Alex Poetipa on Collaborating on Outpatient Procedures

In this episode, host Dr. Aaron Fritts and interventional radiologist Dr. Alex Pavidapha give a primer on the emerging field of hemorrhoidal artery embolization (HAE), including patient presentations and referrals, treatment algorithms, procedural steps, and follow up care.

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SHOW NOTES

To start. Dr. Pavidapha describes the typical patient presenting with hemorrhoids. This is a prevalent condition that peaks at the ages of 45-65 and in the pregnant population. There are a variety of treatment options ranging from banding, hemorrhoidectomy, and cryotherapy; however, many patients may experience recurrence after these treatments or they may not be suitable candidates for surgery. Next, we discuss the current landscape of HAE. This treatment is a good option for patients who have failed other treatment options. The majority of Dr. Pavidapha’s patients come from referrals by gastroenterologists, although some come based on their own research on the web. It is important that all patients have a colonoscopy before HAE, to rule out the possibility of colon cancer. Additionally, a full history and rectal exam should be performed, since the choice to treat can be guided by the patient’s symptom severity and the degree of internal hemorrhoid prolapse. It is also advisable to identify extremely painful external hemorrhoids, since these can be addressed with conservative measures. Dr. Pavidapha notes that patient counseling is extremely important, since hemorrhoids have a high risk of recurrence and bowel habits play a large part in this. In terms of procedural risks, he counsels patients about standard risks of bleeding and infection, recurrence, mild pain in the few days after the procedure, and although it is rare, non-target embolization of skin or other organs.

During the procedure, Dr. Pavidapha prefers femoral access, since this is the easiest way to select the internal mesenteric artery. He does a base catheter run here to visualize the superior rectal arteries. These vessels are the most commonly involved in internal hemorrhoids, and if they are feeding the hemorrhoid, he will inject 500 micron beads and then follow with embolic coils. Next, he navigates through the internal iliac and pudendal arteries to arrive at the middle rectal arteries for another run. If they also supply the hemorrhoids, he will embolize them. The inferior rectal arteries are usually not involved in hemorrhoid formation, embolization of them carries a high risk of skin necrosis. Treatment of inferior rectal arteries is usually avoided. It is important to know typical anatomy very well so you can determine targets for embolization and recognize whether a patient has variant anatomy.

Finally, Dr. Pavidapha sees his patients for follow-up at 1 month, 4 months, and 1 year to check for symptomatic improvement, primarily decreased bleeding. If bleeding has worsened, the patient most likely needs a repeat procedure to identify new blood vessels supplying the hemorrhoid.

To IRs who are interested in starting an HAE service line, Dr. Pavidapha advises them to read the existing literature about hemorrhoids and HAE and be able to show clinical outcomes data to gastroenterologists. Overall, patients with recurrent hemorrhoids are typically an underserved population and have the potential to benefit from this novel procedure.

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RESOURCES

Ep. 319 - How to Collaborate with GI on a New Outpatient Service Line:

https://www.backtable.com/shows/vi/podcasts/319/how-to-collaborate-with-gi-on-a-new-outpatient-service-line

Outcomes of Hemorrhoidal Artery Embolization from a Multidisciplinary Outpatient Interventional Center:

https://pubmed.ncbi.nlm.nih.gov/36736822/

The STREAM Meeting:

​​https://www.thestreammeeting.com/