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342
Landmark Research
Nork JJ, Berger JH, Crain DS, Christman MS.Youth varico-
cele and varicocele treatment: a meta-analysis of semen out-
comes. Fertil Steril. 2014;102(2):381–387.e6. https://doi.
org/10.1016/j.fertnstert.2014.04.049
• Meta-analysis of changes in semen as measured by semen
analysis (SA) in youth with varicocele or undergoing vari-
cocele treatment.
• Measured the effect of varicocele on semen and the effect
of varicocele treatment on semen as measured by SA.
• Sperm density, motility, and morphology were significantly
decreased when associated with a varicocele, and sperm
density and motility were significantly improved following
treatment of varicocele.
Kroese ACJ, de Lange NM, Collins J, Evers JLH.Surgery
or embolization for varicoceles in subfertile men. Cochrane
Database Syst Rev. 2012;10:CD000479. https://doi.
org/10.1002/14651858.CD000479.pub5
• Meta-analysis to evaluate the effect of varicocele treat-
ment on live birth and pregnancy rate in subfertile couples
with known male varicocele.
• Ten randomized controlled trials included which reported
pregnancy rates or live birth rates, and data in treated (sur-
gical ligation or radiological embolization of the ISV)
versus untreated or placebo groups.
• 894 men included from all studies. Study suggests low-
quality evidence favoring benefit of varicocele treatment
over expectant management for pregnancy rate in subfer-
tile couples in whom varicocele was the only abnormal
finding.
Marmar JL, Agarwal A, Prabakaran S, et al. Reassessing
the value of varicocelectomy as a treatment for male subfer-
tility with a new meta-analysis. Fertil Steril. 2007;88(3):639–
648. https://doi.org/10.1016/j.fertnstert.2006.12.008
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• Meta-analysis of two randomized controlled trials and
three observational studies to assess the efficacy of varico-
celectomy in treating male infertility by improving the
chance of spontaneous pregnancy.
• Included infertile men with abnormal semen analysis and
palpable varicocele who underwent surgical varicocelec-
tomy; measured endpoint was spontaneous pregnancy.
• Odds of spontaneous pregnancy after surgical varicocelec-
tomy were 2.87 (95% confidence interval [CI], 1.33–6.20),
and the number needed to treat was 5.7 (95% CI, 4.4–9.5).
Common Questions
What is the technical
success rate of varicocele
embolization?
There is a 93–100% technical success
rate of varicocele embolization for
untreated and recurrent varicoceles.
What is the potential
result of too proximal of
an embolization?
Too proximal of an embolization can
lead to recurrence due to collateral
pathways that can refill the varicocele
through an inferior segment of the
gonadal vein.
Does varicocele
embolization require
inpatient hospitalization?
What is the expected
time to recovery?
Varicocele embolization can be
performed in the outpatient setting,
requiring 2-hour monitoring prior
to discharge. Typically, patients can
return to work by the next day.
What is the clinical
follow-up of patients
after undergoing
varicocele embolization?
Patients undergo a 3-month scrotal
ultrasound to evaluate for adequate
treatment response.
Which embolic agents
are most associated with
phlebitis? What is the
treatment?
Glue and sclerosant embolics,
especially if delivered below the
level of the inguinal ligament, can be
associated with phlebitis. While self-
limited, NSAIDs and reduced physical
activity can be recommended for
symptom management.
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344
Further Reading
Agarwal A, Deepinder F, Cocuzza M, Agarwal R, Short RA,
Sabanegh E, et al. Efficacy of varicocelectomy in improving
semen parameters: new meta-analytical approach. Urology.
2007;70(3):532–8.
Al-Ali BM, Marszalek M, Shamloul R, Pummer K, Trummer
H. Clinical parameters and semen analysis in 716 Austrian
patients with varicocele. Urology. 2010;75(5):1069–73.
Baazeem A, Belzile E, Ciampi A, Dohle G, Jarvi K, Salonia A, etal.
Varicocele and male factor infertility treatment: a new meta-
analysis and review of the role of varicocele repair. Eur Urol.
2011;60(4):796–808.
Bilreiro C, Donato P, Costa JF, Agostinho A, Carvalheiro V, Caseiro-
Alves F. Varicocele embolization with glue and coils: a single
center experience. Diagn Interv Imaging. 2017;98(7–8):529–34.
Cantoro U, Polito M, Muzzonigro G.Reassessing the role of sub-
clinical varicocele in infertile men with impaired semen quality:
a prospective study. Urology. 2015;85(4):826–30.
Chehval MJ, Purcell MH.Deterioration of semen parameters over
time in men with untreated varicocele: evidence of progressive
testicular damage. Fertil Steril. 1992;57(1):174–7.
Crawford P, Crop JA. Evaluation of scrotal masses. Am Fam
Physician. 2014;89(9):723–7.
Dogra VS, Gottlieb RH, Oka M, Rubens DJ. Sonography of the
scrotum. Radiology. 2003;227(1):18–36.
Dubin L, Amelar RD.Varicocelectomy: 986 cases in a twelve- year
study. Urology. 1977;10(5):446–9.
Dubin L, Amelar RD. Varicocele. Urol Clin North Am.
1978;5(3):563–72.
Eisenberg ML, Lipshultz LI. Re: does varicocele repair improve
male infertility? An evidence-based perspective from a random-
ized, controlled trial. Eur Urol. 2011;60(2):395.
Feneley MR, Pal MK, Nockler IB, Hendry WF.Retrograde emboli-
zation and causes of failure in the primary treatment of varico-
cele. Br J Urol. 1997;80(4):642–6.
Gandini R, Konda D, Reale CA, Pampana E, Maresca L, Spinelli
A, etal. Male varicocele: transcatheter foam sclerotherapy with
sodium tetradecyl sulfate--outcome in 244 patients. Radiology.
2008;246(2):612–8.
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Goldstein M, Gilbert BR, Dicker AP, Dwosh J, Gnecco
C. Microsurgical inguinal varicocelectomy with delivery of
the testis: an artery and lymphatic sparing technique. J Urol.
1992;148(6):1808–11.
Gorelick JI, Goldstein M.Loss of fertility in men with varicocele
**Presented in part at the 45th Annual Meeting of the American
Fertility Society, San Francisco, California, November 13 to 16,
1989. Fertil Steril. 1993;59(3):613–6.
Grober ED, O’brien J, Jarvi KA, Zini A.Preservation of testicular
arteries during subinguinal microsurgical varicocelectomy: clini-
cal considerations. J Androl. 2004;25(5):740–3.
Iaccarino V, Venetucci P.Interventional radiology of male varicocele:
current status. Cardiovasc Intervent Radiol. 2012;35(6):1263–80.
Kadyrov ZA, Teodorovich OV, Zokirov OO, Ishonakov KS,
Muminov NO.Bilateral varicocele: epidemiology, clinical pre-
sentation and diagnosis. Urologiia. 2007;(3):64–8.
Kim HH, Goldstein M. Adult varicocele. Curr Opin Urol.
2008;18(6):608–12.
Kroese ACJ, de Lange NM, Collins J, Evers JLH.Surgery or emboli-
zation for varicoceles in subfertile men. Cochrane Database Syst
Rev. 2012;10:CD000479.
Lipshultz LI, Corriere JN.Progressive testicular atrophy in the vari-
cocele patient. J Urol. 1977;117(2):175–6.
Makris GC, Efthymiou E, Little M, Boardman P, Anthony S, Uberoi
R, etal. Safety and effectiveness of the different types of embolic
materials for the treatment of testicular varicoceles: a systematic
review. BJR. 2018;91(1088):20170445.
Marmar JL, Agarwal A, Prabakaran S, Agarwal R, Short RA, Benoff
S, etal. Reassessing the value of varicocelectomy as a treatment
for male subfertility with a new meta-analysis. Fertil Steril.
2007;88(3):639–48.
Masson P, Brannigan RE. The varicocele. Urol Clin North Am.
2014;41(1):129–44.
Mehta AL, Dogra VS.Intratesticular varicocele. J Clin Ultrasound.
1998;26(1):49–51.
Nork JJ, Berger JH, Crain DS, Christman MS.Youth varicocele and
varicocele treatment: a meta-analysis of semen outcomes. Fertil
Steril. 2014;102(2):381–7.e6.
Pajovic B, Radojevic N, Dimitrovski A, Radovic M, Rolovic R,
Vukovic M. Advantages of microsurgical varicocelectomy
28 Varicocele Embolization
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346
over conventional techniques. Eur Rev Med Pharmacol Sci.
2015;19(4):532–8.
Pierik FH, Dohle GR, van Muiswinkel JM, Vreeburg JT, Weber
RF.Is routine scrotal ultrasound advantageous in infertile men?
J Urol. 1999;162(5):1618–20.
Reiner E, Machan L, Pollak J. Varicocele embolization. In:
Handbook of interventional radiologic procedures. 5th ed.
Philadelphia: LWW; 2016. p.413–20.
Reiner E, Pollak JS, Henderson KJ, Weiss RM, White RI.Initial
experience with 3% sodium tetradecyl sulfate foam and fibered
coils for management of adolescent varicocele. J Vasc Interv
Radiol. 2008;19(2 Pt 1):207–10.
Rifkin MD, Kurtz AB, Pasto ME, Goldberg BB. Diagnostic capa-
bilities of high-resolution scrotal ultrasonography: prospective
evaluation. J Ultrasound Med. 1985;4(1):13–9.
Sayfan J, Soffer Y, Orda R.Varicocele treatment: prospective ran-
domized trial of 3 methods. J Urol. 1992;148(5):1447–9.
Schlegel PN, Goldstein M.Alternate indications for varicocele repair:
non-obstructive azoospermia, pain, androgen deficiency and pro-
gressive testicular dysfunction. Fertil Steril. 2011;96(6):1288–93.
Schlesinger MH, Wilets IF, Nagler HM. Treatment outcome after
varicocelectomy. A critical analysis. Urol Clin North Am.
1994;21(3):517–29.
Sze DY, Kao JS, Frisoli JK, McCallum SW, Kennedy WA, Razavi
MK. Persistent and recurrent postsurgical varicoceles: veno-
graphic anatomy and treatment with N-butyl cyanoacrylate
embolization. J Vasc Interv Radiol. 2008;19(4):539–45.
Tulloch WS.Varicocele in subfertility. Br Med J. 1955;2(4935):356–8.
Vanlangenhove P, Everaert K, Van Maele G, Defreyne L.Tolerance
of glue embolization under local anesthesia in varicoceles: a
comparative study of two different cyanoacrylates. Eur J Radiol.
2014;83(3):559–63.
Wang Y-J, Zhang R-Q, Lin Y-J, Zhang R-G, Zhang W-L.Relationship
between varicocele and sperm DNA damage and the effect
of varicocele repair: a meta-analysis. Reprod Biomed Online.
2012;25(3):307–14.
Wan X, Wang H, Ji Z. Microsurgical varicocelectomy for clinical
varicocele: a review for potential new indications. Andrologia.
2017;49(10):e12827.
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World Health Organization. The influence of varicocele on param-
eters of fertility in a large group of men presenting to infertility
clinics **Supported by the Special Programme of Research,
Development, and Research Training in Human Reproduction,
World Health Organization, Geneva, Switzerland. Fertil Steril.
1992;57(6):1289–93.
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R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_29
Evaluating thePatient
What are the physical signs
and symptoms of lower
extremity DVT?
Leg pain, pitting edema, rubor,
and warmth
What is the initial imaging
study of choice for evaluation
of extremity DVT?
Duplex venous ultrasound
What are the key findings
suggestive of venous
thrombus on duplex
ultrasound?
Absent compressibility.
Loss of phasicity with Valsalva.
Absent color flow (if occlusive).
Lack of augmentation response.
Change in venous diameter
(generally increased if acute and
decreased if chronic).
Chapter 29
Vena Cava Filter
DavidMaldow
D. Maldow (*)
University of Rochester Medical Center, Rochester, NY, USA
(continued)
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Proximal (iliofemoral) DVT–
consider CT/MR venography as
ultrasound exam is limited.
In pregnant patients,
why should one consider
suprarenal location for IVC
filter placement?
To reduce radiation exposure
to the fetus and to prevent
complications between the fetus
and filter
What is the optimal contrast
bolus timing for visualization
of the entire IVC on CT?
Approximately 90-second delay
High Yield History
What is Virchow’s triad as it
relates to the development of
DVT?
Stasis, endothelial injury, and
hypercoagulability
Name two transient risk
factors for VTE.
Surgery and severe trauma
(multiple long bone/pelvic
fractures, spinal cord injury, and
closed head injury)
Name two long-standing risk
factors for VTE.
Malignancy and inherited
coagulopathy (e.g., factor V
Leiden deficiency)
Which allergy should be
included in the history when
evaluating a patient for vena
cava filter placement?
Iodinated contrast (patient may
require premedication regimen
prior to procedure)
In the setting of iodinated
contrast allergy, name two
alternative contrast agents
that may be used.
CO2 and gadolinium chelates
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Indications/Contraindications
What are the prophylactic and therapeutic indications for IVC
filter placement?
Therapeutic indications Prophylactic indications
DVT/PE with
contraindication to
anticoagulation
High-risk patient undergoing surgical
procedure
Recurrent DVT/PE
despite anticoagulation
Severe trauma (multiple long bone/
pelvic fractures, spinal cord injury, or
closed head injury)
DVT/PE with
hemorrhage-related
complications
High-risk patient secondary to
underlying medical condition
(prolonged immobilization)
Inability to maintain
therapeutic
anticoagulation
What is the first-line
management of venous
thromboembolism (VTE)?
Systemic anticoagulation (AC)
What is the dosing of
anticoagulation regimens?
Unfractionated heparin: 80units
per kg IV bolus, followed by
maintenance infusion 18units per kg
per hour titrated to a goal aPTT of
60–80seconds or with Xa assay
Enoxaparin (Lovenox, low
molecular weight heparin): 1mg per
kg subcutaneously every 12hours or
1.5mg per kg subcutaneously every
24hours
Warfarin (Coumadin, vitamin K
antagonist): 5–10mg PO once daily
titrated to INR 2 or greater
(continued)
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Vena Cava Filter
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352
Apixaban (Eliquis, direct factor Xa
inhibitor): 10mg PO twice daily for
7days and then 5mg twice daily
Rivaroxaban (Xarelto, direct factor
Xa inhibitor): 15mg PO twice daily
for 21days and then 20mg once
daily
Dabigatran (Pradaxa, direct
thrombin inhibitor): 150mg PO
twice daily
Note: minimum 3-month therapy
duration recommended
What type of filter is
compatible for patients
with megacava (caval
diameter >28mm)?
Cook Bird’s Nest: non-retrievable,
can be used with vena cava diameter
up to 40mm
Name three absolute
contraindications to
systemic anticoagulation.
Active bleeding, acute stroke within
the past 24 hours, uncontrolled
systolic hypertension (> or equal to
230/120 mmHg)
Recent surgery or epidural
intervention (e.g., lumbar puncture
or epidural anesthesia) within prior
4hours or expected within the next
12hours
Name five relative
contraindications to
systemic anticoagulation.
Acquired bleeding disorder (e.g.,
inherited coagulopathy, liver failure)
Stroke within the last 24hours
Uncontrolled hypertension
(e.g., systolic > 230mm Hg, diastolic
> 120mm Hg)
Prior bleeding complication with
systemic AC
Sepsis
D. Maldow
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