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Adrenal Vein Sampling

Adrenal vein sampling is a procedure to help differentiate bilateral adrenal hyperplasia from an aldosterone-secreting adenoma. These two processes have different treatments, typically surgical for adenoma and medical management for hyperplasia. Adrenal vein sampling can be tedious and tedious work but with the appropriate preparation and understanding of the anatomy, this procedure can be accomplished safely and efficiently.

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Pre-Procedure Prep

Indications

• Identification of primary aldosteronism and localization of aldosterone-producing adenoma.
• Confirm adrenal gland as excess cortisol source in Cushing syndrome.
• Elevated cortisol lateralizing to adrenal vein in presence of adrenal mass is confirmatory of endogenous Cushing syndrome

Contraindications

• Adrenalectomy/ablation not possible due to multiple comorbidities
• Patients with familial hyperaldosteronism type I and type III genetic mutations
• Contrast allergy
• Ensure no mineralocorticoid receptor blockers (spironolactone) taken for 6 weeks prior to AVS

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Procedure Steps

Access

• Right common femoral vein
• Place 6 or 7-Fr sheath

Primary Aldosteronism

• Typically cannulate/sample right followed by left adrenal vein, plus peripheral vein
• Peripheral venous sample: Obtain from access sheath or infrarenal IVC
• Submit samples for aldosterone and cortisol assays
• Appropriate cortisol level confirms correct catheter position within adrenal vein
• Consider stimulating with cosyntropin, institution-specific protocol

Cushing Syndrome

• Typically cannulate/sample right followed by left adrenal vein, plus IVC above adrenal glands, and IVC below renal veins
• Cosyntropin stimulation is not necessary
• Submit samples for cortisol assays

When obtaining venous samples, note time obtained and label all tubes with attention to right vs. left
Collect samples in appropriate containers for laboratory analysis; conform to lab requirements for accurate sample analysis (e.g., refrigerated sample)

Right Adrenal Vein

• Right adrenal vein is short (1-15 mm) and located superior and posterior to renal vein:
• Use reverse-curve catheter (SIM 1, VAN) to selectively catheterize right adrenal vein
• Adrenal vein typically arrayed in classic Δ form
• Superficial spider-like veins can be present
• Distinguish adrenal vein vs. accessory hepatic vein
• If adrenal vein drains into accessory hepatic vein, catheter tip should be advanced through hepatic accessory vein into adrenal vein

Left Adrenal Vein

• Use Cobra 2 or Simmons 1 or 2 catheter to cannulate left adrenal vein; may require coaxial microcatheter
• Position catheter tip beyond left inferior phrenic vein confluence but before adrenal tributaries

Adrenal Vein Characteristics

• Triangle-/Δ-shaped angiographic blush
• Central vein communicating with smaller veins in stellate/spiculated pattern
• Communicating retroperitoneal collaterals
• Confirm catheter position, gently inject 1 to 3 mL contrast
• Patient may experience back pain during contrast injection into adrenal vein, particularly on right

Aspirate from Adrenal Glands

• Slow, intermittent aspiration
• Ideally obtain 5 to 8 mL samples (discuss with laboratory at your institution)
• If aspirate flows readily, catheter likely disengaged from adrenal vein
• Punching small hole into catheter tip helps prevent vein collapse as sample is aspirated
• Record time and location (right vs. left) of aspiration on each vial
• Adrenal veins are small, weak, and prone to rupture; avoid forceful contrast injections
• Usually tenuous selective catheter positions in adrenal veins; avoid excessive catheter movement when obtaining samples to prevent dislodgement

Potential Intraprocedural Issues

• Most common difficulty is failure to cannulate right adrenal vein, due to challenging anatomy
• Selective catheterization of hepatic caudate lobe venous drainage often mistaken for right adrenal vein

Post-Procedure

Complications

• Adrenal vein dissection/rupture (< 1%)
• Adrenal hemorrhage or infarction (< 1%)
• Contrast reaction or contrast nephropathy
• Access site complications

Results

• Adrenal adenoma has high aldosterone:cortisol ratio before/after ACTH; lateralizes to affected side
• Lateralization generally considered > 4:1 ratio difference between glands
• In bilateral hyperplasia, no lateralization of ratios before or after ACTH, but aldosterone:cortisol ratio is higher than in IVC

• Adrenal adenoma has high aldosterone:cortisol ratio before/after ACTH; lateralizes to affected side
• Lateralization generally considered > 4:1 ratio difference between glands
• In bilateral hyperplasia, no lateralization of ratios before or after ACTH, but aldosterone:cortisol ratio is higher than in IVC

References

[1] Harsha A, Trerotola SO. Technical aspects of adrenal vein sampling. J Vasc Interv Radiol. 2015;26(2):239. doi:10.1016/j.jvir.2014.11.006
[2] Monticone S, Viola A, Rossato D, et al. Adrenal vein sampling in primary aldosteronism: towards a standardised protocol. Lancet Diabetes Endocrinol. 2015;3(4):296‐303. doi:10.1016/S2213-8587(14)70069-5
[3] Kahn SL, Angle JF. Adrenal vein sampling. Tech Vasc Interv Radiol. 2010;13(2):110‐125. doi:10.1053/j.tvir.2010.02.006
[4] Daunt N. Adrenal vein sampling: how to make it quick, easy, and successful. Radiographics. 2005;25 Suppl 1:S143‐S158. doi:10.1148/rg.25si055514
[5] BackTable, LLC (Producer). (2018, February 20). Ep 23 – Adrenal Vein Sampling [Audio podcast]. Retrieved from https://www.backtable.com/shows/vi

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