An Alternative Method for Adrenal Venous Sampling in Cases in Which Right Adrenal Vein Sampling is Difficult

Abstract PurposeCatheterization of the right adrenal vein (rt.AdV) to obtain blood samples can often be difficult. The aim of the present study was to investigate whether blood sampling from the inferior vena cava (IVC) at its juncture with the rt.AdV can be an alternative to sampling of blood directly from the rt.AdV.Materials and MethodsThis study included 44 patients diagnosed with primary aldosteronism (PA) in whom AVS with adrenocorticotropic hormone (ACTH) was performed, resulting in a diagnosis of idiopathic hyperaldosteronism (IHA) (n=24), and patients diagnosed with unilateral aldosterone-producing adenoma (APA) (n=20; rt.APA=8, lt.APA=12). In addition to regular blood sampling, blood was also sampled from the IVC, as the substitute rt.AdV [S-rt.AdV]. Diagnostic performance with the conventional lateralized index (LI) and the modified LI using the S-rt.AdV was compared to examine the utility of the modified LI.ResultsThe modified LI of the rt.APA (0.4±0.4) was significantly lower than those of the IHA (1.4±0.7) (p<0.001) and the lt.APA (3.5±2.0) (p<0.001). The modified LI of the lt.APA was significantly higher than those of the IHA (p<0.001) and rt.APA (p<0.001). Sensitivity and specificity to diagnose rt.APA and lt.APA using the modified LI with threshold values of 0.7 and 2.2, respectively, they were 87% and 75%, respectively, and 94% and 94%, respectively.ConclusionThe modified LI has the potential to be an alternative method for rt.AdV sampling in cases in which rt.AdV sampling is difficult. Obtaining the modified LI is extremely simple, which might complement conventional AVS.

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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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Location of Aldosterone-Producing Adenomas by the Determination of Plasma Aldosterone in Adrenal Vein or Renal Vein Blood

Clinical Science ◽

10.1042/cs0490187 ◽

1975 ◽

Vol 49 (3) ◽

pp. 187-192 ◽

Cited By ~ 1

Author(s):

S. Fukuchi ◽

T. Takenouchi ◽

K. Nakajima ◽

H. Watanabe ◽

A. Sugita

Keyword(s):

Renal Vein ◽

Inferior Vena ◽

Adrenal Adenoma ◽

Left Renal Vein ◽

Vena Cava ◽

Adrenal Vein ◽

Aldosterone Producing Adenoma ◽

Percutaneous Catheterization ◽

The Right

1. Aldosterone-producing adenomas were located before operation in eighteen patients by comparison of aldosterone concentrations in blood obtained by percutaneous catheterization of the adrenal vein or renal vein. The concentration of aldosterone in the venous effluent from the adrenal glands containing adenomas was significantly greater than in the venous effluent from contralateral glands. 2. Catheterization of the adrenal vein is, however, technically difficult. The location of adrenal adenomas was also possible by analysis of blood from the renal vein. 3. If the concentrations of aldosterone in blood from the left renal vein were higher than those from the right, the existence of a left adrenal adenoma was suggested. A high value in plasma, obtained from the inferior vena cava above the entry of the right adrenal vein, showed a right adrenal adenoma. This procedure identified very small functional adenomas which could not be demonstrated radio-graphically, or seen or palpated at surgery. 4. It was concluded that differential aldosterone measurement after percutaneous bilateral adrenal vein or renal vein catheterization can be used as a definitive test for the location of an aldosterone-producing adenoma, where this is uncertain.

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Adrenal Vein Sampling to Distinguish Between Unilateral and Bilateral Primary Hyperaldosteronism: To ACTH Stimulate or Not?

Journal of Clinical Medicine ◽

10.3390/jcm9051447 ◽

2020 ◽

Vol 9 (5) ◽

pp. 1447

Author(s):

Tae-Yon Sung ◽

Wilson Mawutor Alobuia ◽

Monica Varun Tyagi ◽

Chandrayee Ghosh ◽

Electron Kebebew

Keyword(s):

Adrenocorticotropic Hormone ◽

Primary Hyperaldosteronism ◽

Adrenal Vein ◽

Acth Stimulation ◽

Adrenal Vein Sampling ◽

Successful Cannulation ◽

Unilateral Disease ◽

The Right ◽

Lateralization Index ◽

Prospective Database

The aim of this study is to determine the accuracy of adrenal vein sampling (AVS) with and without adrenocorticotropic hormone (ACTH) stimulation to distinguish between unilateral and bilateral primary hyperaldosteronism (PA). Retrospective analysis of a prospective database from a referral center between 1984 and 2009, 76 patients had simultaneous cannulation of bilateral adrenal veins and AVS with and without ACTH stimulation. All patients had adrenalectomies. The selectivity index (SI, cut-off value ≥2) was used for confirmation of successful cannulation of the adrenal vein. The lateralization index (LI, cut-off value >2 and >4) was used for distinguishing between unilateral and bilateral PA. The SI ratio was higher with ACTH stimulation compared to without for the right adrenal vein (p = 0.027). The LI > 2 ratio was higher with ACTH stimulation compared to without (p = 0.007). For the LI > 4 ratio, there was no difference between with and without ACTH stimulation (p = 0.239). However, for a LI > 4, 7 patients (9.2%) were not lateralized with ACTH stimulation, but they did lateralize without ACTH stimulation. AVS with ACTH stimulation is associated with a higher SI ratio compared to AVS without ACTH stimulation. However, when using LI > 4 for AVS, samples without ACTH stimulation should also be included to detect a subset of patients with unilateral disease that are not detected with ACTH stimulation.

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Effect of loading right atrial and ventricular receptors on stimulated AVP, ACTH, and renin secretion in awake dogs

AJP Regulatory Integrative and Comparative Physiology ◽

10.1152/ajpregu.1995.268.4.r1069 ◽

1995 ◽

Vol 268 (4) ◽

pp. R1069-R1077 ◽

Cited By ~ 2

Author(s):

L. J. Andersen ◽

J. L. Andersen ◽

T. N. Thrasher ◽

L. C. Keil ◽

D. J. Ramsay

Keyword(s):

Mean Arterial Pressure ◽

Left Atrial ◽

Adrenocorticotropic Hormone ◽

Inferior Vena ◽

Vena Cava ◽

Plasma Renin ◽

Atrial Pressure ◽

Right Atrial ◽

Right Heart ◽

The Right

The goal of this study was to test the hypothesis that increasing or decreasing the load on baroreceptors in the right heart influenced the secretion of arginine vasopressin (AVP), adrenocorticotropic hormone (ACTH), and renin during a state of sustained arterial hypotension. The hypothesis was tested in chronically instrumented conscious dogs prepared with inflatable cuffs around the pulmonary artery (PA) and the thoracic inferior vena cava (IVC). In one protocol (n = 5), mean arterial pressure was reduced 10 or 20% below control by constriction of the PA, a maneuver that caused a fall in left atrial pressure (LAP) and an increase in right atrial pressure (RAP). Plasma AVP, ACTH, atrial natriuretic peptide (ANP), and plasma renin activity (PRA) all increased (P < 0.05) in response to constriction of the PA. Reducing RAP to control by constriction of the IVC during maintained constriction of the PA had no effect on MAP, LAP, plasma AVP, ACTH, or PRA, but plasma ANP fell significantly. In a separate protocol (n = 4), constriction of the IVC was used to reduce MAP 10 or 20% below control, and this led to significant decreases in both LAP and RAP and increases in plasma AVP, ACTH, and PRA. RAP was then increased above control by constriction of the PA without altering either MAP or LAP. Raising RAP from a level that was 6.3 +/- 1.3 mmHg below control to 3.5 +/- 1.0 mmHg above control had no effect on plasma AVP, ACTH, or PRA.(ABSTRACT TRUNCATED AT 250 WORDS)

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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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Subtyping of primary aldosteronism by adrenal vein sampling: effect of acute D2 receptor dopaminergic blockade on adrenal vein cortisol and chromogranin A levels

Acta Endocrinologica ◽

10.1530/eje-11-0246 ◽

2011 ◽

Vol 165 (1) ◽

pp. 85-90 ◽

Cited By ~ 4

Author(s):

Teresa M Seccia ◽

Diego Miotto ◽

Renzo De Toni ◽

Valentina Gallina ◽

Matteo Vincenzi ◽

...

Keyword(s):

Primary Aldosteronism ◽

Chromogranin A ◽

Inferior Vena ◽

D2 Receptor ◽

Vena Cava ◽

Adrenal Vein ◽

Aldosterone Secretion ◽

Adrenal Vein Sampling ◽

Plasma Cortisol Concentration ◽

Design And Methods

BackgroundAdrenal vein sampling (AVS) is the gold standard for identifying the surgically curable forms of primary aldosteronism. Dopamine modulates adrenocortical steroidogenesis and tonically inhibits aldosterone secretion via D2 receptor. However, whether it could also affect the release of cortisol and chromogranin A (ChA), which can be used to assess the selectivity of AVS, is unknown.ObjectiveTo investigate whether metoclopramide increased the release of cortisol and ChA and could thereby improve assessment of the selectivity at AVS.Design and methodsWe investigated the effect of acute D2 antagonism with metoclopramide on cortisol and ChA release from the adrenal gland by comparing the adrenal vein and infrarenal inferior vena cava (IVC) hormone levels at baseline and after metoclopramide administration in 34 consecutive patients undergoing AVS.ResultsMetoclopramide increased plasma aldosterone in the IVC (P<0.00001) and in the adrenal vein blood (P<0.002) but failed to increase plasma cortisol concentration or ChA levels. Therefore, it did not increase the selectivity index based on the measurement of either hormone.ConclusionsThis study shows that the release of cortisol and ChA is not subjected to tonic D2 dopaminergic inhibition. Therefore, these findings lend no evidence for the usefulness of acute metoclopramide administration for enhancing the assessment of the selectivity of blood sampling during AVS with the use of either cortisol or ChA assay.

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Emphysematous pyelonephritis with air bubble in the inferior vena cava

African Journal of Urology ◽

10.1186/s12301-020-00081-2 ◽

2020 ◽

Vol 26 (1) ◽

Author(s):

Tiffany A. Perkins ◽

Alberic Rogman ◽

Murali K. Ankem

Keyword(s):

Septic Shock ◽

Inferior Vena Cava ◽

Inferior Vena ◽

Vena Cava ◽

Rare Presentation ◽

Emphysematous Pyelonephritis ◽

Case Presentation ◽

Air Bubble ◽

First Case ◽

The Right

Abstract Background Emphysematous pyelonephritis (EPN) with gas in the inferior vena cava (IVC) is a rare presentation and to our knowledge, this is the first case report in the urologic literature. Case presentation A 35-Year-old obese diabetic Hispanic female presented to the emergency room with a clinical picture of septic shock. Prompt computerized tomography scan revealed EPN with gas throughout the right renal parenchyma and extending to the right renal vein, IVC, and pulmonary artery. She died before surgical intervention Conclusion This case demonstrates that patients presenting with severe EPN have a high mortality risk and providers should acknowledge that septic shock, endogenous air emboli, or a combination of both could result in cardiovascular collapse and sudden death.

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Recanalization and Reconstruction of a Chronically Occluded Inferior Vena Cava Through an Existing Transjugular Intrahepatic Portosystemic Shunt in the Setting of Budd-Chiari Syndrome

Vascular and Endovascular Surgery ◽

10.1177/15385744211002026 ◽

2021 ◽

pp. 153857442110020

Author(s):

Reza Talaie ◽

Hamed Jalaeian ◽

Nassir Rostambeigi ◽

Anthony Spano ◽

Jafar Golzarian

Keyword(s):

Inferior Vena Cava ◽

Transjugular Intrahepatic Portosystemic Shunt ◽

Inferior Vena ◽

Vena Cava ◽

Portosystemic Shunt ◽

Hepatic Veins ◽

Budd Chiari Syndrome ◽

Chiari Syndrome ◽

Intrahepatic Portosystemic Shunt ◽

The Right

Budd-Chiari syndrome (BCS) results from the occlusion or flow reduction in the hepatic veins or inferior vena cava and can be treated with transjugular intrahepatic portosystemic shunt when hepatic vein recanalization fails.1-3 Hypercoagulable patients with primary BCS are predisposed to development of new areas of thrombosis within the TIPS shunt or IVC. This case details a patient with BCS, pre-existing TIPS extending to the right atrium, and chronic retrohepatic IVC thrombosis who underwent sharp recanalization of the IVC with stenting into the TIPS stent bridging the patient until his subsequent hepatic transplantation.

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Stent Graft Placement in the Top-Down Direction for Treating Traumatic Intra-Abdominal Suprahepatic Inferior Vena Cava Rupture: A Case Report

Journal of Endovascular Therapy ◽

10.1177/15266028211025024 ◽

2021 ◽

pp. 152660282110250

Author(s):

Yun Chul Park ◽

Hyoung Ook Kim ◽

Nam Yeol Yim ◽

Byung Chan Lee ◽

Chan Park ◽

...

Keyword(s):

Case Report ◽

Inferior Vena Cava ◽

Stent Graft ◽

Inferior Vena ◽

Vena Cava ◽

Endovascular Management ◽

Top Down ◽

Life Threatening ◽

The Right ◽

Suprahepatic Inferior Vena Cava

Purpose The treatment of suprahepatic inferior vena cava (IVC) ruptures results in high mortality rates due to difficulty in performing the surgical procedure. Here, we present a case of successful endovascular management of a life-threatening suprahepatic IVC rupture with top-down placement of a stent graft. Case Report A 33-year-old woman was involved in a traffic accident and presented to our emergency department due to unstable hemodynamics after blunt abdominal wall trauma. Computed tomography (CT) revealed massive extravasation of contrast agent from the suprahepatic IVC, which suggested traumatic suprahepatic IVC rupture. To seal the IVC, to salvage major hepatic veins, and to prevent migration of the stent graft into the right side of the heart after placement, an aortic cuff with a proximal hook was introduced in a top-down direction via the right internal jugular vein. After closure of the injured IVC, the patient’s hemodynamics improved, and additional laparotomy was performed. After 3 months of trauma care, the patient recovered and was discharged. Follow-up CT after 58 months showed a patent stent graft within the IVC. Conclusion Endovascular management with top-down placement of a stent graft is a viable option for emergent damage control in patients with life-threatening hemorrhage from IVC rupture.

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