Teaching Case

Left-sided varicocele and embolization of the left internal spermatic vein by coils and sclerosing agents

The patient recognized a left-sided varicocele during showering. Palpation of the scrotum demonstrated significant enlargement of the pampiniform plexus only on the left side. The patient was presented for outpatient embolization of his varicocele. The patient was placed on a multifunctional table that allows tilting of the patient into an elevated fashion. After retrograde puncture of the right common femoral vein, a 4 F cobra-shaped catheter (Tempo 4, Cordis Inc.) with a large inner lumen of 0.038 in was inserted through a 5 F angiographic sheath and the left renal vein was selectively catheterized. An enlarged internal spermatic vein with an incompetent valve was found (Fig.1) that was selectively catheterized by use of a coated guidewire. The catheter was advanced deep into the vein to the level of the distal sacroiliac joint and three 5 mm wide 4 cm long embolization spirals were inserted through the 4 F catheter. Then the patient was positioned in a 45 degree elevated position and 5 cc of polidocanol 4% (Äthoxysklerol 4%) were injected into the proximal portion of the internal spermatic vein (Fig. 2)in order to reach also collateral veins. After 15 minutes, all interventional material was removed and the patient remained in a lying position for additional 3 hours, after that he was discharged.

Varicocele embolization is one of the easier venous interventions. It is very effective in occluding the internal spermatic vein if performed completely. The anatomic variations of the internal vein sometimes prevent successful cannulation of the spermatic vein. Then, percutaneous retrograde embolization is technically impossible. Very frequently, the vein has many collaterals. If these collaterals are not involved into the embolization process, a recurrent varicocele may result. Thus, coil occlusion has to take place at the lowest level that allows blocking of possibly all side branches. Additional administration of a sclerosing agent allows also to occlude smaller sidebranches which cannot be reached by selective catheterization. There is some debate about the proper place which the most distal portion of the vein should be. While some groups prefer occlusion at the level of the inguinal canal, other recommend occlusion at the level of the sacroiliac joint to interrupt the main venous pathway but to preserve distal collateral veins in order to allow venous drainage of the testis and to avoid thrombosis of the plexus. There are many diffent ways to embolize the spermatic vein: hot saline, cyanobucrylate, polidocanol, detachable balloons or coils. All techniques are successful as long all proximal sidebranches will be involved in the occlusion process to avoid recurrence.