Varicocele embolization in nutcracker syndrome

A 16-year-old adolescent referred with a history of grade 3 left varicocele from two years ago. He had no other diseases, and his urinalysis was normal. Diagnosed as NCS by abdominal ultrasound and MR angiography, he was referred for an endovascular treatment by a urologist according to abnormal semen analysis. Due to NCS, surgery was likely to result in recurrence of varicocele; therefore, endovascular treatment was selected as the preferred method because recurrence is probably unusual with this procedure.  Venography revealed increased gradient between inferior vena cava and left gonadal vein, which confirmed the diagnosis of NCS. Also, renal vein injection during Valsalva maneuver revealed severe gonadal vein reflux with retrograde filling of pampiniform plexus. Pushable coils were applied in the distal portion of the draining gonadal vein. Foam sclerotherapy was also done as part of the sandwich method. Amplatzer duct occluder was used for complete proximal occlusion of left gonadal vein.