Clinical Outcomes of 1625 Patients With Primary Aldosteronism Subtyped With Adrenal Vein Sampling

Abstract

We sought to measure the clinical benefits of adrenal venous sampling (AVS), a test recommended by guidelines for primary aldosteronism (PA) patients seeking surgical cure, in a large registry of PA patients submitted to AVS. Data of 1625 consecutive patients submitted to AVS in 19 tertiary referral centers located in Asia, Australia, Europe, and North America were collected in a large multicenter international registry. The primary end points were the rate of bilateral success, ascertained lateralization of PA, adrenalectomy, and of cured arterial hypertension among AVS-guided and non AVS-guided adrenalectomy patients. AVS was successful in 80.1% of all cases but allowed identification of unilateral PA in only 45.5% by the criteria in use at each center. Adrenalectomy was performed in 41.8% of all patients and cured arterial hypertension in 19.6% of the patients, 2-fold more frequently in women than men ( P <0.001). When AVS-guided, surgery provided a higher rate of cure of hypertension than when non-AVS-guided (40.0% versus 30.5%; P =0.027). Compared with surgical cases, patients treated medically needed more antihypertensive medications ( P <0.001) and exhibited a higher rate of persistent hypokalemia requiring potassium supplementation (4.9% versus 2.3%; P <0.01). The low rate of adrenalectomy and cure of hypertension in PA patients seeking surgical cure indicates suboptimal AVS use, possibly related to issues in patient selection, technical success, and AVS data interpretation. Given the better outcomes of AVS-guided adrenalectomy, these results call for actions to improve the diagnostic use of this test that is necessary for detection of surgical PA candidates. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT01234220.

Adrenal venous sampling in primary hyperaldosteronism: correlation of hormone indices and collimated C-arm CT findings

“…Higher rates of cardiovascular complications and renal damage compared to essential hypertensives, potentially reversible with surgical or medical treatment, demonstrate the enormous significance of specific and reliable diagnostic tools for differentiating the two most common subtypes, APA and BHA [12,24]. The high diagnostic accuracy and extremely low rate of complications (0.61%), coupled with an improved outcome of AVS guided surgical management according to a global multicenter study [25] and a large registry study (> 1600) [26], represent crucial assets of AVS and have led to its endorsement in the majority of PA patients, excluding patients unable or unwilling to undergo surgical treatment [3,13]. Despite this recommendation in the current guidelines by the Endocrine society, it is not universally performed-potentially due a formed impression of AVS as a challenging, complex intervention with a high failure rate, and a tendency towards avoidance of AVS for easier, though less specific alternatives, such as the sole employment of CT/MRI [1, 2, 4, 6, 8-11, 13, 17].…”

Practice Recommendations for Diagnosis and Treatment of the Most Common Forms of Secondary Hypertension

“…MRAs are also indicated before adrenalectomy to control BP values and serum potassium levels [9,27]. In both surgically and medically treated PA, follow-up is necessary to verify the 'cure' of PA and the effectiveness of treatment [29,30].…”

Utility of adrenocorticotropic hormone in adrenal vein sampling despite the occurrence of discordant lateralization

“…Adrenal imaging alone may sometimes miss APA (false negative) or identify nonfunctioning adrenal incidentalomas (false positive) which are not uncommon in patients over 40 years of age 3 . When guided by AVS, adrenal surgery provides a higher rate of hypertension cure than CT guidance alone 4 . AVS can even guide the selection of side of adrenalectomy in patients with poorly controlled bilateral disease 5 .…”