Impact of Different Diagnostic Criteria During Adrenal Vein Sampling on Reproducibility of Subtype Diagnosis in Patients With Primary Aldosteronism

Abstract

Abstract-In patients with primary aldosteronism, adrenal vein sampling (AVS) is considered the only reliable technique to distinguish between unilateral and bilateral autonomous production of aldosterone, but agreement is lacking on the best criteria indicating successful cannulation and lateralization. The objective of this study was to assess the impact of differing criteria for the successful cannulation and lateralization on the reproducibility of subtype diagnosis. Sixty-two patients with confirmed primary aldosteronism underwent AVS on 2 separate occasions, because the first was unsatisfactory. We compared the different diagnoses of primary aldosteronism subtype reached using AVS data assessed by permissive (type 1), intermediate (type 2), and strict (type 3) criteria. Although 91.1% of all of the (both first and second) AVSs were "successful" by type 1 criteria (50.8% by type 2 and 33.9% by type 3), in only 35.3% of patients was the diagnosis concordant between the first and second AVS. Type 1 criteria also led to a higher rate of diagnosis of unilateral primary aldosteronism (67.3% of successful procedures) than type 2 (36.5%) or type 3 (26.2%). There was considerable disparity in the diagnosis reached using the 3 different criteria, with concordance in only 32.2%. Using either type 1 or 2 criteria, the minimal adrenal/peripheral vein cortisol ratio necessary to obtain the same diagnosis in the first and second AVS procedures was Ն2.75. In conclusion, permissive criteria for successful cannulation and lateralization on AVS achieve poor diagnostic reproducibility and should be avoided. (Hypertension. 2010;55:667-673.)Key Words: endocrine hypertension Ⅲ primary aldosteronism Ⅲ aldosterone Ⅲ aldosterone-producing adenoma Ⅲ bilateral adrenal hyperplasia P rimary aldosteronism (PA) is currently believed to be the most frequent form of secondary endocrine hypertension, accounting for 5% to 10% of all hypertensive patients.

A stress reaction affects assessment of selectivity of adrenal venous sampling and of lateralization of aldosterone excess in primary aldosteronism

“…Hence, within the timeframe of a sequential AVS, use of samples taken at different times affects the assessment of selectivity. Overall, these results support the contention that the time elapsing between samples taken with the sequential technique should be considered when assessing the cannulation success rate by the PCCbased SI (21).…”

“…To minimize the impact of these factors, ACTH infusion was introduced by Weinberger et al (22) and widely used thereafter (21,23,24), thus being held as an essential part of the sequential AVS (11,19,21,25), or even of bilaterally simultaneous AVS (5,26,27). In our hands, cosyntropin stimulation confounded the assessment of lateralization and led to misclassification of the APA side (8,17).…”

Adrenal venous sampling for stratifying patients for surgery of adrenal nodules detected using dynamic contrast enhanced CT

“…This is similar to the cutoff based on the Endocrinonolgy Society guidelines (9,(22)(23)(24). The absolute aldosterone concentration was not as useful as the cortisol-corrected values, which correct for the dilutional effects of the inferior phrenic vein flow into the left adrenal vein and for IVC blood when sampling at or near the orifice of the right adrenal vein (12)(13)(14)25). In addition, the contralateral-gland-to-IVC ratio was accurate, suggesting that not all patients with unilateral disease have complete contralateral aldosterone suppression.…”

“…On univariate analysis, significant predictors of persistent postoperative hypertension were of male gender and a high preoperative systolic BP (23)(24)(25)(26)(27).There are some limitations to this study. First, 15% of the patients had incomplete AVS due to technical difficulties.…”

Adrenal Venous Sampling

“…Some authors defined a 10% higher cortisol value than in inferior vena cava, 14,18 -20 whereas others rely on higher indexes, such as 2, 3, or even 5. 7,15,17,[21][22][23][24][25] Accessory hepatic veins often drain together with the right adrenal vein into the inferior vena cava. Under these circumstances, adrenal blood with high cortisol values mixes with hepatic blood with a low cortisol value (lower than in the peripheral circulation because of hepatic metabolism of cortisol).…”