Haemorrhoid embolization

Hemorrhoid embolization, also known as hemorrhoidal artery embolization (HAE), is a minimally invasive procedure used to treat symptomatic haemorrhoids by reducing blood flow to the hemorrhoidal cushions, thereby shrinking them and relieving symptoms. Here’s an overview of how the procedure is typically performed:

Indications

1. Symptomatic Haemorrhoids: Patients with symptomatic internal haemorrhoids that cause pain, bleeding, itching, or prolapse.
2. Failed Conservative Treatment: When conservative measures such as dietary changes, fibre supplementation, topical medications, or lifestyle modifications fail to provide adequate symptom relief.
3. Avoiding Surgery: Patients who wish to avoid surgical interventions like hemorrhoidectomy due to concerns about pain, recovery time, or complications.

Pre-procedure Preparation

1. Patient Assessment:
   • Comprehensive evaluation of the patient’s medical history, symptoms, severity of haemorrhoids, response to previous treatments, and any contraindications to embolization.
   • Digital rectal examination and anoscopy may be performed to assess the extent and grade of haemorrhoids.
2. Imaging and Planning:
   • MRI or CT angiography may be used to visualise the hemorrhoidal arteries, identify the blood vessels supplying the haemorrhoids, and plan the embolization procedure.
   • Evaluation of the vascular anatomy, collateral circulation, and potential risks of embolization.
3. Informed Consent:
   • Explanation of the procedure, its purpose, potential risks (such as ischemia, infarction, or complications related to embolization), benefits, and alternatives. Informed consent is obtained.

Procedure Steps

1. Patient Positioning:
   • The patient is typically positioned on the angiography table, lying flat on their back or in a prone position, depending on the approach.
2. Local Anaesthesia:
   • Local anaesthesia is administered at the puncture site (usually the femoral artery or radial artery) for vascular access.
3. Catheterization:
   • A catheter is inserted into the femoral or radial artery and guided under fluoroscopic guidance or angiography to selectively access the hemorrhoidal arteries supplying the haemorrhoids.
   • Superselective catheterization may be performed to reach the specific branches of the superior rectal artery (a branch of the inferior mesenteric artery) involved in the haemorrhoids.
4. Angiography:
   • Contrast dye is injected through the catheter to visualise the hemorrhoidal arteries and identify the abnormal vessels supplying the haemorrhoids.
   • Selective angiography helps determine the precise location, extent, and nature of the hemorrhoidal blood supply.
5. Embolization:
   • Embolic agents, such as microspheres, coils, or sclerosing agents, are delivered through the catheter into the abnormal branches of the hemorrhoidal arteries to block blood flow and induce vessel occlusion.
   • The embolic material is carefully selected based on the size, location, and characteristics of the hemorrhoidal arteries to achieve effective hemostasis and shrinkage of haemorrhoids.
6. Post-Embolization Assessment:
   • Angiography or fluoroscopy may be repeated to confirm successful embolization, assess for any residual blood flow, and ensure preservation of normal blood supply to non-target areas.
   • Evaluation of collateral circulation and perfusion to adjacent tissues to avoid ischemic complications.
7. Closure and Recovery:
   • After completing the embolization, the catheter is removed, and pressure is applied to the puncture site to achieve hemostasis.
   • The patient is monitored in a recovery area for a few hours and then discharged with instructions for post-procedure care.

Post-procedure Care

1. Monitoring:
   • Vital signs, pain levels, bowel movements, and urinary function are monitored post-procedure.
   • Analgesics and stool softeners may be prescribed to manage pain and prevent constipation.
2. Dietary and Lifestyle Advice:
   • Patients are advised to follow a high-fibre diet, stay hydrated, avoid straining during bowel movements, and maintain good anal hygiene to promote healing and prevent recurrence.
3. Follow-up:
   • Follow-up appointments are scheduled to monitor the patient’s recovery, assess symptom improvement, and address any concerns or complications.

Benefits of Hemorrhoid Embolization

• Symptom Relief: Reduces symptoms such as pain, bleeding, itching, or prolapse associated with haemorrhoids.
• Minimally Invasive: Compared to surgical options like hemorrhoidectomy, embolization is minimally invasive with shorter recovery times, less pain, and fewer complications.
• Preservation of Anorectal Function: Targets the hemorrhoidal arteries while preserving normal blood supply to the rectum and anus, minimising the risk of complications such as faecal incontinence or anal stenosis.
• Suitable for High-Risk Patients: Provides a treatment option for patients who are not surgical candidates or prefer a less invasive approach.

Risks and Considerations

• Ischemia and Infarction: Risk of ischemia or infarction in non-target areas if embolic material inadvertently travels to normal tissues.
• Recurrence: While hemorrhoid embolization can provide long-term symptom relief, some patients may experience recurrence and require repeat procedures or additional treatments.
• Complications: Potential risks include anal pain, rectal bleeding, urinary retention, allergic reactions to contrast dye, infection, or rare complications such as rectal or pelvic abscesses.

Conclusion

Hemorrhoid embolization (HAE) is an effective and minimally invasive procedure for treating symptomatic haemorrhoids by reducing blood flow to the hemorrhoidal cushions. It offers symptom relief, shorter recovery times, and is suitable for high-risk patients or those who wish to avoid surgical interventions. Close monitoring, patient education, and follow-up care are essential to ensure optimal outcomes and address any complications or concerns.