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434
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J. D. Georgia and D. L. Miller
Arteriography should include selective studies of the
superior mesenteric, gastroduodenal, splenic, and dorsal
pancreatic arteries, if technically feasible. Selective hepatic arteriography also should be performed to identify
liver metastases. A variety of catheter shapes may be used
for catheterization of these vessels; the choice depends
on the patient’s anatomy and the angiographer’s personal preference.
The reported sensitivity of arteriography for localization of primary islet cell tumors has decreased in recent
37
years.
Older studies report a sensitivity of approximately
65%, but more recent studies suggest that fewer than half
of these tumors are detected arteriographically.
54,55
This
difference is probably due in part to earlier detection and
in part to referral bias. On the other hand, the false-positive rate is generally reported as less than 10%. The sensitivity of arteriography for locating primary tumors is
superior to that of CT, MRI, or ultrasound when all four
modalities are compared in the same patient popula-
37,56–58
tion.
Arterial stimulation and venous sampling
ASVS, also sometimes termed selective arterial secretin injection when used for gastrinomas, was first described as
a localization procedure for patients with Zollinger-Ellison syndrome;
oped and refined for localization of both gastrinomas
and insulinomas.
and is performed as part of the arteriographic procedure.
In addition to the arteriographic catheter, a venous
catheter is introduced via the femoral vein, and its tip is
placed in the right hepatic vein. (A Simmons 1 catheter
with one or two sideholes near the tip is ideal for this
purpose.) A secretagogue is injected through the arterial
catheter selectively into the hepatic artery, gastroduodenal artery, splenic artery, and superior mesenteric artery
successively. The hepatic artery is studied in an effort to
detect metastases that may be too small to be identify with
imaging studies.
subjected to ASVS because this vessel usually supplies the
entire pancreas and therefore has no localizing value. If
an insulinoma or gastrinoma is present in the vascular
territory supplied by one of these arteries, the injection
of secretagogue will cause an increase in the insulin or
gastrin concentration in the portal vein and subsequently
in the hepatic vein. Hepatic vein samples are obtained
before and at 20, 40, and 60 sec after the secretagogue
injection.
Secretin is used as a secretagogue for gastrinomas. It
stimulates gastrin release from gastrinomas bymodulation
of adenylate cyclase activation.
quires injection of 30 IU of secretin intraarterially, with
59
the procedure was subsequently devel-
55,60–62
63
It is an adjunct to arteriography
The dorsal pancreatic artery is not
64
Current technique re-
10-min intervals between injections. In the protocol developed at the National Institutes of Health (NIH), an increase in venous hormone concentration of more than
48% at 30 sec or more than 109% at 60 sec after secretin
injection is a positive response.
60,63
This technique results
in a sensitivity of 77 to 100%, with a false-positive rate near
0%, and it is particularly sensitive for the detection of
duodenal gastrinomas.
ria also may be used.
37,55,60,65
46,65
Other protocols and crite-
Calcium is used as a secretagogue for the localization
of insulinomas in the same fashion and is also effec-
61,62,66
tive.
0.025 mEq Ca
Arterial injections of calcium gluconate (0.01–
⫹⫹
/kg), using the same protocol as used
for secretin injections, yielded a sensitivity of 88% in a
series of 25 patients.
62
A positive study is defined as a
100% increase in insulin level within one minute after
calcium injection.
■ Hyperaldosteronism
Several endocrine syndromes caused by an excess of hormone may be caused by tumors or hyperplasia of the
adrenal glands. Cushing syndrome, pheochromocytoma,
and virilizing disorders may be diagnosed on the basis of
endocrine studies and characterized or localized by crosssectional imaging techniques. Adrenal venous sampling
is usually employed only for primary hyperaldosteronism
(Conn syndrome).
Clinical review
Primary hyperaldosteronism often presents with spontaneous (or easily provoked) hypokalemia in a hypertensive patient; It has been estimated that hyperaldosteronism is present in 1 to 2% of hypertensive patients.
Suggestive initial screening tests include hypokalemia in
association with kaliuresis, low plasma renin activity, and
a high plasma aldosterone concentration/plasma renin
activity ratio. Demonstration of nonsuppressible aldosterone excretion in conjunction with normal cortisol excretion is diagnostic.
The two most common causes of primary hyperaldosteronism are a unilateral aldosterone-producing adenoma (APA; 54%) and bilateral adrenal hyperplasia
(idiopathic hyperaldosteronism; 45%).
67
Thability to distinguish between these entities is a crucial part of the
endocrine evaluation, because adenomas are resected,
whereas hyperplasia is treated medically.
Localization
Noninvasive laboratory and imaging studies may be used
to distinguish between an APA and hyperplasia with an
67
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accuracy of 70 to 80%, but most experts agree that bilateral adrenal vein sampling is the gold standard, with
accuracy rates approaching 100.
68–71
In addition, several
rare forms of hyperaldosteronism (e.g., unilateral primary adrenal hyperplasia) are best characterized by adrenal venous sampling because their cross-sectional imaging appearance may be confusing.
68
Patients who have classic endocrine studies indicating
an APA and a unilateral, low attenuation mass on CT
may undergo adrenalectomy without the need for adrenal venous sampling. Bilateral adrenal venous sampling
is indicated in patients with clinical and laboratory evidence of primary hyperaldosteronism but no clear CT or
MRI demonstration of unilateral surgical disease. These
patients often have bilateral adrenal abnormalities on
imaging studies, but these abnormalities are frequently
unrelated to the endocrine disorder. The CT diagnosis
of adrenal hyperplasia is not reliable in patients with
hyperaldosteronism.
69–72
In patients with apparent bilateral adrenal disease, venous sampling provides physiologic data that permit identification of the cause of the
syndrome without resorting to analysis of gland morphology.
Anatomy
Adrenal venous anatomy is fairly constant (Fig. 34-8).
The left adrenal vein virtually always arises from the left
renal vein at the left lateral margin of the vertebral column. In the uncommon case of a retroaortic left renal
vein, the adrenal vein arises either from the anomalous
renal vein or, rarely, directly from the inferior vena cava
(IVC). On the right side, the adrenal vein empties directly into the posterior IVC and is usually both small and
quite short (5–8 mm), making selective catheterization
for sampling challenging (Fig. 34-9).
68
It can be difficult
to locate and is somewhat more variable in position than
the left adrenal vein.
Venous sampling
The procedure consists of simultaneous sampling from a
femoral vein sheath and from catheters selectively placed
in the adrenal veins via ipsilateral femoral vein punctures,
both before and after the intravenous administration of
adrenocorticotropic hormone (ACTH). The left adrenal
vein is catheterized first. A 4 or 5 Fr Weinberg or Berenstein catheter is guided into the left renal vein with the
help of a tip-deflecting wire. Once in the renal vein, the
catheter tip usually encounters the orifice of the left
adrenal vein at the level of the left lateral margin of the
vertebral column. A 4 Fr straight polyethylene catheter,
shaped with the use of the steam into an S-curve, may be
used instead. Alternatively, a 5 Fr Simmons I catheter
placed in the left renal vein will act as a guiding catheter
to direct a microcatheter into the left adrenal vein when
gentle traction is placed on the guiding catheter to direct
its tip superiorly. The left inferior phrenic vein also drains
into the left adrenal vein. The catheter tip should not be
advanced into the inferior phrenic vein because samples
from this catheter will not contain blood from the left
adrenal gland.
Small, gentle hand injections of contrast material are
used to verify catheter position. No attempt should be
made to opacify the gland or to outline tumors. Diagnostic retrograde venography, performed commonly in the
past, is no longer used, because this procedure may cause
hemorrhage or infarction as a result of rupture of small
adrenal venous radicals. This might seem a good way to
ablate the adrenal gland, but it is not a reliable method
for infarcting the gland. Ethanol should not be used for
adrenal ablation either, because ethanol injection into
the adrenal artery in monkeys produces immediate and
severe hypertension as well as arrhythmias.
73
The right adrenal vein is shorter than the left and trifurcates close to its orifice into the IVC. The tip of a standard
Mikaelsson orSimmons catheter often occludesthe trifurcation once it is adequately seated in the right adrenal
vein, which prevents aspiration of right adrenal venous
effluent and reduces the accuracy of the study. A single
hole may be punched 3 to 4 mm from the catheter tip to
permit collection of venous effluent at the point where
the right adrenal vein joins the IVC.
68
Using this modified
technique when necessary, collection from both adrenals
is consistently possible.
After collection of baseline samples from both adrenal
veins and the femoral vein sheath, ACTH is administered
intravenously in the form of a 25 mcg bolus followed by
an infusion of 25 mcg in 500 mL of normal saline at a rate
of 150 to 200 mL/hr. (ACTH stimulates release of aldosterone as well as cortisol.) Repeat samples are obtained
15 minutes after the start of the infusion. Then the ACTH
infusion is discontinued. All samples are submitted for
assay of both aldosterone and cortisol.
Right adrenal vein samples will be diluted to an unknown degree by inclusion of IVC blood. To correct for
this dilution, aldosterone/cortisol (A/C) ratios are used.
The decrease in right adrenal aldosterone levels resulting
from dilution should be equal in proportion to the decrease in cortisol levels. Cortisol production by each adrenal gland is assumed to be equal. Use of the A/C ratio
corrects for any dilution and allows comparison of right
and left adrenal vein samples.
Interpretation of the results is based on the physiologic
suppression of aldosterone production in the adrenal
gland contralateral to an APA. If an APA is present, the
A/C ratio in the contralateral gland will be below back-
436 J. D. Georgia and D. L. Miller
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ground levels, as indicated by the sample obtained from
the femoral vein sheath, whereas the A/C ratio from the
ipsilateral gland will be much greater than the background. On the other hand, in patients with bilateral
hyperplasia, A/C ratios in both adrenals are comparable
because neither is suppressed. The A/C ratios from both
adrenal glands will be greater than that in the femoral
vein sheath sample. Following ACTH stimulation in a
patient with an APA, both cortisol and aldosterone levels
increase significantly on the side with the adenoma,
FIGURE 34-8. Anatomy of the adrenal veins. The drawing demonstrates the typical anatomy.
When sampling the left adrenal vein, it is important to ensure that the catheter tip is not in the left
inferior phrenic vein, or adrenal venous blood will not be obtained. 1, inferior vena cava; 2,
common iliac; 3, internal iliac; 4, renal; 5, adrenal; 6, gonadal; 7, inferior phrenic.
whereas there is a rise in cortisol but only a minimal
increase in aldosterone in the contralateral suppressed
gland. This further increases the difference in A/C ratio
between the two adrenal glands. In bilateral hyperplasia,
however, aldosterone and cortisol levels from both adrenal glands increase after ACTH stimulation, and the A/C
ratios remain comparable between the two glands. When
one gland shows suppressed aldosterone production before ACTH stimulation and a reduced aldosterone response (and normal cortisol response) following ACTH
Arteriography and Venous Sampling 437
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FIGURE 34-9. Bilateral adrenal vein venogram. Catheters are in place for adrenal vein sampling.
Note the short course of the right adrenal vein (
left renal vein just to the left of the spine (
white arrow
short black arrow
inferior phrenic vein joins the left adrenal vein (
angiography and venous sampling.
Radiol Clin North Am
long black arrow
). The left adrenal vein empties into the
). Also note the point at which the left
). (From Miller DL. Endocrine
1993;31:1051–1067, with permission.)
stimulation, surgical removal of the contralateral gland
produces a high cure rate.
68
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https://t.me/med1917
M.A. Mauro and S. E. BlackCentral VenousAccess
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35
■■■
Central Venous Access
MATTHEW A. MAURO AND STEVEN E. BLACK
Modern medical care has rapidly expanded the need for
the placement of catheters into the central venous
circulation for long periods. Long-term central venous
access is commonly used for hemodialysis, plasmapheresis, chemotherapy, long-term antibiotic therapy, blood
drawing, parenteral nutrition, and analgesics. Outpatient
dialysis centers, ambulatory chemotherapy, hospices,
home health care, and other commercial enterprises
have grown dramatically as an indirect result of these
devices.
Broviac and Hickman described the first soft long-term
right atrial silicone catheters in 1973 and 1979, respec-
1,2
tively.
Niederhuber in 1982.
been placed by surgeons within an operating room. The
traditional role for radiologists was to be involved in preoperative venography, catheter relocation, and intravascular catheter fragment retrieval. More recently, the interventional radiologist’s role has expanded to include
complex access cases and the development of an independent venous access service where they function as the
primary operator in the placement and management of
all long-term devices.
technology, in addition to acquired catheterization skills
and a commitment to patient care, place interventional
radiologists in a strong position to become an important
part of this service. The development of a successful
venous access service requires a knowledge of the available devices and their indications, insertion and removal
techniques, and the management of complications relating to these devices.
The first subcutaneous port was reported by
Advances in vascular imaging and catheter/guidewire
3
Historically these devices have
4,5
■ Access Devices
Modern central venous access devices are available in
many sizes and forms. Regardless of these differences,
they all result in the positioning of a catheter in the central venous circulation: the superior vena cava (SVC), inferior vena cava (IVC), or right atrium. Early catheters
were made of polyethylene and frequently were complicated by thrombosis and infection.
composed of either silicone rubber or polyurethane attached to either an external connector or an implantable
port. Silicone is a soft material that has a high coefficient
of friction, making catheters composed of this material
difficult to use with over-the-guidewire techniques when
conventional stainless steel guidewires are used. Newer
hydrophilic guidewires can be used with this material.
Silicone catheters have been used in the central venous
system since the early 1970s and are extremely biocompatible and safe. Polyurethane is a newer material that is
stronger than silicone, which allows a catheter to have a
larger internal diameter while maintaining the same
outer diameter. Polyurethane also can be used with conventional guidewires.
Catheters have either a simple end-hole, a valved tip, or
a staggered tip. Conventional end-hole catheters are the
most common variety and are available with single, dual,
or triple lumen. These catheters can be trimmed at the tip
for proper sizing.
signed slits just proximal to a closed tip, allowing blood to
be withdrawn and solutions to be infused but, when not in
use, will not allow blood to enter the catheter. The potential advantage of these types of catheters is that they do
7
Valved-tip catheters have specially de-
6
Current devices are
441
442 M. A. Mauro and S. E. Black
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not require routine heparinization to prevent catheter
thrombosis. These devices can only be trimmed at the hub
and therefore have a removable external connector.
Staggered-tip catheters are dual-lumen devices designed
for treatments requiring simultaneous rapid aspiration
and infusions (pheresis, hemodialysis) with limited admixture. These devices cannot be trimmed from either
the tip or hub and therefore are available in multiple
lengths to fit the individual patient’s anatomy.
Central venous devices can be separated into peripherally inserted central catheters (PICC), chest-wall external
catheters (nontunnelled and tunnelled), and subcutaneous ports (chest wall and extremity) (Figs. 35-1 through
35-3).
PICCs allow external access and are inserted via an
upper extremity vein (see Fig. 35-1 and Table 35-1). Because they are inserted peripherally, they carry a lower
procedural risk than do centrally inserted catheters and
8
FIGURE 35-3. Photograph of subcutaneous ports: Left: Low
profile chest-wall port used in small adults and in children;
Right: Standard chest-wall port used in average to large adults.
may be preferred by patients who dislike having catheters
on their chest.
9
In many institutions, PICCs are placed at
the bedside by trained nurses; however, for patients with
venous occlusions from previous venipunctures and intravenous lines, blind placement of these devices is frequently unsuccessful. Ultrasound or venography often
will allow successful placement by the interventional radiologists.
9–12
FIGURE 35-1. Photograph of external venous access devices:
From top to bottom, single-lumen Hickman catheter, dual-lumen Hohn catheter, single-lumen peripherally inserted central
catheter (PICC). Only the Hickman catheter has a Dacron cuff
(
straight arrow
Hickman and Hohn catheters have a Vita cuff (
placed at the entry site
FIGURE 35-2. Photograph of dual-lumen, staggered-tip dialysis catheter.
) that is placed in a subcutaneous tunnel. The
curved arrows
Straight arrow:
Dacron cuff.
Curved arrow:
Vita cuff.
Chest wall catheters
Nontunnelled
Chest-wall external catheters ser ve many needs. Acutecare catheters are tapered, nontunnelled catheters that
are placed routinely in the units and on the floors for
relatively short periods (i.e., days to weeks). In cases
where access is difficult (e.g., obesity, coagulopathy, venous thromboses), the interventional radiologist may be
asked to place these devices. Nontapered, nontunnelled
chest wall external catheters are also available with a
single or dual lumen and intended for intermediateterm care (i.e., several weeks to several months) (see Fig.
)
13
35-1).
Because they are nontapered and composed of
silicone, they are more difficult to insert than the acute-
care catheter and typically are placed near the surgeon
or interventional radiologist.
Tunnelled
All tunnelled chest-wall catheters have a small-circumference Dacron cuff attached to the shaft that is positioned
within the subcutaneous tunnel. Subcutaneous tunnelling provides mechanical stability and protects against
infection from the skin. The Dacron cuff allows ingrowth
of fibrous tissue, which secures the catheter within the
tract (4–6 weeks) thus creating a long-term device (i.e.,
months to years).
14
Some catheters are also available with
a second cuff composed of a silver-impregnated collagen
TABLE 35-1. Access Devices
https://t.me/med1917
Type Sizes Lumen material Indications access site Fixation Duration Advantages Disadvantages Comments
Catheter Conventional
Peripherally 3–7 Fr S,D Polyurethane Chemotherapy Antecubital v. Suture/tape Weeks to Low procedural risk Restricted flows Insertions often can be
inserted central Silicone Antibiotics Cephalic v. months Low central v. thrombosis Poor visibility performed following
catheters Fluids Basilic v. Bedside insertion Skin fixation bedside failure
Nontunnelled
chest wall
catheters:
Tapered 5–13 Fr S,D,T Polyethylene Acute care SCV/AV Suture/tape Days to weeks Quick bedside insertion Complications of central
Nontapered 5–7 Fr S,D Silicone Antibiotics SCV/AV Suture/tape Weeks to Hospital or home Complications of central
Tunnelled chest 6–14 Fr S,D,T Polyurethane Chemotherapy SCV/AV Cuff within Months to Full range of indications Complications of central Frequent uses
wall external Silicone Antibiotics IJV subcutaneous years Easy access insertion
catheters Fluids tunnel Internal fixation Limitation of activity
Subcutaneous
ports
Extremity 5–7 Fr S Polyurethane Chemotherapy Antecubital v. Internal Months to Low procedural risk Extremity v. Patient and nurse
Chest wall 6–10 Fr S,D Polyurethane Chemotherapy SCV/AV Internal Months to Large access site Complications of central Infrequent uses
Polyurethane Antibiotics IJV Acute care setting insertion
Silicone Fluids Multiple indications Hospital setting
Silicone Antibiotics Cephalic v. years Low central v. thrombophlebitis preference must be
Silicone Antibiotics IJV years Easier needle access insertion Cost-effective after 6
Blood drawing Inexpensive Extremity v. thrombosis
TPN Limitation of activities
Blood Internal fixation
Pheresis
Dialysis
Fluids IJV months Atraumatic material insertion
TPN Skin fixation
Blood Limitation of activities
TPN High maintenance
Blood
Pheresis
Dialysis
Fluids Basilic v. thrombosis Needle access required considered
TPN Low maintenance Small access site
Blood Unlimited activities Difficult access
Fluids Low maintenance Needle access required mo
TPN Unlimited activities
Blood Self access
Requires intact anatomy
Fr, French; S, single lumen; D, dual lumen; T, triple lumen; TPN, Total parenteral nutrition; SCV/AV, subclavian/axillary vein; IJV, internal jugular vein.
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