What are the keys to successful adrenal venous sampling (AVS) in patients with primary aldosteronism?

Abstract

SummaryAdrenal venous sampling (AVS) is the criterion standard to distinguish between unilateral and bilateral adrenal disease in patients with primary aldosteronism. The keys to successful AVS include appropriate patient selection, careful patient preparation, focused technical expertise, defined protocol, and accurate data interpretation. The use of AVS should be based on patient preferences, patient age, clinical comorbidities, and the clinical probability of finding an aldosterone-producing adenoma. AVS is optimally performed in the fasting state in the morning. AVS is an intricate procedure because the right adrenal vein is small and may be difficult to locate -the success rate depends on the proficiency of the angiographer. The key factors that determine the successful catheterization of both adrenal veins are experience, dedication and repetition. With experience, and focusing the expertise to 1 or 2 radiologists at a referral centre, the AVS success rate can be as high as 96%. A centre-specific, written protocol is mandatory. The protocol should be developed by an interested group of endocrinologists, radiologists and laboratory personnel. Safeguards should be in place to prevent mislabelling of the blood tubes in the radiology suite and to prevent sample mix-up in the laboratory.

Adrenal Venous Sampling

“…In addition, rapid cortisol assays during the procedure can improve the success rate of AVS. 25 Even without rapid cortisol assays, a prompt feedback to the radiologist, whether cannulation was selective or not, should accelerate the learning curve. An endocrinologist or hypertension specialist cannot manually support the interventionalist, but we recommend that, during the procedure, another knowledgeable physician is present for a significant time.…”

“…Some authors defined a 10% higher cortisol value than in inferior vena cava, 14,18 -20 whereas others rely on higher indexes, such as 2, 3, or even 5. 7,15,17,[21][22][23][24][25] Accessory hepatic veins often drain together with the right adrenal vein into the inferior vena cava. Under these circumstances, adrenal blood with high cortisol values mixes with hepatic blood with a low cortisol value (lower than in the peripheral circulation because of hepatic metabolism of cortisol).…”

“…Discussing procedural strategies recommended in recent references may also help to improve AVS quality. 19,23,25,27 In the prospective phase of analysis, 106 AVSs were evaluated in 2008 and 2009. After communication of poor procedure quality, selected centers started to introduce defined standard operating procedures, including rapid cortisol assay and a close collaboration with the local interventional radiologist.…”

A stress reaction affects assessment of selectivity of adrenal venous sampling and of lateralization of aldosterone excess in primary aldosteronism

“…To minimize the impact of these factors, ACTH infusion was introduced by Weinberger et al (22) and widely used thereafter (21,23,24), thus being held as an essential part of the sequential AVS (11,19,21,25), or even of bilaterally simultaneous AVS (5,26,27). In our hands, cosyntropin stimulation confounded the assessment of lateralization and led to misclassification of the APA side (8,17).…”

“…We hypothesized that being brought to the hemodynamic laboratory to undergo AVS could be stressful for the patient (19) and might trigger a cortisol release that is variable, as suggested by the ample variability in adrenal vein catecholamine levels during AVS (20). Such a stress reaction has neither been systematically investigated nor been characterized thus far.…”