Selective Parathyroid Venous Sampling: Practical Pearls, Pitfalls and Evidence-Based Outcomes

Learning Objectives:

• Define the role and indications for parathyroid venous sampling (PVS) in the diagnosis and management of primary hyperparathyroidism (pHPT).


• Examine the relevant clinical and vascular anatomy relevant to PVS.


• Discuss pertinent procedural steps, technical challenges, and considerations.


• Review interpretation of results relevant to treatment planning, and evidence-based outcomes.

Background: Although surgical exploration is regarded as the gold standard of management of pHPT, as many as 5%-10% of patients present with recurrent or persistent disease predominantly due to unsuccessful preoperative localization. Re-exploration carries significant technical challenges, high failure rates and increased risk of complications. Furthermore, minimally invasive parathyroidectomy has also been increasingly utilized to minimize the morbidity associated with an extensive bilateral neck exploration. Thus, meticulous preoperative planning and localization becomes crucial in the management of pHPT. Although relatively rarely used, PVS may prove a vital tool when other non-invasive modalities are inconclusive.

Clinical Findings/Procedure Details: A review of indications and rationale for patient selection will be discussed. Normal and ectopic parathyroid anatomy, including arterial supply and venous drainage with marked implications to localization will be examined. Procedural details will highlight the typical approach with a focus on recommended equipment, super-selective venous sampling tips, approach to altered anatomy in the re-operative patient, as well as other practical pearls, and discussion of pitfalls. Interpretation of results, evidence-based outcomes, and diagnostic utility will also be reviewed. 

Conclusion and/or Teaching Points: Preoperative planning and localization is of utmost importance in the surgical management of pHPT particularly in patients with recurrent/persistent disease after initial surgery. PVS can be an important intervention in the accurate localization of disease in the setting of discordant noninvasive methods, aiding to improve treatment outcomes.