Superior rectal artery embolization for bleeding internal hemorrhoids

Catheter-directed hemorrhoidal embolization for rectal bleeding due to hemorrhoids (Goligher grade I-III): prospective outcomes from a Spanish emborrhoid registry

OBJECTIVES

To evaluate the safety and efficacy of catheter-directed hemorrhoidal embolization (CDHE) by microcoil embolization for rectal bleeding due to hemorrhoids classified as Goligher grade I-III.

METHODS

Eighty patients (62.5% males) with a mean age of 48 ± 9 years were recruited prospectively. All patients had symptomatic bleeding hemorrhoids. All patients were classified according to Goligher classification: grade I (13.7%), grade II (71.1%), grade III (15%), and no grade IV were recruited in this study. In all cases, microcoils were used to embolize the superior rectal artery(SRA), and microspheres if recurrence of bleeding occurred. Follow-up evaluation (1, 3, 6, and 12 months) included clinical examination and anoscopy. A questionnaire was conducted to determine improvement regarding bleeding, quality of life before, and the degree of patient satisfaction of each participant.

RESULTS

Technical success was achieved in 100% of the cases. Fifty-five (68.7%) participants had the absence of rectal bleeding after 12 months of embolization. VAS and QL improved 4 points and 1.5 respectively after embolization. A total of 25/80 (31.3%) had a recurrence in rectal bleeding. Seventeen (21.3%) patients underwent a second embolization, and four patients (5%) were treated with open hemorrhoidectomy. No major complications were observed. Sixteen participants had minor complications. Subjective post-treatment symptom and QL surveys showed significant differences from the baseline survey. Likewise, the degree of satisfaction in the telephone survey at 12 months revealed a high degree of patient satisfaction (8.3±1.1).

CONCLUSIONS

The present study demonstrates that CDHE is a feasible, well-tolerated, ambulatory, anal sphincter-sparing procedure for the treatment of internal hemorrhoids.

CLINICAL RELEVANCE STATEMENT

CDHE is a simple procedure, well tolerated and accepted by patients, that preserves the anal sphincter and presents few complications when metal devices or microspheres are used as embolic agents.

KEY POINTS

• The technical success rate of CDHE, defined as the closure of all the SRA in their distal segment, was achieved 100% of all patients. However, a second embolization treatment was required since 21.25% of the patients experienced rectal bleeding. • Overall, CDHE's safety profile is acceptable. After the procedure and 1 year of follow-up, no significant complications were observed. • Encouraging clinical outcomes have demonstrated CDHE in individuals with hemorrhoids and mild prolapse Goligher grades I-III with persistent rectal bleeding.

Outcomes of Hemorrhoidal Artery Embolization from a Multidisciplinary Outpatient Interventional Center

PURPOSE

To evaluate the safety and efficacy of outpatient transarterial embolization for symptomatic refractory internal hemorrhoids.

MATERIALS AND METHODS

Retrospective analysis of 134 patients who underwent hemorrhoidal artery embolization (HAE) for symptomatic internal hemorrhoids between August 2021 and June 2022 (76 men and 58 women) was performed. The mean age was 54.9 years, with a mean Goligher hemorrhoid grade (HG) of 2.1. Branches of the superior rectal artery (SRA) or middle rectal artery supplying the corpus cavernosum recti were embolized with both spherical particles and microcoils. Standard-of-care evaluations were performed at baseline and the 1 month follow-up, which included hemorrhoid-related pain (HRP) (0-10), hemorrhoid symptoms score (HSS) (5-20), quality of life (QoL) (0-4), French bleeding score (FBS) (0-9), and HG (0-4). Clinical success was defined as improvement of symptoms without additional treatment.

RESULTS

Embolization of at least 1 hemorrhoidal artery was achieved in 133 (99%) of the 134 patients. The mean number of SRA branches embolized per patient was 2.9 ± 1.0. Clinical success was seen in 93% (124 of 134) of patients at the 1-month follow-up, with 10 patients requiring repeat embolization. There were significant improvements in all mean outcomes at 1 month: HSS (11-7.8; P < .01), HRP (4.1-1.3; P < .01), QoL (2.2-0.8; P < .01), FBS (4.4-2.2; P < .01), and HG (2.3-1.2; P < .05). There were no severe adverse events.

CONCLUSIONS

HAE is a safe and effective outpatient treatment for refractory symptomatic internal hemorrhoids in the short term.

The Emborrhoid Technique for Treatment of Bleeding Hemorrhoids in Patients with High Surgical Risk

The Emborrhoid is an innovative non-surgical technique for the treatment of severe hemorrhoidal bleeding. Patient selection and the impact on quality of life have not been fully investigated. This prospective observational study aims to evaluate the clinical outcomes after Emborrhoid in patients with high surgical risk. All patients with high surgical risk and anemia due to hemorrhoids were enrolled. Clinical data and previous blood transfusions were collected. The Hemorrhoidal Disease Symptom Score and Short Health Scala were completed before the procedure and during the follow-up visits at 1, 6 and 12 months. Transfusions and serum hemoglobin level variations were registered. Perioperative complications and the recurrence of bleeding were assessed. Trans-radial/femoral embolization of superior rectal artery, and/or middle rectal artery was performed with Interlock and Detachable Embolization Coils. From September 2020 to February 2022, 21 patients underwent a superselective embolization of all branches of the superior rectal artery. The transradial approach was most frequently performed compared to transfemoral access. After the procedure, no signs of ischemia were identified; three minor complications were observed. The mean follow-up was 18.5 ± 6.0 months. At the last follow-up, the mean increase of hemoglobin for patients was 1.2 ± 1.6 g/dL. Three patients needed transfusions during follow-up for recurrent hemorrhoidal bleeding. The Hemorrhoidal Disease Symptom Score and Short Health Scala decreased from 11.1 ± 4.2 to 4.7 ± 4.6 (p < 0.0001) and from 18.8 ± 4.8 to 10.2 ± 4.9 (p < 0.0001), respectively. Patients who had given up on their daily activities due to anemia have returned to their previous lifestyle. Emborrhoid seems to be a safe and effective option for the treatment of bleeding hemorrhoids in frail patients. The low complication rate and the significant reduction of post-defecation bleeding episodes are related to the improvement of the hemorrhoidal symptoms and patients’ quality of life.

Safety and Effectiveness of a New Electrical Detachable Microcoil for Embolization of Hemorrhoidal Disease, November 2020–December 2021: Results of a Prospective Study

Purpose: The purpose of this study was to prospectively evaluate the efficacy and safety of a new, bare platinum, detachable microcoil as a metallic embolization agent in the treatment of hemorrhoidal disease. Material and Methods: This prospective single-center study evaluated a new, bare platinum, electrical, detachable microcoil (Prestige plus coil (Balt Montmorency France)) for use in vascular embolization in patients with hemorrhoidal disease. Between January 2020 and January 2021, 24 embolization procedures were performed in 21 patients (12 males, 9 females; mean age 44.3 ± 7.3). The inclusion criteria were: (a) participants with grade I, II and III hemorrhoidal disease on the Goligher classification; (b) patients older than 18 years of age with a score of greater than 4 on the French bleeding score (FBS) scale; (c) patients with scores greater than 2 on the scale of discomfort proposed by Tradi and Farfallah. (d) patients who underwent treatment that included the use of the new novel coil (Prestige plus coil (Balt)) as an embolic material. The exclusion criteria were participants who failed to provide informed consent and participants diagnosed with rectal bleeding due to other causes (cancer, fissures or others). Participants with severe renal insufficiency, non-correctable coagulation abnormalities and adverse reactions to the contrast medium not correctable with medication were also excluded. The symptoms, technical aspects, the transarterial approach, clinical and technical success complications and short-term outcomes were assessed. Results: Technical success was obtained in 100% of the cases. Seventeen (80.9%) patients experienced improvements in their hemorrhoidal disease. The VAS and QL scores improved by 4 and 1.5 points (81.2% and 87.5%), respectively, after embolization (pV: 0001). Three (14.2%) patients underwent a second embolization due to rebleeding. One patient (4.7%) underwent surgery. No major complications were observed. Three patients had minor complications. The assessment of subjective post-treatment symptoms and QL surveys showed significant differences from the baseline survey. Likewise, the measurement of the degree of satisfaction using a telephone survey at 12 months revealed a high degree of patient satisfaction over 10 points (mean 8.3 ± 1.1). Conclusions: The present study demonstrates that the use of the new, platinum, detachable, electrical microcoil is safe and well-tolerated in the treatment of hemorrhoidal disease. Key points: Catheter-directed hemorrhoidal dearterialization (CDHD) is the procedure of embolization with embolic agents for the treatment of internal hemorrhoids. CDHD is a simple and safe procedure that is accepted by patients and preserves the anal sphincter; it presents few complications when metal devices or microspheres are used as embolic agents. As the recommended embolization agent in treatments, the Prestige electrical, detachable coil is a safe, easy-to-use and effective arterial embolic device.

Clinical Outcomes Following Rectal Artery Embolisation for the Treatment of Internal Haemorrhoids: A Systematic Review and Meta-Analysis

OBJECTIVES

Haemorrhoidal disease (HD) is a common anorectal disorder which can substantially impair quality of life. Rectal artery embolisation (RAE) is a recently described technique for the management of HD, however, its clinical efficacy and safety are unclear at present. The objective of this systematic review and meta-analysis is to evaluate the clinical outcomes following RAE.

METHODS

The PubMed, MEDLINE and EMBASE databases were searched for studies specifying the management of haemorrhoids with RAE from January 2000 to October 2021. Primary outcomes were: French bleeding score (FBS), Visual analogue scale (VAS) for pain, general quality of life (QoL) score, and the Goligher prolapse score (GPS). Secondary outcomes were technical success, clinical success, postoperative complications, and technical outcomes. A random-effects meta-analysis was conducted. Study heterogeneity was evaluated, and sensitivity analysis was performed.

RESULTS

Thirteen eligible studies were identified including 381 patients. Rectal artery embolisation was associated with improvements in the FBS (mean difference [MD] 2.66; 95% confidence interval [CI] 2.10-3.23), VAS (MD 1.92; 95% CI 1.58-2.27) and QoL (MD 1.41; 95% CI 1.20-3.80), although the grade of internal haemerrhoids increased with uncertain clinical significance (MD 0.30; 95% CI 0.23-0.36). Technical success was achieved in almost all procedures (99%; 95% CI 94-100%) however clinical efficacy was lower (82%; 95% CI 73-89%). Procedural duration and radiation exposure were heterogeneous. No major complications occurred.

CONCLUSION

RAE demonstrates early clinical efficacy with low rates of peri-procedural complications or morbidity. RAE is a promising addition to the treatment options available for HD and warrants ongoing research.

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.

Annoyed with Haemorrhoids? Risks of the Emborrhoid Technique

Haemorrhoids, a common ailment afflicting mostly Western patients, can produce bothersome symptoms, in particular pain, pruritus, and bleeding. There is a wide choice of surgical treatment options available for haemorrhoids in patients that cannot be treated with medical therapy, such as those that are prolapsed. Many patients refuse surgery due to the fear of potential complications; to overcome this obstacle, novel alternative techniques have been developed in recent years that are focussed on ligation or occlusion of haemorrhoidal arterial blood flow. We describe a patient who developed recto-sigmoidal ischaemia after embolization of the haemorrhoidal arteries, known as the "emborrhoid" technique, with persistence of rectal bleeding and progressive rectal stenosis.

Outpatient Transradial Emborrhoid Technique: A Pilot Study

PURPOSE

To determine whether outpatient transradial emborrhoid technique can be performed safely and effectively in the treatment of symptomatic hemorrhoids.

MATERIALS AND METHODS

The transradial emborrhoid technique was used to treat 12 patients with symptomatic hemorrhoids in an outpatient setting during a 4-month period. After percutaneous catheterization of the left radial artery, a 5-Fr sheath was introduced to catheterize the inferior mesenteric artery and a microcatheter was advanced into the branches of the superior rectal artery for embolization with 0.018-inch detachable coils (Interlock and IDC-interlocking detachable coils). After embolization, the sheath was withdrawn and puncture site hemostasis was achieved using a wrist band. All patients were evaluated 6 h after the procedure to determine whether they meet the discharge criteria and were discharged the following day. The results of the emborrhoid treatment were assessed at the 4-week follow-up.

RESULTS

The emborrhoid technique was successful in all patients. There was no major complication associated with the procedure. All patients met the discharge criteria 6 h after the procedure. Reduction of local edema and of hemorrhoidal congestion was observed in all patients. At the follow-up visit, the mean Rorvik score (HDSS + SHS-HD) decreased from 31.50 (7.50) to 13.11 (8.33) (p < .001).

CONCLUSIONS

Transradial rectal artery embolization is a safe and effective treatment option for patients with chronic symptoms of hemorrhoid disease.

Catheter-Directed Hemorrhoidal Dearterialization Technique for the Management of Hemorrhoids: A Meta-Analysis of the Clinical Evidence

PURPOSE

To assess the efficacy and safety of a catheter-directed hemorrhoidal dearterialization technique for the management of hemorrhoidal bleeding.

MATERIALS AND METHODS

A systematic review and meta-analysis of pubmed, cochrane, and scopus databases was conducted according to the preferred reporting items for systematic reviews and meta-Analysis (PRISMA) guidelines. Clinical studies reporting on catheter-directed hemorrhoidal dearterialization for rectal bleeding were analyzed.

RESULTS

Fourteen studies (n = 362) were identified. The mean maximum follow-up duration was 12.1 months (SD, 7.31; range, 1-28; median, 12), and the mean length of hospital stay was 1.5 days (SD, 1.1; range, 0-2.5). The mean technical success was 97.8% (SD, 3.5), and the mean clinical success was 78.9% (SD, 10.5). A statistically significant reduction in the french bleeding score before and after embolization was noted (P = .004). In subgroup analysis, when the coils-only group was compared with the coils and particles group, the average rebleeding rate was 21.5% (n = 111; SD, 18.2; range, 0%-44%) versus 10.05% (N = 108; SD, 4.8; range, 5%-15.7%), respectively (P < .0001). No bowel ischemia/necrosis or anorectal complications were reported.

CONCLUSIONS

The current preliminary clinical evidence suggests that catheter-directed hemorrhoidal dearterialization is an effective and safe procedure for the treatment of hemorrhoidal bleeding. The standardization of the technique and the generation of higher level evidence will be required to compare this minimally invasive procedure with more invasive surgical options for patients with grades I-III hemorrhoids and chronic bleeding.