Safety & Efficacy of Ischemic Preconditioning by Embolization of the Inferior Mesenteric Artery in Surgery for Tumors of Lower and Middle Rectum

Cancer, Rectal Clinical Trial

— AMIREMBOL_2  

Official title:

Evaluation of the Safety and Efficacy of Ischemic Preconditioning by Embolization of the Inferior Mesenteric Artery in Oncologic Surgery for Tumors of the Lower and Middle Rectum. Bicentric Exploratory Pilot Study

Clinical Trial Details — Status: Not yet recruiting

Administrative data

• NCT number: NCT06236633
• Other study ID #: NIMAO/2022-1/MB-01
• Status: Not yet recruiting
• Phase: N/A
• Start date: February 1, 2024
• Est. completion date: February 1, 2026

Study information

• Verified date: February 2024
• Source: Centre Hospitalier Universitaire de Nimes
• Contact: Martin BERTRAND, Professor
• Phone: +336.43.50.35.22
• Email: martin.bertrand[@]chu-nimes.fr
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

The present study will investigate the safety of inferior mesenteric artery embolization prior to rectal surgery, according to IDEAL recommendations (Lancet 2009). It aims to assess the safety of endovascular embolization of the inferior mesenteric artery prior to surgery in patients with rectal tumors, and estimate the potential benefits in terms of time to surgery and the occurrence of post-operative fistulas.The study will also assess the impact of subacute ischemia induced by IMA embolization on colonic vasculature remodeling, colonic ischemic suffering, altered hemostasis and initiation of neo-angiogenesis through blood sampling kinetics.The hypothesis is that ischemic preconditioning by inferior mesenteric artery embolization prior to rectal cancer resection surgery is safe and will result in a decrease in acute relative colon ischemia and a reduction in the rate of fistulas and post-surgical complications. Indeed, we believe that the beneficial effects of the ischemic preconditioning of IMA will be due to better blood perfusion of the colon at 3 weeks, which is apparently linked to remodeling and/or the development of collateral vascularization.

Description:

Anastomotic fistulas are the main cause of morbidity and mortality in colorectal surgery. They are responsible for septic complications, leading to increased mortality, local recurrence, repeat surgery and impaired sexual, urinary and digestive function. Fistulas are multifactorial; among the causes, colonic vascularization seems to be a major one. Ligation of the inferior mesenteric artery during rectal surgery has been shown to reduce intraoperative colonic perfusion flow. The left colon is then vascularized only by the colonic border arcade, perfused by the superior mesenteric artery. Ischemic pre-conditioning of the arterial network prior to surgery should ensure better vascularization by developing arterial collaterality and increasing perfusion flow in the colonic border arcade. In view of major advances in interventional radiology, this preconditioning could be achieved by endovascular ligation of the inferior mesenteric artery (IMA), based on the same principle as during surgery: proximal occlusion of the inferior mesenteric artery (IMA), using embolization material (plug or coils), 3 weeks before surgery, to allow the colonic border arcade to develop. We carried out a single-center pilot study (AMIREMBOL 1, NIMAO 2017; Frandon et al. 2022) to assess the feasibility of ischemic preconditioning of the colon for patients with rectal or sigmoid cancer. The study included 10 patients, randomized into two groups: the control group, with preoperative arteriography and standard management and the "embolization" group, with embolization of the IMA three weeks prior to surgery. IMA embolization was successfully performed in all 5 patients in the embolization group, with no major complications. The effect on colonic perfusion, measured by intraoperative Doppler directly on the border arch, with recording of resistance indexes (independent of measurement angle), showed a drop in resistance indexes in the control arm, after ligation of the IMA, which persisted after 5 minutes. In the "Embolization" arm, no drop in this index was reported during surgery, reflecting good development of vascular collaterality and at least relative acute ischemia of the colon after IMA ligation during surgery. Finally, in the "control" group, one anastomotic fistula was reported after surgery and required re-operation. There were no fistulas in the embolization group.

The present study (AMIREMBOL 2) will investigate the safety of IMA embolization prior to rectal surgery, according to IDEAL recommendations (Lancet 2009). Its aim is to assess the safety of endovascular embolization of the IMA prior to surgery in patients with rectal tumors, and to estimate the potential benefits in terms of time to surgery and the occurrence of post-operative fistulas.

The study will also assess the impact of subacute ischemia induced by IMA embolization on colonic vasculature remodeling, colonic ischemic suffering, altered hemostasis and initiation of neo-angiogenesis through blood sampling kinetics.

The hypothesis is that ischemic preconditioning by inferior mesenteric artery (IMA) embolization prior to rectal cancer resection surgery is safe and will result in a decrease in acute relative colon ischemia and a reduction in the rate of fistulas and post-surgical complications. The hypothesis is that the beneficial effects of the ischemic preconditioning of IMA will be due to better blood perfusion of the colon at 3 weeks, which is apparently linked to remodeling and/or the development of collateral vascularization.

Recruitment information / eligibility

• Status: Not yet recruiting
• Enrollment: 30
• Est. completion date: February 1, 2026
• Est. primary completion date: October 1, 2025
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years to 90 Years

Eligibility

Inclusion Criteria:

• Patients with cancer of the lower or middle rectum, eligible for surgical treatment requiring ligation at the origin of the inferior mesenteric artery.

• Patients with free, informed consent.

• Patients affiliated to or benefiting from a health insurance plan.

Exclusion Criteria:

• Patients with history of abdominal surgery.

• Patients with occlusion of the superior mesenteric artery or stenosis of more than 50%, visible on the CT scan performed as part of conventional management during extension workup.

• Patients with occlusion of the IMA on the extension scan.

• Patients with a systemic disorder responsible for haemostasis (haemophilia, Willebrand's disease, thrombocytopenia) and on anticoagulant therapy.

• Patients taking corticosteroids or immunosuppressants leading to an unacceptable surgical risk.

• Patients with renal insufficiency with clearance < 30mL/min.

• Patients with an allergy to iodine.

• Patients who has had treatment of the abdominal aorta or its branches.

• Patients participating in an interventional study.

• Patients in an exclusion period determined by another study.

• Patients under court protection, guardianship or curatorship.

• Patients unable to give consent.

• Patients for whom it is impossible to provide informed information.

• Pregnant or breast-feeding patients.

Related Conditions & MeSH terms

• Cancer, Rectal
• Rectal Neoplasms

Intervention

Procedure:
• Ischemic preconditioning
Embolization performed via a common right femoral or radial approach, depending on the patient's conformation. Minor complications such as hematoma at the puncture site are rare in less than 1% of cases, and serious complications are exceptional. Proximal occlusion of the inferior mesenteric artery, before its dividing branches, using material adapted to arterial occlusion according to anatomical findings. Proximal occlusion during embolization is evaluated by intravascular injection into the inferior mesenteric artery, and resumption of vascularization of the distal inferior mesenteric artery is controlled by the border arcade injecting into the superior mesenteric artery. In the event of a high-risk anatomical variant, or absence of a border arcade, no embolization will be performed and the patient will be excluded from the study; this will represent no more than 1-2% of patients (surgical series describing 0.83% of ischemia in connection with absence of a border arcade).
• Arteriogram
The interventional radiologist performs an arteriogram of the inferior and superior mesenteric arteries (IMA and SMA respectively) to check that the SMA is free of anomalies and that the IMA has a proximal trunk long enough for embolization. The radiologist also checks for the presence of a colonic border arcade. If this is absent, embolization will not be performed: the patient will be excluded from the study.This arteriogram is carried out under local anaesthetic specifically for research purposes, as follows: Common right femoral or radial approach and placement of a small introducer. Selective arteriogram of the inferior and superior mesenteric arteries to check perfusion of the border arcade.Arterial closure system or manual compression. Return to surgery or interventional radiology department. Patient discharged the same day after medical assessment (surgeon or interventional radiologist).Telephone check-up on Day1 (standard management) and Day 7 (added as part of the protocol).

Locations

Country	Name	City	State
n/a

Sponsors (1)

Lead Sponsor	Collaborator
Centre Hospitalier Universitaire de Nimes

Outcome

Type	Measure	Description	Time frame	Safety issue
Other	Gender	Male/Female	Day 0, on the day of inclusion
Other	Age	In years	Day 0, on the day of inclusion
Other	Height	In centimeters	Day 0, on the day of inclusion
Other	Tumor stage	Stage 0: Cancer cells are limited to the surface of the rectal lining. Stage I: Tumor has grown below the lining and possibly into the rectal wall. Stage II: Tumor has grown into the rectal wall and might extend into tissues around the rectum.; Stage III: Tumor has invaded the lymph nodes next to the rectum and some tissues outside of the rectal wall.; Stage IV: Cancer has spread to distant organs, such as the liver or lungs.	Day 0, on the day of inclusion
Other	Tumor, Node and Metastasis staging (TNM)	Tis:tumor in situ, only in mucosa.T1:tumor only in inner layer of bowel T2:tumor in muscle layer of the bowel wall T3:tumor in outer lining of bowel wall but not through it. T4a: tumor has gone through outer lining of bowel wall and into the peritoneum. T4b:tumor has grown through the bowel wall into nearby organs. N:cancer spread to lymph nodes? N0: no lymph nodes containing cancer cells. N1a:cancer cells in 1 nearby lymph node, N1b:cancer cells in 2 or 3 nearby lymph nodes,N1c:nearby lymph nodes do not contain cancer, but cancer cells in the tissue near the tumor. N2a:cancer cells in 4 to 6 nearby lymph nodes, N2b:cancer cells in >7 nearby lymph nodes. M:cancer in another part of the body (metastasis)? M0:cancer not spread to other organs, M1:cancer spread to elsewhere in the body. M1a: cancer spread to 1 distant site or organ, e.g. liver, but not to peritoneum, M1b:cancer spread to >2 distant sites, not to tissue lining the peritoneum M1c:cancer in distant organs and peritoneum.	Day 0, on the day of inclusion
Other	Circumferential resection margin	In millimeters	Week 3 or 4 on the day of surgery
Other	Distance from the lower pole of the tumor relative to the upper edge of the anal sphincter	In millimeters	Week 3 or 4 on the day of surgery
Other	Bi-ischial diameter	In millimeters	Week 3 or 4 on the day of surgery
Other	Bi-uterine diameter	In millimeters	Week 3 or 4 on the day of surgery
Other	Mesorectal area	In square millimeters	Week 3 or 4 on the day of surgery
Other	Type of surgery	Colorectal or anal anastomosis; Mechanical or manual surgery; Intersphincteric dissection Yes/ No, partial or total; Delayed colo-anal anastomosis.	Week 3 or 4 on the day of surgery
Other	Cardiovascular risk factors	All cardiovascular risk factors will be recorded	Day 0 on the day of inclusion
Other	Presence of the border arcade, occlusion of the mesenteric artery during arteriography.	YES/NO	Day 0 on the day of inclusion
Other	Operative data	Operative data: mobilisation of the colonic angle and ligation of the mesenteric vein.	Week 3 or 4 on the day of surgery
Primary	Safety of endovascular inferior mesenteric artery embolisation prior to surgical resection of the rectum in patients with tumours of the lower and middle rectum.	Percentage of patients with a complication (any grade) within 7 days after embolisation of the inferior mesenteric artery according to the classification of the International Society of Interventional Radiology assessed during the follow-up telephone consultation by the interventional radiologist.; Complications will be classified as minor (Grades A and B) or Major (grades C to F).; Grade A = No therapy, no consequence Grade B = Nominal therapy, no consequence. Includes overnight admission for observation only Grade C = Requires therapy, minor hospitalization (<48 hours) Grade D = Requires major therapy. Unplanned increase in level of care. Prolonged hospitalization (>48 hours) Grade E = Permanent adverse sequelae Grade F= Death	Day 7 post embolization (performed 3 weeks before surgical resection of the rectum)
Secondary	Technical success of the embolization procedure	A control arteriogram of the inferior and superior mesenteric arteries will be carried out at the end of the embolisation procedure: intravascular injection into the inferior mesenteric artery and control of the resumption of vascularisation of the distal inferior mesenteric artery by the border arcade by injecting into the superior mesenteric artery.; If embolisation fails, the patient will continue the study.; The number of failures will be converted into a percentage	Day 0, on the day of embolization
Secondary	Post-surgical complications up to 30 days after surgery. Clavien-Dindo Grade I	Percentage of patients presenting a post-operative complication according to the Clavien-Dindo Classification within 30 days of rectal surgery, assessed during hospitalization and at the 1-month post-surgical consultation, according to standard management.; The Clavien-Dindo classification (Dindo et al 2004, Dindo D. 2004) classifies surgical complications into 7 categories (I, II, IIIa, IIIb, IVa, IVb and V)	Post-operative Day 30
Secondary	Post-surgical complications up to 30 days after surgery. Clavien-Dindo Grade II	Percentage of patients presenting a post-operative complication according to the Clavien-Dindo Classification within 30 days of rectal surgery, assessed during hospitalization and at the 1-month post-surgical consultation, according to standard management.; The Clavien-Dindo classification (Dindo et al 2004, Dindo D. 2004) classifies surgical complications into 7 categories (I, II, IIIa, IIIb, IVa, IVb and V)	Post-operative Day 30
Secondary	Post-surgical complications up to 30 days after surgery. Clavien-Dindo Grade IIIa	Percentage of patients presenting a post-operative complication according to the Clavien-Dindo Classification within 30 days of rectal surgery, assessed during hospitalization and at the 1-month post-surgical consultation, according to standard management.; The Clavien-Dindo classification (Dindo et al 2004, Dindo D. 2004) classifies surgical complications into 7 categories (I, II, IIIa, IIIb, IVa, IVb and V)	Post-operative Day 30
Secondary	Post-surgical complications up to 30 days after surgery. Clavien-Dindo Grade IIIb	Percentage of patients presenting a post-operative complication according to the Clavien-Dindo Classification within 30 days of rectal surgery, assessed during hospitalization and at the 1-month post-surgical consultation, according to standard management.; The Clavien-Dindo classification (Dindo et al 2004, Dindo D. 2004) classifies surgical complications into 7 categories (I, II, IIIa, IIIb, IVa, IVb and V)	Post-operative Day 30
Secondary	Post-surgical complications up to 30 days after surgery. Clavien-Dindo Grade IVa	Percentage of patients presenting a post-operative complication according to the Clavien-Dindo Classification within 30 days of rectal surgery, assessed during hospitalization and at the 1-month post-surgical consultation, according to standard management.; The Clavien-Dindo classification (Dindo et al 2004, Dindo D. 2004) classifies surgical complications into 7 categories (I, II, IIIa, IIIb, IVa, IVb and V)	Post-operative Day 30
Secondary	Post-surgical complications up to 30 days after surgery. Clavien-Dindo Grade IVb	Percentage of patients presenting a post-operative complication according to the Clavien-Dindo Classification within 30 days of rectal surgery, assessed during hospitalization and at the 1-month post-surgical consultation, according to standard management.; The Clavien-Dindo classification (Dindo et al 2004, Dindo D. 2004) classifies surgical complications into 7 categories (I, II, IIIa, IIIb, IVa, IVb and V)	Post-operative Day 30
Secondary	Post-surgical complications up to 30 days after surgery. Clavien-Dindo Grade V	Percentage of patients presenting a post-operative complication according to the Clavien-Dindo Classification within 30 days of rectal surgery, assessed during hospitalization and at the 1-month post-surgical consultation, according to standard management.; The Clavien-Dindo classification (Dindo et al 2004, Dindo D. 2004) classifies surgical complications into 7 categories (I, II, IIIa, IIIb, IVa, IVb and V)	Post-operative Day 30
Secondary	Rate of fistulas up to 30 days after surgery	Percentage of patients with a fistula within 30 days of rectal surgery, assessed during hospitalization and at the 1-month post-surgical consultation, according to standard management.A fistula will be identified either on the basis of clinical criteria (presence of pus or enteric contents in the drains, leakage of contrast medium through the anastomosis, anastomotic dehiscence during a repeat operation), or on the basis of radiological criteria (presence of an abdominal or pelvic collection in the area of the anastomosis on CT scan) if there is clinical doubt or if a CT scan is carried out for another reason (before stoma closure, for example).	Day 0
Secondary	Rate of fistulas up to 30 days after surgery	Percentage of patients with a fistula within 30 days of rectal surgery, assessed during hospitalization and at the 1-month post-surgical consultation, according to standard management.A fistula will be identified either on the basis of clinical criteria (presence of pus or enteric contents in the drains, leakage of contrast medium through the anastomosis, anastomotic dehiscence during a repeat operation), or on the basis of radiological criteria (presence of an abdominal or pelvic collection in the area of the anastomosis on CT scan) if there is clinical doubt or if a CT scan is carried out for another reason (before stoma closure, for example).	Post-operative Day 30
Secondary	Duration of post-surgical hospitalization	Length of hospital stay (number of days)	Up to 30 days after rectal surgery
Secondary	Degree of difficulty experienced by the visceral surgeon during surgery	Surgeon's assessment of degree of difficulty using a 4-point Likert scale after each operation as follows : 1= Dissection of the inferior mesenteric artery was standard 2 = Dissection of the inferior mesenteric artery was more complicated than expected 3 = Dissection of the inferior mesenteric artery was much more complicated than expected; 4 = Dissection of the inferior mesenteric artery was Very difficult.	Week 3 to 4 on the day of rectal surgery
Secondary	Systemic inflammation markers: Pro-inflammation cytokines	Pro-inflammation cytokines (IL-1ß, IL-6, IL-8, Tumor Necrosis Factor-a and Interferon-?) will be measured as percentages	Day 0 (on the day of inclusion)
Secondary	Systemic inflammation markers: Pro-inflammation cytokines	Pro-inflammation cytokines (IL-1ß, IL-6, IL-8, Tumor Necrosis Factor-a and Interferon-?) will be measured as percentages	25 minutes before embolization
Secondary	Systemic inflammation markers: Pro-inflammation cytokines	Pro-inflammation cytokines (IL-1ß, IL-6, IL-8, Tumor Necrosis Factor-a and Interferon-?) will be measured as percentages	60 minutes after embolization
Secondary	Systemic inflammation markers: Pro-inflammation cytokines	Pro-inflammation cytokines (IL-1ß, IL-6, IL-8, Tumor Necrosis Factor-a and Interferon-?) will be measured as percentages	Week 3 to 4 after patient induction just before rectal surgery
Secondary	Systemic inflammation markers: Complement protein C3	Complement protein C3 will be measured as a percentage	Day 0 (on the day of inclusion)
Secondary	Systemic inflammation markers: Complement protein C3	Complement protein C3 will be measured as a percentage	25 minutes before embolization
Secondary	Systemic inflammation markers: Complement protein C3	Complement protein C3 will be measured as a percentage	60 minutes after embolization
Secondary	Systemic inflammation markers: Complement protein C3	Complement protein C3 will be measured as a percentage	Week 3 to 4 after patient induction just before rectal surgery
Secondary	Anti-inflammation markers:	IL-10 and Transforming Growth Factor-ß will be measured as percentages	Day 0 (on the day of inclusion)
Secondary	Anti-inflammation markers:	IL-10 and Transforming Growth Factor-ß will be measured as percentages	25 minutes before embolization
Secondary	Anti-inflammation markers:	IL-10 and Transforming Growth Factor-ß will be measured as percentages	60 minutes after embolization
Secondary	Anti-inflammation markers:	IL-10 and Transforming Growth Factor-ß will be measured as percentages	Week 3 to 4 after patient induction just before rectal surgery
Secondary	Hemostasis markers : Von Willebrand factor	Von Willebrand factor will be measured.	Day 0 (on the day of inclusion)
Secondary	Hemostasis markers : Von Willebrand factor	Von Willebrand factor will be measured.	25 minutes before embolization
Secondary	Hemostasis markers : Von Willebrand factor	Von Willebrand factor will be measured.	60 minutes after embolization
Secondary	Hemostasis markers : Von Willebrand factor	Von Willebrand factor will be measured.	Week 3 to 4 after patient induction just before rectal surgery
Secondary	Hemostasis markers : coagulation factor V	Coagulation factor V will be measured.	Day 0 (on the day of inclusion)
Secondary	Hemostasis markers : coagulation factor V	Coagulation factor V will be measured.	25 minutes before embolization
Secondary	Hemostasis markers : coagulation factor V	Coagulation factor V will be measured.	60 minutes after embolization
Secondary	Hemostasis markers : coagulation factor V	Coagulation factor V will be measured.	Week 3 to 4 after patient induction just before rectal surgery
Secondary	Hemostasis markers : D-dimers	D-dimers will be measured	Day 0 (on the day of inclusion)
Secondary	Hemostasis markers : D-dimers	D-dimers will be measured	25 minutes before embolization
Secondary	Hemostasis markers : D-dimers	D-dimers will be measured	60 minutes after embolization
Secondary	Hemostasis markers : D-dimers	D-dimers will be measured	Week 3 to 4 after patient induction just before rectal surgery
Secondary	Hemostasis markers : platelet-activating factor (PAF)	Platelet-activating factor (PAF) will be measured	Day 0 (on the day of inclusion)
Secondary	Hemostasis markers : platelet-activating factor (PAF)	Platelet-activating factor (PAF) will be measured	25 minutes before embolization
Secondary	Hemostasis markers : platelet-activating factor (PAF)	Platelet-activating factor (PAF) will be measured	60 minutes after embolization
Secondary	Hemostasis markers : platelet-activating factor (PAF)	Platelet-activating factor (PAF) will be measured	Week 3 to 4 after patient induction just before rectal surgery
Secondary	Hemostasis markers : prostaglandin E4	Prostaglandin E4 will be measured	Day 0 (on the day of inclusion)
Secondary	Hemostasis markers : prostaglandin E4	Prostaglandin E4 will be measured	25 minutes before embolization
Secondary	Hemostasis markers : prostaglandin E4	Prostaglandin E4 will be measured	60 minutes after embolization
Secondary	Hemostasis markers : prostaglandin E4	Prostaglandin E4 will be measured	Week 3 to 4 after patient induction just before rectal surgery
Secondary	Hemostasis markers : Thromboxane B2	Thromboxane B2 will be measured.	Day 0 (on the day of inclusion)
Secondary	Hemostasis markers : Thromboxane B2	Thromboxane B2 will be measured.	25 minutes before embolization
Secondary	Hemostasis markers : Thromboxane B2	Thromboxane B2 will be measured.	60 minutes after embolization
Secondary	Hemostasis markers : Thromboxane B2	Thromboxane B2 will be measured.	Week 3 to 4 after patient induction just before rectal surgery
Secondary	Markers of tissue inflammation: Blood pH	Blood pH will be measured	Day 0 (on the day of inclusion)
Secondary	Markers of tissue inflammation: Blood pH	Blood pH will be measured	25 minutes before embolization
Secondary	Markers of tissue inflammation: Blood pH	Blood pH will be measured	60 minutes after embolization
Secondary	Markers of tissue inflammation: Blood pH	Blood pH will be measured	Week 3 to 4 after patient induction just before rectal surgery
Secondary	Markers of tissue inflammation: ischemia-modified albumin	Ischemia-modified albumin will be measured	Day 0 (on the day of inclusion)
Secondary	Markers of tissue inflammation: ischemia-modified albumin	Ischemia-modified albumin will be measured	25 minutes before embolization
Secondary	Markers of tissue inflammation: ischemia-modified albumin	Ischemia-modified albumin will be measured	60 minutes after embolization
Secondary	Markers of tissue inflammation: ischemia-modified albumin	Ischemia-modified albumin will be measured	Week 3 to 4 after patient induction just before rectal surgery
Secondary	Markers of tissue inflammation:intestinal fatty acid-binding protein (I-FABP)	intestinal fatty acid-binding protein (I-FABP) will be measured	Day 0 (on the day of inclusion)
Secondary	Markers of tissue inflammation:intestinal fatty acid-binding protein (I-FABP)	intestinal fatty acid-binding protein (I-FABP) will be measured	25 minutes before embolization
Secondary	Markers of tissue inflammation:intestinal fatty acid-binding protein (I-FABP)	intestinal fatty acid-binding protein (I-FABP) will be measured	60 minutes after embolization
Secondary	Markers of tissue inflammation:intestinal fatty acid-binding protein (I-FABP)	intestinal fatty acid-binding protein (I-FABP) will be measured	Week 3 to 4 after patient induction just before rectal surgery
Secondary	Markers of tissue inflammation: L-lactate	L-lactate will be measured	Day 0 (on the day of inclusion)
Secondary	Markers of tissue inflammation: L-lactate	L-lactate will be measured	25 minutes before embolization
Secondary	Markers of tissue inflammation: L-lactate	L-lactate will be measured	60 minutes after embolization
Secondary	Markers of tissue inflammation: L-lactate	L-lactate will be measured	Week 3 to 4 after patient induction just before rectal surgery
Secondary	Markers of tissue inflammation: D-lactate	D-lactate will be measured	Day 0 (on the day of inclusion)
Secondary	Markers of tissue inflammation: D-lactate	D-lactate will be measured	25 minutes before embolization
Secondary	Markers of tissue inflammation: D-lactate	D-lactate will be measured	60 minutes after embolization
Secondary	Markers of tissue inflammation: D-lactate	D-lactate will be measured	Week 3 to 4 after patient induction just before rectal surgery
Secondary	Markers of tissue inflammation: Lactate dehydrogenase	Lactate dehydrogenase will be measured	Day 0 (on the day of inclusion)
Secondary	Markers of tissue inflammation: Lactate dehydrogenase	Lactate dehydrogenase will be measured	25 minutes before embolization
Secondary	Markers of tissue inflammation: Lactate dehydrogenase	Lactate dehydrogenase will be measured	60 minutes after embolization
Secondary	Markers of tissue inflammation: Lactate dehydrogenase	Lactate dehydrogenase will be measured	Week 3 to 4 after patient induction just before rectal surgery
Secondary	Markers of neoangiogenesis : CD34	CD34 will be measured	Day 0 (on the day of inclusion)
Secondary	Markers of neoangiogenesis : CD34	CD34 will be measured	25 minutes before embolization
Secondary	Markers of neoangiogenesis : CD34	CD34 will be measured	60 minutes after embolization
Secondary	Markers of neoangiogenesis : CD34	CD34 will be measured	Week 3 to 4 after patient induction just before rectal surgery
Secondary	Markers of neoangiogenesis : transcription factor HIF1-a	Transcription factor HIF1-a will be measured	Day 0 (on the day of inclusion)
Secondary	Markers of neoangiogenesis : transcription factor HIF1-a	Transcription factor HIF1-a will be measured	25 minutes before embolization
Secondary	Markers of neoangiogenesis : transcription factor HIF1-a	Transcription factor HIF1-a will be measured	60 minutes after embolization
Secondary	Markers of neoangiogenesis : transcription factor HIF1-a	Transcription factor HIF1-a will be measured	Week 3 to 4 after patient induction just before rectal surgery
Secondary	Markers of neoangiogenesis : Growth factors	Growth factors and their receptors, notably vascular endothelial growth factor (VEGF) and vascular endothelial growth factor receptor (VEGFR), fibroblast growth factor (FGF) and fibroblast growth factor receptor (FGFR) and platelet-derived growth factor (PDGF) and platelet-derived growth factor receptor (PDGFR) will be measured	Day 0 (on the day of inclusion)
Secondary	Markers of neoangiogenesis : Growth factors	Growth factors and their receptors, notably vascular endothelial growth factor (VEGF) and vascular endothelial growth factor receptor (VEGFR), fibroblast growth factor (FGF) and fibroblast growth factor receptor (FGFR) and platelet-derived growth factor (PDGF) and platelet-derived growth factor receptor (PDGFR) will be measured	25 minutes before embolization
Secondary	Markers of neoangiogenesis : Growth factors	Growth factors and their receptors, notably vascular endothelial growth factor (VEGF) and vascular endothelial growth factor receptor (VEGFR), fibroblast growth factor (FGF) and fibroblast growth factor receptor (FGFR) and platelet-derived growth factor (PDGF) and platelet-derived growth factor receptor (PDGFR) will be measured	60 minutes after embolization
Secondary	Markers of neoangiogenesis : Growth factors	Growth factors and their receptors, notably vascular endothelial growth factor (VEGF) and vascular endothelial growth factor receptor (VEGFR), fibroblast growth factor (FGF) and fibroblast growth factor receptor (FGFR) and platelet-derived growth factor (PDGF) and platelet-derived growth factor receptor (PDGFR) will be measured	Week 3 to 4 after patient induction just before rectal surgery
Secondary	Markers of epithelial-mesenchymal transition : matrix metallo-protease - 2	Matrix metallo-protease - 2 will be measured	Day 0 (on the day of inclusion)
Secondary	Markers of epithelial-mesenchymal transition : matrix metallo-protease - 2	Matrix metallo-protease - 2 will be measured	25 minutes before embolization
Secondary	Markers of epithelial-mesenchymal transition : matrix metallo-protease - 2	Matrix metallo-protease - 2 will be measured	60 minutes after embolization
Secondary	Markers of epithelial-mesenchymal transition : matrix metallo-protease - 2	Matrix metallo-protease - 2 will be measured	Week 3 to 4 after patient induction just before rectal surgery
Secondary	Markers of epithelial-mesenchymal transition : matrix metallo-protease - 9	Matrix metallo-protease - 9 will be measured	Day 0 (on the day of inclusion)
Secondary	Markers of epithelial-mesenchymal transition : matrix metallo-protease - 9	Matrix metallo-protease - 9 will be measured	25 minutes before embolization
Secondary	Markers of epithelial-mesenchymal transition : matrix metallo-protease - 9	Matrix metallo-protease - 9 will be measured	60 minutes after embolization
Secondary	Markers of epithelial-mesenchymal transition : matrix metallo-protease - 9	Matrix metallo-protease - 9 will be measured	Week 3 to 4 after patient induction just before rectal surgery
Secondary	Markers of epithelial-mesenchymal transition : transcription factors	Transcription factors SNAI2 (SLUG), SNAI1 (SNAIL) and zinc-finger E-box binding homeobox (ZEB-1) will be measured	Day 0 (on the day of inclusion)
Secondary	Markers of epithelial-mesenchymal transition : transcription factors	Transcription factors SNAI2 (SLUG), SNAI1 (SNAIL) and zinc-finger E-box binding homeobox (ZEB-1) will be measured	25 minutes before embolization
Secondary	Markers of epithelial-mesenchymal transition : transcription factors	Transcription factors SNAI2 (SLUG), SNAIL (SNAI1) and zinc-finger E-box binding homeobox (ZEB-1) will be measured	60 minutes after embolization
Secondary	Markers of epithelial-mesenchymal transition : transcription factors	Transcription factors SNAI2 (SLUG), SNAIL (SNAI1) and zinc-finger E-box binding homeobox (ZEB-1) will be measured	Week 3 to 4 after patient induction just before rectal surgery