Varicocele Embolization

Varicocele Embolization is a minimally invasive endovascular procedure designed to address varicocele, a condition characterized by the abnormal enlargement and dilation of the veins within the scrotum, particularly the testicular veins.

Patients with varicocele may experience a range of symptoms, and the decision to undergo testicular vein embolization is typically based on the severity of symptoms and associated complications. Here are some symptoms that may indicate a need for testicular vein embolization:

Scrotal Discomfort or Pain: Varicocele can cause dull, aching, or throbbing pain in the scrotum. The pain may vary from mild to severe and may worsen with prolonged standing or physical activity.

Testicular Pain: Varicocele-related pain may specifically affect the testicles, leading to discomfort, tenderness, or a feeling of heaviness in the affected testis. The pain may be intermittent or persistent.

Testicular Atrophy: In some cases, varicoceles can result in testicular atrophy or shrinkage. This occurs due to impaired blood flow and oxygenation to the testicles, potentially affecting their size and function.

Fertility Issues: Varicoceles can contribute to male infertility. They may impair sperm production, quality, and motility. If a man experiences fertility issues, such as difficulties conceiving, varicocele may be evaluated as a potential contributing factor.

Visible or Palpable Enlarged Veins: In certain cases, varicoceles can be visually or manually detected as enlarged, dilated, or twisted veins within the scrotum. These veins may be more prominent or palpable when standing or during Valsalva maneuver (straining).

Angiographically, the tortuous varicose veins are demonstrated in the pelvic cavity, where contrast congests or pools within this region as the valves are dysfunctional and fail to regulate normal venous return towards the heart. Most cases only require embolization of the left testicular vein, but other veins including the right testicular vein, and iliac veins are investigated.

Embolic particles are used to interrupt the abnormal blood flow in the varicocele, aiming to alleviate the symptoms associated with this condition.

A&I Protocol

Varicocele Embolization can be performed by either a jugular approach or femoral approach. Both approaches are detailed here:

Jugular Approach:

Seldinger technique is used to gain access into the right internal jugular vein.
A 5 French (F) sheath is inserted into the right internal jugular vein over an 0.035" guidewire.
A 5 F Multi-purpose catheter is navigated down the superior vena cava (SVC), and inferior vena cava (IVC) towards the level of the left renal vein at approximately the second lumbar vertebrae (L2).
Under fluoroscopy, small amounts of contrast is injected to visualize the origin of the left testicular vein and accessed using the 5 F catheter and guidewire.
Different guidewires can be used to try and access the left renal vein and left testicular vein if a standard 0.035" is not compatible (e.g. 0.035" glide-wire).
Under fluoroscopy, the patient is instructed to perform a Valsalva maneuver (forceful expiration under a closed airway) while injecting contrast through the 5 F catheter to highlight the left testicular vein dilatation and the congestion of pelvic varicose veins.
The ovarian vein/s diameters are measured on the angiography machine and the embolization coils are upsized by 10%.
Deployment of embolization coils are performed from the distal to proximal direction. Sclerotherapy drugs which contain sodium tetradecyl sulfate can be used between coils to assist with treating the varicose veins.
Contrast injections under fluoroscopy is used to check that the left testicular vein (single or multiple branches) are embolized and prevent contrast from travelling down towards to the pelvis. It is important to also allow some time to pass before checking to allow the coils to expand.
Following embolization of the left testicular vein, the right renal vein and right testicular vein are checked for contribution to the varicocele. If the varicocele is demonstrated then embolization coils (and sclerosants) are used to block the right testicular vein.
Following this, the left and right internal iliac veins are imaged under fluoroscopy, contrast injection, and Valsalva maneuver. If dilatation and reflux is demonstrated, then embolization coils are deployed to treat these veins.
The vascular devices are removed post-procedure, pressure is applied on the neck region, and the angiography table can be placed in reverse-Trendelenburg position.

Femoral Approach:

Seldinger technique is used to gain access into the right common femoral vein.
A 5 French (F) sheath is inserted into the right common femoral vein over an 0.035" guidewire.
A 5 F Hockey-stick catheter is navigated up the IVC towards the level of the left renal vein at approximately the second lumbar vertebrae (L2).
Under fluoroscopy, small amounts of contrast is injected to visualize the origin of the left testicular vein and accessed using the 5 F catheter and guidewire.
Different guidewires can be used to try and access the left renal vein and left testicular vein if a standard 0.035" is not compatible (e.g. 0.035" glide-wire).
Under fluoroscopy, the patient is instructed to perform a Valsalva maneuver (forceful expiration under a closed airway) while injecting contrast through the 5 F catheter to highlight the left testicular vein dilatation and the congestion of pelvic varicose veins.
The ovarian vein/s diameters are measured on the angiography machine and the embolization coils are upsized by 10%.
Deployment of embolization coils are performed from the distal to proximal direction. Sclerotherapy drugs which contain sodium tetradecyl sulfate can be used between coils to assist with treating the varicose veins.
Contrast injections under fluoroscopy is used to check that the left testicular vein (single or multiple branches) are embolized and prevent contrast from travelling down towards to the pelvis. It is important to also allow some time to pass before checking to allow the coils to expand.
Following embolization of the left testicular vein, the right renal vein and right testicular vein are checked for contribution to the varicocele. If the varicocele is demonstrated then embolization coils (and sclerosants) are used to block the right testicular vein.
Following this, the left and right internal iliac veins are imaged under fluoroscopy, contrast injection, and Valsalva maneuver. If dilatation and reflux is demonstrated, then embolization coils are deployed to treat these veins.
The vascular devices are removed post-procedure, pressure is applied on the groin region, and the angiography table can be placed in reverse-Trendelenburg position.

Fluoroscopy image showing the use of embolization coils to block the testicular veins.

References

Kuroiwa T, Hasuo K, Yasumori K, Mizushima A, Yoshida K, Hirakata R, et al. Transcatheter embolization of testicular vein for varicocele testis. Acta Radiol. 1991 Jul;32(4):311–4.
Bittles MA, Hoffer EK. Gonadal vein embolization: treatment of varicocele and pelvic congestion syndrome. Semin Intervent Radiol. 2008 Sep;25(3):261–70.
Sheehan M, Briody H, O’Neill DC, Bowden D, Davis NF, Given M, et al. Pain relief after varicocele embolization: The patient’s perspective. J Med Imaging Radiat Oncol. 2020 Apr;64(2):215–9.
Kwak N, Siegel D. Imaging and interventional therapy for varicoceles. Curr Urol Rep. 2014 Apr;15(4):399.
Cornud F, Belin X, Amar E, Delafontaine D, Hélénon O, Moreau JF. Varicocele: strategies in diagnosis and treatment. Eur Radiol. 1999;9(3):536–45.