C-Arm Computed Tomography-Assisted Adrenal Venous Sampling Improved Right Adrenal Vein Cannulation and Sampling Quality in Primary Aldosteronism

Abstract

BackgroundAdrenal venous sampling (AVS) is a gold standard for subtype classification of primary aldosteronism (PA). However, this procedure has a high failure rate because of the anatomical difficulties in accessing the right adrenal vein. We investigated whether C-arm computed tomography-assisted AVS (C-AVS) could improve the success rate of adrenal sampling.MethodsA total of 156 patients, diagnosed with PA who underwent AVS from May 2004 through April 2017, were included. Based on the medical records, we retrospectively compared the overall, left, and right catheterization success rates of adrenal veins during the periods without C-AVS (2004 to 2010, n=32) and with C-AVS (2011 to 2016, n=124). The primary outcome was adequate bilateral sampling defined as a selectivity index (SI) >5.ResultsWith C-AVS, the rates of adequate bilateral AVS increased from 40.6% to 88.7% (P<0.001), with substantial decreases in failure rates (43.7% to 0.8%, P<0.001). There were significant increases in adequate sampling rates from right (43.7% to 91.9%, P<0.001) and left adrenal veins (53.1% to 95.9%, P<0.001) as well as decreases in catheterization failure from right adrenal vein (9.3% to 0.0%, P<0.001). Net improvement of SI on right side remained significant after adjustment for left side (adjusted SI, 1.1 to 9.0; P=0.038). C-AVS was an independent predictor of adequate bilateral sampling in the multivariate model (odds ratio, 9.01; P<0.001).ConclusionC-AVS improved the overall success rate of AVS, possibly as a result of better catheterization of right adrenal vein.

Cone-beam Computed Tomography is Not a Mandatory Procedure in Adrenal Venous Sampling for Primary Hyperaldosteronism

“…The value of CBCT during AVS has long been investigated, and most studies have suggested that CBCT is a useful tool for identifying RAV, thereby improving the success rate of AVS [11][12][13][14][15][16][17]. However, the present study showed contrasting results, in which a similar success rate was noted in patients with or without the assistance of CBCT (88.4% vs. 82.3%, P = 0.347).…”

“…The main di culty associated with AVS is the cannulation of the right adrenal vein (RAV), as it is often short and exhibits several anatomical variations [8][9][10]. In previous studies, cone-beam computed tomography (CBCT) was used, which may improve the overall success rate of AVS [11][12][13][14][15][16][17]. However, CBCT is a time-consuming procedure that requires additional radiation exposure.…”

Adrenal Venous Sampling for Subtype Diagnosis of Primary Hyperaldosteronism

“…Metomidate, the methylated version of etomidate, which is an imidazole-based potent inhibitor of steroid 11β-hydroxylase, is another candidate probe. Although 11 C-metomidate positron emission tomography (PET), targeting CYP11B, has been reported to be useful for PA subtype classification [53], clinical application of this method is problematic due to the short halflife of 11 C and the need for pretreatment with dexamethasone to block binding of the isotope to cortisol-producing CYP11B. In addition, Soinio et al [54] reported that the concordance between AVS and 11 C-metomidate PET was 55% in unilateral PA and 44% in bilateral PA and did not outperform adrenal CT.…”

“…Catheter insertion into the adrenal vein is confirmed by intraprocedural angiography, with special care not to damage the adrenal veins [ 9 ], and interventional 3D imaging (DynaCT) during AVS [ 10 , 11 ]. Intraprocedural measurement of the cortisol level in the adrenal veins enables judgment of AVS success [ 12 ].…”

Update on the Aldosterone Resolution Score and Lateralization in Patients with Primary Aldosteronism

“…However, AVS is considered to be a difficult procedure because of the technical difficulty of cannulating the right adrenal vein. Recently, there have been advances in AVS cannulation with the introduction of rapid on-site measurements of adrenal vein cortisol concentrations [ 11 ] and C-arm computed tomography-guided cannulation [ 12 ]. New immunoassay measurements of hybrid steroids, such as 18-hydroxycorticosterone, 18-hydroxycortisol, and 18-oxocortisol, have recently shown improved sensitivity and specificity, suggesting their potential use as surrogate markers for the diagnosis and lateralization of unilateral PA in combination with adrenal imaging [ 13 14 ].…”