Endovascular Treatment of Varicocele and Pelvic Congestion Syndrome

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Endovascular Treatment of Varicocele and Pelvic
Congestion Syndrome

• Peter H. Lin, MD
• Chief of Vascular Surgery Director of
  Interventional Radiology
• Michael E. DeBakey VA Medical Center
• Chief of Vascular Surgery
• Baylor College of Medicine
• Houston, TX

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Why Should Vascular Surgeons Care About
Varicocele or Pelvic Congestion Syndrome (PCS)?
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Why Care about Varicocele or PCS?

• 1. Both conditions share common pathophysiology
  and interventional treatment strategy.
• Reflux of gonadal veins
• 2. Its an extension of endovascular venous
  practice
• 3. Its an endovascular procedure which requires
  common interventional skill set.
• Entry needle, Bentson wire, 0.035 catheter,
  microcatheter, microcoils, embolic agents,
  fluoroscopic procedure.

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Why Care about Varicocele or PCS?

• 4. Its a great way to expand your endovascular
  practice and increase referrals
• Urologist renal tumor embolization
• OB/GYN fibroid embolization, varicose veins
• 5. High patient satisfaction
• 6. Outpatient procedure
• 7. Favorable reimbursement

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Presentation Outline

• Pathophysiology
• Clinical Presentations
• Evaluation
• Treatment

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Pathophysiology

• Varicocele abnormally dilated testicular veins
  of the scrotum
• Commonly due to testicular / internal spermatic
  vein reflux
• Present in 15 of general population, common in
  adolescent but rare in prepubertal boys.
• 35 of men with primary infertility, and 80 of
  men with secondary infertility

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Normal Gonadal Vein Drainage
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Reflux of Gonadal Veins (Varicocele Ovarian
Varices)
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Embolization of Gonadal Vein
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Varicocele

• L. varicocele 5 times more common than R.
  varicocele.
• L. testicular vein drains into L. renal vein, and
  is 8-10 cm longer than R. testicular vein which
  drains into IVC.

• Etiological factors
• longer length, increased tortuosity, potential
  compression which increased pressure, absent or
  incompetent venous valve, or valvular reflux
• Varicocele result in increased scrotal
  temperature which leads to infertility

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Pelvic Congestion Syndrome aka. Ovarian
Varicocele

• Pelvic varicosities
• Retrograde flow in ovarian vein

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Chronic Pelvic Pain

• Definition
• Non-cyclic abdominal and pelvic pain
• At least 6 months duration
• Accounts for 15 of outpatient gynecologic visits
• 30 of diagnostic laparoscopic exams

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Pelvic Congestion Syndrome

• There is an organic cause
• Abnormal flow of blood down into the pelvis
  causing engorgement in the veins of the pelvis
• Studies showing 30 of patients with chronic
  pelvic pain have PCS as a sole cause of their
  pain
• Additional 15 have PCS in addition to other
  pelvic pathology

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Ovarian Vein Varices

• Cause of Ovarian vein varices?
• Increase in size related to previous pregnancy
• Blood flow gt 60 fold
• Pressure
• Hormonal factors
• Unusual in women who have not been pregnant

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Presentation Outline

• Pathophysiology
• Clinical Presentations
• Evaluation
• Treatment

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Varicocele Incompetent venous valve
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Varicose Veins Incompetent venous valve
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Ovarian Vein Varices

• Non-specific physical findings
• Symptoms include chronic pelvic pain, pain with
  intercourse, vaginal discharge, and unusual
  bleeding.

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Presentation Outline

• Pathophysiology
• Clinical Presentations
• Evaluation
• Treatment

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Normal Ovarian Veins
Competent valves prevent reflux Veins are small
lt5 mm
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Ovarian Vein Varices
Dilated ovarian vein with venous reflux, vein
diameter gt 5mm
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Injection of left ovarianvein
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CT Scan
Large left ovarian vein
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Enlarged left ovarian vein
CT Scan

• Cross pelvic collaterals

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CT Reconstruction
Enlarged ovarian vein
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MRI
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Laparoscopy of Pelvic Varices
Evaluation of Pelvic Congestion Syndrome
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Presentation Outline

• Pathophysiology
• Clinical Presentations
• Diagnosis
• Treatment

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Therapy for Varicocele

• Surgical varicocelectomy
• Laparoscopic varicocelectomy
• Endovascular embolization of testicular vein

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Therapy for Ovarian Vein Varices

• Analgesics
• Ovarian suppression
• Surgical
• Hysterectomy, removal of ovaries
• Ligation of left ovarian vein
• Retroperitoneal approach
• Laparoscopic ligation-ovarian vein/collaterals
• Endovascular embolization

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Open Varicocelectomy
Oblique incision over inguinal ring
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Open Varicocelectomy
Isolation of the spermatic cord varicocele
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Open Varicocelectomy
Division of varicocele testicular vein
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Laparoscopic Varicocelectemy
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Laparoscopic Varicocelectemy
Standard abdominal laparoscopy. Spermatic cord
isolated above internal inguinal ring
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Laparoscopic Varicocelectemy
Testicular vein is isolated
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Laparoscopic Varicocelectemy
Laparoscopic clips applied across the testicular
vein
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Endovascular Embolization of Gonadal Vein
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Embolization of Gonadal Vein

• Technique
• Via right groin or jugular vein
• Catheterize left kidney vein with patient on a
  table tilted head-up
• If reflux, catheter is advanced into gonadal vein

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Step 1 - IVC wire access
1_CAVA.avi
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Step 2 left renal vein angiogram
2_renal-V-gram.avi
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Step 3 selective catheterization of left
gonadal vein
0.35 angle catheter selection
Microcatheter placement into gonadal vein
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Step 3 selective catheterization of left
gonadal vein
C2 RDC RC1 Bern
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Step 3 selective catheterization of left
gonadal vein
SIM2 catheter
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Step 3 selective catheterization of left
gonadal vein
2.5_gonadal.avi
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Step 4 microcoil placement in the gonadal vein
3_embolization.avi
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Step 4 microcoil placement in the gonadal vein
3.5_embo.avi
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Step 4 microcoil placement in the gonadal vein
3.7_prox embo.avi
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Step 4 microcoil placement in the gonadal vein
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Step 4 microcoil placement in the gonadal vein
4_completion.avi
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Step 4 microcoil placement in the gonadal vein
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Step 5 Right gonadal vein injection
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Embolization of Gonadal Vein

• Embolic agent
• Sclerosing agent (cyanoacrylate)
• Platinum Fibered Coils (0.035)
• Detachable Microcoils (0.018)

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Detachable Coils

• Used to occlude aneurysms, AVF, parent artery,
  etc.
• Soft, platinum wire
• More control
• Reliable repositioning
• Available in a wide range of sizes

Terumo AZUR hydrocoil
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Controlled Hydrogel Expansion
1 Volume
Conventional Platinum coil
20 minute time-lapse photography
AZUR 3X diameter expansion over 20 minutes
5_hydrocoil.avi
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Expanded Volume Comparison
1 Volume

• Compared to similar length of bare platinum
  coils
• AZUR 18
• x5 volume Platinum 18
• AZUR 35
• x4 volume of Platinum 35

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Detachable Hydrocoil

• A detachable coil system allows
• Better control
• Repositioning of the coil
• Retrieving the coil when necessary prior to
  detachment
• Thrombosis is not affected by anticoagulation

H2O
H2O
BSC GDC
H
H
H
H2O
H2O
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Thermoelectric Coil Detachment
Terumo AZUR hydrocoil
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7_hydrocoil_deploy.avi
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Conclusions

• Embolization of testicular vein or ovarian vein
  are effective treatment strategy in varicocele or
  ovarian varices/pelvic congestion syndrome
• Endovascular embolization is a part of
  multi-disciplinary treatment approach of these
  conditions
• Vascular surgeons with endovenous practice are
  well suited to provide this endovascular treatment

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Conclusions

• Expanded endovascular referrals in urological and
  gynecological endovascular procedures
• renal tumor embolization
• uterine fibroid embolization varicose vein
  ablation
• Detachable coils with microcatheter provide
  procedural safety and increase treatment success