Varicocele and PCS One and the same? · • Varicocele (men) and PCS (women) are frequent...
Transcript of Varicocele and PCS One and the same? · • Varicocele (men) and PCS (women) are frequent...
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Varicocele and PCSOne and the same?
Learning from Cases
Tim Sebastian
University Hospital Zurich
Illustrations: © by nilskucher.com
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Disclosure
Speaker name:
Tim Sebastian............................................................................
I have the following potential conflicts of interest to report:
Consulting
Employment in industry
Stockholder of a healthcare company
Owner of a healthcare company
Other(s)
x I do not have any potential conflict of interest
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Overlapping symptomsbut often different clinical setting
- scrotal swelling («bag of worms»), sometimes painful
«Correctable cause for male infertility»
- pelvic pain (exacerbated by standing, coitus, menstruation), vulvar swelling, leg varicosis
Varicocele Pelvic congestion syndrome
Symptom Overlap:
Pelvic pain, groin pain, leg varicosis, obstipation, hemorrhoids, leg heaviness, rectal discomfort, urinaryurgency
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Case 1 - 36 y female patient with suspected PCS
• Previously delivered 3 infants
• Clinically suspected PCS (symptom duration 5 years)• Position-dependent pelvic pain
• Pain worsened around the menstruation period (dysmenorrhoea)
• Pain was radiating into right groin and thigh
• Multiple medical check-ups with her gynacologists wereunremarkable
Clinical suspicion
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Case 1 - 36 y female patient with suspected PCS
Nutcracker anatomy?
Clinical suspicion
Abnormal Ultrasound
Retrograde flow in ovarian vein?
AMSLRV
Cra
nia
l
Cau
dal
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Case 1 - 36 y female patient with suspected PCS
Parauterine veins with refluxduring valsalva
Clinical suspicion
Abnormal Ultrasound
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Case 1 - 36 y female patient with suspected PCS
Parauterine veins and dilatedleft and right ovarial vein
Clinical suspicion
Abnormal Ultrasound
Abnormal MRI
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Case 1 - 36 y female patient with suspected PCS
A: rule out May Thurner compressionB: rule out nutcracker compression
A B
Clinical suspicion
Abnormal Ultrasound
Abnormal MRI
Diagnosticvenography
Jugular access- 5-French Access
- Cobra catheter
- Soft Terumo wire
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Case 1 - 36 y female patient with suspected PCS
Clinical suspicion
Abnormal Ultrasound
Abnormal MRI
Diagnosticvenography
Embolisation
A B A: Embolisation(ethoxysclerol)B: Coiling
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Three mechanisms for varicocele and PCS (Greiner)
• Type 1: Valvular or parietal insufficiency without deep venousobstruction (primary insufficiency)
• Type 2:
Obstruction in a draining vein responsible for symptomaticcollaterals (e.g. May-Thurner, Nutcracker, post-thromboticcentral veins)
• Type 3:
Others
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Case 2 - 48 y male patient with suspected varicocele
• Symptomatic recurrent varicocele (left > right)• Scortal pain, groin pain (position-dependent)
• Left sided pain during exercise (venous claudication)
• Previous surgery• laparoscopic left testicular vein clipping)
• Surgical varicocelelectomy
• Professional driver (unable to work)
Clinical suspicion
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Case 2 - 48 y male patient with suspected varicocele
Clinical suspicion
Abnormal ultrasound
Recurrent varicocele withreflux during valsalva
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Case 2 - 48 y male patient with suspected varicocele
Atypical compression of the leftcommon iliac vein by the leftcommon iliac artery (?)
Recurrent varicocele
Clinical suspicion
Abnormal ultrasound
Abnormal MRI
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Case 2 - 48 y male patient with suspected varicocele
Outcome:
Improvement of leg pain but persistingscrotal pain
Intervention 1:
Stent implantation to treat atypical MTS
Clinical suspicion
Abnormal ultrasound
Abnormal MRI
Treatment ofobstruction
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Case 2 - 48 y male patient with suspected varicocele
Clinical suspicion
Abnormal ultrasound
Abnormal MRI
Treatment ofobstruction
Embolization
Coils + ethysclerol embolization of rightvaricocele via obturator vein
Intervention 2:
Embolization due to persistent symptoms
Coils + ethysclerol embolization of leftvaricocele via obturator vein and circumflexa
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Three mechanisms for varicocele and PCS (Greiner)
• Type 1: Valvular or parietal insufficiency without deep venousobstruction (primary insufficiency)
• Type 2:
Obstruction in a draining vein responsible for symptomaticcollaterals (e.g. May-Thurner, Nutcracker, post-thromboticcentral veins)
• Type 3:
Others
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What we learn from the cases:
• Varicocele (men) and PCS (women) are frequent conditions with
anatomical similarities that may present with overlapping symptoms
• Choice of treatment depends on the underlying cause of reflux
(primary versus secondary)
• In case of underlying obstruction embolisation should be performed
delayed if symptoms of congestion persist
• There are still many open question regarding the real pathophysiology
and the durability of embolization therapy that need to be answered.
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Varicocele and PCSOne and the same?
Learning from Cases
Tim Sebastian
University Hospital Zurich