What is the proper technique for performing hemorrhoid embolization?

Hemorrhoid Embolization Technique

Hemorrhoid embolization (Emborrhoid technique) is a minimally invasive procedure that can be performed safely and effectively for symptomatic hemorrhoids, particularly for patients with grade II-III hemorrhoids who have failed conservative management or are poor candidates for surgical intervention. 1, 2

Patient Selection

• Best candidates:

  • Patients with grade II-III hemorrhoids 1
  • Patients with disabling chronic rectal bleeding 1
  • Patients with coagulation disorders or on anticoagulants 1
  • Patients who have failed conservative management 2

• Contraindications:

  • Patients with anorectal varices due to portal hypertension (requires different management) 3
  • Active infection

Pre-procedure Assessment

• Confirm diagnosis with anoscopy/proctoscopy to rule out other causes of rectal bleeding
• Assess coagulation parameters
• Consider temporary suspension of anticoagulants if possible

Procedural Technique

1. Access:

   • Transradial approach is preferred for outpatient setting 4
   • Alternative: Transfemoral approach
   • Use 5-Fr sheath for arterial access 4

2. Catheterization:

   • Catheterize the inferior mesenteric artery (IMA) 4
   • Advance a microcatheter into the branches of the superior rectal artery (SRA) 4
   • Perform selective angiography to identify hemorrhoidal arterial supply

3. Target Vessels:

   • Primary target: Terminal branches of superior rectal arteries 1
   • Secondary targets (if needed): Middle rectal arteries from internal iliac artery 5
   • Avoid embolization of inferior rectal artery due to supply to levator ani muscle and skin 5

4. Embolic Agents:

   • Preferred agents:
     • Pushable or detachable microcoils (0.018-inch) 1, 4
     • Alternative/additional: Polyvinyl alcohol (PVA) particles 6
     • Combination approach: Particles followed by coils for more complete embolization 2, 6

5. Embolization Endpoint:

   • Technical success: Complete occlusion of target vessels with cessation of flow to hemorrhoidal plexus 3
   • Avoid reflux of embolic material to non-target vessels

6. Hemostasis:

   • For transradial approach: Use wrist band for puncture site hemostasis 4
   • For transfemoral approach: Standard groin compression or closure device

Post-procedure Care

• Monitor vital signs for 6 hours post-procedure 4
• Discharge criteria: Stable vital signs, no access site complications, adequate pain control
• Prescribe:
  • Stool softeners
  • High-fiber diet and adequate hydration
  • Mild analgesics if needed (typically minimal pain)

Expected Outcomes and Follow-up

• Technical success rate: 100% 1, 4
• Clinical success rate: 72-94% 1, 4, 6
• Follow-up evaluation at 4 weeks to assess:
  • Symptom resolution
  • Hemorrhoid size reduction (expected ~43% reduction) 6
  • Blood flow reduction in hemorrhoidal plexus 6

Potential Complications

• Major complications are rare with proper technique 2
• Minor complications:
  • Temporary painful and edematous perianal reaction (rare) 1
  • Access site complications
  • Rebleeding (may require additional embolization of posterior rectal arteries) 1

Management of Treatment Failure

• For persistent bleeding after initial embolization:
  • Consider additional embolization of middle rectal arteries 1
  • If embolization fails, consider traditional hemorrhoid treatments:
    • Rubber band ligation for grade II hemorrhoids 7
    • Surgical hemorrhoidectomy for refractory cases 7

Advantages Over Other Techniques

• No direct anorectal trauma 2
• Preservation of anal sphincter tone 2
• Minimal post-procedure pain compared to surgical hemorrhoidectomy 5
• Suitable for patients with coagulation disorders 1
• Outpatient procedure with quick recovery 4

Hemorrhoid embolization represents an emerging minimally invasive alternative to traditional surgical approaches, with promising short-term outcomes for symptom management and quality of life improvement in patients with symptomatic hemorrhoids 2, 6.