Consequences of Adrenal Venous Sampling in Primary Hyperaldosteronism and Predictors of Unilateral Adrenal Disease

Mathur, Aarti; Kemp, Clinton D.; Dutta, Utpal Kumar; Baid, Smita; Ayala, Alejandro; Chang, Richard; Steinberg, Seth M.; Papademetriou, Vasilios; Lange, Eileen; Libutti, Steven K.; Pingpank, James F.; Alexander, H. Richard; Phan, Giao Q.; Hughes, Marybeth S.; Linehan, W. Marston; Pinto, Peter A.; Stratakis, Constantine A.; Kebebew, Electron

doi:10.1016/j.jamcollsurg.2010.05.006

Cited by 70 publications

(59 citation statements)

References 21 publications

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“…This is similar to the cutoff based on the Endocrinonolgy Society guidelines (9,(22)(23)(24). The absolute aldosterone concentration was not as useful as the cortisol-corrected values, which correct for the dilutional effects of the inferior phrenic vein flow into the left adrenal vein and for IVC blood when sampling at or near the orifice of the right adrenal vein (12)(13)(14)25). In addition, the contralateral-gland-to-IVC ratio was accurate, suggesting that not all patients with unilateral disease have complete contralateral aldosterone suppression.…”

Section: Discussionmentioning

confidence: 62%

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Adrenal venous sampling for stratifying patients for surgery of adrenal nodules detected using dynamic contrast enhanced CT

Kim

Lee³

et al. 2013

Diagn Interv Radiol

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ORIGINAL ARTICLE PURPOSE We aimed to assess the value of adrenal venous sampling (AVS) for diagnosing primary aldosteronism (PA) subtypes in patients with a unilateral nodule detected on adrenal computed tomography (CT) and scheduled for adrenalectomy. MATERIALS AND METHODSThis retrospective study included 80 consecutive patients with PA undergoing CT and AVS. Different lateralization indices were assessed, and a cutoff established using receiver operating characteristic curve analysis. The value of CT alone versus CT with AVS for differentiating PA subtypes was compared. The adrenalectomy outcome was assessed, and predictors of cure were determined using univariate analysis. RESULTS AVS was successful in 68 patients. A cortisol-corrected aldosterone affected-to-unaffected ratio cutoff of 2.0 and affected-to-inferior vena cava ratio cutoff of 1.4 were the best lateralization indices, with accuracies of 82.5% and 80.4%, respectively. CT and AVS diagnosed 38 patients with aldosterone-producing adenomas, five patients with unilateral adrenal hyperplasia, and 25 patients with bilateral adrenal hyperplasia. Of the 52 patients with a nodule detected on CT, subsequent AVS diagnosed bilateral adrenal hyperplasia in 14 patients (27%). Compared to the results of combining CT with AVS, the accuracy of CT alone for diagnosing aldosterone-producing adenomas was 71.1% (P < 0.001). The cure rate for hypertension after adrenalectomy was 39.2%, with improvement in 53.5% of patients. On univariate analysis, predictors of persistent hypertension were male gender and preoperative systolic blood pressure. CONCLUSIONTo avoid inappropriate surgery, AVS is necessary for diagnosing unilateral nodules with aldosterone hypersecretion detected by CT. P rimary aldosteronism (PA) is the most common form of secondary hypertension, with a prevalence of 5%-11% (1-3). PA is due primarily to the hypersecretion of aldosterone by an aldosterone-producing adenoma (APA) or unilateral (primary) adrenal hyperplasia (UAH), which constitute 30%-40% of cases; the remainder are presumed to be secondary to idiopathic bilateral adrenal hyperplasia (BAH) (1, 4, 5). APA and UAH are two forms of unilateral aldosterone hypersecretion, and both are curable with adrenalectomy. BAH induces bilateral aldosterone hypersecretion, and anti-aldosterone drugs are used in its medical management (5-7).The plasma aldosterone-to-renin ratio is used to screen for PA in patients at high risk for PA (8). Recent guidelines recommend using computed tomography (CT) of the adrenal gland to categorize the subtype after confirming PA. However, CT cannot reliably visualize a microadenoma or distinguish between an incidentaloma or BAH and APA. It has been suggested that adrenal venous sampling (AVS) be performed to determine the subtype of PA and to differentiate between unilateral and bilateral production of aldosterone preoperatively (9). AVS to measure the adrenal vein aldosterone and cortisol is the gold standard for lateralizing aldosterone secretion (10). Lateralization is define...

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Section: Discussionmentioning

confidence: 62%

“…Lateralization is defined using several ratios. In patients with APA or UAH, a unilateral adrenalectomy results in a complete cure or improved hypertension and potassium normalization in approximately 30% of patients, with reported rates up to 86% (11)(12)(13)(14)(15).…”

Section: Resultsmentioning

confidence: 99%

Adrenal venous sampling for stratifying patients for surgery of adrenal nodules detected using dynamic contrast enhanced CT

Kim

Lee³

et al. 2013

Diagn Interv Radiol

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“…The diagnosis of unilateral aldosterone secretion was made, if the aldosterone to cortisol ratio (A/C-ratio) from one adrenal vein was R4.0 times the A/C-ratio of the contralateral side (14).…”

Section: Selectivity and Lateralization Criteriamentioning

confidence: 99%

Adrenal vein sampling using rapid cortisol assays in primary aldosteronism is useful in centers with low success rates

Betz

Degenhart

Fischer

et al. 2011

European Journal of Endocrinology

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Objective: Adrenal vein sampling (AVS) is considered the gold standard in the differential diagnosis of primary aldosteronism (PA), but success rates vary between centers. We hypothesized that rapid (intraprocedure) cortisol measurement can improve performance in a center with initially low AVS success rate. Design: We analyzed 46 patients with confirmed PA studied between 2008 and 2010. Forty-seven PA patients studied between 2004 and 2008 identified by retrospective chart review served as controls. All patients were treated at a single tertiary care university hospital. Methods: Starting in 2008, rapid cortisol assays (RCA) were performed in all patients during the AVS procedure. A cortisol gradient of R2.0 between adrenal vein and a femoral vein sample was used as success criterion. Up to two repeat samples were drawn if adrenal vein cortisol was below this threshold. Results: During the control period 26 of 47 AVS were successful (55%). After introduction of RCA, 39 out of 46 AVS (85%) were successful (PZ0.003). In 21 of the 46 cases (46%) a resampling was necessary. The increase in overall success was due to an increase in successful right AVS (85 vs 62% before introduction of RCA; PZ0.02) and a training effect (PZ0.024 for trend). Conclusion: RCA during AVS are useful in centers with an initially low AVS success rate.

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“…All patients had arterial hypertension, elevated aldosterone-to-renin ratio and abnormal saline suppression (2 L of normal saline infused over four hours). For the diagnosis of unilateral aldosterone secretion the aldosterone-to-cortisol ratio from one adrenal vein had to be ≥4 times that of the contralateral side (14). Interpretation of laboratory results confirmed 45 cases of unilateral excessive aldosterone secretion (27 cases left, 18 cases right) and 24 cases of bilateral disease.…”

Section: Patientsmentioning

confidence: 96%

CT mapping of the vertebral level of right adrenal vein

Degenhart¹,

Strube²,

Betz³

et al. 2015

Diagn Interv Radiol

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ORIGINAL ARTICLE PURPOSEWe aimed to evaluate the accuracy of multidetector computed tomography (MDCT) venous mapping for the localization of the right adrenal veins (RAV) in patients suffering from primary aldosteronism. METHODSMDCT scans of 75 patients with primary aldosteronism between March 2008 and November 2011 were evaluated by two readers (a junior [R1] and a senior [R2] radiologist) according to the following criteria: quality of RAV depiction (scale, 1-5), localization of the RAV confluence with regard to the inferior vena cava, and depiction of anatomical variants. Results were compared with RAV venograms obtained during adrenal vein sampling and corroborated by laboratory testing of cortisol in selective RAV blood samples. Kappa statistics were calculated for interobserver agreement and for concordance of MDCT mapping with the gold standard. RESULTSSuccessful RAV sampling was achieved in 69 of 75 patients (92%). Using MDCT mapping, adrenal veins could be visualized in 78% (R1, 54/69) and 77% (R2, 53/69) of patients. MDCT mapping led to correct identification of RAV in 70% (R1, 48/69) and 88% (R2, 61/69) of patients. Venograms revealed five cases of anatomical variants, which were correctly identified in 60% (R1, R2). MDCT-based localizations were false or misleading in 16% (R1, 11/69) and 7% (R2, 5/69) of cases. CONCLUSION Preinterventional MDCT mapping may facilitate successful catheterization in adrenal vein sampling.

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Consequences of Adrenal Venous Sampling in Primary Hyperaldosteronism and Predictors of Unilateral Adrenal Disease

Cited by 70 publications

References 21 publications

Adrenal venous sampling for stratifying patients for surgery of adrenal nodules detected using dynamic contrast enhanced CT

Adrenal venous sampling for stratifying patients for surgery of adrenal nodules detected using dynamic contrast enhanced CT

Adrenal vein sampling using rapid cortisol assays in primary aldosteronism is useful in centers with low success rates

CT mapping of the vertebral level of right adrenal vein

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