Elsevier

Surgery

Volume 152, Issue 4, October 2012, Pages 643-651
Surgery

Central Surgical Association
Modification of the protocol for selective adrenal venous sampling results in both a significant increase in the accuracy and necessity of the procedure in the management of patients with primary hyperaldosteronism

https://doi.org/10.1016/j.surg.2012.07.007Get rights and content

Background

Adrenal venous sampling (AVS) is used in the work-up of primary hyperaldosteronism (PA) to distinguish unilateral PA from bilateral adrenal hyperplasia. In 2006, we reported that only 44% of AVS had biochemical evidence of bilateral adrenal vein cannulation (BAVC). Critical appraisal of our practice resulted in a protocol change. This study examined the impact of this new protocol on both the technical success rate and its influence on management of PA.

Methods

Since 2006, all patients with biochemically documented PA referred to either a single endocrine surgeon or endocrine specialist underwent AVS. Successful BAVC was defined as an adrenal vein to inferior vena cava/cortisol ratio of >3:1. Lateralization was defined as an aldosterone:cortisol ratio >3 times the unaffected side.

Results

Of the 86 AVS performed on 84 patients with PA, 82 had BAVC (95%). AVS altered the management in 26 of 84 (31%) patients. Despite clear unilateral findings on imaging in 45 patients, AVS demonstrated bilateral adrenal hyperplasia. in 10 and contralateral disease in 3. AVS confirmed unilateral PA in 5 patients with equivocal <1 cm nodules. In 4 of 25 patients with normal adrenal glands, AVS demonstrated lateralization. AVS demonstrated unilateral PA in 4 of 9 patients in whom imaging suggested bilateral adrenal hyperplasia.

Conclusion

Our new AVS protocol resulted in a marked improvement in BAVC. AVS influenced management in a third of patients with PA. Surgical decision-making cannot be made solely on the basis of cross-sectional imaging.

Section snippets

Methods

After the publication of our initial AVS results, a critical appraisal of our practice was undertaken. After the identification of numerous factors believed to have contributed to this poor performance, a new protocol at the University of Calgary was instituted. Since 2006, all patients with documented PA deemed to be appropriate operative candidates, regardless of the imaging findings, were subjected to AVS performed by a single radiologist. ACTH (Cortrosyn) stimulation with a 250-μg bolus

Results

Eighty-six AVS procedures were performed in 84 patients. The median age of this group of patients was 50 years. Forty-four patients were female. Median systolic and diastolic blood pressures at presentation were 148 mm Hg and 90 mm Hg, respectively. Patients were on a median of 2.5 antihypertensive medications (range, 0–5). Hypokalemia was noted in 62% (52/84) patients at presentation. Median aldo:renin ratio was 14,950 (Table I). BAVC was documented in 82 of 86 procedures (95.3%), which

Discussion

During the critical appraisal of our AVS protocol, several factors believed to have limited performance were identified: (1) multiple radiologists; (2) multiple centers; (3) first-year fellows involved in 30% of procedures; (4) lack of ACTH infusion at some centers; and (5) inconsistent standards/cutoffs for interpretation. The described change in the AVS protocol at the University of Calgary resulted in a biochemical success rate of 95% since 2006. Our previously reported low success rate was

References (22)

  • I. Gockel et al.

    Long-term results of endoscopic adrenalectomy for Conn's syndrome

    Am Surg

    (2007)
  • Cited by (0)

    View full text