Adrenal Venous Sampling In Patients Research Articles

Evaluation of adrenal vein anatomy by adrenal venous sampling in patients with primary aldosteronism in Chinese.

Accurate cannulation of the adrenal vein is challenging during adrenal venous sampling (AVS) because of the variations in adrenal vein anatomy. This study aimed to investigate the adrenal venous morphology in Chinese and improve the success rate of AVS. A total of 221 participants with primary aldosteronism (PA) who underwent AVS were enrolled. Compare the morphology among subgroups divided according to sex, body mass index (BMI), and with or without adenoma. The success rate of right, left, and bilateral AVS was 98.60%, 97.20%, and 96.85%, respectively. The triangular pattern was the most common (39.37%) on the right side, while the glandlike pattern (70.14%) on the left. The proportion of adrenal venous morphology varies among patients with different sexes (χ2=21.335, P<.001), BMI (χ2=10.642 P=.031), and with or without adenoma (χ2=10.637, P=.031) on the right side, and the male, obese and adenoma group showed a higher proportion of glandlike pattern than triangular pattern. If only dependent on computed tomography, 9.05% of patients incorrectly diagnose the dominant side, 14.48% of patients would have inappropriate surgery meanwhile 25.34% of patients would miss the surgical opportunity. In conclusion, the most common types of right and left adrenal venous morphology were triangular pattern and glandlike pattern, respectively. Sex, BMI, and the presence of adenoma affected right adrenal venous morphology. Adequate knowledge of the adrenal venous morphology is critical for improving the success rate of AVS and making an appropriate treatment for PA.

Adrenal venous sampling in patients with bilateral adrenal lesions and ACTH-independent cushing's sydrome

Adrenal venous sampling in patients with bilateral adrenal lesions and ACTH-independent cushing's sydrome

A modified single-catheter approach for improving adrenal venous sampling in patients with primary aldosteronism.

Adrenal vein sampling (AVS) is an established procedure for assessing subtype patients with primary aldosteronism (PA). However, it is technically challenging, with high failure rates, which limits its application in clinical practice. Our study aimed to evaluate the safety and efficacy of a single-catheter modified approach for AVS. The clinical, angiographic, and procedural data of 182 consecutive patients who underwent AVS procedures between May 2020 and May 2023 were collected and analyzed. The single-catheter modified approach was performed as a single 5 F Tiger catheter with only one-time manual reshaping, which was recommended for sequential bilateral adrenal cannulations. Of the 182 consecutive patients, 174 (95.6%) had successful bilateral adrenal cannulation. The single-catheter modified approach was successfully performed to cannulate the right adrenal vein in 176 (96.7%) patients, while another six (3.3%) patients needed at least a second manual reshaping for 5 F Tiger catheters. For left adrenal cannulation, a single-catheter modified approach was successfully used in 179 (98.4%) patients, whereas 5 F Tiger catheters with at least second-time manual reshaping were used in the remaining three (1.6%) patients. The procedural period was 15.6 ± 10.8 min, the fluoroscopy time was 4.2 ± 1.5 min, and the diagnostic contrast was 15.5 ± 4.8 mL. The incidence of procedure-related complications associated with AVS was 1.1%. The cumulative summation assessment illustrated that the learning curve for the operating procedure required up to 29 cases, indicating that the procedure time was shortened after 29 cases. The single-catheter modified approach is an effective, safe, and feasible technique for AVS treatment. In particular, this improved method is not difficult for beginners with high technical success rates.

Utility of Carbon Dioxide Venography and Intraprocedural CT for Adrenal Venous Sampling in Patients with an Allergy to Iodinated Contrast Media

PurposeTo assess the diagnostic performance of carbon dioxide (CO2) and intraprocedural unenhanced computed tomography (CT) for adrenal venous sampling (AVS) (CO2–intraprocedural unenhanced CT–AVS) in patients with primary aldosteronism (PA) and a history of iodine contrast medium allergy. Materials and MethodsCO2–intraprocedural unenhanced CT–AVS was performed in 18 patients with iodine contrast media allergies at the authors’ hospital between December 2015 and January 2021. CT and noncontrast magnetic resonance angiography were used to evaluate the preoperative adrenal vein anatomy. CO2 venography was performed to confirm adrenal vein catheterization. Additionally, intraprocedural unenhanced CT was also performed to confirm catheter position in the right adrenal gland. ResultsIn all cases in which CO2–intraprocedural unenhanced CT–AVS was performed, the right and left adrenal veins were catheterized appropriately, leading to a localized diagnosis. Catheterization of the left adrenal vein was confirmed using CO2 venography in all cases. In 7 of the 18 cases, CO2 venography demonstrated selection of the right adrenal vein. In 15 of 18 cases, intraprocedural unenhanced CT demonstrated selection of the right adrenal vein. ConclusionsCO2–intraprocedural unenhanced CT–AVS demonstrated the same diagnostic ability for PA localization as conventional AVS with iodine contrast media. The proposed method is clinically feasible for AVS, in which iodine contrast media use is restricted.

Adrenal venous sampling in patients with hyperaldosteronism

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

Adrenal venous sampling in patients with hyperaldosteronism

Adrenal venous sampling in patients with hyperaldosteronism

Abstract #1000492: Attempting to Define “Normal”: Variability in Catecholamine Levels from Adrenal Venous Sampling in Patients with Primary Aldosteronism

Adrenal venous sampling (AVS) is performed to differentiate between unilateral and bilateral disease in patients with primary aldosteronism (PA). It is unknown if AVS would be helpful in determining the laterality of a pheochromocytoma in patients with bilateral adrenal masses. The objective of this study was to analyze adrenal vein (AV) epinephrine and norepinephrine levels in non-pheochromocytoma patients to determine the range of normal values.

Adrenal venous sampling in patients with ACTH-independent hypercortisolism

PurposeTo study the usefulness of adrenal venous sampling (AVS) in distinguishing unilateral from bilateral cortisol production in patients with ACTH-independent hypercortisolism and bilateral adrenal lesions, or morphologically normal adrenal glands.MethodsA retrospective analysis of ten consecutive patients with ACTH-independent hypercortisolism who underwent AVS at our institution between 2009 and 2017. Unilateral dominant cortisol production was defined as a side-to-side cortisol/aldosterone lateralization ratio >2.ResultsFour of ten patients had overt Cushing’s syndrome. Of these, two had bilateral adrenal lesions on computed tomography and two had normal adrenal glands. One of the two patients with bilateral adrenal lesions had, based on the AVS, a unilateral dominant cortisol production. Following unilateral adrenalectomy the patient developed adrenal insufficiency. The other three patients were considered to have bilateral cortisol production and underwent bilateral adrenalectomy. Six patients had a mild autonomous cortisol secretion and bilateral adrenal lesions. Based on AVS, one patient was considered to have unilateral dominant cortisol production, underwent unilateral adrenalectomy and developed transient adrenal insufficiency postoperatively.ConclusionsAVS may contribute to appropriate treatment in patients with ACTH-independent hypercortisolism and bilateral adrenal lesions. In our series, AVS was helpful in the decision-making of two out of ten patients, avoiding chronic treatment with steroidogenesis inhibitors, or inappropriate bilateral adrenalectomy.

The Value of Adrenal Androgens for Correcting Cortisol Lateralization in Adrenal Venous Sampling in Patients with Normal Cortisol Secretion.

The management of patients with adrenocorticotropic hormone-independent Cushing's syndrome and bilateral adrenal masses is challenging. Adrenal venous sampling (AVS) has been used to identify functional lesions in previous studies, but it is not always reliable. The present study aims to address the variability of cortisol in the adrenal veins of patients without excessive cortisol secretion and investigate the use of adrenal androgens to correct the cortisol lateralization ratio in AVS. Thirty-seven patients with primary aldosteronism underwent successful AVS. Patients with normal cortisol secretion exhibited a wide range of cortisol concentrations in the right (601-89, 400 nmol/l) and left (331-35, 300 nmol/l) adrenal veins. The median cortisol gradients between adrenal venous and peripheral venous samples were 15.25 and 10.14 in the right and left sides, respectively, and the cortisol lateralization ratio (high side to low side) was as high as 9.49 (median 1.54). The mean plasma levels of cortisol in the adrenal venous and peripheral venous samples decreased from t-15 to t0. Significant positive correlations were observed between the cortisol concentrations and both androstenedione and dehydroepiandrosterone concentrations in the right and left adrenal veins. After correcting for androstenedione or dehydroepiandrosterone levels, the cortisol lateralization ratio was less than 2 in most adrenal venous samples. The present study demonstrated the wide variation in cortisol concentrations in the adrenal veins of patients with normal cortisol secretion. The adrenal androgens might be ideal analytes used as normalizers when assessing the cortisol lateralization of AVS in normal or hypercortisolism cases.

Outcomes of Adrenal Venous Sampling in Patients with Bilateral Adrenal Masses and ACTH-Independent Cushing's Syndrome.

Management of patients with bilateral adrenal masses and ACTH-independent Cushing's syndrome (AICS) is challenging, as bilateral adrenalectomy can lead to steroid dependence and lifelong risk of adrenal crisis. Adrenal venous sampling (AVS) has been previously reported to facilitate lateralization for guiding adrenalectomy. The aim of the current study was to investigate the utility of AVS using protocol from study by Young et al. in the management of patients with bilateral adrenal masses and AICS. A retrospective review of all patients with bilateral adrenal masses and AICS who underwent AVS from 2008 to 2016 was performed. AVS for cortisol and epinephrine was performed with dexamethasone suppression. The adrenal vein to peripheral vein cortisol ratios and side-to-side cortisol lateralization ratios were calculated. AVS was successful in 8 of 9 patients. All 8 patients had AVS results indicating bilateral cortisol hypersecretion. Six patients underwent adrenalectomy: 3 had unilateral adrenalectomy of the larger size mass, 2 had bilateral adrenalectomy (both sides >4cm.) and 1 had stepwise bilateral adrenalectomy. Final pathology revealed macronodular adrenal hyperplasia in all 6 patients that underwent surgery. AVS was useful in excluding a unilateral adenoma as the source of AICS in this study of patients with bilateral adrenal masses and AICS. However, adrenal mass size influenced surgical decision making more than AVS results. More data are needed before AVS can be advocated as essential for management of patients with bilateral adrenal masses and AICS.

Adrenal venous sampling in patients with ACTH-independent Cushing's syndrome

Adrenal venous sampling in patients with ACTH-independent Cushing's syndrome

A Multi-institutional Comparison of Adrenal Venous Sampling in Patients with Primary Aldosteronism: Caution Advised if Successful Bilateral Adrenal Vein Sampling is Not Achieved.

In patients with primary aldosteronism (PA), adrenal venous sampling (AVS) is recommended to differentiate between unilateral (UNI) or bilateral (BIL) adrenal disease. A recent study suggested that lateralization could be predicted, based on the ratio of aldosterone/cortisol levels (A/C) between the left adrenal vein (LAV) and inferior vena cava (IVC), with a 100% positive predictive value (PPV). This study aimed to validate those findings utilizing a larger, multi-institutional cohort. A retrospective review was performed of patients with PA who underwent AVS from 2 tertiary-care institutions. Laterality was predicted by an A/C ratio of >3:1 between the dominant and non-dominant adrenal. AVS results were compared to LAV/IVC ratios utilizing the published criteria (Lt≥5.5; Rt≤0.5). Of 222 patients, 124 (57%) had UNI and 98 (43%) had BIL disease based on AVS. AVS and LAV/IVC findings were concordant for laterality in 141 (64%) patients (69 UNI, 72 BIL). Using only the LAV/IVC ratio, 54 (24%) patients with UNI disease on AVS who underwent successful surgery would have been assumed to have BAH unless AVS was repeated, and 24 (11%) patients with BIL disease on AVS may have been incorrectly offered surgery (PPV 70%). Based on median LAV/IVC ratios (left 5.26; right 0.31; BIL 2.84), no LAV/IVC ratio accurately predicted laterality. This multi-institutional study of patients with both UNI and BIL PA failed to validate the previously reported PPV of LAV/IVC ratio for lateralization. Caution should be used in interpreting incomplete AVS data to differentiate between UNI versus BIL disease and strong consideration given to repeat AVS prior to adrenalectomy.

Post-Saline Infusion Plasma Aldosterone Concentrations are Well Correlated with the Lateralized Ratio of Adrenal Venous Sampling in Patients of Primary Aldosteronism

Objective: Adrenal venous sampling (AVS) is the most reliable test to distinguish between unilateral and bilateral primary aldosteronism (PA). However, AVS is invasive, risky, and expensive, and alternative diagnostic methods are desirable. This study aimed to investigate the diagnostic power of saline infusion test (SIT) to distinguish between unilateral and bilateral PA. Design: Retrospective database analysis. Subjects and Methods: We selected 111 patients with PA diagnosed by confirmatory tests who underwent both SIT and successful AVS. Thirty-two patients had lateralized ratio (LR) over 4.0 and 79 patients had LR less than 4.0. Multiple regression analysis and receiver operating characteristic (ROC) analysis were used to examine whether the SIT had good diagnostic power to distinguish between patients with high LR and those with low LR. Results: The patients with high LR had significantly lower serum potassium levels (P<0.0001, Mann-Whitney’s U Test) and higher plasma aldosterone concentrations after SIT (Post-PAC) (P<0.0001). It was revealed that Post-PAC levels were independently associated with the LR by multiple regression analysis (P=0.0112). ROC analysis revealed that the diagnostic accuracy of SIT was very high for distinguishing between patients with high LR and those with low LR. The optimal cut-off value of Post-PAC for the diagnosis of patients with low LR was less than 9.3 ng/dl. Conclusions: SIT is useful for distinguishing between patients with high LR and low LR. It might be possible to omit AVS in patients with a Post-PAC value less than 9.3 ng/dl.Combining the results of serum potassium levels and imaging examinations with SIT might be a potential strategy for PA subtypes.

Adrenal Venous Sampling in Patients with Primary Aldosteronism: Which Is the Best Evaluation Method for Laterality Assessments?

Purpose: The purpose was to investigate the most accurate method of adrenal venous sampling to diagnose unilateral primary aldosteronism (PA) prior to laterality assessment. Materials and Methods: Sixty-four consecutive PA patients were enrolled in this retrospective study. A catheter was placed in the common-trunk-vein (CTV), below the confluence of the inferior-phrenic-vein and the central-adrenal-vein (CAV) and the right-adrenal-vein (RAV). Blood-sampling was performed both pre- and post-adrenocorticotropic hormone stimulation. Lateralized ratio [LR; aldosterone/cortisol ratio (ACR) on high-value side/ACR on low-value side], contralateral ratio (CR; ACR on low-value side/ACR on inferior-vena-cava ratio), and plasma aldosterone concentration (PAC) were evaluated. The diagnostic accuracy of LR, CR and PAC in CTV/ CAV/RAV during pre- and post-ACTH was compared by receiver-operating-characteristic (ROC) analysis. Results: LR-CAV post-ACTH showed the highest detection rate for unilateral adrenal lesions (93.3%; 14/15), with a sensitivity of 0.93 and a specificity of 0.84 at a cut-off value of 2.5. CR-post-ACTH had the highest Az value (0.89), with a detection rate of 86.7% (13/14), a sensitivity of 0.98, and a specificity of 0.88 at a cut-off value of 0.8. Conclusion: CR-post-ACTH and LR-CAV-post-ACTH are accurate predictors for laterality assessment in PA.

Is it useful to repeat an adrenal venous sampling in patients with primary hyperaldosteronism?

Adrenal venous sampling (AVS) is a challenging technical procedure and few patients had AVS procedure twice. AimTo evaluate the reproducibility of the AVS, why AVS were repeated and the conclusions drawn from them. Patients and methodsFrom 1997–2012, 12 patients underwent two AVS. A cortisol level in the adrenal vein greater than or equal to 1.1 to inferior vena cava defined a successful catheterization and a lateralization of secretion corresponded to an aldosterone-to-cortisol vein ratio greater than or equal to 2 between the one side to another. ResultsThe same side of lateralization of secretion was found in 75% of them. The second AVS were due to technical failure (n=4), unproven lateralization (n=2), a lateralization opposite to the main nodule and ipsilateral to hyperplasia (n=4) on first AVS. For two patients, as the CT was normal, AVS was required again. The second AVS was successful in all patients, including those with an initial technical failure but only patient with technical failure underwent surgery, as BP and kaliemia were controlled. Lateralization on the side of hyperplasia or opposite to the biggest nodule was confirmed in two of four cases. ConclusionWhen AVS is unsuccessful for technical reasons, it is worth doing it again but after being sure that surgery is still possibly indicated.