Adrenal Vein Catheterization Research Articles

OR34-03 Variable and Pulsatile Circulating Aldosterone Levels in Primary Aldosteronism: Implications for Diagnosis and Sub-Type Differentiation

Introduction: Considerable intra-individual variability in circulating aldosterone levels has been observed in patients with primary aldosteronism (PA). The magnitude and implications of this phenomenon are not well characterized. Objective: To evaluate the acute variability in aldosterone in patients with confirmed PA. Methods: 373 patients with confirmed PA underwent adrenal venous sampling (AVS) after appropriate catheterization of bilateral adrenal veins. Peripheral venous aldosterone levels were measured 2 hours prior to AVS while in supine posture. After anesthesia induction with fentanyl and midazolam, AVS was performed while in the same supine posture, and aldosterone levels were drawn from the inferior vena cava (IVC) and in triplicate from the bilateral adrenal veins over 10 minutes. Differences between the pre-AVS and intra-AVS IVC aldosterone levels were analyzed, and regression models used to identify independent predictors of change. Coefficients of variation (COV) between triplicate aldosterone levels in each adrenal vein were calculated. Results: 81% of patients demonstrated a decrease in aldosterone concentration from pre-AVS to the intra-AVS IVC measurement. The mean decrease in aldosterone was 10.5 ng/dL (95% CI: 7.6–13.3) and the mean relative decrease in aldosterone was 39% (95% CI: 27–51%, P<0.0001). The absolute decrease in aldosterone was striking, with 48% of patients who had a decrease in aldosterone exhibiting an IVC aldosterone of less than or equal to 5 ng/dL. The absolute decrease in aldosterone was significantly associated with a higher aldosterone level (p<0.001) and lower systolic blood pressure at diagnosis (p=0.02). A wide variation in triplicate aldosterone values was seen in the span of 10-minute sampling, ranging from 1–300%, with COV of 21.0% in the left adrenal vein and 25.0% in the right adrenal vein. If the lowest of three aldosterone-to-cortisol (A/C) ratios on the dominant side and highest of three A/C ratios on the contralateral side were used instead of the average of the three values, the interpretation of the AVS would have changed from unilateral PA to bilateral PA in 15.9% of cases. Conclusions: These findings underscore the pulsatile and variable nature of circulating aldosterone levels in patients with bona fide PA. Aldosterone levels substantially declined in 81% of patients within a period of 2 hours while maintaining a fixed and supine posture. In half of these patients, aldosterone levels declined to 5 ng/dL or below, a threshold typically considered incompatible with PA. Further, adrenal venous aldosterone levels exhibited large variations on repeated sampling within a 10-minute span that could have influenced the interpretation of sub-type differentiation in nearly 16% of cases. Single circulating aldosterone values lack precision and reproducibility and may result in incorrect diagnosis and sub-type differentiation.

Cosyntropin stimulation in adrenal vein sampling improves the judgment of successful adrenal vein catheterization and outcome prediction for primary aldosteronism.

The importance of cosyntropin stimulation during adrenal vein sampling (AVS) is not fully established, partly due to insufficient AVS data relating the presence and absence of cosyntropin stimulation with postoperative outcome. Therefore, we investigated differences in AVS indices before and after cosyntropin stimulation, and determined whether unstimulated or stimulated AVS indices better correlated with treatment outcome. A retrospective study was conducted in two parts: one with 185 patients who underwent AVS and the other with 81 patients who underwent unilateral adrenalectomy for unilateral aldosterone oversecretion. The selectivity index (SI), lateralized ratio (LR), and contralateral ratio (CR) before and after cosyntropin stimulations were determined, along with blood pressure outcome 1 year after surgery. Primary aldosteronism was diagnosed according to the Japanese Endocrine Society 2009 guidelines. The percentage of AVS patients with successful catheterization, defined as unstimulated SI > 2 before and stimulated SI > 5, increased after cosyntropin stimulation from 52% to 93% and from 74% to 98% for the right and left adrenal veins, respectively. LR decreased after cosyntropin stimulation (P < 0.001). In the postoperative patients, complete and partial clinical success was achieved in 49 and 27%, respectively. Low CR (<1) and high LR (≥2.6) after cosyntropin stimulation better correlated with postoperative blood pressure outcome than those before stimulation (CR < 1 and LR ≥ 2). These data suggest that cosyntropin stimulation facilitated the judgment of catheter insertion and postcosyntropin AVS indices may be more useful for predicting treatment outcome after unilateral adrenalectomy. Further study should examine the usefulness of cosyntropin stimulation in AVS performed in other settings.

The utility of adrenal and ovarian venous sampling in a progesterone-producing adrenal tumor and review of the literature

PurposeA clinical case presenting secondary amenorrhea accompanied by an adrenal adenoma and hyperprogesteronemia is described in this study.MethodsSelective catheterization and sampling of adrenal and ovarian veins were performed.ResultsThe source of hyperprogesteronemia was located in the right adrenal gland. A progesterone-producing tumor in the right adrenal gland was diagnosed and removed. Twenty-six days after tumor resection, menstruation occurred.ConclusionsProgesterone-producing tumors should be considered with the presence of an adrenal mass and hyperprogesteronemia. Combined adrenal and ovarian venous sampling may help to identify the source of progesterone secretion.

Adrenal Vein Sampling: How I Do It

Adrenal vein sampling (AVS) is an uncommonly performed interventional procedure. However, it is essential in the management of patients with primary aldosteronism and several other rare hormonal disorders. AVS can be technically challenging, largely from difficulty with right adrenal vein catheterization. Recently described technical modifications have improved the likelihood of successful sampling in every case. This paper highlights the author's approach to patient selection and step-by-step details of his technique.

Simultaneous bilateral adrenal vein sampling for primary aldosteronism: useful tips to make it simple and safe.

Adrenal vein sampling (AVS) is the key test for subtyping patients with primary aldosteronism (PA) before referring those with unilateral disease for laparoscopic unilateral adrenalectomy. However, it is still not systematically used, despite guidelines recommendations, because it is still considered as an invasive, risky, and challenging procedure. Simultaneous bilateral catheterization is believed to add technical difficulties inherent with attempting to catheterize both adrenal veins at the same time, but can be useful to minimize differences between the sides due to timing. We herein report on the protocol for routine clinical use. Tips for preparation of the patient as well as optimal catheterization of adrenal veins and sampling are provided to propose a protocol that is easy, safe, and reliable. Key Points • Adrenal vein sampling is the reference standard in the case of primary aldosteronism to detect the hyper-functioning side and allow subsequent treatment. • Simultaneous bilateral adrenal vein sampling avoids bias related to sampling timing. • Some technical suggestions concerning patient preparation and catheterization are proposed to make simultaneous adrenal vein sampling easier and safer.

Advantages of Intraprocedural Unenhanced CT During Adrenal Venous Sampling to Confirm Accurate Catheterization of the Right Adrenal Vein.

To evaluate the advantages of intraprocedural CT during adrenal venous sampling (AVS) to confirm accurate catheterization of the right adrenal vein (RAV). This single-institution study included 106 patients (mean age 52.4years; range 28-74years) with primary aldosteronism who performed contrast-enhanced CT (CECT) before AVS following AVS between January 2011 and March 2018. After catheterization of the RAV under fluoroscopic guidance, unenhanced CT images were obtained to confirm catheter position on unified CT angiography system. Catheter repositioning was performed when the catheter was inaccurately positioned. Venography findings were classified into two groups: (1) presumably cannulated in the RAV (presumed RAV group) and (2) obscured visualization of the RAV because of collateral vessels (obscured RAV group). Success rates of AVS were compared using Fisher's exact test. The overall success of AVS was achieved in 104 patients (98.1%). Catheter was deviated into the IVC during intraprocedural CT in four patients. Fourteen patients (14.0%) required catheter repositioning by intraprocedural CT images, and accurate catheterization in the RAV was eventually accomplished. The success rate of AVS was significantly higher in the presumed RAV group (90.1% [73/81]) than that in the obscured RAV group (68.4% [13/19]) (p = 0.024). If intraprocedural CT was not acquired during AVS, the success rate of AVS would have been significantly lower (84.9% [90/106]) compared with that use of intraprocedural CT (98.1% [104/106]) (p < 0.001). Intraprocedural unenhanced CT by referring to the preprocedural CECT before AVS enables the confirmation of accurate catheterization of the RAV. Level 4, case series.

A18104 The location spectrum of the right adrenal vein orifices in patients with primary aldosetronism

Objectives: To determine the distribution of the right adrenal vein orifices in patients with primary aldosteronism who underwent successful right adrenal vein sampling (AVS). Methods: 575 patients with confirmed primary aldosteronism who underwent successful AVS in the Hypertension Center of People's Hospital of Xinjiang, China between January 2006 and October 2013 were consecutively enrolled. A SIM-ADS V4.2 medical imaging workstation was used to determine the location of the right adrenal vein orifices. The distribution of the right adrenal vein orifices were analyzed according to the markers in the spine. Results: 1) the orifice of the right adrenal vein is located ranging from the middle edge of Th10 to the middle edge of Th12 in 457 patients (79.5%). Only 3.5% orifices were found between the upper edges of L1 to the middle edge of L1. 2) Distributions of the right adrenal vein orifices varied significantly in different gender, height, weight, body mass index and abdominal circumference, but the age did not show significantly different in 6 groups divided by markers in the spine. Conclusion: The middle edge of Th10 to the middle edge of Th12 should be main target area for successful right adrenal vein catheterization when performing AVS.

A case of postmenopausal ovarian hyperandrogenemia diagnosed only by selective catheterization of ovarian vein

Hyperandrogenemia in a postmenopausal woman is usually related to a tumor in either ovaries or adrenal glands. To differentiate between these two endocrine organs is a diagnostic challenge when the tumor size is too small to be detected with the aid of usual imaging modalities. 54 years-old postmenopausal woman with signs of virilization was referred to our institution with serum total testosteron levels of 294 ng/dl. Contrast-enhanced computed tomography (CT) revealed a lesion consistent with the tumor 1 cm in diameter in the adrenal gland and magnetic resonance imaging (MRI) could not confirm this finding. The location of androgen hypersecretion could only be determined after selective venous catheterization and hormonal sampling of both adrenal and ovarian veins. The right ovarian venous total testosterone level was found as &gt; 1009.40 ng / dl. A right-sided ovarian Leydig cell tumor was diagnosed in the specimen of laparoscopic hysterectomy and bilateral salpingo-oopherectomy. This case report underlines the importance to carry on the search with the selective venous catheterisation and hormonal sampling from both the ovarian and the adrenal veins when there is difficulty to demonstrate the true source of androgen hypersecretion in a postmenopausal woman.

C-Arm Computed Tomography-Assisted Adrenal Venous Sampling Improved Right Adrenal Vein Cannulation and Sampling Quality in Primary Aldosteronism

BackgroundAdrenal venous sampling (AVS) is a gold standard for subtype classification of primary aldosteronism (PA). However, this procedure has a high failure rate because of the anatomical difficulties in accessing the right adrenal vein. We investigated whether C-arm computed tomography-assisted AVS (C-AVS) could improve the success rate of adrenal sampling.MethodsA total of 156 patients, diagnosed with PA who underwent AVS from May 2004 through April 2017, were included. Based on the medical records, we retrospectively compared the overall, left, and right catheterization success rates of adrenal veins during the periods without C-AVS (2004 to 2010, n=32) and with C-AVS (2011 to 2016, n=124). The primary outcome was adequate bilateral sampling defined as a selectivity index (SI) >5.ResultsWith C-AVS, the rates of adequate bilateral AVS increased from 40.6% to 88.7% (P<0.001), with substantial decreases in failure rates (43.7% to 0.8%, P<0.001). There were significant increases in adequate sampling rates from right (43.7% to 91.9%, P<0.001) and left adrenal veins (53.1% to 95.9%, P<0.001) as well as decreases in catheterization failure from right adrenal vein (9.3% to 0.0%, P<0.001). Net improvement of SI on right side remained significant after adjustment for left side (adjusted SI, 1.1 to 9.0; P=0.038). C-AVS was an independent predictor of adequate bilateral sampling in the multivariate model (odds ratio, 9.01; P<0.001).ConclusionC-AVS improved the overall success rate of AVS, possibly as a result of better catheterization of right adrenal vein.

PP.27.04] COMPARISON BETWEEN CORTISOL, FREE METANEPHRINE AND THE FREE/TOTAL METANEPHRINE RATIO TO ASSESS SELECTIVITY OF ADRENAL VEIN SAMPLING

Objective: Primary aldosteronism (PA) is one of the most common forms of secondary hypertension, which can be cured by surgical removal of an adrenal gland if aldosterone secretion is lateralized. Adrenal vein sampling (AVS) is the gold standard method to assess lateralization of aldosterone secretion in PA. Recently, the use of free metanephrine (fMN) instead of cortisol has been proposed to determine correct positioning of the catheter during AVS (selectivity). As almost all fMN is released by the adrenal glands to be sulphate-conjugated peripherally. We hypothesized that free/total metanephrine ratio (FTMR) measured in each adrenal vein would be non inferior to fMN to assess selectivity. The objective of the study was to compare the FTMR to fMN and cortisol to assess selectivity. Design and method: cortisol, free and total metanephrines were measured in the distal and proximal veina cava and in the right and left adrenal veins in patients with PA referred for sequential, non cosyntropin-stimulated AVS. Correct placement of the tip the catheter was assessed by computed tomography angiography (CTA). Receiver operating characteristic (ROC) curves were used to assess the performance of each marker independently of cut-off choices. Results: 76 patients (37 women) were included in the study. Mean age (±SD) was 51.3 ± 9.7 years. Of those, 56 had a successful positioning of the tip of the catheter ascertained in both adrenal veins. ROC curve analyses on the left adrenal vein established an area under the curve (AUC) of 1.0 ± 0 for both free metanephrine and the FTMR compared to an AUC 0.966 ± 0.015 for cortisol. In the right adrenal vein, AUC were respectively 0.967 ± 0.020, 0.968 ± 0.20, and 0.824 ± 0.044 for FTMR, free metanephrine and cortisol. Cut-offs values for the selectivity index determined by ROC for FTMR, fMT and cortisol were respectively 0.41, 10.0 and 2.63 on the left and 0.30, 9.9 and 2.5 on the right. Conclusions: The use of the FTMR performs similarly to fMN to assess the selectivity of the adrenal vein catheterization. Its use could limit the number of blood samples and time of the procedure as only blood from the adrenal veins is necessary.

Androstenedione and 17-α-Hydroxyprogesterone Are Better Indicators of Adrenal Vein Sampling Selectivity Than Cortisol.

For identification of potentially surgically curable primary aldosteronism, guidelines recommend use of adrenal vein sampling (AVS) that requires selective catheterization of both adrenal veins as verified by using the cortisol-derived selectivity index. Unfortunately, bilaterally selective studies are not obtained under unstimulated conditions in a proportion of the cases ranging between 15% and 50% depending on the cutoff used. We therefore investigated whether 17-α-hydroxyprogesterone and androstenedione, which showed a higher step-up between adrenal vein and inferior vena cava blood than cortisol, can ascertain selectivity when cortisol failed to do so. We prospectively recruited 32 hypertensive patients with confirmed primary aldosteronism, who underwent bilaterally simultaneous sampling without cosyntropin stimulation and with the same predefined AVS protocol. All were consecutively selected because of a cortisol-based selectivity index <2.00 in at least one of the paired adrenal vein blood samples collected as per protocol. Results showed that the values of the selectivity index based on 17-α-hydroxyprogesterone and androstenedione were higher (P<0.01) on average by 1.6- and 12-fold, respectively, than those based on cortisol. With use of these steroids, we rescued 43% and 73% of the AVS, respectively, from being judged nonselective. Thus, in challenging patients with primary aldosteronism submitted to AVS use of 17-α-hydroxyprogesterone, and even more so of androstenedione, for ascertaining selectivity allows demonstration of correct catheter placement in a proportion of AVS studies better than cortisol. Thus, replacing cortisol measurement with these steroids, and particularly androstenedione, can improve the diagnostic yield of AVS.

11-Deoxycortisol may be superior to cortisol in confirming a successful adrenal vein catheterization without cosyntropin: a pilot study.

We aimed to compare the performance of nine adrenal steroids in confirming the correct catheter position during adrenal venous sampling (AVS) without cosyntropin in patients with primary hyperaldosteronism. A successful adrenal vein catheterization without cosyntropin was defined as the ratio of steroids from adrenal to peripheral veins being >3:1. AVS samples from four patients with primary hyperaldosteronism were analyzed. Compared with the mean ratio of cortisol without cosyntropin, the ratios of 11-deoxycortisol (p = 0.008), dehydroepiandrosterone (p = 0.01) and androstenedione (p = 0.008) were significantly higher. None of the ratios (n = 8) of cortisol from adrenal to peripheral veins exceeded 3:1, while all ratios of 11-deoxycortisol (p < 0.001) were >3. Cosyntropin infusion during AVS may not be necessary if 11-deoxycortisol is used to confirm catheter position.

The Intra-Procedural Cortisol Assay During Adrenal Vein Sampling: Rationale and Design of a Randomized Study (I-Padua).

Adrenal vein sampling (AVS) is the gold standard test for the subtyping of primary aldosteronism (PA). This procedure is hampered by unsuccessful bilateral cannulation of adrenal veins in up to two thirds of the cases depending on the cutoff of the selectivity index used. The rapid intra-procedural cortisol assay (IRCA) can increase the rate of bilateral success of AVS. This hypothesis needs to be proven using a randomized prospective study approach. We will therefore evaluate if an IRCA guiding adrenal vein sampling can increase the rate of selectivity and success of adrenal vein catheterization. Consecutive patients with a biochemical diagnosis of PA and seeking surgical cure will be randomized to undergo AVS according to the usual practice with or without IRCA. The primary endpoint of the study will be the rate of bilaterally selective AVS studies, as defined by a value of the selective index >2.00 under baseline (unstimulated) conditions. With a total of 200 patients submitted to AVS, e.g. 100 patients in each arm, the study has 82% power to detect a 18% difference between arms at a two-sided α level =0.05. Given this power the study should allow to conclusively determine if IRCA is useful or not for improving the success rate of AVS. From the clinical standpoint this will be a major accomplishment in the field of the subtyping of PA considering the current disastrous situation regarding the clinical use of AVS.

Adrenal Vein Sampling in Primary Aldosteronism: Sensitivity and Specificity of Basal Adrenal Vein to Peripheral Vein Cortisol and Aldosterone Ratios to Confirm Catheterization of the Adrenal Vein.

To assess the sensitivity and specificity for ratios of adrenal vein cortisol level (Ca) to peripheral vein cortisol level (Cp), adrenal vein aldosterone level (Aa) to peripheral vein aldosterone level (Ap), and combined cortisol and aldosterone levels ("combined ratio") for the detection of successful adrenal vein catheterization ("selectivity") in adrenal vein sampling (AVS) without adrenocorticotropic hormone (ACTH) injection at different cutoff values. This retrospective study was approved by the institutional review board, and informed consent was waived. AVS was performed in 160 consecutive patients (49 women and 111 men; mean age, 53.6 years) between December 1989 and January 2014. Cortisol and aldosterone levels were measured in samples from the adrenal veins and left iliac vein every 5 minutes, two times before (basal) and three times after intravenous cosyntropin (ACTH 1-24) injection. Selectivity was defined by Ca/Cp or Aa/Ap ratio of at least 5 in at least one sampling after ACTH administration. Sensitivity and specificity for the detection of selective adrenal vein catheterization were calculated for basal Ca/Cp ratio, Aa/Ap ratio, and combined ratios for three cutoff values reported in the literature. The McNemar test was used to assess differences in sensitivity and specificity to detect selective adrenal vein catheterization. The sensitivity and specificity for the cutoff values of at least 3, at least 2, and at least 1.1 for the detection of AVS selectivity were respectively 50.4% and 100%, 70.8% and 100%, and 98.5% and 76.9% for Ca/Cp ratio; 61.3% and 100%, 70.8% and 100%, and 94.2% and 53.8% for Aa/Ap ratio; and 75.2% and 100%, 88.3% and 100%, and 99.3% and 46.2% for combined ratios (sensitivity at the ≥2 cutoff value: P < .0001 for combined ratio vs Ca/Cp ratio and for combined ratio vs Aa/Ap ratio). Basal combined ratio has the best sensitivity for the detection of AVS selectivity at all cutoff values, and for all ratios, the cutoff value of at least 2 has the best sensitivity for 100% specificity.

The inferior emissary vein: a reliable landmark for right adrenal vein sampling

Right adrenal vein (RAV) catheterization can be a very challenging step in adrenal venous sampling (AVS). Visualization of the inferior emissary vein (IEV) may be an indication of successful RAV catheterization. To compare the rate of successful RAV sampling in the presence of the IEV. Retrospective review of all consecutive patients with PA who underwent AVS between April 2009 and April 2012 was performed. A total of 30 patients were identified. Procedural images, cortisol, and aldosterone values obtained from sampling of the RAV and inferior vena cava (IVC) were reviewed. Cortisol measurements obtained from RAV samples were divided by measurements from the infra-renal IVC blood samples in order to calculate the selectivity index (SI). An SI >3 was considered indicative of technically successful RAV sampling. RAV sampling was considered technically successful in 29 out of 30 cases (97%). In cases of successful RAV sampling (29 patients), the IEV was identified in 25 patients (86%). The IEV was visualized in isolation in 16 patients (64%), and in conjunction with visualization of the RAV or right adrenal gland stain in nine patients (36%). The IEV was not visualized in the one case of unsuccessful RAV sampling. Visualizing the IEV had a sensitivity of 86.2% for successful RAV sampling. The IEV may serve as a reliable landmark for the RAV during RAV sampling.

Technical Aspects of Adrenal Vein Sampling

The most common cause of secondary hypertension is primary aldosteronism, with a prevalence of approximately 30% when screened by specialized hypertension clinics. Adrenal venous sampling is considered the standard for reliably distinguishing between unilateral and bilateral hormone secretion, with unilateral secretion being surgically curable. Success of adrenal vein sampling relies on appropriate patient selection, patient preparation, and recognition and catheterization of both adrenal veins. However, this procedure may prove technically challenging, particularly for inexperienced operators. This video (see Fig; available online at www.jvir.org) is designed to provide the viewer with details on the technical aspects of adrenal vein sampling by using the sequential technique in an immersive format with real-time table-top teaching. Indications, patient preparation, equipment selection, technique, and quality assurance are reviewed in detail, with the goal of providing practitioners an opportunity to successfully incorporate this procedure into their practice.

Outcomes of adrenalectomy in patients with primary hyperaldosteronism--a single centre experience.

Primary hyperaldosteronism is a common cause of secondary hypertension. In patients with proven unilateral overproduction of aldosterone adrenalectomy can cure hyperaldosteronism with high probability and a positive effect on hypertension. The aim of the study was to determine the effects of unilateral adrenalectomy on blood pressure and laboratory parameters. The secondary objective was to identify parameters that would allow the prediction of hypertension cure. We performed a cross-sectional analysis of the data of patients who underwent unilateral adrenalectomy for primary aldosteronism at the Department of Urology of University Hospital Olomouc in the years 2000-2011. We assesed the preoperative clinical conditions of patients, the results of biochemical and radiological examinations, course of the surgery and post-operative course including laboratory and clinical parameters during the 12 months postoperatively. 62 patients underwent adrenalectomy for primary aldosteronism in this period. Four patients were excluded from the study due to surprising histology (myelolipoma in 2, carcinoma in 2), seven patients had incomplete postoperative data. The statistical analysis therefore included 51 patients, of which 57% were females. CT or MRI was performed in all patients; 63% patients underwent superselective catheterization of adrenal veins (AVS). Adrenalectomy was performed in all cases laparoscopically. Histology most often showed adrenal hyperplasia (59%), adenoma was detected in 37% and adenoma on the basis of micronodular hyperplasia in 4%. Twelve months after surgery the antihypertensive drugs were discontinued in 17/51 (33%) and the number or dose of antihypertensive drugs was reduced in 25/51 (49%). Normokalemia and normalisation of the aldosterone-renin ratio (ARR) was detected in 92% and 84% of the patients. Performing AVS did not statistically significantly influence the rate of blood pressure control or normalization of ARR, which is probably due to small study size. This study demonstrated a better effect of surgery on blood pressure in younger patients. Unilateral adrenalectomy had a positive effect in 82% of the patients operated for primary aldosteronism and lead to either blood pressure normalization or reduction of the antihypertensive medication.

3:57 PM; Abstract No. 130; FEATURED ABSTRACT - Cone beam CT venography vs. cortisol measurements to confirm selective right adrenal vein catheterization during adrenal vein sampling: does anatomical selectivity correlate with biochemical selectivity ratios?

body. Regression analysis was performed to determine if there were statistically significant relationships between catheter tip migration distances and innominate vein angles, internal jugular vein access locations, subcutaneous pocket locations, number of catheter lumens and various patient demographics. Results: The range of catheter tip migration distances for the entire population was -4.01 to 9.97 cm with a mean of 1.49 cm 1.97. There was a statistically significant positive relationship between catheter tip migration distance and age (P1⁄40.0319), body mass index (BMI) (P1⁄40.0244), innominate vein angle (P1⁄40.0028) and dual compared to single lumen ports (P1⁄40.0199). Whereas port pocket location, venous access site, gender and number of days between initial placement and follow-up radiograph did not demonstrate statistical significance. Conclusion: Increased age, increased BMI, increased innominate vein angle and dual vs single lumen ports predict increased positional catheter tip migration for left internal jugular subcutaneous central venous ports. This information can be useful during initial port placement and also when deciding whether or not to revise a port with a catheter that has been inadvertently cut short.

Right Adrenal Venography Findings correlated with C-arm CT for Selection During C-arm CT-assisted Adrenal Vein Sampling in Primary Aldosteronism

This study was designed to evaluate retrospectively the efficacy of C-arm CT to confirm right adrenal vein catheterization during adrenal vein sampling (AVS) and to correlate adrenal venography findings with C-arm CT and/or biochemical results for right adrenal vein selection. Forty-two consecutive primary aldosteronism patients (M:F = 21:21; age: 29-70 years) underwent C-arm CT assisted sequential AVS. After catheterization of right adrenal vein, C-arm CT was performed to confirm catheter position. Catheter was repositioned when right adrenal gland was not opacified. Radiological images, medical records, and biochemical results were reviewed for technical/biochemical success rates and complications. Right adrenal venography findings of pinnate pattern, visualization of renal capsular vein, and retroperitoneal vein other than renal capsular vein were correlated with C-arm CT and/or biochemical results for right adrenal vein selection. Both the technical and biochemical success of AVS was achieved in 40 patients (95.2%). C-arm CT failed due to catheter instability in one, and adrenal/vena cava cortisol gradient was <3 in one patient. Catheter was repositioned in four patients (9.5%) according to C-arm CT findings. Right adrenal venography finding of renal capsular vein significantly correlated with C-arm CT and/or biochemical results (100%) for right adrenal vein selection (p = 0.011, χ(2) test), whereas pinnate pattern (p = 0.099) and other retroperitoneal veins (p = 0.347) did not. There was no procedure-related complication. C-arm CT increases confidence of right adrenal vein catheterization during AVS. Visualization of renal capsular vein on adrenal venography suggests right adrenal vein catheterization and C-arm CT may not be required.

Dexamethasone suppressibility and adrenal and ovarian venous effluents of 5α-reduced C19 conjugates in hyperandrogenic women

Several C19 conjugates, derived via 5α-reductase activity, are putative markers of peripheral androgen action and have been shown to correlate well with various clinical manifestations of androgen excess. While no ovarian vein gradient has been found for androsterone sulfate (ADT-S), androsterone glucuronide (ADT-G), 5α-androstane-3α,17β-diol sulfate (3α-diol-S), and 5α-androstane-3α,17β-diol glucuronide (3α-diol-G), the contribution of the adrenal gland to these conjugates has been unclear. Ten hirsute women were treated with 2mg/day dexamethasone (dex) for 7 days to determine the effect of adrenal androgen suppression on 5α-reduced androgen conjugate production. In addition, 11 women with mixed ovarian and adrenal androgen excess of non-neoplastic origin underwent ovarian and adrenal vein catheterization studies in order to assess gradients for the various C19 steroids. These women had significantly higher levels of both unconjugated and conjugated androgens, except for ADT-S, compared to 8 matched normal ovulatory women. After dex treatment, total testosterone (TT), unbound T (UT), androstenedione (A) and DHEAS, all decreased by 31–75%. ADT-S, ADT-G, 3α-diol-S and 3α-diol-G decreased by 48%, 71%, 46% and 68%, respectively. The suppression of the unconjugated androgens correlated highly and significantly with ADT-G. In the 11 patients undergoing adrenal venous catheterization, all patients exhibited a substantial adrenal gradient for TT and A. Of significance, in paired samples of peripheral venous and glandular effluents, no adrenal or ovarian gradient was found for any of the conjugated androgens. The data suggest that because dex suppression significantly decreases levels of the conjugated androgens, they are highly substrate dependent. However, since no adrenal or ovarian vein gradient exists, these markers of the manifestations of androgen excess largely reflect peripheral androgen metabolism.