λ~:(， 1ft. 4‘1*있챔샤，~ f깐 갚 i:1\ 23 장 찌， 4 싸 pp. 626 - 635, 1987 .Journal 01 Korean Radiological Society , 23(4) 626-635, 1987

〈국문초록〉

Venographic Features of Varicocele

Seoung Oh Yang, M .D., Myung Joon Kim , M.D. , In WOO Ro , M.D.

Department of Radiology, Capital Armed Forces Ceneral Hospital

정계정맥류의 정맥조영술 소견

국군수도영원 방사선과

양승오·김명준·노인우

정계정맥류에 대한 원인 및 불입증을 유말하는 기전은 많은 가설이 있을 뿐 정확한 규명응 아직

없다. 저자들은 최근 l 년간 정계정액류의 원인과 발생기선을 연쿠하고자 국군수도벙원에 업원한

좌측의 정계정액류 환자 30 예에 대해 치료전의 정맥조영술을 시행하여 그 방사선학척 소켠에 대

한 다음의 결과를 얻었다.

l. 좌측신정맥 조영술상 10 예 (33 %)에서 신정맥 압박현상과 7 예 (23 %)에서유샤소견을판찰

했￡며 ， 29 예 (97%)에서 내정계정맥으로의 수통적 역류가 보였는데 이 역류의 정도는 정계정백류

의 임상등급과 연판성이 있었다.

2. 선택적 좌측 내정제정맥 조영숭상 내정계정액의 수는 18 예 (60 % )에서 l 개였고 냐머지는 2

개이상이었으며， 그 확장정도는 임상등급과 유판하였으며 측부 문합의 위치는 상부 골반부외 외측

(LIII)파 상부 요추부의 내외측 (L I. M])에 많음을 알 수 있었다.

3. 좌측 총장골 정맥 조영숭상 총장골 정액 압박현상이 11 예 (37 %)에서 ， 유사소견운 8 예 ( 27

%)에서 관찰되었으며 이중에 신정액 앙박현상이 동반된 경우가 13 예 (43 %)였다.

4. 대퇴정액을 통한 내정계정액의 선택은 20 예 (67%)에서 용이하였고. 6 예에서는 카테타의 변

형등이 필요했으며 .4 예에서는 직각의 혈관주행띠l운에 곤란하였마

5. 2 예의 조영제 유출과 1 예의 총장골 정액의 경련이 있었으냐 임상척인 의의는 없었다.

6. 정계정액류의 진단과 치료에 있어서 정액조영술은 정계정맥류의 해부학적 i녕변파 형성기천을

파의L하게 하여 경피석 색전숭이냐 수술방법의 결정에 중요한 역 할을 할 수 있다

The results 01 a prospective study 01 30 patients with scrotal varicocele on the left side during the past

12 months are presented

8y means 01 preoperative venography 01 the renal , internal spermatic and common i1 iac veins, the e tiologic

id entilication is possible. Varicoce le could be distinguished in which the cause arises in the internal spermatic

이 논문은 1987 년 5 월 9 일에 접수하여 1987 년 6월 4 일에 채택되었음.

Recei vecl lVlay 9 , acceptecl June 4 , 1987

- 626

Seoung Oh Yang, et al.: Venograph ic Features of Varicoc ele-

vein and/or proximal nutcracker phenomenon (by compression 01 ISV between the aorta and superior mesenteric

artery) and/or distal nutcracker phenomenon (by obstruction 01 common iliac vein)

Use 01 preoperative venography is essential to estabilish the etiology and anatomy 01 the lesion and its

proper selection 01 treatment methods including subsequent coil embo lization

Key Words: Venography, etiologic evaluation, Varicocele

Spermatic venography was introduced by Ah1berg et al. in 1966. 1.2) Using this diagnostic method the reflux into the interna1 spermatic vein(ISV) was suggested to be characteristic of varicoce1e , but a clearer explication of the etio1ogy of varicoce1e shou1d be investigat ed. 3 , 4) The re1ationship between ma1e subfer-tility and varicoce1e of the testis has been well documented. S , 6 , 7 ,B) More recent1y , attention has been directed at the subclinica1 varicoce1e, which can be conclusive1y demonstrated on1y by spermatic venography.9)

We present our experience with 30 patients who underwent preoperative or preemboliza tiona1 venography of the rena1 , interna1 sper matic , and common iliac veins to determine possib1e causes of varicoce1e and venous ar-chitecture between May 1986 and April1987 , This report dea1s primari1y with the detai1ed radio1ogic aspects of the procedure . The ex-perience of percutaneous spermatic vein em bolization, when indicated , and postocclusion response will be covered in a separate report.

Materials and Methods

A prospective study of 30 consecutive pa-tients during the past 12 months with a vari-coce1e on the 1eft side whose age ranged from 20 to 26 years has been done. The clinica1 size of varicoce1e was classified as grade 1 varicoce1e pa1pab1e on1y during Va1sa1va ’s maneuver, grade 2 - varicoce1e visib1e on1y during Va1sa1va ’s maneuver , and grade 3 - varicoce1e visib1e without Va1sa1va ’s maneuver. 10)

With the transfemora1 venographic techni-que 25-30 m1 Hypaque 50% were injected for

627

3 sec into the 1eft rena1 vein through cobra catheter with performing the Va1sa1va ’s maneuver. The initial fi1ms were made to deter-mine wheather passive reflux into the ISV or fill-ing of the intrarena1 veins and other collatera1s occurred. Reflux out of the rena1 vein into the vena cava , anomalies of the rena1 vein itse1f and a proxima1 nutcracker phenomenon were assessed.

Then se1ective venography of the ISV was done using 15 m1 Hypaque for 2 sec through suitab1e catheter. Films were made to show the ISV and possib1e collatera1s and the scrota1 varicocele .

Last1y , venography of the 1eft common i1-iac vein was performed to eva1uate a dista1 nutcracker phenomenon with same technique as 1eft rena1 venography.

In order to classify reflux, mu1tiplicity , and anastomoses of the ISV s we devide the ISV into six subsegments as shown in Fig. 5 (A) according to Marsman.9) We distinguish six grades of spermatic venous reflux during 1eft rena1 venography: 0 = no reflux or reflux down into the crania11umbar subsegment of the ISV shorter than the height of the L-3 vertebra1 body; 1 reflux down into the crania1 1um-bar subsegment 10nger than the height of L-3; 11 reflux down into the cauda1 1umbar subsegment; 111 = reflux down into the crania1 pe1vic subsegment; IV = reflux down into the cauda1 pe1vic subsegment; V = reflux down into or beyond the inguina1 segment of the ISV.

Mu1tip1icity of the ISV is distinguished from the presence of small paralle1 anastomo-tic veins. In case of thicker paralle1 veins aris ing from the rena1 vein , we speak of mu1tip1e

-大훼)jJ(!j‘t짧뽑작l샘참“ 짜23卷 짜 4 ~iJi. 1987-

ISVs. Anastomoses that run medially or

laterally from the ISV are often visualized. We

used topographic classification for anastomo-

ses based on two criteria. First, we record wheather an anastomosis joins the ISV

medially or laterally(M or L). Secondly, we record the level at which the anastomosis joins

the ISV (1 to V). Consequently, we classify medial and lateral anastomoses from M 1 to

L V.

Results

(1) F indings of left renal venography

(Table 1,2)

1n 10 patients a severe to moderate prox-

imal nutcracker phenomenon (PNP) was observed with obvious compression at the

level of the junction between the aorta and

superior mesenteric artery(SMA) by the “ pm-ching" effect (Fig. 1). In 7 patients a similar

Table 1. Findings of Left Renal Venography (N = 30)

Findings No (%)

Proximal nutcracker phenomenon 10 (33)

Suspicious PNP 7 (23)

Passive reflux into the ISV 29 (97)

Proximal renospermatic shunt 6 (20)

Circumaortic renal vein l ( 3)

Table 2. Clinical and Venographic Grading and Degree of

the ISV ’s Dilatation ‘

Venographic Reflux ISV’s Dilatation

Clinical Grade 0 1 II III IV V min. mod. severe

CJ

。ι

?l

6

9

2

η

-4

2

6

6

1

-7

2

5

-7

2

4

1

7

14

?“

。ι

[D

-2

l

3

-1

-1

m

페 씨

떼

(

(

(

(

。a

nι --

k

k

ιx 때

겐 3

…m 야

mε me

g T

A B C

Fig. 1. Proximal nutcracker phenomenon (Severe case) A. Inferior vena cavogram of the case . B. Left renal venogram shows passive reflux into the ISV and paravertebral collateral veins and hemiazygos continuation (arrows) of the left renal vein without drainage into IVC C. Subtraction film of A,B to demonstrate the compression site (arrows) made by SMA/Aortic angle

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-Seollng Oh Yang. et a l.: Venographic Featllres of Varicocele

but less pronounced minimal compreS5ion was observed. In 9 patients the adrenal vein and paravertebral plexus in 10 patients and hemiazygos continuation of the left renal vein in 11 patients were demonstrated.

Passive reflux into the ISV was seen in 29 patients(97%). Six out of 11 patients with grade 3 varicocele revealed venographic reflux of grade V.

The number of the ISV is single in 18 pa-tients and multiple (mainly two) in 12 patients with various collaterals including vertical anastomosis. Renospermatic shunt is seen in 6 patients (Fig. 2) . In two of these 6 patients , PNP was present , too.

Circumaortic venous ring is shown with renospermatic shunt in one patient (Fig. 3).

(2) Findings of selective internal spermatic venography (Table 2, 3)

Degree of the ISV ’s dilatation is deter-mined as severe (over 7 mm in diameter), moderate (5-7 mm), and minimal (3-5 mm). Severe dilatation was seen in 7 patients whose clinical grade was 2 in two patients and 3 in five patients (Fig. 4).

A

Fig. 2. Multinlicity of the ISV and reno.spermatic shunt

B

Table 3. Occurrence of Anastomoses of the ISV (N = 26)

Location of Anastomosis

M 1 Ll M II LlI M III L III M IV LlV M V L V

No. 8 9 4 7 6 12 잉 5 2 7

% 31 35 15 27 23 46 12 19 8 27

Fig. 3. Circumaortic renal vein with reflux into the ISV. When catheter was advancecl through preaortic superior limb , contast injection into lower pole veins showecl preferential drainage into cir-cumaortic renal vein . Note anastomosis between circumaortic renal ve in and the ISV (arrows)

C

A. Two internal spermatic veins are shown. B. T wo ISVs with reno-spermatic shunt (curved arrow). C. T wo ISVs are joined to form single distal vein at cranial lumbar segment in Y.shape.

- 629 -

λ?:jUjj( n‘'*μ잭l}~ 션 ;w : q~23천 찌 4 싸 1987-

A B C

Fig. 4. Degree of the ISV ’s dilatation in selective venography A. Minimal dilatation (3mm). B. Moderate dilatation (5mm) C. Severe dilatation (9mm)

Concerning medial and lateral anastomo-ses, there was prepollderance of MI, LI, and LII , LIII anastomoses , occurring in 27% 46% of cases (Fig. 5). Four cases of failed superselection were excluded in this analysis about anastomotic sites.

Various forms of varicocele including dilated pampiniform plexus only and dilated both pampiniform and cremasteric plexus and mass-forming varicocele are demonstrated (Fig. 6).

In one patient of our series, crossover at the scrotallevel was seen (Fig. 6(B)). Valves of the ISV were venographical1y detectable in only 2 patients.

No major complications occurred in this series. Minimal perivenous contrast extra-vasation around the ISV was observed in 2 in-stances almost invariably associated with guidewire and catheter mainpulation in at-tempts to superselect the deep portion of the ISV.

(3) Findings of left common iliac venography (Table 4)

Table 4. Finclings of Left COlll1110n l1 iac Venography (N=30)

Findings No (%)

(37) Distal nutcracker phenomenon DNP with left to right shunt DNP without left to right shunt

Suspicious DNP Both PNP and DNP

n 9

2

8

딩

(27)

(43)

menon (DNP) was observed. In 8 patients a similar but less severe feature was seen with delayed persistent visualization of the iliac viens (Fig. 7).

As a result of this phenomenon, col1ateral circulation has developed from the left com-mon iliac system to the right side via dilated pelvic veins in 9 cases. In 5 patients, left ascending lumbar vein was shown. Both PNP and DNP were observed in 13 patients.

Spasm of the left external iliac vein occur-red in one patient. T he spasm passed after a few minutes and left no clinical problem (Fig. 8).

In 11 patients distal nutcracker pheno-

- 630-

- Seollng 011 Yang , et al.: Venographic Featllres of Va ricocele-

CRANtAL Ll!M8 AR SU8 SEGI'!ENT

II CAUDAL LUPm AR S얘SEGI1ENT

r?1t、_eVI : INFRAIHGUINAL SEGMENT

A B C

D E F

Fig. 5. Sites of anast01l10ses A. Subdivision of the ISV into subsegments. a = orifice of the ISV in left renal vein; b = pelvic brim; c = deep in-guinal ring; d = superficial inguinal ring; e = pampiniform plexus. B. Anastomosis at MI. C. Lll. D. ìVI III LllI E. LlV. F. LV (see the text)

Discussion

A varicocele, the most common correctable cause of subfertiliy in men, is present in 8% to 20% of the general male population,5.1 1. 12) and not all of those affected are infertile. However the deleterious effect of the vari-cocele also has been well established by Johnson and Pohl, who found a 70% incidence of significantly abnormal semen characteris-

tics in 93 men with clinically asymptomatic varicoceles. 13 ) The most important implication of varicocele concerns its effect on sper-matogenesis. It is speculated that reversed blood flow in the ISV increases temperature and possibly increases pressure resulting in decreased sperm counts, decreased motility, and increased number of abnormal forms. And other hormonal or toxin theories had been postulated. 14 ) For the time being, the patho-genesis of subfertility associated with vari-

- 631 -

:J얘파}jX~‘t*~챔장‘f깐JE : 껴~23~ 짜 4 싸 1987-

A B C

Fig. 6. Various forms of varicocele

A

C

A. Usual shape of the dilated left pampiniform plexus. B. Varicocele of pampiniform and cremasteric pexuses with crossover at sacrallevel from left to right. External pudendal vein with patent valve is noted (arrow). C. Peculiar round mass formation of the dilated pampiniform plexus.

B

D

632 -

Fig. 7. Distal nutcracker phenome non. A . Left com mon iliac ve nography shows focal compression of the left ex-ternal iliac vein by cO l1ll1lon iliac artery without visible left to right pelvic anasto l1losis. B & c. Ascen-ding lU l1lbar veins (arrows) and left to rig ht pelvic anasto l1loses ‘ D. Multiple lU l1lbar colla terals instead of filling in IVC

Seoung Oh Yang. et al.: Venographic Features of Varicocele-

A B C

Fig. 8. Spasm of left common and external iliac vein during venography. A. Initial fi lm taken at 1 sec after injection of contrast media shows initiation of spasm from above to below B. Slit-like spasmodic peak at 4 sec. C. At 9 seconds. This spasm was relieved after a few minutes

cocele has not been completely elucidated. Many diagnostic methods including physic-

al examination, thermography, radioisotope imaging,15) angiography, ultrasonography, and Doppler flow study are used to evaluate varicocele . Ultrasonographic evaluation appears to have the most success of the nonivasive imaging for defining subtle vari cocele formation of the venous plexus. 16 ) Recently Sigmund and associates compared the Doppler findings of varicocele and veno-graphic features of flow pattern. 17 ) The stop-type varicocele on the Doppler finding show-ed only retrograde blood flow in the ISV and was small subclinical varicocele , whereas each shunt-type varicocele showed both retrograde and orthograde venous flow and that re-presented a kind of venous bypass. The shun ting of venous blood appears to be a pre-condition for medium and large varicoceles and might have some prognostic significance for subfertility associated with varicoceles. To know these flow patterns on venographic study , it is necessary to view the spermatic

cord region intermittently with fluoroscopy for about 2 minutes and to take spot images. We did not make efforts to depict these draining veins in this study, but it should be searched afterward .

Reflux due to anatomical causes include vascular inadequacy, musculo-tendinous structures, anomalous renal and testicular arteries, and anomalies of left renal vein.1B ) Hill and Green6 ) showed that venographic reflux into the ISV occured in 15 out of 26 cases (58%), but we demonstrated it in 29 out of 30 patients. In the present investigation high grade varicocele was generally associated with a higher degree of venographic reflux. 9 ) The importance of the frequently occurring multi-plicity of the ISV and vertical anastomoses lies in the fact that these venous tributaries may lead to persistence or recurrence of varicocele 따ter treatment. Connection between the ISV and other retroperitoneal veins were noted in over half of the cases according to Morag et al. l9 ) The most frequent connections were with the renal ιapsular ， lumbar, or internal iliac veins

633 -

太꾀1M‘r%씩까，~fr;ι{ ‘ 찌î23;하 짜 4 Wi 1987

as in this series. It is our impression that demonstration of these connections is some-what dependent on the amount and pressure of the contrast injection and the site at which it is delivered. The deeper the catheter was placed into the ISV, the more likely were venous connections to be demonstrated. So standardization of the venographic technique is crucial for constant analysis of the lesion

Ahlberg and associates1 ) showed that there was a significant difference between the diameter of the left ISV in patients with a varicocele and that in patients without a varicocele. The mean diameter in these two groups were 6.8 and 4.3 mm respectively. This also made it tenable that the diameter of the ISV is dependent on the rate of reflux in-to this vesse l. Varicoceles usually are con-sidered to result from absence of competent valves in the proximal portion of the ISV. 20) Ahlberg2 ) showed in autopsy material that the valves are absent in 40% of men and in 10% they are incompetent. This finding raises the possibility of other etiologies for the mechanism of varicocele. 2 1) In the concept of the nutcracker phenomenon a central role is assigned to left renal ve in compression. Several causes of this compression have been postulated , including pressure exerted by the SMA, the ligament of Treitz , the aberrant testicular artery or the retroaortic ve in and stretching of the renal vein over the aorta. 19.10) Mali and associates lO ) found a positive correla-tion between the reno.caval pressure gradient and occurrrence of retrograde flow (r = 0.67) and the size of the varicocele (r = 0.75) , by means of pressure monitering and radioisotope study

Crossover at the scrotal level was seen in only 3 out of 140 patients according to Morag et al. 19) and we demonstrated one case of crossover. And we experienced one case of circumaortic venous ring. There are 3 main anatomic varients of the left renal vein: preaortic, retroaortic , and circumaortic. Cir-

cumaortic left renal vein is potentially hazar-dous anomaly inducing hemodynamic changes in kidney return circulation and may be responsible for recurrent hematuria and pro-teinuria. 22.23)

With the usual transfemoral approach , right-sided catheterization is often impossible. Morag et al. l9 ) showed the success rate of superselction of the ISV by transfemoral ap-proach as 93% in left and 62% in right. On the contrary, transjugular approach succeeded in superselection as 92% in left side and 89% in right side. So we think both approaches are equal for left-sided lesion but for the sub-clinical varicocele with right-sided reflux transjugular technique is indispensable. In addition , the technique makes possible the safe, nonsurgical occlusion of both ISV s more frequently. Nonsurgical varicocele occlusion can be performed on an outpatient basis with reduced cost, no general anesthesia, no postoperative sequelae such as hydrocele or hematoma, and a lower recurrence rate. 24.1 9) Report of percutaneous spring coil emboliza-tion of the ISV will be ensued. For the time be-ing , we consider embolization warranted in infertile patients with varicocele.

Venography is invasive and has some disad-vantage of requi,ring an experienced angio-grapher, but it makes possible a detailed study of the arrangement and function of the ISV s necessary in planning treatment, and helps in the diagnosis of persistent or recurrent varicoceles . Its reported morbidity is very low.4 ) Until noninvasive methods such as Dop-pler flow study have been validated , veno-graphic features should be the criteria for the diagnosis of the reflux including venous col-laterals and the tool for the nonsurgical treatment.

Acknowledgement

We thank professor Jae Hyung Park , M.D. for providing valuable advice about all these procedures.

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Seoung Oh Yang, et al.: Venographic Features of Varicocele-

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