Varicocele embolization is a minimally invasive method of treating varicoceles by embolizing the testicular vein (internal spermatic veins).
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Indications
symptomatic varicocele
infertility/subfertility
failed surgical ligation
Contraindications
Relative contraindications include:
renal impairment
coagulopathy
Preparation
full clinical assessment including comprehensive medical history, physical examination, lab tests including coagulation profile, renal function, seminal sperm count and scrotal ultrasound should be performed prior to the procedure
embolization performed on outpatient basis as a day case
conscious sedation may be required but general anesthesia typically not required
Technique
metallic coils, detachable balloons, vascular plugs, NBCA glue, sodium tetradecyl sulfate are used for embolization
may approach from internal jugular vein (IJV) or common femoral vein. Less acute angulation of catheter with IJV approach
lead shield over testes
sheath, angled catheter, microcatheter and guide wire used: products vary according to user preference and availability
Left side
select left renal vein and perform renal venogram to note location of testicular vein entry point and presence of collateral vessels (Bähren classification of left varicoceles)
select left testicular vein from left renal vein and perform venogram to note size of vein and presence of collateral veins. The ability to inject contrast retrogradely from the top of the testicular vein down to the groin indicates absent or incompetent valves
advance catheter to level of superior pubic ramus and insert coils along length of testicular vein in a cephalad direction
coils should not be inserted below level of inguinal ligament because patient may feel them
uppermost coil should not project into lumen of renal vein due to risk of renal vein thrombosis
duplicated testicular veins and collateral draining veins should be occluded otherwise persistent inflow may cause procedural failure. This may be achieved by ensuring coils are placed across point of opening of collateral channel into testicular vein, or by directly entering and embolizing the duplicated or collateral vessel if large enough
perform post-embolization venogram to ensure successful occlusion of flow
Right side
right testicular vein is selected from IVC (or, in a small percentage, from right renal vein, a rare anatomical variant)
otherwise the same procedure as for the left side
Side effects
back pain or abdominal pain: typically mild and resolves in 24 to 48 hours
Complications
venous perforation: generally subclinical and self-limiting
misplacement of coil (e.g. into renal vein): usually retrievable with snare
embolization of coil into pulmonary circulation (if coil undersized): usually retrievable with snare
failed embolization: usually due to patent venous collaterals
Post-procedure management
remove catheter and sheath and secure hemostasis at puncture site
observe for 1 to 4 hours
Outcomes
outcome almost identical for embolotherapy and surgical ligation
technical success rate close to 100%
pregnancy rate approximately 35%
Advantages
minimally invasive
day procedure
Disadvantages
pregnancy rate much lower than technical success rate, but the same as for surgery