Testicular varicocele embolization using CO2, gadolinium and lipiodol as contrast agents in a patient with an iodinated contrast allergy.

A 44-year-old gentleman was referred to IR for varicocele embolization (VE) by the fertility clinic following investigation for oligospermia. A testicular ultrasound identified a left grade II varicocele. The patient had known anaphylaxis to water-soluble iodinated contrast. We planned to perform VE with a combination of alternative contrast agents. The procedure was performed under general anesthetic to mitigate the pain related to carbon dioxide angiography. Following standard venous access techniques of the right internal jugular vein, carbon dioxide was used as the main contrast agent with digital subtraction venogram, to confirm catheter selection of left testicular vein. This demonstrated a large varicocele. After coil deployment the gadolinium-based contrast agent Dotarem, was injected and venography used to confirm occlusion of the left testicular vein. Then a combination of 4 mL of 3% Fibro vein and 2 mL of Lipiodol was injected to achieve embolization of the testicular vein collaterals. The patient made an uneventful recovery. This is the first reported case of both carbon dioxide angiography and gadolinium being used in VE. It appears safe and effective. The use of alternative contrast media appears safe and effective in VE in those patients with contraindications to ionic agents. Due to their different properties, a combination of alternative contrast agents can be more effective than a single agent. We provide a pictorial review of the case and an educational summary on the indications and practical uses of various alternative contrast agents in IR procedures in a patient with a water-soluble iodinated contrast allergy.