CLINICAL STUDY

Embolization of the Superior Rectal

Arteries versus Closed
Hemorrhoidectomy (Ferguson
Technique) in the Treatment of
Hemorrhoidal Disease: A Randomized
Clinical Trial
Priscila Mina Falsarella, MD, Felipe Nasser, PhD, Breno Boueri Affonso, MD,
Francisco Leonardo Galastri, PhD, Joaquim Mauricio da Motta-Leal-Filho, PhD,
Leonardo Guedes Moreira Valle, MD, Marcela Juliano Silva Cunha, MD,
Sergio Eduardo Alonso Araújo, PhD, Rodrigo Gobbo Garcia, PhD, and
Marcelo Katz, PhD

ABSTRACT

Purpose: To compare short-term and medium-term results of superior rectal artery embolization versus surgical hemor-
rhoidectomy in the treatment of patients with hemorrhoidal disease.
Material and Methods: This study was a prospective randomized clinical trial following 33 patients with symptomatic
hemorrhoidal disease Grades 2 and 3 who were randomly assigned to 2 different groups: the superior rectal artery
embolization group (n = 15) and Ferguson closed hemorrhoidectomy surgical group (n = 14). Four patients were excluded
from the analysis. Pain using the visual analog scale and the use of analgesics were evaluated 3 times daily during the first 7
days of the postoperative period. Recurrent symptoms and satisfaction with treatment were also evaluated in the subse-
quent first, third, sixth, and twelfth months.
Results: The mean pain during the first bowel movement after the procedure was 6.08 ± 4.41 in the surgery group and 0 in
the embolization group (P = .001). The mean use of pain medication was higher in the surgery group (28.92 doses ± 15.78 vs
2.4 doses ± 5.21; P < .001). In the embolization group, the most prevalent preprocedural symptom was bleeding in 14
patients, with complete improvement in 12 (83.3%) patients. Mucus, skin tag, and pruritus were symptoms that showed little
improvement in both groups. The frequency of symptoms (bleeding, pain, prolapse, and pruritus) was similar between the
groups at 12 months (P = .691). No severe adverse events were observed in both groups.
Conclusions: Despite no difference in outcomes, embolization of the superior rectal arteries for the treatment of hemor-
rhoidal disease showed pain levels lower than those observed after surgical treatment.

ABBREVIATIONS

AE = adverse event, VAS = visual analog scale

The exact prevalence of symptomatic hemorrhoidal disease years (2). Treatment varies according to the degree of the
is difficult to establish. Although many patients may disease and can be either be nonsurgical (such as pharma-
experience symptomatic hemorrhoids at some point in their cological, banding, and sclerotherapy) or surgical. Surgery
lives (1), the peak incidence occurs between 45 and 65 is indicated in approximately 10% of cases of hemorrhoids

Table E1 can be found by accessing the online version of this article on www. J Vasc Interv Radiol 2023; 34:736–744
jvir.org and selecting the Supplemental Material tab. https://doi.org/10.1016/j.jvir.2023.01.022
© SIR, 2023
Volume 34 Number 5 May 2023
RESEARCH HIGHLIGHTS
• This study was a prospective randomized clinical trial of
33 patients with symptomatic hemorrhoidal disease
Grades 2 and 3 treated with superior rectal artery
embolization (n = 15) or Ferguson closed hemor-
rhoidectomy (n = 14); 4 patients were excluded.
• Embolization was safe with no severe or life-threatening
adverse events, and showed levels of postoperative
pain lower than those observed after surgery (pain at
the first bowel movement, 0 vs 6.08 ± 4.41; P = .001).
• Symptom assessment in the 12-month postoperative
period showed similar results between the groups.
• Bleeding responded well in the embolization group
(resolution in 12 [83.3%] of 14 patients), but mucus
production, skin tag, and pruritis showed little
improvement in both groups.
(3). Surgical management is indicated in patients with
Grade 2 internal hemorrhoids whose symptoms persist even
with clinical measures, patients with Grades 3 and 4 internal
hemorrhoids, and patients with external hemorrhoids (4).
However, they are accompanied by severe pain, with a pain
score of approximately 6.1 ± 1.5 in the first 24 hours and a
pain score of approximately 4.5 ± 1.5 at the first bowel
movement (5).
Vidal et al (6) described the “emborrhoid” technique,
which consists of superselective embolization of branches
of the superior rectal artery. This technique was performed
in 14 patients with massive chronic rectal bleeding sec-
ondary to hemorrhoidal disease who were not candidates for
other nonsurgical or surgical therapies after a multidisci-
plinary discussion (7). Technical success was observed in
100% of cases with no pain or ischemic symptoms (7).
The objective of this study was to compare the post-
procedural pain, technical success, and clinical success in
patients undergoing superior rectal artery embolization for
Grades 2 and 3 internal hemorrhoidal disease with those in
patients undergoing surgical management using the Fergu-
son technique.
MATERIALS AND METHODS
This study was an open randomized clinical trial with 2
parallel arms: the superior rectal artery embolization arm
and Ferguson surgical technique arm (Fig 1). The study was
approved by the institutional review board of the Hospital
Israelita Albert Einstein and was registered in
ClinicalTrials.gov (NCT03402282).
Sample Size Calculation
The primary objective of the study was the comparison of
postprocedural pain between the groups. According to the
literature, the expected pain value given by the visual
analog scale (VAS) in the first 10 days after surgery was 4.2
737
STUDY DETAILS
Study type: Prospective, randomized, trial
Level of evidence: 2 (SIR-B)
in patients undergoing hemorrhoidectomy, with a variability
of 2.24 (SD = 2.24 points). In addition, anticipating that
embolization of the hemorrhoidal arteries would afford a
maximum of 2 points of pain during the same period (series
available until then indicated that patients did not experi-
ence pain during the postoperative [PO] period), with a
power of 80% and 95% confidence, the sample required to
perform the study was 20 patients in each group.
Population
The inclusion criteria were patients aged >18 years with
Grades 2 or 3 symptomatic internal hemorrhoidal disease
according to the Goligher internal hemorrhoid classification
(8) and indication for surgical treatment. Symptoms
included were persistent/recurrent bleeding of hemorrhoidal
origin for >3 months, at least 2 episodes of recurrent
hemorrhoidal thrombosis, pruritus, and mucus of hemor-
rhoidal origin. The exclusion criteria were Grade 4 internal
hemorrhoids, external hemorrhoids, contraindications to
angiography, and daily pain medicine use.
Patients were evaluated on an outpatient basis by a
medical team consisting of a proctologist and an interven-
tional radiologist (S.E.A.A., P.M.F.). Patients underwent a
complete preprocedural workup, including evaluation of
clinical symptoms and their duration, history of previous
treatments related to hemorrhoidal disease, use of chronic
medications, demographic data, a static and dynamic
inspection of the anal region, digital rectal examination, and
anoscopy. Bleeding was classified according to the Paris
bleeding severity score (9). After that, all patients under-
went colonoscopy. During the second clinical evaluation,
the patients were randomly assigned to the embolization
group or the surgery group.
Randomization
Patient were randomly assigned to 2 groups through a
standard permuted block randomization, with a fixed block
design of 4 individuals in each—2 patients from the surgery
group (S) and 2 patients from the embolization group (E)—
totalizing 6 possible blocks. Such randomization was cho-
sen to maintain the balance of the sample size between the
groups during the study and to reduce variability and
potential confusion between the 2 groups (10).
Embolization. Superior rectal artery embolization was
performed under local anesthesia and intravenous moderate
sedation at the Interventional Medicine Center of a qua-
ternary hospital using the following angiography units:
Allura Xper FD20 (Philips Medical Systems, Amsterdam,
738 Superior Rectal Artery Embolization: RCT
Figure 1. Study flowchart. PO7 = postoperative period day 7.
the Netherlands) and Allura Clarity Xper FD20/10 biplane
(Philips Medical Systems, Eindhoven, Netherlands). Embo-
lization of the rectal arteries was performed with 0.018-inch
fibered coils (Interlock IDC; Boston Scientific Marlborough,
Massachusetts) via puncture of the right common femoral
artery with a 5-F sheath, followed by catheterization of the
inferior mesenteric artery with a Simmons-2 5-F catheter
(Imager TM-II; Boston Scientific) (Fig 2a) and super
selective catheterization of the superior rectal artery and its
branches with an angled 150-cm microcatheter (Renegade
STC, Boston Scientific) and 0.016-inch shapeable tip 180-
cm microwire (Fathom; Boston Scientific) (Figs 2b, 3a–c).
The level of embolization was mid-third to the distal
superior rectal artery, and the end point was no further
opacification of the superior rectal arteries on postembolic
angiography. If opacification of the rectal artery persisted,
additional coils were added. After the procedure, manual
compression was performed for 30 minutes at the puncture
site according to hospital protocol, and the patients
remained recumbent and had their vital signs monitored for
6 hours. They were discharged after this period.
Surgery. Surgical procedures were performed according to
the Ferguson closed hemorrhoidectomy technique (11). The
patient was in the lithotomy position and under spinal
anesthesia and intravenous moderate sedation. An
hourglass-shaped incision (centered on the middle portion
Falsarella, et al JVIR
of the anoderm) was made, followed by hemorrhoid
dissection and vascular pedicle ligation.
Excision of the entire internal hemorrhoidal complex
with preservation of the internal and external anal sphincters
was performed. Hemostasis was achieved, and mucosal
defects were submitted to primary closure.
At the end of the procedure, patients were kept at rest in
postanesthetic recovery, and their vital signs were monitored.
After 6 hours, they were discharged home with analgesia.
Outcomes
Postprocedural pain was evaluated according to a ques-
tionnaire for pain assessment and medication use that
patients were instructed to fill out after being randomly
assigned. Upon hospital discharge, patients received the
questionnaire and were again instructed on how to fill it in
and describe the pain level during the first bowel movement
(regardless of how many days after the procedure). Spe-
cifically, patients assessed pain from 0 to 10 according to
VAS 3 times daily (morning, afternoon, and night) in the
first 7 days after treatment. If they experienced any pain and
pain medication was necessary, they were instructed to note
the medications and dosage used. At the 7-day return visit,
the patients delivered the completed questionnaire.
Clinical success was defined as improvement of previous
hemorrhoidal symptoms presented by patients before
Volume 34 Number 5 May 2023 739

Figure 2. Digital subtraction inferior mesenteric arteriography. (a) Selective angiogram of the inferior mesenteric artery (open
arrow) demonstrated the superior rectal artery (black arrowhead) and its right and left branches (black arrows), the sigmoid
artery (white arrowhead), and the left colic artery (open arrowhead). (b) Subselective angiogram of the superior rectal artery
(black arrow) demonstrated branching into the right anterior (white arrowhead), right posterior (open white arrowhead), left
anterior (black arrowhead), and left posterior (open black arrowhead) branches.

Figure 3. Angiography of the superior rectal artery. (a) Superselective angiogram of the left posterior branch of the superior
rectal artery (open black arrowhead) after coil embolization of the left anterior branch (black arrowhead). (b) Superselective
angiogram of the right superior rectal artery showed branching into anterior (white arrowhead) and posterior (open white
arrowhead) branches. (c) Completion angiogram of the superior rectal artery showed coil embolization of all branches.

treatment. Persistence of preprocedural hemorrhoidal
symptoms or return of symptoms (hemorrhoid bleeding,
prolapse, pruritus, mucus, and anal discomfort) and need for
retreatment were also evaluated.
Follow-up. Outpatient follow-up was performed at the
clinic for orificial diseases by a team of proctologists and
interventional radiologists during the post-treatment
period: at postoperative Days 7 and 30 for patients in the
surgery group and at postprocedural Days 2, 7, and 30 for
patients in the embolization group.
After Day 30 of followup, patients were followed
through telephone calls at 3, 6, and 12 months. Degree of
satisfaction with treatment was evaluated using a 4-point
scale (very satisfied, satisfied, a little satisfied, or unsatis-
fied) and either remission or permanence of the same pre-
operative symptoms in the PO period, including whether
there was any presence of new symptoms.
Procedure Safety. Adverse events (AEs) related to
rectal artery embolization were classified into mild, moder-
ate, severe, life-threating, and death according to the new
740 Superior Rectal Artery Embolization: RCT Falsarella, et al JVIR

Table 1. Demographic Distribution of Patients Included in the Table 2. Postprocedural Pain Assessment
Study
Day Group PGroup PDay PInteraction
Variable Group P value
Surgery (n = 13) Embolization (n = 15)
Surgery Embolization
Pain .001 .003 .561
Sex .464* D1 4.3 ± 3.8 0.5 ± 1.4
Female 7 (53.8) 6 (40) D3 4.6 ± 3.8 1.4 ± 2.7
Male 6 (46.2) 9 (60) D7 3.4 ± 3.4 0.5 ± 1.1
Pain 8 (61.5) 9 (60) .934*
Pruritus 3 (23.1) 5 (33.3) .686† Note–Generalized estimating equation with normal distribution and identity
Bleeding 8 (61.5) 14 (93.3) .069† link function assuming correlation matrix AR(1) between days.
D1 = Day 1; D2 = Day 2; D3 = Day 3.
Others 6 (46.2) 3 (20) .228†
Previous hemorrhoidal surgery 1 (7.7) 2 (13.3) >.999†
Age (y) 54.9 ± 14.2 54.6 ± 9.3 .958‡
BMI (kg/m ) 2
26.5 ± 5.2 26.4 ± 3.6 .935‡
Time of symptoms (y) 8.1 ± 10.7 7.8 ± 7.2 .555§

Note–Values are presented as n (%) or mean ± SD.

*χ2 test.
†Fisher exact test.
‡Student t test.
§Mann-Whitney test.

Society of Interventional Radiology classification of AEs

(12), and AEs related to closed hemorrhoidectomy were
classified into I–V according to Clavien-Dindo
classification (13).

Patients
A total of 33 patients were included in the study from
July 2018 to March 2020. There was no difference in
baseline features between the 2 patient cohorts (Table 1).
Of the 33 patients included, 29 underwent intervention
for the treatment of hemorrhoidal disease: 15 patients
underwent embolization of the superior rectal arteries
and 14 patients underwent surgical correction using the
Ferguson hemorrhoidectomy technique. One patient in
the embolization group revoked the consent for
participation, 3 patients in the surgery group missed the
follow-up before the intervention, and 1 patient in the
surgery group missed the follow-up at postoperative
Day 7.
Statistical Analysis
Pain score in the first 7 post-treatment days, use of
analgesics, and the amount of analgesics used were
described according to the groups using summary statis-
tics (mean, SD, median, and quartiles) and compared
between the groups using the generalized estimating
equation with normal distribution and identity link func-
tion assuming AR(1) correlation matrix between
moments. The outcomes, such as clinical success, main-
tenance of preprocedural hemorrhoidal symptoms or
return of symptoms (hemorrhoid bleeding, prolapse,
pruritus, mucus, and anal discomfort), and need for
retreatment, were described according to the groups using
absolute and relative frequencies. Comparison was per-
formed using the χ2 test.
Figure 4. Mean estimated pain during the first week.
RESULTS
The mean procedural time of embolization was 80 minutes
(median, 75 minutes; range, 40–120 minutes), and the mean
procedural time of the surgical treatment was 59 minutes
(median, 75 minutes; range, 46–78 minutes). The mean
time of ionizing radiation during the procedure was 31
minutes (median, 28 minutes; range, 14–60 minutes). The
mean volume of iodinated contrast medium used per pro-
cedure was 110 mL.
The number of branches of the superior rectal artery
embolized per patient ranged from 2 to 5 branches, with a
mean of 3.2 branches ± 0.96 (median, 3 branches). The
number of microcoils used per patient ranged from 3 to 9
(mean, 5.06 ± 1.94; median, 5), with a coil size of 2–5 mm.
Embolization of the superior rectal arteries was possible
in all patients (100% of cases). Among patients who
underwent embolization, no AEs classified as severe, life
threatening, or death were observed. Two early AEs were
observed after the procedure, 1 classified as mild and 1
classified as moderate. A patient in the embolization group
with benign prostatic hyperplasia who interrupted clinical
Volume 34 Number 5 May 2023 741

Table 3. Evaluation of Postprocedural Medication Use: Analgesic, Anti-Inflammatory and Opioid

Variable Group Mean SD Median Minimum Maximum n P value
Sum of medication Surgery 28.9 15.8 28.0 1 63 13 <.001
Embolization 2.4 5.2 0.0 0 16 15
Total 14.7 17.5 8.5 0 63 28
Sum of analgesic Surgery 16.3 6.2 19.0 1 21 13 <.001
Embolization 2.4 5.2 0.0 0 16 15
Total 8.9 9.0 5.5 0 21 28
Sum of NSAID Surgery 11.5 11.6 9.0 0 42 13 <.001
Embolization 0.0 0.0 0.0 0 0 15
Total 5.4 9.7 0.0 0 42 28
Sum of tramadol Surgery 1.1 3.6 0.0 0 13 13 .496
Embolization 0.0 0.0 0.0 0 0 15
Total 0.5 2.5 0.0 0 13 28

Note–Mann-Whitney test was used.

NSAID = nonsteroidal anti-inflammatory drugs.

outpatient dilation of the stenosis was performed, and the

patient remained without symptoms after subsequent eval-
uations, classified as Grade 2.

Pain Assessment, Medication Use, and

Figure 5. Comparison of medication use between the
groups. NSAID = nonsteroidal anti-inflammatory drug.
drug treatment for this condition 60 days before the pro-
cedure developed urinary retention. There was a need for
urinary catheterization in the immediate PO period. A few
days after restarting regular drug treatment for benign
prostatic hyperplasia, the urinary catheter was removed.
This event was classified as moderate and was attributed to
the evolution of underlying disease without adequate
treatment.
Another patient in the embolization group developed
ecchymosis at the puncture site 2 days after the procedure.
Ultrasonography of the inguinal region showed no evidence
of femoral artery pseudoaneurysm, and there was no need
for further intervention. This event was classified as mild.
Among the patients who underwent surgery, no Grade
3–5 complications were observed. One patient developed
edema and acute fissure in the anal region in the late
postoperative period, which improved with nonsurgical
treatment, classified as Grade 2. Six patients presented with
surgical wound dehiscence and mild secretion output,
which evolved with surgical wound healing with nonsur-
gical treatment, classified as Grade 1. One patient showed
symptoms of stenosis, skin tag, and fissure in the late
postoperative period. After improvement of the fissure,
Postprocedural Hemorrhoidal Symptoms
The mean pain during the first bowel movement after the
procedure was 6.08 ± 4.41 in the surgery group and 0 in the
embolization group (P = .001). Evaluation of the distribu-
tion of pain on Days 1, 3, and 7 revealed that the pain
observed in the embolization group was statistically lower
than that observed in the surgery group (Table 2; Fig 4).
The drugs used were common analgesics (dipyrone 500
mg or paracetamol 500 mg), anti-inflammatory (diclofenac
sodium 50 mg), and opioids (tramadol 50 mg). The mean
analgesic, anti-inflammatory, or opioid medication use was
28.9 medication doses ± 15.8 in the surgery group and 2.4
medication doses ± 5.2 in the embolization group (P <
.001). When the use of common analgesics was evaluated
(dipyrone or paracetamol), the mean was 16.3 doses ± 6.2
and 2.4 doses ± 5.2 in the surgery and embolization groups,
respectively (P < .001) (Table 3; Fig 5).
Treatment satisfaction was assessed at 30 days and 3, 6,
and 12 months after the procedure. In the embolization
group, satisfaction (very satisfied or satisfied) with the
treatment was 86.7% (P = .218) at 30 days, 86.7% (P =
.828) at 3 months, 71.5% (P = .253) at 6 months, and 61.6%
(P = .023) at 12 months. When compared with that in the
surgery group, treatment satisfaction did not show any
statistical difference at 30 days, 3 months, and 6 months (P
> .05); however, the degree of satisfaction with treatment
was higher in the surgery group (P = .023) at 12 months of
follow-up.
The presence of symptoms (hemorrhoid bleeding, pru-
ritus, prolapse, and anal discomfort) was evaluated at 6 and
12-months in both groups, showing no statistical difference
at 6 months (P = .695) and 12 months (P = .691) of follow-
up (Table 4). The most prevalent preprocedural symptom
742 Superior Rectal Artery Embolization: RCT Falsarella, et al JVIR

Table 4. Assessment of the Degree of Patient Satisfaction and

hematoma in the anal submucosa, fissure, abscess, anal ste-
Patients’ Symptoms after the Procedure nosis, and rectal perforation (4,15,16), which can occur in up
Variable Group Total P value
to 20% of patients depending on the series (7,17,18).
This study demonstrated 100% technical success for
Surgery Embolization
embolotherapy, similar to that observed in other series in the
Satisfaction at 30 d .218*
literature (6,7,9,19). The clinical success of embolization
Little satisfied 1 (7.7) 2 (13.3) 3 (10.7)
treatment at 12 months is 72% in the literature (7,9,20) and
Satisfied 9 (69.2) 4 (26.7) 13 (46.4)
Very satisfied 3 (23.1) 9 (60.0) 12 (42.9)
61.6% in this study. However, unlike other studies
Satisfaction at 3 mo .828*
(6,7,9,19,20) in which embolization was performed in
Little satisfied 0 (0.0) 2 (13.3) 2 (7.1) patients with severe chronic hemorrhoidal bleeding, this
Satisfied 8 (61.5) 6 (40.0) 14 (50.0) study included patients with mild and moderate bleeding in
Very satisfied 5 (38.5) 7 (46.7) 12 (42.9) association with other symptoms and patients with other
Satisfaction at 6 mo .253* symptoms resulting from hemorrhoidal disease and absence
Little satisfied 0 (0.0) 4 (28.6) 4 (14.8) of hemorrhoidal bleeding. In the surgery group, 3 (23%)
Satisfied 7 (53.8) 4 (28.6) 11 (40.7) patients presented with pruritis, 2 (15%) patients presented
Very satisfied 6 (46.2) 6 (42.9) 12 (44.4) with prolapse, and 2 (15%) patients presented with mucus,
Satisfaction at 1 y .023*
whereas in the embolization group, 5 (33%) patients pre-
Little satisfied 0 (0.0) 5 (38.5) 5 (19.2)
sented with pruritis, 2 (13%) patients presented with pro-
Satisfied 8 (61.5) 6 (46.2) 14 (53.8)
lapse, and 1 (7%) patient presented with mucus. All
Very satisfied 5 (38.5) 2 (15.4) 7 (26.9)
Symptoms at 6 mo .695†
symptoms of prolapse, pruritis, and mucus resolved in the
No 9 (69.2) 8 (57.1) 17 (63.0)
surgery group (although 1 patient developed new pruritis
Yes 4 (30.8) 6 (42.9) 10 (37.0) and 1 patient developed new prolapse), whereas only 3 of 7
Symptoms at 1 y .691‡ patients with any of these symptoms in the embolization
No 8 (61.5) 7 (53.8) 15 (57.7) group were asymptomatic at 12 months.
Yes 5 (38.5) 6 (46.2) 11 (42.3) In this study, 2 patients in the embolization group
Total 13 (100) 13 (100) 26 (100) crossed over and required surgery. One patient developed
an external hemorrhoidal crisis and underwent surgical
Note–Values are presented as n (%).
*Mann-Whitney test.
correction. Moreover, another patient presented with pro-
†Fisher exact test. lapse within 10 months of embolization and underwent
‡χ2 test. surgical correction. No patient from the surgery group
crossed over to the embolization group.
Pain represents the most feared symptom by patients
was bleeding in 14 patients, with complete improvement in after surgical hemorrhoidectomy (21). Senagore et al (17)
12 (83.3%) patients. A total of 2 patients experienced reported pain according to VAS in the first bowel movement
recurrence of bleeding similar to that before embolization. of 6.6 in patients undergoing Ferguson hemorrhoidectomy,
Mucus, skin tag, and pruritus were symptoms that showed similar to that described in this study. The other series
little improvement with the embolization and surgical (6,7,9,20) that describe the treatment of hemorrhoidal dis-
treatments (Table E1, available online on the article’s ease through the embolization of the superior rectal arteries
Supplemental Material page at www.jvir.org). reported the absence of pain at the first bowel movement,
similar to that observed in this study. This study showed
that rectal artery embolization offered similar clinical out-
DISCUSSION comes with reduced pain when compared with surgical
Approximately 10% of patients with hemorrhoidal disease hemorrhoidectomy.
will need surgical treatment (3). Despite its effectiveness, it Satisfaction with treatment in the surgery and emboli-
is an invasive procedure associated with intense post- zation groups did not show statistical difference at 6 months
operative pain and prolonged time to return to routine of follow-up (P = .253); however, at 1 year of follow-up,
activities (2,14). As a result, over the years, alternative treatment satisfaction was higher in the surgery group
techniques have been sought for treatment in cases without (P = .023). The return of symptoms related to hemorrhoidal
improvement with optimized nonsurgical treatment and in disease was also similar between the groups at 6 months
need of interventional treatment. (P = .695) and 12 months (P = .691) after surgery. This may
Alternative techniques for the surgical treatment of hem- be related to several factors causing increased abdominal
orrhoidal disease include anopexy with a circular stapler pressure, such as constipation, in addition to a low-fiber diet
(Longo technique) and the elective ligation of the hemor- (22,23). However, with 1 year of follow-up, satisfaction
rhoidal artery guided by Doppler ultrasound (4,15,16). Both with the treatment was lower in the embolization group,
techniques have less postoperative pain than that with the especially in patients with symptoms such as pruritus,
conventional surgical technique. However, these techniques mucus, and skin tag, which did not show significant
are not free from AEs, such as rectovaginal fistula, bleeding, improvement with the embolization treatment.
Volume 34 Number 5 May 2023
In this series, the most prevalent symptom before the
procedure was bleeding in 14 patients, which resolved in 12
(83.3%) patients, similar to other series in the literature
(7,9,20). On the contrary, mucus, skin tag, and pruritus
showed little improvement with the embolization treatment.
These symptoms were not evaluated in other studies
(9,20,24).
Recently, new embolization techniques have been
described, such as embolization with coils and particles (25)
and with particles only (26,27), with results of clinical
improvement and safety similar to those in studies with
coils alone (25). However, Eberspacher et al (28) reported a
case of a patient who underwent embolization of the
superior rectal arteries with particles, which resulted in
rectosigmoidal ischemia and severe sigmoid stenosis
requiring treatment with dilation.
In this study, no severe, life-threating AEs, such as
thrombosis of the femoral artery, rectal or anal mucosa
necrosis, and death, were observed (12). The most com-
mon complication in interventional and endovascular
procedures is puncture site hematoma, occurring in
approximately 7% of cases and generally requiring no
specific treatment (29). Urinary retention requiring
indwelling urinary catheters was observed in 1 (6.6%)
patient in the immediate postembolic period. The other
series report transient tenesmus (24,30) and do not report
urinary retention or other AEs (7,20).
Among the other limitations of the study, the corona-
virus disease 2019 pandemic led to the interruption of
outpatient clinics for benign proctology diseases at the
institution and the performance of elective surgeries. In
addition, owing to the characteristics of the proposed
treatments, it was not possible to ensure blinding and
concealment of patient allocation. The lack of long-term
data is another limitation. Finally, the power analysis of
this study was performed to determine a sample size for
the primary end point of pain and was not powered for the
other end points.
Despite hemorrhoidal symptom assessment during the
12-month PO period showing similar results between the
groups, superior rectal artery embolization showed levels of
PO pain lower than those observed with surgical treatment
with the Ferguson technique, and therefore, less analgesic
was used. In the embolization group, bleeding symptoms
completely improved in most patients. However, with 1
year of follow-up, satisfaction with the treatment was better
in the surgery group.
ACKNOWLEDGMENTS
This study was supported by grants and equipment from
Boston Scientific, Brazil.
AUTHOR INFORMATION
From the Center of Interventional Medicine, Hospital Israelita Albert Ein-
stein (P.M.F., F.N., B.B.A., F.L.G., J.M.d.M.-L.-F., L.G.M.V., M.J.S.C., R.G.G.),
743
Interventional Radiology, Hospital Municipal Vila Santa Catarina Dr Gilson de
Cassia Marques de Carvalho (P.M.F.), Colorectal Department (S.E.A.A.), and
Department of Cardiology (M.K.), Hospital Israelita Albert Einstein, São Paulo,
Brazil. Received June 12, 2022; final revision received January 12, 2023;
accepted January 20, 2023. Address correspondence to P.M.F., Center of
Interventional Medicine, Hospital Israelita Albert Einstein, Av. Albert Einstein,
627/701 - Morumbi, São Paulo - SP, 05652-900, Brazil; E-mail: primina@
gmail.com
M.K. has received personal consulting fees from AbbVie, Eli Lilly, Novo
Nordisk, Servier, EMS, and Brace Pharma. None of the other authors have
identified a conflict of interest.
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Table E1. Distribution of Symptoms before and after the Procedure in the Embolization Group
Patient Symptoms

Before the procedure 6 mo after the procedure 12 mo after the procedure

Embolization group
1 Bleeding No symptoms No symptoms
2 Pain and bleeding Prolapse Prolapse
3 Bleeding No symptoms No symptoms
4 Pain, bleeding, and pruritus No symptoms No symptoms
5 Pain, bleeding, and pruritus No symptoms No symptoms
6 Pain, bleeding, and prolapse No symptoms No symptoms
7 Bleeding and pruritus No symptoms Pruritus
8 Pain and bleeding No symptoms *
9 Pain and bleeding No symptoms No symptoms
10 Pain and bleeding † †
11 Pain and bleeding Pain No symptoms
12 Pain, bleeding, and pruritus Prolapse Bleeding, pruritus, and prolapse
13 Bleeding and mucus Mucus Mucus and hygiene difficulty
14 Pruritus and prolapse Prolapse Mucus
15 Bleeding Bleeding Bleeding
Surgery group
1 Pain, pruritus, and bleeding Pain No symptoms
2 Prolapse and skin tag Skin tag Pruritus
3 Bleeding No symptoms No symptoms
4 Pain and bleeding No symptoms No symptoms
5 Bleeding and prolapse No symptoms Pain
6 Pain, bleeding, and mucus Skin tag No symptoms
7 Pain and bleeding Bleeding Prolapse
8 Pain and pruritus No symptoms Bleeding
9 Pain No symptoms Anal disconfort
10 Prolapse and mucus No symptoms No symptoms
11 Bleeding and prolapse No symptoms No symptoms
12 Pain No symptoms No symptoms
13 Pain, pruritus, and bleeding No symptoms No symptoms

*The patient presented prolapse within 10 months of embolization and underwent surgical correction.
†The patient developed an external hemorrhoidal crisis and underwent surgical correction.