Hemorrhoids are one of the most common conditions in the United States—and one of the least discussed. An estimated 50% of adults will experience symptomatic hemorrhoids at some point in their lives, and for those whose symptoms progress beyond what fiber supplements and topical treatments can manage, the traditional next step has been surgery: hemorrhoidectomy.
Hemorrhoidectomy works. It has decades of data behind it. But it also comes with something that patients dread: a notoriously painful recovery. For many patients, fear of that recovery is the single biggest reason they delay treatment—sometimes for years.
Hemorrhoidal artery embolization (HAE), also known as the Emborrhoid technique, is changing that equation. This minimally invasive, catheter-based procedure reduces blood flow to the hemorrhoidal tissue without any cutting, incisions, or rectal wounds. It’s performed through a tiny puncture in the wrist or groin, uses only local anesthesia and light sedation, and patients go home the same day.
At Surgical Associates (SACMD), Dr. Albert Chun performs HAE for patients across Maryland, DC, and Northern Virginia who want effective hemorrhoid treatment without the surgical recovery. But we also believe you deserve an honest look at the evidence. Here’s what the clinical data actually shows—including the parts that favor surgery.
The Falsarella Randomized Controlled Trial: The Key Study
The most important piece of evidence comparing HAE to hemorrhoidectomy is a prospective randomized controlled trial (RCT) conducted at Hospital Israelita Albert Einstein in São Paulo, Brazil, led by Dr. Priscila Mina Falsarella and published in the Journal of Vascular and Interventional Radiology in 2023.
This trial enrolled 33 patients with Grade 2 and Grade 3 symptomatic hemorrhoidal disease and randomly assigned them to one of two groups: superior rectal artery embolization (the HAE group, n=15) or Ferguson closed hemorrhoidectomy (the surgical group, n=14). Four patients were excluded from analysis (one withdrew consent in the embolization group; three in the surgery group missed follow-up before their procedure). The remaining 29 patients were followed for 12 months with assessments of pain, analgesic use, symptom recurrence, and satisfaction.
Here’s what they found:
Pain: A Dramatic Difference
The single most striking finding was the difference in post-procedural pain. Using the visual analog scale (VAS, 0–10), pain was assessed three times daily for the first seven days after the procedure.
The mean pain score during the first bowel movement after treatment was 0 in the HAE group versus 6.08 ± 4.41 in the hemorrhoidectomy group (P = .001).
That’s not a marginal improvement. Patients who underwent HAE reported essentially no pain during their first post-procedure bowel movement, while surgical patients reported moderate-to-severe pain.
Analgesic Use: An Order-of-Magnitude Difference
The difference in pain was mirrored by analgesic consumption. Over the first seven post-operative days, HAE patients used an average of 2.4 ± 5.21 doses of pain medication, while hemorrhoidectomy patients used an average of 28.92 ± 15.78 doses (P < .01).
To put that in perspective: surgical patients consumed roughly twelve times more pain medication than embolization patients during the first week of recovery. For anyone who has spoken with a friend or family member about their hemorrhoidectomy experience, this finding will not be surprising—but seeing it quantified is powerful.
Symptom Control at 12 Months: Similar Outcomes
When the investigators looked at symptom resolution over the 12-month follow-up period, the two groups performed similarly in several key areas. Bleeding responded well in the embolization group, with resolution in 12 of 14 patients (83.3%). Symptom assessment in the 12-month postoperative period showed similar results between the groups overall, and there was no statistically significant difference in recurrence rates for bleeding, prolapse, pruritus, or mucus production between the two groups.
However, certain symptoms—particularly mucus production, skin tags, and pruritus—showed limited improvement in both groups, reflecting the fact that these symptoms are not always vascular in origin and may not respond to either treatment approach.
Where Surgery Had an Edge
Here is where intellectual honesty matters, and where we want to be transparent with our patients:
Satisfaction trended higher in the surgery group. Although the study did not report a statistically significant difference in overall satisfaction (the trial was not powered to detect this), the investigators noted that patient satisfaction at one year trended in favor of hemorrhoidectomy. This likely reflects the fact that surgery physically removes the hemorrhoidal tissue, which can provide more definitive relief for symptoms like prolapse.
Two HAE patients required secondary hemorrhoidectomy. Within the first year, 2 patients in the embolization group developed external hemorrhoids and prolapse and ultimately required surgical hemorrhoidectomy. This is an important consideration: HAE reduces blood flow to the hemorrhoidal tissue but does not remove it. For some patients—particularly those with significant prolapse—a secondary procedure may be needed.
The Study’s Limitations
We want to be straightforward about what this trial can and cannot tell us:
Small sample size. With only 29 patients analyzed (15 HAE, 14 surgery), this trial provides important directional evidence but cannot be considered definitive. The study was powered to detect differences in pain—its primary endpoint—but was not large enough to draw firm conclusions about comparative efficacy, satisfaction, or recurrence rates.
Single-center design. The trial was conducted at one institution in Brazil, and results may not perfectly generalize to all patient populations or clinical settings.
Open-label design. Patients knew which treatment they received, which can influence subjective pain reporting and satisfaction scores.
Despite these limitations, this remains the only published RCT directly comparing HAE to hemorrhoidectomy, and its findings on post-procedural pain are consistent with the broader body of HAE literature.
The Larger Body of HAE Evidence
Beyond the Falsarella RCT, the evidence base for HAE has grown steadily since Vidal and colleagues first described the Emborrhoid technique in 2014. A recent Frontiers in Surgery review (2024) summarized the published results of nearly 250 patients who have undergone hemorrhoid embolization across multiple studies, reporting high immediate technical success and clinical success rates ranging from 63% to 94%, with no major complications reported.
Key findings from the broader literature include a high technical success rate across studies, with no cases of sphincteric dysfunction or bowel ischemia reported when microcoils are used as the embolic agent. Complications at the puncture site (such as hematoma or pseudoaneurysm) may occur but are rare, particularly with ultrasound-guided vascular access. Anal discomfort, such as tenesmus, may occur during or shortly after the procedure but typically resolves spontaneously.
One important safety note from the literature: a case report documented rectosigmoid ischemia in a patient who received particles (rather than coils) for superior rectal artery embolization, leading to stenosis that required endoscopic dilatation. This underscores the importance of embolic agent selection and operator experience—and is one reason why HAE should be performed by experienced interventional radiologists who understand the vascular anatomy of the rectum.
HAE vs. Hemorrhoidectomy: A Practical Comparison
| Factor | HAE (Emborrhoid) | Hemorrhoidectomy (Ferguson) |
|---|---|---|
| How it works | Catheter-based embolization of superior rectal arteries reduces blood flow to hemorrhoidal tissue | Surgical excision of hemorrhoidal tissue with suture closure |
| Anesthesia | Local anesthesia + light sedation | General or spinal anesthesia |
| Incision | Tiny arterial puncture (wrist or groin) | Surgical incisions in the anal canal |
| Pain after procedure | Minimal to none (VAS 0 at first bowel movement in the RCT) | Moderate to severe (VAS 6.08 at first bowel movement) |
| Pain medication use (first week) | ~2.4 doses | ~29 doses |
| Recovery time | Same-day discharge; most resume normal activities within 1–3 days | 2–4 weeks before return to normal activities |
| Bleeding control | 83% resolution at 12 months | High resolution rates |
| Prolapse management | Limited (tissue remains in place) | Strong (tissue is physically removed) |
| Risk of sphincter damage | None reported | Small but documented risk |
| Need for secondary procedure | ~14% in the RCT (2 of 14 patients) | Rare, but recurrence is possible |
| Best for | Bleeding-predominant Grade 2–3 hemorrhoids; patients who want to avoid surgery; patients with surgical contraindications | Grade 3–4 hemorrhoids with significant prolapse; patients who need definitive tissue removal |
Who Is the Ideal HAE Patient?
Based on the current evidence, the strongest candidates for HAE are patients with Grade 2 or Grade 3 internal hemorrhoids whose primary symptom is bleeding. Patients who have not responded adequately to conservative management (dietary changes, topical treatments, rubber band ligation), but who want to avoid the pain and recovery of surgery, are excellent candidates. HAE is also particularly well-suited for patients who have medical conditions that increase surgical risk, patients on anticoagulation therapy, and patients whose work or family responsibilities make a multi-week surgical recovery impractical.
HAE may be less appropriate for patients with Grade 4 irreducible prolapse, where physical removal of tissue is more likely to be necessary, or for patients whose primary complaint is external hemorrhoids or skin tags rather than bleeding.
HAE at Surgical Associates: What to Expect
At Surgical Associates, HAE is performed by Dr. Albert Chun, a board-certified interventional radiologist with extensive experience in catheter-based embolization procedures. The procedure takes approximately 60–90 minutes and is performed in our outpatient suite. Patients receive local anesthesia at the access site and light IV sedation for comfort.
Using advanced imaging guidance, Dr. Chun navigates a microcatheter to the superior rectal arteries and selectively embolizes the branches supplying the hemorrhoidal cushions. The goal is not to destroy the tissue, but to reduce the arterial inflow that drives hemorrhoidal engorgement and bleeding.
Patients go home the same day and can typically return to work and normal activities within one to three days. Follow-up appointments are scheduled to monitor symptom improvement.
The Bottom Line
HAE is not a replacement for hemorrhoidectomy in every case. Surgery remains the most definitive treatment for advanced hemorrhoidal disease with significant prolapse. But for the large number of patients whose primary problem is bleeding and who are deterred by the pain of surgery—or who simply want a less invasive first-line intervention—HAE offers a compelling, evidence-based alternative.
The Falsarella RCT showed essentially zero pain at first bowel movement after HAE (compared to a score of 6 out of 10 after surgery) and a twelve-fold reduction in analgesic use, with comparable symptom control at 12 months. Those findings are clinically meaningful, even as we acknowledge the study’s small sample size and the need for larger confirmatory trials.
If you’re living with hemorrhoid symptoms in Maryland, DC, or Northern Virginia and want to learn whether HAE is right for you, schedule a consultation with our team. We’ll give you an honest assessment based on your specific symptoms and anatomy.
Schedule a consultation: Call (240) 427-1630 or visit www.sacmd.com
Disclaimer: This article is for informational purposes only and does not constitute medical advice. Individual results vary. The Falsarella RCT had a sample size of 29 analyzed patients, and larger trials are ongoing. Consult with a qualified physician to determine whether HAE or hemorrhoidectomy is appropriate for your condition.
References:
- Falsarella PM, Nasser F, Affonso BB, et al. Embolization of the Superior Rectal Arteries versus Closed Hemorrhoidectomy (Ferguson Technique) in the Treatment of Hemorrhoidal Disease: A Randomized Clinical Trial. J Vasc Interv Radiol. 2023;34:736-744.
- Vidal V, et al. Emborrhoid technique for hemorrhoidal disease. Diagn Interv Imaging. 2014.
- Frontiers in Surgery. Hemorrhoidal disease: what role can rectal artery embolization play? 2024.
- Latest Research Trends on the Management of Hemorrhoids. PMC. 2025.
- Common design and data elements on rectal artery embolization for treatment of symptomatic internal hemorrhoidal disease: an interactive systematic review of clinical trials. CVIR Endovascular. 2024.
Dr. Rahbar is an esteemed vascular surgeon at Surgical Associates, known for their exceptional contributions to the field of vascular surgery. As a board-certified vascular surgeon with over 20 years of invaluable experience, Dr. Rahbar is a respected authority in the medical community serving Camp Spring, Maryland and the whole community of Maryland. Their unwavering dedication to providing advanced care for patients with diseases of the arteries and veins has earned them a reputation for excellence. Dr. Rahbar’s work embodies a passion for precision and compassion, improving the lives of those they serve, one procedure at a time.