Subtype prediction of primary aldosteronism by combining aldosterone concentrations in the left adrenal vein and inferior vena cava: a multicenter collaborative study on adrenal venous sampling

Adrenal venous sampling (AVS) is the gold standard test to differentiate the unilateral from the bilateral form in patients with primary aldosteronism (PA) although it may be a difficult procedure, especially the successful cannulation of the right adrenal vein. In this report, we describe a 49-year-old female patient diagnosed with PA, after investigating resistant hypertension and refractory hypokalemia. Abdominal computed tomography scan revealed a 2.5 cm adenoma on the right adrenal vein. AVS was performed under cosyntropin infusion. Aldosterone and cortisol concentrations were obtained from the right and left adrenal veins and inferior vena cava (IVC). Cortisol on each adrenal vein divided by cortisol on IVC confirmed successful cannulation of the left side only, which makes it impossible to calculate the lateralization index (LI). From the data on the left adrenal vein and IVC, the aldosterone-to-cortisol ratio divided by the IVC aldosterone-to-cortisol ratio was less than 1.0, suggesting that the left adrenal vein was suppressed with the excess aldosterone originating from the contralateral side (contralateral suppression index (CSI)). Right adrenalectomy was performed; postoperative hypoaldosteronism was confirmed. This report highlights the importance of CSI obtained in AVS when technical difficulties occur making it impossible to obtain LI, which is most commonly used to decide between surgical and clinical management of PA.

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Adrenal venous sampling in a patient with left inferior vena cava

Clinical Case Reports ◽

10.1002/ccr3.875 ◽

2017 ◽

Vol 5 (4) ◽

pp. 482-485

Author(s):

Yuichi Fujii ◽

Tomohiro Ueda ◽

Yuko Uchimura ◽

Hiroki Teragawa

Keyword(s):

Inferior Vena Cava ◽

Inferior Vena ◽

Vena Cava ◽

Adrenal Venous Sampling ◽

Venous Sampling

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Low-grade Cortisol Cosecretion Has Limited Impact on ACTH-stimulated AVS Parameters in Primary Aldosteronism

The Journal of Clinical Endocrinology & Metabolism ◽

10.1210/clinem/dgaa519 ◽

2020 ◽

Vol 105 (10) ◽

pp. e3776-e3784 ◽

Cited By ~ 1

Author(s):

Samuel Matthew O’Toole ◽

Wing-Chiu Candy Sze ◽

Teng-Teng Chung ◽

Scott Alexander Akker ◽

Maralyn Rose Druce ◽

...

Keyword(s):

Primary Aldosteronism ◽

Vena Cava ◽

Adrenal Vein ◽

Adrenal Venous Sampling ◽

Low Grade ◽

Venous Sampling ◽

Retrospective Case ◽

Tertiary Referral Center ◽

Contralateral Suppression ◽

Control Study

Abstract Context In primary aldosteronism, cosecretion of cortisol may alter cortisol-derived adrenal venous sampling indices. Objective To identify whether cortisol cosecretion in primary aldosteronism alters adrenal venous sampling parameters and interpretation. Design Retrospective case–control study Setting A tertiary referral center Patients 144 adult patients with primary aldosteronism who had undergone both adrenocorticotropic hormone-stimulated adrenal venous sampling and dexamethasone suppression testing between 2004 and 2018. Main Outcome Measures Adrenal venous sampling indices including adrenal vein aldosterone/cortisol ratios and the selectivity, lateralization, and contralateral suppression indices. Results 21 (14.6%) patients had evidence of cortisol cosecretion (defined as a failure to suppress cortisol to ≤50 nmol/L post dexamethasone). Patients with evidence of cortisol cosecretion had a higher inferior vena cava cortisol concentration (P = .01) than those without. No difference was observed between the groups in terms of selectivity index, lateralization index, lateralization of aldosterone excess, or adrenal vein cannulation rate. Conclusions Cortisol cosecretion alters some parameters in adrenocorticotrophic hormone-stimulated adrenal venous sampling but does not result in alterations in patient management.

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Difficulty factors of adrenal venous sampling based on patient characteristics and imaging findings

Acta Radiologica ◽

10.1177/02841851211034046 ◽

2021 ◽

pp. 028418512110340

Author(s):

Soma Kumasaka ◽

Hiroyuki Tokue ◽

Yoshito Tsushima

Keyword(s):

Inferior Vena ◽

Vena Cava ◽

Patient Characteristics ◽

Sampling Procedure ◽

Adrenal Vein ◽

Adrenal Venous Sampling ◽

Transverse Diameter ◽

Venous Sampling ◽

Vertebral Level ◽

The Right

Background Primary aldosteronism is one of the most common causes of secondary hypertension. Unilateral primary aldosteronism can be treated with adrenalectomy; therefore, determining laterality is essential, for which adrenal venous sampling is considered the gold standard. However, as catheter insertion and sampling at an appropriate venous point is occasionally difficult, it is a time-consuming procedure. Purpose To evaluate the patient characteristics and imaging findings that influence the adrenal venous sampling procedure. Material and Methods A total of 69 patients who underwent adrenal venous sampling between January 2013 and December 2017 were retrospectively analyzed. The procedure was considered difficult if the duration was > 142 min (mean ± standard deviation [SD] of procedure time in this study) and/or proper sampling failed. Anatomical factors such as belly diameter, presence of adrenal nodules, diameter of the right adrenal vein and inferior vena cava, ratio of the diameters of the right adrenal vein to diameter of the inferior vena cava, vertical direction of the right adrenal vein, and vertebral level of the right adrenal vein were evaluated as predictive factors on computed tomography. Results Fifteen patients (21.7%) were considered difficult cases. The factors associated with difficulty were the long transverse diameter of the belly ( P = 0.004) and high vertebral level of the right adrenal vein ( P = 0.032). No statistical differences were observed in any other factors. Conclusion The long transverse diameter of the belly and high vertebral level of the right adrenal vein may prevent completion of the adrenal venous sampling procedure.

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

Endocrine Practice ◽

10.1016/j.eprac.2021.09.009 ◽

2021 ◽

Author(s):

Sophie Dream ◽

Sandra Park ◽

Tina W. Yen ◽

William Rilling ◽

Lisa Rein ◽

...

Keyword(s):

Primary Aldosteronism ◽

Adrenal Vein ◽

Adrenal Venous Sampling ◽

Venous Sampling ◽

Vein Cannulation

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Comparison of Cortisol, Androstenedione and Metanephrines to Assess Selectivity and Lateralization of Adrenal Vein Sampling in Primary Aldosteronism

Journal of Clinical Medicine ◽

10.3390/jcm10204755 ◽

2021 ◽

Vol 10 (20) ◽

pp. 4755

Author(s):

Giulio Ceolotto ◽

Giorgia Antonelli ◽

Brasilina Caroccia ◽

Michele Battistel ◽

Giulio Barbiero ◽

...

Keyword(s):

Decision Making ◽

Primary Aldosteronism ◽

Inferior Vena ◽

Clinical Decision Making ◽

Vena Cava ◽

Clinical Decision ◽

Selectivity Index ◽

Adrenal Vein ◽

Adrenal Vein Sampling ◽

The Right

Success of adrenal vein sampling (AVS) is verified by the selectivity index (SI), i.e., by a step-up of cortisol levels between the adrenal vein and the infrarenal inferior vena cava samples, beyond a given cut-off. We tested the hypothesis that androstenedione, metanephrine, and normetanephrine, which have higher gradients than cortisol, could increase the rate of AVS studies judged to be bilaterally successful and usable for the clinical decision making. We prospectively compared within-patient, head-to-head, the selectivity index of androstenedione (SIA), metanephrine (SIM), and normetanephrine (SINM), and cortisol (SIC) in consecutive hypertensive patients with primary aldosteronism submitted to AVS. Main outcome measures were rate of bilateral success, SI values, and identification of unilateral PA. We recruited 136 patients (55 + 10 years, 35% women). Compared to the SIC, the SIA values were 3.5-fold higher bilaterally, and the SIM values were 7-fold and 4.4-fold higher on the right and the left side, respectively. With the SIA and the SIM the rate of bilaterally successful AVS increased by 14% and 15%, respectively without impairing the identification of unilateral PA. We concluded that androstenedione and metanephrine outperformed cortisol for ascertaining AVS success, thus increasing the AVS studies useable for the clinical decision making.

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Rare case of left adrenal cortical carcinoma with level 3 inferior vena cava thrombus via adrenal vein

African Journal of Urology ◽

10.1016/j.afju.2016.12.001 ◽

2017 ◽

Vol 23 (3) ◽

pp. 201-203

Author(s):

K. Jain ◽

R.K. Gopala Krishna ◽

S. Basu

Keyword(s):

Inferior Vena Cava ◽

Rare Case ◽

Inferior Vena ◽

Vena Cava ◽

Adrenal Cortical Carcinoma ◽

Adrenal Vein ◽

Inferior Vena Cava Thrombus ◽

Level 3

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Variability of Aldosterone Measurements During Adrenal Venous Sampling for Primary Aldosteronism

American Journal of Hypertension ◽

10.1093/ajh/hpaa151 ◽

2020 ◽

Author(s):

Nicholas Yozamp ◽

Gregory L Hundemer ◽

Marwan Moussa ◽

Johnathan Underhill ◽

Tali Fudim ◽

...

Keyword(s):

Primary Aldosteronism ◽

Vena Cava ◽

Adrenal Venous Sampling ◽

Venous Sampling ◽

Tertiary Referral Center ◽

Percentage Difference ◽

Left And Right ◽

The Mean ◽

Lateralization Index ◽

Cortisol Ratio

Abstract BACKGROUND Variability of aldosterone concentrations has been described in patients with primary aldosteronism. METHODS We performed a retrospective cohort study of 340 patients with primary aldosteronism who underwent adrenal venous sampling (AVS) at a tertiary referral center, 116 of whom also had a peripheral venous aldosterone measured hours before the procedure. AVS was performed by the same interventional radiologist using bilateral, simultaneous sampling, under unstimulated and then stimulated conditions, and each sample was obtained in triplicate. Main outcome measures were: (i) change in day of AVS venous aldosterone from pre-AVS to intra-AVS and (ii) variability of triplicate adrenal venous aldosterone concentrations during AVS. RESULTS Within an average duration of 131 minutes, 81% of patients had a decline in circulating aldosterone concentrations (relative decrease of 51% and median decrease of 7.0 ng/dl). More than a quarter (26%) of all patients had an inferior vena cava aldosterone of ≤5 ng/dl at AVS initiation. The mean coefficient of variation of triplicate adrenal aldosterone concentrations was 30% and 39%, in the left and right veins, respectively (corresponding to a percentage difference of 57% and 73%), resulting in lateralization discordance in up to 17% of patients if the lateralization index were calculated using only one unstimulated aldosterone-to-cortisol ratio rather than the average of triplicate measures. CONCLUSIONS Circulating aldosterone levels can reach nadirs conventionally considered incompatible with the primary aldosteronism diagnosis, and adrenal venous aldosterone concentrations exhibit acute variability that can confound AVS interpretation. A single venous aldosterone measurement lacks precision and reproducibility in primary aldosteronism.

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