Cyanoacrylate in Spermatic-Vein Embolization

Abstract

Six years ago, interventional radiologists became involved in transfemoral therapeutic blockade of spermatic veins for varicocele treatment. A wide variety of percutaneous techniques has been developed for routine use on an outpatient basis without anesthesia. [1][2][3][4][5][6][7][8][9] Results of the radiological methods are similar to those of surgical ligation. 10 We started with sclerotherapy in 1978 and had an 84% overall rate of regression of varicoceles. 6,11 Small veins (< 8 mm in diameter) could be obliterated easily, but in larger veins, sclerotherapy sometimes proved unsuccessful. Since 1981, therefore, we have been investigating the clinical use of Bucrylate (isobutyl-2-cyanoacrylate = IBC; Ethicon), alone and in combination with Aethoxysklerol (hydroxypolyethoxydodecan; Kreussler) in 60 patients using a modified technique which was originally described by Kunnen. 5,12 PATIENTS AND METHODSA total of 75 patients underwent diagnostic spermatic venography. Embolotherapy of the left spermatic vein with IBC was accomplished in 60 patients, 13 to 39 years of age, with a mean of 25 years; bilateral vein occlusion was performed in 11 (18%). Patients were evaluated by thorough physical examination, contact thermography, and spermatic venography. In 42% of the cases, a grade III (>2 cm in diameter 13 ) varicocele was present, in 32% a grade II, and in 21% a grade I. Three patients (5%) had subclinical varicoceles. Semen analysis was performed at the Urological Clinic and will not be discussed in this report. In our patients, only 36% had a wish to father a child. In nine patients (15%), a varicocele was recurrent after surgical suprainguinal ligation.The veins ranged in diameter from 4 to 12 mm, with an average width of 7.5 mm, measured at the point of occlusion. Half of our patients demonstrated vein diameters of 4-7 mm, 37% from 8-9 mm, and 13% from 10-12 mm. There were three types of venous branching: 2 Type A: a single vein with fine ramifications in the proximal third (20%); Type B: a vein accompanied by several parallel venous channels up to 2 mm in diameter (37%); and Type C: numerous branches along the entire course of the spermatic vein (43%).In the majority of the cases (78%), one IBC plug was applied for complete venous occlusion. Four patients were given a double IBC dose. Thirteen patients with vein diameters of 10 to 12 mm and significant collateral vessels represented a "potential-recurrence" group and were treated with IBC and 2-4 ml of 4% Aethoxysklerol as a second occlusive mechanism in the same angiographic session.Three days after the procedure, patients were reexamined clinically and by thermography. Examination was repeated after 1, 6, 12, and 24 months; and suspected failures were reevaluated by venography. TECHNIQUEPatients were placed on a tilting table, and spermatic venograms were performed via the left femoral vein under local anesthesia. First, an attempt was made to selectively demonstrate the right spermatic vein. Mostly, this was accomplished with the use of a sidewinder-2-type ...