Superior rectal artery embolization is a minimally invasive endovascular technique that has a role in the management of acute lower gastrointestinal bleeding and as a potential option for the treatment of symptomatic hemorrhoidal disease, this article will focus on the latter.
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Procedure
Performed under local anesthesia, vascular access is gained via femoral artery puncture. Fluoroscopy and contrast angiography is utilized to map out vascular anatomy and to guide catheterization of the inferior mesenteric artery (IMA) with subsequent super-selective catheterization of the distal superior rectal artery. Embolization of the superior rectal artery and its branches is achieved with the use of embolic material such as gelatin sponge particles of 350-560 μm size and metallic coils of 2-3 mm size, or polyvinyl alcohol. The goal of the procedure is to reduce arterial blood flow to hemorrhoids. The inferior rectal artery branches remain intact, allowing for collateral blood flow and reduction of the risk of ischemic complications 1,2,4,6,7.
Outcomes
Current outcomes appear to be promising, with an effective reduction in hemorrhoidal per rectal bleeding and irritative symptoms, with high rates of patient satisfaction. There are no reported serious early complications related specifically to this procedure. Further comparative and longer-term studies are required to fully evaluate the role of this promising technique 1,2,4-6.
History and etymology
The first cases of superior rectal artery embolization for hemorrhoidal disease were published by Galkin in 1994. The technique re-emerged and gained further interest after a case series published by Vidal et al. in 2014 reported positive results 1-3,4,6. The United Kingdom's National Institute for Health and Care Excellence (NICE) currently (c. 2018) does not recommend the procedure for routine clinical use, only advising use in a research setting 5.