Endovascular Treatment of Varicocele and Pelvic Congestion Syndrome Peter H. Lin, MD Chief of Vascular Surgery & Director of Interventional Radiology Michael E.
Download ReportTranscript Endovascular Treatment of Varicocele and Pelvic Congestion Syndrome Peter H. Lin, MD Chief of Vascular Surgery & Director of Interventional Radiology Michael E.
Slide 1
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
Slide 2
Why Should Vascular
Surgeons Care About
Varicocele or Pelvic
Congestion Syndrome (PCS)?
VASCULAR
Slide 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
VASCULAR
common interventional skill set.
Entry needle, Bentson wire, 0.035” catheter,
microcatheter, microcoils, embolic agents,
fluoroscopic procedure.
Slide 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
VASCULAR
6. Outpatient procedure
7. Favorable reimbursement
Slide 5
Presentation Outline
•
•
•
•
Pathophysiology
Clinical Presentations
Evaluation
VASCULAR
Treatment
Slide 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
VASCULAR
in adolescent but rare in prepubertal boys.
35% of men with primary infertility, and 80% of
men with secondary infertility
Slide 7
Normal Gonadal Vein Drainage
VASCULAR
Slide 8
Reflux of Gonadal Veins
(Varicocele & Ovarian Varices)
VASCULAR
Slide 9
Embolization of Gonadal Vein
VASCULAR
Slide 10
Varicocele
•
•
L. varicocele: 5 times more common than R. varicocele.
•
Etiological factors:
L. testicular vein drains into L. renal vein, and is 8-10
cm longer than R. testicular vein which drains into IVC.
•
longer length, increased tortuosity,
potential compression which
VASCULAR
increased pressure, absent or
incompetent venous valve, or valvular
reflux
Varicocele result in increased scrotal
temperature which leads to infertility
Slide 11
Pelvic Congestion Syndrome
aka. Ovarian “Varicocele”
•
•
VASCULAR
Pelvic varicosities
Retrograde flow in ovarian vein
Slide 12
Chronic Pelvic Pain
•
•
•
Definition
Non-cyclic abdominal and pelvic pain
At least 6 months duration
Accounts for 15% of outpatient gynecologic visits
VASCULAR
30% of diagnostic laparoscopic exams
Slide 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
VASCULAR
Additional 15% have PCS in addition to other
pelvic pathology
Slide 14
Ovarian Vein Varices
•
Cause of Ovarian vein varices?
Increase in size related to previous pregnancy
Blood flow > 60 fold
Pressure
Hormonal
VASCULAR
factors
Unusual in women who have not been pregnant
Slide 15
Presentation Outline
•
•
•
•
Pathophysiology
Clinical Presentations
Evaluation
VASCULAR
Treatment
Slide 16
Varicocele
Incompetent venous valve
VASCULAR
Slide 17
Varicose Veins
Incompetent venous valve
VASCULAR
Slide 18
Ovarian Vein Varices
•
•
Non-specific physical findings
Symptoms include chronic
pelvic pain, pain with
intercourse, vaginal discharge,
VASCULAR
and unusual bleeding.
Slide 19
Presentation Outline
•
•
•
•
Pathophysiology
Clinical Presentations
Evaluation
VASCULAR
Treatment
Slide 20
Normal Ovarian Veins
VASCULAR
Competent valves prevent reflux
Veins are small <5 mm
Slide 21
Ovarian Vein Varices
VASCULAR
Dilated ovarian vein with venous
reflux, vein diameter > 5mm
Delayed image - large
clusters of ovarian varices
Slide 22
VASCULAR
Injection of left ovarian
vein
Slide 23
CT Scan
Large left ovarian vein
VASCULAR
Multiple ovarian varices
Slide 24
CT Scan
Enlarged left ovarian
vein
VASCULAR
Cross pelvic
collaterals
Slide 25
CT
Reconstruction
VASCULAR
Enlarged ovarian vein
Slide 26
MRI
VASCULAR
Slide 27
Evaluation of Pelvic Congestion Syndrome
Laparoscopy of Pelvic Varices
VASCULAR
Slide 28
Presentation Outline
•
•
•
•
Pathophysiology
Clinical Presentations
Diagnosis
VASCULAR
Treatment
Slide 29
Therapy for Varicocele
•
•
•
Surgical varicocelectomy
Laparoscopic varicocelectomy
Endovascular embolization of testicular vein
VASCULAR
Slide 30
Therapy for Ovarian Vein Varices
Analgesics
Ovarian suppression
Surgical
Hysterectomy, removal of ovaries
Ligation of left ovarian vein
VASCULAR
Retroperitoneal approach
Laparoscopic ligation-ovarian
vein/collaterals
Endovascular embolization
Slide 31
Open Varicocelectomy
VASCULAR
Oblique incision over inguinal ring
Slide 32
Open Varicocelectomy
VASCULAR
Isolation of the spermatic cord & varicocele
Slide 33
Open Varicocelectomy
VASCULAR
Division of varicocele & testicular vein
Slide 34
Laparoscopic Varicocelectemy
VASCULAR
Slide 35
Laparoscopic Varicocelectemy
VASCULAR
Standard abdominal laparoscopy.
Spermatic cord isolated above internal
inguinal ring
Slide 36
Laparoscopic Varicocelectemy
VASCULAR
Testicular vein is isolated
Slide 37
Laparoscopic Varicocelectemy
VASCULAR
Laparoscopic clips applied across the testicular vein
Slide 38
Endovascular Embolization of
Gonadal Vein
VASCULAR
Slide 39
Embolization of Gonadal Vein
• Technique
Via
right groin or jugular
vein
Catheterize
left kidney
vein with patient on a
table
tilted head-up
VASCULAR
If
reflux, catheter is
advanced into gonadal
vein
Slide 40
Step 1 - IVC wire access
VASCULAR
1_CAVA.avi
Slide 41
Step 2 – left renal vein angiogram
VASCULAR
2_renal-V-gram.avi
Slide 42
Step 3 – selective catheterization of left
gonadal vein
VASCULAR
0.35” angle catheter selection
Microcatheter placement into
gonadal vein
Slide 43
Step 3 – selective catheterization of left
gonadal vein
VASCULAR
C2
RDC
RC1
Bern
Slide 44
Step 3 – selective catheterization of left
gonadal vein
VASCULAR
SIM2 catheter
Slide 45
Step 3 – selective catheterization of left
gonadal vein
VASCULAR
2.5_gonadal.avi
Slide 46
Step 4 – microcoil placement in the
gonadal vein
VASCULAR
3_embolization.avi
Slide 47
Step 4 – microcoil placement in the
gonadal vein
VASCULAR
3.5_embo.avi
Slide 48
Step 4 – microcoil placement in the
gonadal vein
VASCULAR
3.7_prox embo.avi
Slide 49
Step 4 – microcoil placement in the
gonadal vein
VASCULAR
Slide 50
Step 4 – microcoil placement in the
gonadal vein
VASCULAR
4_completion.avi
Slide 51
Step 4 – microcoil placement in the
gonadal vein
VASCULAR
Slide 52
Step 5 – Right gonadal vein injection
VASCULAR
Slide 53
Embolization of Gonadal Vein
Embolic agent:
Sclerosing agent
(cyanoacrylate)
Platinum Fibered Coils
(0.035”)
Detachable Microcoils
VASCULAR
(0.018”)
Slide 54
Detachable Coils
Used to occlude aneurysms,
AVF, parent artery, etc.
VASCULAR
Terumo AZUR hydrocoil
Soft, platinum wire
More control
Reliable repositioning
Available in a wide
range of sizes
Slide 55
1
Volume
Controlled Hydrogel Expansion
Conventional
Platinum coil
20 minute
time-lapse
photography
VASCULAR
5_hydrocoil.avi
AZUR
3X diameter
expansion
over 20 minutes
Slide 56
1
Volume
Expanded Volume Comparison
Compared to similar length of
bare platinum coils:
AZUR 18
~ x5 volume Platinum 18
AZUR 35
~ x4 volume of Platinum 35
VASCULAR
AZUR 35
AZUR 18
35
Platinum
18
Slide 57
Detachable Hydrocoil
•
A detachable coil system
allows:
Better control
Repositioning of the coil
Retrieving the coil when
VASCULAR
necessary
BSC GDCprior to
detachment
Thrombosis is not affected
by anticoagulation
H2O
H2O
H+
H+
H+
H2O
H2O
Slide 58
Thermoelectric Coil Detachment
VASCULAR
Terumo AZUR
hydrocoil
Slide 59
VASCULAR
7_hydrocoil_deploy.avi
Slide 60
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 multidisciplinary treatment approach of these
conditions
VASCULAR
Vascular surgeons with endovenous practice are
well suited to provide this endovascular
treatment
Slide 61
Conclusions
•
•
Expanded endovascular referrals in urological
and gynecological endovascular procedures
renal tumor embolization
uterine fibroid embolization & varicose vein
ablation
VASCULAR
Detachable
coils with microcatheter provide
procedural safety and increase treatment
success
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
Slide 2
Why Should Vascular
Surgeons Care About
Varicocele or Pelvic
Congestion Syndrome (PCS)?
VASCULAR
Slide 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
VASCULAR
common interventional skill set.
Entry needle, Bentson wire, 0.035” catheter,
microcatheter, microcoils, embolic agents,
fluoroscopic procedure.
Slide 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
VASCULAR
6. Outpatient procedure
7. Favorable reimbursement
Slide 5
Presentation Outline
•
•
•
•
Pathophysiology
Clinical Presentations
Evaluation
VASCULAR
Treatment
Slide 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
VASCULAR
in adolescent but rare in prepubertal boys.
35% of men with primary infertility, and 80% of
men with secondary infertility
Slide 7
Normal Gonadal Vein Drainage
VASCULAR
Slide 8
Reflux of Gonadal Veins
(Varicocele & Ovarian Varices)
VASCULAR
Slide 9
Embolization of Gonadal Vein
VASCULAR
Slide 10
Varicocele
•
•
L. varicocele: 5 times more common than R. varicocele.
•
Etiological factors:
L. testicular vein drains into L. renal vein, and is 8-10
cm longer than R. testicular vein which drains into IVC.
•
longer length, increased tortuosity,
potential compression which
VASCULAR
increased pressure, absent or
incompetent venous valve, or valvular
reflux
Varicocele result in increased scrotal
temperature which leads to infertility
Slide 11
Pelvic Congestion Syndrome
aka. Ovarian “Varicocele”
•
•
VASCULAR
Pelvic varicosities
Retrograde flow in ovarian vein
Slide 12
Chronic Pelvic Pain
•
•
•
Definition
Non-cyclic abdominal and pelvic pain
At least 6 months duration
Accounts for 15% of outpatient gynecologic visits
VASCULAR
30% of diagnostic laparoscopic exams
Slide 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
VASCULAR
Additional 15% have PCS in addition to other
pelvic pathology
Slide 14
Ovarian Vein Varices
•
Cause of Ovarian vein varices?
Increase in size related to previous pregnancy
Blood flow > 60 fold
Pressure
Hormonal
VASCULAR
factors
Unusual in women who have not been pregnant
Slide 15
Presentation Outline
•
•
•
•
Pathophysiology
Clinical Presentations
Evaluation
VASCULAR
Treatment
Slide 16
Varicocele
Incompetent venous valve
VASCULAR
Slide 17
Varicose Veins
Incompetent venous valve
VASCULAR
Slide 18
Ovarian Vein Varices
•
•
Non-specific physical findings
Symptoms include chronic
pelvic pain, pain with
intercourse, vaginal discharge,
VASCULAR
and unusual bleeding.
Slide 19
Presentation Outline
•
•
•
•
Pathophysiology
Clinical Presentations
Evaluation
VASCULAR
Treatment
Slide 20
Normal Ovarian Veins
VASCULAR
Competent valves prevent reflux
Veins are small <5 mm
Slide 21
Ovarian Vein Varices
VASCULAR
Dilated ovarian vein with venous
reflux, vein diameter > 5mm
Delayed image - large
clusters of ovarian varices
Slide 22
VASCULAR
Injection of left ovarian
vein
Slide 23
CT Scan
Large left ovarian vein
VASCULAR
Multiple ovarian varices
Slide 24
CT Scan
Enlarged left ovarian
vein
VASCULAR
Cross pelvic
collaterals
Slide 25
CT
Reconstruction
VASCULAR
Enlarged ovarian vein
Slide 26
MRI
VASCULAR
Slide 27
Evaluation of Pelvic Congestion Syndrome
Laparoscopy of Pelvic Varices
VASCULAR
Slide 28
Presentation Outline
•
•
•
•
Pathophysiology
Clinical Presentations
Diagnosis
VASCULAR
Treatment
Slide 29
Therapy for Varicocele
•
•
•
Surgical varicocelectomy
Laparoscopic varicocelectomy
Endovascular embolization of testicular vein
VASCULAR
Slide 30
Therapy for Ovarian Vein Varices
Analgesics
Ovarian suppression
Surgical
Hysterectomy, removal of ovaries
Ligation of left ovarian vein
VASCULAR
Retroperitoneal approach
Laparoscopic ligation-ovarian
vein/collaterals
Endovascular embolization
Slide 31
Open Varicocelectomy
VASCULAR
Oblique incision over inguinal ring
Slide 32
Open Varicocelectomy
VASCULAR
Isolation of the spermatic cord & varicocele
Slide 33
Open Varicocelectomy
VASCULAR
Division of varicocele & testicular vein
Slide 34
Laparoscopic Varicocelectemy
VASCULAR
Slide 35
Laparoscopic Varicocelectemy
VASCULAR
Standard abdominal laparoscopy.
Spermatic cord isolated above internal
inguinal ring
Slide 36
Laparoscopic Varicocelectemy
VASCULAR
Testicular vein is isolated
Slide 37
Laparoscopic Varicocelectemy
VASCULAR
Laparoscopic clips applied across the testicular vein
Slide 38
Endovascular Embolization of
Gonadal Vein
VASCULAR
Slide 39
Embolization of Gonadal Vein
• Technique
Via
right groin or jugular
vein
Catheterize
left kidney
vein with patient on a
table
tilted head-up
VASCULAR
If
reflux, catheter is
advanced into gonadal
vein
Slide 40
Step 1 - IVC wire access
VASCULAR
1_CAVA.avi
Slide 41
Step 2 – left renal vein angiogram
VASCULAR
2_renal-V-gram.avi
Slide 42
Step 3 – selective catheterization of left
gonadal vein
VASCULAR
0.35” angle catheter selection
Microcatheter placement into
gonadal vein
Slide 43
Step 3 – selective catheterization of left
gonadal vein
VASCULAR
C2
RDC
RC1
Bern
Slide 44
Step 3 – selective catheterization of left
gonadal vein
VASCULAR
SIM2 catheter
Slide 45
Step 3 – selective catheterization of left
gonadal vein
VASCULAR
2.5_gonadal.avi
Slide 46
Step 4 – microcoil placement in the
gonadal vein
VASCULAR
3_embolization.avi
Slide 47
Step 4 – microcoil placement in the
gonadal vein
VASCULAR
3.5_embo.avi
Slide 48
Step 4 – microcoil placement in the
gonadal vein
VASCULAR
3.7_prox embo.avi
Slide 49
Step 4 – microcoil placement in the
gonadal vein
VASCULAR
Slide 50
Step 4 – microcoil placement in the
gonadal vein
VASCULAR
4_completion.avi
Slide 51
Step 4 – microcoil placement in the
gonadal vein
VASCULAR
Slide 52
Step 5 – Right gonadal vein injection
VASCULAR
Slide 53
Embolization of Gonadal Vein
Embolic agent:
Sclerosing agent
(cyanoacrylate)
Platinum Fibered Coils
(0.035”)
Detachable Microcoils
VASCULAR
(0.018”)
Slide 54
Detachable Coils
Used to occlude aneurysms,
AVF, parent artery, etc.
VASCULAR
Terumo AZUR hydrocoil
Soft, platinum wire
More control
Reliable repositioning
Available in a wide
range of sizes
Slide 55
1
Volume
Controlled Hydrogel Expansion
Conventional
Platinum coil
20 minute
time-lapse
photography
VASCULAR
5_hydrocoil.avi
AZUR
3X diameter
expansion
over 20 minutes
Slide 56
1
Volume
Expanded Volume Comparison
Compared to similar length of
bare platinum coils:
AZUR 18
~ x5 volume Platinum 18
AZUR 35
~ x4 volume of Platinum 35
VASCULAR
AZUR 35
AZUR 18
35
Platinum
18
Slide 57
Detachable Hydrocoil
•
A detachable coil system
allows:
Better control
Repositioning of the coil
Retrieving the coil when
VASCULAR
necessary
BSC GDCprior to
detachment
Thrombosis is not affected
by anticoagulation
H2O
H2O
H+
H+
H+
H2O
H2O
Slide 58
Thermoelectric Coil Detachment
VASCULAR
Terumo AZUR
hydrocoil
Slide 59
VASCULAR
7_hydrocoil_deploy.avi
Slide 60
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 multidisciplinary treatment approach of these
conditions
VASCULAR
Vascular surgeons with endovenous practice are
well suited to provide this endovascular
treatment
Slide 61
Conclusions
•
•
Expanded endovascular referrals in urological
and gynecological endovascular procedures
renal tumor embolization
uterine fibroid embolization & varicose vein
ablation
VASCULAR
Detachable
coils with microcatheter provide
procedural safety and increase treatment
success