The Journal of Bone and Joint Surgery 79:594-6 (1997)
© 1997 The Journal of Bone and Joint Surgery, Inc.
Spontaneous Recurrent Hemarthrosis of the Knee Joint: Endovascular Treatment of a Ruptured Aneurysm with Platinum Microcoils. A Case Report*
GUENTHER E. KLEIN, M.D. ,
JOHANN RAITH, M.D.,
JOERG PASSLER, M.D.,
DIETER H. SZOLAR, M.D.,
ERICH SORANTIN, M.D. and
KLAUS A. HAUSEGGER, M.D., GRAZ, AUSTRIA
Investigation performed at the Departments of Radiology and Orthopaedic Surgery, Karl-Franzens Medical School and University Hospital, Graz
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Introduction
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Arterial aneurysms are a rare cause of hemarthrosis and, in the reports in which such a lesion did lead to hemarthrosis, the aneurysm was postoperative (a pseudoaneurysm)9. These pseudoaneurysms have usually been repaired operatively, although we found two reports, involving three patients, in which therapeutic embolization was performed7,10. We present a case in which massive recurrent hemarthrosis of the left knee joint occurred spontaneously because of a ruptured true aneurysm of the descending genicular artery. This artery was occluded by means of endovascular placement of platinum microcoils.
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Case Report
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A fifty-one-year-old man was seen because of recurrent swelling of the left knee. He reported pain and tenderness and had a decreased range of motion of that knee. The patient had a three-month history of spontaneously recurring hemorrhagic effusions in the knee, which had been treated with aspiration on three occasions. Blood cultures had been negative. Arthroscopy had been performed one month before the patient was admitted to our hospital, but no source of bleeding was found.
Radiographs of the left knee revealed signs of osteoarthrosis (degenerative joint disease) and chondrocalcinosis of the menisci. Magnetic resonance imaging of the left knee demonstrated hemorrhagic joint effusion and thickening of the synovial tissue in the suprapatellar pouch, suggesting proliferative synovial tissue disease. A second arthroscopic procedure, with therapeutic partial synovectomy, was performed. There were massive blood clots in the suprapatellar pouch, and the synovial tissue was hemosiderin-stained with signs of proliferative synovitis. Again, no source of bleeding was detected.
Subsequently, intra-arterial digital subtraction angiography of the left popliteal artery through an antegrade transfemoral approach revealed a three-millimeter-diameter aneurysm of the descending genicular artery (Fig. 1-A). The feeding vessel was a branch of the descending genicular artery, coursing medial to the femoropopliteal artery and crossing laterally just proximal to the knee joint. A flexible, atraumatic 5-French guiding catheter (Tracker 38; Target Therapeutics, Fremont, California) was placed into the proximal part of the superficial femoral artery. With a coaxially inserted 2.2-French microcatheter guide-wire system (Tracker 18; Target Therapeutics), the descending genicular artery was catheterized and the microcatheter was placed into the feeding artery of the aneurysm. Superselective angiography demonstrated the bleeding aneurysm, with extravasation of contrast medium (Fig. 1-B). The microcatheter was advanced, the tip was placed proximal to the aneurysm, and two straight platinum microcoils (Hilal Microcoil; William Cook, Copenhagen, Denmark) were implanted into the thin pre-aneurysmal segment of the artery with use of a coil-pusher (Fig. 1-C). Angiography by means of the microcatheter and through the guiding catheter demonstrated complete occlusion of the feeding segment. The aneurysm was isolated from the circulation (Fig. 1-D), and there was normal perfusion of the descending genicular artery, including all of its branches. Six months after the procedure, the patient had no pain or swelling in the knee.
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Figs. 1-A through 1-D: A fifty-one-year-old man who had spontaneous recurrent hemarthrosis.
Fig. 1-A: Digital subtraction angiogram showing an aneurysm (arrow) of the descending genicular artery. The feeding vessel is a filamentous branch of the artery.
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Fig. 1-B Superselective angiogram made by means of the microcatheter (small arrows), with its tip (long large arrow) in the pre-aneurysmal segment of the artery, demonstrating extravasation of contrast medium (short large arrow).
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Fig. 1-C Angiogram showing two straight microcoils (curved arrow), implanted by means of the microcatheter (straight arrow).
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Discussion
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The causes of spontaneously recurrent hemarthrosis include hemophilia, iatrogenic coagulopathy, sickle-cell anemia, pigmented villonodular synovitis, myopathic arthropathy, synovial sarcoma, and, very rarely, hemangioma or aneurysm1,8. In the literature from 1945 to 1995, there are no reports of aneurysms—other than postoperative pseudoaneurysms7,9—as causes of hemarthrosis, as far as we know. In the patient described in the present report, magnetic resonance imaging and arthroscopy showed proliferative synovitis with hemorrhagic joint effusion and degenerative joint disease; however, the source of bleeding could not be identified arthroscopically. Pigmented villonodular synovitis and synovial hemangioma, which can cause signs and symptoms that are very similar to those seen in our patient, were ruled out on the basis of the histopathological findings and the results of the imaging1. Other diagnoses were excluded on the basis of the clinical and laboratory findings.
Because recurrent hemarthrosis persisted even after synovectomy, angiography was performed in our patient to assess the vascular anatomy. Catheter embolization of bleeding arteries or aneurysms through a percutaneous transfemoral approach has been performed successfully in various parts of the body2,11,12. Several studies have shown that endovascular occlusion can be used successfully to isolate peripheral aneurysms or pseudoaneurysms from the circulation while maintaining perfusion to the surrounding normal tissues. Several embolic agents, including detachable balloons, Gianturco steel coils, particulate agents, and minicoils, are available4-6,11,12. The selection of the embolic agent depends on the diameter of the feeding vessel. We know of only three reported cases in which embolization with Gianturco macrocoils or Gelfoam fragments was used for a pseudoaneurysm of the knee joint7,10.
The use of a microcatheter and microcoils for endovascular treatment of aneurysms of the knee joint has not been reported previously, to our knowledge. In our patient, the feeding artery of the aneurysm was a filamentous branch of the descending genicular artery, which could be negotiated only with a microcatheter system. Superselective angiography by means of the microcatheter showed acute bleeding of the aneurysm, as demonstrated by extravasation of contrast medium. To spare the weak wall of the aneurysm, intraaneurysmal embolization was not attempted. The tip of the microcatheter was placed a few millimeters proximal to the aneurysm in order to preserve even small branches to the surrounding tissue. Because of the very small diameter of the feeding vessel, 0.5-centimeter-long straight microcoils were implanted to occlude the feeding artery and to isolate the aneurysm from the arterial circulation. A number of studies have indicated that the use of microcoils is simpler and safer than the use of other embolic agents such as particles of Histoacryl. Those agents are associated with a risk of reflux into normal arterial branches, resulting in occlusion of vessels and tissue infarction3-6. With the invention of microcatheter systems (initially designed for interventional neuroradiological procedures), the potential use of embolization for the treatment of peripheral vascular abnormalities has been broadened considerably3-6.
Therapeutic embolization of small aneurysms with use of a microcatheter system is an effective, safe procedure for the treatment of spontaneous recurrent hemarthrosis when operative exploration fails or is contraindicated.
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Footnotes
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*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
Departments of Radiology (G. E. K., J. R., D. H. S., E. S., and K. A. H.) and Orthopaedic Surgery (J. P.), Karl-Franzens Medical School and University Hospital, Auenbruggerplatz 9, 8036 Graz, Austria.
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References
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Wallace, S.; Gianturco, C.; Anderson, J. H.; Goldstein, H. M.; Davis, L. J.; and Bree, R. L.: Therapeutic vascular occlusion utilizing steel coil technique: clinical applications. AJR: Am. J. Roentgenol., 127: 381-387, 1976.[Abstract]
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Introduction
Case Report