Role of Venous Sampling in the Diagnosis of Endocrine Disorders

Abstract

Venous sampling is the gold standard for localizing abnormal hormone secretion in several endocrine disorders. The most common indication for venous sampling is in the workup of primary aldosteronism, adrenocorticotropic hormone-dependent Cushing's syndrome, and hyperparathyroidism. In experienced hands, venous sampling is safe and accurate. This review discusses the role of venous sampling in the workup of endocrine disease, describing the underlying anatomy and pathophysiology, as an understanding of these concepts is essential for technical and clinical success.

Keywords: Cushing’s disease; adrenal vein; hyperparathyroidism; inferior petrosal sinus; primary aldosteronism; venous sampling.

Figure 1

Workup of Cushing’s syndrome. Suspected endogenous Cushing’s syndrome is evaluated in a stepwise manner. BIPSS is indicated when noninvasive testing is inconclusive for diagnosing Cushing’s disease which involves a pituitary source of ACTH. CS: Cushing’s syndrome; ACTH: adrenocorticotropic hormone; CRH: corticotropin-releasing hormone; IPS: inferior petrosal sinus; P: peripheral; BIPSS: bilateral inferior petrosal sinus sampling.

Figure 2

Workup of hyperaldosteronism. Primary aldosteronism is evaluated in a stepwise manner. If imaging fails to demonstrate suspected adrenal malignancy, AVS is performed to diagnose a unilateral source of excess aldosterone secretion, prior to adrenalectomy. PA: primary aldosteronism; AVS: adrenal vein sampling; APA: aldosterone-producing adenoma; BAH: bilateral adrenal hyperplasia.

Figure 3

Workup of hypercalcemia. Primary hyperparathyroidism is diagnosed in patients with elevated parathyroid hormone and normal to elevated 24-h urinary calcium excretion. PTH: parathyroid hormone; PHPT: primary hyperparathyroidism; FHH: familial hypocalciuric hypercalcemia; PVS: parathyroid venous sampling.

Figure 4

Inferior petrosal sinus venography. During bilateral inferior petrosal sinus sampling, the inferior petrosal sinuses are cannulated with microcatheters (arrows). Gentle hand injection demonstrates contralateral reflux (arrowhead) when the IPS is adequately cannulated.

Figure 5

Right adrenal venography. During adrenal vein sampling, the right adrenal vein is cannulated with a 4- or 5-French catheter. Gentle hand injection demonstrates downward or laterally sloping veins that do not communicate with the hepatic veins.

Figure 6

Left adrenal venography. The left adrenal vein (arrow) merges with the inferior phrenic vein. The common trunk empties into the left renal vein (arrowhead). In this venogram, the left adrenal is hypertrophied due to a hormone-secreting nodule.

Figure 7

Thyroidal venography. During parathyroid hormone venous sampling, the thyroidal veins are key to target as most abnormal tissue will be located in the neck. The superior and medial thyroidal veins empty into the internal jugular vein (asterisk). In this image, the superior thyroidal vein (arrowhead) has been cannulated and hand injection with prolonged imaging demonstrates the orifices of the middle thyroidal vein (arrow) at the caudal internal jugular vein, and the inferior thyroid trunk (double arrowhead), which empties into the left brachiocephalic vein (double asterisk).