Current State of Adrenal Vein Sampling: Towards a Unified Protocol

To explain the role of Adrenal Vein Sampling (AVS) in the workup of primary aldosteronism (PA), describe standard variations in procedural steps and discuss the need for a unified protocol.

Background: Adrenal vein sampling (AVS) is considered the gold standard for subtyping primary aldosteronism (PA) into unilateral or bilateral disease; a diagnostic step which has great implications for management as treatment for unilateral disease is adrenalectomy, while for bilateral disease, management is medical. Recent data suggests that PA is far more common than previously recognized, comprising up to 10% of the underlying etiology in patients with hypertension. With the widespread prevalence of hypertension, this implies a growing need for interventionalists capable of performing this procedure with a high success rate. Sampling success is most often limited by the innate difficulty in cannulating the diminutive right adrenal vein. Even with experienced interventionalists capable of successful cannulation, there are a wide variety of procedural and interpretation protocols. Without a unified, standardized procedural and interpretation protocol, research into the accuracy and reproducibility of this procedure, steps towards optimizing procedural success and the ability to train interventionalists skilled in this procedure, is severely limited. It is time to evaluate the current protocols and move towards a more unified approach.

Clinical Findings/Procedure Details: In this exhibit, we will discuss (1) the basic endocrine science behind AVS (2) General, required steps to the AVS procedure (3) The two major technical variations (a) sampling performed w/ cosyntropin stimulation, w/o cosyntropin stimulation or both and (b) sequential or simultaneous sampling (4) Typical and atypical interpretation cutoff values for sampling performed w/ and w/o cosyntropin stimulation and cutoff data (5) The data necessary to take the next steps in either creating a standardized procedure protocol or a generalized interpretation schema that can be utilized for whichever protocol is performed.

Conclusion and/or Teaching Points: AVS is pivotal in determining the definitive treatment for PA, a significantly morbid disease process which is more prevalent than previously thought. There is a growing need for skilled interventionalists who can successfully perform this procedure thus a need for unified standardized procedural and interpretation protocol. With a standardized protocol, IR will be able to provide improved AVS research that are accurate, reliable, reproducible and can be passed on to the next generation of interventionalists.