Adrenal Vein Sampling: How to Make It Quick, Easy, and Successful

Abstract

Adrenal vein sampling has a reputation as a difficult procedure. However, it is being performed more frequently at some institutions due to the realization that primary aldosteronism is more common than previously believed. At the author's institution, adrenal vein sampling with computed tomographic (CT) and laboratory correlation has been performed more than 800 times in the past 10 years. Adrenal vein sampling is used to determine whether autonomous hormone production is unilateral or bilateral; unilateral secretion can be treated with surgery. The venous drainage of each adrenal gland is predominantly via a central vein. Recognition of the right adrenal vein is the crux of adrenal vein sampling. CT is useful in planning adrenal vein sampling by demonstrating the anatomy and positions of the adrenal veins. A small amount of contrast material is injected gently and slowly into the adrenal vein; it is not necessary to perform formal venography to outline the entire gland. To confirm that the vein is draining the majority of adrenal cortical blood, the adrenal vein sample should have a significantly higher level of cortisol than a peripheral sample. Adrenal glands that are producing aldosterone demonstrate an aldosterone-cortisol ratio that is higher than the peripheral value.

Indication and Technical Aspects of Adrenal Blood Sampling

“…The CT is used to assess the position of the adrenal vein, in the DSA, the outlet for the vein should be considered to be 1 -1.5 cm upward from the position indicated in the CT image. If the right adrenal vein cannot be differentiated in the CT, the center of the adrenal gland should be used to estimate the position of the vein [43].…”

“…For the sake of completeness, the Mikaelsson catheter should be mentioned; this likewise does not possess additional lateral perforations. In principle the left adrenal vein can be probed using various catheters; in addition to C1 or C2 configurations, probing is also possible using a vertebral catheter [43,44]. In our opinion, a SIM 2 Glidex catheter provides simpler and faster probing; depending on its configuration in the inferior vena cava or right chamber, if the catheter is withdrawn with the tip pointing left, it automatically lies in the left renal vein, and then upon additional careful withdrawal will rest in the left adrenal vein or the common end section ( • " Fig.…”

Adrenal Venous Sampling

“…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

“…While both techniques can easily be performed by experienced radiologists, whether one outperforms the other remains contentious (10,11).…”