Imaging Findings
Patient presented with clinical signs of bilateral varicoceles. A spermiogram turned out to be pathologic and the urologist referred the patient for outpatient bilateral embolization of his varicoceles. After treating the left-sided varicocele after access through the right femoral vein, a 4 F Sidewinder I catheter with an 0.038 in inner lumen (Tempo 4, Cordis Inc.) was inserted and managed into the right internal spermatic vein whose valve turned out to be incompetent (Fig. 1 a).
After inserting the Sidewinder catheter into the spermatic vein as deep as possible (Fig. 1 b), a 2.8 F superselective catheter was coaxially inserted deeply into the spermatic vein with its end positioned at the level of the right sacroiliac joint . Then, three 4 mm diameter platinum coils were placed into the vein (Fig. 1 c). In addition, 5cc of polidocanol were administered into the vein via the 2.8 F catheter while the patient was positioned in a 45 degree upright position. After 15 minutes, all material besides the coils was removed .
Discussion
Appearance of a varicocele is relativily frequent. In the male population, 10-15 % present with a varicocele. Treatment should be performed if the varicocele is symptomatic or subfertility is proven by a spermiogram.
There is some dispute about the relevance of right-sided varicoceles. In a subfertile population, 8 to 9% have bilateral varicoceles. Some authors found up to 60% of right sided varicoceles, if a left varicocele was present.
Subclinical right varicoceles may be a cause of treatment failure after successful occlusion of a left one. So it is recommended by some authors to search for a right varicocele in all patients being admitted for treatment of a left.
Transfemoral embolization of right-sided varicoceles is more difficult than of those of the left internal spermatic vein. Sidewinder catheters are most useful for selective intubation of the vein but are difficult to be advanced further down into the vein. Thus a coaxial technique is helpful. By use of catheters with a 0.038 in inner lumen, insertion of coaxial catheters becomes possible. Nevertheless, this approach is cost-intensive and should be applied only if adequate reimbursement is achievable.
Technically more difficult, exchange of the sidewinder catheter for a headhunter or cobra shaped catheter over a long exchange guidewire would be an option but can be technically challenging because of the acute angulation of the internal spermatic vein when entering into the vena cava. Alternatively, bilateral varicocele embolization may be performed via a transjugular access by use of headhunter catheters. By this route, insertion into both internal spermatic veins is easier.
In our case, we used coils to block the vein in order to keep the sclerosing agent in place not being washed out by persistent blood flow. Alternatively blocking the spermatic vein proximally by use of a n occlusion balloon would have been an alternative.
This rather expensive approach with regard to the material used saved a lot of room time and provided a more successful approach.
Many different occlusion material have been used for tretament of varicoceles including detachable balloons, coils, hot contrast material , hot saline or sclerosants. More or less, all techniques are effective.
Differential Diagnosis List
Transfemoral coil embolization and application of a sclerosing agent
Final Diagnosis
Transfemoral coil embolization and application of a sclerosing agent
