[Adrenal Vein Sampling in Primary Aldosteronism: A Pictorial Essay for Optimal Left-Side Sampling]

Abstract

Primary aldosteronism (PA) is a curable cause of hypertension. Recent studies have revealed that the actual prevalence of PA is higher than previously recognized. Adrenal vein sampling (AVS) is an essential diagnostic procedure for revealing the cause of PA and determining the treatment plan. The success of AVS is confirmed by comparing cortisol levels between the samples from each adrenal vein and peripheral vein. The failure rate of the procedure is reported to be high in the right adrenal vein, which is directly connected to the inferior vena cava, while that in the left adrenal vein is relatively low; however, this has rarely been reported. In this review, we introduce and analyze cases of failure in left adrenal vein sampling.

Fig. 1. CT and fluoroscopic images of a 54-year-old male patient show right adrenal vein and its mimics.

A. CT image of right adrenal vein (arrow) draining into the inferior vena cava, T12 level. B. Fluoroscopic image of right adrenal vein, confirmed by selectivity index higher than 3 (with cosyntropin use). C, D. Fluoroscopic images of accessory hepatic veins mimicking right adrenal vein. E. Fluoroscopic image of retroperitoneal vein mimicking right adrenal vein.

Fig. 2. Morphologies of right adrenal veins on adrenal venography. All images were obtained from patients confirmed by selectivity index higher than 3 (with cosyntropin use).

A. Digital subtraction angiography image shows triangular pattern of right adrenal vein with inferior emissary vein (arrow). B-D. Digital subtraction angiography images show various morphologies of right adrenal vein. E. Digital subtraction angiography image shows communication between right adrenal vein and hepatic vein.

Fig. 3. Fluoroscopic image of left common trunk shows valve of left phrenic vein (arrow) and morphology of left adrenal vein well.

Fig. 4. Right adrenal vein in a 32-year-old female patient.

A. Fluoroscopic image of right accessory hepatic vein staining liver parenchyma (arrow). B. Cone beam CT image of right accessory hepatic vein (arrow). C. Digital subtraction angiography image (left anterior oblique, 48°) of right adrenal vein and right accessory hepatic vein. Anteroposterior imaging could not distinguish the two veins (not shown). D-F. Cone beam CT image of right adrenal vein (pink dot). Three-dimensional cone beam CT image makes clear view of right adrenal vein.

Fig. 5. Case 1. Both adrenal vein sampling with suspicion of right adrenal gland aldostroma in a 57-year-old female patients, complaining right upper abdominal pain.

A. CT image shows a 4.2 cm heterogeneously enhancing right adrenal mass (arrow) which contains suspicious tiny calcifications. Hounsfield unit of right adrenal mass was 22 on pre-contrast, 92 on contrast-enhanced, and 53 on 15-minute delayed scans. B. Normal appearing left adrenal gland (arrow). C. Fluoroscopic image of right adrenal vein (arrow). D. CT image of left common trunk (arrow, about 16 mm in length) and left phrenic vein. E. CT image of left adrenal vein (arrow) and left phrenic vein (arrowhead) after bifurcation. Left phrenic vein shows more acute angle with left renal than left adrenal vein. F. Fluoroscopic image of left adrenal vein sampling shows catheter advanced beyond the bifurcation of common trunk (about 29 mm). Near vertical angle of catheter (arrow) suggests it is placed in left phrenic, not left adrenal vein.

Fig. 6. Case 2. Fluoroscopic image of left adrenal venous sampling.

A, B. First (without cosyntropin use) (A) and second (with cosyntropin use) (B) adrenal vein sampling images show same location of catheter tips.