6.2 Comparison of Three Different Doses of ACTH Stimulation During Adrenal Vein Sampling (AVS) in the Work-Up of Primary Aldosteronism

Background. ACTH stimulation was proposed to overcome the potential biases associated with pulsatile aldosterone secretion during AVS. Different protocols and doses of synthetic ACTH have been used but no systematic comparison between them was available. Aim. To compare the effects of 3 different doses of ACTH on the selectivity (SI) and the lateralization index (LI). Patients and Methods. We prospectively tested the effect of a high dose (HD; 250 μg as an i.v. bolus, n=41), a very low dose (VLD, 250 pg as an i.v. bolus followed by 0.5 pg/min infusion, n=6) and an intermediate dose (ID 50 μg/hr; n=7) on the SI and LI in patient referred for primary aldosteronism. Blood sampling for the measurement of plasma aldosterone (PAC) and cortisol (PCC) concentration were obtained at baseline and 30 minutes after ACTH stimulation, using bilaterally simultaneous AVS. The SI was calculated as the ratio between cortisol levels in the right (C RAV ) or left (C LAV ) adrenal vein and the infrarenal inferior vena cava (C IVC ); the LI was assessed as the ratio of aldosterone to cortisol on the side with the higher ratio (A/C SIDE ) over the contralateral aldosterone to cortisol (A/C CTRL ). The diagnosis of APA was based on pathology and follow-up data. Results. The HD induced a highly significant increase of PCC in IVC (+83%, P<0.003) and on the SI on both sides (SI RIGHT +120%; SI LEFT +122%, P<0.001), as compared to baseline values. By contrast, no significant change of PCC in IVC and of the SI was seen with the VLD. The ID elicited a significant increase of PCC in the infrarenal IVC (+82%, P<0.001), which was not significantly different from that seen with the HD. Likewise, the ID increased the SI (SI RIGHT +177%, P<0.001; SI LEFT + 727%, P<0.001). In the patients with an unequivocal diagnosis or APA based on the ‘four corners’ criteria, the HD and the ID led to wrong identification of the APA side in 28 and 25%, respectively. Conclusions. The HD and the ID improve the ascertainment of the selectivity of adrenal vein catheterization during AVS; by contrast, no significant effect of the VLD on either PAC or PCC was seen. The improvement in the assessment of selectivity with both the HD and the ID should be weighed against the confounding effect on correct identification of lateralized aldosterone excess to the APA side.

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Effect of Adrenocorticotropic Hormone Stimulation During Simultaneous Bilateral Adrenal Vein Sampling in Primary Aldosteronism

Hormone and Metabolic Research ◽

10.1055/a-1498-6958 ◽

2021 ◽

Vol 53 (06) ◽

pp. 364-370

Author(s):

Wei Liu ◽

Jingjing Zhang ◽

Yaling Yang ◽

Yinxin Jin ◽

Zaizhao Li ◽

...

Keyword(s):

Primary Aldosteronism ◽

Adrenocorticotropic Hormone ◽

Base Excess ◽

Serum Potassium Level ◽

Adrenal Vein ◽

Acth Stimulation ◽

Adrenal Vein Sampling ◽

Before And After ◽

Carbon Dioxide Combining Power ◽

Lateralization Index

AbstractThe aim of the study was to investigate the significance and influence of adrenocorticotropic hormone (ACTH) stimulation in primary aldosteronism (PA) patients with simultaneous bilateral adrenal vein sampling (AVS). All patients diagnosed with PA underwent simultaneous bilateral AVS with ACTH. In 95 patients, the post-ACTH SI significantly increased (p<0.001), and it gradually decreased from t10–t30 after ACTH stimulation (p<0.001). The unsuccessful catheterization decreased after ACTH stimulation. Time points within 20 min after ACTH stimulation were better for sampling, and the selectivity did not increase over longer periods. According to lateralization before and after ACTH stimulation, the patients could be divided into 3 groups (U, unilateral; B, bilateral): U/U , U/B or B/U, and B/B. Compared with the U/U group, in the U/B or B/U and B/B groups, the lateralization index (LI) was lower both at baseline and after ACTH stimulation (p<0.0001), the contralateral index (CLI) was higher after ACTH stimulation (p<0.003), the serum potassium level was higher (p<0.001), and the carbon dioxide combining power (CO2CP) and base excess (BE) levels were lower. In conclusion, in simultaneous bilateral AVS, ACTH stimulation had significant effects on increasing the catheterization selectivity. Lateralization change was observed after stimulation. After ACTH stimulation, fewer patients could be diagnosed with lateralized PA. Patients with consistent lateralized PA showed a more serious phenotype.

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Laterality Diagnosis of Adrenal Vein Sampling for Primary Aldosteronism Using Aldosterone Alone

Journal of the Endocrine Society ◽

10.1210/jendso/bvab048.592 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

pp. A291-A291

Author(s):

Norio Wada ◽

Shuhei Baba ◽

Hajime Sugawara ◽

Arina Miyoshi ◽

Shinji Obara ◽

...

Keyword(s):

Primary Aldosteronism ◽

Roc Analysis ◽

Vena Cava ◽

Area Under The Curve ◽

Adrenal Vein ◽

Acth Stimulation ◽

Adrenal Vein Sampling ◽

Left And Right ◽

Lateralization Index

Abstract Background: In adrenal vein sampling (AVS) for primary aldosteronism (PA), cortisol concentration is used to determine successful AVS, and laterality diagnosis is performed using a combination of aldosterone and cortisol concentrations. In this study, we examined the comparison with the conventional method when AVS was determined by aldosterone alone. Subjects and methods: We studied the data from 277 patients with PA who underwent AVS in Sapporo City General Hospital from July 2007 to April 2020. The patients with autonomous cortisol production were excluded. Using the blood samples from adrenal veins and inferior vena cava (IVC) after ACTH stimulation, the predicting ability of the left and right ratio of aldosterone concentration (aldosterone ratio, AR) for lateralization Index (LI) was examined by Receiver operating characteristic (ROC) analysis. The predicting abilities of the ratio of aldosterone concentration between adrenal vein and IVC (aldosterone index, AI) and aldosterone concentration for selectivity index (SI) and contralateral ratio (CR) were also examined by ROC analysis. Results: Six samples (0.01%) with SI <5 after ACTH stimulation those were determined unsuccessful AVS. The results of the area under the curve (AUC) in ROC analysis of aldosterone concentration and AI for prediction of SI>5 was 0.998, 0.990, respectively, p=0.39. The optimal cut-off values of aldosterone concentration and AI for prediction successful AVS were 1700 pg/ml (sensitivity 99.5%, specificity 100%), 7.44 (sensitivity 94.0%, specificity 100%), respectively. Seventy-two patients (27.3%) had LI >4 who were diagnosed as unilateral aldosterone excess. AR had 0.94 of AUC for prediction of LR >4. The optimal cut-off value of AR was 3.53 (sensitivity 86.1%, specificity 94.8%). Eighty-two patients (31.1%) had unilateral CR<1. The AUC of aldosterone concentration and AI for prediction of CR<1 was 0.96, 0.98, respectively, p=0.07. The optimal cut-off values of aldosterone concentration and AI were 13600 pg/ml, 42, respectively. The sensitivity and the specificity at the optimal cut-off points of aldosterone concentration and AI were 91.5%, 91.5% and 91.5%, 94.8%, respectively. Conclusions: The determination of successful AVS and unilateral result in AVS can be predicted using aldosterone alone. It was suggested that AR is useful for tentative interpretation in the cases where the results of aldosterone were previously reported and lateralizing diagnosis of the cases with autonomous cortisol production.

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A single-centre experience of the implementation of adrenal vein sampling procedure: the impact on the diagnostic work-up in primary aldosteronism

Kardiologia Polska ◽

10.5603/kp.a2016.0166 ◽

2016 ◽

pp. 28-34 ◽

Cited By ~ 1

Author(s):

Jacek Kądziela ◽

Aleksander Prejbisz ◽

Ilona Michałowska ◽

Sylwia Kołodziejczyk-Kruk ◽

Leo Schultze Kool ◽

...

Keyword(s):

Primary Aldosteronism ◽

Sampling Procedure ◽

Adrenal Vein ◽

Single Centre ◽

Adrenal Vein Sampling ◽

Single Centre Experience ◽

Diagnostic Work ◽

The Impact ◽

Work Up ◽

Diagnostic Work Up

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633 THE DIFFERENCES OF CRITERIA FOR LATERALIZATION OF ALDOSTERONE EXCESS BETWEEN BASELINE AND ACTH STIMULATION IN THE ADRENAL VEIN SAMPLING OF PATIENTS WITH PRIMARY ALDOSTERONISM

Journal of Hypertension ◽

10.1097/01.hjh.0000420653.89321.93 ◽

2012 ◽

Vol 30 ◽

pp. e185

Author(s):

M. Kometani ◽

T. Yoneda ◽

R. Okuda ◽

T. Sawamura ◽

M. Demura ◽

...

Keyword(s):

Primary Aldosteronism ◽

Adrenal Vein ◽

Acth Stimulation ◽

Adrenal Vein Sampling

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Adrenal vein sampling: technique and protocol, a systematic review

CVIR Endovascular ◽

10.1186/s42155-021-00220-y ◽

2021 ◽

Vol 4 (1) ◽

Author(s):

Keith B. Quencer

Keyword(s):

Primary Aldosteronism ◽

Reliable Method ◽

Sampling Technique ◽

Secondary Hypertension ◽

Adrenal Vein ◽

Adrenal Vein Sampling ◽

Blood Pressure Elevation ◽

Aldosterone Production ◽

Procedural Success ◽

Work Up

AbstractPrimary aldosteronism is the leading cause of secondary hypertension worldwide. Its deleterious effects outstrip those due to blood pressure elevation alone. An essential part of the work-up of a patient with primary aldosteronism is determining if aldosterone production is unilateral or bilateral. With the former, surgery offers a potential cure and better overall outcomes. Adrenal vein sampling is considered the most reliable method to determine whether production is unilateral or bilateral. Sampling may be non-diagnostic when the vein cannot be properly cannulated. But with proper knowledge and experience as well as the utilization of certain techniques, procedure success can be high. Multiple protocols exist; their rationale and drawbacks are reviewed here. This article will give the reader an overview of techniques for improving procedural success as well as background, rationale and evidence to guide one in choosing the appropriate procedural and interpretation protocol.

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OR34-01 11C Metomidate PET-CT Identifies More Unilateral Primary Aldosteronism Than Adrenal Vein Sampling

Journal of the Endocrine Society ◽

10.1210/jendso/bvaa046.581 ◽

2020 ◽

Vol 4 (Supplement_1) ◽

Author(s):

Troy Puar ◽

Colin Tan ◽

Aaron Tong ◽

Meifen Zhang ◽

ChinMeng Khoo ◽

...

Keyword(s):

Primary Aldosteronism ◽

Prospective Trial ◽

Adrenal Vein ◽

Secondary Outcome ◽

Acth Stimulation ◽

Adrenal Vein Sampling ◽

Non Invasive ◽

Post Surgery ◽

Pet Ct ◽

Biochemical Cure

Abstract Introduction. Adrenal vein sampling (AVS) is the current reference test to identify unilateral, surgically-curable primary aldosteronism (PA). However, AVS is invasive and technically difficult. Even in AVS-proven unilateral PA, up to 6% of patients with fail to have biochemical cure after surgery using the PASO criteria. 11C-Metomidate PET-CT offers a non-invasive alternative. We compared the accuracy of both PET-CT and AVS using post-surgery cure (PASO criteria) as the reference. Methods. This multi-centre prospective trial recruited 25 patients with confirmed PA, and all underwent CT, AVS, and PET-CT tests. Sequential AVS under ACTH-stimulation was done by an experienced interventionalist, and cortisol gradient of >5 was taken to be successful cannulation. Lateralization ratio >4 was consistent with unilateral PA. All results were reviewed at a multidisciplinary meeting to decide on the diagnosis (unilateral or bilateral PA) and management (secondary outcome). Primary outcome was biochemical cure using PASO criteria at 6 months post-surgery (ClinicalTrials.gov: NCTxxxxxxxx). Results. Recruitment for the study has been complete with 25 patients, 49.2 ± 9.5 yr, 14 females (56.0%). All 25 patients had successful AVS. 22 of 25 patients (88.0%) had unilateral PA, and 3 patients (12.0%) had bilateral PA. PET-CT identified unilateral PA in 18 of 22 patients (sensitivity 81.8%), while AVS identified unilateral PA in 15 of 22 patients (sensitivity 68.2%). In one patient, repeat AVS done simultaneously without ACTH-stimulation aided to identify unilateral PA, when initial AVS failed to do so. Other cases where AVS failed to identify unilateral PA were due to venous anomalies, and limitation of the lateralization cut-off of 4. 18 of 22 patients have undergone surgery, with 3 patients awaiting surgery, and 1 opting for medical treatment. Post-surgery, all patients had complete normalization of aldosterone-renin ratio, and hypokalemia (if present). 2 patients had bilateral PA on both PET-CT and AVS. 1 patient had discordant AVS and PET-CT results, with AVS lateralizing to right, and PET-CT to left. This patient was classified as bilateral PA and treated medically. Conclusion. This is the first study to demonstrate that 11C-Metomidate PET-CT may identify cases of unilateral PA not detected with AVS, using the stringent PASO criteria for post-operative biochemical cure.

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