정계정맥류의인터벤션치료 초음파는임상적진찰보다더객관적이고재현성이있는검사로덩굴정맥얼기의직경이 2 mm 이상이면보통임상적으로의미있는정계정맥류에합당한소견이다 (Fig. 1). 색도플러검사에서 1초이상지속되는역방향혈류가관찰되는경우진단이가능하며 (8), CT나 MRI 는특히우측정

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1 Review Article pissn / eissn J Korean Soc Radiol 2016;75(3): Interventional Treatment of Varicocele 정계정맥류의인터벤션치료 Ji Hoon Shin, MD* Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea Varicocele is a dilatation of the veins in the pampiniform plexus and manifests as mass-effect, pain, testicular atrophy, or male infertility. Traditionally, surgical treatment has been the mainstay of treatment of varicocele, while interventional treatment, which is endovascular embolization of the testicular vein, has been gaining popularity recently. In this review, diagnosis of the disease, indications and procedure details of interventional treatment, results, and complications are discussed. Index terms Genital Diseases, Male Varicocele Sclerosing Solutions Received March 30, 2016 Revised May 1, 2016 Accepted May 24, 2016 *Corresponding author: Ji Hoon Shin, MD Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea. Tel Fax jhshin@amc.seoul.kr This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 서론 정계정맥류는고환정맥 (testicular vein) 에역류가발생하여덩굴정맥얼기 (pampiniform plexus) 가늘어나고구불구불하게된것으로종괴감, 통증, 고환위축, 불임의원인이된다. 정계정맥류는일반남성에서약 15%, 일차성불임남성의 35%, 이차성불임남성의 80% 까지보고되는비교적흔한질환이며남성불임의가장흔한원인이다 (1-3). 우측고환정맥은하대정맥으로직접연결되는반면좌측고환정맥은좌신정맥으로연결되어혈류가다소느리고주위조직으로부터눌릴가능성이높기때문에좌측정계정맥류가월등히많다. 정계정맥류는대부분고환정맥의판막이없거나이상에의한역류에의해고환정맥혈압이올라가서생긴다. 이차적원인으로고환정맥혈압상승이초래되는경우로는복부나골반내의종괴나임파선종대, 또는 Nutcracker syndrome ( 대동맥과상장간막동맥사이에좌신정맥이눌리는현상 ) 등이있다 (1, 2, 4). 이차적원인의정계정맥류는악성종양에의해생기는경우가많으므로, 특히우측정계정맥류만있는경우에는이차적 원인이있는지를염두에두어야한다. 정계정맥류가불임을일으키는이유는덩굴정맥얼기로의과혈류 (hyperemia) 로인한고환온도상승이나, hydrostatic pressure 상승으로인해고환내의소동맥및소정맥압력의역전으로인한저산소증으로알려지고있다 (5, 6). 이러한고환의환경변화는 Leydig cell 을감소시키고남성호르몬 (testosterone) 의분비를감소시켜정자부족증에서무정자증에이르기까지다양한남성불임을초래할수있다. 진단 임상적진찰은서있는상태에서발살바법 (valsalva maneuver) 으로복압을증가시켜덩굴정맥얼기의확장을보면된다. Dubin 과 Amelar (7) 는정도에따라 3단계로분류하였는데 grade 1 (small) 은발살바법으로복압을올릴경우에만만져지는경우이고, grade 2 (moderate) 는육안으로보이지는않으나힘을주지않았을때만져지는경우이며, grade 3 (large) 은덩굴정맥얼기의확장이육안으로도관찰되는경우이다. Copyrights 2016 The Korean Society of Radiology 163

정계정맥류의인터벤션치료 초음파는임상적진찰보다더객관적이고재현성이있는검사로덩굴정맥얼기의직경이 2 mm 이상이면보통임상적으로의미있는정계정맥류에합당한소견이다 (Fig. 1).

정맥조영술 (venography) 은고환정맥이나덩굴정맥얼기로의조영제역류를직접보여주는가장확실한검사라고할수있으나다소침습적검사여서색전술을시행할때같이시행하는경우가대부분이다. 고환정맥기능부전의정맥조영술형태분류는 Bähren 등 (9) 이 1983 년에발표한것을근간으로하며좌측고환정맥에해당한다 (Fig. 2, Table 1)(10). Type I은판막이없 A Fig.

Color Doppler image shows hypervascularity of the dilated pampiniform plexus. B Type I Type II Type III Type IV Type V Fig. 2.

2 정계정맥류의인터벤션치료 초음파는임상적진찰보다더객관적이고재현성이있는검사로덩굴정맥얼기의직경이 2 mm 이상이면보통임상적으로의미있는정계정맥류에합당한소견이다 (Fig. 1). 색도플러검사에서 1초이상지속되는역방향혈류가관찰되는경우진단이가능하며 (8), CT나 MRI 는특히우측정계정맥류환자에서고환정맥을압박하는병변이있는지확인하기위해쓰일수있고, CT reconstruction 으로고환정맥의역류와덩굴정맥얼기의 확장을확인할수있다. 정맥조영술 (venography) 은고환정맥이나덩굴정맥얼기로의조영제역류를직접보여주는가장확실한검사라고할수있으나다소침습적검사여서색전술을시행할때같이시행하는경우가대부분이다. 고환정맥기능부전의정맥조영술형태분류는 Bähren 등 (9) 이 1983 년에발표한것을근간으로하며좌측고환정맥에해당한다 (Fig. 2, Table 1)(10). Type I은판막이없 A Fig. 1. Ultrasonographic features of a varicocele. A. On ultrasonographic image, pampiniform plexus of veins is dilated more than 2 mm in diameter. B. Color Doppler image shows hypervascularity of the dilated pampiniform plexus. B Type I Type II Type III Type IV Type V Fig. 2. Bähren classification of varicocele anatomy (details of each type are described in Table 1). Table 1. Venography of a Left Varicocele (Bähren Classification) Type I II III IV V TV = testicular vein Reflux into a single incompetent TV Characteristics Reflux into a single TV which communicates with iliac veins, lumbar veins, perivertebral venous plexus or inferior vena cava Reflux into a duplicated TV Reflux through renal hilar or capsular veins IVa: Incompetent valve function IVb: Competent valve function Reflux into a TV that drains into the circumaortic renal vein 164 대한영상의학회지 2016;75(3): jksronline.org

3 신지훈 거나부전인단일고환정맥으로역류인경우, type II 는고환정맥의내측에위치하는 iliac vein 또는 lumbar vein 등과교통이있는고환정맥으로역류인경우, type III 는중복 (duplication) 이있는고환정맥으로의역류인경우 (Fig. 3), type IV 는고환정맥의주로외측에위치하는 renal hilar or capsular veins 로역류가있는경우로, 고환정맥과우회정맥모두기능부전이있는경우가 IVa, 고환정맥의판막은정상이나우회정맥에판막부전이있는경우가 IVb 이다 (Fig. 4). Type V는 duplicated renal vein 과같은좌신정맥의해부학적변이가있어서 cricumaortic renal vein 으로연결되는고환정맥으로역류가있는경우이다. 이중 type I이가장흔한것으로보고되며 (10), 수술후재발한경우에는 type III 가가장흔하나 (11, 12), 실제 venography 를해보면두 type 이상이혼재되는경우도드물지않다. 인터벤션치료 적응증인터벤션치료의적응증은수술의적응증과같이다음과같다. 1) 성인남성불임, 2) 청소년이나소아에서고환위축이동반된정계정맥류, 3) 통증이있을때, 4) 커서미용적인문제를동반할때 (grade 3). 반대로크기가작거나준임상적 (subclinical) 정계정맥류의경우에는치료후에도호전될가능성이적어서치료의적응증이되지않으며정액검사와도플러초음파검사를정기적으로받을필요가있다 (13). 실제적으로는수술을하고재발하는경우재수술을원하지않거나하기어려운경우에의뢰되어인터벤션치료를받는경우가가장많다 (3, 14). 인터벤션치료가수술과비교해서는수술의가능한합병증인음낭수종이나고환위축이발생하지않으므로잠재적불임에대한예방을목적으로하는청소년이나소아에서는보다안전한인터벤션치료를일차적으로고려하는것이좋다 (15). 수술과비교해서정맥조영술을할수있는장점이있어서재발을줄이는데수술보다유리하다. 수술적치료후재발의가장흔한원인이고환정맥중복을간과해서생기는것으로알려져있다 (11). Jargiello 등 (11) 의보고에의하면수술후재발한 33 명의환자에서고환정맥조영을얻었을때 22 명 (67%) 의환자에서 type III 인중복이있는고환정맥이있음을보고하였다. 시술방법입원한상태에서또는외래에서도시행할수있는시술이다. 대퇴정맥, 내경정맥, 상지의척골쪽피부정맥 (basilic vein) 등을천자하여 5 Fr 혈관초 (vascular sheath) 를삽입한다. 유도철사는 inch J-tipped 180-cm-long hydrophilic guide wire (Radifocus, Terumo, Tokyo, Japan) 를사용한다. 일반적으로대퇴정맥이많이쓰이는데시술자에게편한위치이지만좌신정맥의경우카테터의지지역할이충분하지못한경우가있어고환정맥선택에어려움이있을수있다. 내경정맥이나상지의척골쪽피부정맥은하대정맥과좌신정맥이둔각을이루어고환정맥으로보다쉽게진입할수있다 (Fig. 3). 좌측정계정맥류의경우, 4 Fr나 5 Fr Cobra 또는 Headhunter catheter (Cook, Bloomington, IL, USA) 를많이사용한다. 카테터의끝을좌신정맥에위치시킨후발살바법이나 table tilting 을하여환자의다리쪽이낮게테이블을기울여 reverse Trendelenburg 체위에서혈관조영을얻게되면고환정맥으로의조영제역류가잘보인다. 이를참조하여카테터끝을고환정맥을따라덩굴정맥얼기근처까지도달시킬수있으나해부학적으로 4 Fr 나 5 Fr 카테터를진입시킬수없을경우 2~2.4 Fr 미세카테터를사용하여덩굴정맥얼기까지도달한다. 우측정계정맥류의경우대퇴정맥으로진입할경우 Simmons catheter (Cook) 와같은 reverse curve catheter 를사용하고내경정맥, 척골쪽피부정맥으로진입할경우 4 Fr 나 5 Fr Cobra 또는 Headhunter catheter 를사용하여우측고환정맥을선택한다. 우측고환정맥의경우우신정맥바로아래의하대정맥의우전외측면 (anterolateral surface) 에서시작하는경우가많다. 정상판막을가진고환정맥의경우좌신정맥에서조영제를주었을때원위부가보이지않아측부순환정맥 (collateral vein) 등을잘파악할수없다 (Fig. 4). 이런경우에는유도철사를부드럽게조작하여정상판막을통과시킨후정맥조영술을시행하여야하기때문에기술적으로어려울수있으며고환정맥을통해들어갈수없을경우에는측부순환정맥을통해서들어가야하나기술적으로어려운경우가많다. 정맥조영술을얻어서덩굴정맥얼기까지역류됨을확인하고해부학적변이의형태를파악한다. 치료를위해서는카테터를고환정맥의원위부인안쪽샅굴구멍 (internal inguinal ring) 직상방까지진입시킨다. 고환정맥색전방법으로는코일을이용한기계적폐색법과경화제를사용하는정맥경화요법이주로사용되며그외에 N- butyl cyanoacrylate, 뜨거운조영제 (hot contrast medium), 분리형풍선등이보고되었다 (16-19). 시술자의성향이나해부학적구조에따라색전물질을선택하게되며단독또는조합으로사용하게되나, 측부순환정맥을잘막기위해서는코일보다는경화제나액상색전물질이더효과가좋을것으로기대된다. 코일의경우지금까지가장많이쓰여왔으며, 이동을방지하기위해고환정맥의직경보다약간큰직경의코일을사용하며원위부에서는샅굴 (inguinal canal) 위치에, 근위부에서는신정 jksronline.org 대한영상의학회지 2016;75(3):

정계정맥류의인터벤션치료 A B C D Fig. 3. Type III varicocele.

The testicular vein shows duplication (arrows) in its distal part (B).

The distal testicular vein is embolized with coils and treated with

4 정계정맥류의인터벤션치료 A B C D Fig. 3. Type III varicocele. Left renal venogram shows reflux of contrast medium into the testicular vein (arrows) (A). The catheter is inserted from above, through the right basilic vein access. The testicular vein shows duplication (arrows) in its distal part (B). Note the contrast medium reflux into the pampiniform plexus (arrowhead) (B). The distal testicular vein is embolized with coils and treated with sclerotherapy (C); then, the proximal testicular vein is also embolized with coils (D). Left renal venogram shows no further reflux into the testicular vein (D). 166 대한영상의학회지 2016;75(3): jksronline.org

boratories, Montreal, Canada), sodium morrhuate 등이 있으 되는 모든 부위에 색전술을 시행하여야 한다.

거품으로 쓸 경 경화제는 최근 많이 사용하게 되는 색전물질로 polidocanol, A B 우 혈관내피세포 표면(endothelial surface)에 고루 분포를 하 C D E

Left renal venogram shows reflux of contrast medium into the tortuous collateral vein (arrows).

The collateral vein (arrows) is connected with the probable testicular vein (arrowheads). C.

5 신지훈 맥과 연결되는 입구 근처에서 2~3 cm 떨어진 위치가 좋다. 코 sodium tetradecyl sulfate (이하 STS; thromboject, Omega La- 일을 단독으로 사용할 경우, 우회정맥을 정확히 파악하여 연결 boratories, Montreal, Canada), sodium morrhuate 등이 있으 되는 모든 부위에 색전술을 시행하여야 한다. 며 거품형성방법(foam technique)을 이용한다. 거품으로 쓸 경 경화제는 최근 많이 사용하게 되는 색전물질로 polidocanol, A B 우 혈관내피세포 표면(endothelial surface)에 고루 분포를 하 C D E Fig. 4. Type IVb varicocele. A. Left renal venogram shows reflux of contrast medium into the tortuous collateral vein (arrows). The proximal testicular vein is not seen. B. The collateral vein (arrows) is connected with the probable testicular vein (arrowheads). C. The testicular vein (arrows) is refluxed distally below the inguinal canal. D. The distal testicular vein is embolized with coils and treated with sclerotherapy, followed by coil embolization of the proximal testicular vein. E. Ultrasonographic image shows a dramatic reduction in the vascularity of the pampiniform plexus six days after sclerotherapy. jksronline.org 대한영상의학회지 2016;75(3):

6 정계정맥류의인터벤션치료 고유순성 (malleability) 이뛰어나서여러측부순환정맥을효과적으로색전할수있다 (17). STS 거품형성방법은저자에따라배율에차이가있으며저자의경우 3% STS 2 ml 와리피오돌 0.5 ml, 그리고공기 3.5 ml 를 three way stopcock 을이용하여잘섞어서거품형태로만들어사용하며, Gandini 등 (17) 은 3% STS 1 ml 와공기 4 ml 만을섞어서거품형태로사용함을보고하였다 (14). 경화제는단독으로사용하거나코일로고환정맥의원위부와근위부색전을병행할수도있다 (Figs. 3, 4). 덩굴정맥얼기로경화제가들어가면혈전정맥염이생길수있어서안쪽샅굴구멍부위에코일색전술을하거나손으로압박하고경화제를투시영상으로보면서주입하거나 (14, 17), 조영제를고환정맥에충분히채우고경화제를주입할경우경화제가 filling defect 로보여서시술이용이할수있다 (20). 경화제를주입할때발살바법을하거나 20 도정도 reverse Trendelenburg 체위에서시행하면신정맥으로의경화제유출을최소화할수있다. 색전술을시행한후효과적으로역류가차단되었는지를확인하기위해시술후 10 분후에다시신정맥에서정맥조영술을시행한다. 정도안정을취한후퇴실하고다음날부터일상생활이가능하며통증이있을경우 nonsteroidal anti-inflammatory drug ( 이하 NSAID) 를처방한다. 일반적으로시술후 1~3개월후에외래를방문하여문진과임상적진찰을하며 6개월과 12 개월후에임상적관찰과함께초음파검사를시행하여정계정맥류의호전여부와재발여부를파악한다. 시술과관련된합병증으로정맥파열 (vein perforation) 이나혈관경련 (vasospasm) 이생길수있다. 정맥파열은정상판막을통과할때더잘생기며대부분스스로좋아진다. Vasospasm 이심한경우더이상시술이어려울수있어서카테터나유도철사조작시세심한주의가요구된다. 덩굴정맥얼기의혈전정맥염이약 5% 정도까지보고되며대부분경화제의유출로생긴다. 혈전정맥염은시술후 1~2일후에통증과종창이동반되며항생제와 NSAID 로치료한다. 심각한후유증을만들수있는합병증으로는폐색전증으로코일이나경화제가신정맥을통하여하대정맥으로들어갈때생길수있어서고환정맥에서신정맥으로이어지는부위까지색전물질이도달하지않도록세심한주의가요구된다. 결과 Bähren 분류에따라치료성적에차이가있다. 코일색전술의경우 Bähren type I, III 와같이비교적단순한형태에서는기술적성공률이 97% 이지만, 해부학적변이가있을때에는왼쪽은 73%, 오른쪽은 57% 의기술적성공률을보였고 (16), 경화요법에서도 Bähren type IVb 의경우에는 82% 의낮은성공률이보고되었다 (21). Type IVb 의경우에는고환정맥으로의역류가보이지않고측부순환을통해역류하는형태를보여서시술이어려운경우가많다 (Fig. 4). 기본적으로고환정맥의해부학적변이에대한이해와기술적숙달이있을경우기술적성공률은향상될것이다. 최근 10년내의논문들에서색전물질에큰차이없이 93~ 100% 의높은기술적성공률을보고하였으며실패한경우의대부분은고환정맥을선택하지못한경우였다 (11, 17, 18, 20, 22-24). 경화요법의경우 1년후재발률이 11% 정도로알려져있으며 Dubin 등급이올라갈수록재발률도올라가며수술적치료후의재발률과차이는없다 (25). 시술후처치및합병증 시술후에는혈관초와카테터를제거하고지혈한후몇시간 결론 정계정맥류는남성불임의주원인으로환자의병력과초음파소견으로치료의적응증여부를어렵지않게판단할수있다. 인터벤션치료는보다덜침습적이면서도수술이상의치료효과를내고합병증또한적어서일차적치료방법으로고려할수있다. REFERENCES 1. Shiraishi K, Matsuyama H, Takihara H. Pathophysiology of varicocele in male infertility in the era of assisted reproductive technology. Int J Urol 2012;19: Raheem OA. Surgical management of adolescent varicocele: systematic review of the world literature. Urol Ann 2013;5: Halpern J, Mittal S, Pereira K, Bhatia S, Ramasamy R. Percutaneous embolization of varicocele: technique, indications, relative contraindications, and complications. Asian J Androl 2016;18: Mohammadi A, Ghasemi-Rad M, Mladkova N, Masudi S. Varicocele and nutcracker syndrome: sonographic find- 168 대한영상의학회지 2016;75(3): jksronline.org

7 신지훈 ings. J Ultrasound Med 2010;29: Wright EJ, Young GP, Goldstein M. Reduction in testicular temperature after varicocelectomy in infertile men. Urology 1997;50: Gat Y, Gornish M, Chakraborty J, Perlow A, Levinger U, Pasqualotto F. Azoospermia and maturation arrest: malfunction of valves in erect poster of humans leads to hypoxia in sperm production site. Andrologia 2010;42: Dubin L, Amelar RD. Varicocele size and results of varicocelectomy in selected subfertile men with varicocele. Fertil Steril 1970;21: Mihmanli I, Kurugoglu S, Cantasdemir M, Zulfikar Z, Halit Yilmaz M, Numan F. Color Doppler ultrasound in subclinical varicocele: an attempt to determine new criteria. Eur J Ultrasound 2000;12: Bähren W, Lenz M, Porst H, Wierschin W. [Side effects, complications and contraindications for percutaneous sclerotherapy of the internal spermatic vein in the treatment of idiopathic varicocele]. Rofo 1983;138: Sigmund G, Bähren W, Gall H, Lenz M, Thon W. Idiopathic varicoceles: feasibility of percutaneous sclerotherapy. Radiology 1987;164: Jargiello T, Drelich-Zbroja A, Falkowski A, Sojka M, Pyra K, Szczerbo-Trojanowska M. Endovascular transcatheter embolization of recurrent postsurgical varicocele: anatomic reasons for surgical failure. Acta Radiol 2015;56: Nagappan P, Keene D, Ferrara F, Shabani A, Cervellione RM. Antegrade venography identifies parallel venous duplications in the majority of adolescents with varicocele. J Urol 2015;193: Iaccarino V, Venetucci P. Interventional radiology of male varicocele: current status. Cardiovasc Intervent Radiol 2012; 35: Kim J, Shin JH, Yoon HK, Ko GY, Gwon DI, Kim EY, et al. Persistent or recurrent varicocoele after failed varicocoelectomy: outcome in patients treated using percutaneous transcatheter embolization. Clin Radiol 2012;67: Storm DW, Hogan MJ, Jayanthi VR. Initial experience with percutaneous selective embolization: a truly minimally invasive treatment of the adolescent varicocele with no risk of hydrocele development. J Pediatr Urol 2010;6: Marsman JW. The aberrantly fed varicocele: frequency, venographic appearance, and results of transcatheter embolization. AJR Am J Roentgenol 1995;164: Gandini R, Konda D, Reale CA, Pampana E, Maresca L, Spinelli A, et al. Male varicocele: transcatheter foam sclerotherapy with sodium tetradecyl sulfate--outcome in 244 patients. Radiology 2008;246: Urbano J, Cabrera M, Alonso-Burgos A. Sclerosis and varicocele embolization with N-butyl cyanoacrylate: experience in 41 patients. Acta Radiol 2014;55: Hawkins CM, Racadio JM, McKinney DN, Racadio JM, Vu DN. Varicocele retrograde embolization with boiling contrast medium and gelatin sponges in adolescent subjects: a clinically effective therapeutic alternative. J Vasc Interv Radiol 2012;23: Li L, Zeng XQ, Li YH. Safety and effectiveness of transcatheter foam sclerotherapy for testicular varicocele with a fluoroscopic tracing technique. J Vasc Interv Radiol 2010;21: Lenz M, Hof N, Kersting-Sommerhoff B, Bautz W. Anatomic variants of the spermatic vein: importance for percutaneous sclerotherapy of idiopathic varicocele. Radiology 1996;198: Wunsch R, Efinger K. The interventional therapy of varicoceles amongst children, adolescents and young men. Eur J Radiol 2005;53: Reiner E, Pollak JS, Henderson KJ, Weiss RM, White RI Jr. Initial experience with 3% sodium tetradecyl sulfate foam and fibered coils for management of adolescent varicocele. J Vasc Interv Radiol 2008;19(2 Pt 1): Sze DY, Kao JS, Frisoli JK, McCallum SW, Kennedy WA 2nd, Razavi MK. Persistent and recurrent postsurgical varicoceles: venographic anatomy and treatment with N-butyl cyanoacrylate embolization. J Vasc Interv Radiol 2008;19: Abdulmaaboud MR, Shokeir AA, Farage Y, Abd El-Rahman A, El-Rakhawy MM, Mutabagani H. Treatment of varicocele: a comparative study of conventional open surgery, percutaneous retrograde sclerotherapy, and laparoscopy. Urology 1998;52: jksronline.org 대한영상의학회지 2016;75(3):

8 정계정맥류의인터벤션치료 정계정맥류의인터벤션치료 신지훈 * 정계정맥류는덩굴정맥얼기의확장으로종괴감, 통증, 고환위축과같은증상이나남성불임으로나타난다. 수술적치료가전통적으로많이이루어져왔으나, 최근고환정맥의색전술과같은인터벤션치료가꾸준히각광을받고있다. 본종설에서는정계정맥류의진단, 인터벤션치료의적응증과시술방법, 결과, 합병증에대해서다루고자한다. 울산대학교의과대학서울아산병원영상의학과 170 대한영상의학회지 2016;75(3): jksronline.org

Jksvs019(8-15).hwp

Jksvs019(8-15).hwp Grade I Grade II Grade III 12 대한혈관외과학회지 : 제 20 권 제 1 호 2004 Control Group A Group B Fig. 4. Microscopic findings of vein wall in control, group A and group B on the day of 7 after venous occlusion. The