The Emborrhoid technique for treatment of haemorrhoids

DOI: https://doi.org/10.58974/bjss/azbc053

Introduction

Haemorrhoids are one of the most common benign pathologies of the anorectal area, with a prevalence of 4.4-39% ¹. Haemorrhoids are equally distributed among women and men, being most common between 45 and 65 years ². Risk factors for haemorrhoids include chronic constipation, obesity, pregnancy, and old age ¹.

Recurrent rectal bleeding is the most common presentation. Other clinical presentations are prolapse and anal pruritus due to tissue exudation. In the advanced phases of disease, pain is frequently reported related to thrombosis, fissure formation or anal gland infection ³. The aforementioned symptoms lead to a reduction in quality of life. Haemorrhoids are classified in 4 grades, based on the degree of prolapse using the Goligher classification (Table 1) ⁴.

GRADE	DESCRIPTION
I	Bleeding, non-prolapsing haemorrhoids
II	Haemorrhoids prolapse on straining but reduce spontaneously
III	Haemorrhoids prolapse but require manual reduction
IV	Irreducible and fixed prolapsing haemorrhoids

Arterial vascularisation of the ano-rectal area comes from the superior haemorrhoidal artery, which arises from the inferior mesenteric artery (Figure 1), and by the middle and inferior haemorrhoidal arteries, which arise from the pudendal artery, a branch of the anterior division of the internal iliac artery (Figure 2). The superior rectal artery originates as a single trunk from the inferior mesenteric artery and divides into right and left branches, each of which will further branch into anterior and posterior branches (Figure 3) ¹.

Treatment options vary depending on the stage of haemorrhoidal disease. Conservative management (dietary measures and topical medications) represent the first stage treatment, useful in haemorrhoids graded I and II. However, 10% of patients may require office-based treatments such as rubber band ligation or injection sclerotherapy, or invasive treatments such as Milligan-Morgan open haemorrhoidectomy, and circular-stapled anopexy ^5,6.

Other less invasive surgical techniques have been developed that have become standard treatment options, like Doppler-guided haemorrhoidal ligation and Doppler-guided trans-anal haemorrhoidal dearterialization ^7,8. More recently, Vidal and colleagues reported a new endovascular technique for the treatment of chronic symptoms of haemorrhoidal disease, consisting of haemorrhoidal artery embolisation, the so-called Emborrhoid technique ^2,9. Emborrhoid is a minimally invasive procedure that has gained increasing popularity in the last few years, which is used to treat symptomatic haemorrhoids, for symptom control and to improve a patient’s quality of life ¹⁰.

Emborrhoid: when and why

The aim of this interventional radiology therapeutic procedure is to stop the blood flow in the haemorrhoidal artery, to reduce the load on the venous haemorrhoidal plexus (Figure 4), leading to a decrease in the haemorrhoid’s dimension and improvement of symptoms ⁹.

Emborrhoid is indicated in patients with grade II-IV symptomatic haemorrhoids in which conservative treatment has been ineffective ¹. It can also be performed in patients who do not wish to undergo surgical excision/ligation, or have contraindications to surgery, such as frailty or comorbidities. Emborrhoid can also be performed in patients with post-surgical recurrence ^11,12. Emborrhoid is contraindicated for grade IV haemorrhoids with non-reducible prolapse ¹³.

A team including interventional radiologists and proctologists is required in order to evaluate the indications for treatment. The patient’s goals are also of great importance, and clear information on the outcomes, as well as on procedural risks and benefits, must be supplied. Long-term  follow-up is warranted, to assess late complications and recurrence. Among the contraindications to the Emborrhoid procedure, the most important are anorectal cancer, grade IV haemorrhoids, active rectal infection, uncontrolled coagulopathy, known allergy to iodinated contrast medium, and pregnancy ¹.

How to do it – the technique

Emborrhoid is usually performed in a dedicated angiographic suite, with sterile equipment, under local anaesthesia or conscious sedation, using the radial or femoral artery for vascular access based on operator preference and the patient’s anatomical characteristics ¹⁴. Under fluoroscopic guidance, the interventional radiologist navigates a small catheter up to the inferior mesenteric artery; then a careful evaluation of the arterial supply, aberrant vascularisation, as well as anatomical variance is performed (Figures 5-6). Particular care must be taken in evaluating the need to embolize the middle and inferior haemorrhoidal arteries (Figure 7). Their vertical direction and tortuous appearance make the haemorrhoidal feeding arteries easily recognisable. At this point, using a microcatheter, a superselective catheterization of the superior haemorrhoidal artery and its four main branches is performed (Figures 8-9). Next, embolic agents, such as small metallic coils (2 or 3 mm in diameter) or polyvinyl microparticles, are deployed/injected in the target vessels to reduce or stop the blood flow (Figures 10-14) ¹⁵. The use of coils allows occlusion of the vessels, reducing the risk of intestinal ischaemia due to distal but not terminal embolization. There are no objective data on which is the best embolizing agent. According to the data reported in a recent prospective randomized study, large spheres (> 700 microns) administered through selective infusion could reduce the recurrence rate associated with the use of coils, without increasing the risks of ischaemia ¹⁶. Liquid embolic agents are not recommended for haemorrhoid embolization.

Emborrhoid can also be used as a minimally invasive treatment in controlling haemorrhoidal bleeding in frail patients with liver cirrhosis or portal hypertension, which can have variceal enlargement of the haemorrhoidal veins and a high risk of bleeding due to impaired coagulation and low platelet count ³.

Haemorrhoidal artery embolisation is usually well tolerated and takes a total of about 30-45 minutes. When compared to surgical ligation, Emborrhoid is less invasive, has less postoperative pain, lower risk of complications, faster ambulation and hospital discharge, and lower impact on a patient’s quality of life¹⁷. Moreover, the use of transradial artery access makes Emborrhoid an outpatient procedure, with no need for hospitalisation: we evaluated the feasibility of the Emborrhoid procedure in an outpatent setting, using a transradial approach, with good results in terms of patient safety, treatment effectiveness, and quality of life improvement ¹⁴.

Risks and complications

Even though Emborrhoid is a safe technique for treating symptomatic haemorrhoids without major complications, like every medical intervention, it carries the risk of potential complications. Among them, there are:

• during the procedure, anal symptoms such as tenesmus may occur, which resolve spontaneously;  
• post-procedural discomfort or pain in the pelvic area or around the anus, usually mild to moderate, which can be easily managed with analgesics;
• bleeding from the anorectal area or from the vascular access site, leading to haematoma or pseudoaneurysm formation, sometimes requiring additional endovascular or surgical treatment;
• infection of the access site, leading to fever;
• allergic reaction to the iodinated contrast medium or to the local anaesthetic drug;
• local ischaemia, leading to pain, bleeding, infection, ulceration, and necrosis of the ano-rectal mucosa and skin ¹⁸.

Prompt recognition and treatment of these complications is essential to prevent or limit permanent damage. It is mandatory for the procedure to be performed by an expert practitioner, in a safe angiographic suite setting, under close and continuous monitoring of vital signs, to minimise the risks and improve the outcomes. To date, no cases of sphincter dysfunction have been reported.

Despite haemorrhoidal artery embolisation being an effective treatment for reducing haemorrhoidal symptoms, there is always the possibility of recurrence months or even years after the first procedure. Luckily, Emborrhoid is a treatment that can be repeated. In redo procedures, a careful search and identification of the new source of arterial supply must be performed for the treatment to be effective. In most cases, treatment failure is due to blood flow redistribution and hypertrophy of the middle rectal artery, as observed in 24% of patients¹.

Outcomes and future perspectives

The success rates associated with this technique are very high, ranging from 93 to 100%, while the clinical success rates vary between 63 and 94%, without major complications. The results described in the current literature support the effectiveness and safety of embolisation of the rectal artery for chronic haemorrhoidal disease. Variations of the classical technique have been described, such as the “spaghetti technique” and techniques involving the use of resorbable or non-resorbable microparticles ^3,19,20. One ongoing randomized clinical trial (RCT) (NCT05697562) is evaluating the non-inferiority of the Emborrhoid technique compared to Doppler-guided haemorrhoidal artery ligation, and is expected to be completed by the end of 2026. As the technique application is relatively recent, clinical trials with prolonged follow-up are desirable, to establish the role of embolisation in haemorrhoidal pathology, and assisting in selecting patients who would benefit most from this interventional radiology procedure.