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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3892_Библиотеки_им_академика_М_И_Перельмана
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331
Waybill PN, Brown DB.Patient care in vascular and interventional
radiology. 3rd ed. Fairfax: Society of Interventional Radiology;
2016.
Youn YJ, Lee J.Chronic venous insufficiency and varicose veins of
the lower extremities. Korean J Intern Med. 2019;34(2):269–83.
27 Varicose Vein
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333© Springer Nature Switzerland AG 2022
R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_28
Evaluating Patient
What are the common
physical exam findings
in varicoceles?
Varicoceles may be asymptomatic, but
commonly present with dull, aching,
usually left-sided scrotal pain. Pain is
typically worsened with standing and
relieved by laying supine. Testicular
atrophy may be present, believed to be
from loss of germ cell mass by increased
scrotal temperature.
What is the differential
diagnosis in scrotal
swelling?
Common causes of scrotal swelling
include inguinal hernia, hydrocele,
hematocele, and pyocele. Other
considerations include heart failure,
idiopathic lymphedema, liver failure,
and lymphatic or venous obstruction.
Epidermoid cysts of the scrotal wall
have also been described. Neoplastic
causes must be excluded.
Chapter 28
Varicocele Embolization
AvinashPillutla
A. Pillutla (*)
Department of Radiology, Virginia Commonwealth University
Health System, Richmond, VA, USA
e-mail: Avinash.Pillutla@vcuhealth.org
(continued)
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334
How are varicoceles
diagnosed with the aid
of sonography?
The sensitivity and specificity of
varicocele detection is close to 100%
with color Doppler ultrasound (US). US
should be performed with the patient in
both a supine and a standing position.
The general appearance of a varicocele
consists of multiple, hypoechoic,
serpiginous, tubular structures of varying
sizes larger than 2mm in diameter. Large
varicoceles can extend inferiorly to the
testis. Color flow and duplex Doppler
US demonstrates a venous flow pattern
of phasic variation and retrograde filling
during Valsalva maneuvering.
What are the grading
criteria for varicoceles?
Grade 1 denotes small-sized varicoceles
that are palpable only with Valsalva
maneuver.
Grade 2 denotes moderate-sized
varicoceles that are nonvisible on
inspection but palpable upon standing.
Grade 3 denotes large-sized varicoceles
that are visible on gross inspection.
Why are the findings
of non-compressibility
and right-sided
presentation generally
more concerning
features of varicoceles?
Unilateral right varicoceles are rare and
should therefore may represent more
ominous pathologies that may cause
inferior vena cava (IVC) obstruction since
the right internal spermatic vein (ISV)
directly drains into the IVC.Examples
include renal cell carcinoma with IVC
thrombus or right renal vein thrombosis
with extension to the IVC.All unilateral
right-sided varicoceles should be further
investigated with a computed tomography
(CT) of the abdomen and pelvis with
contrast. Varicoceles on either side that do
not decompress in the recumbent position
(non- diminishing) also raise concern for
obstruction such as thrombus or extrinsic
masses and should be further evaluated
by CT.
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335
High Yield History
How common
are varicoceles in
the postpubertal
population?
Varicoceles are a common finding and
present in approximately 15–20% of
postpubertal males. In addition, up to 40%
of varicoceles are associated with male
infertility.
What is the most
common age
of presentation
for idiopathic
varicoceles?
Idiopathic varicoceles most commonly
present between the ages of 15 and 25.
Is there an
inheritance factor in
the development of
varicoceles?
While genetic mechanisms predisposing
to varicocele formation have not yet
been discovered, there may be a genetic
basis for valvular dysfunction leading to
varicocele development as suggested by
epidemiological studies.
How are varicoceles
implicated in the
development of
infertility?
It is well established that varicoceles are
strongly associated with male infertility.
Up to 40% of males presenting varicoceles
may suffer from infertility. Varicoceles can
result in disordered spermatogenesis, germ
cell sloughing within the seminiferous
tubules, testicular atrophy, and decreased
testosterone secretion.
Why is routine
scrotal ultrasound
important in
evaluating men with
infertility?
Varicoceles are present in 35–40% of
infertile men and represent a highly
treatable form of male infertility.
Additionally, there is an association
between testicular malignancies and male
infertility; thus, scrotal ultrasound provides
valuable information in the diagnostic
evaluation of infertile men. Compared to
clinical palpation, US evaluation provides
added diagnostic information.
(continued)
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336
What are the
treatment options
for varicoceles? Is
there a benefit in
treating varicoceles
associated with
infertility?
While symptomatic varicoceles warrant
treatment by themselves, there is evidence
supporting improvement in male infertility
rates following varicocele treatment.
Options include surgical varicocelectomy,
which can be performed via open,
laparoscopic, and robotic approaches.
Newer microsurgical techniques also have
been described. Percutaneous varicocele
embolization has also emerged as a viable,
minimally invasive option with comparable
efficacy; however, no direct comparison
between surgical and radiological
approaches has been performed.
Indications/Contraindications
What are the
indications for
percutaneous
endovascular treatment
of varicoceles?
Indications for endovascular treatment
of varicoceles include chronic pain,
infertility, recurrent varicocele after
surgical repair, and testicular atrophy
with or without evidence of worsening
semen parameters.
What are the
contraindications
for percutaneous
endovascular treatment
of varicoceles?
For varicocele embolization, no
absolute contraindications exist
outside of contrast allergy and severe
coagulopathy.
What are the
indications for
surgical treatment of
varicoceles?
Symptomatic varicoceles, hypogonadism,
and infertility are all indications for
surgical intervention. Criteria for
varicocele-associated infertility include
palpable varicocele with no evidence
of female infertility or abnormal semen
analysis.
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What are the
contraindications for
surgical treatment of
varicoceles?
Relative contraindications for surgical
varicocelectomy for infertility include
severe oligozoospermia or azoospermia,
high serum FSH concentrations,
and small testes. Varicoceles that
are clinically less severe than grade
1 can also be considered relative
contraindications.
How do surgical and
endovascular treatment
of varicoceles compare
in efficacy?
Standard laparoscopic and robotic
surgical approaches have shown a
considerable recurrence rate due to
venous collaterals bypassing the inguinal
portion of the spermatic cord, scrotal
collaterals, and dilated cremasteric
veins. Newer microsurgical techniques
perform better in ligating collateral flow
and have demonstrated low recurrence
rates. Varicocele embolization allows for
effective targeting of collateral flow of
the ISV in addition to treating the ISV
prior to branching within the inguinal
canal.
Relevant Anatomy
What is the definition
of a varicocele?
A varicocele is defined as the
dilatation or tortuosity of the veins
of the pampiniform plexus, which is a
collection of collaterals and tributaries
joining spermatic vein branches within
the scrotum.
What are the anatomic
differences between
the left and right
internal spermatic
veins?
The left ISV drains perpendicularly into
the left renal vein, whereas the right
ISV vein drains obliquely into the vena
cava. The course of the left ISV is also
approximately 8–10cm longer than the
right.
(continued)
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338
On what side do
varicoceles generally
occur? Why?
Varicoceles are more common on the
left side (85%) due to (a) longer course
of the left ISV; (b) perpendicular angle
of insertion of the left ISV into the left
renal vein; (c) occasional arching of the
left testicular artery over the left renal
vein causing external compression and
left ISV reflux; and (d) compression of
the left ISV by a distended descending
left colon.
What are all of the
structures within the
spermatic cord?
The following structures are located in
the spermatic cord: the testicular artery,
the artery to the ductus deferens, the
cremasteric artery, the cremasteric nerve,
the testicular nerves, the vas deferens
(ductus deferens), the pampiniform
plexus, the tunica vaginalis, and
lymphatic vessels.
What is the anatomic
level at which the
internal spermatic vein
begins to demonstrate
extensive branching?
The ISV begins to branch extensively at
the level of the inguinal canal.
What are the possible
collateral pathways to
the internal spermatic
vein when treating
varicoceles?
Commonly developed collateral
pathways to the ISV include parallel,
colic, hilar, and capsular collaterals.
What are the various
surgical approaches to
varicocelectomy?
There are multiple approaches to
varicocelectomy: retroperitoneal ISV
ligation, laparoscopic ISV ligation,
and inguinal or subinguinal approach
varicocelectomies with or without
microsurgery.
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Relevant Materials
What are the
most common
embolic agents
used in varicocele
embolization?
The most common agents are metallic
coils and liquid sclerosants, such as sodium
tetradecyl sulfate (STS) and glue. These
agents can be used independently or in
combination. Glue embolization requires
considerable operator experience. Sodium
tetradecyl sulfate (STS) is a common
liquid sclerosant. Metallic coils typically
are 0.035–0.038 inches in diameter and can
be delivered in the ISV with care not to
encroach into the renal vein.
What agents can
be used for post-
procedure pain
control?
Typically, a course of nonsteroidal anti-
inflammatory drugs (NSAIDs) with or
without additional nonnarcotic analgesics
can be used. Narcotics are usually not used
or necessary.
What standard
features of
fluoroscopic
equipment can be
used to minimize
testicular radiation
exposure?
Use of the last image hold as opposed
to spot film acquisition and avoidance of
formal DSA “runs.”
General Step by Step
What is the relevant
laboratory workup
prior to varicocele
embolization?
Pre-procedural laboratory workup is
not routinely performed in otherwise
healthy, young males.
(continued)
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340
What is the
technique for
successful retrograde
advancement of a
selective catheter in
the ISV?
Successful advancement can be
facilitated by coaxial insertion of a 4–5
Fr angled catheter with gentle injection
of contrast to opacify the ISV in a
retrograde fashion through incompetent
valves. Valsalva maneuvering will aid in
opacification of the ISV by increasing
abdominal pressure. Tilting the table
in a reverse-Trendelenburg position
may be of benefit if Valsalva cannot be
adequately performed.
What is a common
technique of
embolization?
Coil embolization of the entire ISV
with or without liquid sclerosant for the
pampiniform
After embolization of
the ISV and collateral
flow, what findings on
venography signify
procedural success?
Venography performed with Valsalva
maneuvering demonstrates no reflux of
flow down the gonadal vein.
After varicocele
embolization and stasis
of flow in the gonadal
vein and pampiniform
plexus, what additional
step is required to
prevent procedure
failure?
Repeat venography must be
performed to identify and embolize
any new significant collateral
pathways developing because of flow
redistribution from embolization.
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Complications
What are the potential
complications of
surgical techniques
in treatment of
varicoceles?
Surgical complications include testicular
arterial injury, postoperative hydrocele,
testicular atrophy, infection, and
recurrence of varicoceles. A newer
surgical technique called microsurgical
varicocelectomy has a higher success
rate and lower complication rates when
compared with older laparoscopic and
robotic techniques. The risk of general
anesthesia for surgical approaches should
also be considered.
What are the potential
complications
of endovascular
techniques in
treatment of
varicoceles?
Varicocele embolization can result in coil
misplacement or migration, venospasm
or venous perforation, phlebitis, and
testicular radiation exposure.
What steps can be
taken to minimize
the risk of metallic
coil migration
after varicocele
embolization?
Though rare with modern coils,
inappropriately sized metallic coils
can become dislodged and migrate
centrally to the pulmonary circuit. Care
must be taken to appropriately size
coils (approximately 120% of the ISV
diameter), and to avoid protrusion of
the cephalad-most coil into the left renal
vein.
What procedure-
related symptoms
can be expected and
are not necessarily
considered
complications? How
can they be managed?
Commonly, patients may experience
temporary back pain, mild scrotal
swelling, and scrotal discomfort. These
symptoms are generally self-limited, but
can be treated with NSAIDs, heating pad,
and rest for 2–3days.
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