Superior Rectal Artery Embolisation for Haemorrhoids: What Do We Know So Far?

Superselective superior rectal artery embolization in the treatment of hemorrhoidal disease

Hemorrhoids are a prevalent and benign anal disorder for which minimally invasive treatments are increasingly preferred. The UK National Institute for Health and Care Excellence clinical guideline (2010) recommends hemorrhoidal artery ligation as a treatment option for hemorrhoidal disease. Superior rectal artery embolization (SRAE) leverages this principle by using digital subtraction angiography to precisely identify and superselectively embolize the arteries supplying the hemorrhoidal region. This procedure has demonstrated favorable clinical outcomes. SRAE is minimally invasive, painless, preserves the anal sphincter and normal anal anatomy, and offers a quick recovery, establishing it as an effective minimally invasive surgical option. As a result, this technique has gained increasing clinical recognition and adoption. This article examines the efficacy and safety of superselective SRAE for hemorrhoidal disease.

Hemorrhoidal disease: what role can rectal artery embolization play?

INTRODUCTION

Hemorrhoidal artery embolization, also known as Emborrhoid, has emerged in recent years as a minimally invasive treatment option for patients with recurrent and unresponsive to medical therapies hemorrhoidal bleeding symptoms. We present here an overview of the profile of rectal artery embolization based on the most relevant and recent literature.

METHODS

A comprehensive review of literature on Hemorrhoidal artery embolization, was conducted on PubMed-Medline. The most relevant literature was summarized narratively.

RESULTS

Current literature confirms the feasibility, efficacy and safety of rectal artery embolization for bleeding hemorrhoids. To date, the results of nearly 250 patients who have undergone hemorrhoid embolization have been published in several studies. All these authors have reported high immediate technical success, with also high clinical success, ranging from 63% to 94%, without major complications. Because of its beneficial safety profile, rectal artery embolization represents an attractive option for selected patients. In case of recurrence of bleeding it is possible to consider repeating the embolization procedure. Treatment failure may be due to the presence of anatomical variants such as dominant middle rectal arteries, which can be investigated and treated in the second session if necessary.

CONCLUSION

Rectal artery embolization represents a valuable addition to the therapeutic armamentarium of bleeding hemorrhoidal disease, if patients are selected appropriately.

Prevalent Technique and Results of Hemorrhoidal Embolization

Hemorrhoids are blood cushions located in the anus and lower rectum, acknowledged as a common cause of bleeding, which can reduce quality of life. The development of minimally invasive techniques such as endovascular embolization of superior rectal artery, "Emborrhoid technique", is an effective treatment, with no pain or ischemic complications, and allows quick patient recovery. Our purpose is to describe the general technique and discuss the results of the current literature.

Comparison of different embolic particles for superior rectal arterial embolization of chronic hemorrhoidal bleeding: gelfoam versus microparticle

BACKGROUND

Whether different embolic particles with comparable diameter lead to similar beneficial effects in endovascular embolization of hemorrhoidal disease remains to be established. We sought to evaluate the efficacy and safety of different types of agents for superior rectal arterial embolization (SRAE) in patients with bleeding hemorrhoids.

METHODS

Patients with recurrent episodes of internal hemorrhoidal bleeding and chronic anemia treated by SRAE in three tertiary hospitals between March 2017 and June 2020 were retrospectively evaluated. The patients were divided into two study groups based on the embolic materials: embolization with coils (2-3 mm) + gelfoam particles at 350-560 μm (Group A, n = 23), embolization with coils (2-3 mm) + microparticles at 300-500 μm (Group B, n = 18). The technical success, preliminary clinical efficacy (percentage of patients without hematochezia), postoperative complications and short-term follow-up outcomes were analysed.

RESULTS

A total of 41 patients (27 males) with symptomatic hemorrhoids were included in the study, mean age was 47 ± 12 years (range 25-72). 39% (16) patients with grade II hemorrhoids while 61% (25) patients with grade III. The technical success rate of the embolization procedure was 100%, and the preliminary clinical efficacy (87.0% vs 88.9%) showed no significant difference between the 2 groups (p = 0.098). No patients reported post-procedural and short-term serious complications, such as infection, intestinal ischemia or massive hemorrhage during the follow-up period (range 6-15 months).

CONCLUSIONS

Both gelfoam particles and microparticles with comparable diameter in the endovascular treatment of hemorrhoidal bleeding demonstrated similarly good short-term efficacy and safety profile.

Superior Rectal Artery Embolization for Symptomatic Grades 2 and 3 Hemorrhoidal Disease: 6-Month Follow-up among 43 Patients

PURPOSE

To assess the technical and clinical success rates of superior rectal artery embolization in the treatment of symptomatic Grades 2 and 3 hemorrhoidal disease.

MATERIALS AND METHODS

Since March 2019, 43 patients (24 men and 19 women; mean age, 52 years [18-77 years]) with symptomatic hemorrhoidal disease have been treated and completed the 6-month follow-up with anamnestic questionnaire and disease scores, including French bleeding, Goligher prolapse, visual analog scale for pain, and quality of life. Clinical success was assessed at 7 days, 1 month, and 6 months of follow-up by updating the clinical scores. Statistical analysis was performed using SPSS 25.0.

RESULTS

In all, 25 patients had Grade 2 prolapse and 18 patients had Grade 3 prolapse, with 96% and 77%, respectively, having bleeding as a symptom. All patients were discharged within 24 hours. The reduction in the French bleeding score (global and single entity) in Grade 3 prolapse was statistically significant (P = .001). Improvement in the quality of life was significant in both groups (P < .05). No serious complications were registered.

CONCLUSIONS

Hemorrhoidal embolization was a safe and effective technique in the treatment of symptomatic hemorrhoidal disease with minimal hospitalization, pain, and disruption of daily activities. It can be offered to patients unwilling to undergo a surgical procedure but can also be indicated in the emergency setting for patients on anticoagulant therapy or those unfit for surgery.