Varicocele Embolization: Tips and Tricks for Success
Purpose: Varicoceles are a common cause of chronic pain and infertility. Percutaneous embolization has largely replaced surgical ligation in Canada because of the low-risk nature of the procedure, outpatient setting, and quick recovery time. Embolization success rates range between 87% and 95%. Numerous protocols have been described using different equipment and embolic agents, which vary among institutions. This article reviews common protocols and methods and provides valuable tips and tricks that can improve success rates, particularly for new operators.
Materials and Methods: A case review and assessment of our institutions embolization protocols for varicoceles was undertaken. Specifically, we looked at preprocedural preparation, which may be helpful but is often overlooked, including a review of common anatomical variants. Furthermore, we examined commonly used equipment, the reasons why this equipment used, and helpful alternatives to consider. Equipment alternatives included various wires and catheter sizes and models. We also accurately reviewed and assessed common pitfalls encountered, providing simple tips and tricks to enhance procedural success.
Results: While reviewing the expertise gained from our institution, it was found that five main components and variations in procedural methodology ultimately lead to successful embolization. These are (1) access: conventional jugular access versus femoral access; (2) equipment: comparison of commonly used catheters and wires, operator usage, and alternatives to consider (e.g., in cases of acute vessel take-off or crossing venous valves; (3) anatomy and variants: knowledge of common variants can prevent undue operator frustration; these include right gonadal vein emptying into the right renal vein, circumaortic renal veins, supernumerary renal, or gonadal veins; (4) embolic agents: commonly used coils, appropriate sizing, ideal landing zones, and liquid embolic agents were most significantly noted as providing benefits during embolization; and (5) salvage maneuvers: despite best efforts, complications can occur, of which snaring a coil was noted to be beneficial.
Conclusions: Varicocele embolization is a safe and effective procedure. Thorough understanding of the purpose and justification of each step and each piece of equipment can increase operator success and overall patient satisfaction.