engines or first idea. Some cases we have to do permanence in bodies, but we start to avoid it. Especially in patients with knee replacement, because they have already injury skin, they have a scar. Sometimes it's a very huge scar with a lot of issues to catheterization. People older, so we try to not do permanent embolic endoswetions. Yeah, yeah, gotcha, gotcha. I want to dive into that. I want to go back to the devices real quick. So it's a 2.4-french micro that you're using primarily. What was the wire diameter? I missed that. I'm sorry. 0.0-4-G. Okay, so it's a 14-french or 14,000s. And then your base catheter, what was your base catheter? You turn on my marty catheter. Internal, okay. So you're using an IAM. I'm tending. Everybody uses something different, right? I tend to use a C2, a glide C2, and my sheet is either a 5-french slender or a 4-french prelude. And then I tend to use a 2-french micro, 1.7-2-french micro, and a 1/4 wire, just like you said. But yeah, I love the idea of going integrate femoral. I integrate superficial femoral in particular. I don't really stick integrate common femoral. Are you doing any peatle? I haven't really graduated to a lot of peatle yet. I have never done that. From lucky for us, we still be able to to catheter say it's all of genus cholesterol from the anterior approach. But we won't be able to do, it's not having a necessary effect. Yeah, I gotcha. I gotcha. Yeah, I think it's, you know, not as common for us either. But you know, something that seems to be interesting, especially in the US, in the outpatient world, to try to get patients out faster, especially if you're not using a closure device and I tend to not use a closure device. What about you? You're using closure devices with your femoral axis? I really like closure device, to be honest, we do especially because we have a lot of peatle, merideplato, a city where I live. It's our retirement city, you know. So we have an population with very old. So mostly half anti-coeation, half a lot of dual anti-placid therapy. So I really like to use closure device. But then sure is, actually right now it's not covering that devices. The most interesting. They don't cover so I have to do manual compression. Okay, which is what I'm doing as well. And one of the reasons I try to keep my access site as small as I can keep it effectively, right? So, okay, that's fascinating. And then you're talking about particles you're using predominantly resorbable. So what are you using in the resorbable space? And the resorbable space, I use lipidined. It's, okay. I start doing as almost everybody in this world, antibiotics. But, you know, the infectious, the factor is MD on the other half of the star as in questions that, why are you using that? Where are you injectable antibiotics in a patient with non-infections? Okay. And she start with the cross allergies also. So we were worried because maybe even 10% of patients can get allergic reactions. So it's like, it's not a minor issue. And you know, the factor is start to make some questions that we didn't have the answer for that. So about what's going to happen with the bacterial resistance. And she showed us some papers about that one dose of karma paintings, like in painting, can change the bacteria flora of the intestinal patients. Interesting. Some very bad effects on the clip, Ciel anemoneae, bacteria, sonal, that. So it's like, in that moment, we were get kind of lost because we start doing, we start with antibiotics. We were thinking about me great because of that going to a sphere. So about, frontally, doctor, subvolval and the team started to leave the joint and we may read to that. So it's all more lapidone. Okay. Got it. So you stopped using an epenem completely at this point. Okay. I still have access to it while I was waiting to put opti-ray. It's the lapid joint has only been tested with opti-ray, right? And specifically opti-ray, 300 and 320. So while I was waiting to get opti-ray on the shelf, I was using an epenem and now I finally have opti-ray on the shelf, which is nice. So lapid joint, how do you make your lapid joint emotion? My lapid joint emotion is lapile of six six centimeters and two centimeters of opti-ray contrast. Okay. You have 300 or 320? 300. 300. I believe we don't have to 20 on my hospital. And I don't think the US has 300 at all. So I think the US is only 320 at this moment, but both work. So as you know, for the lucky. So we start to do the in two syringe, we don't have to dedicate a device to a lapid joint, let you know like, bector or something like that. So we use conventional syringe and we start to pump in first the contrast to the lapid joint. And after that, we do 40 pumps and we inject that solution. We also do the drop test, you know, after we get the final mixture, we use you put a drop of the, we take a one CC syringe, we put one drop in the water. So it should stay as a drop and not dissolved because that's the weathering all the solution. And after that, we inject. Okay. The direction you push what into what really matters here, right? Water in oil, just like conventional taste, you have to push the opti-ray into the lapidol or, you know, for taste, the ducts of ribosin into the lapidol. Otherwise, you get an oil and water emotion, which is not what you want. So that's a great point. And then yeah, we have a nylon three way that doesn't melt. That's what I tend to use. And then, I tend to use regular BD syringes, 'cause I find some of the other nicer syringes that we have tend to melt a little bit easier and obviously don't want it to melt, right? So your point is good. I think the US now has access to the dedicated syringe system that is meant to mix lapidol that's marketed by Gerbe. I don't have it on the shelf currently, but yeah, it sounds like you don't either. So it's nice to have at least a few devices that won't melt from the lapidol, right? And then so the drop test, tell me a little bit more about the drop test. Do you drop one drop into normal sailing, you said? - But we pass the lapidol into a one CC syringe. We put one drop in normal syringe. It should be, it gets stay as a drop and then melt into the water. - Yeah, okay, got it. Okay, okay, all right, that's good to know. I haven't been routinely doing that, but I probably should start. That's a great point. But regardless, water into oil is I think the important aspect if you do it the other way around it, obviously it's not the same. So in the US we have Sakura bead and next sphere on clinical trial. Do you guys have either of those two products? - Nothing, we don't have it. - Nothing. - So there is tar, okay. The company that we will work with our medical supplies, is tar making some questions if we can bring it or not, but it's not prove it yet here. So it's not a proof here. So it's very composed for us to try it yet. - Okay, okay, got it. Yeah, and so you really only have lapidol, which so and you're using reservoir for native knees and post-TK knees, real lapid joints specifically. - Yeah, the last time I used antibiotics was when I was treating in a hand issue. I didn't was worried about antipylic in the hand. So I used antibiotics, but that was the last time a few months ago, the time I used lapion joint. And there is a residual blush. I had a lot of residual blush after the realization. I used to use the same broad endosphere, but they only they had done the option. - Okay, and so and that's for native end for TK, you'll do that if there's a lot of residual blush. Okay, and then what size are you using for the residual blush? - 250. - After lapidon. Okay, Mocin. - Mocin. - Mocins. - 250. - Okay, got it. So you'll go to, what's your end point with lapid joint? Your angiographic endpoint. - Yeah, complete. It's a piece of the blush. Okay, so complete occlusion. - Okay, in the completion. - In the TK. - In TK. - TK. - What about native? - Disappears of the blush, but without a complete occlusion, it's like a pruning of the vessel. - Pruning, pruning. Okay, got it. So you're a little bit more aggressive with the TK patients than in the native patients. - Yeah, the patient has more blood flow, but the the vessels are bigger, they have more diameter. There's much, much more blush that they are patients. So I have to be more aggressive because there is a lot of kind of a lot of stuff happening there. - Okay, that's a great point. And then I know you already articulated this, the concern about cutaneous perfusion in the post TK patients or the lack thereof and using permanent particles. You're still using permanent particles selectively, right? But you're very, I assume you're just more careful with permanent particles in the TK patient because of the risk of cutaneous ischemia. - When we use tip early end body ganges, we don't use cryoprotraction, but when we are doing post TK, we have in the room the cryopax, because if we have to move up, move up and go to particles, we start to, we start the protection with cryopax. But that's the only protection measure we do in case we have to move up and use particles. If we use just lapillon, we don't have any concerns. The patients, all the patients go out of the room with skin-chantic colorations, but one or two hours later, it's completely normal. - Got it, and that's the resorbable nature of the envelope, right? So, but probably also, I presume the larger size, the MZ250 also helps with a little bit of skin protection. Obviously, if you went down to 100 MZ or less than 100, I would assume the risk to the skin would be higher, right? - Maybe higher, yeah. So the TK patient is complicated, right? I mean, compared to the native patient identifying the vessels behind the implant and the TK patient is challenging. So, you know, some of us use cone beam and the native knee are using cone beam and the TK knee at all, is it helpful? Is it not helpful? - There's a lot of artifacts during the coming, so with the endowment, we generally, we put our base catheter in the superior femoral artery, we do a good injection and try to identify by anatomy all the endicular vessels. And something that's very helpful in this patient is when, for example, you see the DGA, you put your microinded DGA and you do like a very big or a selection. By collateral, you can see all the genocular arteries, that's something we're starting to do. Or for example, if you do the superior mid-regular artery, you do like a big or a selection, and you see the superior and the inferior sometime in the same injection. The main issue with the dispassion has to see the origins of the arteries because the protocytral, the scurres, that all. So the patient will do like, start to move in the knee from the patient, you know, make some flexion, try to open the protocies in the middle to see the, or especially for inferior lateral and inferior medial, it's more complex to see. - Yeah, okay, so rotation and flexion, those are the two big ones, and hopefully, obviously supporting the knee. I assume you're doing most of these cases with just some, need a modern sedation, correct? - Elcelation, insulation, we have an infinite problem for the, okay. - Got it, got it. - Okay, so a little bit of, you know, some tips to kind of help identify those vessels. As you said, how many vessels are you going after in the TKA patient? - All of them. - All of them. Everything you see, everything with the blush. - Everything with the blush, because we see a lot of things, for example, those vessels are more hypertrophic in the patient, TKA, and there is more collateral. So we can, you can lift any vessel behind because it's going to, it's going to reverse color size or it's going to do re-engaging, so it's not like that. So we are very aggressive with those patients. They're not half knee, so it's just metal. - Okay, great point. Okay, so all the vessels give you the same for the native patients as well, native away? - Yeah, we do embolize all, but in native patients, I mean, we're trying first to do the most painful side, for example, if internal, external, and. - Medial lateral, okay. - Yeah, and if you lift some vessel in the contour lateral, no pain size, it's not a big deal. In the knee, in the post-TK patient, we try to do all the vessels. - Everything. - I'm trying to move the patient, move the knee, to see if there is any other vessels, but do very big or as injection, is here any ever residual blush. - Okay, got it. Yeah, it's interesting. I find myself, especially with the, you know, added safety of resurbles, right? Resurble and bollocks, I find myself going after everything in all scenarios. So, both native patients and then post-TK patients, I tend to embolize everything that I can find. But again, you know, there's a little bit, you know, there's a better safety profile with the resurbles, right? So, if there's a little bit of reflux, it's not, you know, I don't wanna say not a big deal, but it's not as big of a deal, right? So, yeah, great, great point. Okay, so, we talked about closure devices. You're not using closure devices. I'm not using closure devices either. How are you following these patients after intervention? - One month, three months, six months, and 12 months follow-up in the sterone consult, and we, the pre-embelication was the nuclear medicine study with red blood studies. So, we repeated after six months of the procedure. - Okay. - My anxiety told me that I should do three months about the nuclear medicine, especially say, it's not going to change in three months, you have to wait a week, six months, and, you know, this day area, so we start, we do the, we repeat the nuclear medicine that six months. - No, and that's TK, and native, we, we scheduled the same, the same way, one month, three months, six months, 12 months, and, but with this, I mean, this patient is MRI at three months and 12 months. - Okay, so you do an MRI at three months and 12 months, okay, and you're, assume actively comparing post-imaging to pre-imaging, what are you looking for? - At least improving of the bone edema is something we are looking for, and the patient's pre-embolization has a lot of sign ofitis, so, you know, it's thinking of the synovial tissue, we hope to see that a little reduction of the tissue. Maybe, this is a fusion, we also do that, nothing else. - And less fusion, okay, got it. And then, what are you noticing on the post-red blood cell scan in particular? Are you seeing a lot of decreased pooling, I guess? - Yeah, it's, we see that the pooling is decreasing, but we are not sure how important is the measuring of that, because, for example, the last patient is, we have, I want to show you a few cases of lard, but they have 8,000 of pooling uptake, or something like that, and she went to an embolization, six-month-layer, completed as intomatic, free of pain, and then she have only a decrease of 30% of the pooling. We are not fully understanding how does this mean, but it works, so the patient is completely free of pain, she's happy, so it's just more like a calemic issue, to see this reduction of the pooling. - And where I are, where I are, right? We want a visual confirmation of what we did, right? That's the best, it's appealing to us. And so I think when we don't see that, academically, that's a little bit of a gap in the knowledge, and hopefully we try to answer that in the relative near future. So, what about failures? How are you dealing with patients don't get it. the response that you hope for or expect. All patients have some intake patients. All patients have some net level of repons. Some achieve a very good response that this patient is not was talking about with complete resolution. Other 50% or other 10% that is very valuable. So when the patients is not happy or the pain is highly enough to make his life quality bad, we go to CREO. We talk with the internal pain medicine doctors and just get you a CREO therapy. We also recheck that there is worse any component of the protein that was I don't know losing or for example we check the X axis of the skeleton, both of the patient in the legs. There's no any external force compartment in the compartment like operating in the hip or the spine. But in those cases we don't do rehabilitation. It's not or usual or a standard practice because like I say we go for all the vessels. So if there is no any vessel behind we we should think that is maybe another problem that is making the patient have pain. So we go to CREO and back to the ortho. And you're talking about cryonorlicis specifically. And then your technique is it a three-side technique, four-side technique? What do you do for cryonorlicis? They did. I don't do it because it's the pain department because we have an intervention of pain medicine doctor dedicated to that. But they do a three-point technique. That's what I use as well. Supermeter, superlateral, infrared medial, you know, and I do a lot of cryonorlicis of the knee. Sounds like you guys have had you have access to radio frequency or only cryo? No, we have access to radio frequency. Yeah. Okay, but you prefer sounds like the pain team prefers cryo. It's because the CREO machine, you know, the the the the console of CREO and Irolysis, the host to Pital owns that one and the radio frequency they have to rent it. So it's a problem. Economics. Yeah. Sometimes. Yeah. Well, and there's a recent comparative paper radio frequency versus cryonorlicis for the for the knee specifically, right? That you know, it doesn't show a significant difference in outcomes and actually showed that if I remember correctly, cryo was better at six months, even though there was no significant difference at 12 months. But I have to go back and look that up. So, you know, cryo is being done fairly commonly. I do a lot of cryo as well. But that's a I think a topic for a different episode. We'll go back to the GA part of this. And then just to point out another thing you said. So you're if you have a failure, you're not repeating GA but you're looking for other causes and other joints that might contribute to the overall kind of function of that limb. Basically, correct? Yeah, we don't do it because we don't let facility highs in our practice. So we start to look in another case of pain. Got it. Okay. And then so then the general follow up, aside from imaging, you're just looking at the VAS and the Wilmax scores again, anything else you're looking at in those follow up. There's nothing else. Just pain scores. And the six months new VAS cooler pool. Imagine we nuclear medicine. That's all. Okay. I got you. What about adjunctive therapies that you're offering in the TK patient with GAE? You know, we've talked about this before. Sounds like there is a subset of patients that may have increased pain post GAE in the very short term. How are you dealing with that? Yeah, we will turn notice that these patients in the first the first days have a lot of pain after emolizations. So we were wondering is that not about the high grade of say no values and this came out when those so we start to do it especially in those patients, we have to do permanent embolic set materials. We do genicular block, tripone genicular block in the room after we finish the emolization. We do the we call the pain medicine interventionals and they do the genicular block. And standard just pipi-pavikin and seren. Yeah, it's the never be talking stir it. Yeah, but only when you're adding three points, but only when you're adding Amazon on top of the lapidroid. Yeah, okay. Okay. We'll have to do a second embolic danger because we noticed that the ischemia windows in the in the synovial joints are very intense. So there's a lot of pain with the patient. I got you. It's not a problem, but the patients start to get worried about we have more pain than the previous treatment. Maybe they do or so we just making them more comfortable the fear stays. Yeah, yeah, absolutely. Well, and I think it goes back to that introductory clinic visit, right? And setting expectations and what to expect. And you know, I know we'll talk about this when we talk about your team's paper, but that's such an important conversation to have because not everybody is going to respond the same way. And I find that the patient has less pain. Wonderful. But I also have patients that don't really have improved pain, but have improved functionality and mobility. And they're still happy, right? So I think there are a lot of flavors to this conversation that are very important to have in that clinical setting. So yeah, great point. Okay. So with that notion, let's you know, go to the the paper that you guys just published. Just came out at last month in November, right? And tell us a little bit about this paper. Yeah, it's an experience of two centers in Argentina. And one in Buenos Aires, capital city here in Mar de Plata. We join forces with another IR doctors in in Buenos Aires to see the to polish your experience with these patients is almost 20 patients with the public stations with different symbolic materials. We have antibiotics. We have permanent and buildings and we have lapag joints almost half of patients were treated with lapag joints. So this does very excited for us. We very good to respond. The reduction of the pain, the target clinical response, what degrees of 50% of bus or warm-ascar so and almost 60% patients achieved. So it's very good. We're happy for it. I think that's a that's a great point. I think, you know, for as we're looking at these articles, it's really important to dive into what is defined as clinical success in the paper, right? Because 63% clinical success by VAS score. And I think it was 50% VAS by Will Mac, right? I think you said that. But that's by the definition of clinical success. Outside of that 50% that met that definition, you still had patients that responded and felt better and were happy. Correct? That's a very interesting point. You know, because all the patients have response. All the patients improve. That's a very important case tone in this. But not all the patients unfortunately achieve reduction of pain more than half. But patient improve and something very important to consider is what you do. Evolation of pain with the warm-acquist scale. You have to know in this kind of patient that the stiffness is very difficult to improve because it's five pluses and the patients, you have already a point or a sub-scale that contributes to the total score that is going not to get you better. So the patients and the main issue of the patients, they don't complain about the stiffness of the joint. That's not the problem. Probably it's the pain score. So we should do, but we didn't do it, but we should do maybe in a future more details. So our analysis of the warm-acquist score to see is that the improvement of the pain is more highly that the other sub-scals. We noticed that the stiffness, it was an improvement. That's something. An issue. Yeah, that's also a great point. I think the other aspect to this is that no matter what we do, I'm very happy to hear that a lot of your patients are responding. I've definitely had patients that have not responded or have not been happy with the response. But again, that goes back to that clinical conversation that you have about the potential of non-response. 63% clinical success by VAS is actually for me, I think, a great number that doesn't dissuade me from offering this therapy. No matter what we offer, there's going to be a level of non-response. Again, that's the conversation you have. But I think given the lack of work in this space, this is a great publication by your and your team to put out there to guide the rest of us. That's very cool. There are a couple of patients in the manuscript that had repeat intervention and then a couple of small ulcers. Can you talk about those a little bit? Yeah, the two patients have to in the other center. We don't have, as I say before, we don't repeat embellization. The other center have to do a second session of VA patients. Those two patients respond as initial treatment, but they could with complete the solution. They didn't achieve the reduction of pain more than 50%. So they were during the follow-up at six or seven months. They started to have been pain again or pain increase more than the initial decreases. So they do a second session of embellizations and they saw receive a blush in those patients. I believe that's important because we work, that's what we're talking about. We have to go for all the vessels at the beginning. And the small ulcers, they use small particles, 75% I believe, as some 75 microns. So it's very small, especially in these patients who has an increased blood flow in the knee. So that's why we use inner 250. So sub 100 and then permanent, as you said. Okay, that's a great point. And a good lesson, I think, for the rest of us to not use the small particles. But again, in the era of resorbital particles, I think we're in a lot of us are moving that direction. We'll see in the next several years what the cost of those resorbital particles are going to be. And I'm sure that will dictate some of their utilization as well. And I'm sure permanent particles will always have a role in the space as a result of costs for sure. And particles are very cheap, right? Okay, shall we show some cases? Yeah, for sure. I have two cases for you. So this was our last complete follow-up patient. I believe it was very interesting because it was a very complex case. She was a she's a certified year old patient. She received a K.A. a few years ago and after that, she still remains with pain. She didn't improve. You know, these patients, when this patient arrives to the clinical consult, it's like this, they, you want to offer a solution because the solution supposed to be the complete, the K.A. and now they still remain the very first three patients. So as you would say, we have a small talk and we say of ten patients, three are not responders. So if you want to take the chances and most of the time they say yes because there is no water pollution out this and a new progressive revision that no one is supposed to do that. And the ortho don't want to do that. So this is the X-ray. We rely off causes of protesic losing on another pain. And this is the past career pool with red cells in the nuclear medicine. We see there is a increase of take in the superior part of the protesis. We were going to show you and compare with the DCA to see that's the region for ball blush in that area. And then to point out what you said, just to reiterate. So the X-ray showed no loosening, no other issues, rule out other causes of pain. Nothing else was able to be found. And for me, this is actually a fairly common thing that I see, you know, or myself and my partner that do a lot of the MSK work or the joint work I should say. This is a fairly common scenario, right? So that's your standard workup. And then I think you told me before as well, these patients are evaluated by the pain management team and they'll be offered neurolysis first. Yeah, they try to do a molecular block test. If the patient fails to the molecular blocks of half some insurance issue to create a neurolysis, it's going to a bulge session. So really when these patients are coming to you, they have zero other options. And this is it. Okay. Well, this is it. Or last option. Yeah. The last stand. Yeah. So this is the image. This is the nuclear medicine. This is the initial DCA. As you can see, this is a superpatellar artery. It's very hypertrophic. We usually don't see this size of the larytric. It's just a great example that's repuginous, you know, the classic example, right? So cool. Yeah. And you can see here, this is the DGA, the superpatellar artery, a superhannic larytrist right here. So you see there is an increase of the vascular diameter. So this is as I was talking to you, this is sort of initial evaluation or initial injection to see the complete anatomy of the femoral and the genicular arteries. You can see the host use of the organs of the arteries because of the processes. So this is a more late acquisition to see if you see the blush and you can compare this with the nuclear medicine. This is exactly when the more intake of the pulling was noticed. So we start using our practice or regular practice with the catheterization of each artery. You can see here, I put this image because I really like how the increase of the flow is, you can see a huge bank here, you know. So this bank is an amazing example of blush. For a person who is not used to use the embellization of the austral arteries, you can see that I would have a way to explain what is the blush and all that is using the image of patients with decay because there is a very increased blush in those patients. We do micro-catedrization with the or rubber 2.4 and we do it right here. I just want to point out one thing if you can go back to that last image. So I do a lot of MSK work, I do a lot of liver work ironically. So I see a lot of early venous filling in the liver as well with big tumors obviously. What it looks like to me, there's no active shunting. This is just hypervascularity and early venous drainage, correct? There's no risk of the embellic going out the venous side. No, because there is no shortage. There is just a lot of facial utilization. So we do catatization with our micro-injects, lapio, and we got this complete resolution of the blush. We still proximal arteries open, go to the con with another superior in the unicular, lateral one and the same thing, let the joint, resolution, go to the inferior medial and as usual, in J-leap joint, complete occlusion. We see the final DCA and we say, "Okay, we're happy or not happy," but we see a lot of vessels in the lateral compartment of the knee. So it's like, "Okay, let's go into check out," because we noticed we haven't checked the inferior lateral, so we catatization, we say, "Okay, let's go home," we did all the arteries, but we do a final DCA, we can see there is still receivable blush in the inferior medial. So we have to go back, occlude it, and we say, "Okay, now we're done, we're going to go home." Another DCA and you can see there is still receivable and in very important blush, especially in the lateral compartment, superior lateral compartment. Other knee. So in this moment, when this happened, we go to permanent embolics because we're not sure why this is happening because we don't see this in the natif or predicate joints. We see it, more in the patient with post-DKE, so we do catatization, injection of the embossed freers, 250, and this is the final DCA after complete abolization, completes appearance of the blush. And six more later, remember, we are in South America, so this is the month. So five months later, you can see the degrees of the tape to 81 to 64, it's almost 30% but, as I say, the patient is complete free of pain. So we're not sure what this means about the rate of decrease, but the patient is very happy with us with this. So this is the patient, the classification with pain, and I can show you another patient, but this one has a lot of effusion of the knee. Yeah, real quick, I want to ask a couple questions. So what percentage of your post-DKE patients do you think you're giving permanent particles to? Less than 20. So the majority are even post-DKE or still a pie joint only. Yeah. Okay. Thank you for us. Okay. So that's helpful to know. And then, I think there has been some work on MRI pre and post-GA in the native patient. I don't recall anything in the post-DKE patient, obviously. So I think it's interesting to see there's a decrease in or, you know, TEC-RBC pooling there, but yeah, it'd be nice to have a larger data set or larger series to have a better correlation. Maybe that's that kind of post-operative or post-interventional test that we start incorporating into our algorithm. But we'll see. I don't know yet, right? So regardless, that was a great case. Yeah. Thank you, man. And this is the other patient. Of course, she has pain, but the main issue with this woman was the fushia of the knee. And you see, we see this a lot. There is a difference between the blush in the patients with just pain and the patients who have fushions. It's more focused in the blush in those patients. It's not like the fused. A more localized. Sure. It's more localized. It's different. Yeah. So this is the DGA. We embolyze with lipid joint as usual practice. And after that, you can see even better, the other focus, the other places with the hyper blush, because if you can see here, maybe the catheter was a little directed to the DGA, but there is not a lot of blush right now. But when you do the embolication, as you take out the blood flow to the bad part of the knee, you can see that the other areas where it's in blush, so we did as usual practice embolication in this case. Lepidrogen again, correct? Lepidrogen again. Yeah. But this patient, especially this patient in particular, she had a lot of fear to the pain. And she made the main concern of that was the positive pain. So after we finish our embolication, we do all the genocular vessels we found with lipid joint, we do a genocular block in the angiosuite because his major concern was the post-procedural pain. We haven't seen a lot of procedure pain, post-procedural pain when lipid joint. We've seen some discomfort of the patient, but in this case, we give adjunct therapy with this. Hey, everyone. Our new backtabled app is now live. Go get early access to episodes, case discussions, courses, and an overall better learning experience, all free to download and use. Search back table in the app store and join us there. As you know, I mean, genicular, I mean, the nerve block is a very easy thing to do, right? It's a, you know, foroscopic. I mean, there is an ultrasound guy, a technique aspect to it if anyone's interested, but most people just do it foroscopically, at least in IR. It's very simple. It takes all of like three minutes to do and seems like it helps your patients post-operably, right? Yeah. And you can see the places of the knee is very close to the genicular arteries. That's something very cool to see. Okay. Got it. So you're, yeah. the arteries with the block or you just fluoroscopically, you do the fluoroscopically. No, fluoroscopy. No, this, the payment is intervention. I'll put the knees and I did a acquisition to see the relation of the arteries and the needles. That's a great idea. You know, my technique actually, and I learned this from some colleagues at UNC as well, but I actually look for the artery with ultrasound and then I mark that spot and then I stick under fluoro and then that's, that's, so with the idea that the needle is close to the artery, which is in close to the nerve, right? So different ways to do the same thing, but super, super cool. Okay. Great. That's awesome. And then I know you said it before, but again, ice packs, if you're using permanent particles in embassies and you're using ice packs, right? Yeah. Okay. Got it. Okay. Cool. Well, I appreciate you showing those cases, Renee. I mean, I think, I think, you know, the post-TK space is starting to, you know, come into its own a little bit, some of your work and your team's work. There was, there have been other small publications as well. So I think we're all excited to see more work come out, hopefully in the next few years. Also, you know, what we're going to know in the next couple of years, there were what, five, six randomized control trials for GE and native OA that are going to come out in the next few years as well. So we're going to have a lot more data coming in the next few years, which is very, very, very exciting. What are the other gaps in the space in the, for the knee specifically that you see now? What's the gaps about what? Just gaps in knowledge, things that we need to learn over the next few years as the space continues to grow and develop. Yeah, we need to increase our understanding of what's really happening in these patients because some patients, especially in the native one, we see a lot of synobatics and we do embellication and the patients still remain with pain. So I think we have to learn and understand what are the, the better selection for these patients. I strongly believe that just an X-ray is not enough. But we need to understand and I think us is doing a great job with that about what is at the bear biomarking indication for gay, bullization failure because that's our main issue because the patients have an, an hope that is going to work and it's only innocent. So it's like, we're, I believe we are not fully understanding what is the problem. Yeah, it's, I mean, it's, it's such a complicated, like, genetic organization failure is such a complicated topic, right? On one hand, we know that kale scoring is highly subjective and it's not reproducible, right? And that's, that's been shown in the literature. And so as you said, it's very hard to rely on just the kale score by itself, but we don't know what the right thing is to do yet. You know, there's been some work again on MRI pre and post and then you've done some work with, you know, red blood cell scans as well. So I think that'll be interesting to see there's also been work on sub typing arthritis and the knee as well as biomarking, biomarker testing of arthritis, you know, around GAE. So, you know, that, those areas will continue to expand, but regardless, there's a, we're learning a lot, but there's still a lot to learn, right? And then that's part of what makes this exciting and we're also helping a lot of patients. So kudos to you and your team. Really, really wonderful work. That's awesome. Thank you. Thank you. Any comments? No, I just say thank you. And encourage the IRs to start doing these patients because as I say early, these patients have already the best treatments that was the knee replacement and it's a good way, I believe, to start and introducing the MSK and realization in your practice because, you know, when they start this or the, all the orthos in my hospital, we're like, you're going to take out our patients or that's our pathology if you're not going to treat that. But I say, don't give me the, then my sadly worse work, don't give me the neti joints, give me the post-surgical patients that you already treat. So we have a lot of patients with shoulder replacement, hip replacement with retrochranocineroam, patients that they already have their surgical solution and it fails. So it's a way to gain confidence and to see, to prove to the or to and the other doctors that is a technique that really works. So I believe that this patients are very good to start your, even there are more complex, even if there are more complex. But you know, something, the genocular arteries are bigger, the diameter is increased, there is a lot of blush so you can easily identify it. So these patients is a very way, a very good way to start doing embolications of the authentic. Great. And we have resorbital options as well as we've already spoken about multiple times. But I'll also say though, you know, for the native away patient, this is not, we're not replacing TK. It's just, this is a bridge therapy, you know, for some patients to get them to TK later on, you know, especially if they're really young or, you know, patients that are just never going to get a TK because of comorbidities or age or whatever, right? So it's an addition to the algorithm. It's not replacing anything in the algorithm, right? I think. Yeah, but I believe in, in, or on a special day in the year, the initial response to the classic or conventional treatments is like, you're never taking my work, you know, it's really for the church. Sure. GAE, GAE, all that is like, it's my work. So it's really difficult at the beginning, but just start to show in the, and giving solutions also to the orthosurgeons, for example, they don't like to do a second revision of the processes. They hate that. So it's like, yeah, if you can bring the solutions, go to work on them. After that, they start getting confidence and start sending patients with native needs and all that. Absolutely. Well, importance of having a multi-disciplinary team, right? So again, strong work. All right, Renee, I very much appreciate your time. Thank you for being here and great chatting is always and wonderful work. Thank you, man. Thank you for your time. I'm Sean, I'll be to do more. Absolutely. Absolutely. We'll see you back soon. See you, man. Thank you. Thank you so much for listening. If you haven't already, be sure to follow, rate the show five stars, and share with a friend. If you have any questions or comments, direct messages at @_backtablemsk on Instagram, X or LinkedIn. @tablemsk is hosted by Jacob Fleming, Michael Boraza, and Chris Beck. Our audio team is led by Keir and Gannon with support from Aaron Bolz, Josh McWirter, and Josh Spencer, design and digital marketing led by Brian Schmitz. Social media and show notes written by Marvie Espirito, and Anne Deng, administrative support provided by Judy Della Cruz. Thanks again, and see you next time. Backtable now offers a personalized specialty feed inside our new app. Whether you practice IR, faster surgery, ENT, urology, or oncology, you can follow curated playlists and explore case discussions. Download Backtable and tailor your learning experience on your phone via the Apple Store or Google Play.