A 53-year-old man with alcohol use disorder (abstinent for six months) and alcohol-related cirrhosis presented to an outside hospital with persistent left scrotal heaviness, pain, and swelling and was found on physical examination and ultrasound to have a large left varicocele. Given his history of cirrhosis, a contrast-enhanced CT of the abdomen and pelvis was obtained showing that the varices were supplied by a vessel arising from the splenic vein and draining into the left renal vein (Figs. 1, 2). Stigmata of cirrhosis and portal hypertension were also present, including splenomegaly and large gastric varices (Fig. 3). Labs were notable for MELD 16/MELD-Na 16, calculated from sodium 138 mmol/L, creatinine 0.78 mg/dl, total bilirubin 2.71 mg/dl, and INR 1.7. Given his symptomatology, he was referred for varicocele embolization.

Coronal contrast enhanced CT image showing dilated left spermatic veins (arrow)

Maximum intensity projection of the prior image showing the dilated left spermatic veins (arrow) arising from the splenic vein and draining into the left renal vein

Axial contrast enhanced CT image showing dilated gastric varices (arrow)

Because there was reversal of flow in the portal and splenic veins such that the varicocele provided most of the portal outflow, isolated embolization would pressurize the gastric varices and possibly precipitate an upper gastrointestinal bleed. Thus, concurrent gastric variceal embolization was also planned. However, because both shunts were functioning as pathways for portal decompression, closing them could result in portal vein thrombosis. Consequently, transjugular intrahepatic portosystemic shunt (TIPS) placement was also planned to provide venous outflow.

Access was obtained in the right internal jugular vein and right atrial, free hepatic vein, and wedged hepatic vein pressures measured. A Rosch-Uchida set (Cook Medical, Bloomington, IN) was subsequently used to obtain transhepatic access to the portal vein and a TIPS placed using a Gore Viator endograft (Gore Medical, Newark, DE) and dilated to 6 mm. The varicocele (Fig. 4a) was then embolized using a combination of plugs and coils, after which the gastric varix (Fig. 4b) was embolized with coils. Final imaging confirmed antegrade flow in the portal vein and TIPS without opacification of the varicocele or gastric varices (Fig. 4c).

a Post TIPS angiogram showing a dilated left testicular vein arising from the splenic vein (arrow). b Post TIPS angiogram showing gastric varices (arrow). c Post TIPS and embolization angiogram showing successful embolization of the gastric varices (arrow) and varicocele (arrowhead)

The patient experienced worsening scrotal pain on post procedure day 1, which was controlled with non-steroidal anti-inflammatory drugs. He was discharged on post procedure day 2. As of follow up one month later, he was asymptomatic and had experienced no encephalopathy.