Varicocele retrograde embolization with boiling contrast medium and gelatin sponges in adolescent subjects: a clinically effective therapeutic alternative.

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, 12-18 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.

Where there is blood, there is a way: unusual collateral vessels in superior and inferior vena cava obstruction.

Obstruction of the superior vena cava (SVC) or inferior vena cava (IVC) is most commonly an acquired condition, typically caused by malignancy, benign conditions such as mediastinal fibrosis, and iatrogenic causes such as venous catheterization. In the event of chronic occlusion, collateral pathways must develop to maintain venous drainage. The major collateral pathways seen with SVC or IVC obstruction are well described and include the azygos-hemiazygos, internal and external mammary, lateral thoracic, and vertebral pathways. In addition, several unusual collateral pathways may be seen with SVC or IVC obstruction; these include systemic-to-pulmonary venous, cavoportal, and intrahepatic collateral pathways. In patients with systemic-to-pulmonary venous collateral vessels, the systemic veins drain directly into the left side of the heart, resulting in a right-to-left shunt. The collateral veins consist of mediastinal connections between the innominate veins and the superior pulmonary veins through bronchial venous plexuses around the airways, hilar vessels, and pleura. The cavoportal collateral pathways consist of collateral formation between the SVC or IVC and a tributary to the portal system. They include the caval-superficial-umbilical-portal pathway, caval-mammary-phrenic-hepatic capsule-portal pathway, caval-mesenteric-portal pathway, caval-renal-portal pathway, caval-retroperitoneal-portal pathway, and intrahepatic cavoportal pathway. These types of collateral pathways may result in unusual enhancement patterns in the liver. An understanding of these unusual collateral pathways is essential in a patient with caval occlusion who presents with signs and symptoms of a right-to-left shunt or has unusual enhancing lesions in the liver.

Embolization of an arterioportal fistula by injection of D-stat into the portal venous outflow.

Arterioportal fistulas may occur in liver transplant recipients after percutaneous biopsy. This report describes a case in which a 13-year-old liver transplant patient developed an arterioportal fistula after multiple liver biopsies and underwent coil embolization; however, at that time, there were at least two small arterial feeders that were not amenable to subselection. He later developed recurrent variceal bleeding, and repeat angiogram revealed multiple tiny serpentine feeding arteries. Because these arteries could not be subselectively catheterized, the collagen-thrombin mixture, D-Stat, was used to occlude the portal venous outflow of the arterioportal fistula. Subsequent angiography demonstrated successful complete occlusion of the arterioportal fistula.

Biliary duct ablation with N-butyl cyanoacrylate.

PURPOSE: To assess the efficacy of percutaneous insertion of n-butyl cyanoacrylate (NBCA) in the ablation of bile ducts in patients with persistent postsurgical bile leaks in which traditional means of treatment have failed. MATERIALS AND METHODS: Ablation of bile ducts with NBCA was performed in six patients (two men and four women). The average length of follow-up was 27 months (range, 13-46 months). Four patients presented after hepatic lobectomy with a persistent bile leak, one patient presented after cholecystectomy with a chronically obstructed bile duct, and one patient presented after cholecystectomy from intraoperative bile duct injury. After access to the biliary system was obtained, a cholangiogram was obtained. After the desired duct was isolated, it was copiously irrigated with saline solution. A glue solution containing NBCA glue, Ethiodol, and tantalum powder was delivered into the duct through a polyethylene catheter that had been irrigated with dextrose solution. RESULTS: Four patients had problems arising from isolated segmental ductal systems that had no communication with the normal biliary ductal system and were treated successfully on the first attempt. In two patients, there was communication to the main biliary ductal system and a persistent bile leak occurred that required placement of a coil and a second final gluing procedure. The only complication observed was unintentional spillage of glue into the main biliary system in one patient, which was ultimately clinically insignificant. CONCLUSIONS: The use of NBCA glue in obliteration of bile ducts is a safe procedure with excellent results in patients with complications from isolated segmental ducts. Although a repeat procedure may be necessary if the duct communicates with the main biliary tree, the procedure can decrease the morbidity associated with chronic external biliary drainage.