Multiple microaneurysms of the superior hemorrhoidal artery: unusual recurrent massive rectal bleeding: report of a case

Angiographic description of the superior rectal artery and its anatomical variations in patients undergoing embolization of the superior rectal arteries in hemorrhoidal disease treatment

BACKGROUND

Angiography of the superior rectal artery showed that its branches were divided into four main branches (two left and two right) in 46.8%; the second most frequent variation was one right and two left branches in 26.6%, followed by two branches to the right and one to the left in 20%; the most uncommon variations were one to the right and one to the left without further subdivision in 6.6%.

BACKGROUND

◼ The superior rectal artery, when it reaches the rectum, divides into two or more branches.

BACKGROUND

◼ Four patterns were observed in the angiographic anatomy of the superior rectal artery.

BACKGROUND

◼ Understanding the angiographic anatomy of the superior rectal artery is important to achieve optimal embolization results.

OBJECTIVE

To describe angiographic findings of the superior rectal artery, its branches, and anatomical variations in the hemorrhoidal plexus in patients undergoing rectal artery embolization for hemorrhoidal disease treatment.

METHODS

Angiographic findings of 15 patients were obtained from a single-center, prospective clinical study that compared superior rectal artery embolization with the Ferguson technique for hemorrhoidal disease between July 2018 and March 2020.

RESULTS

Angiography of the superior rectal artery showed that in seven patients (46.8%), its branches were divided into four main branches (two left and two right), while in four patients (26.6%), the branches divided into one right and two left branches. The most uncommon variation observed in three cases (20%) was the branches divided into two branches to the right and one to the left; no further subdivision into the main branches was observed in one case (6.6%).

CONCLUSION

Four patterns were observed in the angiographic anatomy of the superior rectal arteries. Knowledge of the angiographic anatomy of this region and its variations is essential to improve the effectiveness of superior rectal artery embolization.

REGISTRY OF CLINICAL TRIALS

NCT03402282.

Treatment of ruptured rectal artery aneurysm in a patient with neurofibromatosis

Background

Superior rectal artery (SRA) aneurysms are rare. Although melena is the most common symptom, it has not been observed in cases of aneurysms located in the SRA trunk. Here, we report a case of a ruptured SRA trunk aneurysm successfully treated with coil embolization. Including our case, three of the four reported cases of SRA trunk aneurysms were related to neurofibromatosis type 1 (NF1).

Case presentation

A 52-year-old woman with NF1 was referred to our hospital for the investigation of an abdominal mass with back pain. She had previously undergone a blood transfusion at another hospital for anemia without melena. Computed tomography angiography revealed a ruptured SRA trunk aneurysm measuring 3 cm in diameter and surrounded by a retroperitoneal hematoma. The aneurysm was isolated by embolizing the SRA trunk distally and proximally. Distal embolization was performed retrogradely from the internal iliac artery (IIA) via the middle rectal artery (MRA)-SRA anastomosis because the antegrade approach from the inferior mesenteric artery (IMA) failed. To our knowledge, this is the first case of successful coil embolization of an IMA branch through the IIA.

Conclusion

SRA trunk aneurysms are rare; however, they are frequently associated with NF1. Antegrade distal embolization beyond the aneurysm is sometimes difficult to achieve. In such cases, a retrograde approach via MRA-SRA anastomosis can be the choice for isolating SRA trunk aneurysms.

Lower Gastrointestinal Hemorrhage Caused by Superior Rectal Artery Pseudoaneurysm

Acute lower gastrointestinal (GI) bleeding is self-limiting and managed conservatively. Ongoing bleeding from a lower GI source and hemodynamic instability can create difficult diagnostic and therapeutic dilemmas. The severity of bleeding can necessitate emergent diagnostic and therapeutic interventions. Diverticulosis and angiodysplasias are the most common causes of massive lower GI hemorrhage. Other etiologies that can lead to life-threatening hemorrhage are important to recognize. We present a rare case of massive lower GI hemorrhage attributable to a superior rectal artery pseudoaneurysm. The absence of a preceding traumatic or iatrogenic cause distinguishes this case from other reports in the literature.

Post-Traumatic Retroperitoneal Hematoma Caused by Superior Rectal Artery Pseudoaneurysm

Patient: Male, 79-year-old

Final Diagnosis: Superior rectal artery pseudoaneurysm

Symptoms: Abdominal pain • gastrointestinal bleeding

Medication:—

Clinical Procedure: Embolization

Specialty: Radiology • Surgery

Pseudoaneurysm rupture causing hemoperitoneum following rectal impalement injury: A case report

INTRODUCTION

Although vascular anatomy of the rectum is complex, pseudoaneurysm followed by massive hemoperitoneum after rectal impalement injury is extremely rare.

CASE PRESENTATION

A 43-year-old man presented with abdominal distension. One day earlier, he had undergone sigmoid loop colostomy for rectal implement injury at a local hospital. After the operation, he had become hemodynamically unstable. Digital rectal examination showed a penny-sized anterior rectal wall defect 6 cm from the anal verge. Computed tomography (CT) revealed a hematoma (12 × 10 × 15 cm) with bleeding in the pelvic cavity and an adjacent pseudoaneurysm in the rectum. A large amount of blood and massive hematoma were evacuated by surgery. The Hartmann procedure was performed, but the pseudoaneurysm was not resected. On the 11th postoperative day, hemoglobin decreased (11.6 g/dL-7.9 g/dL), and CT revealed a recurrent hematoma (6.0 × 4.2 cm) in the pelvic cavity, with a residual pseudoaneurysm. Angiography failed to localize the pseudoaneurysm. Consequently, prophylactic embolization at the anterior branch of both the internal iliac arteries was performed. The subsequent hospitalization course was uneventful.

DISCUSSION

Rectal impalement injury may result in pseudoaneurysm of the rectal arteries. However, pseudoaneurysm rupture of the mid rectal artery, followed by massive hemoperitoneum, has not been reported in the English literature. From our experience, preoperative diagnosis of a pseudoaneurysm is crucial for definite surgical management. When surgical resection is indicated, it should include the underlying pseudoaneurysm.

CONCLUSION

Although pseudoaneurysm rupture causing hemoperitoneum after a rectal impalement injury is extremely rare, meticulous preoperative evaluation is necessary for correct management.

Embolization of the superior rectal arteries for chronic bleeding due to haemorrhoidal disease

AIM

The aim of this study was to assess the safety and efficacy of the emborrhoid technique (embolization of the superior haemorrhoidal arteries) in patients ineligible for surgery.

METHODS

Between January 2014 and April 2015, 30 consecutive patients (average age 58 years) suffering from disabling chronic bleeding due to haemorrhoidal disease and with a contraindication for surgery (n = 23) or with a failure of instrumental or surgical treatment (n = 7) underwent embolization. All cases were discussed at multidisciplinary meetings including a proctology specialist or a surgeon and an interventional radiologist. We performed super selective micro coil embolization (pushable 2-3 mm fibre coils) of the distal branches of the superior rectal arteries with a microcatheter, via a right femoral approach, under local anaesthesia. We assessed clinical outcome by evaluating bleeding and specific clinical scores relating to bleeding and changes in quality of life.

RESULTS

Immediate technical success, with no complication, was achieved in 93% of cases. A mean of 3.1 arteries per patient was embolized, with a mean of 7.6 coils per patient. Median follow-up was 5 months. Clinical score improvement was observed in 72%, in 17 patients after a single embolization session, and in four additional patients after a second embolization session. No improvement in bleeding was observed in eight patients (28%).

CONCLUSION

Distal coil embolization of the superior rectal arteries for disabling chronic bleeding due to haemorrhoidal disease is safe and effective in patients untreatable by surgery.

Safety and efficacy of superior rectal artery embolization with particles and metallic coils for the treatment of hemorrhoids (Emborrhoid technique)

PURPOSE

The purpose of this study was to comprehensively evaluate the short-term outcomes after percutaneous embolization of the superior rectal artery (SRA) with metallic coils and particles for the management of hemorrhoids.

MATERIALS AND METHODS

Forty patients (15 men, 25 women) with a mean age of 35±5 years (SD) (range: 25-65 years) were prospectively enrolled. All patients had symptomatic hemorrhoids. The distribution of internal hemorrhoids was as follows: grade I (n=6, 16%); grade II (n=28, 69%) and grade III (n=6; 15%). All patients had percutaneous embolization of the SRA with metallic coils and synthetic polyvinyl alcohol particles. Follow-up evaluation included clinical examination, rectoscopy, histopathological analysis of rectal mucosa, duplex Doppler blood flow quantification, electromyography, sphincterometry of the anal sphincter and analysis of patient satisfaction.

RESULTS

No immediate complications were observed and no patients had anal pain syndrome after embolization. Hemorrhoids showed a 43% size reduction after embolization (P<0.05). Taking into account the symptom resolutions such as irritation, discomfort, bloody discharge and pain, satisfaction was observed in 5/6 (83%) patients with grade III hemorrhoids and 32/34 patients (94%) with grades I-II hemorrhoids. One month after embolization, anal sphincter contractility normalized and no changes in anal electromyography were observed. Blood flow in the hemorrhoidal plexus dropped from 109±1.2ml/min/100g (SD) before treatment to 60.2±4.4ml/min/100g (SD) (P<0.05) the day after embolization and remained unchanged one month after embolization.

CONCLUSION

Our study demonstrates that embolization of SRA with particle and coils does not lead to ischemia in patients with symptomatic hemorrhoids. Short-term results with regard to symptom management for hemorrhoidal disease are very encouraging and should stimulate further prospective and multicenter studies.

Emborrhoid: a new concept for the treatment of hemorrhoids with arterial embolization: the first 14 cases

PURPOSE

The 'emborrhoid' technique consists of the embolization of the hemorrhoidal arteries. The endovascular arterial occlusion is performed using coils placed in the terminal branches of the superior rectal arteries. The emborrhoid technique has been modeled after elective transanal Doppler-guided hemorrhoidal artery ligation which has been shown to be effective in hemorrhoidal disease. We report the first 14 cases of our experience with emborrhoid technique.

MATERIALS AND METHODS

Fourteen patients with disabling chronic rectal bleeding were treated using the emborrhoid technique (3 women, 11 men). The stage of the hemorrhoidal disease was II (10 patients), III (3), and IV (1). This treatment was decided by a multidisciplinary team (proctologist, visceral surgeon, and radiologist). Seven patients underwent previous proctological surgery. Ten patients had coagulation disorders (anticoagulants or cirrhosis). Superior rectal arteries were embolized with pushable microcoils (0.018).

RESULTS

Technical success of the embolization procedure was 100 %. Clinical success at 1 month was 72 % (10/14). Of the 4 patients who experienced rebleeding, two underwent additional embolization of the posterior rectal arteries with success. No pain or ischemic complications were observed in 13 patients. One patient experienced a temporary painful and edematous, perianal reaction.

CONCLUSION

Our case studies suggest that coil embolization of the superior rectal arteries is technically feasible, safe and well tolerated. Additional studies are needed to evaluate the efficacy of this new 'emborrhoid' technique in the management of hemorrhoidal disease.

Traumatic Pseudoaneurysm of Superior Rectal Artery - an Unusual Cause of Massive Lower Gastrointestinal Bleed: A Case Report

Traumatic pseudoaneurysm of superior rectal artery is an unusual cause of massive lower gastrointestinal bleed. We are reporting the first case as we could not come across any similar report in the literature. Patient underwent exploratory laparotomy, diversion sigmoid loop colostomy, perineal wound debridement and antiseptic dressing for traumatic perineal wound. Patient had repeated episode of massive lower gastrointestinal bleeding and was diagnosed as a case of bleeding from superior rectal artery pseudoaneurysm which was managed by selective superior rectal artery embolization after failure of surgical treatment.

Embolization of a Hemorrhoid Following 18 Hours of Life-Threatening Bleeding

Hemorrhoids usually do not pose diagnostic difficulties and they rarely cause massive bleeding. We report a case of massive rectal bleeding over 18 h needing 22 U blood transfusion treated by superselective transcatheter coil embolization 12 h following operative treatment performed in a different hospital. Diagnostic angiography with a view to superselective embolization, following failure of sigmoidoscopy to localize and treat the cause of hemorrhage, might act as a life-saving treatment in massive rectal bleeding, obviating the need for repeated endoscopy or emergency surgery.