Catheterization During Adrenal Vein Sampling for Primary Aldosteronism: Failure to Use (1–24) ACTH May Increase Apparent Failure Rate

Abstract

“Successful” adrenal vein catheterization in primary aldosteronism (PA) is often defined by a ratio of >3:1 of cortisol in the adrenal vein vs the inferior vena cava. Non‐use of corticotropin (ACTH) during sampling may increase the apparent failure rate of adrenal vein catheterization due to lower cortisol levels. A retrospective study was performed on all patients with confirmed unilateral PA between June 2005 and August 2011. Adrenal vein sampling (AVS) included simultaneous bilateral baseline samples with repeat sampling 15 minutes after intravenous infusion of 250 μg of Cortrosyn (ACTH‐S). Successful catheter placement was judged as adrenal cortisol:IVC cortisol of >3:1, applied to both baseline and ACTH‐S samples and lateralization of aldosteronism was judged as normalized aldosterone/cortisol (A/C) ratio >3 times the contralateral A/C ratio. In ACTH‐S samples, 94% of right‐sided catheterizations were biochemically successful with 100% success on the left. Among baseline samples, only 47% of right‐ and 44% of left‐sided samples met the 3:1 cortisol criteria. However, 95% of apparent “failed” baseline cortisol sets still showed lateralization of A/C ratios that matched the ultimate pathology. Non–ACTH‐stimulated samples may be incorrectly judged as failed catheter placement when a 3:1 ratio is used. ACTH‐stimulated sampling is the preferred means to confirm catheterization during AVS.

11‐Deoxycortisol may be Superior to Cortisol in Confirming a Successful Adrenal Vein Catheterization without Cosyntropin: A Pilot Study

“…future science group previous report [15]. The use of cosyntropin to exaggerate the cortisol levels from the adrenal vein compared with peripheral cortisol levels has been considered to be a requirement to improve success rates of AVS [15,21].…”

“…The use of cosyntropin to exaggerate the cortisol levels from the adrenal vein compared with peripheral cortisol levels has been considered to be a requirement to improve success rates of AVS [15,21]. We used a highly accurate LC-MS/MS to simultaneously assess the levels of cortisol and eight other steroids from AVS and identify 11-deoxycortisol as a superior marker compared with cortisol for biochemically confirming catheter position without cosyntropin infusion.…”

“…The omission of cosyntropin may increase the biochemical failure rate of adrenal vein catheterization because of the lack of exaggerated cortisol levels. Compared with the cosyntropinstimulated cortisol ratio of adrenal to peripheral veins, the nonstimulated ratio can be falsely low, suggesting incorrect catheter placement occurred in approximately 50% of the samples when the cortisol ratio of adrenal to peripheral vein of 3:1 was used [15].…”

Clinical and Physiological Aspects of Salt Sensitive Hypertension

“…The proportion of tests that are inadequate due to this phenomenon is unknown, and probably vary depending on how AVS is performed. In one study of 32 patients who had pre and post ACTH samples taken without repositioning of the catheters, the proportion of samples that achieved adequate (SI >3) gradients increased after ACTH from 44% to 88% on the right and from 47% to 100% on the left, suggesting that about half of the baseline samples were taken from a satisfactory position but did not achieve adequate gradients [69]. It is thought that the chance of this circumstance occurring may be minimised somewhat by performing the procedure in the morning when cortisol production is at its peak, but in the aforementioned study the time of AVS was not specified, which might contribute to the low initial success rate.…”

“…The authors also highlight the importance of strict AVS criteria, without which concordance of diagnosis drops significantly. on a retrospective review of results from their now standardised protocol [69]. This group do not perform a confirmatory step, instead proceeding directly to AVS in patients with an elevated ARR which may add some bias to the study group as the majority of patients had hypokalaemia and an adrenal mass.…”