E2760. Adrenal Venous Sampling: A Primer to an Underutilized Tool for Future Interventionalists
  1. Arka Dutta; Cooperman Barnabas Medical Center
  2. Akhil Sureen; Cooperman Barnabas Medical Center
  3. Irfan Hassan; Cooperman Barnabas Medical Center
  4. Bhavana Devanabanda; Cooperman Barnabas Medical Center
  5. Jay Patel; Cooperman Barnabas Medical Center
  6. Cornelius McCarthy; Cooperman Barnabas Medical Center
This educational exhibit will be a primer to an underutilized tool for diagnosing a common cause of primary hypertension. Primary hyperaldosteronism is now recognized as the most common form of secondary hypertension. It is initially diagnosed based on clinical and biochemical features, but adrenal venous sampling plays an important role in differentiating between the two main causes of primary hyperaldosteronism namely aldosterone-producing adenoma (APA) and bilateral adrenal hyperplasia (BAH). The purpose of adrenal venous sampling (AVS) will help confirm aldosterone production and if production is unilateral or bilateral. This can help the referring endocrinologist/nephrologist direct further management as APA is treated surgically with either a partial or total adrenalectomy whereas BAH is managed medically.

Educational Goals / Teaching Points
Interventional radiologists and residents should know the indications for adrenal venous sampling, review adrenal anatomy and evaluate common anatomical variants regarding vasculature. They should learn the interventional technique with respect to the use of different catheters and different sample protocols that are in place. In reviewing the material and multiple cases residents and interventionalists will know how to handle the technical issues and complications of this intervention such as infarction or adrenal venous rupture. Understanding the interpretation of venous sampling values will also let the interventionalist confirm if a sufficient sample for analysis was obtained.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
As one of the biggest obstacles is catheterization of the right adrenal vein, preprocedural imaging with computed tomography can help plan the expected location of the adrenal gland in regard to the level of the vertebra and also help delineate the adrenal veins with respect to other venous vasculature. Imaging also helps plan for different anatomical variants that can arise, especially in the venous system and the left renal vein. As there the right adrenal vein branches off the IVC and the left adrenal vein branches off the left renal vein, different catheters are used to gain better accessibility for the small caliber vessel. After obtaining initial sampling results there have been two different schools of thought regarding the use of adrenocorticotropic hormone (ACTH) stimulation and obtaining further samples. The necessity of ACTH stimulation is usually discussed with the referring provider to see if it increases the sensitivity or specificity of the sample.

Adrenal venous sampling which is performed by interventional radiologists can now play a role in differentiating between unilateral aldesterone-producing adenomas and bilateral adrenal hyperplasia. Interventional radiologists should be able to obtain a sufficient sample skillfully while minimizing the risks associated with the procedure. This will allow patients to get the proper management by either excising the adenoma or continuing likely life-long management with medication.