Transcatheter Embolization of Varicocele Using Sotradecol Foam
Eric Reiner, D.O., Melih Arici, M.D., Jonathan Kirsch, M.D., Hamid Mojibian, M.D., Jeffrey Pollak, M.D., Katharine Henderson, M.S., Robert White Jr., M.D., Robert Weiss, M.D..
Yale University School of Medicine, New Haven, CT, USA.
To describe an improved Sotradecol foam (STS) and pushable fibered coil embolization method for the treatment of varicocele and to report the results of treatment.
Between September 2004 and August 2008, 55 patients with varicoceles associated with pain, testicular atrophy or infertility were seen in our clinic and treated as outpatients by transcatheter embolization of the internal spermatic vein using distal pushable fibered coils and STS. Follow up between 3 and 12 months post treatment was performed by ultrasound and/or physical exam by the interventional radiologist or the referring urologist. Outcomes were tabulated with human investigation committee approval.
Our improved technique included right femoral vein access with a 7 French guiding catheter and distal catheterization of the internal spermatic vein (ISV) with a 5 French glide catheter or microcatheter. Pushable fibered coils were packed into the distal ISV at the level of the inguinal canal. Undiluted contrast material was injected during a valsalva maneuver, distally into the ISV beyond the inguinal set of coils and into parallel collateral veins which were not apparent on the initial venogram. 2% STS foam was injected in 2-3 ml aliquots to displace the static contrast material. The foam injections were repeated 1-2 additional times. After the deployment of a second set of coils at the level of the upper 1/3 of the sacroiliac joint, additional foam was injected.
55 consecutive patients (mean age 21 years (range 11-58 years)) were treated successfully during 58 procedures. The primary technical success rate was 98% (57/58). There were no procedure related complications but 10/55 (18%) had mild self limited pampiniform phlebitis. All returned to regular activities the next day. Follow-up by ultrasound and/or physical exam is complete in 40 patients at this time. There have been 3 recurrences and 2 of 3 have been successfully retreated.
STS foam treatment of varicoceles after distal coil embolization of the ISV represents an important modification of our earlier work. The advantages of this improved technique are greater penetration of ISV collaterals, fewer coils, permitting greater future access, if needed, and no further need for left groin compression during foam administration.