Abstract-Adrenal vein sampling is the gold standard for identification of surgically curable primary aldosteronism, but its accuracy might be hindered by blood dilution from accessory vein blood. We prospectively investigated the presence of accessory veins draining into adrenal veins and their effect on the selectivity index (SI) Key Words: adrenal vein sampling Ⅲ aldosterone Ⅲ aldosteronism Ⅲ adrenocorticophic hormone Ⅲ catheterization P rimary aldosteronism (PA), the most common endocrine cause of curable arterial hypertension, 1 is usually attributed to aldosterone-producing adenoma (APA) and, less commonly, to unilateral 2 or bilateral adrenal hyperplasia. 3 The former two conditions are characterized by lateralized aldosterone secretion and are best treated by adrenalectomy, whereas the latter, featuring bilateral aldosterone excess, requires lifelong antihypertensive therapy on the basis of mineralocorticoid receptor antagonists.Discrimination between unilateral aldosterone excess and bilateral adrenal hyperplasia is feasible with NP59 scintigraphy or adrenal vein sampling (AVS). Because NP59 has a low sensitivity and is not generally available, 3,4 AVS is currently considered the gold diagnostic standard for identifying the surgically curable forms of PA. 5,6 However, interpretation of AVS results requires attention to several issues and particularly to the criteria to be used for assessing selectivity and establishing the lateralization of aldosterone excess. 7,8 With regard to selectivity, experience has shown that selective catheterization can be consistently achieved on the left side, whereas on the right side the success rate is lower. 7 The difficulty of selectively cannulating the right adrenal vein, is due to its brevity and direct draining in the inferior vena cava (IVC), while the training and experience of the operator do not seem to fully account for this lower success rate. 3,7 Because, on the right side, the adrenal vein often shares egress in the IVC with accessory hepatic veins, we hypothesized that the dilution of adrenal vein blood with blood draining from the liver, which carries a low cortisol concentration, might account for the lower success rate of catheterization on this side. However, there was no information on how common accessory hepatic veins are and on their impact on the selectivity of an AVS index. Therefore, this study was designed to prospectively investigate these questions. Patients and MethodsThe patients to be submitted to AVS were selected among those with a diagnosis of PA, as described previously, 1 who had no contraindications to general anesthesia and surgery. They were asked to sign a written consent to undergo not only AVS but also laparoscopic adrenalectomy in case a lateralized aldosterone secretion was eventually identified. 3,9

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From January, 1972 to June, 1989, 51 patients with liver hemangiomas (32 females and 19 males, mean age 35 years) were evaluated for surgical treatment. Diameters of the masses were 5 cm to 20 cm (median 8.5 cm). Nine of the patients had already been treated for cancer. Twenty-two (43.1%) of the 51 patients were symptomatic and 29 (56.9%) patients were asymptomatic. In 34 patients (66.7%) a definite diagnosis of hemangioma was made by scintiscan and/or ultrasound and/or computed tomography and/or angiography while in the remaining 17 (33.3%) patients the diagnosis was uncertain. The most common indications for resection were the presence of a symptomatic angioma, a symptomatic mass with an uncertain diagnosis, and/or lack of a definite pre-operative diagnosis. Surgery was performed on 25 patients. Ten anatomic and 15 atypical resections or enucleations were performed. There were no postoperative deaths. Two further patients, operated for probable hemangioma, were found to have primary hepatic malignancies. In the 26 unresected patients, no complications were observed during follow-up. In 3 patients, hemangioma enlargement was detected by ultrasound, but there were no symptoms. As cavernous liver hemangiomas are now more reliably diagnosed and their natural history is usually uneventful, surgery can be avoided in most cases. However, when a non-resection policy is adopted, an exact diagnosis is essential in order to rule out primary or metastatic cancer. Surgical exploration and treatment should be limited to symptomatic or complicated cases as well as to patients with an uncertain diagnosis.

Long-standing stenosis of the celiac axis is a rare cause of aneurysm of the inferior pancreaticoduodenal artery, which serves as a collateral pathway; the etiology is believed to be due to turbulence from increased blood flow. The authors describe 2 cases of such aneurysm, which ruptured in the retroperitoneum and were treated with transcatheter embolization.

Seven cases of congenital anomalies of brachiocephalic arteries are presented; malformations include unilateral absence of the internal carotid artery (ICA) (n = 3), unilateral hypoplasia of the ICA (n = 2), agenesis of the innominate artery (n = 1), and atresia of the subclavian artery (n = 1). All patients but 1 exhibited symptoms of cerebrovascular insufficiency at the time of radiologic investigation; they were not affected by other cardiovascular malformations, except right aortic arch in 2 cases and left cervical arch in another case. Two patients suffering from congenital subclavian steal syndrome underwent surgery to correct the vascular malformations. Embryogenesis and natural history of such malformations are briefly discussed.