Varicocele Embolization

• Definition

A varicocele is a collection of dilated veins within the pampiniform due to reflux in the gonadal vein. The condition affects 10% to 15% of the general population; and a greater percentage of men undergoing infertility workup. The condition is usually bilateral or isolated to the left side. Isolated right varicoceles are rare and should initiate cross-sectional imaging to exclude more serious causes. Diagnosis can be made by clinical examination and/or ultrasound.

• Indications

1. Pain causes by the varicocele
2. Infertility, if thought to be related to the varicocele
3. Testicular atrophy in the pediatric population

• Work-up

1. Clinical history and examination
2. Scrotal ultrasound to evaluate for abnormal reflux and dilated veins
3. Laboratory workup including CBC, BMP, Coagulation profile

• Procedure

After administration of local anesthetic, typically the right internal jugular vein or right common femoral vein are accessed under ultrasound guidance. Through this access a wire is introduced into the vein and a sheath is placed. Through the sheath a combination of catheters and wires are used to negotiate the path into the gonadal vein to be treated. Multiple contrast injections will be performed throughout the procedure to confirm location of the instruments. Once the wire and catheter are placed into the caudal aspect of the enlarged and/or refluxing gonadal vein, embolization is performed. There are many options for choice of embolic. Typically, a combination of metallic coils and sodium tetradecyl sulfate (STS) are used, however embolization with Cyanoacrylate glue and vascular plugs have also been described. The goal of this portion of the procedure is to obtain a complete embolization of the vein and branches to prevent recanalization. Once complete, a final venogram is performed to confirm treatment. All instruments are removed and hemostasis is obtained with 3-5 minutes of manual compression.

• Risks and complications

Overall complication rate with the procedure is low. As with any procedure that involves access into a blood vessel, there is a small risk for significant bleeding and infection. Additional risks are present related to specific embolic material used, for example:

1. Coils:
   • Misplacement or migration of coil to non-target site.
   • Venous perforation which is usually self-limiting.

2. Sclerosant and glue

• Phlebitis, (STS foam) which is usually self-limiting, and can be treated with NSAIDs and rest.

• Post-procedure care and follow-up

Post-procedure care varies between institutions. Likely, you will be monitored for 1-2 hours in recovery and then be discharged home. A small percent of patient will have some back pain and/or mild scrotal swelling, which typically resolve in 1-2 days. NSAIDs can be taken during this time to alleviate some of the symptoms, though you should check with your doctor before taking any medications. You should avoid any heavy exercise or lifting more that 10 pounds for 3-5 days after the procedure. Your doctor may order a follow-up scrotal ultrasound in 3-6 months and/or have you return to clinic to evaluate treatment response.