Artery Embolization in the Treatment of Refractory Internal Hemorrhoids

Abstract Hemorrhoids are naturally occurring vascular cushions within the anal canal, but today have become synonymous with the pathology of symptomatic hemorrhoid disease. Internal hemorrhoids are classified using the Goligher system, and management traditionally begins with conservative and office-based therapies. Many patients, however, experience recurrent or refractory symptoms, and surgical hemorrhoidectomy carries risks of pain, complications, and prolonged recovery. Hemorrhoid artery embolization (HAE) has emerged as a minimally invasive, nonsurgical option for patients with bleeding internal hemorrhoids. Appropriate patient selection is crucial, with ideal candidates experiencing significant bleeding refractory to conservative medical therapy. A comprehensive evaluation, including colonoscopy and bleeding/prolapse grading, is required. HAE involves selective embolization of hypertrophied superior rectal artery branches supplying the corpus cavernosum recti, using microspheres, coils, or both. The endpoint is decreased hemorrhoidal blush without complete stasis, followed by durable occlusion with coils. Data from nearly 400 patients demonstrate technical success rates of 93-100% and clinical success rates of 63-94%. Outcomes include significant reductions in bleeding scores, hemorrhoid size, prolapse, and pain. Patient satisfaction is high, with rates up to 94%. Early randomized controlled trial data show efficacy comparable to hemorrhoidectomy, but with shorter recovery, reduced pain, and fewer complications. HAE is a safe and effective treatment for internal hemorrhoids, particularly in patients with refractory bleeding who are not ideal surgical candidates or wish to avoid surgery. Future studies should refine patient selection, standardize procedural technique, and establish long-term comparative outcomes.