Liquid and Solid Embolic Agents in Gonadal Veins

Abstract

Male varicocele and pelvic congestion syndrome (PCS) are common pathologies with high predominance in young patients, having a high impact on the quality of life and infertility. Lately, the use of different endovascular embolization techniques, with various embolizing agents, shows good technical results and clinical outcomes. With the aim of presenting the "state of the art" of endovascular techniques for the treatment of male varicocele and PCS, and to discuss the performance of the different embolic agents proposed, we conducted an extensive analysis of the relevant literature and we reported and discussed the results of original studies and previous meta-analyses, providing an updated guide on this topic to clinicians and interventional radiologists. We have also underlined the technical aspects for the benefit of those who approach this type of interventional treatment. Our review suggests promising results in both the endovascular embolic treatment of male varicocele and PCS; for varicocele, a success rate of between 70% and 100% and a recurrence rate of up to 16% is reported, while for PCS it has been found that technical success is achieved in almost all cases of endovascular treatment, with a highly variable recurrence rate based on reports. Complications are overall rather rare and are represented by periprocedural pain, migration of embolic media and vascular perforations: severe adverse events have been reported very rarely.

Keywords: embolic agent; interventional radiology; pelvic congestion syndrome; varicocele; vein embolization.

Figure 1

Drawing shows spermatic vein embolization with coils: coils are first deployed as distal as possible and up to the inguinal canal. Then, a sandwich occlusion of the spermatic vein is performed with additional coils in the proximal part of the spermatic vein.

Figure 2

Drawing shows spermatic vein embolization with glue: glue is sequentially injected and pushed into the distal intrapelvic segment of the gonadal vein as well as into the collaterals; injection should be stopped before the pampiniform plexus is reached.

Figure 3

Drawing shows spermatic vein embolization with sclerosing agent: the sclerosant is administered through a catheter whose tip is placed in the most distal part of the ISV, at the level of the sacroiliac joint. Additional coils are deployed at the proximal part of the spermatic vein according to the sandwich technique.

Figure 4

Drawing shows spermatic vein embolization with sclerosing agent according to occluding balloon technique: this technique refers to the use of a temporary proximal OB catheter in addition to distal barrage, to stop the retrograde blood flow. The sclerosing agent is injected through the OB catheter into the distal portion of the ISV.

Figure 5

Drawing shows left and right ovarian veins and left and right hypogastric veins embolization with coils, as reported by Laborda et al. [76].

Figure 6

Drawing shows left and right ovarian veins embolization with glue: embolization should start from the distal portion of the ovarian vein at the level of the upper half of the sacroiliac joint, to include possible collateral branches.

Figure 7

Drawing shows left ovarian vein embolization using the stop-flow foam sclerotherapy (SFFS) reported by Gandini et al. [82]: the sclerosing agent was injected into the pelvic vessels after having inflated the balloon catheter to occlude the major tributary vessels (hypogastric and/or ovarian veins) and excluding high-outflow venous collaterals.

Figure 8

Drawing shows left ovarian vein embolization with sclerosing agent and coils: an occluding balloon is advanced to the lower third of the sacroiliac joint for the embolization of the gonadal vein; balloon insufflation was maintained for 5 min after the administration of sclerosant and the procedure was completed with the placement of metallic coils as reported by Meneses et al. [84].