Procedure Guides
Venous

Adrenal Vein Sampling

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Procedure Guide

Indications

Primary hyperaldosteronism - bilateral hyperplasia vs adenoma

Other suspected functional adrenal lesion

Contraindications

Uncorrected coagulopathy (INR >1.7, Plt <50K)

Bacteremia

Critical illness - generally an elective procedure

Severe hypokalemia - no exact cutoff. Some will correct during procedure vs reschedule.

Efficacy and alternatives

Technical success rate in studies vary widely from 40% to >90%. Most common failure is due to inability to select the right adrenal vein or misidentification of it.

Alternative would be adrenalectomy without sampling if high level of clinical suspicious, but this rarely done.

Pre-procedure care

Hold spironolactone for 6 weeks prior

Hold any medications affecting renin secretion for 4 weeks prior (CCBs and a-antagonists okay, ACEIs, ARBs, and b-blockers usually okay). Can try 2-week protocol if patient is unable to tolerate 4-6 weeks.

Hold coumadin/Plavix 5d, lovenox 1d. No need to hold ASA/NSAID

Labs: PT/INR, CBC, BMP

Review available cross sectional imaging if available (not required)

procedure

  • ACTH (cosyntropin) stimulation via 50 ug/h drip started >30 min prior to sampling and throughout the procedure OR bolus of 250 ug 15 min prior to sampling if collecting pre- and post stimulation

  • (Optional) Some use hole puncher to make a hole near the catheter tip to aid with sampling with location of hole depending on side and catheter

    • E.g. hole on the inferior aspect of a SIM 2 for the left and superior aspect of a RDC for the right

  • Central venous access - CFV or IJ, two points of access to sample nearly simultaneously vs single access doing one side at a time (right then left)

  • (Optional) Cavagram if pre-procedural imaging is sufficient

  • Select the adrenal veins

    • If doing bilateral access, select left then right. If doing single access, select and sample right and then left since left is easier to select.

    • Right adrenal vein - often directly off IVC 4-5 cm above the right renal vein in the region of the accessory right hepatic vein if present, RDC works well, others use Mikaelsson, C2, SIM 1, or VAN

    • Left adrenal vein - often off left renal as common adrenophrenic trunk, Sim 2, Sim 3, Kumpe, or C2. Microcatheter is optional.

  • Confirm positioning with GENTLE hand injections +/- cone-beam CT (easy to cause hemorrhage with forceful infection)

  • Can collect samples simultaneously or sequentially

  • Often redo hand injections to document stable catheter positioning after sampling

  • (Optional) Rapid Cortisol Assay to confirm adequate sampling. Can also redo hand injections to confirm stable catheter positioning at the end.

  • Obtain peripheral sample by pulling down catheter to IVC bifurcation or from access sheath

  • Remove catheter(s)/sheath(s) and achieve hemostasis

Complications

Adrenal hemorrhage (<1%)

Incorrect lateralization

Adrenal insufficiency or hypertensive crisis are extremely rare

Interpretation of results

Selectivity Index (SI): cortisol in adrenal vein/IVC, should be >2 w/out stimulation and >5 w/ stimulation to confirm correct sampling location

Lateralization Index (LI): cortisol in dominant AV / non-dominant AV, >2-4 lateralizes to one side, no lateralization suggests benign adrenal hyperplasia

Contralateral Suppression Index (CSI): cortisol in non-dominant AV / IVC,  <1 indicated suppression of contralateral gland