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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3591_Библиотеки_им_академика_М_И_Перельмана.pdf
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anastomotic vessels. Pulmonary embolization following
UAE is rare. Death following UAE is reported in less than
1in 1000 patients, commonly due to uterine infection and
sepsis or pulmonary embolism [1, 2].
25.2.8 Outcome
Randomized control trial by Mara et al. showed that at
6months follow-up, UAE had similar improvement in symptoms, quality of life, and ovarian function, when compared to
myomectomy. However, the same group at a 2-year follow up reported that pregnancy rate was better following myomectomy (78%) compared to UAE (50%) [5, 6]. Systematic
review of 7 RCTs and 793 patients by Gupta etal., which
included study by Mara et al., suggested that evidence of
higher fertility rate in myomectomy group over UAE is low
quality evidence, and should be considered with caution. The
study also reported that there is no statistically signicant
difference between UAE and myomectomy in patient satisfaction and major complications rate; however, UAE had
higher minor complications rate and increased chance of
requirement of surgical intervention in two to ve years following UAE [7]. Systematic review by Zhang etal. included
84 studies. Six studies showed that in up to 95% of patients,
myomectomy was associated with signicant decrease in
bleeding related symptoms. Forty-one studies on UAE
showed that 79 to 98.5% of patients had signicant decrease
bleeding bleeding-related symptoms following UAE.Three
studies suggested that UAE may be better than myomectomy
in control of broid-related bleeding [8].
Systematic review by Popovic etal. (2011) which included
15 studies, and 511 patients, showed aggregate symptomatic
improvement in 75% of patients with adenomyosis [9].
Metanalysis by de Bruijn etal. (2017) showed symptomatic
improvement in 83.1% of patients [10].
In patients with postpartum hemorrhage, technical suc-
cess rate of UAE approaches 100%, and UAE is effective in
~86–96% of patients with postpartum hemorrhage [4, 11].
Patients with prior UAE for postpartum hemorrhage is associated with increased risk of abnormal placentation, and
postpartum hemorrhage in next pregnancy [12].
Systematic review by Yang etal. included 16 studies and
421 patients, which showed that in patients with abnormal
placentation, UAE was associated with signicant reduction
in intraoperative blood loss during cesarean delivery or
cesarean hysterectomy. Requirement of emergent hysterectomy was also signicantly decreased following UAE with
cumulative rate of 19.6%. Incidence of major complications
was low; however, there was no signicant decrease in the
length of hospital stay [13].
Systematic review by Fowler et al. which included 204
studies, and 454 patients with cervical ectopic pregnancy,
showed that in comparison with methotrexate alone, dilatation and curettage alone (odds ratio—2.26) or with UAE
(odds ratio—4.85), and UAE alone (odds ratio—0.17)
showed more effective results [14].
25.3 Prostatic Artery Embolization (PAE)
Benign prostatic hyperplasia (BPH) is characterized by benign
enlargement of transitional zone of prostate gland, which can
cause bladder outlet obstruction and lower urinary tract symptoms (LUTS). BPH is more common in elderly men, with up
to 80% of men above 70years of age having lower urinary
tract symptoms secondary to BPH [15, 16]. Medical management is the rst line of treatment for mild to moderate symptoms. Surgery such as transurethral resection of prostate and
open prostatectomy is indicated when medical management
fails or is contraindicated. However, surgery can be associated
with considerable morbidity such as major bleeding, erectile
dysfunction, ejaculatory dysfunction, urinary incontinence,
urethral stricture, urinary retention, and urinary tract infection.
Prostatic artery embolization (PAE) offers minimally invasive
alternative to surgery in patients with BPH (Fig.25.2) [15].
PAE is a safe and effective procedure and avoids complications associated with surgery such as erectile dysfunction, retrograde ejaculation, and urinary incontinence [16].
Fig. 25.2 Schematic diagram of prostatic artery embolization. The
enlarged prostate is supplied by tortuous hypertrophied prostatic artery
25 Interventions ofthePelvic Vessels
307
25.3.1 Rationale Behind PAE
• Prostate artery embolization causes ischemic shrinkage of
prostatic gland and subsequent improvement in lower urinary tract symptoms.
• Following PAE, level of intra-prostatic testosterone and
its highly active metabolite dihydrotestosterone decreases.
• There is also a reduction of alpha 1 androgenic receptor in
the prostate gland, following PAE, which results in the
relaxation of prostatic smooth muscles.
25.3.2 Indications [17, 18]
• BPH with moderate to severe LUTS refractory to medical
treatment, or intolerance to medical treatment
• Patients with prostate volume >65ml as an alternative to
surgery
• Contraindication to surgery or patient’s refusal of
surgery
• Long waiting time for surgery
• Sexually active men (to avoid risk of retrograde ejaculation)
• Urinary retention with indwelling Foley’s catheter
• Hematuria of prostatic origin
25.3.5 Clinical Assessment
International Prostate Symptom Score (IPSS) is the gold standard for assessing severity of symptoms of BPH.It includes
seven questions regarding symptoms related to BPH, such as
incomplete emptying, frequency, intermittency, urgency,
weak stream, straining, and nocturia, that are scored from 0 to
5 bases on severity of the symptom. Total score of 0 to 7 suggests mild disease, score 8 to 19 suggests moderate disease,
and score of 20 or more suggests severe disease. IPSS is also
useful in monitoring improvement after PAE.
Quality of Life (QoL) questionnaire asks patients with
BPH to rate from 0 to 6 on how would they feel if they had
to live the rest of their life with current symptoms, where 0
suggests delighted and 6 suggests terrible. It is useful for
patient selection, and also follow-up following intervention.
International Index of Erectile Function (IIEF) is the sum
of ve questions, which are scored from 0 to 5. Lower score
indicates more severe perceived erectile dysfunction. It is
useful in assessing the effect of BPH treatment on erectile
function [16, 18].
25.3.6 Urodynamic Testing, andPost-Void
Residual (PVR) Urine
25.3.3 Contraindications [18]
• Urinary tract infection
• Prostate cancer
• Urethral stricture
• Large bladder diverticulum
• Neurogenic bladder
• Severe atherosclerosis
• Renal insufciency
25.3.4 Preprocedural Evaluation [17]
Clinical Assessment
• IPSS—International Prostate Symptom Score
• IIEF—International Index of Erectile Dysfunction
• QoL (Quality of Life) questionnaire
Urodynamic Study and Laboratory Evaluation
• Urodynamic testing
• Complete hemogram, Renal function test, Coagulation
parameters, Serum PSA, Urine analysis
Imaging
• Ultrasound prostate, Urinary bladder and kidneys
• Pelvic CT angiography
• MRI prostate and MR angiography
Uroowmetry and PVR offer objective assessment of bladder outlet obstruction before intervention. Volume of at least
150ml of voided urine is necessary for accurate assessment
during uroowmetry. Uroowmetry measures voided volume, maximum ow rate, average ow rate, time to maximum, and ow time. Maximum ow rate of less than or
equal to 15ml/s is a requirement for prostatic artery embolization. PVR is measured on ultrasonography or by catheterization of bladder. PVR of more than 300ml suggests chronic
bladder outlet obstruction [16, 18].
25.3.7 Imaging
25.3.7.1 Ultrasonography (USG)
Transabdominal or transrectal USG can be performed. Prostate
volume is measured. PAE is generally recommended when
prostate size is greater than 30–40ml. Post void residual urine is
measured to assess severity of bladder outlet obstruction.
Kidney, and urinary bladder are also evaluated. Ultrasound elastography is newer technique that can be used assess the degree
of stiffness in transitional zone of the prostate, which correlates
well with the severity of bladder outlet obstruction [16, 17].
25.3.7.2 Computed Tomography (CT)
CT is not routinely used for preprocedural evaluation before
PAE.CT angiography can be used to assess relevant pelvic
308
V. Kubihal et al.
vascular anatomy. It may be useful to assess severity of atherosclerosis before PAE.Disadvantages of CT include poor
soft tissue resolution, and limited parenchymal evaluation,
radiation exposure, and requirement of intravenous iodinated
contrast [17].
25.3.7.3 Magnetic Resonance Imaging (MRI)
MRI has a better soft tissue resolution and allows excellent
assessment of prostate parenchyma. Preprocedural evaluation of prostate volume, prostate zonal volume index, and
intravesical protrusion of prostate gland is better appreciated
with MRI.Prostate zonal volume index is a ratio calculated
by dividing central gland volume by whole prostate volume.
Preprocedural prostate zonal volume index correlates well
with degree of clinical improvement following PAE.Baseline
value of more than 0.45 is associated with better clinical outcome following PAE, with sensitivity of 85% and specicity
of 75%. MRI is also useful to rule out other causes of bladder
outlet obstruction and prostate cancer.
MR angiography can be used for preprocedural evalua-
tion of pelvic vasculature. Preprocedural knowledge of vascular anatomy and prostatic artery origin can reduce the
number of digital subtraction angiography (DSA) runs and
therefore reduce radiation dose, contrast volume, and procedure time [17].
25.3.8 Requirements forProstatic Artery
Embolization [17, 18]
• Prostate volume: >30–40ml.
• IPSS: ≥18.
• QoL: ≥3.
• Maximum urine ow rate: ≤15ml/s.
• IIEF and PVR are only used for monitoring purpose.
25.3.9 Relevant Vascular Anatomy
Detailed knowledge of patient’s pelvic arterial anatomy is
necessary for safe and effective PAE.BPH arises from central gland (transitional zone) of the prostate, and arterials
supplying the central gland are the primary target in PAE.
Internal iliac artery has two major divisions, namely,
anterior and posterior division, which supply visceral
branches and parietal branches. Posterior division gives
three branches, namely, iliolumbar artery, lateral sacral
arteries, and superior gluteal artery. Anterior division of the
internal iliac artery gives origin to superior vesical artery,
inferior vesical artery / prostatic artery, obturator artery,
middle rectal artery, internal pudendal artery, and inferior
gluteal artery. Acronym PROVISO (internal Pudendal
artery, middle Rectal artery, Obturator artery, Inferior
Vesical artery (prostatic artery), and Superior vesical artery
under Oblique view) is used to remember medial branches
of the anterior division of internal iliac artery under ipsilateral oblique angiogram [16, 17].
Prostatic artery that supplies the prostate gland can be
divided into branches that supply central gland and that supply the periphery. Based on the course, artery that supplies
the central gland is termed anteromedial / superior pedicle,
and artery that supplies peripheral gland is termed posterolateral / inferior pedicle. Both often arise as a common trunk
from the inferior vesical artery. Bilateral prostatic arteries
are often asymmetric in origin and size. Prostatic artery is
often tortuous in course, especially with enlarged prostate in
BPH. Intraglandular prostatic arteries show characteristic
“cork screw appearance” which helps in identication of
prostatic artery during angiogram. Prostatic artery can have
variable origin [16, 17]. De Assis etal. classied prostatic
artery origin into four main types [19]. In Type I (28.7%),
prostatic artery / inferior vesical artery arises as common origin with superior vesical artery. In Type II (14.7%), prostatic
artery arises from anterior division of internal iliac artery. In
Type III (18.9%), prostatic artery arises from obturator
artery. In Type IV (31.1%), prostatic artery arises from proximal internal pudendal artery. Type V includes less common
origins of prostatic artery from distal internal pudendal
artery, accessory internal pudendal artery, inferior gluteal
artery, anterior division of internal iliac artery trifurcation or
quadrifurcation, or posterior division of internal iliac artery
[16, 19]. In 8%, two prostatic arteries can be seen on the
single side of the pelvis [16].
25.3.10 Technique
Procedure is performed under moderate sedation. Antibiotics
and non-steroidal anti-inammatory drugs can be administered during the procedure and recovery. Common femoral
or radial access can be used. Transradial approach may allow
early ambulation and provide better patient satisfaction.
Foley’s catheter may be placed within the bladder as a landmark to identify prostatic artery [16]. PERFECTED technique of PAE is associated with better clinical outcome and
lower rate of recurrence compared to previously described
techniques [17]. PAE can be described in 10 steps, where
steps 1 to 7 involve proximal embolization, and steps 8 to 10
describe distal embolization [17].
• Step 1: Pelvic angiogram can be performed to evaluate
pelvic vasculature. This step can be skipped if preproce-
dural MR or CT angiography has been performed.
• Step 2: Guiding catheter is placed in the internal iliac
artery, and cone beam CT angiogram, under 40 to 45
ipsilateral oblique view, is obtained to study its branches,
0
25 Interventions ofthePelvic Vessels
309
identify blood supply to prostate, and selective catheterize
inferior vesical/prostatic artery.
• Step 3: After successful catheterization of inferior vesical
artery using microcatheter of size 2.4F or smaller, a vasodilator (isosorbide mononitrate or nitroglycerine) is
injected to prevent vasospasm and facilitate navigation of
microcatheter.
• Step 4: Microcatheter is negotiated beyond the arterial
supply to the bladder, seminal vesical, rectum, gonads,
corpus cavernosum, and penis, and is placed distal within
the prostatic artery before its division into superior and
inferior pedicle. Cone beam CT can be performed to conrm the catheter position within the prostatic artery and
identication of non-target vessels. Non-target vessels
can be selective embolized using coils or gel foam.
• Step 5: Another dose of vasodilator is administered to
facilitate deposition of greater volume of embolic agent.
• Step 6: Slow injection of highly diluted microparticles or
microspheres are administered using 1 ml syringe to
achieve diffuse parenchyma penetration and avoid early
occlusion of proximal vessel. Slow injection and limited
uoroscopy are done during embolization. Polyvinyl
alcohol particles and microspheres are the common
embolic agents used for PAE. There is no ideal size of
PVA particles that has been recommended in the literature. Smaller particles achieve greater degree of ischemic
of the prostate gland and reduction in serum PSA value.
However, they are associated with higher chances of
minor complications that include transient hematospermia, transient hematuria, and decreased ejaculatory volume [16, 20, 21]. A study showed no signicant difference
in symptomatic improvement between particle sizes of
100–300 micrometers and 300–500 micrometers [21].
Another study showed better results with use of combination of both 100–300 micrometers and 300–500 micrometers particle sizes [22].
• Step 7: When there is near stasis following proximal
embolization, angiogram is taken using 1ml contrast to
look for effectiveness of proximal embolization and identify any collaterals.
• Step 8: Microcatheter is negotiated into intra-prostatic
branches for distal embolization. Superior pedicle supplying central gland is embolized rst followed by inferior
pedicle supplying peripheral gland. Slow DSA run is
taken after successful cannulation of distal intra-prostatic
vessels.
• Step 9: Slow and careful injection of additional embolic
agent is done. Limited intermittent uoroscopy is used
and care is taken to avoid reux and non-target embolization. Additional 30% to 100% of embolic agent can be
used during distal embolization.
• Step 10: Flow stasis is conrmed. Catheter is slowly
pulled back with pack back embolization of prostatic
artery till its proximal end as the catheter is pulled out.
Angiogram is then taken to look for effectiveness of treatment, and also to look for any additional collaterals [17].
25.3.11 Complications
Prostatic artery embolization is associated with lower rates
of complication. Majority of the complications are transient
and include hematuria (5.6%), dysuria (9%), hematospermia
(0.5%), urinary retention (7.6%), urinary tract infection
(2.5%), and rectal bleeding (2.5%). Post-embolization syndrome, characterized by irritative lower urinary tract symptoms, pelvic pain, nausea, vomiting, and fever, is often
considered as expected side effect following PAE.Prostatitis,
prostatic abscess, and urosepsis can occur following
PAE.Prostatic urethra can be affected by embolization; however, risk of stricture is low. Non-target embolization is
uncommon complication following PAE.Non-target embolization can occur to bladder (cystitis, and perforation), seminal vesical, rectum (ischemic proctitis, and sometimes
abscess and stula formation), and penis. Non-target embolization can be avoided by adequate preprocedural and intraprocedural evaluation of vascular anatomy, and use of
prophylactic protective embolization for collateral vessels
[17, 18].
25.3.12 Post-Procedural Follow-Up
Both clinical and imaging follow-up is required following
PAE. Clinical and imaging assessment is generally recommended at 3 and 12months following PAE, and then annually [17]. Clinical follow-up is based on assessment of IPSS,
IIEF and QoL scores. Imaging follow-up should include
ultrasound and MRI [17].
Ultrasound can be used to document improvement in both
static and dynamic components of BPH. Improvement in
static component of BPH is evident by decrease in size of the
prostate gland. Ultrasound elastography is useful to assess
the dynamic component of BPH. BPH patients have high
smooth muscle tone, evident on ultrasound elastography as
higher elastic modulus, or stiffness. Following PAE, there is
a decrease in alpha-adrenergic receptors in embolized
prostate gland, with associated decrease in smooth muscle
tone and elastic modulus and stiffness of prostate gland [17].
MRI is very useful in the assessment of success following
PAE. MRI protocol should include dynamic contrast
enhancement and diffusion-weighted imaging. MRI is useful
in the assessment of reduction in size of prostate, central
gland, and median lobe [17]. MRI is useful in the identication of prostatic infarction by changes in signal intensity and
diffusion parameters and also identication of the lesions of
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V. Kubihal et al.
non-target embolization [17]. Prostatic infarction is seen as
T1 hyperintense, and T2 hypointense area, which with time,
become isointense to rest of the central gland. High b-value
diffusion-weighted images allow better identication of
prostatic infarction [16, 17].
25.3.13 Outcome
Comparison of prostatic artery embolization with conventional surgery such as TURP and open prostatectomy can be
discussed under ve major aspects. (1) At 3months follow up, there is no statistically signicant difference in reduction
of IPSS score following PAE and conventional surgery; (2)
clinical failure rates are similar; (3) complications are less
with PAE; (4) duration of hospital stay is short with PAE; (5)
improvement in prostate volume, post-void residual urine,
and peak urine ow is lesser in PAE [17].
CIRSE (Cardiovascular and Interventional Radiological
Society of Europe) dened terms such as symptomatic
improvement and clinical failure to assess effectiveness of
PAE. Symptomatic improvement is dened as at least 25%
decrease in IPSS score, with post-procedural IPSS score of
<18, and >1 decrease in QoL score with post-procedural
QoL score being ≤3. Clinical failure is dened as less than
25% decrease in IPSS score, post-procedural IPSS score of
18% or more, ≤1 decrease in QoL score, post-procedural
QoL score of 4 or more, or decrease in maximum urine ow
rate [17].
Success rate of PAE is approximately 78% at 6 months
and 75% at 12months. In patients with indwelling catheter,
catheter removal following PAE is observed in 86.7% of
patients. PAE is effective in treatment of refractory hematuria, with good results in 92% of patients at 18months follow up [17]. Carnevale etal. showed early clinical failure rate of
1.9% and 23% recurrence rate for lower urinary tract symptoms at median follow-up period of 72months [20].
25.4 Varicocele Embolization
of toxic metabolites from adrenal glands, and hormonal
abnormalities [24]. Patients may also present with scrotal
pain or discomfort [21, 25]. Percutaneous varicocele embolization is a minimally invasive alternative to surgery in
patients with symptomatic varicocele or infertility.
25.4.1 Indications [22, 26]
• Infertility: Percutaneous varicocele embolization is indicated, if all of the following criteria are met.
– Palpable varicocele on physical examination.
– The couple has known infertility.
– The male partner has abnormal semen parameters or
sperm function tests.
– The female partner has normal fertility or a potentially
treatable cause of infertility.
• Testicular atrophy in pediatric or adolescent males.
• Correction of pain associated with varicoceles.
• To improve testicular function in hypogonadal men with
varicocele.
25.4.2 Advantages ofPercutaneous
Embolization Over Surgery [25, 26]
• Least invasive.
• No surgical incisions.
• Often performed under local anesthesia.
• Selective venous catheterization virtually eliminates the
potential damage to testicular artery.
• No or very low risk of hydrocele due to sparing of
lymphatics.
• Higher technical success rate (93 to 100%) in cases with
recurrence after surgery or failed surgery.
25.4.3 Contraindications (Relative)
toPercutaneous Varicocele
Embolization
Varicocele is dened as abnormally dilated and tortuous
pampiniform plexus of veins. It is seen in 15% of all men and
~35% of men with primary infertility [21]. In ~85% of
patients, varicocele is unilateral and on the left side, and in
remaining patients, the condition is bilateral. Unilateral and
right-sided involvement is rare, and when present, one should
exclude secondary causes such as renal mass, retroperitoneal
mass, and situs inversus [21–23]. Varicocele is asymptomatic
in majority of the cases. Some of the patients may have progressive decline in testicular function and infertility, possibly
related to increased scrotal temperature, increased testicular
venous pressure, hypoxia due to reduced blood ow, reux
• Severe contrast allergy
• Impaired renal function
• Coagulopathy
25.4.4 Relevant Vascular Anatomy
Spermatic vein begins at the conuence of pampiniform
plexus of veins, at the root of scrotum. On the left side, it
typically drains into left renal vein. On the right side, spermatic vein typically drains into the anterolateral wall of IVC,
at an acute angle, just below the right renal vein. Variations
25 Interventions ofthePelvic Vessels
311
in venous drainage of spermatic veins are common. Variable
communications/collaterals with retroperitoneal veins, renal
capsular veins, colic veins, and abdominal wall veins can be
seen. Intercommunication between bilateral spermatic veins
can exist. Identication of these collateral and selective
embolization is necessary to prevent recurrence [25].
25.4.5 Preprocedural Evaluation [23, 25]
• Standard pre-angiography work-up and preparation.
• Scrotal ultrasonography should be performed with patient
in both recumbent and upright position. Valsalva maneuver may help in engorgement of veins and documentation
of reux. Documentation of reux is preferred over rigid
size criteria of 2mm, as size of the veins may vary signicantly with hydration. Inspiratory effort, and anxiety.
• Semen analysis in male patients with infertility.
25.4.6 Technique
25.4.6.1 Anesthesia andRadiation [25]
Percutaneous varicocele embolization is often performed as
a day-care procedure under local anesthesia and mild intravenous sedation. Limited uoroscopy is used to reduce
gonadal exposure. Gonadal shielding can be used, especially
in young and adolescent men.
reux into spermatic vein in retrograde manner, toward the
testis, especially during Valsalva maneuver.
Size of the spermatic vein should be measured, and position and size of the collaterals should be noted. Typical collateral pattern is seen as medial and lateral parallel divisions
of spermatic vein at the level of L4 vertebral body, with
medial division draining into left renal vein or IVC and lateral division draining into renal capsular or colonic veins. All
the collateral pathways and cross-communication between
bilateral spermatic vein are to be noted, as unsuccessful
embolization of these collaterals may contribute to varicocele recurrence.
25.4.6.4 Embolization [25, 27, 29–31]
Choice of embolizing agent depends on the operator’s preference (Fig.25.3). Liquid embolization agents with or without metallic coils are most commonly used in percutaneous
varicocele embolization.
A. Liquid embolization agents with metallic coil
Coils of 0.035 inch or 0.038 inch are deployed at lower
spermatic vein, usually at the inguinal canal. In case of difcult access, smaller coils (0.025 inch or 0.018 inch) are
deployed using coaxial microcatheter. Oversizing by 20% of
the estimated spermatic vein diameter is preferred. Two to
25.4.6.2 Venous Access [25, 27, 28]
Commonly used venous access includes right common femoral vein, right internal jugular vein, and basilic vein.
Femoral approach—right femoral vein is most commonly
used access site. For left-sided varicocele, 7F guiding catheter can be used to access left femoral vein, and coaxially
introduce 4F or 5F catheter, to selectively catheterize spermatic vein. If needed, 3F microcatheter can be used. For
right-sided varicocele, reverse curve catheters such as
Simmons 1 catheter can be helpful to catheterize right spermatic vein.
Internal jugular or basilic approach—Multipurpose catheters can be used to selectively catheterize both the spermatic
veins, usually without the need for coaxial catheters. Some
authors prefer right internal jugular access for right-sided
varicocele, as right spermatic vein opens at an acute angle
with IVC, and forms near straight line approach from internal jugular access.
25.4.6.3 Venography [25, 27]
After selective catheterization of spermatic vein ostia, venogram is obtained by gentle injection of contrast, with patients
in reverse Trendelenburg position, or performing Valsalva
maneuver. If there are incompetent valves, contrast will
Fig. 25.3 Schematic diagram of varicocele embolization using the
coils
312
V. Kubihal et al.
three coils are often required for near complete occlusion of
lower spermatic vein. Venogram during Valsalva maneuver is
performed again, which can reveal new collaterals, due to
high pressure distally occluded spermatic vein. Each of the
collaterals is to be occluded directly or at its opening in spermatic vein, using coils, if collaterals are large enough.
Alternatively, liquid embolization agent can be used to
occlude collaterals.
Commonly used liquid embolization agents include:
1. Sodium tetradecyl sulfate (STS) foam—3% STS is mixed
with sterile normal saline in the ratio of 2:1 to form a 2%
STS solution, which is then mixed with equal quantity of
air to form the STS foam. Foam is injected through the
catheter in spermatic vein which is visualized by displacement of the previous contrast column in spermatic
vein.
2. STS solution—2% STS solution is formed by mixing 3%
STS with contrast in the ratio of 2:1.
3. Glue (n-butyl cyanoacrylate)—Glue-lipiodol mixture of
ratio ranging from 1:1 to 1:6 is injected through the catheter after ushing the catheter with 5% dextrose solution.
Glue is ushed out of the catheter by another bolus of 5%
dextrose solution.
matic vein to stop the retrograde ow into renal vein or
IVC, and sclerosant is injected into the spermatic vein
without Valsalva maneuver. “OB technique” allows controlled injection of sclerosant and longer contact of sclerosant with vessel wall.
C. Use of metallic coils or plugs alone without liquid embo-
lization agent is not preferred due to associated high
recurrence rate.
25.4.7 Post-Procedural Care
Patient is discharged after observation for 2 to 4 hours.
Patients can resume routine activity after 24 to 48 hours.
Patients are advised to avoid strenuous activity and heavy
lifting for 5 to 7 days, and to have soft high ber diet for
3days to avoid constipation. Follow-up ultrasound evaluation is advised at 1month and 3months following intervention. Although dilated veins can be seen clinically following
embolization, success of procedure is determined by absence
of reux into veins. Semen analysis is advised at 4 to
6months following intervention, in patients treated for infertility [25, 31].
Spermatic vein is occluded at inguinal canal by external
pressure. Two methods of injection of liquid embolization
agents can be followed.
(a) Catheter is advanced till distal spermatic vein, and liquid
embolization agent is slowly injected as the catheter is
pulled back.
(b) If the catheter cannot be placed in distal spermatic vein,
liquid embolization agents can be injected from proximal spermatic vein, aided by reux, during Valsalva
maneuver, taking care to avoid reux into renal vein or
IVC.
Liquid embolization agent is injected from the coils at
inguinal canal till 1 to 2cm from the spermatic vein ostium,
taking care to avoid reux into left renal vein or IVC.Often
a solution of 2 to 5ml is adequate.
The last coil is used to occlude the most proximal portion
of spermatic vein, without extension into renal vein or
IVC.Occlusive plugs are rarely used considering high cost
of the occlusive plugs.
B. Liquid embolization agents alone without coils can be
used with good results. Extra care is taken to avoid reux
into pampiniform plexus of veins in scrotum, by external
compression at inguinal canal, using patient’s hand or
compressive device. “OB technique” is where temporary
occlusive balloon catheter is placed in the proximal sper-
25.4.8 Complications
Most common complication following embolization is scrotal pain, which is seen in nearly 17% of patients. It may persist up to 10 days following intervention. Other minor
complications include hematoma (10%) and epididymitis
(3%). There is no or very low risk of hydrocele following
embolization, due to sparing of lymphatics. When seen,
hydrocele may be related to thrombophlebitis associated
with embolization, rather than lymphatic occlusion [23, 25].
Major complications are rare. Spermatic vein perforation
is reported in up to 4.6% of patients and IVC / renal vein dissection is reported in up to 4.1% of the cases. These complications are rarely clinically signicant. Coil migration is a
rare complication and can lead to renal vein thrombosis.
More proximal migration can occur into IVC and pulmonary
arteries. Coil migration can be prevented by accurately oversizing the coils and use of detachable coils. Clinically signicant non-target embolization following varicocele
embolization with liquid embolizing agents is rare. Vicini
etal. reported a case of large bowl infarction following varicocele sclerotherapy [23, 25].
25.4.9 Outcome
Technical success is dened as cessation of ow in spermatic
vein in intraoperative post embolization imaging [25].
25 Interventions ofthePelvic Vessels
313
Percutaneous embolization is technically successful in
nearly 90 to 97% of patients [23]. Meta-analysis by Cayan
etal. showed technical success rate of 13.05%, irrespective
of laterality [32]. Technical success depends on various factors such as vascular anatomy, ease of venous access, and
intra-operative factors such as vasospasm and embolizing
agent used. Technical failure is rare with left-sided varicocele embolization; however, right-sided varicocele embolization can have a technical failure rate as high as 49%, often
related to difcult anatomy [25].
Recurrence rate following embolization range from 0 to
24%, comparable to that of surgery [23, 25]. Newer studies
show lower recurrence rate, probably related to improved operator experience and varicocele embolization technique [25].
Cochrane review of 894 patients in 10 studies showed
improvement in fertility and pregnancy rate following varicocele treatment [23]. In literature, pregnancy rate of 11 to
60% has been reported [33]. No statistically signicant difference has been reported between varicocele embolization
and surgery for the improvement in semen parameters and
fertility [23].
Varicocele embolization is useful in relieving scrotal pain
secondary to varicocele. Retrospective study of 154 patients
by Puche-Sanz etal. showed that 86.9% of patients had complete pain relief following varicocele embolization [31].
Varicocele embolization is an ideal treatment in patients
with post-surgery recurrence. Jargiello et al. reviewed 33
patients with recurrent left-sided varicocele following surgery and reported technical success rate of 100% with varicocele embolization in these patients [34].
25.5 Pelvic Congestion Syndrome
Pelvic congestion syndrome is dened as chronic pelvic pain
lasting for more than 6months, associated with pelvic varicosities, and can increase on standing, sexual intercourse,
and menstruation [35]. Up to 10% of women can have pelvic
varicosities; however, only up to 40% of these women will
have chronic pelvic pain / pelvic congestion syndrome [36].
Pelvic congestion syndrome typically affects young women
between the age of 20 to 30years, and multiparity and hormonal inuences are the common risk factors. It is suspected
only after exclusion of more common causes of pelvic pain
such as adenomyosis, endometriosis, gastrointestinal, and
urological diseases [35, 37]. Several medical and surgical
management are effective in the treatment of pelvic congestion syndrome. However, embolization of pelvic varicosities
is the preferred curative treatment for patients with pelvic
congestion syndrome [37].
25.5.1 Indication [38]
Embolization of pelvic varicosities is the standard treatment
for patients with chronic pelvic pain and pelvic varicosities,
where other causes have been excluded.
25.5.2 Contraindications [38]
• Active pelvic infection
• Pregnancy
• Prior severe contrast allergy
• Renal insufciency
• Uncorrectable coagulopathy
25.5.3 Preprocedural Evaluation
Thorough clinical evaluation and laboratory tests are conducted to rule out other causes of chronic pelvic pain.
Pregnancy status, renal function, coagulation parameters,
and complete hemogram are obtained prior to procedure
[38].
Non-invasive imaging workup for pelvic congestion
include transvaginal/transabdominal ultrasonography, MRI,
and CT. Ultrasound is the ideal investigation for pelvic
venous congestion syndrome, because of its wider availability and ability to perform dynamic imaging while standing or
performing provocative maneuver. Transvaginal ultrasound
with doppler evaluation is preferred over transabdominal
ultrasound because pelvic veins are better visualized on
transvaginal ultrasound. Criteria for diagnosis on transvaginal ultrasound include >4 mm dilated Para uterine vein,
dilated arcuate vein in the myometrium communicating with
pelvic varicosities, and slow ow (≤3cm/s) or reux in ovarian veins. Semi-upright position and provocative maneuver
such as Valsalva maneuver can be performed to accentuate
reux. Ultrasound has limited sensitivity in evaluation for
other causes of chronic pelvic pain. MRI is the preferred
investigation to rule out other causes of chronic pelvic pain
because of its excellent soft tissue resolution. Time-resolved
MR angiography with high temporal resolution can be used
to evaluate reux in ovarian and pelvic veins. Ct has a limited role in evaluation of pelvic congestion syndrome. CT
can be used to rule out structural causes of venous obstruction and pelvic varicosities (such as May-Thurner syndrome,
nutcracker syndrome, absence of IVC, and pelvic or abdominal mass), along with pelvic venous anatomy. CT criteria for
pelvic varicosities include dilated para uterine vein >4mm
and ovarian vein >8mm [36, 38].
314
V. Kubihal et al.
Invasive catheter-directed venogram is the gold standard
for diagnosis of pelvic varicosities and venous reux.
Diagnostic criteria suggested by the Society of Interventional
Radiology include >5mm diameter of ovarian vein, uterine
vein, or utero-ovarian arcade, reux of contrast in ovarian
vein with incompetent valves, reux of contrast to contralateral side through utero–ovarian arcade, contras reux in vulvar or thigh veins, and stagnation of contrast in pelvic veins.
Diagnostic angiogram is often reserved for patients who are
planned for embolization [36, 38].
25.5.4 Relevant Vascular Anatomy
In females, pelvic venous drainage is complex with extensive
collateral drainage. Internal iliac veins receive both parietal
and visceral venous tributaries, including from venous plexus
around uterus and vagina. Ovarian veins receive blood from
gonadal venous plexus and commonly drain into left renal
vein on the left side and IVC on the right side. Variations in
venous drainage can be seen. Complex communication can
exist between venous drainage of uterus and ovaries. Vulvar
and perineal veins can drain into internal pudendal vein or
circumex femoral vein. Variations in venous anatomy and
collateral pathways are common and can affect success of
embolization procedure [36].
25.5.5 Technique
varicosities are embolized rst, followed by other pelvic
varicose veins.
Both solid (coils and vascular plugs) and liquid (glue,
sclerosant) embolic agents, either alone or in combination,
can be used for embolization. Choice of embolic agents
depends on operator’s preference, as all of them have shown
high success rate. Similar to varicocele embolization, embolization techniques can be (1) coil embolization with or without sclerosant injection; (2) sclerotherapy, more commonly
with 3% sodium tetradecyl sulfate; (3) glue (n-butyl cyanoacrylate) and lipiodol injection. Following occlusion of
abnormal ovarian veins, internal iliac veins with reux into
visceral tributaries are embolized, commonly by balloon
occluded retrograde injection of sclerosant. Balloonoccluded technique has the advantage of controlled sclerosant injection and prevention of systemic dispersion.
Technical success is dened as the absence of ow in veins
that previously showed reux. All these techniques have very
high technical success rate ranging from 98 to 100%.
Previous studies have shown no statistically signicant difference in clinical response between unilateral and bilateral
embolization, when there is unilateral embolization.
Rationale behind bilateral embolization was the existence of
rich collateralization of bilateral pelvic veins. Percutaneous
sclerotherapy can be performed for vulvar varicosities, as an
adjunct procedure to catheter-directed pelvic varicosity
embolization, particularly if there is incomplete response to
endovascular embolization [35–38].
The goal of management is to occlude pelvic veins or ovarian veins with spontaneous or induced reux and/or treat
other vascular abnormalities responsible for pelvic congestion syndrome. Embolization for pelvic congestion syndrome is often performed as the outpatient procedure.
Moderate conscious sedation is recommended. Femoral or
jugular/brachial venous access can be used. Jugular/brachial
venous access is preferred for right ovarian vein embolization. Bilateral pelvic venogram is obtained to evaluate reux
in visceral tributaries of internal iliac vein, and to look for
any abnormal narrowing of common iliac vein (for example,
left common iliac vein narrowing in May Thurner syndrome). In case of signicant narrowing of common iliac
vein, stenting of vein can be considered, alternative to embolization of internal iliac vein. After selective catheterization
of left renal vein, venogram is performed to look for the presence of signicant narrowing of left renal vein (for example,
nutcracker syndrome) or reux into left ovarian vein.
Stenting of left renal vein can be considered if signicant
narrowing is identied. And if there is reux in left ovarian
vein, selective left ovarian venogram is obtained to look for
reux into pelvic varicosities. Most abnormal or most distal
25.5.6 Post-Procedural Care
Endovascular embolization for pelvic congestion syndrome
is often a day care procedure, and the patient is discharged
after hemostasis is achieved and the patient is out of sedation. Post-embolization syndrome is common. Patient is
counseled regarding mild to moderate post-embolization
pain that can last for few days. Oral pain medication such as
non-steroidal anti-inammatory drugs can be prescribed. If
pain is severe enough, patient can admitted overnight for
pain control. Patient is advised for follow-up clinical examination after 3–6 months to assess the resolution of pelvic
pain. In case of persistence of symptoms, repeat imaging and
embolization can be planned [36, 38].
25.5.7 Complications
Major complications are rare (complication rate—0.85 to
10%). Coil migration is rare complication and is more common with internal iliac vein embolization, seen in 3–4% of
patients. Coil migration can occur into left renal vein, infe-
25 Interventions ofthePelvic Vessels
315
rior vena cava, or pulmonary veins. Often migrated coils can
be easily retrieved, without long-lasting complication. Risk
of coil migration increases with the size of the vein embolized, and is more common in vein larger than 12mm. Thirty
to fty percent oversizing of coils is preferred for embolization of internal iliac vein.
Other complications include post-embolization syndrome, mild menorrhagia, puncture site hematoma, venous
perforation, and venous spasm preventing catheterization
[35, 38, 39].
25.5.8 Outcome
Technical success rate for embolization for pelvic congestion syndrome is high, up to 98 to 100%. Symptomatic
improvement is seen in 93 to 96% of patients following bilateral ovarian and internal iliac vein embolization and 82 to
100% of patients with bilateral ovarian vein embolization
alone [35, 36].
25.6 Penile Angiography
Penile angiography and vascular interventional procedures
are indicated in the treatment of high ow or non-ischemic
priapism and vasculogenic erectile dysfunction from insufcient penile arterial ow [40, 41]. High-ow priapism
occurs due to unregulated increased arterial ow to the corpora cavernosa of penis and is most commonly seen in the
setting of trauma. Other causes include iatrogenic injury and
malignant inltration. Injury to cavernosal artery or its
branches can result in arterio-cavernosal stula or arterial
pseudoaneurysm, with resultant increase in cavernosal blood
ow and priapism. In patients not responding to conservative
management (such as manual compression, ice application,
or ultrasound-guided compression), cavernosal artery embolization can be considered [40]. Erectile dysfunction due to
insufcient penile arterial ow is responsible for nearly 55%
of cases of erectile dysfunction [41]. Angiographically signicant penile arterial narrowing is seen in nearly 90% of
patients unresponsive to phosphodiesterase therapy [41].
Endovascular penile revascularization can be useful minimally invasive procedure for the treatment of erectile dysfunction in these cases [41].
25.6.1 Penile Vascular Anatomy
Arterial supply to the penis often arises from the internal
pudendal artery, a smaller of the two terminal branches of
anterior division of internal iliac artery. Internal pudendal
artery exits the pelvis through the lower half of the greater
sciatic foramen, below the pyriformis muscle and then reenters perineum through lesser sciatic foramen. On PA view,
during angiography, internal pudendal artery usually overlaps the femoral head as it leaves the pelvis, which is useful
in the differentiation of internal pudendal artery from superior vesical artery. Internal pudendal artery gives three
branches to penis, namely, deep artery of the penis (cavernosal artery), dorsal artery of the penis (supplies glans penis)
and bulbar artery (supplies corpora spongiosum and bulb).
Variations in arterial supply to the penis are common.
Common variations include bulbo-cavernosal artery, multiple cavernosal artery, and extracavernosal communication
between cavernosal arteries. In nearly 25% of cases, dorsal
artery and deep artery of penis can arise from accessory
pudendal artery, which can arise from external iliac artery,
femoral artery, obturator artery, or vesical artery [41, 42].
25.6.2 Technique
Foley’s catheter is placed with in urinary bladder, and penis
is taped to contralateral thigh when angiography of internal
iliac artery and internal pudendal artery is done. Common
femoral artery access is most commonly used. Some authors
prefer radial or brachial artery access. Pelvic angiogram can
be obtained with pigtail catheter placed in the distal aorta
above the bifurcation. It allows assessment of distal aorta
and common and internal iliac arteries and also provide
roadmap for selective catheterization of internal pudendal
artery or accessory arteries supplying penis. Internal iliac
artery is selectively catheterized using 4F or 5F catheter, and
selective angiography is performed in 20–300 contralateral
oblique view to evaluate proximal artery and 20–300 ipsilateral oblique view to evaluate mid and distal segment of internal iliac artery [40, 41, 43].
High ow priapism: High ow priapism commonly
occurs from injury to cavernosal artery or its branches with
formation of arterio-cavernosal stula or cavernosal artery
pseudoaneurysm. Selective catheterization of culprit artery
with 2.7F microcatheter is preferred with distal embolization to avoid ischemia to the healthy tissue. Commonly
used embolic agents include micro coils, polyvinyl alcohol
particles, glue, or gelatin sponge slurry. Micro coils are
preferred in large vessel injury, and polyvinyl alcohol particles, glue, and gelatine sponge slurry are preferred when
small vessel injury is present. Selective angiogram of internal iliac arteries is performed to conrm complete occlusion and rule out accessory arterial supply to the lesion.
Hemostasis is achieved. Patients are evaluated after
24 hours of procedure at discharge and at 6 weeks and
6 months following discharge by clinical evaluation and
color Doppler ultrasound. Then, patients can be followed
up annually [40, 43].