Varicocele embolization

VaricocoeleVaricocele embolisation is a minimally invasive method of treating varicoceles by embolising the testicular vein (internal spermatic veins).

Indications

• symptomatic varicocoelevaricocele
• infertility/subfertility
• failed surgical ligation

Contraindications

Relative contraindications include:

• intravenous contrast allergy
• renal impairment
• coagulopathy

Preparation

• full clinical assessment including comprehensive medical history, physical examination, lab tests including coagulation profile renal function sperm count and scrotal ultrasound should be performed prior to the procedure 
• embolisation performed on outpatient basis as a day case
• conscious sedation rarely required but general anaesthesia typically not required

Technique

• metallic coils, detachable balloons, vascular plugs, NBCA glue, Na tetradecyl sulfate are used for embolisation
• may approach from internal jugular vein or common femoral vein. Less acute angulation of catheter with IJV approach
• lead shield over testicles
• sheath, angled catheter, microcatheter and guidewire 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
• upper-most 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 embolising the duplicated or collateral vessel if large enough
• perform post-embolisation 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 - anatomical variant)
• same procedure as for 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
• embolisation of coil into pulmonary circulation (if coil undersized): usually retrievable with snare
• failed embolisation: usually due to patent collaterals

Post procedure-procedure management

• remove catheter and sheath and secure haemostasis 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.