Elsevier

Surgery

Volume 140, Issue 6, December 2006, Pages 847-855
Surgery

American Association of Endocrine Surgeons
Adrenal venous sampling in primary hyperaldosteronism: Comparison of radiographic with biochemical success and the clinical decision-making with “less than ideal” testing

Presented at the 27th Annual Meeting of the American Association of Endocrine Surgeons, New York, New York, May, 2006.
https://doi.org/10.1016/j.surg.2006.07.026Get rights and content

Background

Adrenal venous sampling (AVS) is used in the workup of primary hyperaldosteronism (PA). The purpose of this study was to determine the success rate of AVS and to examine the decision-making process after “less than ideal” AVS.

Methods

A total of 60 patients underwent 62 AVS for PA. Biochemical evidence of adrenal vein cannulization was analyzed with adrenal–peripheral cortisol ratios. Pathology and clinical outcomes were reviewed in patients undergoing adrenalectomy.

Results

Bilateral cannulization was confirmed in only 21% (pre-adrenocorticotropic hormone [ACTH] infusion) and 44% (post-ACTH infusion) AVS. Of 39 patients who underwent adrenalectomy for presumed unilateral disease, only 16 patients had “ideal” AVS, and 18 patients had only unilateral cannulization on AVS. Despite this, 11 appeared to lateralize and 7 had imaging to support unilateral disease. Postoperatively, 15 (82%) had a significant reduction in their blood pressure, and 7 (39%) of these were cured. Surgery failed in 2 patients; both were found to have bilateral hyperplasia. Bilaterally unsuccessful cannulization (n = 5) still lateralized in 3 patients, and 2 patients had nodules on computed tomography scan. All 5 patients had significant reduction in blood pressure, and 2 were cured.

Conclusions

ACTH infusion during AVS enhances the biochemical evidence of adrenal vein cannulization. Following “less than ideal” AVS, clinical decisions can still be made using anatomic and partial AVS data.

Section snippets

Material and methods

A retrospective review of all patients referred to an endocrine surgeon or an endocrinologist for evaluation and treatment of PA. The office charts of all patients undergoing AVS were reviewed. Dictated procedure reports from the radiologist performing the venous sampling were graded as “successful” (class 1), “successful but with some technical difficulties” (class 2), or “unsuccessful/modified due to technical difficulties” (class 3). The AVS protocol involved simultaneous bilateral

Results

A total of 60 patients underwent 62 AVS procedures for PA. ACTH stimulation was done in 55 of these AVS. Demographic characteristics of the patients are found in Table I. Dictated radiology reports were available for 61 procedures. Of the procedures, 26 were reported as successful without difficulty, 18 procedures had some technical problems but were ultimately deemed successful, and 17 procedures were difficult requiring modification of the procedure (ie, sampling from outside the orifice of

Discussion

As stated above, AVS is a technologically challenging procedure, especially cannulization of the right adrenal vein. Several large centers report success rates of up to 95% for this procedure.8, 9, 10 However, a recent review of 47 reports that included 384 patients, showed that the overall success rate of AVS in a variety of centers was only 74%.11 In this present series, successful cannulation of both adrenal veins as defined biochemically was achieved in only 21% by pre-ACTH criteria and 42%

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      The concern with AVS is that it is an invasive and technically demanding test that requires skilled radiologists for successful cannulation of both adrenal veins. The technical success rate of AVS judged by biochemical criteria occurs in only 44% of attempts40 with a complication rate as high as 2.5%,33 even in experienced hands. Despite Endocrine Society recommendations, several groups advocate for the selective use of AVS.

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