Women's and Men's Health
Procedure Guide
Indications
Symptomatic (scrotal pain/swelling) varicoceles, occurs in 10-15% of men
Infertility or adolescent vaicocele with testicular atrophy
Post-surgical ligation recurrence
Grading:
Grade 1 - palpable only with valsalva
Grade 2 - non-visible but palpable upon standing
Grade 3 - visible on gross inspection
Contraindications
No safe access
Uncorrected coagulopathy (INR >2.0, Plts <50K)
Efficacy and alternatives
Embolization: ~100% technical success. Most patients can work the following day.
30-35% of couples with male-factor infertility are able to achieve normal pregnancy.
Similar efficacy for microsurgical ligation/varicocelectomy. May be superior for bilateral varicoceles.
Pre-procedure care
Nothing specific necessary for young otherwise healthy patient
Labs for older/sicker patients: CBC, BUN, Cr, PT/INR
Procedure
Internal jugular, greater saphenous, or common femoral vein access.
Advance working wire (e.g. Amplatz) into IVC.
Advance curved catheter (C2, MPA, Berstein) and exchange working wire for angled glidewire.
Select the left renal vein. Optional venogram +/- Valsalva to assess for gonadal venous reflux.
Select left gonadal vein and perform a venogram +/- Valsalva to assess for gonadal venous reflux.
Advance microcatheter (e.g. 2.7 ProGreat) to level of inguinal ligament (~roof of acetabulum)
Embolize up to origin from left renal vein via coils, glue, 3% STS foam, etc
Many do coil-foam-coil but some advocate for glue to fill small collaterals that can lessen effectiveness if not embolized.
Systematic review found no difference in complication rate between embolics. Recurrence rate was lowest for glue (4%) and highest for sclerosant alone (11%) but less follow up for glue in included studies.
Post-embolization venogram to identify and embolize any capsular, hilar, or colic collaterals.
Select right gonadal vein, often arising from IVC or right renal vein.
Repeat process described above with venography and embolization.
Remove catheter/sheath and achieve hemostasis.
Complications
Infection, bleeding, mild-transient scrotal pain, coil migration, venous perforation, phlebitis
Post-procedure care and follow up
Monitor 2-3 hrs post-procedure
Heat pack/pad + NSAID for scrotal pain/swelling or back pain (~10% of patients)
No lifting >20 lbs for 48 hrs post-procedure
3 month follow up US
1-3 month clinic follow up