adrenal vein sampling

Adrenal vein
sampling: technique and protocol, a systematic review. Varied appearance of the right adrenal vein in 4 different patients. All 4 images are of the right adrenal vein, confirmed by elevated cortisol levels. Images c and d show an inferior emissary vein (black arrows), diagnostic of adrenal vein cannulation
CVIRendovasc.springeropen.com • CC-by-4.0
Adrenal vein
sampling: technique and protocol, a systematic review. Cone-beam CT of an accessory hepatic vein (a) and the right adrenal vein (b). In this patient, two different veins were cannulated. Given ambiguous conventional venographic appearance, cone-beam CT was performed. a Shows opacification of hepatic parenchyma. b Confirms cannulation of the adrenal vein
CVIRendovasc.springeropen.com • CC-by-4.0
Adrenal vein
sampling: technique and protocol, a systematic review. Venographic appearance of an accessory hepatics vein. Images A + B, taken in the same patient show two different accessory hepatic veins. The parenchymal staining and lack of capsular/communicating veins are consistent with hepatic vein rather than adrenal vein cannulation. Occasionally, one may see intrahepatic communication to larger hepatic veins
CVIRendovasc.springeropen.com • CC-by-4.0
Adrenal vein
sampling: technique and protocol, a systematic review. Venographic appearance of the left adrenal vein. In both A + B a Simmons-2 catheter is used to select the left renal vein and then the common phrenic adrenal trunk. In a, contrast refluxes into the adrenal branch (lateral). In b, the common trunk and a small part of the inferior phrenic vein (medial) and the left adrenal vein (lateral) are seen. Reflux of contrast into the adrenal vein proper is not necessary to confirm correct location
CVIRendovasc.springeropen.com • CC-by-4.0
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Adrenal vein sampling (AVS) is a procedure where blood is collected from the adrenal veins via catheter to confirm autonomous hormone production, if it is unilateral or bilateral, and to guide further treatment.

Indication

Adrenal vein sampling is commonly performed in primary aldosteronism, being indicated to identify aldosterone-secreting adenomas and to differentiate adenomas from bilateral adrenal hyperplasia. It can be performed also to identify a biochemically proved pheochromocytoma that is not visible at CT or MRI .

In rare occasions, adrenal vein sampling could be used for adrenal Cushing disease or for syndromes of androgen excess.

Technique

Although technique varies a standard modern approach would consist of :

  • review prior imaging as CT or MRI
  • obtain a venous access from common femoral vein puncture with guiding catheter / microcatheter set-up
  • place selective catheter in IVC and sequentially cannulate and sample right followed by left adrenal vein
  • confirm catheter position with contrast injection
    • back pain could be reported by the patient while contrast is injected into adrenal vein, particularly on the right
  • venous sampling from each adrenal vein and peripheral source (e.g., femoral vein)
    • some institutions use adrenocorticotropic hormone (ACTH) infusions before and during adrenal sampling.
    • other institutions avoid it due a suspicion of possible misdiagnosed bilateral cases .
  • label all tubes (attention to right vs. left)
  • submit samples for laboratory assays (aldosterone and cortisol)