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27 Y.O. MALE WITH TWO PRIOR VARICOCELE SURGICAL LIGATIONS (ONE VIA SCROTAL INCISION AND ONE VIA INGUINAL INCISION) PRESENTS WITH CONTINUING LEFT SCROTAL DISCOMFORT.
PHYSICAL EXAM DEMONSTRATED DILATED LEFT - SIDED PAMPINFIFORM PLEXUS.
SELECTED VENOGRAPHY OF THE LEFT GONADAL VEIN DEMONSTRATED SIGNIFICANT VENOUS DILITATION FROM THE LEVEL OF THE LEFT RENAL VEIN TO THE SCROTUM.
RECURRENT LEFT-SIDED VARICOCELE
POST EMBOLIZATION, THE PATIENT'S VARICOCELE RESOLVED. DESPITE THIS, HE HAD CONTINUED SCROTAL PAIN AND UNDERWENT ORCHIECTOMY.
The two accepted methods of treating varicoceles are surgical ligation and percutaneous embolization.
The goal of both procedures is occlusion of the internal spermatic vein, thereby preventing retrograde blood flow into the scrotum.
Surgical ligation can be performed at multiple levels to include: high retroperitoneal(Palomo), low retroperitoneal(Ivanissevich), and subinguinal(Marmar).
Reccurent varicocele is often a problem with the above surgical techniques (10-20%) due to collateral flow, loose ligature, or missed accessory internal spermatic vein.
Percutaneous varicocele embolization often overcomes these problems by interrupting flow throught the entire vein. Thus reccurence due to collateralization or accessory internal spermatic veins is unlikely.
Initial venous access can be obtained through either a femoral or jugular approach. Catheter and wire systems are then used to subselect the desired gonadal vein (from renal vein on the left and directly off the IVC from the right).
A dedicated gondal venogram is then performed to access for any variant anatomy or potential sources of collateral flow.
Embolization is not performed if competent valves are identified.
Embolic coils are then placed within the vein beginning at the level of the inguinal canal, and continuing in an antegrade fashion to the level of the gonadal vein takeoff.
A post-embolization venogram is obtained to ensure absence of residual flow.
Alternative embolic agents include; detachable ballons, sotradecol sclerosant, and boiling contrast agents.
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This Image: 31065 - is linked to Topic: 7292
|Title: Varicocele - Gonadal Vein Embolization|
Selected left renal venography demonstrates reflux of contrast down the left gonadal vein into the scrotum.
| Image Modality: Venogram |
Image Plane: Frontal
|Image/Caption Source: william T lewis|
|MedPix™ Caption 31065|
Caption/Image Contributor: John D Statler - ::
Affiliation: Uniformed Services University
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