Abstract
Learning Objectives We described a simple technique and recipe for bilateral inferior petrosal sinus sampling. Background Bilateral inferior petrosal sinus sampling (BIPSS) is the gold standard in diagnosing Cushing disease and distinguishing a central source of adrenocorticotropic hormone (ACTH) secretion (i.e., a pituitary adenoma) from an ectopic source. Catheterization of IPS is technically demanding and even an experienced interventionalist may fail in up to 30% of cases. Clinical Findings/Procedure Details 1. Review contrast enhanced MRV to identify IPS venous anatomy. 2. Obtain access from right common femoral and left brachial vein and place 7 French vascular sheaths. This allows easy cannulation of left internal jugular vein and two separate sample collection stations. 3. Two 5 French MPA or Davis catheters are parked in mid- low internal jugular vein (IJV) and high flow micro-catheters with straight 0.0014 wires pulled back several inches from their tip are advanced back and forth several times beyond the level of the sigmoid sinus. This maneuver allows the microcatheter tip to seek and engage the IPS given its origin from the medial and superior curve of sigmoid sinus. 4. If the above described “bare back selection fails, we proceed with sweeping of the entire length of IJV with the mircocatheter and subsequently with a 5 French catheter aiming for engaging a low inserting IPS. If the later fails we proceed with cannulation of contralateral IPS using the above described steps. Once unilateral IPS catheterization is achieved we perform selective IPS venogram to identify the anatomy of the contralateral IPS and its take off from IJV. 5. Subsequent to bilateral cannulation venous sampling is carried out using modified University of Pittsburgh protocol prior and after peripheral intravenous injection of desmopressin (DDAVP). Conclusion and/or Teaching Points Using the above described method we were able to perform 5 successful BIPSS with fluoroscopy time ranging between 5-15 minutes in the past 18 month in our center. Reference 1. Deipolyi AR, et al. Bilateral inferior petrosal sinus sampling. J Neurointerv Surg 2011;4:215-18.
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