Is there a role for segmental adrenal venous sampling and adrenal sparing surgery in patients with primary aldosteronism?

Abstract

Objective and design: Adrenal venous sampling (AVS) is critical to determine the subtype of primary aldosteronism (PA). Central AVS (C-AVS) -that is, the collection of effluents from bilateral adrenal central veins (CV) -sometimes does not allow differentiation between bilateral aldosterone-producing adenomas (APA) and idiopathic hyperaldosteronism. To establish the best treatment course, we have developed segmental AVS (S-AVS); that is, we collect effluents from the tributaries of CV to determine the intra-adrenal sources of aldosterone overproduction. We then evaluated the clinical utility of this novel approach in the diagnosis and treatment of PA. Methods: We performed C-AVS and/or S-AVS in 297 PA patients and assessed the accuracy of diagnosis based on the results of C-AVS (nZ138, 46.5%) and S-AVS (nZ159, 53.5%) by comparison with those of clinicopathological evaluation of resected specimens.Results: S-AVS demonstrated both elevated and attenuated secretion of aldosterone from APA and non-tumorous segments, respectively, in patients with bilateral APA and recurrent APA. These findings were completely confirmed by detailed histopathological examination after surgery. S-AVS, but not C-AVS, also served to identify APA located distal from the CV. Conclusions: Compared to C-AVS, S-AVS served to identify APA in some patients, and its use should expand the pool of patients eligible for adrenal sparing surgery through the identification of unaffected segments, despite the fact that S-AVS requires more expertise and time. Especially, this new technique could enormously benefit patients with bilateral or recurrent APA because of the preservation of non-tumorous glandular tissue.

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

“…21 However, this technique is highly demanding and is only available in few specialized centers. 22 In addition to performing short synacthen testing postoperatively, preoperative testing for residual adrenal function in the gland bearing the AH by performing adrenal scintiscan using 131 Inor cholesterol without dexamethasone suppression could be considered. This procedure has been suggested previously 23 and successfully undertaken in one of our patients (TO-01) before contralateral adrenalectomy to the AH.…”

Primary Aldosteronism: Changing Definitions and New Concepts of Physiology and Pathophysiology Both Inside and Outside the Kidney

“…tomy (385,452). This is particularly relevant for patients suspected of having bilateral APAs or those who have only one functioning adrenal that may contain an APA, for whom partial adrenalectomy may correct PA and yet leave sufficient normal adrenal in situ to avoid the need for steroid replacement therapy post-operatively.…”

“…This approach does, however, carry a risk of persistent PA or a further recurrence. As discussed in section XIG, "super-selective" AVS has been used to provide greater confidence that visualized lesions in such circumstances are indeed the source of aldosterone excess (385,452), but this procedure is only performed in a very small number of centers.…”

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

“…Some authors propose segmental AVS as a way to refer PA patients for a selective nodulectomy, instead of the total resection of the adrenal gland [53]. This is particularly relevant to enable the surgical cure of patients with bilateral APA and in patients with APA in the remaining adrenal gland after a contralateral adrenalectomy [53].…”