Adrenal Vein Sampling In Patients Research Articles

6808 Effect of Corticosteroid Premedication on Adrenal Vein Sampling in Patients with Primary Aldosteronism and Iodine Contrast Allergy

6808 Effect of Corticosteroid Premedication on Adrenal Vein Sampling in Patients with Primary Aldosteronism and Iodine Contrast Allergy

A Practical Guide for Left Adrenal Vein Sampling in Patients with Left Renal Vein Variants.

The presence of left renal vein (LRV) variants can increase the complexity of adrenal vein sampling (AVS), an already technically demanding procedure. While AVS literature often focuses on the right adrenal vein, an understanding of common LRV variants, their relationship with the left adrenal vein, and principles for successful catheterization can facilitate AVS. This guide provides practical, technical tips for AVS for duplicated (Du), circumaortic (Ca), and retroaortic (Ra) LRVs. AVS cases were identified at a single institution (June 2009-March 2023) based on adrenophrenic trunk drainage relative to variant LRVs. Available cross-sectional imaging was reviewed to evaluate LRV anatomy pre-procedure. Twenty-seven cases (1 DuLRV, 13 CaLRVs, and 13 RaLRVs) were identified. Diagnostic AVS was confirmed by a threshold selectivity index. Literature on LRV anatomic variants was also reviewed. Based on the authors' experience and literature review, the following principles can guide AVS in the setting of LRV variants. In the presence of DuLRV or CaLRV, the left adrenal vein invariably drains into a normally positioned, pre-aortic LRV limb, so AVS can proceed as expected with a Simmons as the catheter of choice. In contrast, a LAV draining into a RaLRV may require a hockey stick-like catheter, or in rare cases a microcatheter, for selecting and sampling, due to the longer RaLRV course, which usually drains into the IVC more inferiorly and can be stenotic where the aorta crosses. Knowing the presence and understanding the anatomy of LRV variants can facilitate an efficient AVS.

Indication, performance and outcomes of adrenal vein sampling in patients with primary hyperaldosteronism

Primary hyperaldosteronism (PAH) is an important cause of secondary hypertension (HTN). The study of the same requires a high clinical suspicion in addition to a hormonal study that confirms hormonal hypersecretion. It is important to start the appropriate treatment once the diagnosis is confirmed, and for this is necessary to demonstrate whether the hormonal hypersecretion is unilateral (patients who could be candidates for surgical treatment) or bilateral (patients who are candidates for pharmacological treatment only).At the Hospital del Mar since 2016 there has been a multidisciplinary work team in which Nephrologists, Endocrinologists, Radiologists and Surgeons participate to evaluate cases with suspected hyperaldosteronism and agree on the best diagnostic-therapeutic approach for these patients, including the need for adrenal vein sampling, which is a technique that in recent years has become the gold standard for the study of PAH.In the present study we collect the experience of our centre in performing AVC and its usefulness for the management of these patients.

Steroid profiling using liquid chromatography mass spectrometry during adrenal vein sampling in patients with primary bilateral macronodular adrenocortical hyperplasia.

Adrenal vein sampling (AVS) is not a routine procedure in patients with primary bilateral macronodular adrenocortical hyperplasia (PBMAH), but has been used to determine lateralization of cortisol secretion in order to guide decision of unilateral adrenalectomy. Our aim was to characterize the steroid fingerprints in AVS samples of patients with PBMAH and hypercortisolism and to identify a reference hormone for AVS interpretation. Retrospectively, we included 17 patients with PBMAH from the German Cushing's registry who underwent AVS. 15 steroids were quantified in AVS and peripheral blood samples using LC-MS/MS. We calculated lateralization indices and conversion ratios indicative of steroidogenic enzyme activity to elucidate differences between individual adrenal steroidomes and in steroidogenic pathways. Adrenal volume was negatively correlated with peripheral cortisone (r=0.62, p<0.05). 24-hour urinary free cortisol correlated positively with peripheral androgens (rDHEA=0.57, rDHEAS=0.82, rA=0.73, rT=0.54, p<0.05). DHEA was found to be a powerful reference hormone with high selectivity index, which did not correlate with serume cortisol and has a short half-life. All investigated steroids showed lateralization in single patients indicating the heterogenous steroid secretion pattern in patients with PBMAH. The ratios of corticosterone/aldosterone (catalyzed by CYP11B2), androstenedione/dehydroepiandrosterone (catalyzed by HSD3B2) and cortisone/cortisol (catalyzed by HSD11B2) in adrenal vein samples were higher in smaller adrenals (p<0.05). ARMC5 mutation carriers (n=6) showed lower androstenedione/17-hydroxyprogesterone and higher testosterone/androstenedione (p<0.05) ratios in peripheral blood, in line with lower peripheral androstenedione concentrations (p<0.05). Steroid profiling by LC-MS/MS led us to select DHEA as a candidate reference hormone for cortisol secretion. Lateralization and different steroid ratios showed that each steroid and all three steroidogenic pathways may be affected in PBMAH patients. In patients with germline ARMC5 mutations, the androgen pathway was particularly dysregulated.

Prognosis of adrenalectomy guided by computed tomography versus adrenal vein sampling in patients with primary aldosteronism: A systematic review and meta‐analysis

Adrenal vein sampling (AVS) is recommended to be the gold standard for patients with unilateral subtypes of primary aldosteronism to clinical diagnosis and surgery therapy. However, it is uncertain whether AVS is better for prognosis than computed tomography (CT), which is the most widely used. Pubmed, Embase, and Cochrane Library were searched for articles with no start date restriction. The last search was conducted on Jun 15, 2021. Eligible studies compared the distinct subtypes of primary aldosteronism by AVS with CT (as a control group) and reported the prognosis at follow‐up. Evaluation of cohort studies referred to Newcastle ‐ Ottawa Quality Assessment Scale, and randomized controlled trials referred to Updated Cochrane Collaboration tool. A random‐effect model or fixed‐effect model was chosen according to the heterogeneity test. All processes were performed following the PRISMA 2020 statement. Eleven studies were identified, including 1325 patients based on AVS and 907 patients based on CT. Compared with patients guided by CT, patients who underwent AVS had an increased possibility of complete biochemical success (odds ratio [OR] 2.78, 95% CI 1.88–4.12) and a decreased chance of absent biochemical success (OR 0.23, 95% CI 0.13–0.40) at follow‐up. Nevertheless, the rate of complete clinical success (OR 1.09, 95% CI 0.89–1.35) and absent clinical success (OR 0.96, 95% CI 0.68–1.33) had no significant difference. Therefore, distinguishing subtypes by AVS for early treatment may be crucial since it can promote biochemical improvement.

Diagnosis and therapy of primary aldosteronism: new aspects

Primary aldosteronism represents the most frequent cause of endocrine hypertension. It is associated with a higher morbidity and mortality compared to essential hypertension. Early identification of the affected patients is crucial, as the adequate therapy leads to an excellent long-term prognosis, especially after unilateral adrenalectomy. Diagnosis consists of three steps: diagnosis, confirmation test and subtype differentiation. The 2 most frequent causes of primary aldosteronism are aldosterone producing adenoma, which can be cured by surgery, and idiopathic bilateral adrenal hyperplasia, which is treated with mineralocorticoid receptor antagonists.Screening by aldosterone-to-renin ratio is recommended in designed risk populations. As the aldosterone-to-renin ratio displays a limited sensitivity and specificity, confirmatory testing is recommended in most patients with positive screening test. Prediction scores allow to skip confirmatory testing under certain circumstances. Adrenal vein sampling still represents the gold standard in subtype differentiation of primary aldosteronism. Steroid profiling could possibly make dispensable adrenal vein sampling in patients with bilateral hyperplasia. Different studies investigate the potential of functional imaging for differential diagnosis of primary aldosteronism.

Steroid profiling using liquid chromatography mass spectrometry during adrenal vein sampling in patients with primary bilateral massive adrenal hyperplasia

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Feasibility and effectiveness of a single-catheter approach for adrenal vein sampling in patients with primary aldosteronism

BackgroundAdrenal vein sampling (AVS) is the preferred method for subtyping patients with primary aldosteronism, while the procedure is technically challenging. This study evaluated the feasibility and effectiveness of a single-catheter approach for AVS.MethodsA retrospective analysis of 106 consecutive patients who underwent AVS was performed to determine the procedural success and complication rates. Bilateral AVS procedures were performed using a single 5-Fr Tiger catheter with repeated manual reshaping.ResultsWe successfully advanced the catheter into the bilateral adrenal veins of all patients and reached a 90.6% procedural success rate of AVS. The procedural period was 33.0 ± 8.2 min, the fluoroscopy period was 5.8 ± 1.7 min, and the diagnostic contrast used was 17.3 ± 5.5 ml. Only one patient (0.9%) had a hematoma at the femoral puncture site. No other complications were observed. The operation period gradually shortened as the cumulative number of operations increased. The number of procedures required to overcome the learning curve was about 33 cases.ConclusionsThe single-catheter approach is feasible and effective for AVS. Moreover, this approach required a relatively short learning curve for an inexperienced trainee.

Abstract No. 675 Use of preprocedural computed tomography in adrenal vein sampling in patients with primary hyperaldosteronism

Adrenal vein sampling (AVS) is performed to determine if there is unilateral or bilateral hypersecretion of aldosterone in patients with primary hyperaldosteronism. The procedure can be technically challenging in large part due to anatomy of the adrenal veins, with the right adrenal vein being more challenging than the left for localization and catheterization. The purpose of this study is to determine the whether reviewing a preprocedural diagnostic computed tomography (CT) improves the technical outcomes of an AVS procedure. 76 patients who underwent adrenal vein sampling performed by a single operator at one institution were retrospectively analyzed. Patients were divided into two groups, group 1 who had a preprocedural CT available for review at the time of the AVS procedure, and group 2 who had no preprocedural CT available at the time of the AVS. The two groups were compared on the following basis: technical success of the procedure, as defined by successful localization and sampling of the adrenal veins, overall time of the procedure, contrast load, and fluoroscopy time. Out of the 76 AVS cases reviewed, 37 (49%) had a preprocedural CT available at the time of the AVS, and 39(51%) did not. The technical success rate for group 1 was 100%, compared to 92% for group 2. The mean procedural time for group 1 was 63 minutes compared to 67 minutes for group 2, not statistically significant. The mean fluro time for group 1 was 13.7 minutes compared to 15.1 minutes for group 2, not statistically significant. The mean contrast load given for group 1 was 61 cc compared with 57 cc for group 2, not statistically significant. AVS can be technically challenging due to the anatomy and difficulty in localization of the right greater than the left adrenal vein. The availability of a preprocedural CT for planning purposes has not been evaluated fully. Based on our data, preprocedural diagnostic CT does not result in improved technical outcome of adrenal vein sampling.

Lateralizing Asymmetry of Adrenal Imaging and Adrenal Vein Sampling in Patients With Primary Aldosteronism.

ContextIn patients with primary aldosteronism (PA), it remains unclear whether aldosterone-producing adenomas are likely to develop in the left or right adrenal gland.ObjectiveTo investigate left-right differences of PA laterality diagnoses via CT imaging and adrenal vein sampling (AVS).DesignRetrospective, observational study.PatientsFrom the Japan Primary Aldosteronism Study, 1493 patients with PA were enrolled who underwent CT and ACTH-stimulated AVS.MeasurementsLeft or right adrenal nodular lesion distribution and laterality observed on CT scans and from AVS were noted.ResultsBoth on CT scans and AVS, unilateral results were observed more frequently on the left side than on the right side (25.1% vs 15.4% and 17.3% vs 13.5%, respectively; P < 0.01for both diagnostic techniques). There was no significant difference in the concordance rate for CT and AVS between patients with left and right unilateral nodular lesions observed on CT scans (44.1% and 50.9%, respectively; P = 0.15). In patients with nodules <20 mm, the concordance rate was significantly greater on the right side than the left side (45.8% vs 56.4%; P = 0.03). In patients with bilateral results of AVS, unilateral nodular lesions were detected more frequently on the left side than the right side (17.8% vs 9.4%; P < 0.01).ConclusionThese results suggest aldosterone-producing adenomas and nonfunctioning tumors are more likely to develop on the left side in patients with PA and that misdiagnosis of CT-based lateralization may occur more frequently on the left side.

Rapid cortisol assay during adrenal vein sampling in patients with primary aldosteronism

Background Adrenal vein sampling (AVS) is considered the “gold standard” test to identify the subtypes of primary aldosteronism (PA). In fact imaging techniques (CT, RM and scintigraphy) have a low sensitivity and specificity in the diagnosis of surgically treatable forms of primary aldosteronism. Technical difficulties with this procedure may be overcome by monitoring cortisol concentrations in the different sampling sites, during catheterization. Methods We applied a rapid automated cortisol assay performed on a benchtop immunoassay analyzer near the operating suite during the catheterization procedures in twenty patients with confirmed PA.

Adrenocorticotropic Hormone Stimulation During Adrenal Vein Sampling

HomeHypertensionVol. 54, No. 3Adrenocorticotropic Hormone Stimulation During Adrenal Vein Sampling Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBAdrenocorticotropic Hormone Stimulation During Adrenal Vein Sampling Masayuki Tanemoto, Eikan Mishima, Yoichi Takeuchi and Takaaki Abe Masayuki TanemotoMasayuki Tanemoto Division of Nephrology, Hypertension, and Endocrinology, Department of Medicine, Tohoku University Graduate School of Medicine, Miyagi, Japan Search for more papers by this author , Eikan MishimaEikan Mishima Division of Nephrology, Hypertension, and Endocrinology, Department of Medicine, Tohoku University Graduate School of Medicine, Miyagi, Japan Search for more papers by this author , Yoichi TakeuchiYoichi Takeuchi Division of Nephrology, Hypertension, and Endocrinology, Department of Medicine, Tohoku University Graduate School of Medicine, Miyagi, Japan Search for more papers by this author and Takaaki AbeTakaaki Abe Division of Nephrology, Hypertension, and Endocrinology, Department of Medicine, Tohoku University Graduate School of Medicine, Miyagi, Japan Search for more papers by this author Originally published20 Jul 2009https://doi.org/10.1161/HYPERTENSIONAHA.109.137141Hypertension. 2009;54:e23Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: July 20, 2009: Previous Version 1 To the Editor:We read with interest the article by Seccia et al,1 which investigated the effect of adrenocorticotropic hormone stimulation during adrenal vein sampling on the identification of lateralized aldosterone excess in primary aldosteronism. The authors concluded that a high or an intermediate dose of adrenocorticotropic hormone stimulation lowered the correct identification of the aldosterone-producing adenoma (APA) side. However, the cases with the lowered identification by the stimulation might have been the cases with bilateral aldosterone excess. Reduction of blood pressure (BP) and plasma aldosterone concentration after adrenalectomy could not exclude the possibility of bilateral aldosterone excess.2Several APAs are difficult to detect on computed tomography and magnetic resonance findings, and these small APAs would not be rare.3 In the case with a small APA in the adrenal gland contralateral to the resected side, the remaining APA would retain aldosterone excess, which could result in poor BP reduction after unilateral adrenalectomy. From the BP response to adrenalectomy in the cases of Seccia et al,1 we suspect that several of them might have had small APAs in the contralateral sides. Furthermore, in some cases, the plasma aldosterone concentration after adrenalectomy remained at >12.1 ng/dL (the value taken for aldosterone excess before adrenalectomy), presumed from its values (median: 10.1; range: 2.3 to 15.8 ng/dL). We suspect that these cases might have been the cases with lowered identification by the stimulation. Reduction of BP and plasma aldosterone concentration after adrenalectomy should be compared between the cases with and without the lowered identification. If the cases with the lowered identification had poor BP and plasma aldosterone concentration reduction, the adrenocorticotropic hormone–stimulated adrenal vein sampling would be preferable to the unstimulated one for the identification of lateralized aldosterone excess in primary aldosteronism.4DisclosuresNone.1 Seccia TM, Miotto D, De Toni R, Pitter G, Mantero F, Pessina AC, Rossi GP. Adrenocorticotropic hormone stimulation during adrenal vein sampling for identifying surgically curable subtypes of primary aldosteronism: comparison of 3 different protocols. Hypertension. 2009; 53: 761–766.LinkGoogle Scholar2 Sukor N, Gordon RD, Ku YK, Jones M, Stowasser M. Role of unilateral adrenalectomy in bilateral primary aldosteronism: a 22-year single center experience. J Clin Endocrinol Metab. 2009; 94: 2437–2445.CrossrefMedlineGoogle Scholar3 Rossi GP, Sacchetto A, Chiesura-Corona M, De Toni R, Gallina M, Feltrin GP, Pessina AC. Identification of the etiology of primary aldosteronism with adrenal vein sampling in patients with equivocal computed tomography and magnetic resonance findings: results in 104 consecutive cases. J Clin Endocrinol Metab. 2001; 86: 1083–1090.CrossrefMedlineGoogle Scholar4 Tanemoto M, Suzuki T, Abe M, Abe T, Ito S. Physiological variance of corticotropin affects diagnosis in adrenal vein sampling. Eur J Endocrinol. 2009; 160: 459–463.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Bardet S, Chamontin B, Douillard C, Pagny J, Hernigou A, Joffre F, Plouin P and Steichen O (2016) SFE/SFHTA/AFCE consensus on primary aldosteronism, part 4: Subtype diagnosis, Annales d'Endocrinologie, 10.1016/j.ando.2016.01.008, 77:3, (208-213), Online publication date: 1-Jul-2016. Wolley M, Gordon R, Pimenta E, Daunt N, Slater G, Ahmed A and Stowasser M (2013) Repeating adrenal vein sampling when neither aldosterone/cortisol ratio exceeds peripheral yields a high incidence of aldosterone-producing adenoma, Journal of Hypertension, 10.1097/HJH.0b013e328362add3, 31:10, (2005-2009), Online publication date: 1-Oct-2013. September 2009Vol 54, Issue 3 Advertisement Article InformationMetrics https://doi.org/10.1161/HYPERTENSIONAHA.109.137141PMID: 19620508 Originally publishedJuly 20, 2009 PDF download Advertisement

6.16 Rapid Cortisol Assay during Adrenal Vein Sampling in Patients with Primary Aldosteronism

6.16 Rapid Cortisol Assay during Adrenal Vein Sampling in Patients with Primary Aldosteronism

Abstract No. 81: Comparison of Simultaneous and Sequential Adrenal Vein Sampling in Patients with Primary Hyperaldosteronism

Abstract No. 81: Comparison of Simultaneous and Sequential Adrenal Vein Sampling in Patients with Primary Hyperaldosteronism

Rapid Cortisol Assay during Adrenal Vein Sampling in Patients with Primary Aldosteronism

Adrenal vein sampling is considered the gold standard test to identify primary aldosteronism, the most frequent form of secondary hypertension. Technical difficulties with this procedure may be overcome by monitoring cortisol concentrations in the different sampling sites during catheterization. We applied a rapid automated cortisol assay performed on a benchtop immunoassay analyzer near the operating suite during the catheterization procedures in 5 hypertensive patients. A mean of 7.8 samples (range, 5-13) were collected from the vena cava as well as from right and left adrenal veins. Cortisol concentrations measured by the rapid assay and by our routine method were comparable. Two of 5 patients were found to be affected by an aldosterone-producing adenoma and 3 of 5 by a bilateral adrenal hyperplasia. Cortisol determination during the adrenal vein sampling procedure allowed a successful cannulation in all patients, including a patient in whom it was necessary to cannulate 9 different candidate right adrenal veins before finding the correct one. Intraoperative cortisol assays appeared safe, reproducible, simple to perform, rapid, and cost-effective. The approach represents a service-oriented model for the laboratory and can provide valuable and timely information for improving the success rate of adrenal vein catheterization.

The Clinical Implication and Problems of Adrenal Vein Sampling in Patients with Primary Aldosteronism

Background: Recently, the significance of primary aldosteronism is being recognized due to an increase in its incidence and its complications. However, it is difficult to differentiate primary aldosteronism based on radiological studies as the size of an aldosterone producing adenoma (APA) is small, and nonfunctioning adrenal incidentalomas are common. Adrenal vein sampling (AVS) has been considered as the gold standard for differentiating an aldosterone producing adenoma (APA) from bilateral idiopathic adrenal hyperplasia (BAH). The clinical implications and problems associated with AVS have not yet been reported in Korea. Method: Clinical data of 28 patients with primary aldosteronism who had undergone AVS in a hospital from 1995 to 2006 were retrospectively analyzed. Result: The study group comprised 13 males (46.4%) and 15 females (53. 5%), with a mean age of 44.5 ± 11.9 years. Clinical data indicated that 19 patients (67.9%) had APA and nine patients (32.1%) had BAH. AVS data demonstrated that 11 patients had APA and five patients had BAH. Two patients were not diagnosed despite successful AVS. AVS was not successful in 10 patients (37.5%); AV catheterization failed in two patients, was not selective in seven patients on the right side, and was not selective in one patient on the left side. Conclusion: AVS was helpful in primary aldosteronism patients with inconclusive CT and MRI findings. Selectivity of AVS should be appropriately assessed because of the technical problem of selective catheterization. (J Kor Endocr Soc 22:428~435, 2007)

Identification of the etiology of primary aldosteronism with adrenal vein sampling in patients with equivocal computed tomography and magnetic resonance findings: results in 104 consecutive cases.

The objectives of this study were to investigate the usefulness of adrenal vein sampling in identifying the etiology of primary aldosteronism (PA) in patients with equivocal CT and MR findings. Between 1990 and 1999, 104 referred hypertensive patients (45 women and 59 men, aged 49.6 +/- 11.6 yr) were diagnosed to have PA with inconclusive computed tomography scan and magnetic resonance results, based on established criteria. Adrenal vein sampling (AVS) for measurement of plasma aldosterone (A) and cortisol (C) levels was performed in all. Selectivity of AVS was assessed by the ratio between C levels in each adrenal vein and in the infrarenal inferior vena cava plasma (C(side)/C(IVC)). A receiver operator characteristics analysis was carried out to establish 1) the best AVS-derived index, 2) the degree of selectivity that could provide an accurate diagnosis, and 3) whether a correct diagnosis could be made from a unilaterally selective AVS. An aldosterone-producing adenoma (average diameter, 12.2 +/- 0.08 mm) was eventually diagnosed in 41 patients (39.4%) and was excluded in the rest. Adrenal vein rupture leading to partial adrenal loss occurred in 1 patient (0.9% complication rate). By assuming a cut-off value of C(side)/C(IVC) > or = 1.1, AVS was selective in 85.7% and 94.1% of cases on the right and left sides, respectively, and bilaterally in 80.6% of cases. Of all AVS-derived indexes, the A/C of one over the A/C contralateral side [(A/C)(side)/(A/C)(contralateral side)] furnished the best diagnostic accuracy. With a bilaterally selective AVS, a value of (A/C)(side)/(A/C)(contralateral side) > or = 2 provided a conclusive etiological diagnosis of PA in 79.7% of cases. At variance, no accurate diagnosis could be made from unilaterally selective AVS. AVS was feasible and safe in most PA patients with inconclusive computed tomography and magnetic resonance scans. When bilaterally selective (i.e. C(side)/C(IVC) > or = 1.1) a ratio of (A/C)(side)/(A/C)(control) > or = 2 provided the best compromise of sensitivity and false positive rate for lateralization of the etiology of PA.

Identification of the Etiology of Primary Aldosteronism with Adrenal Vein Sampling in Patients with Equivocal Computed Tomography and Magnetic Resonance Findings: Results in 104 Consecutive Cases

Identification of the Etiology of Primary Aldosteronism with Adrenal Vein Sampling in Patients with Equivocal Computed Tomography and Magnetic Resonance Findings: Results in 104 Consecutive Cases