Tushar Garg, MD (he/him/his)
Postdoctoral Research Fellow
Johns Hopkins University School of Medicine
Disclosure information not submitted.
Mark L. Lessne, MD
Vascular and Interventional Radiologist
Vascular & Interventional Specialists, Charlotte Radiology
This study aims to identify patient demographics and pre-procedural laboratory values that can influence adrenal vein sampling (AVS) lateralization rates and clinical or biochemical response after surgical resection.
Materials and Methods:
This study included 294 consecutive patients who underwent 310 bilateral AVS procedures to evaluate for primary hyperaldosteronism from 2014 to 2022. Sampling was considered selective if the adrenal vein to peripheral vein cortisol ratio was >4 with cosyntropin stimulation, or >2 without stimulation. A lateralization index >4 was used to identify unilateral secretion. Patient demographics, comorbidities, size of dominant adrenal nodule, number of anti-hypertensives, pre-procedural Na+, K+, aldosterone (PAC), renin (PRC), aldosterone to renin ratio (ARR), final pathological diagnosis, and post-operative clinical responses were recorded. The positive operative response was defined as a decrease in the use of anti-hypertensive medication, PAC < 9 ng/dl, or PRC >2 ng/ml/hr measured post-operatively within 8 weeks.
AVS was selective in 94.8% of procedures (294/310), and lateralization was determined in 74.1% (218/294) of them. Appropriate follow-up was available 96 patients that underwent surgical adrenalectomy, of which 78.1% (75/96) were found to have an adenoma, 18.8% (18/96) hyperplasia, and 3.1% (3/96) normal adrenal tissue. In patients that underwent surgical resection, 91.7% (88/96) had positive operative responses based on clinical or biochemical criteria. Of all the variables that were included in the study, patients with obesity (67.2% vs. 50.5%; p=.04), smaller size of the dominant adrenal nodule (1.6 ± 0.9 vs. 2 ± 1.7; p=.04), lower K+ levels (3.6 ± 0.6 vs. 3.8 ± 0.5; p=.002), lower PRC levels (0.4 ± 0.6 vs. 0.7 ± 1; p=.002) and higher ARR (180.9 ± 192.3 vs. 119.4 ± 250.2; p=.02) were more likely to lateralize on AVS. Additionally, the presence of collagen vascular disease (2/4 vs. 42/46; 50% vs. 91.3%; p=.02), hypothyroidism (2/4 vs. 42/46; 50% vs. 91.3%; p=.02) and obesity (15/21 vs. 29/29; 71.4% vs. 100%; p=.002) resulted in a decrease in the chances of a positive operative response.
In this large single center study, AVS was shown to be highly successful in determining lateralization and positive operative responses after adrenalectomy were achieved in over 90% patients. This study highlights that patients with more biochemically active primary aldosteronism have increased chances of lateralization, and that the presence of significant comorbidities can reduce the chances of a positive operative response.