CLINICAL STUDY

Varicocele Retrograde Embolization with Boiling

Contrast Medium and Gelatin Sponges in
Adolescent Subjects: A Clinically Effective
Therapeutic Alternative
C. Matthew Hawkins, MD, John M. Racadio, MD, David N. McKinney, MD,
Judy M. Racadio, MD, and Doan N. Vu, MD

ABSTRACT
Purpose: Varicoceles occur in approximately 15% of adolescent male subjects and may impair future fertility. The present study
describes a varicocele treatment technique involving percutaneous retrograde embolization with boiling hot contrast medium and
gelatin sponge pledgets.
Materials and Methods: A retrospective review of medical records and imaging of all patients who underwent percutaneous
retrograde varicocele embolization from 2005 to 2010 was performed. Pre- and postembolization symptoms, physical findings, and
ultrasound findings were documented. Fifteen patients (16 embolizations) were identified, with an average age of 15.9 years (range,
1218 y). Nine were referred because of persistent varicocele after surgical ligation. Three had grade 2 and nine had grade 3
varicoceles. Two had grade 1 varicoceles; one was painful and one was associated with poor semen quality. One varicocele was not
clinically evident, but was associated with persistently decreased testicular size. Nine patients had pain or discomfort, and six had no
discomfort. Clinical resolution was defined by a combination of symptom resolution and a lack of physical examination findings of
varicocele or findings of treated varicocele.
Results: Fifteen of the 16 embolizations (94%) were technically successful. Clinical resolution was documented in 14 of 15 patients
(95%); one patient experienced a recurrence at 30 months, which was successfully reembolized. One patient experienced temporary
paresthesia of the left thigh. There were no major postprocedural complications. Mean follow-up duration was 11 months.
Conclusions: Retrograde embolization of varicoceles in adolescent subjects with the use of boiling hot contrast medium and gelatin
sponges is a promising technique that appears effective.

ABBREVIATION
RDC renal double curve

Varicocele, or dilation of the testicular pampiniform plexus,

occurs in approximately 15% of adolescent male subjects
(1). Varicoceles often present with pain and discomfort, but
also have significant future fertility consequences. Approx-

From the Department of Radiology (C.M.H., D.N.V.), University of Cincinnati

College of Medicine; and Department of Radiology and Division of Pediatric
Interventional Radiology (John M.R., D.N.M., Judy M.R.), Cincinnati Childrens Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH
45229-3039. Received June 23, 2011; final revision received October 22,
2011; accepted October 24, 2011. Address correspondence to John M.R.;
E-mail: john.racadio@cchmc.org
None of the authors have identified a conflict of interest.
SIR, 2012
J Vasc Interv Radiol 2012; 23:206 210
DOI: 10.1016/j.jvir.2011.10.021

imately 37% 41% of men evaluated for infertility are diagnosed with a left varicocele (2); of those afflicted, only
40% will achieve paternity even after surgical correction.
It is currently impossible to predict which adolescent
subjects with varicoceles will be at risk for future infertility
(3). However, because the gonadotoxic effect of varicoceles
increases with age (4) and there is evidence that early
treatment may lead to increased testicular volume (5,6) and
increased sperm concentration (6), early intervention has
been recommended (3,4,7), even in asymptomatic adolescent subjects (8,9). Outcomes and complications of various
surgical and percutaneous techniques have been extensively
compared, with various results and recommendations (10
12). Although surgical techniques have very high published
success rates (70%98%) (1), postprocedural hydroceles
occur relatively frequently (2,10,12). There are several dif-

Volume 23 Number 2 February 2012

ferent surgical techniques, including open inguinal, laparoscopic, and subinguinal microscopic varicocelectomies, and
recurrence rates vary widely among techniques and studies,
ranging from 1% to 22% (1315). Unrecognized duplication of the gonadal vein is a common finding in patients
with recurrence after surgery (16).
Percutaneous varicocele embolization techniques generally involve the use of a sclerosing agent such as sodium
tetradecyl sulfate or ethanol, coils, foam, or a combination
of these to block flow through the internal spermatic vein to
the varicocele. Although percutaneous embolization techniques are less invasive, their use may be complicated by
technical difficulties, such as venous spasm and irregular
anatomy not discovered until the initial spermatic venogram is obtained. Technical success rates in the pediatric
population following retrograde varicocele embolization
have been reported between 60% and 95% (9,11,12,1720),
with long-term recurrence rates between 7% and 11%
(9,17,19).
Transcatheter thermal venous occlusion has been
shown to be an effective technique in a series of (primarily
adult) human subjects (21). Injection of boiling hot contrast
medium induces local venous thrombosis followed by endothelial necrosis without damaging surrounding tissues or
vessels (22). The success rates with the use of this technique, as determined by complete occlusion on follow-up
venography, have been documented at 83%91% (21). We
modified the technique by using multiple smaller aliquots
of hot contrast medium for greater control and by adding
gelatin sponge pledgets (Gelfoam; Pfizer, New York, New
York). We report a retrospective analysis of our results in
15 patients with varicoceles treated via percutaneous embolization with boiling hot contrast medium and gelatin
sponge pledgets.

MATERIALS AND METHODS

After institutional review board approval was obtained, a
retrospective review of the medical records and imaging
studies of all patients who underwent varicocele embolization in our interventional radiology department from 2006
to 2010 (53 mo) was performed. The clinical charts were
reviewed for technical success of the procedure, procedural
or postprocedural complications, and follow-up, including
evidence of recurrence. All patients were referred by a
pediatric urologist and underwent scrotal ultrasound (US)
before percutaneous embolization to confirm the presence
of varicocele. All patients were also seen in follow-up by
the referring pediatric urologist following their intervention.
Fifteen patients were identified who had been treated
via percutaneous retrograde embolization (16 embolizations). The average age was 15.9 years (range, 1218 y).
Nine of the patients had been referred because of persistent
varicocele after surgical ligation. Three patients had leftsided grade 2 (ie, palpable without Valsalva maneuver)

207

varicoceles and nine had left-sided grade 3 (ie, visible)

varicoceles. One patient had a left-sided grade 1 (ie, palpable by Valsalva maneuver only) varicocele that was painful,
and one patient had bilateral grade 1 varicoceles with poor
semen quality. One patient had a left-sided varicocele that
was not clinically evident; this was a residual postsurgical
varicocele that was diagnosed by US and was associated
with persistently decreased testicular size. Six patients had
pain associated with their varicocele, three had a sense of
fullness or discomfort, and six had no associated discomfort.
Postembolization scrotal US images are not routinely
obtained at our institution; therefore, clinical resolution was
defined by a combination of symptom resolution and lack
of physical examination findings of varicocele or findings
of treated varicocele (ie, residual varicocele with no impulse on Valsalva maneuver, as typically seen at initial
6-wk follow-up). Scrotal US studies were performed for
any patient with recurrent symptoms or physical examination findings consistent with varicocele, such as impulse on
Valsalva maneuver. Recurrence was confirmed in any patient in whom increased color flow was seen with Valsalva
maneuver on US.

Technique
All patients were administered general anesthesia. The right
femoral vein was then accessed by using US guidance, and
a 5-F renal double curve (RDC) directional catheter (Abbott, Abbott Park, Illinois) was used to select the left renal
vein. Left renal venography was performed during a Valsalva maneuver, which aided in identifying the origin of the
left internal spermatic vein as it generated retrograde flow.
All subsequent diagnostic selective gonadal venography
was also performed by using a Valsalva maneuver. An
0.035-inch angled Glidewire (Terumo, Somerset, New Jersey) was then advanced through the RDC catheter to select
the left internal spermatic vein; after advancing the RDC
catheter, retrograde left internal spermatic venography was
performed (Figure, a). A 0.035-inch Rosen wire (Cook,
Bloomington, Indiana) was then advanced through the RDC
catheter and into the internal spermatic vein approximately
to the level of the iliac crest; over this guide wire, a 6-F
Balkin guide sheath (Cook) was advanced into the internal
spermatic vein just at its confluence with the left renal vein.
A 5-F angled Glide catheter (Terumo) was advanced coaxially through the Balkin guide sheath into the internal
spermatic vein, and additional left internal spermatic
venography was performed to evaluate the vein to the level
of the pubic symphysis. In the two cases in which multiple
internal spermatic veins arose from the renal vein, all were
addressed in a similar manner. A retrograde contrast medium injection (ie, roadmap technique) and 0.035-inch
angled Glidewire were used to help advance the Glide
catheter into the inferior portion of the internal spermatic
vein to a position approximately 5 cm above the inguinal
ligament (Figure, b,c). By gently advancing catheters and
guide wires, venospasm was typically avoided; if veno-

208 Retrograde Varicocele Embolization Method in Adolescent Subjects

Hawkins et al JVIR

Figure. Left percutaneous retrograde embolization of persistent grade 3 varicocele after surgical ligation in a 15-year-old patient. (a)
Left retrograde gonadal venography through 5-F RDC catheter during Valsalva maneuver demonstrates the main gonadal vein
(arrowheads) and a smaller, more lateral parallel channel (arrows) extending separately to the varicocele (which is intentionally
excluded from the field of view to limit radiation exposure of the testicle). (b) The tip of an 5-F angled Glide catheter (arrowhead) has
been advanced through the main gonadal vein and positioned caudal to the origin of the more lateral parallel channel seen in a. (c)
With the angled Glide catheter positioned as in b, initial injection of boiling hot contrast medium is performed under live fluoroscopy
to assure that no hot contrast medium extends below the inguinal ligament. (d) After embolization of the caudal portion of the main
gonadal vein, the more lateral parallel channel (arrows) has been selectively catheterized, and boiling hot contrast medium is injected.
(e) After embolization, there is a standing column of contrast medium in the main gonadal vein (arrowheads) and the more lateral
parallel channel (arrows). Asterisk shows the tip of a Balkin sheath, which has been withdrawn into the inferior vena cava.

spasm was encountered, we waited for 510 minutes for it

to resolve spontaneously. Final diagnostic spermatic venography was performed to identify all parallel channels contributing to the varicocele. To decrease radiation exposure,
we stored venograms through fluoroscopy screen capture
(ie, fluoro store), which allows us to store as much as the
last 20 seconds of fluoroscopy as a dynamic cine run,
instead of digital subtraction angiography. In addition, fluoroscopy was not performed over the testicles.
Optiray 350 contrast medium was brought to a boil in
a sterile stainless-steel bowl on a hotplate. Throughout the
procedure, normal saline solution (approximately 10 mL for
50 mL of contrast medium) was periodically added to the
boiling contrast medium to offset evaporation and avoid the
contrast medium becoming too viscous. The boiling contrast medium was drawn into a 10-mL glass syringe, and
23 mL was immediately injected into the Glide catheter in
the left internal spermatic vein under fluoroscopic visualization. The Valsalva maneuver was not performed during
hot contrast medium injection to allow better control and to
avoid retrograde flow below the inguinal ligament and
subsequent thermal injury to the pampiniform plexus or
testis. Because of direct real-time fluoroscopic visualization
during controlled hand injection, no compression at the
groin was needed to prevent hot contrast medium from
refluxing below the inguinal ligament. The boiling contrast
medium injection immediately decreased venous flow. This
was repeated three or four times and was then followed by
three or four gelatin sponge pledget injections. After complete venous occlusion was documented, the catheter was
withdrawn 3 4 cm into a more cephalic portion of the
internal spermatic vein, and the combination boiling con-

trast medium and gelatin sponge pledget injections were

repeated. This was performed three or four times (depending on patient size) until the inferior one third to one half of
the internal spermatic vein had been embolized. When
possible, each parallel channel was selectively catheterized
and embolized with boiling contrast medium and gelatin
sponge pledgets through the 5-F angled Glide catheter
(Figure, d). If a parallel channel could not be selectively
catheterized, boiling contrast medium was injected at its
connection to the main channel in such a manner that the
hot contrast medium would reflux into the parallel channel.
Embolization resulted in stasis in the gonadal vein (Figure,
e). Microcatheters were not used. Following embolization,
the catheters and guide sheath were removed, and pressure
was held over the puncture site until hemostasis was
achieved.

RESULTS
Fifteen of the 16 retrograde embolization attempts (94%)
were technically successful, with the one technical failure
occurring in the setting of a very small gonadal vein, into
which the catheter could not be advanced inferiorly more
than 2 cm from its junction to the renal vein. One patient
experienced temporary (2 wk) paresthesia of the left upper
thigh. No other patients experienced postprocedural complications, including hydrocele, pampiniform phlebitis, or
epididymoorchits. Mean fluoroscopy time was 25.4 minutes
(range, 1356 min; median, 23.8 min).
Average follow-up duration by the pediatric urologists
was 11.2 months (range, 139 mo). All 15 patients who

Volume 23 Number 2 February 2012

underwent embolization had initial clinical resolution of

their varicoceles, and the nine patients who had preembolization pain or discomfort experienced symptom resolution. Fourteen of the patients had no further physical evidence of varicocele during follow-up. One of the 15
patients (6.66%) experienced a painless recurrence 30
months after initial technically successful embolization,
which was detected by clinical examination and confirmed
by scrotal US. Retrograde embolization was performed
again on that patient with the use of coil embolization in
addition to repeat boiling contrast agent/gelatin sponge
technique, and the patient has not had recurrence after 22
months of additional follow-up.

DISCUSSION
We have successfully performed retrograde embolization of
varicoceles in adolescent subjects with the use of boiling
hot contrast medium and gelatin sponge pledgets as a
first-line therapy and in patients who experienced recurrence after surgical ligation. Our immediate technical success rate of 94% (15 of 16 cases) and recurrence rate of 7%
(one of 15 immediate technical success cases) are consistent with those seen in the surgical and interventional
radiology literature (9,1115,1720).
Varicocele embolization has been performed with two
fundamental methods, mechanical occlusion and the use of
chemical sclerosant agents. The primary agent for mechanical occlusion is coils. Coils are most frequently used in the
main gonadal vein or major branches; success rates for coil
embolization are lower when aberrant vessels are present
(23). In addition, splanchnic collateral vessels may communicate caudally with the varicocele, and therefore recanalization may occur below the coils (24). Tungsten coils
also have the potential to corrode (1,25). N-butyl cyanoacrylate has also been used to mechanically occlude varicoceles (26), although there has been a report of gluing the
catheter into the vein while using N-butyl cyanoacrylate
(27). Chemical sclerosant agents, including ethanol and
sodium tetradecyl sulfate, cause intimal injury, which also
leads to occlusion of the vessel.
There are several advantages to the technique described here. The use of hot contrast medium as the sclerosing agent allows precise visualization of the venous
anatomy as well as visualization of the occlusion process as
it occurs. Controlled thermal endothelial injury occurs immediately close to the catheter tip, and the hot contrast
medium then dissipates rapidly as a result of local blood
flow, eliminating the risk of thermal injury to the renal vein
or inferior vena cava. In addition, the Balkin sheath, positioned in the relatively small adolescent internal spermatic
vein, also serves to limit the reflux of hot contrast medium
into the left renal vein and inferior vena cava. This technique also allows visualization and embolization of any
small collateral vessels not readily accessible to catheterization that may be contributing to the disease process, thus

209

minimizing recurrence. Finally, no additional chemical

sclerosant agents or embolization coils are required. In our
technique, the sclerosing agent (boiling contrast medium) is
simply a heated version of the diagnostic agent, which is
needed in all percutaneous approaches.
Hunter et al (21) used a similar technique in a series of
patients and reported excellent success rates; however, they
treated only five patients younger than the age of 18 years.
To our knowledge, the present study is the first report of the
use of this technique in this many adolescent patients. In
addition, we made several modifications to the technique.
In the previous report (21), access was obtained through the
right internal jugular vein, the catheter was advanced to the
level of the mid- to upper sacroiliac joint, and 8 10 mL of
boiling contrast medium was injected at one catheter level
while the inguinal canal was being compressed. We access
the right femoral vein and advance the catheter more inferiorly to a level just below the inferior aspect of the sacroiliac joint. We then begin injecting multiple small aliquots
at multiple levels, which we believe is a more complete
method of thermal embolization. It provides greater control
than achieved with one large injection, so it is easier to
ensure that no hot contrast medium passes below the inguinal ligament. Finally, we added the use of gelatin sponge
pledgets to maximize thrombosis formation.
The technique described here is limited by pain during
injection, so it requires conscious sedation or general anesthesia. Although embolization with boiling contrast medium is performed in adults with the use of conscious
sedation (21), we prefer general anesthesia for these procedures in adolescent patients. Any postprocedure pain was
minor and controlled with acetaminophen.
The cause of the temporary paresthesia of the left upper
thigh in one patient is uncertain, but is likely related to
irritation of a branch of the genitofemoral nerve.
Our small sample size (N 16 embolizations) and
limited follow-up duration (mean, 11 mo) are limitations to
the present study. However, our results demonstrate adequate success rates with very low risk of procedural complications. This technique does involve exposing the patient
to ionizing radiation, which is always a concern in children.
However, proper dose-limiting techniques, such as tight
collimation, use of pulse fluoroscopy and image capture,
and performing fluoro-store runs instead of digital subtraction angiography acquisitions, can minimize the exposure.
Based on the review of patients treated at our institution, we believe retrograde embolization of adolescent varicoceles with boiling hot contrast medium and gelatin
sponge is a promising technique that appears effective.

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