Antegrade pampiniform plexus venography in recurrent varicocele: Case report and anatomy review

Abstract

Varicoceles are often treated with percutaneous embolization, using fibered coils and sclerosing agents, with the latter targeted at occlusion of pre-existing collateral veins. While various methods of surgical and embolization treatment are available, varicoceles may still recur from venous collateralization. We present a case, where following demonstration of complete occlusion of the right and left gonadal veins, direct puncture of the pampiniform venous plexus under ultrasound guidance revealed recurrent varicoceles supplied by anastomoses from the ipsilateral saphenous and femoral veins to the pampiniform plexus. In doing so, we describe a technique of percutaneous pampiniform venography in a case where the pertinent anatomy was not easily demonstrated by other methods.

Keywords: Embolization; Pampiniform plexus; Varicocele; Venography.

Figure 1

Venography following transjugular access. A: Left gonadal venogram with transjugular access demonstrating large left varicocele; B: Left gonadal venogram, following coil occlusion of the gonadal vein at the internal inguinal ring, demonstrating extensive retroperitoneal collateralization.

Figure 2

Repeat venography via transjugular access, showing a cyanoacrylate cast of left gonadal vein and collaterals following coil placement and cyanoacrylate occlusion of collateral circulation.

Figure 3

Direct percutaneous pampiniform venography performed under ultrasound guidance. A: Collateral flow into the saphenous (arrow) and femoral (arrowhead) venous system through the external pudendal vein (double arrowhead). Cross filling from right to left through the scrotal veins is also demonstrated (double arrow); B: Collateral flow to the saphenous vein (arrow) through the external pudendal vein (double arrowhead) and to the external iliac vein through the cremasteric/inferior epigastric vein (double arrow).

Figure 4

Diagram illustrating retroperitoneal collaterals to the left gonadal vein. Gonadal vein (1) parallel retroperitoneal vein (2) renal capsular collateral vein (3) axial lateral retroperitoneal collateral vein to the colon (4) axial medial collateral (5).

Figure 5

Diagram illustrating trans-scrotal collateral communication with the pampiniform plexus. Cremasteric (external spermatic) vein (1) to inferior epigastric/external iliac vein; external pudendal vein (2) to saphenous vein; vein of the vas deferens (3) to internal iliac vein; left gonadal vein (4) trans-scrotal collateral veins (5).