Intraprocedural cortisol testing improves adrenal vein cannulation success and diagnostic accuracy in assessment of primary aldosteronism, in a medium throughput centre

Abstract

Primary aldosteronism is the most common cause of secondary hypertension. Identifying individuals who have unilateral secretion from aldosterone secreting adenomas allows adrenalectomy. Surgical treatment when feasible may be superior to medical management with improved cardiovascular outcomes and reduced medication dependence. Adrenal vein sampling (AVS) is required to biochemically lateralise aldosterone secretion prior to adrenalectomy. However, diagnostic success of AVS is variable and can be poor even at tertiary centres; failure is largely due to unsuccessful adrenal vein cannulation. Intra-procedural rapid semiquantitative cortisol testing (RCT) identifies correct catheter placement in real time. We compared diagnostic success rates of AVS before and after the introduction of intraprocedural cortisol testing at the Royal Adelaide Hospital—a medium throughput tertiary centre (average 6.2 procedures a year over the last 8 years). We observed an increase in success rate from 63% to 94%. Intraprocedural cortisol testing also led to a net financial saving of ~$100 AUD per procedure. RCT is likely to be cost effective if pre-RCT success rate is less than 78%. Procedure time and number of samples collected, however, were increased with RCT. This suggests that intraprocedural cortisol testing will improve success in low to medium throughput centres and may make AVS feasible in less specialised centres.

A clinical assessment of portable point-of-care testing for quick cortisol assay during adrenal vein sampling

“…The results also demonstrated additional advantages in incorporating our QCA clinically. The average turnaround time was 20.5 min, relatively quick compared to the previously reported ICM (20–120 min) 18 , 32 – 34 , 36 , 37 . The average dilutions required to determine AVS success or failure was 0.83.…”

“…Furthermore, the turnaround time of cortisol measurement is long (20–120 min) 18 , 32 – 34 , 36 , 37 . These procedures make patients uncomfortable, and moving between the same facility’s radiology suite and laboratory room increases the financial burden.…”

“…These procedures make patients uncomfortable, and moving between the same facility’s radiology suite and laboratory room increases the financial burden. Our new POCT-QCA enables us to perform ICM rapidly in a simple process with low costs and high success rates 16 , 18 , 19 . As the ICM reported previously, studies have revealed that our QCA improves radiation exposure during AVS and the success rate of AVS 20 .…”