Results of current literature, from almost 250 patients analysed in a review article from Talaie et al. (2021), support the feasibility, efficacy, and safety of SRA embolization for hemorrhoids using microcoils, embolic particles or a combination of both. Results of immediate technical success rates (defined as the occlusion of all visible branches of the SRA above the pubic symphysis with closure of the corpus cavernosum recti plexus) range between 93 and 100%, and clinical success rates (classified as improved post procedural scores or well tolerated rectal bleeding) range between 63% and 94%, with no major complications. Recurrence of bleeding is the main reason for clinical failure, in most cases due to significant anastomosis with the branches from the middle rectal artery (found in up to 24% of patients), which can be treated by second procedures as needed.

Patient selection is the most heterogeneous variable among published series on emborrhoid technique, and this likely reflects the lack of well-established clinical indications and the uncertainty about which patients would benefit more from this procedure.

In a case report by Maiettini et al. (2018), embolization of the right terminal branch of the SRA was performed on a patient with rectal varices from portal hypertension and active hemorrhoidal bleeding on the right side, as a bridge treatment to TIPS placement. On retrograde phlebography of the superior hemorrhoidal veins after TIPS, there was a clear asymmetry on the rectal venous plexus congestion, substantially reduced on the (previously embolized) right side. These findings argue against a complete dissociation between hemorrhoidal disease and the increased downstream venous pressure on patients with rectal varices.

In a prospective study by Giurazza et al. (2020), five patients with chronic anaemia due to internal hemorrhoidal bleeding and cirrhotic portal hypertension were treated with the emborrhoid technique. The authors found it to be a safe and effective procedure, with clinical improvement in four out of the five patients, and no complications, at 3-month follow-up.

Hemorrhoidal disease and rectal varices may co-exist, and in most cases where portal hypertension is secondary to liver cirrhosis, there will be an increased risk of bleeding resultant from associated coagulopathy. Moreover, these patients frequently have multiple comorbidities and are not optimal candidates for conventional surgery.

Given the complex and not fully understood pathogenesis of hemorrhoidal bleeding in such patients with overlapping disease, and the safeness of the emborrhoid technique with no major complications reported in the literature, the authors argue that it would be pertinent to investigate the effectiveness of this procedure in patients with portal hypertension and refractory rectal bleeding.

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