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Purpose Genicular artery embolization (GAE) has been proposed as a novel technique to treat painful synovitis related to osteoarthritis. An in-depth understanding of the genicular arterial anatomy is crucial to achieve technical success and avoid nontarget-related complications. Given the lack of previous angiographic description, the present study analyzes genicular arterial anatomy and proposes an angiographic classification system. Materials and Methods Angiographic findings from 41 GAEs performed during two US clinical trials from January 2017 to July 2019 were reviewed to analyze the anatomical details of the following vessels: descending genicular artery (DGA), medial superior genicular artery (MSGA), medial inferior genicular artery (MIGA), lateral superior genicular artery (LSGA), lateral inferior genicular artery (LIGA), and anterior tibial recurrent artery (ATRA). The diameter, angle of origin, and anastomotic pathways were recorded for each vessel. The branching patterns were classified as: medially, M1 (3/3 arteries present) vs M2 (2/3 arteries present); and laterally, L1 (3/3 arteries present) vs L2 (2/3 arteries present). Results A total of 91 genicular arteries were embolized: DGA (26.4%), MIGA (23.1%), MSGA (22.0%), LIGA (14.3%), and LSGA/ATRA (14.3%). The branching patterns were: medially = M1, 74.4% (n = 29), M2, 25.6% (n = 10); and laterally = L1, 94.9% (n = 37), L2, 5.1% (n = 2). A common origin for MSGA and LSGA was noted in 11 patients (28.2%). A direct DGA origin from the popliteal artery was reported in three patients (7.7%, n = 3). Conclusions A thorough understanding of the geniculate arterial anatomy is important for maximizing postprocedural pain reduction while minimizing complications, procedure time, and radiation exposure during GAE.

An 88-year-old catheter-dependent patient with peripheral vascular disease and benign prostatic hyperplasia was referred for prostatic artery embolization (PAE). Selective angiography of the left internal iliac artery (IIA) revealed a 2.5-cm aneurysm and a single artery comprising the anterior division of the IIA (inferior gluteal artery). No prostatic artery (PA) was identified on the left. Additional angiography of the left external iliac artery (EIA), right IIA, and right EIA did not demonstrate prostatic perfusion. The right profunda femoris artery was then selected given previously reported atherosclerotic collaterals, which revealed an ascending branch of the medial circumflex femoral artery coursing through the upper thigh into the pelvis and reconstituting the right anterior division of the IIA. A 2.4-French microcatheter (Terumo) and 0.018-inch wire (Transcend, Boston Scientific) were used to enter the pelvic vasculature, right PA was identified, and a 2-mm coil was used to perform embolization of a potential nontarget anterior division branch. Embolization of the right PA was then performed with 250-µm particulate and Gelfoam slurry. Two-week follow-up revealed spontaneous voiding and catheter independence.