Hemorrhoidal disease is a common benign anal disorder, with one of its primary clinical symptoms being rectal bleeding, which, in severe cases, can lead to anemia and significantly reduce a patient’s quality of life (QOL). The prevalence of hemorrhoidal disease ranges from 4% to 35% (1). It is characterized by the dilation of the hemorrhoidal venous plexus and requires clinical treatment in symptomatic patients (2). Internal hemorrhoids are classified into four stages according to the Goligher classification (3). Recent research indicates a trend toward minimally invasive treatment methods for hemorrhoids. The UK National Institute for Health and Care Excellence 2010 clinical guideline recommends hemorrhoidal artery ligation, based on the principle of vascular dissection, as a safe alternative to traditional hemorrhoidectomy (4). Additionally, Vidal et al. (5) were the first to propose embolization of the superior rectal artery (SRA) using coils, demonstrating that this technique is feasible, safe, and well-tolerated.

Superior rectal artery embolization (SRAE), also referred to as the emborrhoid technique, is a minimally invasive, image-guided procedure for treating hemorrhagic hemorrhoidal disease, with efficacy and recurrence rates comparable to those of stapled hemorrhoidopexy (6). Digital subtraction angiography (DSA) is globally recognized as the “gold standard” for vascular imaging, and using DSA for endovascular embolization offers significant advantages over Doppler-guided hemorrhoidal artery ligation. These advantages include clear visualization of the hemorrhoidal blood supply and its branches, precise localization, and permanent occlusion of the hemorrhoidal arteries using endovascular coils. This innovative approach provides a minimally invasive solution for managing hemorrhoid-related bleeding disorders (7, 8). Given its simplicity, SRAE can be broadly implemented in hospitals equipped with vascular intervention centers. This article reviews the efficacy and safety of superselective SRAE for the treatment of hemorrhoidal disease.

Understanding the anatomy of the anorectum and the vascular branching pattern is crucial for effectively managing rectal and hemorrhoidal bleeding disorders and providing optimal treatment options. Recent studies have shown that the development of hemorrhoidal disease is closely associated with hyperperfusion and neovascularization in the arteries supplying the affected area. Hemorrhoidal disease is characterized by localized masses formed from the pathological thickening, hypertrophy, or migration of the anal cushion (9). Internal hemorrhoids, in particular, result from the dilation and tortuosity of the complex venous plexus (10). The dilation of the internal hemorrhoidal venous plexus is primarily attributed to increased arterial blood flow from the SRA to the anal cushion (8). The development of the anal cushion is influenced by the arterial supply to the rectal corpus cavernosum (CCR) (11), which is mainly provided by the terminal branches of the SRA. The SRA, the primary artery supplying internal hemorrhoids, divides into three to five branches (12). Additionally, the lower rectum and anal canal receive blood from the middle rectal artery and the inferior rectal artery (IRA), which, along with the SRA, supply blood to the rectum. Embolizing the distal branches of the SRA with embolic agents effectively reduces blood flow to the anal cushion and controls hemorrhoidal bleeding. Even if all visible branches of the SRA are occluded, this procedure does not cause ischemic complications (8).

Angiography of the SRA is an advanced technique that enables precise assessment and localization of hemorrhoidal artery branches. It provides visualization throughout the entire process of endovascular interventional embolization, facilitating superselective embolization of the arteries supplying the hemorrhoidal region, and has demonstrated strong clinical efficacy (13, 14). This minimally invasive and painless procedure preserves normal anal anatomy, including the anal sphincter, and allows for rapid postoperative recovery (15), reduced length of hospitalization (16) making it a highly effective minimally invasive surgical option. Consequently, this technique has gained increasing recognition and widespread clinical use.

Various embolic agents are used in the SRAE technique, each yielding different results (13). The effectiveness of these agents depends on the extent of the blood supply area blocked and the degree of vessel occlusion. Commonly used embolic agents include spring coils, gelatin sponge particles, and polyvinyl alcohol (PVA) particles. Several studies (14, 16, 20) have demonstrated that spring coil embolization of the SRA is technically feasible, safe, and well-tolerated. In a prospective study by Tradi et al. (29), which compared multiple embolic agents in a healthy porcine model, microspheres were found to have fewer complications than liquid embolizers and were able to occlude farther than microcoils. The study concluded that microsphere embolic agents are more effective while maintaining the same safety profile as spring coils. Vidal et al. (5) emphasized that spring coil embolization should be as thorough as possible to prevent rebleeding. Zakharchenko et al. (22) reported that using a combination of pellets and coils for SRA embolization does not cause ischemic symptoms and is effective. The hemostasis rate for gelatin sponge pellet embolization was 84.4% (13), lower than that of 92.5% achieved with coils combined with PVA pellet embolization (22) but higher than that of 72% achieved with coil embolization alone (30). Conversely, another study (17) indicated no significant difference in clinical success rates between using pellets with spring coils versus spring coils alone, with a success rate of 68%. The use of alternative embolization materials, such as liquid embolic agents, may yield better outcomes. Huang et al. (31) conducted a study involving 27 patients with acute hemodynamic instability from lower gastrointestinal bleeding who underwent N-butyl cyanoacrylate (NBCA) microcatheterization. Bleeding stopped immediately in all patients. In four patients, recurrent bleeding was observed at different times after embolization. Kickuth el al (32). retrospectively reviewed 20 patients who had undergone diagnostic angiography and superselective microcatheter embolization to control acute LGI hemorrhage superselective microcatheter embolization to control acute LGI hemorrhage, 14 patients he last treatment was in a time span of 5 years. The results suggested that NBCA embolization could be a safe alternative for treating lower gastrointestinal bleeding, although further clinical trials are necessary.

Superselective SRAE is particularly well-suited for patients who decline traditional surgical options or for those with bleeding-dominant internal hemorrhoids of grades II and III who are unable to tolerate conventional surgery due to underlying conditions such as cardiovascular disease, blood disorders, diabetes mellitus, or inflammatory bowel disease. It is also an option for patients who have experienced a recurrence after previous surgery. Currently, no studies have identified specific contraindications for using this method to treat internal hemorrhoids. However, it is not recommended for patients with grade IV internal hemorrhoids, external hemorrhoids or thrombosed hemorrhoidal disease (14), or contraindications to interventional procedures.

Recent studies (12, 13) have shown that no significant complications have been observed following embolization, with no cases of local ischemia or inflammatory complications reported. Only a very small number of patients experienced mild pain or bleeding discomfort, which resolved on its own without the need for medication (17, 22). Sun et al. (9) found that among 23 patients with hemorrhagic internal hemorrhoids who underwent embolization of the IRA, 34.78% experienced a sense of urgency during the procedure. Additionally, embolization of the IRA branches was less effective for patients with contraindications to interventional procedures. When IRA branches were embolized simultaneously, the likelihood of acute, severe sensations increased, but these symptoms typically resolved within 1–3 days postoperatively. Furthermore, 17.4% of patients experienced minor bleeding within 3–6 days after the procedure. This technique also allows for repeated embolization, which may enhance treatment effectiveness for some patients (8, 17, 21).

Several clinical studies (33–38) have reported short-term efficacy rates of approximately 90% and long-term efficacy rates of 70–92% in small-scale studies, with follow-up periods of 6–46 months. Minimally invasive treatments for hemorrhoidal disease are becoming increasingly popular, and numerous studies have confirmed that the SRAE technique is both feasible and a safe alternative. Nevertheless, larger and more comprehensive studies with longer follow-up periods are necessary to better understand the efficacy, recurrence rates, and potential complications of the procedure. Given the high levels of patient satisfaction and improvement in hemorrhoidal symptoms, further prospective and multicenter studies are warranted.