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184 Interventional radiology and endovascular procedures
The embolic agent of choice is gelatin sponge, which provides rapid occlusion and
cessation of haemorrhage. Small embolic particles (150–250μm) should be avoided
because of the increased risk of ischaemic complications [12]. Coils are rarely used
because they occlude proximally, allowing ongoing bleeding from collateral vessels, and also impede further attempts at embolization [11]. If there is disseminated
intravascular coagulopathy (DIC), there may be a need for other embolic agents,
including glue and coils.
Complications arising secondary to interventional radiology in postpartum haemorrhage
Most complications are minor and common to all procedures involving arterial
puncture, including groin haematoma or pseudo-aneurysm. Severe complications
can arise from arterial balloon occlusion and embolization, but the incidence is low.
As described in the case reported here, migration of the uterine occlusion balloons can occur and the operator must be vigilant. Additionally, attention should
be paid to pericatheter thrombosis, as there are relatively long periods (>24 hours)
with the intravascular balloons or sheaths in situ during these procedures. Regular
ushing of the catheters and sheaths is recommended. If thrombus forms within
the external iliac arteries, or if the balloon migrates for a signicant period of time
whilst inated, there is potential for leg ischaemia which may require further vascular intervention.
Pelvic ischaemic complications associated with embolization are rare but have
been reported. They may include uterine, vaginal, buttock, and bladder necroses
[12,13]. Caution must be exercised if large amounts of embolic agents are used without signicant reduction in ow, with care taken to avoid non-target embolization.
Post-embolization syndrome is common and includes fever, leucocytosis, nausea,
and abdominal pain.
Fetal complications from interventional radiology in post-partum
haemorrhage
Direct rates of fetal complication are difcult to assess, as there are a number of
adverse factors that are already present in the context of major peri-partum haemorrhage. We advocate avoidance of catheter placement within the uterine arteries
during balloon positioning, as arterial spasm may occur and result in fetal ischaemia or fetal bradycardia.
Fetal radiation exposure should be minimized with strict coning and reduction
of uoroscopy pulse rates. The fetal radiation dose has been estimated at 0.03–0.06
Gray (Gy) [14,15] which theoretically may convey a 0.25% risk of developing a childhood cancer. However no fetal abnormality or subsequent malignancy has yet been
associated with IIAOB placement.
Evidence base
A small number of comparative studies have been performed demonstrating a mixed outcome/
benefit from using uterine artery occlusion balloons. Outcome measures of intra-operative
blood loss, transfusion requirements, and mortality have been used but trial methodologies are
variable.
A systematic review published in 2012 [16] summarized several major studies [14,15,17]
demonstrating inconclusive results with occlusion balloons, but these were used with caesarean
(continued)
hysterectomy rather than uterine conservation. However, more recent publications have reported
beneficial effects of occlusion balloons with Caesarean hysterectomy [7].
Our experience is mainly with uterine conserving techniques and we have found great benefit in using
IIAOBs. Trends are emerging to conserve the uterus with excellent results. The use of prophylactic
balloons will allow a uterus preserving operation to be performed rather than a caesarean
hysterectomy. Uterine occlusion balloons are intuitively of great benefit and their use is increasing.
A final word from the expert
●
Meticulous technique must be employed to ensure minimal maternal and fetal morbidity
in the peri-partum period.
●
It is essential for the interventional radiologist to attend the obstetric theatre and supervise
balloon inflation, with preparation for pelvic arterial embolization in case of uncontrolled
bleeding.
●
Always avoid direct catheterization of the uterine arteries during balloon placement, as
there is the potential for fetal compromise if there is arterial spasm.
●
Internal iliac artery occlusion balloons are principally reserved for placenta percreta, but
this is not always clear from antenatal imaging and as long as the technique of occlusion
balloon placement is demonstrated to be safe for mother and baby, it can be also be
used safely in placenta increta. Trends to conserve the uterus are now emerging and the
recognition of the role of occlusion balloons means that their use is increasing.
185Case 21 Postpartum haemorrhage: role of occlusion balloons?
References
1. Chandraharan E. Should the Triple-P procedure be used as an alternative to peripartum
hysterectomy in the surgical treatment of placenta percreta? Womens Health (Lond Engl)
2012; 8(4): 351–3.
2. Wu S, Kocherginsky M, Hibbard JU. Abnormal placentation: twenty-year analysis. Am J
Obstet Gynecol 2005; 192(5), 1458–61
3. Miller DA, Chollet JA, Murphy TM. Clinical risk factors for placenta previa-placenta
accreta. Am J Obstet Gynecol 1997; 177: 210–14
4. Hudon L, Belfort M A, Broome DR. Diagnosis and management of placenta percreta: a
review. Obstet Gynecol Surv 1998; 53(8): 509–17.
5. Chandraharan E, Rao S, Belli AM, Arulkumaran S. The Triple-P procedure as a conservative surgical alternative to peripartum hysterectomy for placenta percreta. Int J Gynaecol
Obstet 2012; 117(2): 191–4.
6. Royal College of Obstetricians and Gynaecologists. The role of emergency and elective
interventional radiology in postpartum hemorrhage. Good Practice Guideline No. 6, Royal
College of Obstetricians and Gynaecologists, London; 2007.
7. Carnevale FC, Kondo MM, de Oliveira Sousa W, et al. Perioperative temporary occlusion
of the internal iliac arteries as prophylaxis in cesarean section at risk of hemorrhage in
placenta accreta. Cardiovasc Intervent Radiol 2011; 34(4): 758–64.
8. Hansch E, Chitkara U, McAlpine J, et al. Pelvic arterial embolization for control of obstetric hemorrhage: a ve-year experience. Am J Obstet Gynecol 1999; 180: 1454–60.
9. Kidney DD, Nguyen AM, Ahdoot D, et al. Prophylactic perioperative hypogastric artery
balloon occlusion in abnormal placentation. AJR Am J Roentgenol 2001; 176: 1521–4.
186 Interventional radiology and endovascular procedures
10. Evans S, McShane P. The efcacy of internal iliac artery ligation in obstetric hemorrhage.
Surg Gynecol Obstet 1985; 160: 250–3.
11. Gonsalves M, Belli A. The role of interventional radiology in obstetric hemorrhage.
Cardiovasc Intervent Radiol 2010; 33(5): 887–95
12. Cottier JP, Fignon A, Tranquart F, et al. Uterine necrosis after arterial embolization for
postpartum hemorrhage. Obstet Gynecol 20 02; 100: 1074–7
13. Ornan D, White R, Pollak J, et al. Pelvic embolization for intractable postpartum hemorrhage: long-term follow-up and implications for fertility. Obstet Gynecol 2003; 102: 90 4–10.
14. Levine AB, Kulhman K, Bonn J. Placenta accreta: comparison of cases managed with and
without pelvic arter y balloon catheters. J Matern Fetal Med 1999; 8: 173–6.
15. Bodner LJ, Nosher JL, Gribbin C, et al. Balloon-assisted occlusion of the internal iliac
arteries in patients with placenta accreta/percreta. Cardiovasc Intervent Radiol 2006;
29(3): 35 4–61.
16. Dilauro MD, Dason S, Athreya S. Prophylactic balloon occlusion of internal iliac arteries
in women with placenta accreta: literature review and analysis. Clin Radiol 2012; 67(6):
515–20.
17. Shrivastava V, Nageotte M, Major C, et al. Case-control comparison of cesarean hysterectomy with and without prophylactic placement of intravascular balloon catheters for
placenta accreta. Am J Obstet Gynecol 2007; 197(4): 402.e 1–5.
CASE
22
Percutaneous varicelectomy: coils
or sclerosant agents?
Piero Venetucci and Miltiadis Krokidis
Expert commentary Vittorio Iaccarino
Case history
A 19-year-old male with a previous history of surgical treatment of varicocele of the
left side presented two years after his initial operation with signs of recurrence. His
general practitioner referred him directly to interventional radiology.
Learning point varicocele
Varicocele formation is based on the pathological dilatation of the pampiniform plexus (PP) as a
consequence of increased venous pressure at the level of the renal vein [1–3]. The incidence of
varicocele in young males varies between 8% and 23% [4,5]; it affects the left side most frequently
because of the anatomy of the left spermatic vein, but it may also present bilaterally as reported in
various series (0–23%) [4,6]. The presence of varicocele may be clinically expressed with pain and/or
weight sensation and may also be linked to male infertility.
Meticulous knowledge of the anatomy and physiology of the venous circulation in the renal vein, the
spermatic vein, and the PP is of paramount importance for understanding and planning endovascular
treatment in order to offer a permanent solution without recurrence. The internal spermatic vein (ISV)
is a venous plexus and not a single vein and needs to be treated as such. The angiographic evaluation
of the ISV always confirms the presence of a dominant branch, but also indicates the presence of
other smaller branches that are not dilated but may be the cause of recurrence if there is surgical or
percutaneous obliteration of the single dominant branch. The ISV plexus is connected with the PP at
the level of the inguinal canal.
The patient was examined in an outpatient setting and an accurate clinical history was obtained using a questionnaire in order to exclude other potential causes of
infertility. A physical examination was performed in both the recumbent and erect
positions and conrmed the presence of a left side varicocele and the suspicion of a
right side varicocele.
Learning point Questionnaire and physical examination
It is important for the interventional radiologist to perform a meticulous physical examination of the
patient after the exclusion of other causes of infertility. These include the following: alcohol abuse;
prolonged drug therapy with antiepileptics or neuroleptics, antibiotics, or steroids; exposure to toxic
substances such as heavy metals, pesticides, paint fumes, or hazardous substances [7]; metabolic
and hereditary diseases such as cystic fibrosis or Klinefelter syndrome; previous obesity; scrotal
dermatoses; surgically corrected hypospadia, cryptorchidism, hydrocele, or haematocele; infected
prostate/urethritis due to Chlamydia trachomatis, post-pubertal mumps, or orchiepididymitis.
The physical examination needs to be performed in both the recumbent and erect positions in order
to exclude hydrocele, inguinal hernias, edpidydimal cysts, haemangiomas, vascular malformation,
haematoma, and testicular cancer. A varicocele present in the recumbent position is considered as
secondary to other causes and is not the first problem to treat [8–11].
188 Interventional radiology and endovascular procedures
Evidence base Varicocele and male infertility
Varicocele is the most common treatable cause of male infertility. The exact link between the two is
not completely clear, but approximately 20–40% of patients affected with varicocele have a reduced
reproductive ability [12]. Numerous explanations for this connection have been proposed. The most
important factor appears to be the increase in the scrotal temperature [6,13–16]. This hypothesis is
supported by the fact that the testicles that are extensively retained in an intra-abdominal position are
usually hypoplastic. Telethermography can be used to identify patients who may potentially become
infertile and may benefit from treatment of the varicocele. A large varicocele of the left side may cause
an increase in temperature that may also affect the contralateral side because of haemodynamic
overload over the right plexus.
A colour Doppler ultrasound (CDU) scan was performed and conrmed the presence of a large left-side varicocele (Sarteschi grade 5). US measurement of the testicular volume conrmed a relative reduction of the volume on the left side (11.8ml
on the left and 17ml on the right). Laboratory evaluation of the seminal liquid of
the patient revealed severe oligospermia (1.4 milion/ml) which appeared to have
reduced compared with the value prior to the surgical treatment.
Evidence base
Varicocele is classified on the basis of colour Doppler ultrasound of the scrotum. The most widely
used classification is that of Sarteschi [17] which defines five grades.
1. A prolonged reflux is detected in vessels in the inguinal channel only during Valsalva’s manoeuvre.
Scrotal varicosity is not evident in a grey-scale study.
2. A small posterior varicosity that reaches the superior pole of the testis and whose diameter
increases after Valsalva’s manoeuvre is present. The CDU evaluation clearly demonstrates the
presence of a venous reflux in the supratesticular region only during Valsalva’s manoeuvre
3. Vessels in the inferior pole of the testis appear enlarged when the patient is evaluated in a standing
position,but no ectasia is detected if the examination is performed in the recumbent position.
CDU demonstrates a clear reflux only under Valsalva’s manoeuvre
4. The vessels appear enlarged, even if the patient is examined in the recumbent position; dilatation
increases in the upright position and during Valsalva’s manoeuvre. Enhancement of the venous
reflux after Valsalva’s manoeuvre is the criterion that allow the distinction os this grade from grades
3 and 5. Hypotrophy of the testis is common in this stage.
5. There is an evident venous ectasia even in the upright position. CDU demonstrates the presence
of a marked basal venous reflux that does not increase after Valsalva’s manoeuvre
This classification is simple and easily reproducible. It is very important to evaluate the testicular
volume [18] because in the case of significant volume reduction no treatment may be of any use,
particularly for paediatric patients where a seminal liquid examination may not be possible.
A CT venogram (Figure 22.1) was performed to evaluate the level of the surgical
clips. The scan revealed the presence of previous surgical clips in the left iliac fossa
and a stenosis of the left renal vein caused by external compression from the aortomesenteric axis and subsequent dilatation of the ipsilateral venous plexus.
Learning point Imaging
In order to obtain a definitive cure for recurrent or persistent varicocele it is of paramount importance
to understand the previous treatment approach. CT and MRI are important for this purpose [19–22]
because they can demonstrate the level of the surgical clips, coils, or glue used and offer a complete
venous map in order to plan a retrograde or an antegrade approach. If the antegrade approach is
the treatment of choice a non-invasive venogram of the non-occluded venous pathways through the
anterior PP is required.
(a) (b)
189Case 22 Varicocele embolization
(c) (d)
Figure 22.1 (a) CT scan confirming the presence of metallic clips in the left iliac fossa (black circle).
(b) CT axial slice showing stenosis of the left renal vein from the aortomesenteric axis (white circle). (c),
(d) reconstructed CT images in an oblique coronal plain showing extensive dilatation of the left internal
spermatic vein and the PP (white arrows) and confirming the presence of the metallic clips (white circle)
at the level of some of the veins of the internal spermatic plexus.
After evaluation of the CT we decided to treat the patient with percutaneous retro-
grade approach through access from the common right common femoral vein (Figure
22.2). First, a hydrophilic cobra type catheter was used in conjunction with a hydrophilic guidewire in order to catheterize the left internal spermatic vein up to the level
of the pre-existing surgical clips. The catheter was then changed to a vertebral type
(Slip-Cath Beacon) for the distal catheterization of the PP. When the PP was catheterized occlusion of the distal vessels with ‘scrotal barrage’ was performed using an
externally applied elastic band. After venographic conrmation that no reux was
present, sclerotherapy was performed 8ml of sodium tetradecyl sulphate 3%.
Learning point Sclerotherapy
Our preference for sclerotherapy alone is based not only on our expertise but also on
physiopathological considerations. Since varicocele is expressed as a dilatation of the PPA it is
essential to block all the plexus and not just the single spermatic vein, and sclerotherapy is the only
technique that allows us to do this safely. The use of coils and surgical ligation is limited because only
blockage of the ISV occurs.
190 Interventional radiology and endovascular procedures
(a) (b)
Figure 22.2 (a) Venogram of the internal spermatic vein of the left side from a retrograde access confirmed
that there is dilatation of the main venous branch of the internal spermatic vein (white arrows). The flow is
occluded at the level of the surgical clips (white circle). (b) Catheterization of the plexus distally to the surgical
clips (white circle) and venogram of the anterior PP. Sclerotherapy from this position followed (asterisk).
Evidence base Treatment of varicocele
A variety of surgical and percutaneous techniques to treat left-side varicocele. The most common
surgical techniques are as follows.
●
Open varicocelectomy and ligation of the internal spermatic vein at various levels:
●
high retropetitoneal ligation—the ‘Palomo technique’ [23]
●
inguinal, in which the incision is performed at the external inguinal ring
●
subinguinal.
●
Laparoscopic vericocelectomy which is generally performed via a transperitoneal shunt [24,25].
●
Microsurgical subinguinal varicocelectomy [26,27]. This is the most advanced and most successful
surgical technique with the lowest complication rate.
The first step in any percutaneous technique is catheterization of the spermatic vein. In most the
cases this access through the right femoral vein is feasible, but in cases of anatomical variants or when
the left renal vein has a caudal direction the preferred access is from the brachial vein or the internal
jugular vein [28]. The embolization of the ISV can be performed using a variety of techniques and
embolic agents.
●
Coils are the most common embolic agent and are used by the majority of operators. Coils have
evolved significantly over the the years, and those currently used are detachable, permitting a
controlled and more precise release. The coating is more thrombogenic but this technology has
increased the cost [29].
●
Acrylic glue is mainly used in the cases of post-surgical recurrence [30]. However, it is not easy to
control and complications may be severe.
●
Retrograde sclerotherapy is a very effective technique. Occlusion of the PP with an elastic band is
of paramount importance in order to avoid complications, but otherwise it is very safe [31]. Distal
catheterization of the ISV (to the ischiopubic level) and the use of a hydrophilic catheter are also
required.
●
Antegrade sclerotherapy is performed when the retrograde approach is not feasible [32].
Surgical access under local anesthesia, either from the groin or from a subinguinal position, and
catheterization of one of the veins of the PP with a 23–25G needle is required,. An elastic band
is applied distally to the access site and a venogram is performed to confirm the position. Then
injection of the sclerosant follows under Valsalva’s manoeuvre [33]. The initial venogram is of
paramount importance to avoid serious complications.
Three months later CDU conrmed successful treatment with no residual ow in
the anterior PP. The veins of the medial and posterior part of the plexus were patent
without evidence of reux during Valsalva’s manoeuvre. The patient remained free
of symptoms.
Discussion
The percentage of varicocele recurrence or persistence varies signicantly (2–45%)
depending on the technique used for varcicocelectomy. It is not always easy to
explain the cause of recurrence or persistence; in the case described here the CT
scan revealed the presence of the ISV even though ligation of some of the branches
was performed. The ISV plexus was maintained patent because of the high pressure
in the circuit between the ISV and the left renal vein. Sclerotherapy through retrograde catheterization of the distal segment of the ISV and ‘barrage’ of the PP with
an externally applied elastic band allows occlusion of all the vessels in the anterior PP at the level of the inguinal canal, excluding the formation of collaterals and
therefore the likelihood of recurrence. However, the procedure still does not address
the cause of the problem, which is the high pressure in the circuit between the left
renal vein and the ISV. Therefore the patients may complain of pain in the initial
post-treatment phase. Nevertheless, in the long term the procedure offers a denitive treatment and in our view should be the preferred option for the percutaneous
treatment of varicocele.
191Case 22 Varicocele embolization
A final word from the expert
Varicocele is a very common pathology that affects approximately 15% of young males; in
40% of the cases it is linked with male infertility and therefore treatment is required. The
follow-up and treatment of patients with varicocele requires the collaboration between a
number of specialties. The role of interventional radiology is crucial in the treatment not
only of primary varicocele, but also of recurrence (in my personal 40 years of experience
I have had to treat a patient after the recurrence of three surgical interventions and one
percutaneous intervention). In the treatment of recurrence a detailed description of the
number and type of previous interventions is highly desirable in order to plan access
(antegrade or retrograde).
The initial approach is via percutaneous retrograde sclerotherapy, even in the treatment of
recurrence, because this is a simple, cheap, quick, and reliable technique. However, the vast
majority of patients with varicocele are treated surgically and the recurrence rate is still very
high. The role of the interventional radiologist is to make an accurate patient selection after
clinical evaluation. Follow-up at three to six months is also required.
References
1. Morvay Z, Nagy E. The diagnosis and treatment of intratesticular varicocele. Cardiovasc
Intervent Radiol 1998; 21(1): 76–8.
2. van der Sluiszen PL, Leguit P, Sanders FB. Subcutaneous varices of the scrotum: a pos-
sible presentation of varicocele. Eur J Radiol 1990; 10(3): 198–200.
192 Interventional radiology and endovascular procedures
3. Weiss AJ, Kellman GM, Middleton WD, Kirkemo A. Intratesticular varicocele: sonographic ndings in two patients. AJR Am J Roentgenol 1992; 158(5): 1061–3.
4. Meacham RB, Townsend RR, Rademacher D, Drose JA. The incidence of varicoceles in
the general population when evaluated by physical examination, gray scale sonography
and color Doppler sonography. J Urol. 1994; 151(6): 1535–8.
5. Steeno O, Knops J, Declerck L, et al. Prevention of fertility disorders by detection and
treatment of varicocele at school and college age. Andrologia 1976; 8(1): 47–53.
6. Turner TT. Varicocele: still an enigma. J Urol 1983; 129(4): 695–9.
7. Gorelick JI, Goldstein M. Loss of fertility in men with varicocele. Fertil Steril 1993; 59(3):
613–16.
8. Ali JI, Weaver DJ, Weinstein SH, Grimes EM. Scrotal temperature and semen quality in
men with and without varicocele. Arch Androl 1990; 24(2): 215–19.
9. Charny CW. Effect of varicocele on fertility. Results of varicocelectomy. Fertil Steril 1962;
13: 47–56.
10. Takihara H, Sakatoku J, Cockett AT. The pathophysiology of varicocele in male infertility.
Fertil Steril 1991; 55(5): 861–8.
11. Zorgniotti AW, Macleod J. Studies in temperature, human semen quality, and varicocele.
Fertil Steril 1973; 24(11): 854–63.
12. Mattison DR, Plowchalk DR, Meadows MJ, et al. Reproductive toxicity: male and female
reproductive systems as targets for chemical injury. Med Clin North Am. 1990; 74(2):
391–411.
13. Roy CR 2nd, Wilson T, Raife M, Horne D. Varicocele as the presenting sign of an abdominal mass. J Urol 1989; 141(3): 597–9.
14. Dogra VS, Gottlieb RH, Oka M, Rubens DJ. Sonography of the scrotum. Radiology 2003;
227(1): 18–36.
15. Corlett MP, Gwynn BR, Hamer JD. Right-sided varicocele caused by false aneurysm from
aortic graft. Br J Urol 1992; 70(2): 20 4–5.
16. Linsell JC, Rowe PH, Owen WJ. Rupture an aortic aneurysm in the renal vein presenting
as a left-sided varicocele. Case report. Acta Chir Scand 1987; 153: 477–8.
17. Sarteschi LM. Lo studio del varicocele con color Doppler. G Ital Ultrasonologia 1993; 4:
43 –9.
18. Behre HM, Nashan D, Nieschlag E. Objective measurement of testicular volume by ultrasonography: evaluation of the technique and comparison with orchidometer estimates.
Int J Androl 1989; 12(6): 395–403.
19. Karaman B, Koplay M, Ozturk E, et al. Retroaortic left renal vein: multidetector computed tomography angiography ndings and its clinical importance. Acta Radiol 2007; 48(3):
355–60.
20. Lakhani P, Papanicolaou N, Ramchandani P, Torigian DA. Asymmetric spermatic cord
vessel enhancement and enlargement on contrast-enhanced MDCT as indicators of ipsilateral scrotal pathology. Eur J Radiol 2010; 75(2): e92–6.
21. Varma MK, Ho VB, Haggerty M, et al. MR venography as a diagnostic tool in the assessment of recurrent varicocele in an adolescent. Pediatr Radiol 1998; 28(8): 636–7.
22. von Heijne A. Recurrent varicocele: demonstration by 3D phase-contrast MR angiography. Acta Radiol 1997; 38(6): 1020–2.
23. Palomo A. Radical cure of varicocele by a new technique: preliminary report. J Urol 1949;
61(3): 604–7.
24. Hirsch IH, Abdel-Meguid TA, Gomella LG. Postsurgical outcomes assessment following
varicocele ligation: laparoscopic versus subinguinal approach. Urology 1998; 51(5): 810–15.
25. Cayan S, Shavakhabov S, Kadioglu A. Treatment of palpable varicocele in infertile men: a
meta-analysis to dene the best technique. J Androl 2009; 30(1): 33–40.
26. Chan PT, Wright EJ, Goldstein M. Incidence and postoperative outcomes of accidental
ligation of the testicular artery during microsurgical varicocelectomy. J Urol 2005; 173(2):
482–4.
27. Marmar JL, Kim Y. Subinguinal microsurgical varicocelectomy: a technical critique and
statistical analysis of semen and pregnancy data. J Urol 1994; 152(4): 1127–32.
28. Kuroiwa T, Hasuo K, Yasumori K, et al. Transcatheter embolization of testicular vein for
varicocele testis. Acta Radiol 1991; 32(4): 311–14.
29. Bechara CF, Weakley SM, Kougias P, et al. Percutaneous treatment of varicocele with
microcoil embolization: comparison of treatment outcome with laparoscopic varicocelecto my. Va scu lar 2009; 17(Suppl 3): S129–36.
30. Sze DY, Kao JS, Frisoli JK, et al. Persistent and recurrent postsurgical varicoceles: venographic anatomy and treatment with n-butyl cyanoacrylate embolization. J Vasc Interv
Radiol 20 08; 19(4): 539–45.
31. Iaccarino V, Venetucci P. Interventional radiology of male varicocele: current status.
Cardiovasc Intervent Radiol 2012; 35(6): 1263–80.
32. Tauber R, Johnsen N. Antegrade scrotal sclerotherapy for the treatment of varicocele:
technique and late results. J Urol 1994; 151(2): 386–90.
33. Colpi GM, Carmignani L, Nerva F, et al. Surgical treatment of varicocele by a subinguinal
approach combined with antegrade intraoperative sclerotherapy of venous vessels. BJU
Int 2006; 97(1): 142–5.
193Case 22 Varicocele embolization
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