Clinical Management and Outcomes of Adrenal Hemorrhage Following Adrenal Vein Sampling in Primary Aldosteronism

Abstract

Aldosterone-producing adenoma and bilateral adrenal hyperplasia account for >90% of all primary aldosteronism cases. Distinguishing between bilateral and unilateral disease is of fundamental importance because it allows targeted therapy. Adrenal vein sampling (AVS) is the only reliable means to preoperatively differentiate between unilateral and bilateral subtypes. A rare but serious complication of AVS is an adrenal hemorrhage (AH). We retrospectively examined in detail 24 cases of AH during AVS in 6 different referral hypertension centers. AH more often affected the right adrenal (n=18) than the left (n=5, P <0.001); 1 bilateral. Median duration of experience of the radiologist in AVS at the time of AH was 5.0 years (0.6–7.8) and AH occurred with both highly experienced (>10 years) and less experienced radiologists. Of 9 patients who suffered AH in the gland contralateral to an aldosterone-producing adenoma and who underwent complete (n=6) or partial (n=3) unilateral adrenalectomy, only one required long-term corticosteroid replacement for adrenal insufficiency. No reduction in blood pressure or biochemical resolution of primary aldosteronism occurred in any of those patients who experienced AH in the gland ipsilateral to an aldosterone-producing adenoma (n=6) or who had bilateral adrenal hyperplasia (n=9). No patient required invasive treatments to control bleeding or blood transfusion. In conclusion, AH usually has a positive outcome causing either no or minor effects on adrenal function, and AVS should remain the best approach to primary aldosteronism subtype differentiation.

Subtype Diagnosis of Primary Aldosteronism: Is Adrenal Vein Sampling Always Necessary?

“…The left adrenal vein is usually easily cannulated, because it generally drains directly into the left renal vein [49], while the cannulation of the shorter and smaller right adrenal vein, which usually drains directly into the inferior vena cava, can be difficult. Despite being a challenging procedure, the complication rate associated with AVS is very low (0.61%) [20]; adrenal haemorrhage, which is the most serious complication, has a favourable outcome in the majority of patients, causing minor or no permanent effects on adrenal function [50]. Other AVS protocols are described below.…”

Management of primary aldosteronism in patients with adrenal hemorrhage following adrenal vein sampling: A brief review with illustrative cases

“…In instances where AVS lateralization data are successfully acquired, if the AH affects the contralateral adrenal to an APA, one may question whether surgically removing the adrenal with the APA will render the patient adrenally insufficient (Figure ). As demonstrated by Monticone and colleagues, only one case of adrenal insufficiency was encountered in such a scenario, suggesting that this is a rare occurrence. However, because of the limited sample size, one cannot make definitive conclusions.…”

“…The investigators also found that AH was inversely correlated with the number of procedures performed by each radiologist . In another study that primarily explored the management and outcomes of AH during AVS, Monticone and colleagues reported 24 cases of PA with AH from six different centers. AH occurred more frequently (n=18 of 24) in the right adrenal vein, in keeping with previously published reports .…”

“…For example, if the AVS was terminated early as a result of the AH, or was nondiagnostic, it is unclear whether to repeat AVS testing, treat with lifelong medical therapy, or, in the case of a suspected APA, to simply proceed to unilateral adrenalectomy. Because AH rarely obliterates the entire gland, it often has no effect on blood pressure control or biochemical levels, even if ipsilateral to the culprit APA . Therefore, the lack of a “blood pressure response” after AH gives no discriminatory information regarding the laterality of the disease.…”

“…Therefore, the lack of a “blood pressure response” after AH gives no discriminatory information regarding the laterality of the disease. In the study by Monticone and colleagues, two patients with AH with nondiagnostic AVS results had repeat AVS successfully performed without complications . However, because repeat AVS testing after AH is rarely described in the literature, the risk of complications and repeat nondiagnostic results or the optimal timing on when to perform the repeat procedure is entirely unclear.…”