title: Angiographic findings of primary versus salvage varicoceles treated with selective gonadal vein embolization: an explanation for surgical treatment failure.
abstract: OBJECTIVE
  Gonadal vein angioembolization is a successful means of primary and salvage treatment for symptomatic varicoceles. We aim to investigate angiographic findings during embolization of primary varicoceles vs those with failed surgical ligation.
  
  
  METHODS
  Between 1992 and 2010, 106 cases referred to our interventional radiologists for primary or salvage varicocelectomy were reviewed. These patients underwent venography and gonadal vein embolization using a combination of embolization coils and vascular plugs. All images were reviewed by an interventional radiologist to determine the anatomic etiology of the varicocele. Primary and salvage embolization cohorts were compared using t test and chi-square analyses for continuous and categorical variables, respectively. Angiographic parameters were analyzed using univariate and multivariable regression models to determine significance in predicting primary vs salvage status.
  
  
  RESULTS
  Of the 106 patients, 46 patients (57 testicles) underwent primary and 60 patients (62 testicles) underwent salvage embolization. The salvage cohort of patients was younger (P<0.001) and comprised more solely left-sided pathology (P=0.002). An equivalent number of gonadal vein divisions and proportion of patent gonadal veins was found. However, there was a significantly higher proportion (27.8% vs 6.7%) of inguinal collateral vessels and combined presence of inguinal and retroperitoneal collateral veins (8.5% vs 2.1%) identified in the cohort undergoing embolization after failed surgical varicocelectomy. Presence of inguinal collaterals (P=0.008) as well as presence of both inguinal and retroperitoneal collaterals (P=0.038) on multivariable regression analysis revealed both as independent prognosticators of salvage status.
  
  
  CONCLUSIONS
  Recurrence after surgical varicocelectomy is associated with increased inguinal collaterals. The pitfall presented by this anatomic variant to surgical ligation may be successfully managed with selective gonadal vein embolization.
authors.affiliation: The Arthur Smith Institute for Urology, Cohen Children's Medical Center of New York, North Shore LIJ Health System, Long Island, New York 11040, USA. soroushraisbahrami@gmail.com
authors.forename: Soroush
authors.initials: S
authors.lastname: Rais-Bahrami
authors.forename: Sylvia
authors.initials: S
authors.lastname: Montag
authors.forename: Arvin K
authors.initials: AK
authors.lastname: George
authors.forename: Ardeshir R
authors.initials: AR
authors.lastname: Rastinehad
authors.forename: Lane S
authors.initials: LS
authors.lastname: Palmer
authors.forename: David N
authors.initials: DN
authors.lastname: Siegel
mesh_terms: D000293:Adolescent; D000328:Adult; D000792:Angiography / Q000379:methods*; D002648:Child; D004621:Embolization, Therapeutic / Q000379:methods*; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010690:Phlebography; D013737:Testis / Q000098:blood supply*; D017211:Treatment Failure; D014646:Varicocele / Q000000981:diagnostic imaging* / Q000601:surgery*; D055815:Young Adult