Retrograde sclerotherapy of male varicocele with veno-venous shunts - incidence and management: a single-centre experience

Abstract

Objectives: The aim of our study is to compare the incidence of veno-venous shunts in male varicocele and evaluate the possibility to exclude them with manual compression or/and scrotal ligation in order to carry out the procedure of retrograde sclero-embolization.

Methods: In our retrospective study, all patients undergone retrograde sclerotherapy for varicocele in our Interventional Radiology Unit in the last four years were evaluated. Collaterals toward other venous shunts were identified and how many and which patients would be able to complete the procedure safely were considered.

Results: Of the 91 patients, as many as 22 (i.e., 24.17%) patients presented anatomical variants, consisting on shunting into left iliac vein (9 [9.89%]), lumbar left veins (3 [3.29%]), right iliac vein (1 [1.09%]), both iliac veins (1 [1.09%]), left femoral vein (1 [1.09%]) or a more proximal portion of the ISV itself without shunting (3 [3.29%]). Patients with duplication could benefit from a more distal injection in order to prevent back-flow; of the 19 left, nine successfully underwent sclerotherapy with manual compression or/and scrotal ligation, whereas in 10 flow through the collaterals could not be interrupted and patients were demanded for surgery.

Conclusions: Many patients with abnormal communications between the internal spermatic vein and the iliac veins (that is, shunts towards the iliac veins) may as well undergo retrograde sclerotherapy safely if compression/ligation is applied.

Advances in knowledge: No large previous study highlighted the impact of veno-venous shunts in technical feasibility of retrograde sclerotherapy of varicocele.

Figure 1.

phlebographies from two different patients with duplication of the ISV (Bahren Class III). In patient 1, the ISV shows multiple duplications (red arrows), originating from the mean tract of the spermatic vein and directed to renal, retroperitoneal, and ureteral veins (fluoroscopy images at a higher level-A and B) to pelvic viscera through iliac vein branches (fluoroscopy images at a lower level-C); distal injection of the SA (at the level of the iliac branch) shows that collateral branches are not involved by reflux, while manual compression avoids penetration of the embolic agent into pampiniform plexus (D). In patient 2, additional retroperitoneal branches (red arrows) reach the level of the sacroiliac joint (A);distal injection (at the same level) allows the exclusion of these collaterals and technical success without complications.

Figure 2.

phlebographies from 6 patients (patients 3–8) successfully treated presenting flow through collaterals towards iliac veins (Bahren Class IV). Per each patient a homo-lateral iliac shunt is shown in figure A (red arrow) originating at the level of the internal inguinal ring and flow through shunts is excluded after manual compression at the level of the external inguinal ring or ileo-pubic branch; sometimes scrotal ligation (patients 6 and 7) was necessary to exclude shunting correctly. In patient eight contra lateral iliac shunt is seen at the level of the ileo-pubic branch (red arrows in A) and flow is reduced (red arrow in B) after scrotal ligation.

Figure 3.

(patients 9–15): phlebographies from non-treated patients, where neither compression nor ligation yielded stop or adequate flow reduction through the collaterals (red arrows). Patients 9 and 10 DSA showed a massive left iliac shunt at the level of the internal inguinal ring (Bahren Class IV). Patient 11: DSA showing bilateral iliac shunts below the level of the coxofemoral joint, persisting after compression and ligation (Bahren Class IV). Patient 12: minimum left femoral shunt below the level of the coxofemoral joint (Bahren Class IV). Patient 13: a small-caliber vessel (yellow arrow) arising from the left renal vein anastomosing with the true ISV (red arrow), which drains into a lumbar collector (left paravertebral, level L2-L4, Bahren Class II). Patient 14: internal spermatic vein draining into a left lumbar collector (left paravertebral, level L3-L4; Bahren Class II). Patient 15: internal spermatic vein with collaterals towards pyelo-ureteral veins (level L3-L4; red arrows) draining into left iliac (Level S1; yellow arrow) and retroperitoneal veins (level L4; blue arrow; Bahren Class IV).