Left Adrenal Vein Research Articles

High aldosterone levels in the renal capsular vein from the left aldosterone-producing adenoma on adrenal venous sampling.

A 42-year-old female patient was referred to our hospital with hypertension and hypokalemia and was diagnosed with primary aldosteronism. Dynamic contrast-enhanced computed tomography images revealed a 13-mm nodule on the lateral segment of the left adrenal gland and a fine venous connection between the nodule and the prominent renal capsular vein running nearby. The venograms in the left lateral tributary with a microcatheter confirmed alternative drainage to the left renal capsular vein during adrenal venous sampling, and the left renal capsular vein sampling was added. The patient was diagnosed with a left aldosterone-producing adenoma (APA) using the lateralization index (48.3) and a higher plasma aldosterone concentration (PAC) of the left lateral tributary (66 700 pg/mL) than other tributary samples after adrenocorticotropic hormone stimulation. Furthermore, markedly higher PAC (224 000 pg/mL) was observed in the left renal capsular vein blood than in the left adrenal central vein (45 000 pg/mL) and tributaries, confirming the diagnosis. Laparoscopic left partial adrenalectomy and following histopathological analysis revealed a CYP11B2-positive adrenocortical adenoma. Complete clinical and biochemical success for primary aldosteronism was achieved after 6 months. Direct evidence of APA blood venous drainage into the renal capsular vein has been demonstrated. Sampling from an alternative drainage pathway could be beneficial for APA diagnosis if such APA blood drainage is assumed. Aldosterone-producing adenomas may drain blood into an alternative pathway but for the adrenal vein. The presence of alternative venous drainage could be assumed by contrast-enhanced computed tomography or venogram during adrenal venous sampling. Sampling in the alternative drainage veins and demonstrating elevated aldosterone levels could help in diagnosing aldosterone-producing adenoma.

RENAL SYMPATHETIC DENERVATION AND NEURO-HORMONAL EVALUATION BY SELECTIVE VENOUS CATHETERIZATION: THE RESIDENCY STUDY

Objective: Renal denervation (RD) is effective in reducing blood pressure (BP) in hypertensive patients, but the pathophysiologic mechanisms underlying the variable individual response are unclear and early markers of procedural success are lacking. The aim of the study was to evaluate intra-/peri-operative effects of RD on the renin-angiotensin-aldosterone system (RAAS) either as determinants and markers of efficacy. Design and method: Patients with resistant hypertension and eGFR>45 ml/min underwent radiofrequency-RD (Medtronic Symplicity-Spyral) with simultaneous sampling of the renal veins (RV), left adrenal vein and pre-renal inferior vena cava (IVC). Samples were collected before (t0) and 15’ after RD from each sequentially-approached side. Additional peripheral blood samples collected on the morning before RD and 3h, 24h and 7 days after the procedure were tested for renin, aldosterone and cortisol. During this timeframe, antihypertensive therapy remained unchanged. Results: Ten patients were recruited (61±11yo; 30%F; BP = 149/84 ±11/12 mmHg on 4 (range 3-6) antihypertensive drugs). Peripheral renin concentration showed no significant changes during/immediately after RD and up to 7 days after, in spite of the observed BP reduction (136/78 ±17/15 mmHg; p<0.05). Similarly, RV renin was unaffected by ipsilateral RD compared to the corresponding t0 values (p = 0.899). Aldosterone and cortisol increased in the adrenal vein during RD (p<0.001), but their IVC-corrected ratio and their peripheral plasma concentrations at follow-up did not, likely reflecting a self-limiting stress reaction. Conclusions: These results do not suggest any direct blunting effect of RD on RAAS, and do not support the contention of monitoring acute RAAS changes as proxies for procedural effectiveness.

Adrenocorticotropic hormone application lowered aldosterone/cortisol value on dominant side without superior surgical outcomes during adrenal venous sampling.

Adrenal venous sampling (AVS) is thought to be the gold standard for primary aldosteronism (PA) subtype discrimination, during which the application of adrenocorticotropic hormone (ACTH) arouses heated debate. We aimed to identify the effect of ACTH on AVS and surgical outcomes. After propensity score matching (PSM), a total of 220 patients diagnosed with PA and completed AVS were included (110 without ACTH stimulation and 110 with ACTH stimulation). According to AVS results, surgeries were conducted in appropriate patients. ACTH stimulation significantly increased almost all selectivity index (SI) in both left adrenal vein (LAV) and right adrenal vein (RAV). We discovered that aldosterone/cortisol (A/C) value on dominant side significantly reduced after ACTH stimulation, with a reduction in lateralization index (LI) observed. Finally, 39 patients in unstimulated group and 32 patients in stimulated group completed surgery and enough follow-up. The comparison between surgical outcomes with and without ACTH stimulation was analyzed and the difference was not significant (p=.464). In conclusion, ACTH application significantly lowered A/C value instead of the relative aldosterone secretion index (RASI) value on dominant side, which did not yield superior surgical outcomes and might render confusing AVS interpretation.

Surgical Anatomy of the Mesopancreas in Obese Patients: A Retrospective Study.

Introduction The mesopancreas is described as a triangle formed by the superior mesenteric vein, celiac axis (CA), and superior mesenteric artery (SMA). It is the most likely siteof residual cancer and local recurrence after surgical resection, making it the key site of the current radical resection of pancreatic head cancer.The surgical anatomy of the mesopancreas triangle has not been studied in detail. Furthermore, to the best of our knowledge, no information is available on the impact of obesity on the anatomy of the mesopancreas triangle. Methods Between January 2016 and August 2016,200 consecutive triple-phase computed tomographyscans of the abdomen were performed and included in this retrospective study aiming to define the anatomical relation of the left renal vein (LRV) to the root of the SMA and focusing on the relevance of the LRVas a landmark to guidance for the dissection of the mesopancreas. Furthermore, by studying six surgically relevant anatomical parameters namely the thickness of the areolar tissue separating the LRV from the root of the SMA, IVC from the root of the SMA, the left adrenal vein (LAV) from the root of the SMA, splenic veinfrom the aorta, and CA from the SMA at two levels, we investigated the impact of obesity on the mesopancreas anatomy. Results The mean distance from the upper border of the LRV to the root of the SMA (LRV-SMA distance) was 2.3 ± 5.4 mm. There was no correlation between this distance and patient's age (r = -0.02), height (r = -0.07), BMI (r = -0.01), visceral fat area (r = -0.04), or abdominal circumference (r = -0.02). There was no correlation between the distance from the IVC to the root of the SMA, and patient's age (r = 0.01), height (r = 0.11), BMI (r = 0.15), or abdominal circumference (r = 0.00). However, there was a negligible correlation between the IVC-SMA distance and patient's visceral fat area (r = 0.15, p = 0.036). Conclusion In the current study, the LRV was reliably identified in more than 99% of the studied patients, and in 96% of patients, the LRV crosses anterior to the aorta at the level of the second lumbar vertebra, making it easily accessible following mobilization of the duodenum and the head of the pancreas. The relationship between the LRV and SMA remains unchanged following Kocherization. Most importantly, we demonstrated that the LRV-SMA distance does not correlate with patient's age, height, BMI, visceral fat area, or abdominal circumference. This makes the LRV a reliable landmark in both obese and non-obese patients.

Primary adrenal Ewing’s sarcoma family of tumors with tumor thrombus of the inferior vena cava: a case report

BackgroundEwing’s sarcoma is a malignant neoplasm that mainly occurs in skeletal tissue but can rarely arise in soft tissues. Recently, small round cell tumors (including Ewing’s sarcoma) caused by chromosomal translocations have been collectively termed Ewing’s sarcoma family of tumors. We report a rare case of primary adrenal Ewing’s sarcoma family of tumors with tumor thrombus.Case presentationA 22-year-old Asian woman was referred to our hospital with a left retroperitoneal tumor 19 cm in diameter. Tumor thrombus was identified from the left adrenal vein to the inferior vena cava, infiltrating the right atrium. Total tumor excision with left adrenalectomy, nephrectomy, and thrombectomy was performed under hypothermic circulatory arrest, followed by seven courses of adjuvant chemotherapy. The patient has shown no signs of recurrence as of 26 months postoperatively.ConclusionRadical surgery combined with systemic chemotherapy may contribute to good prognosis in patients with primary adrenal Ewing’s sarcoma family of tumors.

Improving the Visualization of the Adrenal Veins Using Virtual Monoenergetic Images from Dual-Energy Computed Tomography before Adrenal Venous Sampling

(1) Background: This study explored the optimal energy level in advanced virtual monoenergetic images (VMI+) from dual-energy computed tomography angiography (DE-CTA) for adrenal veins visualization before adrenal venous sampling (AVS). (2) Methods: Thirty-nine patients were included in this prospective single-center study. The CT value, noise, signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were measured in both adrenal veins and abdominal solid organs and were then compared between VMI+ within the range of 40-80 kiloelectron volt (keV). The visualization rate of the adrenal veins and the overall image quality of solid organs were subjectively compared among different keV VMI+. The AVS success rate was recorded for 20 patients. (3) Results: For the adrenal veins, 40 keV VMI+ had the peak CT value, noise and CNR (p < 0.05). Subjectively, the visualization rate was the highest at 40 keV (100% for the right adrenal vein, and 97.4% for the left adrenal vein) (p < 0.05). For solid organs, the CT value, noise and CNR at 50 keV were lower than those at 40 keV (p < 0.05), but the SNR was similar between 40 keV and 50 keV. The overall subjective image quality of solid organs at 50 keV was the best (p < 0.05). The AVS success rate was 95%. (4) Conclusions: For VMI+, 40 keV was the preferential energy level to obtain a high visualization rate of the adrenal veins and a high success rate of AVS, while 50 keV was the favorable energy level for the depiction of abdominal organs.

PS-C21-7: IMPACT OF THE TIME OF DAY PERFORMING AVS ON THE SUCCESS RATE AND SUBTYPE DIAGNOSIS IN PRIMARY ALDOSTERONISM

Purpose: Adrenal vein sampling (AVS) is the gold-standard technique for the subtype diagnosis of primary aldosteronism (PA). Measurements of aldosterone and cortisol in adrenal venous blood are used to determine the success or failure of AVS and to diagnose the PA subtype, but these hormone secretions show diurnal change. In this study, we examined the effect of the time of AVS on the results. Design: Multicenter, retrospective, observational study Setting: Three centers in Japan Patients: 591 patients diagnosed with PA and undergoing AVS at 3 centers were used. All patients underwent basal AVS and ACTH-stimulated AVS on the same day. 382 patients underwent AVS in the morning (AM-AVS) and 209 patients in the afternoon (PM-AVS). Results: In terms of Selectivity Index (SI) in AVS, there was no significant difference in the right adrenal vein in basal AVS (22 vs. 23, p = 0.26), but SI of AM-AVS group was significantly higher in the left adrenal vein (19 vs. 17, p = 0.03). 03) than PM-AVS. However, in AVS after ACTH loading, SIs of both right and left adrenal veins were significantly higher in the PM group (Right: 42 vs. 44, p = 0.03; Left: 48 vs. 50, p = 0.01). However, there was no significant difference in AVS success rates between the two groups for basal AVS (81% vs. 74%, p = 0.08) and ACTH-stimulated AVS (92% vs. 88%, p = 0.19). There was also no significant difference in the proportion of patients diagnosed with unilateral PA in basal AVS (57% vs. 48%, p = 0.09) and ACTH-stimulated AVS (17% vs. 14%, p = 0.41). Conclusions: In a multicenter observational study, there was no significant difference in AVS success rate or subtype diagnosis of AVS between the different AVS times.

PS-R07-5: A CASE OF PRIMARY ALDOSTERONISM WITH DECLINED GLOMERULAR FILTRATION RATE AFTER ADRENALECTOMY

Background: Primary aldosteronism (PA) has been known to cause organ damage, such as renal and cardiovascular disorders more frequently than essential hypertension (EH), independently of blood pressure. Among renal disorders, albuminuria is more prevalent in patients with PA than EH, while GFR tends to be higher in PA due to glomerular hyperfiltration. Surgical and medical treatments for PA correct these effects of excess aldosterone, which sometimes uncover preexisting chronic kidney disease (CKD). Here we present a case of PA with CKD who manifested decline of glomerular filtration rate (GFR) and overt renal failure following resection of aldosterone-producing adenoma. Case report: A 53-year-old woman was diagnosed with hypertension at the age of 40. Her primary care physician started treatment with a calcium channel blocker (CCB). At the age of 49, she was diagnosed with Sjogren's syndrome (SS). Blood tests revealed severe hypokalemia and eGFR of 50 mL/min/1.73m2, while 24-hr urine collection showed urinary protein of 0.5 g per day. SS was suspected to underlie her renal disease. A renal biopsy was performed, and suggested nephrosclerosis and IgA nephropathy. On the other hand, a 11mm-sized tumor in the left adrenal gland was discovered during the investigation of secondary hypertension. PA was confirmed based on active renin concentration (ARC) of 4.3 pg/mL, plasma aldosterone concentration (PAC) of 342 pg/mL, an aldosterone-to-renin ratio of 79.5 (&gt; 40), and 24-hr urinary aldosterone levels of 15.9 μg per day under the adequate salt-loaded condition. Adrenal venous sampling yielded aldosterone hypersecretion from the left adrenal vein, which indicated aldosterone-producing adenoma. Laparoscopic partial left adrenalectomy was performed and fully normalized ARC, PAC, and urinary aldosterone levels, which indicated biochemical cure of PA. Consequently, blood pressure had been well controlled with a single CCB. However, while her preoperative serum creatine level ranged from 0.9 to 1.1 mg/dL and eGFR was around 40–50 mL/min/1.73m2, her postoperative serum creatine level increased to 1.4 to 1.9 mg/dL and eGFR decreased to 25 to 35 mL/min/1.73m2 on average. In contrast, urinary protein level improved to less than 0.1 g/day, suggesting that post-treatment increase in creatine level indicated unveiling CKD rather than deterioration of renal function. Conclusion: PA treatment may unmask CKD through improving glomerular hyperfiltration from aldosterone excess.

S-55-5: CT GUIDED AND TRANSVENOUS RADIOFREQUENCY ABLATION FOR PRIMARY ALDOSTERONISM

We are developing minimally invasive treatments for primary aldosteronism. In this presentation, we will introduce our research and clinical studies on percutaneous and transvenous radiofrequency ablation (RFA). Based on the preclinical studies, a protocol for ablating human adrenal glands and intraoperative blood pressure control methods were developed. First-in-human procedure was performed. Flexible RFA catheter was inserted into the upper lateral tributary of the left adrenal vein. The position of the RFA catheter was confirmed by CT. Ablations were performed while applying energy of 7000 J twice to each location, pulling back the catheter several millimeters in sequence. The aldosterone-producing adenoma was completely ablated to normalize the serum aldosterone level. CT-guided RFA was able to treat PA with a high success rate. However, approximately 50% of the left aldosterone producing adenomas were difficult to puncture due to anatomical reason, while most of the right adrenal adenoma could be treated by CT-guided RFA. The transvenous RFA catheter is much easier to insert into the left adrenal vein than into the right, suggesting that the two RFA methods have complementary roles. Furthermore, it may be possible to perform AVS diagnosis and RFA treatment in a single procedure.

PS-BPR01-4: A CASE OF ALDOSTERONE-PRODUCING ADENOMA DIAGNOSED BY ADRENAL ARTERIOGRAPHY AND BRANCH SELECTIVE ADRENAL VENOUS SAMPLING

Case report: A 43-year-old man had been followed up for hypertension and hypokalemia, but self-interrupted his hospital visits for the last four years. Based on the serum potassium level of 2.7 mEq/L, plasma aldosterone concentration of 202 pg/mL, and plasma renin activity of 1.1 ng/mL/hr, he was suspected of primary aldosteronism and was admitted to the previous hospital. A saline suppression test and a rapid ACTH stimulation test were both positive, and 24-hr urinary aldosterone level was 19 μg/day under sodium loading of 170 mEq/day, leading to the diagnosis of primary aldosteronism. Since contrast-enhanced CT showed an 8 mm-sized adenoma in the lower portion of the left adrenal gland, an aldosterone-producing adenoma was suspected and a non-segmental adrenal venous sampling (AVS) was performed. However, it yielded apparent bilateral aldosterone suppression in the main trunk of the bilateral adrenal veins, where the aldosterone-to-cortisol (A/C) ratio was lower than that in the inferior vena cava even after ACTH loading. The patient was referred to our hospital for a segmental AVS. Arteriography was first performed from the left inferior adrenal artery to confirm the outflow vessels from the adenoma. Strikingly, there was an aberrant vein which drained into the proximal segment of the left adrenal vein. CT imaging at the time of arteriography revealed, in addition to the known adenoma, a 6 mm-sized micronodule in the lateral region of the left adrenal gland, and the aberrant vein appeared to be the main outflow vessel from the micronodule. A segmental AVS was performed, and blood samples were taken from the bilateral adrenal veins including the aberrant vein and the main trunk of the left adrenal vein proximal to its confluence. The A/C ratio was highest in the aberrant vein, followed by in the main trunk of the proximal left adrenal vein, while it was markedly suppressed in other branches and the main trunk of the left adrenal vein distal to the confluence of the aberrant vein. Based on these results, the presence of aldosterone-producing adenoma in the left adrenal gland was suggested. Laparoscopic partial left adrenalectomy was performed without postoperative complications. Hypertension and hypokalemia were fully resolved afterwards. Conclusions: Adrenal arteriography and segmental AVS should be considered in such cases that apparent bilateral aldosterone suppression is noted in conventional AVS in patients with clinically suspected aldosterone-producing adenoma.

PS-R07-7: USE OF GADOLINIUM CONTRAST MEDIUM ENABLES ADRENAL VEIN SAMPLING IN A FLORID PRIMARY ALDOSTERONISM PATIENT WITH IODINE ALLERGY

Case: A 35-year-old woman was allergic to iodine contrast medium and was diagnosed with primary aldosteronism (PA) based on functional confirmatory tests. She was suspected to have unilateral PA because of marked hypertension, spontaneous hypokalemia, high plasma aldosterone, reduced plasma renin activity, and a right hypodense adrenal tumor. She wanted to become pregnant and requested adrenalectomy instead of medical treatment with mineralocorticoid receptor antagonists. Localization of PA by adrenal vein sampling (AVS) was necessary, but angiography with iodine contrast medium was not possible because of her allergy. AVS was performed using gadolinium contrast agent (gadoterate meglumine) instead of iodine, in combination with computed tomography angiography (CTA) because the American College of Radiology manual does not recommend prior steroid administration for high-risk patients who have already exhibited adverse reactions to iodine contrast medium. In AVS, before and after adrenocorticotropic hormone (ACTH) loading, 12 blood samples were drawn from the right adrenal vein, left adrenal central vein, left adrenal common duct, left and right renal veins, and the lower inferior vena cava with only 5 mL of gadolinium medium. There were no complications during AVS. Examination revealed an elevated aldosterone/cortisol ratio on the right side, lateralized ratio of 7.4, and contralateral ratio of 0.76; the patient was diagnosed with right unilateral PA. She underwent right adrenalectomy and showed improvements in aldosterone level from 312.4 pg/mL to 83.0 pg/mL, potassium from 3.0 mEq/L to 3.9 mEq/L, and systolic blood pressure from 138 mmHg to 117 mmHg. She is currently off her medications. Conclusion: In PA patients with iodine allergy, AVS can be performed safely and precisely using gadolinium contrast combined with CTA.

PS-C37-6: IDENTIFICATION OF ALDOSTERONE-DRIVER SOMATIC MUTATIONS IN CELL-FREE DNA FROM ADRENAL VEIN SAMPLES OF PRIMARY ALDOSTERONISM PATIENTS

Objective: Cell-free DNA fragments (cf-DNA) of tumour cells are often found in the blood downstream to the tumour due to the high apoptosis or necrosis rate of the cells. Primary aldosteronism (PA), a curable cause of secondary hypertension, are commonly due to an autonomous aldosterone-producing adenoma that harbours a somatic mutation in an aldosterone-driver gene. We thus aimed to see if genotyping of cf-DNA for mutations in aldosterone-driver genes could be used as a biomarker for APA. Design and Methods: Genotyping of cf-DNA from the adrenal vein samples (AVS) of PA patients was performed using the Agena MassARRAY platform and validated by Sanger sequencing. In this study, six samples of cf-DNA from the left and right adrenals of three PA patients were interrogated. Results: Of the three PA patients, two had left adrenalectomy and one had right adrenalectomy. CTNNB1 S45 mutation was detected by the Agena MassArray platform in the cf-DNA of both right adrenal and left adrenal vein samples of all patients (Patient 1, Patient 2 and Patient 3). In Patient 1, Sanger sequencing confirmed a CTNNB1 S45del mutation in both cf-DNA of right adrenal and left adrenal vein samples. In Patient 3, who was found to have left adrenal hyperplasia, the cf-DNA of the right adrenal and left adrenal vein samples was also detected to have a KCNJ5 G151R mutation by the Agena MassArray platform which was confirmed by Sanger sequencing. Interestingly, only the cf-DNA of the left adrenal was found to have a CACNA1D S672L mutation in Patient 3. Conclusion: These results suggest that genotyping cf-DNA from AVS samples are able to detect aldosterone-driver mutations present in the APA. However, as AVS is an invasive procedure, it would be best if genotyping of cf-DNA from periphery blood can be performed. Therefore, further work is needed to ensure this strategy can be non-invasive as then it can be used as a screening method before AVS.

A case of serous cystic neoplasm with tumor growth acceleration leading to extrapancreatic invasion.

Serous cystic neoplasm (SCN) is a potentially malignant and invasive disease. However, there are no established guidelines regarding the surgical management of SCN. Here, we report a case of SCN with jejunal invasion that ultimately required a distal pancreatectomy with partial resection of the jejunum. The patient was a 65-year-old female who was referred to our department after a diagnosis of SCN in the pancreatic tail. CT and MRI showed a 75-mm multifocal cystic mass with calcifications; the splenic vein and left adrenal vein were entrapped within the tumor. Furthermore, the tumor was in contact with the beginning of the jejunum. Finally, she underwent a posterior radical antegrade modular pancreatosplenectomy with a partial wedge-shaped resection of the jejunum. Histological findings indicated serous cystadenoma. In addition, the tumor cells were found to have infiltrated the jejunal muscularis propria in some areas, suggesting that the tumor had malignant potential. Currently, 14months have passed since surgery and there is no evidence of metastasis or recurrence. Surveillance and the decision to perform surgical resection should be made based on tumor size and growth rate to avoid malignant transformation as well as to provide SCN patients with organ-sparing, less invasive surgery.

OR20-1 Impact of Intra-Procedural Sedation on Outcomes of Adrenal Vein Sampling

Abstract Background The subtyping of primary aldosteronism (PA) requires interpretation of aldosterone and cortisol concentrations measured during adrenal vein sampling (AVS). The use of intravenous sedation during AVS is not standardized but may affect AVS outcomes. Purpose To characterize the impact of sedation on the outcomes of AVS, including cortisol and aldosterone concentrations, cannulation success and rates of lateralisation. Materials and Methods This is a retrospective cohort study based at a tertiary health centre. Consecutive patients who underwent AVS both before and after ACTH stimulation between June 2018 and July 2020 were included. AVS was performed without IV sedation in patient cohort 1 (n = 70), with sedation (midazolam and fentanyl) in cohort 2 (n = 34) and both before and after sedation in cohort 3 (n = 14). Comparisons were performed using the nonparametric (Mann Whitney U) test for continuous variables and the Chi square test for categorical variables. Results Overall, 118 patients (median age, 53 years; 67 men) were evaluated with no significant demographic differences between the three cohorts. Compared to cohort 1, patients in cohort 2 displayed significantly lower cortisol concentrations in the peripheral vein (median of 141 nmol/L vs 218 nmol/L), left adrenal vein (522 nmol/L vs 1284 nmol/L) and right adrenal vein (577 nmol/L vs 1578 nmol/L) in unstimulated AVS. Fewer patients were assessed to have successful right sided cannulation in cohort 2 (79% vs 93% in cohort 1, p = 0.047). In cohort 3, cortisol concentrations were markedly lower after sedation, with the decrease being more marked in the adrenal veins compared to peripheral veins, hence leading to lower selectivity indices. There were no clinically significant changes in aldosterone concentration or rates of lateralisation after sedation. Conclusions IV sedation reduces cortisol concentrations during unstimulated-AVS, leading to lower selectivity indices and fewer cannulations judged as successful. Importantly, radiologists are turning to point-of-care rapid cortisol tests to determine if the catheter is 'in' the adrenal vein in real-time. Adrenal vein samples collected after sedation are more likely to be considered "unsuccessful" using these semi-quantitative assays. The need for IV sedation during AVS should be carefully assessed. Presentation: Monday, June 13, 2022 11:00 a.m. - 11:15 a.m.

Morphometric assessment of the left inferior phrenic vein in patients with portal hypertension

The left inferior phrenic vein (LIPV) is a major drainage vessel of gastric varices and serves as an important conduit in endovascular treatment for gastric varices. The narrowing of LIPV has been empirically demonstrated and sometimes hinders catheter insertion for the treatment of gastric varices. We herein investigated the morphology of narrowed LIPV in patients with portal hypertension. Venograms of LIPV on 25 patients with gastric varices (15 males; 10 females; age range, 45–79 years with a mean of 67 years) were retrospectively reviewed, the following four parameters were measured: the diameter of LIPV, the diameter of narrowed LIPV, the narrowing rate, and the distance to narrowed LIPV from the left renal vein. On all 25 venograms, a narrowing was detected just above the common trunk with the left adrenal vein. The diameter of LIPV was 9.0 ± 4.2 mm, the diameter of narrowed LIPV was 5.1 ± 2.3 mm, the narrowing rate was 40.6 ± 16.0%, and the distance to narrowed LIPV from the left renal vein was 20.0 ± 7.4 mm. This anatomical information about the narrowing of LIPV may contribute to the safe and efficacious treatment of gastric varices.

Wide Variability in Catecholamine Levels From Adrenal Venous Sampling in Primary Aldosteronism.

While adrenal venous sampling (AVS) differentiates between the unilateral and bilateral disease in patients with primary aldosteronism (PA), it is unknown if AVS can determine laterality of pheochromocytoma in patients with bilateral adrenal masses. This study analyzes adrenal vein (AV) epinephrine and norepinephrine levels in nonpheochromocytoma patients to determine the "normal" range. We reviewed patients who underwent AVS for PA between 2009 and 2019 at a single institution; pheochromocytoma was excluded. Aldosterone, cortisol, epinephrine, and norepinephrine levels were obtained from the inferior vena cava (IVC), left adrenal vein (LAV), and right adrenal vein (RAV). Successful AV cannulation was defined by an AV/IVC cortisol ratio of ≥3:1 or an AV epinephrine level ≥364pg/mL. Plasma measurements (pg/mL) are median values with interquartile ranges; normal ranges for epinephrine and norepinephrine are 10-200pg/mL and 80-520pg/mL, respectively. AVS was performed in 172 patients in 405 AVs (173 LAV and 232 RAV). Median epinephrine levels were IVC=19 (14 and 34), LAV=3811 (1870 and 6915), and RAV=2897 (1500 and 5288). Median norepinephrine levels were IVC=325 (186 and 479), LAV=1450 (896 and 2050), and RAV=786 (436 and 1582). There was a difference between LAV and RAV epinephrine levels (P=0.024) and between LAV and RAV norepinephrine (P=0.002) levels. This extensive experience with AVS demonstrated a wide range of "normal" AV catecholamine levels in patients without pheochromocytoma, which suggests that the utility of AVS to determine disease laterality in patients with pheochromocytoma and bilateral adrenal nodules is likely to be limited.

Transvenous Radiofrequency Ablation of Adrenal Gland: Experimental Study.

The aim was to evaluate a flexible device for transvenous adrenal gland radiofrequency ablation in vitro and in an in vivo animal model. A flexible radiofrequency-tip catheter with an inner-cooling mechanism and a guidewire lumen was made. Then, using a polyvinyl alcohol gel model, the ablation diameter was evaluated and how much energy to deliver in vivo was determined. Finally, transvenous radiofrequency ablation of the left adrenal glands of two pigs was performed, delivering 5000 or 7000J in a single dose to each. The ablation effects were also assessed by histological examination of hematoxylin-eosin-stained sections. The mean ablation diameters in the gel model were 20.2 and 21.9mm in the short axis and 15 and 20mm in the long axis for 5000 or 7000J, respectively. The device was inserted into porcine left adrenal vein with no complications. The mean ablation diameters were 10mm in the shorter axis (whole thickness of porcine left adrenal gland) in the porcine model for 7000J. Transient increases in blood pressure and heart rate occurred during ablation. Histologically, the adrenal gland showed severe necrosis at ablated area. There was venous congestion upstream in a non-ablated area, and thermal damage to surrounding organs was not observed. A flexible radiofrequency-tip catheter could be inserted successfully into the left adrenal vein. The left adrenal gland was entirely ablated without any thermal damage to surrounding organs. We suggest transvenous adrenal ablation has potential as a therapeutic option for primary aldosteronism.

Horseshoe Kidney with Surplus Renal Arteries, Veins, and Roots of the Ureters

We report the anatomical findings of a kidney discovered in a 92‐year‐old male during a routine dissection of the abdominal viscera performed by medical students at the Oakland University William Beaumont School of Medicine. The lower poles of the kidney are fused together, forming an isthmus anterior to the aorta and inferior vena cava at the L3‐L4 vertebral level. The right and left kidneys ascend past the isthmus, forming a “U” shape, the defining feature of a horseshoe kidney. The left kidney stops prematurely, approximately 3.2 cm below the inferior mesenteric artery at the level of the left inferior renal artery. The right kidney drains into superior, inferior, and middle renal arteries which have three, two, and one branches respectively. Due to the size and position of the hilum, five separate roots extend outside the kidney into the right ureter. The left side is supplied by a superior and inferior renal artery, each dividing into two branches. The left inferior renal artery branches off the ventral face of the descending aorta. The left renal vein notably has three prominent tributaries from the kidney and an additional branch of the left adrenal vein. Six roots extend from the left hilum and drain into the left ureter. In total, the kidney has nine veins, six arteries, and eleven ureteric branches draining into the left and right ureters. These findings will be useful in regard to research and surgery on other horseshoe kidneys.

A cadaveric anatomical study: anatomy and anatomical variations of left adrenal vein.

Control of adrenal vein is the key of adrenal surgery. Its anatomy can present variations. Our aim was to study the anatomy of the main left adrenal vein (LAV) and its anatomical variations. Our work is based on dissection of 40 cadavers. We studied the number of LAV and the drainage of the main adrenal vein as well as its level of termination. We measured its length, its width and the distance between its termination level and the termination level of the gonadal vein (GV). The average length of the LAV was 21mm its mean width was 5mm. It ended in 100% of cases at the upper edge of the left renal vein after an anastomosis with the lower phrenic vein in 36 cases (90%) and without anastomosis with the lower phrenic vein in four cases (10%). The left adrenal vein ended at the upper edge of the left renal vein either at the same level as the termination of the left GV in 14 cases (35%) or within the termination of the left GV in 26 cases (65%) by an average of 8mm. The LAV was unique central vein in 22 cases (55%) and in 12 cases (30%), a major central adrenal vein with several small veins was found. The LAV is usually unique but there are variations in number. There are also variations in the level of its termination in the left renal vein as well as its anastomosis. During surgery, in case of difficulty, the left GV and the adrenal-diaphragmatic venous trunk could be used as benchmarks.

Functional side-to-side splenorenal shunts to treat extrahepatic portal vein thrombosis in children

BackgroundSurgical shunts are commonly used to manage complications resulting from extrahepatic portal vein thrombosis (EHPVT) in children. We describe a single-center experience utilizing a functional Side-to-Side Splenorenal Shunt (fSRS), created using either an enlarged inferior mesenteric vein (IMV) or left adrenal vein (LAV). MethodsPediatric patients with isolated EHPVT who were poor candidates for a Rex shunt and who underwent a fSRS procedure at our institution between 2003 and 2020 were reviewed. The pre/post shunt portosystemic gradient change, rates of early and late complications, postoperative shunt patency, and mortality were evaluated. ResultsTwelve EHPVT patients (mean age of 6.1 years) underwent a fSRS procedure. The mean portosystemic gradient change for the cohort was −11.7 mmHg (±4.9). There were no cases of recurrent variceal bleeding or episodes of shunt thrombosis reported after fSRS procedures. ConclusionsSurgical shunts continue to be an important adjunct in the treatment of complications related to EHPVT. The functional Side-to-Side Splenorenal Shunt is a safe alternative that is easy to perform, involves minimal dissection and requires only a single anastomosis.