Figure 1
ISV embolization with glue. Right: Selective venography in erect position with the diagnostic catheter (arrow) in the outflow of the internal left spermatic vein. Internal spermatic vein insufficiency (small arrows) is proved with visualization of the pampiniform plexus (arrowhead). Right middle: Microcatheter (arrow) venography performed in horizontal supine position, revealed a small paraspermatic collateral (small arrows) originating from the lateral duplication of the inguinal internal spermatic vein. This anatomy forced us to reposition the microcatheter in the lateral bifurcation of the internal spermatic vein to be sure that the small collateral is also occluded during controlled injection of glue. Glue embolization will be started in the lateral branch at the level of the coxofemoral joint. During withdrawing of the microcatheter, the glue is pushed into the lateral branch, the small collateral and finally into the medial branch and the main internal spermatic vein then up to the level of the crista iliaca. Left middle: Embolization cast in the left spermatic vein with the glue located between the coxo-femoral joint and the crista iliaca including the small paraspermatic branch. Left: Control venography with the diagnostic catheter in the internal spermatic vein (arrow) demonstrates contrast agent up to the glue cast (small arrows) and the absence of contrast to the pampiniform plexus (arrowhead).
Table 1
Published series of varicoceles treated with glue.
| N (pt) | Tissue-adhesive | glue/ lipiodol | Technical failure | Technical complications | Clinical complications (mild to moderate discomfort) | Recurrences | Pregnancy rate | ||
|---|---|---|---|---|---|---|---|---|---|
| during embolization | 1 wk after embolization | ||||||||
| Kunnen ’80 | 35 | IBCA | NA | 0% | 2.8% (1 glued catheter) | 0% (PE+T+CDUS) | NA | ||
| Comhaire ’85 | 97 | IBCA | NA | 0% | NA | 0% (PE+T+CDUS) | 50.5% | ||
| Mansfeld ’86 | 30 | NBCA | NA | 3% (1pt on PE) | |||||
| Nieschlag ’93 | 33 | NBCA | NA | 6% (2pt) | 33% (12 months) | ||||
| Heye ’06 | 64 | NBCA–MS (32) NBCA (32) | 1/0.8 1/0.8 | 0% | 17% (11 perforations) | 3.28 NBCA–MS 3.23 NBCA*** | 2.1% (1pt) | ||
| Sze ’08 | 9 8 | NBCA NBCA+coils | 1/3* | 0% | 5.9% (thromboplebitis | 5.9% | |||
| Vanlangenhove ’12 | 83 | NBCA (54) NBCA–MS (58) | 1/1.2 1/1 | 0% | 1.2% (1 acute allergic reaction) | 48% NBCA 38% NBCA–MS | 57% NBCA 60% NBCA–MS | 0 | |
| Pietura ’13 | 17 | NBCA | 1/1 | 0%** | 0% | 100% | 17.6% | 0% (3 months/CDUS) | |
| Urbano ’14**** | 41 | NBCA–MS | 1/1 | 0% | 0% | NA | 17% | 0% (12 months PE+CDUS) | |
[i] NA: Not available.
*: Ethiodol.
**: only phlebographic control in 3 of the 17 patients.
***: mean VAS pain score.
****: no coaxially catheter system/all patients took NSAID during 3 days.
italic: same patient group.
PE: physical examination, T: thermography, CDUS: colour Doppler ultrasound.
Table 2a
Phlebographic characteristics of the left insufficient ISV in adults and adolescents.
| Phlebographic characteristics of the left ISV | Adolescents N = number adolescents/total N = 191(%)* | Adults N = number adults/total N = 218 (%)* | P-value | |
|---|---|---|---|---|
| Spontaneous visualization of the ISV | 164/190 (86.3) | 154/214 (72.0) | 0.001 | |
| Incompetence of the outflow valve** | 128/190 (67.4) | 125/216 (57.9) | 0.052 | |
| Outflow of the ISV in the RV | Single outflow | 179/191 (93.7) | 189/218 (86.7) | 0.021 |
| Complex outflow | 12/191 (6.3) | 29/218 (13.3) | ||
| Reno-spermatic bypass | Absent | 142/191 (74.3) | 175/218 (80.3) | 0.157 |
| Complete | 49/191 (25.7) | 43/218 (19.7) | ||
| Mean nr. of competent valves below the outflow valve | 0.17 | 0.33 | 0.000 | |
| Duplication of the ISV | Solitary ISV | 130/191 (68.1) | 127/218 (58.3) | 0.052 |
| Multiple/duplication | 61/191 (31.9) | 91/218 (41.6) | ||
| Paraspermatic veins | 178/191 (93.2) | 204/218 (93.6) | 1.000 | |
| Collaterals | collaterals | 108/191 (56.5) | 154/218 (70.6) | 0.030 |
| lateral collaterals | 92/191 (48.2) | 128/218 (58.7) | 0.037 | |
| medial collaterals | 58/191 (30.4) | 97/218 (44.5) | 0.004 | |
| Nutcracker Phenomenon | Absent | 120/157 (76.4) | 189/200 (94.5) | 0.000 |
| Anterior | 14/157 (8.9) | 4/200 (2) | ||
| Posterior | 22/157 (14) | 6/200 (3) | ||
| Combined | 1/157 (0.6) | 1/200 (0.5) | ||
| Diameter of the ISV(mean) cm | 4.00 | 3.96 | 0.378 | |
| Outflow angle of the ISV(mean) | 103.66 | 108.30 | 0.076 | |
| Outflow angle of the ISV if Bährens type 2(mean) | 110.00 | 106.46 | 0.885 | |
| Bähren classification** | Type 1 | 60/185 (32.4) | 51/209 (24.4) | 0.009 |
| Type 2 | 32/185 (17.3) | 36/209 (17.2) | ||
| Type 2b | 12/185 (6.5) | 38/209 (18.2) | ||
| Type 3 | 20/185 (10.8) | 12/209 (5.7) | ||
| Type 4a | 11/185 (5.9) | 18/209 (8.6) | ||
| Type 4b | 45/185 (24.3) | 44/209 (21.1) | ||
| Type 5 | 5/185 (2.7) | 10/209 (4.8) | ||
[i] * For some characteristics the number of patients does not equal the total number of adults or adolescents because we omitted patients in whom the characteristics could not be determined.
** The sum of type 2b and 4b is lower than the number of competent outflow valves, because the Bähren classification does not take into account insufficiencies that can only be proven by passing the competent outflow valve. Moreover 15 patients were excluded (nine adults and six adolescents) because their phlebography could not be classified according Bähren. Type 0 was encountered in six adults.
Figure 2a
Bähren classification (left ISV) [Bahren, et al. 1992, Rofo, 157, 355–60] (with permission of Röfo, Thieme).
Table 2b
Phlebographic characteristics of the right insufficient ISV in adults and adolescents.
| Phlebographic characteristics of the right ISV | Adolescents N = number adolescents/total N = 28 (%)* | Adults N = number adults/total N = 80(%)* | P-value | |
|---|---|---|---|---|
| Spontaneous visualization of the ISV (IVC injection) | 0/27 (0.0) | 5/77 (6.5) | 0.323 | |
| Spontaneous visualization of the ISV (RV injection) | 4/27 (14.8) | 11/78 (14.1) | 1.000 | |
| Incompetence of the outflow valve (IVC injection) | 1/26 (3.8) | 5/77 (6.5) | 1.000 | |
| Incompetence of the outflow valve (RV injection) | 4/26 (15.4) | 10/71 (14.1) | 1.000 | |
| Reno-spermatic bypass | Absent | 26/28 (92.9) | 78/80 (97.5) | 0.290 |
| Complete | 2/28 (7.1) | 2/80 (2.5) | ||
| Mean nr. of competent valves below the outflow valve | 0.11 | 0.23 | 0.514 | |
| Duplication of the ISV | Solitary ISV | 12/28 (42.9) | 37/80 (46.2) | 0.304 |
| Multiple/duplication | 16/28 (47.2) | 43/80 (53.7) | ||
| Paraspermatic veins | 23/28 (82.1) | 71/80 (88.8) | 0.513 | |
| Collaterals | collaterals | 13/28 (46.4) | 40/80 (50) | 0.744 |
| lateral collaterals | 12/28 (42.9) | 34/80 (42.5) | 1.000 | |
| medial collaterals | 5/28 (17.9) | 28/80 (35.4) | 0.099 | |
| Outflow level of the ISV into the ICV | L1 | 0/28 (0) | 3/79 (3.8) | 0.964 |
| L1–L2 | 6/28 (21.4) | 17/79 (21.5) | ||
| L2 | 10/28 (35.7) | 30/79 (38) | ||
| L2–L3 | 9/28 (32.1) | 20/79 (25.3) | ||
| L3 | 3/28 (10.7) | 8/79 (10.1) | ||
| L3–L4 | 0/28 (0) | 1/79 (1.3) | ||
| Diameter of the ISV(mean) cm | 3.51 | 3.99 | 0.023 | |
| Outflow angle of the ISV and the ICV (mean)° | 31.04 | 25.13 | 0.070 | |
| Outflow angle of the ISV and RV (Siegel type 4a) (mean)° | 110.60 | 90.83 | 0.383 | |
| Siegel classification | Type 1 | 9/28 (32.1) | 29/79 (36.7) | 0.532 |
| Type 2 | 8/28 (28.6) | 21/79 (26.6) | ||
| Type 2a | 6/28 (21.4) | 13/79 (16.4) | ||
| Type 3 | 0/28 (0) | 5/79 (6.3) | ||
| Type 4 | 1/28 (3.6) | 7/79 (8.9) | ||
| Type 4a | 4/28 (14.3) | 4/79 (5.1) | ||
[i] * For some characteristics the number of patients does not equal the total number of adults or adolescents because we omitted patients in whom the characteristics could not be determined.
Figure 2b
Siegel classification (right ISV) [Siegel, et al. 2006, Cardiovasc Intervent Radiol, 29, 192–7] (with permission of CVIR, Springer).
Figure 3
Locations of venous pressure measurements. Pressure measurements performed in the renal vein (small arrow), in the outflow (double small arrows) and inguinal segment (triple small arrows) of the internal spermatic vein in 0° and 45° position. Radio-opaque yardstick (curved arrow).
Figure 4
Extrapolation of 45° to 90°: (RV = renal vein/ISV = internal spermatic vein). The pressure P at 45° was calculated as h = P / ρ × g to obtain the height of the corresponding fluid column (A). This height (A) corresponds to the perpendicular side of a triangle, of which the oblique side (C) would correspond to the theoretical height in 90° erect position. This oblique side (C) can be calculated with the formula: sin 45° = obtained height/oblique side. Then the oblique side was put in the formula P = ρ × g × h to calculate the extrapolated pressure at 90° erect position.