Imagine being told that walking is your medicine – the one thing that could save your leg from amputation – but every step feels like knives stabbing your knee. This impossible situation is reality for millions of Americans caught between peripheral artery disease (PAD - Poor leg circulation) and knee osteoarthritis.
For these patients, traditional knee replacement often isn’t an option due to other health issues. Instead, they’re caught in a devastating cycle: Can’t walk due to knee pain → Can’t improve circulation → Condition worsens → Face amputation.
But what if a 45-minute outpatient procedure could break this cycle? That’s the promise of Genicular Arterial Embolization (GAE), an innovation that’s offering new hope where traditional approaches fall short.
On a recent episode of The Heart of Innovation, I spoke with pioneers Dr. Osman Ahmed and Dr. Sid Rao, along with guest co-host Dr. Misha Ginsburg, about this game-changing approach.
What Is Genicular Arterial Embolization?
“Genicular artery embolization is treating or targeting the inflammation associated with arthritis,” Dr. Ahmed explained. “We take a very small catheter, put it into the artery, find where those areas of inflammation are, and block that blood flow.”
The genius of GAE lies in its precision. Using specialized imaging, doctors identify a telltale “blush” or “background haze” that reveals inflamed areas. They then inject microscopic particles that block only the abnormal blood vessels feeding the inflammation, while leaving healthy vessels intact.
“I’m not going to block your blood vessels off,” Dr. Rao emphasized. “When you were born, you were born with a few blood vessels. I’m going to try to restore you to that state.”
This challenges the long-held misconception that osteoarthritis is “non-inflammatory.” As Dr. Rao pointed out, “That’s why people take NSAIDs. That’s why they get steroid injections. What’s destroying the joint? It’s inflammation.”
Breaking the Walking Paradox
For patients with PAD – where narrowed arteries reduce blood flow to the limbs – walking is essential medicine. Exercise stimulates the growth of collateral vessels that bypass blockages. But knee arthritis makes this nearly impossible.
The consequences are severe. “It doesn’t matter why you can’t walk,” Dr. Rao explained, “you have a 50% higher chance of dying from cardiovascular disease and cancer if you don’t walk.”
Unlike knee replacement, which requires three months of rehabilitation to reach “60-70% of normal” function, GAE patients often walk the same day. Dr. Ginsburg’s father, treated by Dr. Ahmed, “walked with his dog the same day” after his procedure.
Who Benefits Most?
GAE isn’t competing with knee replacement, which remains the gold standard for severe osteoarthritis. Instead, it fills a critical treatment gap for:
Patients who aren’t surgical candidates
Those wanting to delay knee replacement
People who’ve failed conservative treatments
Patients with mild to moderate osteoarthritis
The prevalence of these conditions is staggering. While about 25 million Americans have coronary artery disease, approximately 33-34 million have knee arthritis. Include other forms of arthritis, and the number jumps to about 67 million.
“The disease burden is enormous,” Dr. Rao emphasized. “It’s about 10 times that of PAD.”
Breaking the “Lose Weight First” Cycle
During our aftershow, Justin Lesh from Patient Pro Marketing raised an important point about patients being told to simply lose weight before addressing their knee pain – creating another impossible cycle.
As Dr. Ginsburg explained: “They can’t lose weight because they can’t walk as their knees hurt, but they can’t get treatment for what prevents them from walking in the first place.”
This is particularly relevant for patients like Jose, who we’ll feature next week. At 600 pounds with both PAD and knee arthritis, doctors told him they couldn’t help until he lost weight – but how could he lose weight when he couldn’t walk?
GAE offers a potential way to break this cycle, allowing patients to become mobile enough to address other health challenges.
The Innovation Challenge: Creating Evidence While Helping Patients
Despite promising results, GAE isn’t yet widely available. Douglas, the head of our PAD Warrior Task Force, asked during our live session why more doctors don’t know about this procedure – especially in rural areas.
“I live in the country,” Douglas said. “How hard is it for y’all to get that information out there to those doctors if I walked into my doctor Monday morning and said what about this procedure and he goes, ‘I’ve never even heard of it?’”
Dr. Rao acknowledged this challenge: “There is no easy fix for this, Doug. But people like me who are passionate about this new field, I think they have to put windshield miles on. They got to go out and meet people and educate.”
Dr. Ginsburg added that we’re still building the evidence base: “It’s still not in the guidelines. It takes time to get incorporated.”
This creates a frustrating situation that Dr. Rao highlighted in our aftershow: “By the time the guidelines come out, they’re well behind where the evidence actually is.”
During our discussion, I raised a point about innovation resistance in medicine more broadly: “I just had this discussion on my LinkedIn page about doctors still using plain old balloon for PAD angioplasty and not accepting potentially better approaches. They say, ‘There’s not enough evidence.’”
“Isn’t medicine a practice?” I challenged. “Don’t you need to practice medicine to create evidence? Why aren’t these doctors engaging in creating evidence while patients are suffering?”
This tension – between waiting for perfect evidence and helping suffering patients today – defines the medical innovation landscape across specialties, including emerging treatments like GAE.
Temporary vs. Permanent Embolic Agents: The PAD Question
Dr. Nik Patel, who joined us later in the show, raised a critical technical question: “Do you tend to use more temporary agents when you have PAD patients for OA compared to permanent agents? Is it more or less safer in these patients?”
This question gets to the heart of a key decision in GAE – whether to use temporary embolic agents (like imipenem, which eventually dissolves) or permanent ones.
Dr. Rao explained that the choice isn’t determined solely by the presence of PAD, but rather by the angiographic appearance of the inflammation: “It’s really the angiographic blush that determines what you’re going to use.”
He noted that PAD can affect how the inflammation appears: “When the PAD does affect these distal portions or the end portions of the blood vessels, then your blush tends to be a little less profound. I probably will use a reversible or a temporary agent a lot more commonly.”
However, in certain scenarios – like persistent pain after knee replacement where patients have “humongous arteries” – permanent agents might be appropriate.
Dr. Ahmed agreed with this nuanced approach, adding that newer, safer embolics are changing the risk profile, making the procedure potentially safer for patients with PAD.
While severe PAD was once considered a contraindication for GAE, both doctors now believe it’s not an absolute barrier. Dr. Rao often treats both conditions in the same sitting, first addressing the PAD to “clear the path” to the genicular arteries.
Beyond Knees: The Future of Therapeutic Embolization
What’s particularly exciting about GAE is its potential to help with numerous painful conditions. By targeting inflammation, similar embolization approaches might help with:
Sports injuries
Patellar tendonitis
Plantar fasciitis
Achilles tendonitis
Frozen shoulder
Hip bursitis
Even back pain
Dr. Rao mentioned upcoming publication of six-month data on hand arthritis treatment showing “about 85% efficacy.” This hit close to home for me – as someone who developed osteoarthritis in my right hand following a COVID vaccine reaction, I might be exploring this option myself in the future.
Finding a Qualified Doctor
For those interested in GAE, finding a qualified specialist is crucial. Dr. Rao suggested searching for “genicular artery embolization” in your area. These procedures are typically performed by interventional radiologists or interventional cardiologists with specific training.
You can also contact the Global PAD Association’s leg saver hotline at 1-833-PAD-LEGS for help finding qualified specialists.
Medicare now covers GAE for beneficiaries who aren’t candidates for knee replacement, a significant step toward broader access.
The Bottom Line
What makes GAE so compelling isn’t just the procedure itself, but how it addresses the real-world challenges patients face – particularly those caught between conditions that create impossible treatment dilemmas.
For someone with PAD who also has knee arthritis, the inability to walk isn’t just about pain – it can literally be a matter of life and limb. As Dr. Rao put it, treating these patients is “a moral imperative.”
While GAE isn’t right for everyone, it represents an important advancement that offers hope where conventional options fail. That’s what innovation in healthcare should be – finding new paths forward for patients who’ve been told “there’s nothing more we can do.”
If knee pain is preventing your essential walking therapy, ask about GAE or seek a second opinion from a specialist who performs this procedure. Sometimes innovation is the bridge between impossible situations and new possibilities.
For more information on GAE or other innovative treatments, visit theheartofinnovation.org or contact the Global PAD Association’s leg saver hotline at 1-833-PAD-LEGS.
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