Adrenal Vein Sampling With Gadolinium Contrast Medium in a Patient With Florid Primary Aldosteronism and Iodine Allergy

Abstract

We describe a 35-year-old woman who was allergic to iodine contrast medium and was diagnosed with primary aldosteronism (PA) based on functional confirmatory tests. She was suspected to have unilateral PA because of marked hypertension, spontaneous hypokalemia, high plasma aldosterone, reduced plasma renin activity, and a right hypodense adrenal tumor. She wanted to become pregnant and requested adrenalectomy instead of medical treatment with mineralocorticoid receptor antagonists. Localization of PA by adrenal vein sampling (AVS) was necessary, but angiography with iodine contrast medium was not possible because of her allergy. AVS was performed using gadolinium contrast agent (gadoterate meglumine) instead of iodine, in combination with computed tomography angiography (CTA). In AVS, before and after adrenocorticotropic hormone (ACTH) loading, 12 blood samples were drawn from the right adrenal vein, left adrenal central vein, left adrenal common duct, left and right renal veins, and the lower inferior vena cava with only 5 mL of gadolinium medium. There were no complications during AVS. Examination revealed an elevated aldosterone/cortisol ratio on the right side, lateralized ratio of 7.4, and contralateral ratio of 0.76; the patient was diagnosed with right unilateral PA. She underwent right adrenalectomy and showed improvements in aldosterone level from 312.4 pg/mL to 83.0 pg/mL, potassium from 3.0 mEq/L to 3.9 mEq/L, and systolic blood pressure from 138 mmHg to 117 mmHg. In conclusion, in PA patients with iodine allergy, AVS can be performed safely and precisely using gadolinium contrast combined with CTA.

Successful Adrenal Vein Sampling Using Dexamethasone Premedication in Patients With Iodine Contrast Media Allergy

“…As such, alternative options are being suggested for patients with PA who have a history of ICM allergy and require AVS to guide therapeutic management, although not all have proven to have a high diagnostic accuracy [ 10 , 11 , 13 , 14 ]. Our results show that patients with ICM allergy also benefit from AVS despite premedication with a glucocorticoid.…”

“…Only 1 case in the literature reported successful AVS with concomitant dexamethasone for ICM allergy [ 20 ]. In a recent case report, the authors commented that they used gadolinium since they believed that glucocorticoid pretreatment may alter AVS interpretation and is insufficiently safe to prevent ICM allergy [ 11 ]. As we have successfully utilized dexamethasone premedication for performing AVS in patients with ICM allergy in our center over several years, we performed the retrospective analysis of the 7 patients who were studied with this approach.…”