A Blessing in Disguise: A Rare But Major Complication of Adrenal Vein Sampling

Thursday, May 12, 2022

12:10 PM – 12:25 PM

Location: Station 14, Sapphire E

Submitter(s)

RZ
Rabia Zulfiqar, MD
Internal Medicine Resident
Cleveland Clinic Akron General
Uniontown, Ohio, United States

Primary Author(s)

RZ
Rabia Zulfiqar, MD
Internal Medicine Resident
Cleveland Clinic Akron General
Uniontown, Ohio, United States

Co-Author(s)

IS
Irtsam Shahid, MD
Attending
Cleveland Clinic hospital , Ohio, United States
MM
Michael Morocco, MD
Attending Physician
Cleveland clinic Akron General
Akron, Ohio, United States

Introduction : Primary hyperaldosteronism(PA), caused by adrenal adenoma or adrenal hyperplasia₁, is a common cause of resistant Hypertension (HTN)₂. Adrenal vein sampling (AVS) helps in differentiating between these two conditions, as treatment will vary. This case highlights a rare complication of AVS.

Case Description : A 64 year old female with a history of HTN, COPD, OSA on CPAP presented with uncontrolled HTN despite being on maximal dose of diltiazem and losartan-Hydrochlorothiazide. Work up for resistant HTN, off antihypertensives showed Serum Renin < 0.1 (3.6-81.6 pg/ml), aldosterone 19.1 ng/dl (3.1-35.4 ng/dl), while serum cortisol, metanephrines/normetanephrines, TSH and electrolytes were normal. A CT chest from 5 years ago showed right adrenal nodule and left adrenal hyperplasia. Repeat imaging was unchanged. A 24 hour urinary aldosterone was elevated at 13 ug/24 hr ( < 10 mcg/24hr). The patient was started on spironolactone with improvement in HTN. After discussion, AVS was planned with possible surgery based on the findings. On AVS the aldosterone lateralized to the right adrenal vein. A few hours post-procedure she went to the Emergency Department for abdominal pain. CT abdomen showed a 5.3x2.3x4.7 cm right suprarenal mass representing right adrenal hemorrhage. She was managed conservatively. During her hospital stay she was normotensive without anti Hypertensives. Repeat serum aldosterone and morning cortisol were within normal range. Follow up imaging after discharge showed decreased size of right adrenal nodule, with normal serum renin, aldosterone, cortisol, cosyntropin test and electrolytes. A decision was made to monitor, with planned imaging in 6 months.

Discussion : Patients with resistant HTN should be screened for PA by plasma aldosterone/renin assay, which, if positive, is followed by one or more confirmatory tests₃,₄. Once Confirmed, imaging and AVS are used to diagnose the subtype and to lateralize the source of excess aldosterone₁. The sensitivity and specificity of AVS (95 & 100%, respectively) to lateralize the source is superior to that of CT(78 & 75%, respectively) and is thus the gold standard₅,₆,₇. AVS is a costly and invasive procedure that requires a high level of expertise. The major complication of AVS is adrenal vein rupture commonly on the right side due to difficult anatomy₈. Other complications are dissection, infarction, thrombosis and subsequent hematoma₉. Per some reports the complication rate is 5-10%₉,₁₀ but a recent global multicenter study demonstrated that the rate of adrenal vein rupture was 0.61%₁₁. These complications lead to adrenal insufficiency, but in our patient it proved to be curative by rendering adenoma non functional after hemorrhage.