Introduction

Varicoceles are abnormal dilatations of the pampiniform venous plexus resting just above each testicle that can result in either symptoms (eg, pain, swelling) or suboptimal fertility. The primary cause of varicoceles is the absence of functioning venous valves of the left spermatic vein. Treatment of varicoceles includes surgery or percutaneous embolization with the intention of occluding the incompetent spermatic vein. To date, results for both approaches have similar outcomes, with embolization having the distinct advantage of being minimally invasive and having fewer periprocedural complications. The selection of a durable, effective embolic agent is critical despite working in the relative safety of a closed venous system, as local anatomical constraints (hidden collaterals) and propensity of the spermatic vein to spasm can contribute to recurrences and treatment failure.

The following case study highlights the use of an embolization agent that allowed for quick and effective spermatic vein embolization.

Procedure Description

A 30-year-old man presented with painful left scrotal swelling diagnosed on ultrasound as a left varicocele. Catheterization of the origin of the left spermatic vein was achieved with a 7-F Hopkins Guide Catheter, and the venogram demonstrated an incompetent left gonadal vein. Multiple collaterals joined at the level of the acetabulum, in the main incompetent gonadal vein, with an additional small, separate medial collateral vein. We proceeded with catheterization, advancing a 5-F JB1 Catheter and 0.035-inch Bentson Guidewire to the main distal gonadal vein, approximately 2 cm above the internal inguinal ring. We placed a Renegade® STC Microcatheter through the JB1 Catheter and advanced it into the main spermatic vein (Figure 1).

The main spermatic vein was coiled with a combination of 2D Helical Interlock™ Fibered IDC Occlusion Coils (4 mm X 8 cm, 5 mm X 15 cm, 6 mm X 20 cm, 8 mm X 20 cm, and 10 mm X 30 cm) for scaffolding wall apposition and stability and filled with VortX® Diamond-shaped coils (5 mm X 5.8 cm, 6 mm X 8 cm). The medial collateral vein was then catheterized, which bypassed the main spermatic vein to fill the varicocele and embolized with two small VortX® Diamond-shaped coils (3 mm X 2.3 cm).

The end-of-procedure venogram with Valsava demonstrated complete embolization of the spermatic vein feeders with a tight nest of nine total Interlock™ Detachable Coils (Figure 2). Total procedure time was 45 minutes.

Discussion

In selecting the embolic coil for varicocele embolization, several features of the spermatic vein have to be considered. Despite the relatively low risk of nontarget embolization within a varicocele, the spermatic vein is very susceptible to spasm and can have hidden collateral veins that contribute to both technical failure and recurrence. The Interlock coil offers the clinician the ability to retract and manipulate the coil prior to detachment, which allowed for optimal packing of a tight nest of coils in this case. In addition, the wide variety of available lengths shortened procedures, reducing gonadal radiation exposure, which is especially important in the adolescent male. Moreover, inadequate coil nesting, as is sometimes seen with pushable coils, may leave slow residual spermatic vein flow and allow collateral veins to remain obscured and treated.

Kelvin Hong, MD, is an Interventional Radiologist at Johns Hopkins University Medical School in Baltimore, Maryland.