Genicular artery embolization for the treatment of knee osteoarthritis: a living systematic evidence synthesis (Update report)

Background: Genicular artery embolization has been recently adopted for the management of secondary pain due to inflammatory diseases of the locomotor apparatus and studies assessing its use in the treatment of knee osteoarthritis have been increasing their publication rate in recent years, hence, it constitutes a suitable target for a living evidence synthesis.Objective: This living evidence synthesis aims to provide a timely, rigorous, and continuously updated summary of the evidence available on the role of genicular artery embolization for the treatment of patients with chronic pain secondary to knee osteoarthritis.Methods.Design: We are conducting a Living Evidence Synthesis; this is the first update report since our previous baseline evidence synthesis report completed on February 2024. Based on its conclusions we activated the evidence monitoring to identify emerging studies addressing the safety and effectiveness of genicular artery embolization in patients with chronic pain secondary to knee osteoarthritis refractory to standard-of-care treatment—an issue that remains unresolved by the available evidence and requires a living evidence approach.Evidence identification, screening and selection: The initial evidence identification involved comprehensive searches in the Epistemonikos database to locate systematic reviews (SRs) and randomized controlled trials (RCTs) pertinent to our research question included in the Epistemonikos "Living Overview of Evidence" (L·OVE) platform. Searches were limited to studies published in English or Spanish. Two independent reviewers screened titles and abstracts against predefined inclusion criteria, focusing on moderate-to-high quality SRs and RCTs comparing GAE to conservative management or pharmacological therapy in patients with KO refractory to standard care. Full-text reviews were conducted for studies meeting the initial criteria. Post-baseline, the L·OVE platform's artificial intelligence algorithms provided real-time alerts for new studies with high relevance potential. Additionally, manual searches for ongoing studies were performed quarterly in the WHO International Clinical Trials Registry Platform and ClinicalTrials.gov. Monthly, two reviewers independently assessed new evidence, applying the same inclusion criteria.Synthesis and assessment: Two independent reviewers extracted data and assessed the risk of bias using appropriate tools. Critical or important outcome measures for decision-making included knee pain, overall functional improvement, changes in the need for pain medication, health-related quality of life, complications, and adverse events. Meta-analyses were conducted for the baseline synthesis, and the GRADE approach was applied to assess the certainty of the evidence for each outcome.During the living evidence monitoring phase, newly identified eligible studies underwent the same processes of data extraction, risk of bias assessment, meta-analysis, and evaluation of the certainty of the evidence promptly after inclusion.Results: The searches retrieved nine SRs and, subsequently, nine RCTs to the L·OVE platform. All SRs and seven RCTs were deemed potentially eligible and were assessed in full text. No high-quality SRs that could be included according to the pre-established selection criteria were found. Finally, we located and included two RCTs that evaluated the use of genicular artery embolization compared to conservative management or drug therapy in patients with chronic pain secondary to knee osteoarthritis refractory to standard-of-care. After 18 months of evidence monitoring, a newly available report was found and included in the current update.No significant effects were observed for pain, overall function, health-related quality of life, and changes in the need for pain medication. No serious complications or major adverse events were observed. The GRADE quality of evidence for the main outcomes was moderate to low.Conclusions: Overall, evidence of moderate-to-low certainty suggests that GAE may have little to no effect on knee pain when compared to standard treatment. Similarly, GAE likely results in little to no difference in overall functional improvement and HRQoL. The evidence also indicates that GAE likely does not significantly reduce or increase the need for pain medication or the occurrence of minor adverse events. However, long-term data on the durability of its effects, its comparative effectiveness with other treatment modalities, and its safety beyond the short-term are still lacking, which limits its current applicability in clinical practice.In accordance with our protocol and following this update, this question has been withdrawn from the living mode. This report constitutes the final update of this living systematic review.