Endovascular Treatment of Varicocele and Pelvic Congestion Syndrome

1. 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 Endovascular Treatment of Varicocele and Pelvic Congestion Syndrome

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

3. Why Care about Varicocele or PCS? 1. Both conditions share common pathophysiology and interventional treatment strategy. • Reflux of gonadal veins 2. It’s an extension of endovascular venous practice 3. It’s an endovascular procedure which requires common interventional skill set. • Entry needle, Bentson wire, 0.035” catheter, microcatheter, microcoils, embolic agents, fluoroscopic procedure.

4. Why Care about Varicocele or PCS? 4. It’s 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

5. Presentation Outline • Pathophysiology • Clinical Presentations • Evaluation • Treatment

6. 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

7. Normal Gonadal Vein Drainage

8. Reflux of Gonadal Veins (Varicocele & Ovarian Varices)

9. Embolization of Gonadal Vein

10. 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

11. Pelvic Congestion Syndrome aka. Ovarian “Varicocele” • Pelvic varicosities • Retrograde flow in ovarian vein

12. 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

13. 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

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

15. Presentation Outline • Pathophysiology • Clinical Presentations • Evaluation • Treatment

16. Varicocele Incompetent venous valve

17. Varicose Veins Incompetent venous valve

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

19. Presentation Outline • Pathophysiology • Clinical Presentations • Evaluation • Treatment

20. Normal Ovarian Veins Competent valves prevent reflux Veins are small <5 mm

21. Delayed image - large clusters of ovarian varices Ovarian Vein Varices Dilated ovarian vein with venous reflux, vein diameter > 5mm

22. Injection of left ovarianvein

23. Multiple ovarian varices CTScan Large left ovarian vein

24. Enlarged left ovarian vein Cross pelvic collaterals CTScan

25. CT Reconstruction Enlarged ovarian vein

26. MRI

27. Laparoscopy of Pelvic Varices Evaluation of Pelvic Congestion Syndrome

28. Presentation Outline • Pathophysiology • Clinical Presentations • Diagnosis • Treatment

29. Therapy for Varicocele • Surgical varicocelectomy • Laparoscopic varicocelectomy • Endovascular embolization of testicular vein

30. 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

31. Open Varicocelectomy Oblique incision over inguinal ring

32. Open Varicocelectomy Isolation of the spermatic cord & varicocele

33. Open Varicocelectomy Division of varicocele & testicular vein

34. Laparoscopic Varicocelectemy

35. Laparoscopic Varicocelectemy Standard abdominal laparoscopy. Spermatic cord isolated above internal inguinal ring

36. Laparoscopic Varicocelectemy Testicular vein is isolated

37. Laparoscopic Varicocelectemy Laparoscopic clips applied across the testicular vein

38. Endovascular Embolization of Gonadal Vein

39. 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

40. Step 1 - IVC wire access 1_CAVA.avi

41. Step 2 – left renal vein angiogram 2_renal-V-gram.avi

42. Step 3 – selective catheterization of left gonadal vein 0.35” angle catheter selection Microcatheter placement into gonadal vein

43. Step 3 – selective catheterization of left gonadal vein C2 RDC RC1 Bern

44. Step 3 – selective catheterization of left gonadal vein SIM2 catheter

45. Step 3 – selective catheterization of left gonadal vein 2.5_gonadal.avi

46. Step 4 – microcoil placement in the gonadal vein 3_embolization.avi

47. Step 4 – microcoil placement in the gonadal vein 3.5_embo.avi

48. Step 4 – microcoil placement in the gonadal vein 3.7_prox embo.avi

49. Step 4 – microcoil placement in the gonadal vein

50. Step 4 – microcoil placement in the gonadal vein 4_completion.avi