Endovascular Treatment of Varicocele and Pelvic Congestion SyndromePeter H. Lin, MDChief of Vascular Surgery & Director of Interventional RadiologyMichael E. DeBakey VA Medical CenterChief of Vascular Surgery Baylor College of MedicineHouston, TX

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Why Should Vascular Surgeons Care About Varicocele or Pelvic Congestion Syndrome (PCS)?

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Why Care about Varicocele or PCS?1. Both conditions share common pathophysiology and interventional treatment strategy.Reflux of gonadal veins2. Its an extension of endovascular venous practice 3. Its an endovascular procedure which requires common interventional skill set. Entry needle, Bentson wire, 0.035 catheter, microcatheter, microcoils, embolic agents, fluoroscopic procedure.

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4. Its a great way to expand your endovascular practice and increase referrals Urologist renal tumor embolization OB/GYN fibroid embolization, varicose veins5. High patient satisfaction 6. Outpatient procedure7. Favorable reimbursementWhy Care about Varicocele or PCS?

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Presentation OutlinePathophysiologyClinical PresentationsEvaluationTreatment

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PathophysiologyVaricocele abnormally dilated testicular veins of the scrotumCommonly due to testicular / internal spermatic vein refluxPresent in 15% of general population, common in adolescent but rare in prepubertal boys.35% of men with primary infertility, and 80% of men with secondary infertility

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Normal Gonadal Vein Drainage

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Reflux of Gonadal Veins (Varicocele & Ovarian Varices)

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Embolization of Gonadal Vein

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VaricoceleL. varicocele: 5 times more common than R. varicocele.L. testicular vein drains into L. renal vein, and is 8-10 cm longer than R. testicular vein which drains into IVC.Etiological factors: longer length, increased tortuosity, potential compression which increased pressure, absent or incompetent venous valve, or valvular reflux Varicocele result in increased scrotal temperature which leads to infertility

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Pelvic Congestion Syndrome aka. Ovarian VaricocelePelvic varicositiesRetrograde flow in ovarian vein

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Chronic Pelvic PainDefinitionNon-cyclic abdominal and pelvic painAt least 6 months durationAccounts for 15% of outpatient gynecologic visits30% of diagnostic laparoscopic exams

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Pelvic Congestion SyndromeThere is an organic causeAbnormal flow of blood down into the pelvis causing engorgement in the veins of the pelvisStudies showing 30% of patients with chronic pelvic pain have PCS as a sole cause of their painAdditional 15% have PCS in addition to other pelvic pathology

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Ovarian Vein VaricesCause of Ovarian vein varices?Increase in size related to previous pregnancyBlood flow > 60 foldPressureHormonal factorsUnusual in women who have not been pregnant

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Presentation OutlinePathophysiologyClinical PresentationsEvaluationTreatment

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VaricoceleIncompetent venous valve

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Varicose VeinsIncompetent venous valve

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Ovarian Vein VaricesNon-specific physical findingsSymptoms include chronic pelvic pain, pain with intercourse, vaginal discharge, and unusual bleeding.

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Presentation OutlinePathophysiologyClinical PresentationsEvaluationTreatment

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Normal Ovarian VeinsCompetent valves prevent refluxVeins are small 5mm

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Injection of left ovarianvein

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Large left ovarian veinCT Scan

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Enlarged left ovarian veinCross pelvic collateralsCT Scan

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CT ReconstructionEnlarged ovarian vein

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MRI

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Laparoscopy of Pelvic VaricesEvaluation of Pelvic Congestion Syndrome

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Presentation OutlinePathophysiologyClinical PresentationsDiagnosisTreatment

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Therapy for Varicocele Surgical varicocelectomyLaparoscopic varicocelectomyEndovascular embolization of testicular vein

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Therapy for Ovarian Vein VaricesAnalgesicsOvarian suppressionSurgicalHysterectomy, removal of ovariesLigation of left ovarian veinRetroperitoneal approachLaparoscopic ligation-ovarian vein/collateralsEndovascular embolization

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Open VaricocelectomyOblique incision over inguinal ring

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Isolation of the spermatic cord & varicoceleOpen Varicocelectomy

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Open VaricocelectomyDivision of varicocele & testicular vein

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Laparoscopic Varicocelectemy

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Laparoscopic VaricocelectemyStandard abdominal laparoscopy. Spermatic cord isolated above internal inguinal ring

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Laparoscopic VaricocelectemyTesticular vein is isolated

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Laparoscopic VaricocelectemyLaparoscopic clips applied across the testicular vein

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Endovascular Embolization of Gonadal Vein

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Embolization of Gonadal Vein TechniqueVia right groin or jugular veinCatheterize left kidney vein with patient on a table tilted head-upIf reflux, catheter is advanced into gonadal vein

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Step 1 - IVC wire access1_CAVA.avi

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Step 2 left renal vein angiogram2_renal-V-gram.avi

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Step 3 selective catheterization of left gonadal vein 0.35 angle catheter selectionMicrocatheter placement into gonadal vein

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Step 3 selective catheterization of left gonadal vein C2 RDC RC1 Bern

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Step 3 selective catheterization of left gonadal vein SIM2 catheter

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Step 3 selective catheterization of left gonadal vein2.5_gonadal.avi

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Step 4 microcoil placement in the gonadal vein3_embolization.avi

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Step 4 microcoil placement in the gonadal vein3.5_embo.avi

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Step 4 microcoil placement in the gonadal vein3.7_prox embo.avi

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Step 4 microcoil placement in the gonadal vein

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Step 4 microcoil placement in the gonadal vein4_completion.avi

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Step 4 microcoil placement in the gonadal vein

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Step 5 Right gonadal vein injection

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Embolization of Gonadal Vein Embolic agent:Sclerosing agent (cyanoacrylate) Platinum Fibered Coils (0.035) Detachable Microcoils (0.018)

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Detachable CoilsUsed to occlude aneurysms, AVF, parent artery, etc.

Soft, platinum wireMore controlReliable repositioning Available in a wide range of sizes

Terumo AZUR hydrocoil

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Controlled Hydrogel Expansion20 minutetime-lapsephotographyAZUR

3X diameterexpansionover 20 minutesConventionalPlatinum coil1 Volume5_hydrocoil.avi

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Expanded Volume ComparisonCompared to similar length of bare platinum coils:

AZUR 18~ x5 volume Platinum 18AZUR 35~ x4 volume of Platinum 351 Volume

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Detachable Hydrocoil BSC GDCA detachable coil system allows:Better controlRepositioning of the coilRetrieving the coil when necessary prior to detachmentThrombosis is not affected by anticoagulationH+H+H+H2OH2OH2OH2O

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Thermoelectric Coil DetachmentTerumo AZUR hydrocoil

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7_hydrocoil_deploy.avi

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ConclusionsEmbolization of testicular vein or ovarian vein are effective treatment strategy in varicocele or ovarian varices/pelvic congestion syndromeEndovascular embolization is a part of multi-disciplinary treatment approach of these conditionsVascular surgeons with endovenous practice are well suited to provide this endovascular treatment

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ConclusionsExpanded endovascular referrals in urological and gynecological endovascular procedures renal tumor embolizationuterine fibroid embolization & varicose vein ablationDetachable coils with microcatheter provide procedural safety and increase treatment success

Varicoceles are abnormally dilated testicular veins (pampiniform plexus) of in the scrotum, which is normally secondary to internal spermatic vein reflux. Varicocele is found in approximately 15% of the general population, 35% of men with primary infertility and in 75-81% of men with secondary infertility. It is more common on the left side. In adolescents, the incidence of varicocele is approximately 15%; the abnormality is extremely rare in prepubertal boys When placed in a buffered solution (e.g. blood), gradual de-protonation of carboxylic acid groups allows uptake of water into the polymer matrix (after about 5 minutes), resulting in expansion