Comparison of Sequential versus Simultaneous Methods of Adrenal Venous Sampling

https://doi.org/10.1097/01.RVI.0000134495.26900.6AGet rights and content

PURPOSE

To compare two methods of adrenal venous sampling (AVS) in preoperative localization of adrenal lesions in primary hyperaldosteronism.

MATERIALS AND METHODS

Twenty-one patients (13 men, eight women) underwent selective adrenal venous sampling between July 2001 and May 2003. One of the 21 patients underwent repeat AVS, for a total of 22 procedures. In half the procedures (n = 11), simultaneous bilateral adrenal venous catheterization and sampling was performed before and after intraprocedural adrenocorticotropic hormone (ACTH) administration; in the remaining half (n = 11), sequential catheterization of the left and right adrenal veins was performed during continuous ACTH infusion 1 hour before and throughout AVS. Chart review provided procedural data, including sampling intervals and aldosterone/ cortisol ratios. Patient records provided clinical data, including blood pressure, serum aldosterone levels, and computed tomography and magnetic resonance imaging findings. Surgical pathology reports confirmed unilateral disease but were not applicable to bilateral disease.

RESULTS

Selective AVS was completed successfully in 21 of 22 procedures (95%); the unsuccessful sampling was repeated successfully. Disease lateralized in 13 of 22 cases. Simultaneous bilateral AVS localized unilateral disease in seven of eight cases (88%) and was nondiagnostic in one case (13%), with cases confirmed by surgical pathology reports. Sequential bilateral AVS localized unilateral disease in four of four cases (100%) confirmed by surgical pathology reports, with one lost to follow-up. Bilateral disease was diagnosed in six of 22 cases: two of 11 by simultaneous AVS and four of 11 by sequential AVS. Three of 22 cases demonstrated borderline hormone levels that failed to meet the diagnostic threshold for recommended adrenalectomy. Mean elapsed time between acquisition of right and left samples did not differ between simultaneous and sequential AVS (P = .09). Baseline (prestimulation) sampling did not contribute unique diagnostic information in any case and provided contradictory or confounding information in three of 11 simultaneous AVS procedures (27%).

CONCLUSIONS

Sequential bilateral catheterization does not compromise the reliability of time-sensitive AVS. Both simultaneous and sequential AVS are adequate studies; however, obtaining baseline prestimulation samples during simultaneous AVS is unnecessary and increases the cost of the procedure.

Section snippets

MATERIALS AND METHODS

The institutional review board granted exemption for retrospective study of patients referred to the division of interventional radiology at our institution for adrenal venous sampling between July 2001 and May 2003. Two interventional radiologists (C.C., S.O.T.), both with more than 10 years of experience with AVS, each performed 11 AVS procedures, for a total of 22 procedures. Twenty-one patients, 13 men and eight women with a mean age of 50 years (range, 40–68 years), were included in the

RESULTS

Clinical data are shown in Table 1 (online only, see www.jvir.org). Preprocedural adrenal CT/MR imaging revealed unilateral lesions in 19 of 21 patients (90%). AVS results were concordant in 12 of 19 cases (63%) and discordant in seven of 19 cases (37%) with unilateral findings on CT/MR imaging. AVS demonstrated bilateral disease in five of seven discordant cases (71%), whereas the remaining two (29%) had adrenal disease that lateralized to the side opposite that predicted by CT/MR imaging.

DISCUSSION

Primary hyperaldosteronism, first described by Conn (15), contributes to hypertension in an estimated 1%–13% of patients in clinical practice (1, 2). Although hyperaldosteronism afflicts a minority of patients with hypertension, unlike other causes of essential or secondary hypertension, the condition is potentially curable by surgical excision of the abnormal adrenal gland. A spectrum of structural and functional abnormalities produce hyperaldosteronism (4, 8, 13). The most common morphologies

CONCLUSION

This study presents sequential bilateral catheterization as an accurate and economical alternative to the twocatheter technique of AVS for preoperative localization and judicious clinical management of primary hyperaldosteronism. Our results do not support the use of prestimulation samples because they do not affect management and may in fact confound the diagnosis.

Acknowledgments

The authors thank Medcomp for a grant that supported this project, Lori Deslandes for her secretarial support, and Myron Weinberger, MD, for his insight into adrenal venous sampling and hyperaldosteronism.

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    Supported in part by a grant from MedComp, Harleysvile, PA.

    From the 2004 SIR Annual Meeting.

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