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Friday, November 5, 2021

Catheter-Directed Hemorrhoidal Dearterialization Technique for the Management of Hemorrhoids: A Meta-Analysis of the Clinical Evidence

Catheter-Directed Hemorrhoidal Dearterialization Technique for the Management of Hemorrhoids: A Meta-Analysis of the Clinical Evidence


Clinical question
Is catheter-directed hemorrhoidal dearterialization (CDHD) a safe and effective treatment strategy for the management of hemorrhoidal bleeding?

Take away point
Preliminary evidence supports CDHD as an effective, safe treatment for grade I-III hemorrhoids and suggests embolization with a combination of coils and particles decreases rebleeding rates compared to coils alone.

Reference
Makris G,Thulasidasan N, Malietzis G, Kontovounisios C, Saibudeen A, Uberoi R, Diamantopoulos A, Sapoval M, Vidal V. Catheter-Directed Hemorrhoidal Dearterialization Technique for the Management of Hemorrhoids: A Meta-Analysis of the Clinical Evidence. J Vasc Interv Radiol. 2021;32(8):1119-1127. doi:10.1016/j.jvir.2020.03.548

Click here for abstract

Study design
Systematic review and meta-analysis.

Funding Source
No reported funding.

Setting
Studies selected from PubMed, Cochrane, and Scopus databases.

Figure


French bleeding score before and after rectal artery embolization.

Summary


Catheter-directed hemorrhoidal dearterialization (CDHD) for the treatment of hemorrhoidal bleeding is an emerging technique described in small studies and case reports as a minimally invasive alternative to surgical management. In an effort to evaluate the current evidence regarding the efficacy and safety of CDHD for rectal bleeding, the authors performed a systematic review and meta-analysis of 14 studies assessing CDHD.

Keyword searches via PubMed, Cochrane, and Scopus were performed to include clinical studies that evaluated patients with confirmed rectal bleeding secondary to hemorrhoids, treated patients with CDHD and reported clinical outcomes, and recruited five or more patients. Animal studies and case reports were excluded.

Data were extracted regarding study design, patient characteristics, disease burden, technique details, clinical follow up (including complications and symptom recurrence), and technical and clinical success rates. Statistical analyses were performed, primarily calculating and comparing means (range; standard deviation) via t tests.

A total of 14 studies met criteria (8 prospective, 6 retrospective) with a total of 362 patients. In all studies, the superior rectal artery (SRA) was embolized, most commonly using a combination of coils and other embolics (including particles, spheres, polyvinyl alcohol, gelatin sponge, and/or ethanol) versus coils alone.

There was no statistical difference among technical success rates, with an average of 97.8% (90-100%; 3.5%). Mean clinical success was 78.9% (66-96.9%; 10.6%). Four studies (n=98) reported bleeding score with a mean pre-embolization score of 6.78 (5.5-7.6; 0.90) and post-embolization score of 3.95 (2.8-5.0; 0.90) (p=.004). Average bleeding recurrence over the mean maximum follow-up of 12.1 months (1-28; 7.3), was 22.5% (5.4-44%). Of these, five studies (n=111) used coils alone for primarily grade II hemorrhoids with a mean rebleeding rate of 21.5% (0-44%; 18.2), one study used particles alone for primarily grade III hemorrhoids with a mean rebleeding rate of 29%, and four studies (n=108) used a combination of coils and particles for primarily grade III hemorrhoids with a mean rebleeding rate of 10.1% (5-15.7%; 4.8). Rebleed rates were statistically lower in the coils plus particles group compared to the coils alone group (p<.0001).

Reported major complications included one instance of IMA dissection that did not result in bowel ischemia, and one instance of puncture site arterial thrombosis and patient death.

Commentary


The authors perform a systematic review of 14 studies describing CDHD for the treatment of hemorrhoidal bleeding in a total of 362 patients. The aggregation of data in this meta-analysis offers more robust results compared to individual smaller studies, which more confidently supports the conclusion that CDHD is safe and effective in treating hemorrhoidal bleeding.

The authors discuss that there is a significant lack of comparative data between CDHD and surgery. Only one nonrandomized, non-blinded study attempted to directly compare stapled hemorrhoidectomy with coil and particle SRA embolization and reported significantly better pain and bleeding scores in the CDHD group (which included older patients with more comorbidities). They also discuss the lack of standardized technique, although highlight the statistically lower rebleed rates in studies that used a combination of coils and particles.

The mean follow-up period of 12.1 months likely underestimates the true complication and rebleeding rates. Additionally, publication bias against inconclusive or negative results and the absence of randomized, controlled trials introduce substantial confounds that may be amplified in subgroup analyses. Nonetheless, this meta-analysis is a valuable summarization of the existing primary data suggesting CDHD as a safe and effective treatment strategy for hemorrhoidal bleeding. Future studies should focus on direct comparison with surgical treatment to more confidently inform clinical decision-making.

Post Author
Catherine (Rin) Panick, MD
Resident Physician, Integrated Interventional Radiology
Dotter Interventional Institute
Oregon Health & Science University
@MdPanick

Edited and formatted by @NingchengLi

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