Association of Adrenal Venous Sampling With Outcomes in Primary Aldosteronism for Unilateral Adenomas

Abstract

Adrenal venous sampling is recommended prior to adrenalectomy for all patients with hyperaldosteronism; however, cross-sectional imaging resolution continues to improve, while the procedure remains invasive and technically difficult. Therefore, certain patients may benefit from advancing straight to surgery. OBJECTIVE To determine whether clinical and biochemical resolution varied for patients with primary aldosteronism with unilateral adenomas who underwent adrenal venous sampling vs those who proceeded to surgery based on imaging alone. DESIGN, SETTING, AND PARTICIPANTS Retrospective, international cohort study of patients treated at 3 tertiary medical centers from 2004 to 2019, with a median follow-up of approximately 6 months. A total of 217 patients were consecutively enrolled. Exclusion criteria consisted of unknown postoperative serum aldosterone level and imaging inconsistent with unilateral adenoma with a normal contralateral gland. A total of 125 patients were included in the analysis. Data were analyzed between October 2019 and July 2020.EXPOSURES Adrenal venous sampling performed preoperatively. MAIN OUTCOMES AND MEASURESThe primary outcome measurements were the clinical and biochemical success rates of surgery for the cure of hyperaldosteronism secondary to aldosterone-producing adenoma.RESULTS A total of 125 patients were included (45 cross-sectional imaging with adrenal venous sampling and 80 imaging only). The mean (SD) age of the study participants was 50.2 (10.6) years and the cohort was 42.4% female (n = 53). Of those patients for whom race or ethnicity were reported (n = 80), most were White (72.5%). Adrenal venous sampling failure rate was 16.7%, and the imaging concordance rate was 100%. Relevant preoperative variables were similar between groups, except ambulatory systolic blood pressure, which was higher in the imaging-only group (150 mm Hg; interquartile range [IQR], 140-172 mm Hg vs 143 mm Hg, IQR, 130-158 mm Hg; P = .03). Resolution of autonomous aldosterone secretion was attained in 98.8% of imaging-only patients and 95.6% of adrenal venous sampling patients (P = .26). There was no difference in complete clinical success (43.6% [n = 34] vs 42.2% [n = 19]) or partial clinical success (47.4% [n = 37] vs 51.1% [n = 23]; P = .87) between groups. Complete biochemical resolution was similar as well (75.9% [n = 41] vs 84.4% [n = 27]; P = .35). There was no difference in clinical or biochemical cure rates when stratified by age, although complete clinical success rates downtrended in the older cohorts, and sample sizes were small. CONCLUSIONS AND RELEVANCEGiven the improved sensitivity of cross-sectional imaging in detection of adrenal tumors, adrenal venous sampling may be selectively performed in appropriate patients with clearly visualized unilateral adenomas without affecting outcomes. This may facilitate increased access to surgical cure for aldosterone-producing adenomas and will decrease the incidence of morbidities associated with the procedure.

Differences in the presentation and evolution of primary aldosteronism in elderly (≥65 years) and young patients (<65 years)

“…Despite the underlying disease and the significant comorbidity and longer hypertension duration in the elderly group, we did not find statistically significant differences in the rates of biochemical and clinical success between the elderly and non-elderly groups. Our findings are consistent with the previously reported that no significant differences in clinical or biochemical cure rate in PA were observed when stratified by age ( 34 ). Most patients experienced at least partial clinical success, even in the group older than 65 years, and complete biochemical success after adrenalectomy was found in at least 50% of patients, regardless of age at the time of surgery ( 34 ).…”

“…Our findings are consistent with the previously reported that no significant differences in clinical or biochemical cure rate in PA were observed when stratified by age ( 34 ). Most patients experienced at least partial clinical success, even in the group older than 65 years, and complete biochemical success after adrenalectomy was found in at least 50% of patients, regardless of age at the time of surgery ( 34 ). A long history of hypertension has been described as an independent predictor of hyperkalemia after surgery in elderly patients ( 32 ), however, in our analysis we found no significant differences.…”

Prognosis of adrenalectomy guided by computed tomography versus adrenal vein sampling in patients with primary aldosteronism: A systematic review and meta‐analysis

“…Eleven studies [13][14][15][23][24][25][26][27][28][29][30] were included in the analysis (detailed literature search described in Figure 1), including 1325 primary aldosteronism patients who underwent adrenalectomy guided by AVS and 907 patients guided by CT. Characteristics of the studies meeting the criteria and included in the final meta-analysis were in Tables 1 and S5. There were one randomized controlled trial and ten cohort studies.…”

External Validation of Clinical Prediction Models in Unilateral Primary Aldosteronism

“… 38 Previous studies supporting the use of computed tomography alone were limited by small sample sizes and inconsistent verification with AVS. 10 , 39 Moreover, hypokalemia is frequently detected in patients with both unilateral and bilateral subtypes. 40 As such, the common variables purported to be associated with lateralization are not sufficiently sensitive to guide most clinical decisions.…”