Left Adrenal Vein Research Articles

Етапність хірургічних маніпуляцій при раку лівої нирки з імплантаційним венозним тромбом

Introduction. Defeat of the left kidney by cancer and left-sided tumor venous invasion are diagnosed almost half as often as the right one. Only radical treatment for renal cancer (RC) complicated by a tumor thrombus of the inferior vena cava (IVC) is considered to be surgical. The use of aggressive surgery, which involves the implementation of radical nephrectomy and thrombectomy with IVC, leads to a number of complications that can be prevented by improving surgical techniques. Insufficiently covered issues of surgical tactics in left kidney cancer with implantation venous thrombus lead to their detailed discussion. Objective. To improve the results of surgical treatment of left renal cancer complicated by implantation thrombus of IVC by developing a differentiated approach to access and stages of surgical procedures. Materials and methods. The study included 147 patients with RC complicated by IVC tumor thrombosis, of which 96 (65.3%) – with right renal cancer, 51 (34.7%) – with left renal cancer. All patients underwent surgical treatment at the Transcarpathian Regional Clinical Hospital named after Andriy Novak or the Transcarpathian Antitumor Center in the period from 2005 to 2020. The level of spreading of tumor thrombus by IVC was determined according to the classification of the Mayo clinic. At defeat of the left kidney by a tumor 0 the level of a thrombus was diagnosed in 17 (33,3%) patients, I level – in 17 (33,3%), II level – in 10 (19,6%), III level – in 5 (9,8%), IV level – in 2 (3,4%). In 6 (11,8%) cases, the implantation thrombus of the IVC was combined with retrograde spread to the left adrenal and left gonadal veins, and in 12 (23,5%) – with descending phlebothrombosis of the IVC and the common iliac vein. All patients underwent surgery with a «chevron» or «mercedes» transabdominal approach using the en block organ mobilization technique in the right and left abdominal and retroperitoneal regions. Results. The average time of the operation was 196 minutes, the average volume of blood loss was 400 ml. The spleen was injured during surgery in 2 (3.9%) patients. Tumor IVC thrombus was removed in all (100%) cases. Postoperative complications of I-II degrees according to the Clavien-Dindo classification were recorded in 12 (23,5%) cases. Overall 1, 3, 5 year survival was 98,0%; 70,6%; 47,1% respectively. The use of the presented stages in the surgical treatment of left kidney tumors with implantation IVC thrombus made it possible to perform radical intervention in all cases: cavatrombectomy and nephrectomy, without episodes of pulmonary embolism, without significant bleeding and without repeated thrombosis. Conclusion. Transabdominal «chevron» or «mercedes» access with the use of the «en block» organ mobilization technique in the right and left sides of the abdominal cavity and retroperitoneal space, priority complete control of IVC and renal veins with priority performance of the venous stage of the operation and transfer of the stump of the left renal vein through the mesenteric window of the small intestine to the left provide successful radical surgical treatment of patients with left renal cancer with implantation venous thrombus.

Renal cell carcinoma with tumor thrombus growing against the direction of venous return: an indicator of complicated surgery and poor prognosis

PurposeTo explore the effect of tumor thrombus growing against the direction of venous return (GADVR) tumor thrombus on the choice of surgical approach, the impact on the complexity of the surgery and the prognosis.MethodsWe retrospectively analyzed the clinicopathological data of 213 patients, who underwent surgery in a single center of Peking University Third Hospital between January 2016 and June 2020. For right renal cell carcinoma (RCC) and venous tumor thrombus (VTT), imaging revealed a filling defect in the left renal vein, which was significantly enhanced in enhanced imaging, suggesting that the tumor thrombus grew against the direction of venous return into the left renal vein. For left RCC and VTT, at least one of the left renal vein branches has tumor thrombus. The branches include the left adrenal vein, the left gonadal vein (testicular vein or ovarian vein), and the left ascending lumbar vein. The patients were divided into two groups according to whether they were GADVR tumor thrombus, and we compare the clinicopathological characteristics of GADVR tumor thrombus and non-GADVR tumor thrombus. Univariate and multivariate Cox regression analyses were performed to explore the risk factors that affect the prognosis of patients with RCC and VTT. Kaplan–Meier plots were conducted to evaluate the effect of GADVR on progression-free survival (PFS).ResultsCompared with non-GADVR tumor thrombus, patients with GADVR tumor thrombus had a higher proportion of open surgery (76.2% vs. 52.1%, P = 0.035), a higher proportion of tumor thrombus adhering to the inferior vena cava (IVC) vessel wall (81% vs. 45.8%, P = 0.002), a higher proportion of segmental resection of the IVC vessel wall (61.9% vs. 15.6%, P < 0.001); higher preoperative serum creatinine value (110.0 μmol/L vs. 91.0 μmol/L, P = 0.015), a higher proportion of tumor thrombus combined with bland thrombus (non-tumor thrombus) (57.1% vs. 19.8%, P < 0.001). In terms of surgical complexity, patients with GADVR tumor thrombus had a longer median operation time (379 min vs. 308 min, P = 0.038), more median surgical blood loss (1400 mL vs. 600 mL, P = 0.018), and more postoperative complications (52.4% vs. 30.7%, P = 0.045). Multivariate Cox regression analysis showed that GADVR tumor thrombus, symptoms, postoperative serum creatinine, distant metastasis, sarcomatoid feature, pathological type, lymph node dissection were independent risk factors for PFS. Patients with GADVR tumor thrombus’s median survival time was 14.0 months, while patients with non-GADVR tumor thrombus were 32.0 months (P = 0.016). GADVR tumor thrombus is an independent risk factor for PFS in patients with RCC and VTT.ConclusionGADVR tumor thrombus is a characteristic feature of tumor thrombus, with an incidence of 9.9%. It has a higher proportion of open surgery and higher surgical complexity, which is an independent risk factor for PFS.

Utility of Epinephrine Levels in Determining Adrenal Vein Cannulation During Adrenal Venous Sampling for Primary Aldosteronism

ObjectiveIn patients with primary aldosteronism, adrenal venous sampling (AVS) is performed to determine the presence of unilateral or bilateral adrenal disease. During AVS, verification of catheter positioning within the left adrenal vein (AV) and the right AV by comparison of AV and inferior vena cava (IVC) cortisol levels can be variable. The objective of this study was to determine the utility of AV epinephrine levels in assessing successful AV cannulation. MethodsThis was a single institution, retrospective review of patients who underwent AVS with cosyntropin stimulation for primary aldosteronism between 2009 and 2018. Successful cannulation of the AV was defined by an AV/IVC cortisol ratio selectivity index (SI) ≥3:1. Epinephrine thresholds to predict catheter placement in the AV were determined using logistic regression. The calculated epinephrine thresholds were compared with previously published thresholds. ResultsAVS was performed on 101 consecutive patients and, based on the SI, successful cannulation of the left AV and right AV occurred in 98 (97%) and 91(90%) patients, respectively. The calculated optimal epinephrine threshold to predict AV cannulation was 364 pg/mL (sensitivity, 92.1%; specificity, 94.6%) and the calculated optimal AV/IVC epinephrine ratio threshold was 27.4, (sensitivity, 92.1%; specificity, 91.3%). Among the 14 patients with failed AV cannulation, 3 patients would have been considered to have successful AVS using AV epinephrine levels >364 pg/mL and AV/IVC epinephrine ratio >27.4 thresholds. ConclusionObtaining 2 right AV samples routinely as well as AV and IVC epinephrine levels during AVS could prevent unnecessary repeat AVS in patients with failed AV cannulation based on cortisol-based SI <3:1.

Anatomical Variations of the Left Adrenal Vein Encountered During Venous Sampling

PurposeTo identify anatomical variations in the left adrenal vein (LAV) and to evaluate the role of preprocedural contrast-enhanced computed tomography (CT) planning. MethodsThe length of the left adrenal central vein (LACV), the vessel that receives blood from all tributaries of the left adrenal gland, was measured using venograms of patients who had undergone adrenal venous sampling (AVS) for the diagnosis of primary aldosteronism between October 2017 and December 2019. The anatomical variants of the LAV were described and classified. Contrast-enhanced CT was used to evaluate the detection rate of the following: (a) confluence of the left inferior phrenic vein and the LAV and (b) the last tributary flowing into the LAV. ResultsIn total, 311 patients (143 men, 168 women; mean age: 49.3 years ± 11.0) were enrolled. Of them, 9 (2.9%) patients had anatomical variants lacking a LACV. In patients with a LACV (n = 302), the venographic LACV length was 9.0 mm ± 3.9 (<1 mm in 9 patients). The detection rate of the confluence of the left inferior phrenic vein and LAV, as determined using contrast-enhanced CT, was high (96.2%), whereas that of the last tributary flowing into the LAV was low (0.8%). In 4 of 18 patients with short or absent LACV, the variant was visualized using contrast-enhanced CT. ConclusionsIn some patients, the LACV is absent or short, which is an anatomical variation. Understanding venographic anatomical variations can help avoid misleading results resulting from a suboptimal sampling site in AVS. For some subtypes, contrast-enhanced CT may also help in planning the AVS procedure.

The potential application of a three-dimensional visualization technique in adrenal vein sampling

Objective: To explore the potential application of a three-dimensional visualization technique in adrenal vein sampling (AVS). Methods: The clinical data were retrospectively analyzed, which included 76 patients with primary aldosteronism (PA) who have undergone AVS in Guizhou Provincial People's Hospital from December 2017 to May 2020. All cases were examined by adrenal thin-section enhanced CT and blood was drawn by bilateral AVS. Among them, the adrenal vein blood of 46 cases was sampled with the help of three-dimensional (3D) visualization processing of CT data, while that of 30 cases was without 3D visualization processing. The rate of the catheter in place, the successful rate of AVS, the time of blood collection, the dosage of the contrast agent, and surgical complications were compared between the two groups. Results: There were 76 cases included, while 38 were male and 38 were female. The average age was 45 (25-57) years. Compared with the patients without the aid of 3D visualization, the success rate of right AVS of the patients with the aid of 3D visualization technology increased from 43% to 78% (P<0.05). The success rate of adrenal vein blood collection increased from 53% to 83%. The dose of contrast agent decreased [the M(Q1,Q3) were78 (59, 89) ml vs 28 (16, 51) ml, P<0.05], and the time of blood sampling from the right adrenal vein approximately decreased [the M（Q1，Q3） were 70 (66, 88) min vs 44 (22, 61) min, P<0.05]. Compared with the case without the aid of 3D visualization, the left adrenal vein catheterization rate of patients in the 3D visualization group increased from 97% to 98%, the success rate of adrenal vein blood collection increased from 97% to 98%, and the differences of the time of blood sampling and the dosage of the contrast were not statistically significant between the two groups. Among all the cases experienced bilateral AVS, only one patient without 3D reconstruction had contrast extravasation, and the others had no obvious complications. Conclusions: Before AVS, 3D visualization processing of adrenal vein from CT data is capable of increasing the success rate of blood sampling from the right adrenal vein, as well as reducing the dosage of contrast agent and the time of adrenal vein blood sampling. Therefore, it has a potential clinical value of the application.

Limited diagnostic utility of partially successful adrenal vein sampling for primary aldosteronism subtyping.

Failure of adrenal vein sampling (AVS) due to difficult cannulation of the right adrenal vein (AV) frequently precludes subtyping of patients with primary aldosteronism (PA) before adrenalectomy. According to a recent study, lateralized PA could be accurately predicted from partial AVS data based on the gradient of the aldosterone-to-cortisol ratios (ACR) between left AV and inferior vena cava (IVC) (LAV/IVC index). We aimed to validate the diagnostic utility of this index for PA subtyping in our cohort. A retrospective cross-sectional study included all patients who underwent bilaterally successful AVS at our centre and were diagnosed with either bilateral PA according to AVS or with lateralized PA after successful adrenalectomy from November 2004 to the end of 2019. Final diagnoses were compared to originally suggested LAV/IVC index cut-offs of ≥ 5.5 for ipsilateral disease and of ≤ 0.5 for contralateral disease, respectively. The inclusion criteria were met in 168 patients: 46 women and 122 men, aged 54 years on average (range 32-72 years); 67 with lateralized and 101 with bilateral PA. LAV/IVC index using cut-offs of ≥ 5.5 or ≤ 0.5 anticipated ipsilateral (left lateralized) PA with a sensitivity of 32% and specificity of 97%, while a sensitivity of 47% and specificity of 95%, were found for contralateral (right lateralized) PA in our cohort. The overall inappropriate adrenalectomy rate was 29.7% (p = 0.314 for comparison between sides). When ascertaining ipsilateral disease (LAV/IVC index ≥ 5.5), 4 out of 16 patients (25%) would have been incorrectly sent to left adrenalectomy. Inappropriate right adrenalectomy would have occurred in 7 out of 21 patients (33.3%) when predicting contralateral disease (LAV/IVC index of ≤ 0.5). Thus, 11 patients with bilateral PA (6.5% of the entire cohort) would have been misclassified as lateralized PA and referred to surgery. Failed lateralization would have occurred in 61.2% of patients overall (53.3% for overlooked contralateral disease, 67.6% for missed ipsilateral disease; p = 0.723 for comparison between sides). Based on our cohort, we conclude that application of the suggested LAV/IVC index cut-offs did not predict lateralized PA with the high accuracy previously reported.

Imaging Analysis During Adrenal Venous Sampling Operations

Abstract Background To investigate the imaging anatomy and variations of bilateral adrenal veins to improve the success rate during adrenal venous sampling (AVS) and reduce the incidence of complications. Methods A total of 120 patients who underwent AVS from June 2017 to January 2019 were collected. RadiAnt Viewer software was used to retrospectively analyze the intraoperative imaging data, intraoperative anatomical variation data, the success rate, and complications of AVS. Results The ostium of the right adrenal vein was located mainly between the lower 1/3 of the 11th thoracic vertebra and the middle 1/3 of the 12th thoracic vertebra, accounting for 75.5% of the cases. Most of the ostium (83.3%) was transversely distributed between 9 o’clock and 12 o’clock. The main morphology of the right adrenal venography was a triangular pattern (48.2%). As the body mass index increased, the ostium was higher, and the distance between the ostium and the spine was greater (P &amp;lt; 0.05). The success rate of the right AVS, the left AVS, and the bilateral AVS was 95.0%, 97.5%, and 92.5%, respectively. The anatomical variation rate of the right adrenal vein was 5.3%. All cases showed that the right adrenal vein entered the accessory right hepatic vein and then into the inferior vena cava. The anatomical variation rate of the left adrenal vein was 4.3%. Conclusions Body mass index can be used to predict the location of the right adrenal vein ostium. Understanding of the anatomy and variation of the adrenal vein and right adrenal venography is essential to a successful AVS.

Pathogenetic Development Factors of Position-dependent Changes in Oxygen Saturation

It is known that the oxygen saturation of the peripheral blood is determined by the efficiency of the heart, the state of the microcirculatorybed, so position-dependent fluctuations in systolic blood pressure, pressure in the left renal and left adrenal veins,mediated bursts of hormones of the adrenal cortex can affect SO2. There is every reason to believe that SO2 will change in differentstatic positions. Aim. To study position-dependent changes in oxygen saturation based on the study of the pathogenetic effect of venous bloodflow in the “pool” of the left renal vein on the general hemodynamics and hormones of the adrenal cortex. Material and methods. A method for the polypositional assessment of oxygen saturation disturbances in six static states has beendeveloped: standing, sitting, on the back, on the abdomen, on your right side, on your left side. Statistical data processing was carriedout, which made it possible to determine the relationship between the indicators. Results. Polypositional studies of oxygen saturation hemodynamic parameters (SрO2) in six static states revealed the variability ofthe relationships of these groups when comparing them. The correlation was high, statistically significant between diastolic (DBP)and systolic (SBP) pressure, moderate between pulse (Ps) and SBP, pulse and DBP, weak between pulse and saturation. The groupsdivided by body positions relative to the pulse, SBP and DBP did not have a cluster structure. In the pron-position, SO2 had a minimalvalue, significantly different from the data in the other positions. Conclusion. Body position is one of the pathogenetically significant factors regulating blood oxygen saturation, which can helpin the treatment and rehabilitation of patients with respiratory failure (COVID-19). Polypositional saturation measurement in sixstatic states can determine a new, more effective algorithm for the management of patients with respiratory failure, both duringtreatment and during rehabilitation.

Adrenal venous sampling with adrenocorticotropic hormone stimulation: A meta-analysis.

This meta-analysis was performed to compare the effect of adrenal venous sampling with adrenocorticotropic hormone with that without adrenocorticotropic hormone in subjects with primary aldosteronism. A systematic literature search up to May 2020 was performed and 17 studies were detected with 1878 subjects who had adrenal venous sampling operations. They reported relationships between with and without adrenocorticotropic hormone stimulation during adrenal venous sampling in subjects with primary aldosteronism. We calculated the odds ratio (OR) with 95% confidence intervals (CIs), using the dichotomous method with a random- or fixed-effect model. Adrenal venous sampling operations with adrenocorticotropic hormone stimulation had statistically significant lower incorrect lateralisation (OR, 0.57; 95% CI, 0.43-0.75, P < .001); lower unsuccessful cannulations in both adrenal veins (OR, 0.35; 95% CI, 0.21-0.58, P < .001); lower unsuccessful cannulations of left adrenal vein (OR, 0.10; 95% CI, 0.06-0.17, P < .001) and lower unsuccessful cannulations of right adrenal vein (OR, 0.25; 95% CI, 0.11-0.54, P < .001) compared with without adrenocorticotropic hormone stimulation in subjects with primary aldosteronism. Adrenal venous sampling operations with adrenocorticotropic hormone stimulation had significantly lower incorrect lateralisation, unsuccessful cannulations in both adrenal veins, unsuccessful cannulations of the left adrenal vein and unsuccessful cannulations of the right adrenal vein compared with adrenal venous sampling operations without adrenocorticotropic hormone stimulation in subjects with primary aldosteronism. Larger prospective studies are recommended to confirm these findings.

Computed tomography image fusion, Coaxial guidewire technique, Fast intraprocedural cortisol testing technique improves success rate and decreases radiation exposure, procedure time, and contrast use for adrenal vein sampling.

Adrenal vein sampling (AVS) is recommended for discriminating patients with unilateral primary aldosteronism from bilateral disease. However, it is a technically demanding procedure that is markedly underused. We developed a computed tomography image fusion, coaxial guidewire technique, fast intraprocedural cortisol testing (CCF) technique to improve AVS success rate, which combines CT image fusion, coaxial guidewire technique, and fast intraprocedural cortisol testing. To evaluate the effectiveness and safety of the AVS--CCF technique. We retrospectively evaluated 105 patients who undervent AVS from June 2016 to October 2020. There were 51 patients in the AVS--CCF group and 54 patients in the AVS group. We compared two groups with technical success rate, procedure time, radiation exposure, volume of contrast medium, and complications (adrenal vein rupture, dissection, infarction, or thrombosis; intraglandular or periadrenal hematoma; and contrast-induced nephropathy). The technical success rate was higher for AVS--CCF than for AVS without CCF (98 vs. 83.3% for bilateral adrenal veins, P = 0.016). AVS--CCF was associated with a shorter procedure time (63.6 ± 24.6 vs. 94.8 ± 40.8 min, P < 0.001), shorter fluoroscopy time (15.6 ± 12.6 vs. 20.4 ± 15.0 min, P = 0.043), and lower contrast medium volume (25.10 ± 21.82 vs. 44.1 ± 31.0 ml, P < 0.001). There were no significant differences between groups with respect to the time for cannulating the left or right adrenal vein or the peak skin radiation dose. Adrenal vein rupture occurred in 14 patients and intraglandular hematoma in 1 patient. The CCF technique during AVS not only contributed to improved technical success rates but also associated with decreased procedure time, radiation exposure, and contrast medium volume.

Large Invasive Adrenal Cortical Carcinoma in a Patient With Neurofibromatosis Type I

Background: Adrenal cortical carcinoma is a rare neoplasm. Adrenal cortical carcinoma has previously been reported in less than 10 cases of patients with Neurofibromatosis Type I. Clinical Case: A 44-year-old Hispanic man with Neurofibromatosis Type I (NF1) presented with progressive hypoxia, tachypnea and abdominal pain. Intubation was required with 100% FiO2. CT angiogram of the chest and abdomen showed a 9.5 cm left adrenal mass with tumor thrombus in the left adrenal vein, distal left renal vein, IVC extending into the right atrium, suggestive of an adrenocortical carcinoma. Café-au-spots, neurofibromas and Lisch nodules were seen on physical exam but no signs suggestive of a functional adrenal cortical carcinoma. Transthoracic echocardiogram demonstrated a large well circumscribed echo-dense mass filling the right atrial cavity. Hemodynamically he was unstable with labile blood pressures due to right atrium thrombus burden. He was supported pending pheochromocytoma investigation. Biochemical work up revealed an elevated 24-hour free cortisol concentration of 95.9 ug/d (<=60ug/d) with a normal 24-hour urine metanephrine and normetanephrine [140ug/d (55-320ug/d) and 448 ug/d (114-865ug/d]. Plasma free metanephrine level was normal 0.43 (0.00-0.49nmol/L) and the normetanephrine levels was increased at 2.7 (0.00-0.89nmol/L) consistent with stress response. Serum aldosterone level and renin activity with potassium and DHEA-S levels were normal. Once pheochromocytoma was ruled out, he successfully underwent a left nephrectomy, left adrenalectomy, IVC thrombectomy, right atrium thrombectomy under a multidisciplinary team of surgeons. Surgery was well tolerated and he was discharged home 11 days later. Pathology confirmed adrenal cortical carcinoma, stage 4, with involvement of endocardium and left renal vein with mitotic count greater than 20/50 high-power fields, consistent with a high-grade tumor. Summary: Patients with NF1 have a higher predilection to develop tumors including pheochromocytoma, paraganglioma, gastrointestinal stromal tumor, and pancreatic neuroendocrine tumor. NF1 association with adrenal tumors is well known, most commonly pheochromocytomas which occur in 0.1–5.7% of patients with NF1. However, based on a literature search there have been less than 10 case reports which postulate an association between NF1 and ACC. Genetic analysis of these reported cases suggest a loss of heterozygosity at the NF1 locus as a possible explanation of development of ACC in patients with NF1. Conclusion: Adrenal cortical carcinoma is rare but should be considered in a patient with NF1 and adrenal mass when plasma/urine metanephrines are not suggestive of pheochromocytoma.

Aldosterone/Direct Renin Concentration Ratio Versus Aldosterone/Plasma Renin Activity for Diagnosis of Primary Hyperaldosteronism: Case Presentation

Aldosterone/Direct Renin concentration ratio versus Aldosterone/Plasma renin activity for diagnosis of Primary Hyperaldosteronism: Case presentation. Introduction: Primary hyperaldosteronism (PA) is the most common cause of secondary hypertension. Endocrine Society guidelines recommend using aldosterone-to-renin ratio (ARR) for screening of PA1. This ratio can be obtained using two different methods. The first is plasma aldosterone concentration (PAC) divided by plasma renin activity. ARR greater than 20 is suggestive of PA. Further testing is required for confirmation. Due to limitations and challenges in obtaining PRA, another method of measurement was developed in which the direct renin concentration (DRC) is measured. There have been inconsistent recommendations regarding what ratio is appropriate using this assay to diagnose hyperaldosteronism. The aim of this case presentation is to review a patient with PA in whom both measurement methods were used and compared for screening. Case Presentation: A 45-year woman with past medical history of Graves’ disease and hypertension presented with hypokalemia. Blood pressure was well-controlled on amlodopine for 3 years. PAC and DRC were measured. PAC was 21.2 ng/dL and DRC 2.8 pg/ml with ARR 7.6. This was repeated and confirmed (PAC 19.6 ng/dL and DRC 3.9 pg/ml with ARR 5). Plasma Renin Activity (PRA) was measured. PAC was 36.3 ng/dL and PRA was 0.19 ng/ml/hr (ARR 191), suggestive of hyperaldosteronism. Further workup including a CT scan of the abdomen with IV and oral contrast demonstrated an enhancing 1.8 cm nodule in the left adrenal gland. Adrenal vein sampling was performed. Left adrenal vein aldosterone level was 1400 ng/dl and on the right, 33.1 ng/dl. The patient was treated with left laparoscopic adrenalectomy. The pathological evaluation of the specimen demonstrated a 2.5 cm adenoma of benign etiology. Later follow-up showed the patient was normokalemic with PAC of 3.1. Conclusion: Patients with PA despite controlled hypertension, experience higher rates of cardiovascular events, hence early and accurate diagnosis is essential. PRA measurement has multiple limitations including inter-laboratory variations, higher cost, availability in only advanced laboratories and values influenced by blood pressure medications. Therefore, some institutions have replaced it with direct renin concentration (DRC) which is cheaper and more widely available. DRC has limitations with fewer positive ARR results. When the clinical suspicion is high, PRA is the more precise study to calculate ARR. The Management of Primary Aldosteronism: Case Detection, Diagnosis, and Treatment: An Endocrine Society Clinical Practice Guideline. John W. Funder, Robert M. Carey, Franco Mantero, et al. The Journal of Clinical Endocrinology & Metabolism, Volume 101, Issue 5, 1 May 2016, Pages 1889–1916, https://doi.org/10.1210/jc.2015–4061.

Use of Bony Landmarks during Adrenal Venous Sampling to Guide Catheterization of the Left Adrenal Vein

Abstract Purpose The aim of this study was to examine the utility of fluoroscopic bony landmarks in predicting the location of the left adrenal vein during adrenal vein sampling (AVS). Methods Eighty-six AVS procedures were performed in 81 patients between August 2013 and March 2020. A selectivity index was calculated for each case by dividing the measured left adrenal vein cortisol level by the peripheral vein cortisol level. Successful “target” left adrenal vein catheterization was confirmed in cases with a selectivity index of three or greater. Intraprocedural AVS fluoroscopic images were selected that demonstrated catheter position in the left adrenal vein. Lateral distance from the catheter tip in the left adrenal vein to the lateral margin of the left pedicle at the associated vertebral body level was measured. Results Mean patient age was 56.4 years (range: 19–80 years) and 48 (59.3%) patients were male. Target sampling in the left adrenal vein was confirmed in 82 (95.3%) cases. In 78 (95.1%) targeted cases, the catheter terminated less than 25 mm from the left lateral pedicle at a mean distance of 11.2 mm. The catheter was most frequently placed at the T12 and L1 vertebral body levels. Four (4.7%) cases demonstrated nontarget catheter positioning, two (50.0%) of these cases were within 25 mm. Conclusion The position of the left adrenal vein is generally located in a predictable position relative to bony landmarks. By utilizing these landmarks, positioning of the sampling catheter during AVS can be more reliable with the potential to avoid repeat procedures and delays in patient care.

Significance of aldosterone gradient within left adrenal vein in diagnosing unilateral subtype of primary aldosteronism.

The success rate of cannulation of the right adrenal vein is limited. The aldosterone gradient within the same adrenal vein branch is specific for aldosterone-producing adenoma. This study was performed to investigate whether the absolute aldosterone gradient within the left adrenal vein (left-AV absolute aldosterone gradient) indicates unilateral excess aldosterone. A retrospective cross-sectional study in a single referral centre. In total, 123 consecutive patients with primary aldosteronism who had successful adrenal vein sampling (AVS) data were examined. The left-AV absolute aldosterone gradient was considered significant when a gradient of >4:1 in the aldosterone-to-cortisol ratio between the common trunk vein and central vein was found. The prevalence of the unilateral subtype in patients with a significant left-AV absolute aldosterone gradient. The prevalence of the unilateral subtype was higher in patients with than without a significant left-AV absolute aldosterone gradient (88.2% [15/17] vs 21.7% [23/106], P<.001). Of 60 patients with spontaneous hypokalemia, left unilateral disease on computed tomography, or both, a significant left-AV absolute aldosterone gradient was present only in patients with the unilateral subtype on AVS (42.9% [15/35]), but not in those with the bilateral subtype (0.0% [0/25]). These data were validated in an external cohort. The presence of a significant left-AV absolute aldosterone gradient can be used to diagnose the left unilateral subtype of primary aldosteronism on AVS in patients with spontaneous hypokalemia, left unilateral disease on computed tomography or both.

Clinical outcomes of primary aldosteronism based on lateralization index and contralateral suppression index after adrenal venous sampling in real-world practice: a retrospective cohort study

BackgroundWe investigated whether the contralateral suppression index in aldosterone-producing adrenal adenoma could be used as a diagnostic criterion when catheterization in either right or left adrenal vein fails or when a discrepancy in the adrenal vein sampling (AVS) results and imaging findings occurs in the real-world practice.MethodsWe retrospectively reviewed 48 patients who had resistant hypertension (HTN) or hypokalemia with a biochemical diagnosis of primary aldosteronism and who underwent AVS from January 2009 to June 2017 at a tertiary referral hospital. Selection index (SI), lateralization index (LI), and contralateral suppression index (CSI) were calculated based on AVS results and the final clinical outcomes were evaluated.ResultsThe catheterization of both adrenal veins was successful in 43 of 48 (89.6%) patients. The lateralization based only on LI was performed in 23 out of 43 (53.5%) patients. When CSI and LI were combined in decision making, the concordance between adrenal computed tomography scan and AVS for unilateral lesion improved from 59.3% (19/32) to 75.0% (24/32). CSI also correlated well with unilateral adrenal disease in the catheterization failure group. The final outcomes of HTN were better in the contralateral suppression group.ConclusionCSI combined with LI could be a supplementary diagnostic tool in patients with non-lateralization or catheterization failure and predict the clinical outcomes of HTN in patients with primary aldosteronism.

SUN-202 Is a “Failed” Adrenal Venous Sampling Useful for Surgical Decision Making in Primary Hyperaldosteronism?

BackgroundAdrenal venous sampling (AVS) is important in differentiating unilateral vs bilateral primary hyperaldosteronism. A limitation is the difficult cannulation of the right adrenal vein (RAV).A study in 2016(1) investigated the usefulness of AVS with failed right sided cannulation. The investigators calculated the ratios of plasma aldosterone and cortisol in the periphery (IVC) and in the left adrenal vein (LAV), then corrected the aldosterone/cortisol ratio of the LAV for that of the IVC with the following equation: LAV/ IVC = [aldosterone in LAV/cortisol in LAV] / [aldosterone in IVC/ cortisol in IVC]. A LAV/IVC ratio ≥5.5 and ≤0.5 predicted unilateral aldosterone hypersecretion on left and right side respectively with a 100% specificity and positive predictive value.Clinical caseWe present a case of a 51-year-old patient with primary hyperaldosteronism and a failed right sided cannulation. Patient presented with uncontrolled hypertension of 10 years and hypokalemia. His blood pressure (BP) was 190/100 on amlodipine, lisinopril, atenolol, hydralazine and spironolactone.Screening labs obtained off spironolactone and atenolol showed:Aldosterone 18.5ng/dl(0-30), renin 0.215ng/ml(0.167-5.738), plasma aldosterone concentration (PAC)/ plasma renin concentration (PRC) 86.CT abdomen showed a 1.2cmX1cm left adrenal adenoma.A 24-hour urine collection without salt loading showed an aldosterone of 43.46 microg/L (0-19). He underwent an AVS with a failed RAV cannulation with the following results:IVC: cortisol=17.2 microg/dl, aldosterone= 8.9ng/dl, aldosterone/cortisol= 0.52LAV: cortisol=420, aldosterone=2860, aldosterone/cortisol=6.8.Partial left adrenalectomy was performed. Pathology showed a benign adenoma.Although his BP initially improved, over several weeks, his BP was high again, and he had a recurrence of hypokalemia. A repeat PAC/PRC of 80 confirmed persistent hyperaldosteronism.He refused further interventions. Eplerenone was added resulting in BP control.ConclusionBased on the above study, his LAV/IVC of 13 predicts the source to be the left adrenal gland. However, this ratio did not apply in our patient and should be utilized carefully.

SAT-548 Significance of Adrenal Vein Aldosterone Gradient in the Diagnosis of Unilateral Subtype of Primary Aldosteronism

Context: Adrenal vein sampling (AVS) is the standard method for subtype diagnosis in primary aldosteronism (PA), while success rate of its procedures, especially in right adrenal vein (AV), has limited. However, unilateral subtype of PA can be completely cured by surgical treatment and hence diagnostic approach for PA should be established especially when patients with apparent adrenal disease on computed tomography (CT) lack complete AVS result. In recent years, segmental AVS demonstrates that apparent aldosterone gradient in each adrenal vein branch is specific finding in aldosterone producing adenoma. Since we have reported that plasma aldosterone concentrations different in the proximal and distal regions of the left AV in some of the patients with PA, we hypothesized that solo finding of adrenal aldosterone gradient in the left AV (left AV gradient) should be the clue for unilateral subtype of PA. Objective: The aim was to investigate whether left AV gradient indicate the left unilateral subtype of PA. Design and Setting This study was a part of the Kyushu Adrenal Network Database for Advanced medicine (Q-AND-A) study, a cross-sectional and retrospective study in a single referral center. Participants and AVS procedure: Of 194 PA patients who underwent AVS with cosyntropin stimulation between January 2007 and April 2019, 111 patients had available and successful AVS data. Blood samples in left adrenal veins were obtained from following two positions; the common trunk and the central adrenal vein. We calculated left AV gradient by the ratio of aldosterone-to-cortisol ratio on the higher position in left AV to that on the lower position. We determined the presence of left AV gradient if it was greater than four. Main outcome measures: Prevalence of unilateral subtype in patients with left AV gradient who had unilateral disease on CT. Results: Of 111 patients with complete AVS data, 43 who had left unilateral disease on CT were analyzed in present study. Twenty-nine patients were diagnosed as left unilateral subtype on AVS and 14 were bilateral subtype. Aldosterone gradient was observed only in patients with unilateral subtype (41% [12/29]), not in patients with bilateral subtype (0% [0/14]). Of 29 patients with unilateral subtype on AVS, clinical parameters, including plasma aldosterone concentrations, plasma renin activity, and serum potassium levels, were not different in those with and without left AV gradient. The receiver operative curve analysis for the diagnosis of unilateral subtype on AVS showed that the optimal cutoff value of left AV gradient was 3.3 with a sensitivity of 45% and specificity of 100%. Conclusion: The presence of left AV gradient is the reliable finding for the diagnosis of left unilateral subtype in patients with PA who have unilateral disease on CT. However, further study in a larger number of cases is required to validate this finding.

MON-LB035 Adrenal Venous Sampling in the Lateralization of Acth-Independent Cushing Syndrome With Bilateral Adrenal Masses: A Case With a 5-Year Follow-Up

Background Nearly 25% of adrenal Cushing syndrome (CS) patients with bilateral adrenal masses have unilateral hypercortisolism, making localization crucial for surgical planning. Since there is no standardized protocol for adrenal venous sampling (AVS) in lateralizing adrenal hypercortisolism, we share our experience with a case of CS with bilateral adrenal masses in which lateralization via AVS permitted unilateral adrenalectomy. Clinical Case A 59-year-old woman with hypertension, hyperlipidemia, and prediabetes was hospitalized for worsening back pain and hypertension. Her BMI was 26.5 kg/m2, BP 173/93 mmHg, HR 73/min, she was anxious, diaphoretic, and hirsute. Glucose was 118 mg/dL and HbA1c 6.6%. Abdominal computed tomography revealed a type B aortic dissection with both right (6.1 x 3.1cm and 3.6 x 2.4cm), and left (largest 1.7 cm) sided adrenal masses. Plasma and 24 hour-urine metanephrine, normetanephrine and catecholamines, as well as plasma renin and aldosterone levels, were normal. AM cortisol on three different occasions was 21.30, 20.70, and 21.30 mcg/dL. Midnight cortisol was 17.8 mcg/dL, and 24-hour urine free cortisol on two occasions was 163 mcg (urine volume 3.4L with creatinine 1.14) and 99.2 mcg (urine volume 1.15L). After 1mg dexamethasone her AM ACTH and cortisol were <5 and 18.70 mcg/dL, respectively. Preoperative AVS was performed and 8mg of dexamethasone was administered the night prior to ensure ACTH suppression during the procedure, and epinephrine was measured to ascertain adequate adrenal vein cannulation. Cortisol levels (in mcg/dL) from the common iliac, right and left adrenal veins were 14.7, 61.5, and 23.5 at 0 minute and 15.2, 61.0, and 22.7 at 2 minutes, respectively. Epinephrine levels (in pg/dL) from the common iliac, right and left adrenal veins were 42, 577, and 3225 at 0 minutes, and 46, 718, and 2989 at 2 minutes. Despite higher epinephrine levels from the left adrenal, the cortisol ratio of the right adrenal vein to peripheral vein was 4.18 with the right-to-left ratio of 2.59 and 2.68 at 0 and 2 minutes, suggesting hypersecretion of cortisol from the right adrenal gland. Unilateral right adrenalectomy revealed a 5.6 cm adrenal adenoma arising in a background of adrenal cortical hyperplasia. Morning postoperative cortisol was 2.2 mcg/dL. She was placed on hydrocortisone and tapered over a 10-month period with remission maintained for more than 3.5 years post-operatively. Conclusion This case demonstrates the safety, usefulness, and necessity, of AVS in localizing cortisol production when bilateral adrenal masses are present. In addition, this case suggests that the use of high dose dexamethasone and measurement of catecholamines may be helpful for more accurate interpretation. More data on AVS in CS patients with bilateral adrenal masses is needed so a well-validated and standardized CS-specific ACS protocol can be developed.

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.