Bilateral Aldosterone Suppression in Patients With Right Unilateral Primary Aldosteronism and Review of the Literature

Abstract

Introduction Adrenal vein sampling (AVS) identifies unilateral primary aldosteronism but may occasionally show paradoxically low aldosterone–cortisol ratios bilaterally. Postulated reasons include venous anomalies, fluctuating aldosterone secretion, or superselective cannulation. We report our findings in patients who underwent repeat AVS and reviewed the current literature. Methods We performed a retrospective observational study of patients undergoing AVS in an experienced high-volume tertiary center over a 5-year period. Results From 2015 to 2019, 61 patients underwent sequential cosyntropin-stimulated AVS and all had bilateral successful cannulation (100%). Four of 61 (6.6%) patients had bilaterally low aldosterone–cortisol ratios. Three patients underwent repeat AVS, with all 3 cases demonstrating right-sided lateralization and cure of disease postadrenalectomy. Right-sided disease was also more common in other reports. This may be due to inadvertent superselective cannulation of the short right adrenal vein, resulting in sampling of the adjacent normal gland. Cortisol results cannot detect this problem. In 1 patient, computed tomography venography excluded any accessory right adrenal veins. In another patient, repeat bilateral simultaneous unstimulated AVS was done, and measurements of metanephrines aided in accurately identifying right-sided lateralization. Conclusion In addition to technical difficulties in cannulating the right adrenal vein, we also have to avoid performing superselective cannulation inadvertently. In cases of inconclusive AVS, repeat sampling may identify patients with potentially curable unilateral primary aldosteronism. The role of corticotropin stimulation and metanephrines measurements during repeat AVS requires further study.

11C-Metomidate PET-CT versus adrenal vein sampling to subtype primary aldosteronism: a prospective clinical trial

“…Amongst the four PET-only lateralization, two patients had AVS lateralization ratios of 2.8 and 3.1, while the other two patients had initial successful but non-lateralizing AVS, and repeat AVS subsequently showed lateralization concordant with PET (repeat AVS done without cosyntropin in one patient, and with cosyntropin in the other). One patient did not fulfil lateralization with either PET or initial AVS (lateralization ratio 3.5), but repeat AVS without cosyntropin showed lateralization [17].…”

Improved adrenal vein sampling from a dedicated programme: experience of a low-volume single centre in Singapore

“…These three cases have been reported separately. (25) In total, 76 patients had a successful AVS procedure. CT and AVS led to concordant findings in only 49 (64.5%) of 76 patients (Fig.…”

Adrenal Vein Sampling With Gadolinium Contrast Medium in a Patient With Florid Primary Aldosteronism and Iodine Allergy

“…Unilateral PA is sometimes difficult to diagnose because of adrenal vein anomalies, which result in a bilateral adrenal suppression pattern on AVS that may be related to blood sampling from nontumorous lesions of both adrenal glands [ 15 ]. In patients with suspected unilateral PA, the current recommendations are to collect blood multiple times [ 15-17 ] and/or before and after ACTH loading [ 15 ] when performing AVS. In patients with suspected left unilateral PA, Ogata et al [ 18 ] recommend that blood be drawn from the left adrenal vein at 2 locations: the central vein and the common duct.…”