DSA引導(dǎo)下使用泡沫硬化劑治療精索靜脈曲張的技術(shù)方法

1、Va seula r a nd Inter vent iona l R adiolog y ? Technic al Innovat ionAJR:193, October 2009#AJR:193, October 2009#Li et al.Track ing Scleros ing Foam Un der DSA Guida neeVascular and In terve nti onal Radiology Tech ni cal Inno vatio nAJR:193, October 2009#AJR:193, October 2009#Long Li1,2Xi n-Qiao Z

2、engp Ya n-Hao LlLi L, Zeng XQ, Li YHDigital Subtracti on An giography Guided Percuta neous Tran scatheter Foam Sclerotherapy of Varicocele: A Novel Track ing Tech niqueOBJECTIVE. The purpose of this article is to describe a new tracking technique for using sclerosing foam with radiologic guidance. T

3、hirty-nine men with varicocele underwent transcatheter foam sclerotherapy. Sclerosing foam was produced by the Tessari technique using 5% sodium morrhuate solution, and foam sclerotherapy was performed by the new tracking technique, the filling-defects technique, under digital subtraction angiograph

4、y (DSA) guidance using a step-by-step process consisting of spermatic phlebography, injection of sclerosing foam as a negative radiographic contrast material, and rinse of the catheter.CONCLUSION. The DSA-guided filling-defects technique is a feasible method for tracking the sclerosing foam and shou

5、ld be used in the treatment of other venous disorders when using sclerosing foam with radiologic guidance.AJR:193, October 2009#AJR:193, October 2009#Keywords: digital subtraction angiography, DSA, en dove nous tech niq ue, foam sclerotherapy, sodium morrhuate, varicocelesraditional sclerotherapy wi

6、th liquid sclerosants has been used for many years in the treatment of varicose veins and vascular malformations. The use of liquid sclerosants has the limitations of their dilution and progressive inactivation in the circulation and the irregular distribution of the liquid sclerosant on the endothe

7、lium 1. The use of the foam sclerotherapy technique has become increasingly popular in the treatment of lower extremity varicose veins, venous malformations, and Klippel-Tr naunay syndrome 1. The advantages of this use include an increase in contact between theauthors described an air-block techniqu

8、e using the foamy air during percutaneous sclerotherapy for the treatment of varicoceles, in which a small amount of air was injected before the injection of sclerosant to avoid dilution of the liquid. However, the methods of using the air were different in all these articles, and the technique was

9、not a true foam sclerotherapy. Moreover, the disadvantage of the air-block technique in large vessels was that the air bubble floating on the blood column protected the vessel from Contact with the sclerosant at the upper circumference, thus being only partially effective. The air-block technique is

10、 generallyAJR:193, October 2009#DOI:10.2214/AJR.09.2394Received January 14, 2009; accepted after revisi on April 28, 2009.1Department of Interventional Radiology, Nanfang Hospital, Southern Medical Uni versity, 1838 Gua ngzhou Ave. N, Gua ngzhou, Gua ngdo ng 510515, Chi na. Address corresp ondence t

11、o Y. H. Li (liya nhao).sclerosing liquid and the vessel wall, a decrease in dilution of the sclerosing agent secondary to displacement of blood by the foam as opposed to mixing with the blood, and an increase in the amount of contact time between the sclerosant and the vein. Foam also has the benefi

12、t of creating a more uniform distribution of sclerosing liquid within the venousno longer used by phlebologists during sclerotherapy of venous disorders.We think that at least one of technical difficulties of foam sclerotherapy with radiologic guidance is the visualization and tracking of the sclero

13、sing foam. The purpose of this article is to describe a new tracking technique of the standardized sclerosing foam under digi-AJR:193, October 2009#2Prese nt address: Departme nt of Radiology, Guangdong Provin cial Corps Hospital, Chin ese PeoplePolice Forces, Guangdong, China.3Departme nt of Radiol

14、ogy, Guangdong Provi ncial Corps Hospital, Chin ese People Guan gdo ng, China.system, with decreased side effects 1. Studies tal subtraction angiography (DSA). on hATfdam technique have been published that suggest greater efficacy with a lower total amount of sclerosants compared with liquidAJR 2009

15、; 193:978一 9800361 - 803X/09/1934- 978? America n Roen tge n Ray Societys Armed Police ForcessclerosantS 1.Since the late 1970s and early 1980s, percutaneous transcatheter sclerotherapy using liquid sclerosants has been used successfully to treat varicoceles in men 2. However, there are few reports

16、concerning foam sclerotherapy for the treatment of varicoceles 3, 4. SeveralMaterials and MethodsThe study design was a retrospective review of prospectively collected data. The study was approved by our local ethics committee, and informed consent was obtained from all patients. The study included

17、39 men (age range, 19 - 25 years; mean age, 21.2 3.7 SD years) from twoinstitutions who underwent transcatheter foam sclerotherapy under DSA for grades II and III leftAJR:193, October 2009979Tracking Sclerosing Foam Under DSA Guidancevaricocele with abnormal semen parameters between October 2007 and

18、 June 2008.The technique for phlebography involved se-Healthcare), 5 mL of the sodium morrhuate foam, and 1 mL of iohexol were sequentially injected into the target vessel under DSA. When the sclerosinglective catheterization of the internal spermaticfoam entered the internal spermatic vein, it push

19、edvein via the right femoral vein approach with the the previously injected contrast medium and ap- patient under local anesthesia and was performed as described in the literature 5, 6. An Axiom- Artis dFA Angiographic System (Siemens Healthcare) was used, with a 100-kW high-frequency generator (Pol

20、ydoros A100, Model no. 07716900, VAMP) and a 30 x 40 cm flat detector. In the exploratory segments, we used posteroanterior projection with a focus- detector distance of 100a focus - skin distance of 65 cm, and a field size of 20 cm. Pulsed fluoroscopy at 10 frames per second and DSA at 3 frames per

21、 second was performed.The voltage and amperage of the x-ray tube were automatically adjusted by automatic brightness control. Comprehensive, real-time updates of all relevant radiation dose levels were offered on the imaging system suspension display. Furthermore, all radiation dose values of the ex

22、amination were automatically documented in the examination protocol, including kVp, peak mA, total fluoroscopy time, DSA time of injection process, and dose - area product (DAP).The standardized sclerosing foam was produced by the Tessari technique using two syringes and the three-way connector tech

23、nique with an air - liquid sclerosant ratio of 4:1 7. This procedure was achieved by mixing 1 mL of 5% sodium morrhuate solution and 4 mL of unfilteredpeared as radiolucent filling defects in the vein filled with contrast medium on DSA. The purpose of the last injection of contrast material was to r

24、inse the remnants of the sclerosing foam from the catheter; it was visualized as the radiopaque shadowABroom air through 20 passages between two 5-mL syringes and a three-way tap (stopcock) that had a 30 rotation of the hub to narrow the aperture through which the foam passed.All patients rehearsed

25、a 25-second breath-hold before the procedure. After the correct position of the catheter (5-French Cobra II, Terumo) and abdominal pressure was found with a Valsalva maneuver, 5 mL of iohexol (Omnipaque 350, GEFig. 1 Percuta neous tran scatheter foam sclerotherapy using filli ng-defects tech nique u

26、n der digital subtracti on an giography (DSA) in 22-year-old man with varicocele.A, Selective spermatic veno gram shows vein enters left pelvis and runs in feroexter nal, and the n turnsin feromedial just above superior boun dary of pecte n pubis, en teri ng inguinal can al. Point of orie ntatio n c

27、ha nge shows deep inguinal ring (arrow).B, Duri ng injecti on of foam sclerosa nt un der con sta nt DSA guida nee, scleros ing foam was pushed in ferior in relation to previously injected contrast material and appears on DSA image as radiolucent filling defect (arrow) in vein filled with con trast m

28、aterial.C, DSA image shows spill out of tip of catheter rin sed with con trast material and flow into radioluce nt shadow of scleros ing foam (arrow), prese nting as radiopaque filli ng defect.D, After 15 minu tes, repeat spermatic phlebography shows left spermatic vein has bee n occluded completely

29、 (arrow).CAJR:193, October 2009981Li et al.of the contrast medium as it flowed into the radiolu- motility (20.13% 5.95% vs 36.45% icph4flfi%raphy, injection of the sclerosingcent shadow of the sclerosing foam (Fig. 1). Thus, it p 0.01). There have been no testes lost and nofoam, and rinse of the cat

30、heter. The processAJR:193, October 2009#success- -zwerBcoresed with transcatheter foam sclero- 3.2 SD seconds) on achiev-therapy using sodium tetradecyl sulfate. Al- 5.1 minutes; DSA time of injecor iodized oil (Lipiodol, Guerbet). And, it is un-with a small amount of contrast material produces only

31、 pastel shades in the fluoroscopic im- sclerosing foam and should be used in the treat-was quite easy to control the flow of the sclerosing foam. If flow near the external inguinal ring occurs (equivalent to the superior boundary of pecten pubis), the procedure can be stopped immediately.After 15 mi

32、nutes, repeat spermatic phlebography was performed to check the result. After the internal spermatic vein was obstructed satisfactorily, the catheter and the sheath were withdrawn in turn, and the puncture site was briefly compressed.The patient was ordered to stay in bed for 2 hours and to avoid in

33、tense exercise and heavy lifting for 7 days. Telephone follow-up was performed the next day. The patients could return to school or work the next day.To determine symptomatic relief, the patients were interviewed by telephone at 3 and 6 months after the procedure. Follow-up was performed using a que

34、stionnaire to evaluate the success rate of the procedure, complications, and any treatment of infertility by the patient or his partner after the procedure. A record of the semen analysis was obtained at 6 months after the procedure, and the Student test was used to compare the significant differenc

35、e between pre- and posttreatment.ResultsThe procedure was technically ful in all patients. We spent 16 (mean, 18.8 ing the sequential injection process, including superselective spermatic phlebography, the injection of the sclerosing foam, and the rinse of the catheter. No major complications were e

36、ncountered in our series. In all 39 patients, the injection of the foam sclerosant caused transient discomfort that lasted only a few minutes in the left flank or lower abdomen. No patient developed edema of the left scrotum.Mean radiation dose values automatically documented in the examination prot

37、ocol were as follows: peak voltage of the x-ray tube, 79.0 2.6 kV; peak amperage of the x-ray tube, 242.5 49.48 mA; total fluoroscopy time, 23.9recurrent or persistent varicoceles.DiscussionIn recent years, foam sclerotherapy has become a popular means of treating all types of abnormal veins of the

38、lower extremities and congenital vascular malformations. In most articles regarding foam sclerotherapy, ultrasound guidance has been used for identifying treated veins and monitoring foam injection or foam flow 1. However, duplex ultrasound examination requires experience, and ultrasound guidance is

39、 not available currently for transcatheter foam sclerotherapy of varicocele. In traditional liquid sclerotherapy, the liquid sclerosant can be visualized under fluoroscopy by mixing the sclerosant with moderate doses of contrast material.Lord and Burrows 3 in 2003 suggested that the foam sclerosant

40、was opacified under fluoroscopy by the addition of ethiodized oil. It is well known that the liquid sclerosant mixed ages. Recently, Gandini et al. 4 published the results of a study of 244 consecutive patients with a total of 280 varicoceles. These patients though this study is the true first repor

41、t on the subject of percutaneous foam sclerotherapy in varicoceles, the methods used actually replicated the air-block technique, and thus the authors did not have the ability to monitor sclerosing foam flow. Moreover, we do not know whether peculiar properties (adhesiveness and compactness, syringe

42、ability, greater volume for the same quantity of liquid agent, long duration, enhanced spasm generation, echovisibility, enhancement of sclerosing power with reduced drug dose and concentration, and selectivity of action on the endothelium) of the sclerosing foam that were mentioned by Frullini 8 wo

43、uld be changed by mixing contrast materialis started as soon as the assistant has prepared the sclerosing foam, and DSA is performed at the same time. As soon as the sclerosing foam nears the superior boundary of the pecten pubis, the procedure must be stopped immediately to prevent passage of foam

44、into the pampiniform plexus. The entire procedure forms a coherent whole within 30 seconds under a single DSA procedure. Using our methods of percutaneous foam sclerotherapy in varicoceles, we obtain durable results with no major side effects or complications. DSA-guided foam injection can be perfor

45、med in 20 seconds or less by an experienced operator. The radiation dose is similar to the maximum radiation skin dose published previously in cerebral endovascular embolization 9 and cardiac interventional procedures 10. Certainly, x-ray exposure parameters and the data collection process should be

46、 considered to reduce the risk associated with radiation exposure.In summary, the DSA-guided filling-defects technique is a feasible method for tracking the ment of other venous disorders when using sclerosing foam under radiologic guidance.AJR:193, October 2009#7. Tessari L, Cavezzi A, Frulli ni A.

47、 Prelim in ary experience with a new scleros ing foam in the treatme nt of varicose veins.Dermatol Surg 2001; 27:58- 60tion, 18.8 3.2 seconds; DAP of injection known whether the chemical reaction would be process, 2,011.96 54.66 References Berga n J, Cheng VL. Foam sclerotherapy: a textbook. London,

48、 UK: Royal Society of Medicine Press, 2008:100- 109 Lima SS, Castro MPCosta OF. A new method for thetreatme nt of varicocele. ndrologia 1978; 10:103- 106 Lord DJ, Burrows PE. Pediatric varicocele embolization. Tech Vasc Interv Radiol 2003; 6:169- 175 Gandini R, Konda D, Reale CA, et al. Male varicocele: tran scatheter foam sclerotherapy with sodium tetradecyl sulfate outcome in 244 patie ntsRadiology 2008; 246:612- 618 Wun sch R, Efin ger K. The in terve nti onal therapyof varicoceles amon gst childre n, adolesce nts