Ovarian vein embolization in women
Embolization is used to treat chronic pelvic pain associated with pelvic venous insufficiency. Systematic reviews confirm the efficacy and safety of the method (symptoms are relieved in the majority of female patients), although the overall evidence base requires reinforcement from randomized controlled trials.
- Features: Bilateral intervention is very frequently required, meaning the embolization of both ovarian veins.
- Causes of failure: If clinical improvement does not occur (in 25% of cases), this is most frequently due to additional, untreated incompetent collaterals originating from the internal iliac vein system (v. iliaca interna).
- Association with vulvar varicosities: This pathology can lead to unilateral or bilateral labial hypertrophy. The primary treatment for vulvar varicosities themselves is direct injection sclerotherapy (using sodium tetradecyl sulfate). However, a strict rule applies: prior to sclerotherapy, reflux through the ovarian veins must be definitively ruled out and eliminated.
- Diagnostics: Contrast-enhanced MR venography is performed (MIP mode, steady-state). It allows for clear visualization of early left ovarian vein reflux, as well as tracking how ipsilateral thigh varicosities drain into pelvic varices.
Varicocele: the male counterpart of pelvic congestion
Varicocele is an abnormal dilation of the pampiniform plexus (plexus pampiniformis) draining the testis. It arises due to valvular incompetence of the testicular vein (v. testicularis). The pathology is common, affecting up to 10% of the male population.
In most cases, the condition is asymptomatic and requires observation only. Clinically, it may manifest as a dragging sensation in the scrotum (typically on the left), which worsens with physical exertion. Upon palpation, the dilated plexus presents the classic "bag of worms" sign. Bilateral involvement is detected in 10–15% of cases.
- Diagnostics: Ultrasound is the gold standard for imaging (very high sensitivity and specificity). The diagnostic criterion is tortuous veins with a diameter exceeding 3 mm.
- Caution: If the varicocele is isolated and located on the right side, this is regarded as a red flag. Retroperitoneal lymphadenopathy, anatomical anomalies (e.g., situs inversus), or renal tumors must be ruled out.
- Infertility: Varicocele is frequently found during infertility evaluations. Despite data showing improved spermiogram parameters after treatment, current NICE guidelines prohibit offering surgical or endovascular varicocele correction as a fertility treatment, as it does not increase pregnancy rates.
- Important note: The presence of a varicocele can be an incidental finding unrelated to scrotal pain; therefore, other causes of the pain syndrome should always be excluded.
Procedural technique
Vascular access most commonly utilizes the right common femoral vein (v. femoralis communis dextra) or, increasingly, the right internal jugular vein (v. jugularis interna dextra).
- Selective catheterization of the left renal vein (v. renalis sinistra) and the testicular vein is performed.
- Diagnostic venography is performed to assess anatomy and confirm the presence of venous reflux.
- Coils (the most frequent operator choice, although the armamentarium includes particles and liquids) are positioned distally at the level of the inguinal ligament (ligamentum inguinale). Embolization is performed from bottom to top (from distal to proximal).
Technical difficulty often arises when working with the right testicular vein: unlike the left, it typically originates directly from the inferior vena cava (IVC) just below the renal vein, making selective catheterization challenging. During the procedure, gonadal shielding must be used to minimize radiation exposure to the testes.
Gonadal vein anatomy classification
Catheterization success and the absence of recurrences depend directly on the structure of the venous system. Several anatomical types are distinguished:
- Type 0: Normal structure without anomalies.
- Type I: Single testicular vein without valves.
- Type II: Afferent medial retroperitoneal collaterals draining into the ascending lumbar or retroperitoneal veins. Subtype IIa is valve-less, while subtype IIb has a valve at the confluence with the renal vein.
- Type III: Doubled testicular (internal spermatic) vein.
- Type IV: Collateral blood flow from perirenal and lateral renal veins is present. Subtype IVa is valve-less; subtype IVb has a valve, but it is bypassed by incompetent collaterals.
- Type V: Bifid renal vein with a retroaortic component.
Briefly: answers to topical questions
What ultrasound criteria and maneuvers are used to confirm a varicocele diagnosis?
Venous dilation criteria and special provocative maneuvers are used to confirm a varicocele diagnosis.
- Ultrasound findings — multiple dilated, tortuous tubular structures posterior to the testis, which may extend to its lower pole.
- Vein diameter — tortuous veins with a diameter greater than 3 mm are considered a diagnostic criterion. Alternative threshold values: > 2 mm, or 2.7 mm for subclinical and 3.6 mm for clinical varicocele.
- Provocative maneuvers — coughing, deep inspiration, and the Valsalva maneuver (Valsalva manoeuvre), which are effective for detecting blood flow.
To increase vascular prominence, the patient is placed in a standing position.
Class and exam questions
What complications can occur during gonadal vein embolization?
The intervention is considered safe, but in rare cases, vascular perforation, vasospasm, non-target embolization, and post-procedural thrombophlebitis may occur.
How to treat varicocele in patients presenting with infertility?
According to strict NICE guidelines, endovascular or surgical treatment of varicocele should not be offered as a male infertility therapy, as it does not increase the likelihood of pregnancy.
What else to study on this topic
- Prostatic artery embolization for benign prostatic hyperplasia (NICE 2018 guidelines)
- Uterine artery embolization for uterine fibroids and postpartum hemorrhage
- Endovascular treatment of renal tumors (angiomyolipomas and renal cell carcinoma)
- Principles of diagnosis and treatment of renal arteriovenous malformations and fistulas
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