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Lindquist J, Hart J, Marchak K, Bent Robinson E, Trivedi P. Imaging for Hemorrhoidal Disease: Navigating Rectal Artery Embolization from Planning to Follow-up. Semin Intervent Radiol 2024; 41:263-269. [PMID: 39165649 PMCID: PMC11333117 DOI: 10.1055/s-0044-1788056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2024]
Abstract
Hemorrhoid disease is very common, affecting greater than one-third of adults. Conservative management and several office-based procedures are useful in the treatment of internal hemorrhoids. Patients with refractory hemorrhoid disease have traditionally been treated with surgical hemorrhoidectomy. Rectal artery embolization has emerged as an alternative to surgical hemorrhoidectomy and has been shown to be safe and effective in case series and clinical trials completed over the past decade. Embolization has significantly less postprocedure pain when compared with surgical hemorrhoidectomy with similar outcomes. Pre- and postprocedure imaging are not routinely performed. Intraprocedural imaging consists of selective catheterization of the superior rectal arteries from the inferior mesenteric artery, and the middle rectal arteries from the internal iliac artery. The inferior rectal artery is seldom embolized due to the supply of the levator ani muscle and skin. To date, intermediate and large particles and fibered and nonfibered coils have been used successfully.
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Affiliation(s)
- Jonathan Lindquist
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - James Hart
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Katherine Marchak
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Eduardo Bent Robinson
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Premal Trivedi
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Colorado Anschutz Medical Center, Aurora, Colorado
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De Gregorio MA, Guirola JA, Serrano-Casorran C, Urbano J, Gutiérrez C, Gregorio A, Sierre S, Ciampi-Dopazo JJ, Bernal R, Gil I, De Blas I, Sánchez-Ballestín M, Millera A. Catheter-directed hemorrhoidal embolization for rectal bleeding due to hemorrhoids (Goligher grade I-III): prospective outcomes from a Spanish emborrhoid registry. Eur Radiol 2023; 33:8754-8763. [PMID: 37458757 DOI: 10.1007/s00330-023-09923-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 03/16/2023] [Accepted: 03/30/2023] [Indexed: 11/26/2023]
Abstract
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.
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Affiliation(s)
- Miguel A De Gregorio
- Interventional Radiology, Hospital Clínica Quiron, University of Zaragoza, Zaragoza, Spain
| | - Jose A Guirola
- GITMI, Hospital Clínico Universitario Lozano Blesa, University of Zaragoza, Zaragoza, Spain.
| | | | - José Urbano
- Interventional Radiology, Hospital Ramon y Cajal, GITMI, Madrid, Madrid, Spain
| | - Carolina Gutiérrez
- Interventional Radiology, Hospital de Denia Marina Salud, Alicante, Spain
| | - Abel Gregorio
- Interventional Radiology, Hospital de Denia Marina Salud, Alicante, Spain
| | - Sergio Sierre
- Interventional Radiology, Hospital Prof JP Garrahan, Buenos Aires, Argentina
| | | | - Roman Bernal
- GITMI, Interventional Radiology, Hospital Clínica Quiron, Zaragoza, Spain
| | - Ismael Gil
- Department of Surgery, Hospital Clinico Universitario Lozano Blesa, Zaragoza, Spain
| | | | | | - Alfonso Millera
- Department of Surgery, Hospital Clinico Universitario Lozano Blesa, Zaragoza, Spain
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Embolization of the Superior Rectal Arteries versus Closed Hemorrhoidectomy (Ferguson Technique) in the Treatment of Hemorrhoidal Disease: A Randomized Clinical Trial. J Vasc Interv Radiol 2023; 34:736-744.e1. [PMID: 36736690 DOI: 10.1016/j.jvir.2023.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 01/12/2023] [Accepted: 01/20/2023] [Indexed: 02/03/2023] Open
Abstract
PURPOSE To compare short-term and medium-term results of superior rectal artery embolization versus surgical hemorrhoidectomy in the treatment of patients with hemorrhoidal disease. MATERIAL AND METHODS This study was a prospective randomized clinical trial following 33 patients with symptomatic hemorrhoidal disease Grades 2 and 3 who were randomly assigned to 2 different groups: the superior rectal artery embolization group (n = 15) and Ferguson closed hemorrhoidectomy surgical group (n = 14). Four patients were excluded from the analysis. Pain using the visual analog scale and the use of analgesics were evaluated 3 times daily during the first 7 days of the postoperative period. Recurrent symptoms and satisfaction with treatment were also evaluated in the subsequent first, third, sixth, and twelfth months. RESULTS The mean pain during the first bowel movement after the procedure was 6.08 ± 4.41 in the surgery group and 0 in the embolization group (P = .001). The mean use of pain medication was higher in the surgery group (28.92 doses ± 15.78 vs 2.4 doses ± 5.21; P < .001). In the embolization group, the most prevalent preprocedural symptom was bleeding in 14 patients, with complete improvement in 12 (83.3%) patients. Mucus, skin tag, and pruritus were symptoms that showed little improvement in both groups. The frequency of symptoms (bleeding, pain, prolapse, and pruritus) was similar between the groups at 12 months (P = .691). No severe adverse events were observed in both groups. CONCLUSIONS Despite no difference in outcomes, embolization of the superior rectal arteries for the treatment of hemorrhoidal disease showed pain levels lower than those observed after surgical treatment.
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Prevalent Technique and Results of Hemorrhoidal Embolization. J Clin Med 2022; 11:jcm11226631. [PMID: 36431108 PMCID: PMC9698593 DOI: 10.3390/jcm11226631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 11/01/2022] [Accepted: 11/04/2022] [Indexed: 11/11/2022] Open
Abstract
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.
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Panneau J, Mege D, Di Biseglie M, Duclos J, Habert P, Bartoli A, Vidal V, Tradi F. Rectal Artery Embolization for Hemorrhoidal Disease: Anatomy, Evaluation, and Treatment Techniques. Radiographics 2022; 42:1829-1844. [DOI: 10.1148/rg.220014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
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The Emborrhoid Technique for Treatment of Bleeding Hemorrhoids in Patients with High Surgical Risk. J Clin Med 2022; 11:jcm11195533. [PMID: 36233395 PMCID: PMC9571675 DOI: 10.3390/jcm11195533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 09/14/2022] [Accepted: 09/19/2022] [Indexed: 02/01/2023] Open
Abstract
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.
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Safety and Effectiveness of a New Electrical Detachable Microcoil for Embolization of Hemorrhoidal Disease, November 2020–December 2021: Results of a Prospective Study. J Clin Med 2022; 11:jcm11113049. [PMID: 35683436 PMCID: PMC9181639 DOI: 10.3390/jcm11113049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 05/05/2022] [Accepted: 05/23/2022] [Indexed: 12/26/2022] Open
Abstract
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.
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Nguyenhuy M, Xu Y, Kok HK, Maingard J, Joglekar S, Jhamb A, Brooks M, Asadi H. Clinical Outcomes Following Rectal Artery Embolisation for the Treatment of Internal Haemorrhoids: A Systematic Review and Meta-Analysis. Cardiovasc Intervent Radiol 2022; 45:1351-1361. [PMID: 35551442 DOI: 10.1007/s00270-022-03154-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 04/09/2022] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
| | - Yifan Xu
- Peninsula Health, Frankston, VIC, 3199, Australia
| | - Hong Kuan Kok
- Interventional Radiology Service, Northern Health Radiology, Epping, VIC, 3076, Australia
| | - Julian Maingard
- Department of Interventional Radiology, Monash Health, Clayton, VIC, 3168, Australia
| | - Shantanu Joglekar
- Department of General Surgery, Eastern Health, Box Hill, VIC, 3128, Australia
| | - Ashu Jhamb
- Department of Interventional Radiology, St Vincent's Melbourne, Fitzroy, VIC, 3065, Australia
| | - Mark Brooks
- Department of Interventional Radiology, Austin Health, Heidelberg, VIC, Australia
| | - Hamed Asadi
- Department of Interventional Radiology, Monash Health, Clayton, VIC, 3168, Australia
- Department of Interventional Radiology, Austin Health, Heidelberg, VIC, Australia
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Tradi F, Panneau J, Brige P, Mege D, Habert P, Hak JF, Di Bisceglie M, Vidal V. Evaluation of Multiple Embolic Agents for Embolization of the Superior Rectal Artery in an Animal Model. Cardiovasc Intervent Radiol 2022; 45:510-519. [PMID: 34988702 DOI: 10.1007/s00270-021-03041-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 12/04/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To prospectively compare the safety of transcatheter embolization of superior rectal arteries in healthy pigs with multiple agents such as coils, spheres and liquids. MATERIALS AND METHODS Nine adult domestic pigs (three males, mean weight: 60 kg [50-70]) were randomly assigned to the embolization group: copolymer of ethylene vinyl alcohol (EVOH)-Onyx® (group 1, n = 3), microspheres 500 µ (group 2, n = 3), 2-mm micro-coils (group 3, n = 3). After a selective angiogram has been acquired, the embolic agent was infused at the distal part of rectal arteries. An angio-CT was performed before and after each embolization. After one week, angiography was repeated prior to euthanasia. At necropsy, the anorectal juncture was removed for histopathologic examination. RESULTS At necropsy, 100% of animals embolized with Onyx developed a significant necrosis zone of the distal part of the rectum. Histological examination revealed a mural infarction. For the micro-coil and microsphere groups, gross examination of the intestines did not reveal any evidence of ischaemia. The coils were found in the distal arterial vasculature of the meso-rectum, allowing a downstream revascularization by collaterals. The microspheres and onyx in the rectal wall, more distally. CONCLUSION Microspheres appear to induce fewer histologic complications than the liquid embolic agent and provide a more distal occlusion than micro-coils. These results suggest that, for superior rectal artery embolization, a super-selective embolization using spheres in human clinical conditions should be more effective and as safe as coil embolization. EVOH might be an unsafe embolization agent for haemorrhoids.
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Affiliation(s)
- Farouk Tradi
- Department of Interventional Radiology, Marseille Public University Hospital System (APHM), La Timone University Hospital, 264 Rue Saint Pierre, 13385, Marseille, Cedex 05, France.
- Experimental Interventional Imaging Laboratory (LIIE), UR 4264, Aix Marseille University, 27 boulevard Jean Moulin, 13005, Marseille, France.
| | - Julien Panneau
- Experimental Interventional Imaging Laboratory (LIIE), UR 4264, Aix Marseille University, 27 boulevard Jean Moulin, 13005, Marseille, France
| | - Pauline Brige
- Experimental Interventional Imaging Laboratory (LIIE), UR 4264, Aix Marseille University, 27 boulevard Jean Moulin, 13005, Marseille, France
| | - Diane Mege
- Department of General and Visceral Surgery, APHM, La Timone University Hospital, 264 Rue Saint Pierre, 13385, Marseille, Cedex 05, France
- Vascular Research Center of Marseille (VRCM), INSERM UMR-S 1076, Aix Marseille University, 27 Boulevard Jean Moulin 13005, Marseille, France
| | - Paul Habert
- Department of Interventional Radiology, Marseille Public University Hospital System (APHM), La Timone University Hospital, 264 Rue Saint Pierre, 13385, Marseille, Cedex 05, France
- Experimental Interventional Imaging Laboratory (LIIE), UR 4264, Aix Marseille University, 27 boulevard Jean Moulin, 13005, Marseille, France
| | - Jean Francois Hak
- Experimental Interventional Imaging Laboratory (LIIE), UR 4264, Aix Marseille University, 27 boulevard Jean Moulin, 13005, Marseille, France
| | - Mathieu Di Bisceglie
- Experimental Interventional Imaging Laboratory (LIIE), UR 4264, Aix Marseille University, 27 boulevard Jean Moulin, 13005, Marseille, France
| | - Vincent Vidal
- Department of Interventional Radiology, Marseille Public University Hospital System (APHM), La Timone University Hospital, 264 Rue Saint Pierre, 13385, Marseille, Cedex 05, France
- Experimental Interventional Imaging Laboratory (LIIE), UR 4264, Aix Marseille University, 27 boulevard Jean Moulin, 13005, Marseille, France
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Wang X, Sheng Y, Wang Z, Wang W, Xia F, Zhao M, Han X. Comparison of different embolic particles for superior rectal arterial embolization of chronic hemorrhoidal bleeding: gelfoam versus microparticle. BMC Gastroenterol 2021; 21:465. [PMID: 34906095 PMCID: PMC8670118 DOI: 10.1186/s12876-021-02046-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 11/30/2021] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- Xuemin Wang
- Department of Gastroenterology, Binzhou Medical University Hospital, Binzhou, Shandong, People's Republic of China, 256603
| | - Yuguo Sheng
- Department of Interventional Medicine and Vascular, Binzhou Medical University Hospital, No. 661 Huanghe 2nd Road, Binzhou, 256603, Shandong Province, People's Republic of China
| | - Zhu Wang
- Department of Interventional Medicine and Vascular, Binzhou Medical University Hospital, No. 661 Huanghe 2nd Road, Binzhou, 256603, Shandong Province, People's Republic of China
| | - Wenming Wang
- Department of Interventional Medicine and Vascular, Binzhou Medical University Hospital, No. 661 Huanghe 2nd Road, Binzhou, 256603, Shandong Province, People's Republic of China
| | - Fengfei Xia
- Department of Interventional Medicine and Vascular, Binzhou Peoples Hospital, Binzhou, Shandong, People's Republic of China, 256600
| | - Mengpeng Zhao
- Department of Interventional Medicine and Vascular, Binzhou Medical University Hospital, No. 661 Huanghe 2nd Road, Binzhou, 256603, Shandong Province, People's Republic of China
| | - Xinqiang Han
- Department of Interventional Medicine and Vascular, Binzhou Medical University Hospital, No. 661 Huanghe 2nd Road, Binzhou, 256603, Shandong Province, People's Republic of China.
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Abstract
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.
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Talaie R, Torkian P, Moghadam AD, Tradi F, Vidal V, Sapoval M, Golzarian J. Hemorrhoid embolization: A review of current evidences. Diagn Interv Imaging 2021; 103:3-11. [PMID: 34456172 DOI: 10.1016/j.diii.2021.07.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 07/04/2021] [Accepted: 07/07/2021] [Indexed: 12/21/2022]
Abstract
Hemorrhoids are local vascular structure dilations in the lower rectum, associated with morbidity and reduced quality of life. Endovascular coil or particle embolization of the superior rectal arteries, known as Emborrhoid technique, is a minimally invasive, image-guided therapy that targets the hemorrhoidal plexus and reduces hemorrhage. The purpose of this review was to analyze the results of published studies to determine the efficacy, clinical outcomes, and morbidities associated with the endovascular occlusion of hemorrhoidal arteries for the treatment of internal hemorrhoids. Current evidences suggest that hemorrhoids treated by Emborrhoid technique using microcoils, embolic particles or a combination is safe with no reported serious complications. Hemorrhoid embolization can preserve the anal tone without direct anorectal trauma and maintain the hemorrhoidal tissue in place requiring minimal local wound care on an outpatient basis. However, due to the paucity of high-quality trials, further research is warranted to evaluate its long-term outcomes, compare its efficacy with other treatment modalities, and fully assess its role in the treatment of hemorrhoid.
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Affiliation(s)
- Reza Talaie
- Vascular and Interventional Radiology, Department of Radiology, University of Minnesota, 55455 Minneapolis, USA.
| | - Pooya Torkian
- Vascular and Interventional Radiology, Department of Radiology, University of Minnesota, 55455 Minneapolis, USA
| | - Arash Dooghaie Moghadam
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany
| | - Farouk Tradi
- Interventional Radiology Section, Department of Medical Imaging, University Hospital Timone, AP-HM, 13005 Marseille, France
| | - Vincent Vidal
- Interventional Radiology Section, Department of Medical Imaging, University Hospital Timone, AP-HM, 13005 Marseille, France
| | - Marc Sapoval
- Vascular and Oncological Interventional Radiology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, 75015 Paris, France; Université de Paris, Faculté de Médecine, 75006 Paris, France
| | - Jafar Golzarian
- Vascular and Interventional Radiology, Department of Radiology, University of Minnesota, 55455 Minneapolis, USA
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Stecca T, Farneti F, Balestriero G, Barban M, Caratozzolo E, Zilio S, Massani M. Superior Rectal Artery Embolization for Symptomatic Grades 2 and 3 Hemorrhoidal Disease: 6-Month Follow-up among 43 Patients. J Vasc Interv Radiol 2021; 32:1348-1357. [PMID: 34166805 DOI: 10.1016/j.jvir.2021.06.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 05/21/2021] [Accepted: 06/14/2021] [Indexed: 12/16/2022] Open
Abstract
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.
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Affiliation(s)
- Tommaso Stecca
- UOC Prima Chirurgia, Dipartimento di Chirurgia, Azienda ULSS2 Marca Trevigiana, Treviso, Italy.
| | - Fabrizio Farneti
- Servizio di Radiologia Interventistica, Dipartimento di Radiologia, Azienda ULSS2 Marca Trevigiana, Treviso, Italy
| | - Giovanni Balestriero
- Servizio di Radiologia Interventistica, Dipartimento di Radiologia, Azienda ULSS2 Marca Trevigiana, Treviso, Italy
| | - Mario Barban
- UOC Prima Chirurgia, Dipartimento di Chirurgia, Azienda ULSS2 Marca Trevigiana, Treviso, Italy
| | - Ezio Caratozzolo
- UOC Prima Chirurgia, Dipartimento di Chirurgia, Azienda ULSS2 Marca Trevigiana, Treviso, Italy
| | - Silvia Zilio
- Dipartimento di Scienza Chirurgiche Oncologiche e Gastroenterologiche, Università di Padova, Padua, Italy
| | - Marco Massani
- UOC Prima Chirurgia, Dipartimento di Chirurgia, Azienda ULSS2 Marca Trevigiana, Treviso, Italy
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Makris GC, Thulasidasan N, Malietzis G, Kontovounisios C, Saibudeen A, Uberoi R, Diamantopoulos A, Sapoval M, Vidal V. Catheter-Directed Hemorrhoidal Dearterialization Technique for the Management of Hemorrhoids: A Meta-Analysis of the Clinical Evidence. J Vasc Interv Radiol 2021; 32:1119-1127. [PMID: 33971251 DOI: 10.1016/j.jvir.2021.03.548] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 03/25/2021] [Accepted: 03/31/2021] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Gregory C Makris
- Vascular and Interventional Radiology Department, Guy's and St Thomas' Hospital, NHS Foundation Trust, London, United Kingdom; Clinical Imaging Department, Alfa Institute of Biomedical Sciences, Athens, Greece.
| | - Narayan Thulasidasan
- Vascular and Interventional Radiology Department, Guy's and St Thomas' Hospital, NHS Foundation Trust, London, United Kingdom
| | - George Malietzis
- Department of Surgery and Cancer, Imperial College of London, London, United Kingdom
| | | | - Affan Saibudeen
- Clinical Imaging Department, Medical School, University of Oxford, Oxford, United Kingdom
| | - Raman Uberoi
- Vascular and Interventional Radiology Department, Oxford University Hospitals, NHS Foundation Trust, Oxford, United Kingdom
| | - Athanasios Diamantopoulos
- Vascular and Interventional Radiology Department, Guy's and St Thomas' Hospital, NHS Foundation Trust, London, United Kingdom
| | - Marc Sapoval
- Interventional Radiology Section, Department of Medical Imaging, University Hospital Timone, Marseille, France
| | - Vincent Vidal
- Vascular and Oncologic Interventional Radiology Department, Hôpital Européen Georges Pompidou, Paris, France
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Küçükay MB, Küçükay F. Superior Rectal Artery Embolization with Tris-Acryl Gelatin Microspheres: A Randomized Comparison of Particle Size. J Vasc Interv Radiol 2021; 32:819-825. [PMID: 33640516 DOI: 10.1016/j.jvir.2021.02.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 02/09/2021] [Accepted: 02/14/2021] [Indexed: 12/19/2022] Open
Abstract
PURPOSE To evaluate the safety and efficacy of superior rectal artery embolization (SRAE) with different-sized tris-acryl gelatin microspheres in symptomatic hemorrhoidal disease (HD). MATERIALS AND METHODS Forty-two patients (male, 30; female, 12; median age, 45 years) with symptomatic HD (2 grade I, 8 grade II, 17 grade III, and 15 grade IV) were divided into 3 experimental arms (500-700 μm, 700-900 μm, and 900-1,200 μm groups; each had 14 patients) in a prospective randomized style to perform SRAE. Follow-up was performed by rectoscopy, clinical examination, and questionnaires. The primary outcome measure was the clinical success rate at 12 months. Secondary outcome measures were technical success rate, recurrence rate, procedure-related mortality, procedure-related complications, and any outcome changes between particle sizes. RESULTS No procedure-related deaths or major morbidities were observed. There was a 54% minor complication rate (n = 23/42) in the treated zone: 45% sustained small superficial ulcerations (n = 19/42), 7% small rectosigmoid junction ulcerations (n = 3/42), and 2% small fibrotic scar tissue (n = 1/42). The clinical success rate was 93%. Of the groups, the best French bleeding score decrease was obtained in the 900-1,200 μm group. There were improvements in the quality of life score and visual analogue scale score after the SRAE procedure, although not in the Goligher score. No recurrent disease was observed. CONCLUSIONS SRAE with tris-acryl gelatin microspheres for symptomatic HD is a safe and efficient treatment, with results favoring the use of larger microspheres.
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Affiliation(s)
- Murat Bülent Küçükay
- Department of Internal Medicine, Lokman Hekim University Hospital, Sincan, Ankara, Turkey
| | - Fahrettin Küçükay
- Department of Interventional Radiology, Eskisehir Osmangazi University, Eskisehir, Turkey.
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Sirakaya M, O'Balogun A, Kassamali RH. Superior Rectal Artery Embolisation for Haemorrhoids: What Do We Know So Far? Cardiovasc Intervent Radiol 2021; 44:675-685. [PMID: 33388875 DOI: 10.1007/s00270-020-02733-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 11/27/2020] [Indexed: 01/02/2023]
Abstract
Haemorrhoids are abnormally enlarged anal cushions within the lower rectum. They are common, and have potential to significantly impact patients' quality of life. Superior rectal artery embolisation is a technique which has been discussed in the literature as far back as 40 years ago. More recently, there has been interest in the role of embolisation in the treatment for haemorrhoids, as an alternative to established minimally invasive and conventional surgical techniques. In this review, we discuss the current literature on the topic, with particular focus on technique, clinical outcomes and complications. Emerging procedural and technical considerations are discussed, with further review of the role of coil vs. particle embolisation.
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Affiliation(s)
| | | | - Rahil H Kassamali
- Department of Interventional Radiology, Hamad Medical Corporation, Doha, Qatar
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Mid-Term Results of Superior Rectal Artery and Coils for Hemorrhoidal Embolization with Particles Bleeding. Cardiovasc Intervent Radiol 2020; 43:1062-1069. [PMID: 32342155 DOI: 10.1007/s00270-020-02441-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 02/19/2020] [Indexed: 01/28/2023]
Abstract
OBJECTIVES To compare safety and clinical outcomes of embolization of the superior rectal arteries in patients with hemorrhoidal bleeding using particles and coils versus coils only. METHODS We retrospectively reviewed data for patients undergoing embolization for chronic hemorrhoidal bleeding from January 2014 to April 2017. Embolization was performed with coils alone or with particles and coils. Clinical scores (Paris bleeding severity score, Goligher classification and quality of life score) were obtained, and embolization was performed with microparticles (300-500 μm) followed by fibered pushable coils. Clinical success was defined as an improvement of > 2 points in the Paris bleeding severity score, without complications. Outcomes were compared between the two groups in a matched-pairs analysis (1:1 scenario), with patients embolized with particles and coils as the study group and patients embolized with coils alone as the control. RESULTS We treated 45 consecutive patients. After matched-pairs analysis, the final study population was 38 patients (19 study group and 19 controls). Clinical success did not differ significantly between the two populations: 63% for control group and 68% for the study group (p = 0.790). The median change in clinical score was - 3 [- 6; - 1] for the control group and - 3 [- 4; - 1] for the study group (p = 0.187). Grade 1 complications were reported in 15% of patients, with no major complications. CONCLUSIONS Embolization was feasible, with a technical success of 100% and no major complications. Clinical success was obtained in 66% in patients with no difference when using combined embolization with particles and coils versus coils only.
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Giurazza F, Corvino F, Cavaglià E, Silvestre M, Cangiano G, Amodio F, De Magistris G, Niola R. Emborrhoid in patients with portal hypertension and chronic hemorrhoidal bleeding: preliminary results in five cases with a new coiling release fashion “Spaghetti technique”. Radiol Med 2020; 125:1008-1011. [DOI: 10.1007/s11547-020-01194-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 04/02/2020] [Indexed: 02/07/2023]
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