Case Report
Inadvertent Left Common Iliac Vein Catheterisation during Left Varicocoele Embolisation–A Potential Pitfall
Z Zia and H Hafez*
Department of Vascular & Endovascular Surgeon, King Faisal Specialist Hospital & Research Centre, KSA
*Corresponding author: Hany Hafez, Department of Vascular & Endovascular Surgeon, King Faisal Specialist Hospital & Research Centre, Jeddah, KSA
Published: 14 Oct, 2016
Cite this article as: Zia Z, Hafez H. Inadvertent Left
Common Iliac Vein Catheterisation
during Left Varicocoele Embolisation–A
Potential Pitfall. Clin Surg. 2016; 1:
1155.
Abstract
Testicular vein embolisation has become the first line therapy in treatment of varicocoele with good technical success and low complication rate. We report two cases of anatomical anomalies in which the left iliac vein was catheterised after selective catheterization of the left renal vein. This is a potential pitfall, which has not been previously reported. Reasons for catheterisation of the left iliac vein through the left renal vein are discussed and angiographic features to recognise and prevent potential left iliac embolisation are reviewed.
Introduction
Testicular vein embolisation has become the first line therapy in treatment of varicocoele with
good technical success and low complication rate [1]. We report two cases in which the left iliac
vein was inadvertently catheterized after selective catheterization of the left renal vein with a view
to testicular vein embolization. This potential pitfall has not been previously reported and has an
important clinical and medico-legal implication.
Reasons for catheterisation of the left iliac vein through the left renal vein are discussed and
angiographic features to recognise and prevent potential left iliac embolisation are reviewed.
Case Presentation
Case 1
A 51 year old patient with left varicocoele was referred for embolization. At the start of the
procedure, the right common femoral vein (CFV) accessed. A 4 Fr. sheath (Cordis, Miami Lakes,
USA) was introduced then a 4 Fr. cobra catheter (Cordis, Miami Lakes, USA) and angled hydrophilic
wire (Radiofocus, Terumo, Tokyo) were manipulated through the Inferior Vena Cava (IVC) into the
left renal vein. Venography demonstrated contrast reflux into a vein arising from the caudal surface
of the left renal vein. Assuming it was the testicular vein, this vein was catheterised selectively and
the catheter and wire were advanced into the pelvis. At this stage, the catheter was noted to pass
laterally in the pelvis and moving away from the scrotum (Figure 1a). This was recognised and a
venogram revealed that catheter was actually in the left external iliac vein (Figure 1b). At this point,
the catheter and wire were withdrawn and the procedure was abandoned.
Case 2
A 19 Year old male referred for left sided varicocoele embolisation, which was confirmed on
ultrasound. After ultrasound guided right Internal jugular vein punctured and a 5 Fr. vascular
sheath (Cordis, Miami Lakes, USA) was inserted. An angled hydrophilic wire (Radiofocus, Terumo,
Tokyo) and 5 Fr. MPA catheter (Cordis, Miami Lakes, USA) were manipulated through the right
atrium into the IVC and then into the left renal vein. Venography demonstrated reflux of contrast
into a vein arising from the caudal surface of the left renal vein (Figure 2a). The catheter and wire
were manipulated into the presumed left testicular vein and advanced into the pelvis. Further
venography suggested that the catheter was placed into the left testicular vein (Figure 2b). A 9
mm fibred platinum Coil (Target Vascular, Boston Scientific, Cork, Ireland) was deployed initially
followed by a 10 x 400 mm spiral coil (Balt Extrusion, Montmorency, France). The last deployed
coil showed unconstrained widening of coil, which was not expected in a vessel of the size of the
left testicular vein. This raised the suspicion of non-targeted embolisation and a further venogram
confirmed the inadvertent deployment of coils in the left common iliac vein, left internal iliac vein
and its tributaries (Figure 3a). The 10 mm Spirale Coil was successfully removed with a gooseneck
snare (10 mm Multisnare, BVM). However, a small coil in a tributary of the left internal iliac vein
was not retrievable and was left in-situ (Figure 3b) with no immediate post procedure implications.
Figure 1
Figure 1
Figure 1a: Catheter noted to pass laterally in the pelvis with the tip pointing away from the scrotum (white arrow).
Figure 1b: A venogram confirms suspicion of catheter placement in the left external iliac vein.
Figure 2
Figure 2
Figure 2a: Demonstrates reflux of contrast into a vein draining into the caudal surface of the left renal vein.
Figure 2b: Venogram after advancing the catheter into the vein draining into the caudal surface of the left renal vein shows filling of some veins in the pelvis, which was presumed to be the testicular vein.
Figure 3
Figure 3
Figure 3a: Digital subtraction venogram after unconstrained widening of the coil shows deployment of coils in the left common iliac vein, left internal iliac vein and its tributaries.
Figure 3b: Digital subtraction venogram showed a small coil in a tributary of the left internal iliac vein was not retrievable and left in situ.
Figure 4
Figure 4
The definitive sign of cannulation of the testicular vein on venogram is contrast passing medially towards the scrotum inferior to the inguinal ligament.
Discussion
Percutaneous testicular vein embolisation has a good technical
success with some authors, such as Nabi et al. [2], reporting a
technical success of 95.7%. The long-term success and complication
rates of percutaneous embolisation of adolescent varicocoele remain
comparable to those with surgical ligation [3].
Complications of percutaneous therapy are infrequent and are
generally minor. Complication rates in recent literature have been
reported from 0% [2] to 11% [4]. Such complications include contrast
material reaction, testicular thrombophlebitis from sclerosing
agents, venous spasm, and non-targeted embolization to the lungs,
retroperitoneal haematoma due to vessel injury and those associated
with the venous access puncture.
Apart from the above reported potential complications,
cannulation of the left common iliac vein after selective catheterisation
of the left renal vein has not been previously described as a possible
complication of varicocoele embolisation. Failure to recognise this
during procedure may lead to non-target vessel embolisation which
may have significant clinical and medico-legal implications.
There are certain signs during fluoroscopy and angiography,
which would help recognize that the catheter is not in the desired
position (the left testicular vein) despite selective catheterisation of
the left renal vein. If the catheter or the wire are pointing and moving
away from the scrotum, as in case 1 (Figure 1a), it would suggest
that the catheter is in the external iliac vein. In this case, venography
would confirm the position of the catheter in the left external iliac
vein. However, if the catheter passes into the tributaries of the left
internal iliac vein, the catheter would point medially as it would if
it was correctly positioned in a testicular vein (Case 2 (Figure 2b)).
Venography at this stage should be reviewed carefully to differentiate
between tributaries of the internal iliac vein and the testicular
vein. The definitive sign of cannulation of the left testicular vein
on venography is contrast passing medially towards the scrotum
inferior to the inguinal ligament (Figure 4). If this is not seen, then
the possibility that the catheter tip is in one of the tributaries of the
internal iliac vein should be considered.
Cannulation of the left common iliac vein after selective
catheterisation of the left renal vein can be explained anatomically by
the variations in the collaterals of the left testicular vein. Bahren and
co-workers introduced a classification for the left-sided varicocele
that is used as a basis for the most frequent anatomical variants [5].
Relevant to the described complication in this report is the Bahren
Type II variant, which is described as the presence of collaterals
from the left testicular vein to the inferior vena cave, left iliac vein
or lumbar veins on phlebography. This variation has a relatively
common frequency of 12.7%. This would explain how it is possible to
pass the catheter into the left common iliac vein after catheterisation
of the left testicular vein.
The other possible anatomical pathway for the catheterization of
the left common iliac vein through the left renal vein is through the
left ascending lumbar vein. The ascending lumbar veins arise from
the embryological lumbar venous line and connect the common iliac,
ilio-lumbar and lumbar veins. They ascend deep to the psoas muscle
anterior to the medial portions of the lumber transverse processes
to join with the subcostal veins forming the azygos on the right and
the hemiazygos on the left. Communication with the left renal vein
rather than the subcostal vein occurs commonly. The incidence of left
ascending lumbar vein draining to the left renal vein ranges from 34%
[6] to 68% [7]. Baniel et al. [8] noted that lumbar veins draining in to
the left renal vein are posterior to the entrance of the left testicular
vein. This relatively common anatomical variant would allow the
passage of catheter from the left renal vein through the left ascending
lumbar vein into the left common iliac vein.
Double IVC with the left IVC draining into the left renal vein is
another potential anatomic pathway for this complication. However,
venography after selective catheterisation of the left renal vein would
demonstrate a large high flow vein draining into the left renal vein,
which would clearly differentiate the left IVC from the ipsilateral
testicular vein.
The two cases described highlight the importance of recognizing
the potential for left iliac vein catheterisation after selective
catheterisation of the renal vein as a procedure related complication.
Failure to recognise this could lead to the erroneous embolisation
of the left iliac vein and its tributaries. Catheter tip pointing and
moving away from the scrotum should be carefully monitored, and
if observed, should suggest that the catheter is in the left external
iliac vein. However, catheter tip pointing is not a reliable anatomical
marker particularly if the catheter tip has already passed into one
of the internal iliac vein tributaries. A venogram after the catheter
has been introduced in to the pelvis through the testicular vein can
differentiate between internal iliac vein tributaries and testicular
vein tributaries. This should demonstrate contrast flow distal to the
inguinal ligament towards the scrotum, which is the definite proof of
selective catheterisation of the testicular vein.
References
- Beddy P, Geoghegan T, Browne RF, Torreggiani WC. Testicular varicoceles. Clin Radiol. 2005; 60: 1248-1255.
- Nabi G, Asterlings S, Greene DR, Marsh RL. Percutaneous embolization of varicoceles: outcomes and correlation of semen improvement with pregnancy. Urology. 2004; 63: 359-363.
- Reyes BL, Trerotola SO, Venbrux AC, Savader SJ, Lund GB, Peppas DS, et al. Percutaneous Embolotherapy of Adolescent Varicocele: Results and Long-term Follow-up. J Vasc Interv Radiol. 1994; 5: 131-134.
- Shlansky-Goldberg RD, VanArsdalen KN, Rutter CM, Soulen MC, Haskal ZJ, Baum RA, et al. Percutaneous Varicocele Embolization versus Surgical Ligation for the Treatment of Infertility: Changes in Seminal Parameters and Pregnancy Outcomes. J Vasc Interv Radiol. 1997; 8: 759-767.
- B¨ahren W, Lenz M, Porst H, Wierschin W. Nebenwirkungen, Komplikationen und Kontraindikationen der perkutanen Sklerotherapie der Internal spermatic vein zur Behandlung der idiopathischen Varikozele. Rofo. 1983; 138: 172-179.
- Lein HH, Kolbenschmidt. A. Phlebography appearances of the left renal and left testicular veins. Acta Radiol Diagn. 1977; 18: 321-333.
- Pick J, Anson B. The renal vascular pedicle. An anatomical study of 430 body-halves. J Urology. 1940; 44: 411-443.
- Baniel J, Foster RS, Donohue JP. Surgical Anatomy of the Lumbar Vessels: Implications for Retroperitoneal Surgery. J Urol. 1995; 153: 1422-1425.