Alex Pavidapha, MD
Vascular & Interventional Radiologist
Prostate Centers USA
Disclosure(s): No financial relationships to disclose
Hemorrhoid artery embolization (HAE) is an emerging and effective intervention to treat patients with symptomatic hemorrhoidal disease. Early reported studies indicated the presence of middle rectal supply might impact success rates. An in-depth understanding of the vascular anatomy is crucial to achieve technical success and avoid non-target related complications. The purpose of this study was to define hemorrhoidal arterial anatomy in a large cohort and propose an angiographic classification system.
Materials and Methods:
Angiographic findings from 176 HAEs performed between August 2021 and October 2022 were analyzed for the presence, course, and branching patterns of the superior rectal artery (SRA) and middle rectal artery (MRA) with a focus on supply to the hemorrhoidal cushions. Five unique branching patterns were identified based on arterial supply: Bilateral SRA only (type I), Unilateral SRA and Contralateral MRA (type II), Bilateral SRA and unilateral MRA collateral supply (type III), Bilateral SRA and Bilateral MRA collateral inflow (type IV), and Bilateral MRA supply only (type V).
A total of 176 patients were included in the analysis (average age: 54.5). The distribution of the arterial subtypes were as follows: Type I (72/176, 40.9%), Type II (8/176, 4.5%), Type III (66/176, 37.5%), Type IV (24/176, 13.6%), and Type V (6/176, 3.4%). An MRA supply was present in 104 out of 176 patients (59.1%). Of the 10 patients who initially failed HAE at 1 month-follow up, 9 patients were noted to have MRA supply requiring reintervention.
The arterial supply in hemorrhoidal disease can be complex, with numerous common variants. A thorough understanding of the vascular anatomy helps to identify the target vessels and potentially minimize non-target embolization.