Embolization of the superior rectal arteries for chronic bleeding due to hemorrhoidal disease Moussa N1 Sielezneff I3; De Parades V4; Tradi F2; Del Guidice C1; Fathallah N5; Amouyal G1; Pellerin O1; Vidal V2; Sapoval M1
1Interventional
radiology department - 5Gastro-enterology department Georges Pompidou European Hospital, Paris, France 2Interventional radiology department, 3 Visceral Surgery department - La Timone Hospital, Marseille, France 4Proctology department - Saint-Joseph Hospital, Léopold-Bellan Institute, Paris, France
Nadia Moussa, M.D. • No relevant financial relationship reported
HEMORRHOID: BACKGROUND The most common anorectal disease Prevalence of 4-35%
Main symptoms: chronic bleeding Poor quality of life
HEMORRHOID: BACKGROUND Hemorrhoidal disease is defined as enlargement and symptomatic prolapse of normal hemorrhoidal cushions.
Hemorrhoidal bleeding is related to excessive arterial inflow.
HEMORRHOID: BACKGROUND Hemorrhoids are not veins It’s a vascular plexus above the dentate line described as the "corpus cavernosum recti” Dentate line
Mechanical occluding functions rather than nutritional
Corpus cavernosum recti
ANATOMY *SUPERIOR RECTAL ARTERY: Main vascularization of hemorrhoidal plexus
* *
*
#
#
# PUDENDAL ARTERY: For the middle rectal artery, rarely involved in the hemorrhoidal process
HEMORRHOID: BACKGROUND Favorable results of DopplerGuided Hemorrhoidal Arteries Ligation (DG-HAL) contributed developping the “Emborrhoid technique” consisting in occluding the distal branches of the superior rectal (hemorrhoidal) arteries
We reported our favorable technical and clinical experience after a first feasibility report in 2014.
DG-HAL
PURPOSE
Assess the safety and efficacy of the embolization of superior rectal arteries in patients unfit for surgery.
METHODS AND MATERIALS: PATIENTS CHARACTERISTICS Between January 2014 and April 2015 Patients presenting chronic rectal bleeding related to hemorrhoidal disease Contraindication to conventional therapies Discussed in multidisciplinary team including a proctologist/surgeon and an interventional radiologist. 30 consecutive patients
Haemostasis disorders=
Previous surgery=
17 (57%)
7 (23%)
Both haemostasis disorders & previous surgery= 3 (10%)
Inflammatory disease of the colon= 3 (10%)
METHODS AND MATERIALS: CLINICAL ASSESSEMENT Before and after embolization: - Proctologic examination - Goligher’s classification scale (prolapse stage) - General symptom score - Quality Of Life score - Bleeding severity score (Table 1)
Frequency
Bleeding
Anemia
Never
0
≥ 1 per year
1
≥ 1 per months
2
≥ 1 per week
3
≥ 1 per day or per saddle
4
Never
0
At wiping
1
In the toilet
2
In underwear
3
Never
0
Without transfusion
1
With transfusion
2
Table 1: Bleeding severity score /9
METHODS AND MATERIALS: PROCEDURE DETAILS 5 Fr right femoral approach Local anaesthesia. Super-selective micro-coils embolization (pushable fibered 2-3 mm /0.018 coils - Tornado and Nester - Cook) with a micro catheter Occlusion of the distal branches of the superior rectal arteries
RESULTS Mean follow-up was 6 +/- 3.8 months 1 - 15months
30 patients
Total success rate 83 % (25 patients)
Failure* 17% (5 patients)
Immediate technical success was 93%. No complication, including no case of rectal ischemia
Primary success 70% (21 patients)
Secondary success 13% (4 patients)
The average number of embolized arteries per patients were 3, for an average of 7.6 coils per patient Primary success: Significant bleeding reduction after a single embolization session. Secondary sucess: Significant bleedind reduction after a second embolization. Failure: No significant bleeding reduction
*even after 3 embolization for one patient
RESULTS: SCORE EVOLUTIONS Before
After
Bleeding severity score
7 +/- 1.2
3.7 +/- 1.2
General symptom score
11 +/- 3.2
6.5 +/- 3.8
Quality Of Life
3.5 +/- 0.9
1.9 +/- 0.8
Goligher’s classification score
2.2 +/- 0.78
2.1 +/-0.69
Table 2: Clinical scores evolution
Significant decrease of clinical scores linked to bleeding No modification of the hemorrhoidal prolapse as classified by Goligher’s scale
DISCUSSION 83 % clinical success means that the technique might need improvement Moving toward particles + coils (See Dr Zakharchenko presentation) More evidence in more centers is needed
CONCLUSIONS Distal coil Embolization of superior rectal arteries for disabling chronic rectal bleeding is safe and effective in patients beyond proctologic resources This technique is a new field of peripheral embolization, relatively easy and could be offered in many vascular interventional radiology centers worldwide
REFERENCES 1. Vidal, V., Louis, G., Bartoli, J. M. & Sielezneff, I. Embolization of the hemorrhoidal arteries (the emborrhoid technique): a new concept and challenge for interventional radiology. Diagn. Interv. Imaging 95, 307–315 (2014). 2. Vidal, V., Sapoval, M., Sielezneff, Y., De Parades, V., Tradi, F., Louis, G., Bartoli, J.M., and Pellerin, O. (2014). Emborrhoid: A New Concept for the Treatment of Hemorrhoids with Arterial Embolization: The First 14 Cases. Cardiovasc Intervent Radiol. 3. Aigner, F. et al. The vascular nature of hemorrhoids. J. Gastrointest. Surg. Off. J. Soc. Surg. Aliment. Tract 10, 1044–1050 (2006). 4. Denoya, P., Tam, J. & Bergamaschi, R. Hemorrhoidal dearterialization with mucopexy versus hemorrhoidectomy: 3-year follow-up assessment of a randomized controlled trial. Tech. Coloproctology 18, 1081–1085 (2014). 5. Lohsiriwat, V. Hemorrhoids: from basic pathophysiology to clinical management. World J. Gastroenterol. WJG 18, 2009–2017 (2012). 6. Aigner, F. et al. The superior rectal artery and its branching pattern with regard to its clinical influence on ligation techniques for internal hemorrhoids. Am. J. Surg. 187, 102–108 (2004). 7. Ratto, C. & de Parades, V. Doppler-guided ligation of hemorrhoidal arteries with mucopexy: A technique for the future. J. Visc. Surg. (2014). doi:10.1016/j.jviscsurg.2014.08.003 8. Parnaud E. & Guntz M., Bidart J.M., Bernard A., Chome J. Considération sur la vascularisation normale de la sous muqueuse anale Rev Proct 1981 ; 1 : 44-54.
